Foregrounding ‘Community’ in Community Management of Severe Acute Malnutrition

Abstract

The issue of widespread food insecurity amongst children in Africa and Asia has often been narrowed to the discourse on 'severe acute malnutrition (SAM)' in the last decade. Further, conflicting notions exist in relation to the root causes and solutions for SAM; ranging from the dominant view that it is a medical emergency needing medical/technical assistance, to its being perceived as a socio-economic-political phenomenon, to be managed largely by enhancing the agency of the affected families and communities. Much recent experience, and some evidence, has emerged that suggests that SAM in India is a unique phenomenon with distinct differences from its counterpart in Africa. Nonetheless, the technical community has been slow to acknowledge these differences, leave alone alter their recommendations accordingly. These differences in understanding are sharply evident in the interpretation of community management of acute malnutrition (CMAM) in particular. This paper examines these differences; factual and perceptual, and critically interrogates the definition and programmatic interpretation of CMAM that is in current usage, which results in the further marginalization and dependence of the affected community upon external resources. It also highlights the characteristics of alternate programmes for CMAM using a few models for illustration.

Alarming level of severe acute malnutrition in Indian districts

“…Given the current burden of children with SAM and the available NRCs in India, operationally, it is not feasible to treat all the SAM children in NRCs. Considering the relatively lower mortality and morbidity rate among the SAM children in India compared with African countries, mainstreaming of community-based management of acute malnutrition (CMAM) for the management of uncomplicated SAM has been suggested 26 27. CMAM requires additional provisioning in the existing subcentres and primary healthcare centres to provide facility-based treatment to children with medically complicated SAM at the community, and children with uncomplicated SAM to be monitored every week and treated using ready to use therapeutic food and other nutrient-dense food at home 28.…”

The malnutrition bazaar: the case of RUTF

“…An IBFAN policy brief lists several other trials which cast doubts on the efficacy of RUTF as compared to treating SAM with enriched food (IBFAN, 2017). There are also several studies debunking RUTF as a miracle food for reducing SAM (Nutrition Advocacy in Public Interest (NAPi), 2017), as well as studies on the use of family foods and interventions that include improving care practices (Gope et al, 2019;Prasad, 2015;PHRN & APPI, 2021) as well as critiques of studies promoting the use of RUTF (Prasad, 2017). Visser et al (2018) question the effectiveness of RUTF, especially as the only intervention to deal with SAM.…”

“…For instance, the program does not include measures to prevent further deterioration when growth faltering is first noticed. Nor does the program include treatment of SAM with locally available resources, which have been shown to be effective, and which in addition, support community agriculture and lead to changes in feeding practices so that relapses are prevented (Prasad, 2017).…”