"Food and nutrition used to be seen as one, so the response to malnutrition was through food security; we started talking about nutrition security relatively recently. There is the question of access to food, but also of its nutritional quality and safety, child care practices, access to health, hygiene and sanitation," said Félicité Tchibindat, West Africa adviser on nutrition to the UN Children's Fund (UNICEF).
IRIN provides a brief overview of this quiet nutrition revolution in the Sahel, the vast transitional zone along the southern edge of the Sahara Desert.
The Great Sahelian Drought, 1968-1974
Several years of low rainfall sapped water reserves in Mali, Niger and Chad. By 1971 Lake Chad was one-third its normal size, grass and shallow-rooted plants shrivelled, cattle died.
Pastoralists began migrating to cities and towns, joined by rural communities no longer able to farm; the population of Senegal's capital, Dakar, swelled by 42 percent. Up to 100,000 people and a third of livestock died of starvation and disease, according to the United States Agency for International Development [http://www.adf.gov/ndpart1-thedrought.pdf].
"The response to malnutrition depends on our understanding of the causes," Tchibindat told IRIN. In the 1960s and '70s, malnutrition was defined as a deficit in protein and energy.
"The distinction between hunger and malnutrition was unclear. It was thought that malnutrition could be cured by providing enough food - children were hospitalized and given high-protein treatments; mortality rates were up to 50 percent."
1983-84 Sahel drought
Sahelian countries received some of the lowest rainfall ever recorded until 1983 and '84. Even though this drought was more severe than that of the 1970s, the UN Environment Programme says that there was less damage because economies and societies had developed better coping mechanisms [http://www.unep.org/Themes/Freshwater/Documents/pdf/ClimateChangeSahelCombine.pdf]. Still, crops failed, pastures shrank and one-third of the livestock died, according to a 2008 study by the Organisation for Economic Co-operation and Development and the Economic Community of West African States
A decade after the Great Sahelian Drought, scientific understanding of malnutrition was evolving - malnutrition was not only empty stomachs, but also a lack of life-sustaining nutrients - nevertheless, treatment remained the same.
"We still thought that the crises were exceptional, and intervened when the situation was catastrophic," Stéphane Doyon, head of the Médecins sans Frontières (MSF) nutrition campaign, told IRIN. "We put up hospitals to treat the severely malnourished children with porridge; in the meantime, general food distributions were taking place."
The treatment was relatively successful - three out of four children recovered, but were undersized; it was also labour-intensive - every bed required a medical worker and health facilities hosted a maximum of 200 children.
"We focused on the most affected children, [those] with high mortality risks," said Doyon. "We would have to turn patients away and give them food out of compassion. [Mothers] had to come to hospitals in urban centres and stay for 30 to 40 days with their child, leaving other children behind."
2005 Niger food crisis
First the rains ended early and then the locusts came. In Niger the shortages of cereals and animal fodder brought death, compounded by rocketing food prices. Some 3.3 million people were affected, including 800,000 under-five children, the UN said. [http://irinnews.org/Report.aspx?ReportId=56324]
The development of ready-to-use therapeutic food (RUTF) [http://www.irinnews.org/report.aspx?ReportId=72897], like Plumpy'nut, in the late 1990s, meant that children without medical complications could be treated for severe acute malnutrition as outpatients.
"It allowed us to treat many more children, with similar or even better success rates - 85 to 90 percent - and a much better coverage of the population. People responded well to mobile clinics since they no longer had to leave home for days. It also spared children from being exposed to other diseases in the hospital," said MSF's Doyon.
Large-scale responses became possible. In 2002 MSF needed 2,000 staff [http://www.irinnews.org/Report.aspx?ReportId=32719] to treat 10,000 malnourished children in Angola; two years later a similar number were treated in Niger by 120 people dispensing nutrient-dense spreads from mobile clinics.
When the crisis hit Niger in 2005, MSF reached 70,000 children. "That is about the number that we had treated during the three previous decades," Doyon commented.
2010 food crisis and beyond
Falling cereal production and poor pastoral conditions, set against a backdrop of poverty, rapid population growth and high food prices, have put over 10 million people at risk of hunger before the September harvests in Niger, Chad, Mali, Burkina Faso and northern Nigeria, according to the UN Food and Agriculture Organization [http://irinnews.org/Report.aspx?ReportId=89598].
Nowadays, most children are treated at home but aid organizations have called for more attention to children aged under two, and to moderate acute malnutrition [http://www.irinnews.org/Report.aspx?ReportId=88233]. In countries like Niger, 3 to 4 percent of children are typically severely malnourished, compared to 10 to 15 percent who are moderately so, noted UNICEF's Tchibindat.
The World Health Organization (WHO) indicates that without adequate support, moderately malnourished children may progress towards severe acute malnutrition, "But it took a long time before we started seeing this as a continuum," she added.
"In 2006, we realized that we were constantly facing high [rates of acute] malnutrition, and that the lean season would always be difficult," said MSF's Doyon. "We thought that we should try treating children before they become severely malnourished. It worked."
The usual treatment for moderate malnutrition, which has remained virtually unchanged over the last 30 years, should be improved. "Cereal-based flours lack essential nutrients and are not in line with WHO's criteria," he said.
Banda Ndiaye, Senegal country director of the Micronutrient Initiative, pointed out that children with insufficient micronutrient intake and absorption could suffer lifelong repercussions. "For example, a deficit in vitamin A will reduce a child's resistance to infection and put him more at risk of death from diarrhoea or measles, while a lack of iron will affect the development of intellectual capacity."
Tchibindat agreed. "The earlier we act, the greater the impact. We should even intervene during pregnancy to prevent children from being born with intra-uterine growth deficit, which leads to children being born with a low weight and a high risk of developing malnutrition during early childhood," she said.
"We have to look at the genesis of malnutrition and step away from medical intervention. The investment needs to be done over 5 to 10 years, and not over 12 to 18 months." [http://www.irinnews.org/report.aspx?ReportId=76527]
Factbox: The Sahel [http://www.irinnews.org/Report.aspx?ReportId=78514] is a semi-arid belt of barren, sandy and rock-strewn land that stretches 3,860km from Senegal to Eritrea and marks the physical and cultural divide between Africa's more fertile south and Saharan desert north. It covers parts of Senegal, Mauritania, Mali, Burkina Faso, Algeria, Niger, Nigeria, Chad, Sudan, Somalia, Djibouti, Ethiopia and Eritrea.
Factbox: Malnutrition terms
Chronic malnutrition occurs over the long term and is caused by an insufficient intake of some nutrients. It especially affects children younger than five.
The symptoms of short-term chronic malnutrition in children include growth faltering and weight loss, with associated micronutrient deficiencies. The longer-term effects are associated with impaired physical and mental development.
Acute malnutrition: A drastic deterioration of nutritional status in a short time can lead to acute malnutrition or wasting (individuals too thin for their height). This form of malnutrition poses more severe health risks than chronic malnutrition and leads to weight loss, impaired bodily functions, and specific micronutrient deficiencies. In its severe form acute malnutrition can lead to death.