by Dr. Marie-Pierre Allié
President, Médecins Sans Frontières France

First published in April 2012 in Le Monde newspaper in French.

Chad © Andrea Bussotti/MSF
MSF doctors evaluate a young patient in the pediatric care unit of a hospital in N'Djamena, Chad.A nutritional evaluation in central Chad run by MSF in March 2012 showed global malnutrition rates up to 20 per cent. At the end of March MSF started a nutritional program in Yao district, Batha region, adding to other nutrition programs the organization already runs in the country.

A new nutritional crisis is brewing in the Sahel region of Africa. Repeated warnings and appeals to the public's generosity remind us of it every day. But what do these calls actually reveal?

That more than 600 children are dying every day from the consequences of lack of food in the Sahel.

That more than 500,000 severely malnourished children were treated in 2011 in eight Sahelian countries of West Africa.  

That the seasonal peak of malnutrition, which corresponds to the hunger season, will probably be more serious than usual in certain regions, where contingent factors – climatic, political and economic – will exacerbate poverty, lack of access to healthcare and the inequitable distribution of food resources.

That a catastrophe of yet undefined intensity again threatens the children of the Sahel and that we are dealing with a cyclical and structural reality.

Yet these calls are not telling us everything.

They do not mention, for example, that the extent of the predicted nutritional crisis will vary dramatically by country, as will those countries' ability to prepare and manage, although some have been mobilizing since the fall. Humanitarian aid efforts will not be subject to identical financial, logistics and security constraints, either. In Mali, for example, political instability related to the recent coup d'état and the conflict underway in the northern part of the country (and the risks of kidnapping) will complicate aid delivery and the populations' access to medical care.

Nor are we informed -- or, at least, not adequately – that malnutrition is a disease and that we have made major progress in treating it. In most cases, a malnourished child's mother can now take responsibility for his or her care, thus avoiding systematic hospitalization. Treatment programs have expanded dramatically, increasing the number of children treated ten-fold. In Niger, 300,000 children were treated in 2011, compared to only a few thousand seven years earlier. This exponential growth reflects the growth in treatment possibilities, not an increase in malnutrition.

The latest scientific results regarding prevention are also encouraging. The distribution of milk-based enriched products to young children has reduced malnutrition and related mortality considerably. There is little doubt that the development of treatment and preventive measures helped to reduce the deaths of children less than five years of age in Niger by one-third between 2005 and 2011. The fight against malnutrition has thus moved forward, even if bad years continue, one after another, in the Sahel.

However, these repeated calls and warnings are creating a shared awareness among all actors and decision-makers that the nutritional crises in the Sahel must be addressed differently. Malnutrition has long been associated with crisis and its treatment with disaster medicine. Humanitarian action has thus been the default response, undertaken to prevent the immediate death of huge numbers of children.

With the incidence of malnutrition at 30 per cent in 2011 among Nigerien children between six and 23 months of age, this is no longer just a humanitarian problem but, indeed, a public health one. These statistics call for a different approach that involves moving beyond emergency medical response (a necessary but insufficient stopgap measure) to develop responses that will be viable over the long term.

In 2012, the humanitarian emergency system will be deployed once again. The efforts of emergency fund donors and humanitarian organizations will be critical because they are still our only current response to recurring nutritional crises. However, we must simultaneously begin a transition to more long-term, ongoing solutions.

Fighting malnutrition as a public health problem requires implementing appropriate, effective medical and nutritional measures by integrating them into basic healthcare services that are already established for young children, such as vaccinations. This will be the basis for developing new models for action and funding. Some promising approaches do exist: the availability of less expensive nutritional products, produced locally; the decentralization of treatment and prevention, provided by non-medical workers; the implementation of simple, less expensive systems providing access to food; and the release of funding from institutional donors that support development programs.

MSF's work in the region is now focused on that dual approach. We are treating children at immediate risk of death in regions where malnutrition may be most severe, such as certain areas of Chad, Senegal and Mauritania, and we are continuing to work on simplified, decentralized treatment and prevention models while maintaining the same quality of care.

This year may be a turning point in the Sahel if we are able to link an unprecedented humanitarian response with a true change in the approach taken by development actors. This change will allow us to relegate nutritional crises, and the humanitarian emergencies that accompany them, to the rank of tragic exception -- no longer the unbearable rule for millions of children.

In the fight against AIDS, tuberculosis (TB) and malaria, we should be dealing a knock-out blow. The Global Fund must call an emergency donor conference so countries can reverse these killer epidemics.

By Unni Karunakara, physician and international president of Médecins Sans Frontières (MSF).

When the Global Fund to Fight AIDS, Tuberculosis and Malaria announced it had to cancel its new round of funding because it was running out of funds, it felt like a punch in the face for me and for thousands of other health workers at MSF. The news could not have come at a worse time. Just when years of hard work, coupled with new scientific advances, bring hope that we can push back the three diseases that kill millions every year, donors drop their commitment to the Global Fund. So instead of continuing on a path toward reversing the epidemic killers, health ministries in the hardest-hit countries may have to witness a reversal of hard-won progress itself.

MSF’s treatment programs are mainly funded by the contributions of private individual donors, but ministries of health rely heavily on the Global Fund. Set up in January 2002, the fund has become a lifeline to millions of people in the countries where MSF works, estimating that its funding stream has directly contributed to preventing an average of one million deaths per year. We have seen ministries of health successfully run ambitious programs that they never could have imagined without outside support.

Somalia © MSF
Dr. Unni Karunakara examining a child during an MSF mobile clinic in Somalia in July of this year.

But donors have left the Global Fund in the lurch, with some withholding or delaying their promised contributions, and others not giving anything at all. With no resources to pay for any new proposals until 2014, the fund has told hard-hit countries they can’t scale up effective HIV treatment for three years, unless they have already approved grants. TB and malaria will also suffer. This effectively means health ministries will be forced to ration care, and make the difficult decision to provide less than optimal treatment because the better treatment simply costs too much.

And this at a time when scientific advances could successfully be pushing back all three diseases:

Take AIDS. Ten years ago, in countries like Thailand and South Africa, MSF piloted programs that challenged the very notion that treatment couldn’t be rolled out in poor communities. This year, 30 years into the epidemic, research has delivered the evidence that HIV treatment itself can be a decisive tool for pushing back the pandemic. A person put on treatment earlier is 96 per cent less likely to pass the virus on to others. Yet today, the majority of people tested positive continue to go untreated.

With HIV treatment now a key tool for HIV prevention, we have a historic opportunity to reverse AIDS. At this crucial time, donors should be funding the Global Fund, so countries are empowered to seize this opportunity and implement bold programs that can turn the tide on the epidemic. But instead, countries have been told to hit the brakes.

Take tuberculosis. For the first time, the number of TB cases worldwide is on the decline, although it remains shockingly high for a curable disease, with more lethal, drug-resistant forms on the rise. Here, too, treatment is prevention: if people are on treatment, they are less infectious. A new advance in diagnostic technology has improved our ability to determine who has drug-resistant TB and therefore to put them on the right treatment. Scaling up is now a matter of urgency.

Take malaria. The combination of providing bed nets to prevent malaria and effective combination therapy to treat the disease have significantly reduced incidence. A landmark clinical trial in 2010 showed that better treatment for severe forms of malaria in children can dramatically reduce death rates. But kids continue to be treated with quinine, which is cheaper, but far less effective. And malaria continues to kill hundreds of thousands of people every year, most of them young children. While prevention remains the mainstay of the fight against malaria, MSF has estimated that switching treatment for severe forms would cost around $30 million more, but can save 200,000 lives per year.

There has never been a better time to push forward, build upon progress and use new scientific evidence to rein in these epidemics. Affected countries should take their responsibility. Many of them want to be ambitious, and also want to take on a bigger role in footing the bill. Uganda, for instance, wants to double the rate at which people are put on to HIV treatment, and Uzbekistan wants to significantly increase the number of people receiving treatment for drug-resistant TB.

But countries can’t do this alone. So where will the funding come from, with a ‘closed for new business’ sign hanging on the front door of the Global Fund?

It’s time for the Global Fund Board to end its passivity and raise the alarm about the urgency of the situation – it must refuse to settle for rationed care and stalled ambitions caused by donors turning their backs. The board needs to hold an emergency donor conference within the next half-year to raise the resources needed to finance a new funding opportunity for countries in 2012. Donors that have promised funding need to pay up. Old and new donors, including emerging economic powers like China, India and Brazil, who have yet to give this year need to step up to the plate. It is unacceptable and unconscionable that as the Global Fund turns 10 in January, its bitter gift to the world is a three-year hiatus in the fight against the three killer diseases. Donors must deliver on their promises.

In my work with MSF, I have seen people die from AIDS, from TB, and from malaria. But in recent years, I have most of all seen people survive these diseases. The Global Fund is a crucial part of the most ambitious health project in history, and millions of people alive today are testimony to its success. We simply can’t afford to squander the opportunity we have now to deal these diseases a final blow.

In 2010, MSF provided HIV treatment to more than 180,000 people in nearly 20 countries, TB treatment to 30,000 patients, and malaria treatment to 1.6 million.