Windhoek, Nabimia. How fast the days turn into weeks, weeks into months and then years. I remember 2001 like yesterday, but ten years have passed and so have many opportunities to make a difference. We public health nutritionists must act fast if we want to make any difference in health and well-being of populations. Many children are dying of malnutrition all the time, even as I write this column, while many others are losing working years and potential for productive adult life due to nutritional and other health problems.
Above is a photo of a beautiful sight in Namibia, where I began to draft this column. This month I write about my experience in Namibia, and my thoughts on nutrition leadership, and I interview Florence Turyashemererwa, a young Ugandan nutritionist. First I start with some thoughts about 'food'.
Food and culture
There are aspects of food that are unique from country to country and from culture to culture, some of which can be amusing. In Ghana, where I come from, different ethnic groups have different staple foods. I am sure this is true for many African countries. People's definition of 'food' can also be different from one ethnic group to the other. Sometimes when people say 'food', they may actually be referring to the staple food from their culture. So when people tells you 'the whole of today, I have not had any food' it may be actually that they have eaten, but not anything they define as 'food', which is the staple.
For instance, the tribe that I come from is called the 'Ga' and the people are 'Gas'. The Gas come from Accra, the capital city of Ghana. Kenkey is our staple food. This is prepared from fermented milled maize or corn (corn dough), put in corn husks, and boiled. See the recipe for kenkey at http://en.wikipedia.org/wiki/Kenkey. It is eaten with fried fish and different kinds of sauces (for examples, stews and soups). See the picture above of the food being eaten. So if you meet and ask Ga people what they ate on a particular day, they may say 'I have not eaten the whole of today' though they may actually mean is, I have not eaten kenkey today.
This is also true for other ethnicities. Among the Akans of Ghana whose staple food is fufu (pictured above) made from boiled plantain and cassava, eaten with different types of soup, it is not unusual for people to claim they have not eaten all day when actually they have eaten other things such as sandwiches, fruits, salad, roasted peanuts, and so on.
Here is one explanation for high trends of overweight and obesity in countries that have rapidly urbanised. In the cities, there has been increasing consumption of fast foods, which may still not be considered as 'food' at all.
Managing malnutrition in Uganda
A new feature of my column from now on, is that I will be interviewing Africans (especially the younger scientists), and also others working in public health nutrition and related areas in Africa. The aim is to know what these people are doing, the challenges they face, the lessons we can learn from their experiences and how they see the future practice. This month, I start with Florence Turyashemererwa, a PhD public health nutrition student from Uganda.
What are the practices regarding treating malnourished children in Uganda?
I started working as a nutritionist in Uganda in late 2005 in Mbarara hospital, a regional referral hospital in Uganda. On my first day, I didn't know what to do. There was no functioning kitchen to prepare milk for the children. The milk did not come regularly and if it was available, it was a drop in the ocean. When prepared, it was usually boiled with no additional nutrients (minerals, vitamins and oil) and served on a first come first served basis.
The hospital had never had a nutritionist before, so all the children stayed on the main ward till they were ready for discharge. The would-be nutrition ward for rehabilitation had been turned into an occasional classroom. I therefore had the challenge of making it functional. This would require additional staff and sufficient feeds for these children. Mothers of the children were always sad, and they never wanted to stay at the hospital. They came to seek hope from people they believed in, but it seemed the more they stayed, the more their hope faded. To me, this was a very big challenge; I needed to use my skills to bring back hope to these women and their children.
Would you say guidelines on malnutrition management such as those from WHO were not followed?
I did not know about any such guidelines. Neither was there information on any guidelines in the ward. I was aware there was a stabilisation and rehabilitation phase of treatment, but it was not emphasised in my training that this was the most important period of treatment which had to be followed carefully in order to ensure recovery.
Would you say that these guidelines should be taught to Nutritionists in Schools?
Absolutely. Acute malnutrition is high in sub-Saharan Africa including Uganda. Knowing what to do is crucial
Were malnourished children treated the same way as other children in the hospital wards?
Yes. They were. They did not receive any special treatment apart from the fact that every sick child did not have to queue. Malnourished children came in very sick. We know that treatment and correction of hypothermia, hypoglycaemia, dehydration, electrolyte imbalances, and so on, are all vital. But I can confidently say that some of these things were not done. Looking back, I can see that there were all sorts of human, structural and organisational reasons why so much was not done as expected.
How did these practices influence case fatality and recovery?
I would not know what the case fatality was for malnutrition at the time. Many children died on the ward, but there was no distinction as to cause, because these children were mixed up. Deaths were attributed to specific diseases such as malaria, fever, infections.
Making a difference
In the period you were there, did you do anything to change the situation?
Yes. I started by ensuring that the children had enough feeds. I also realised that the treatment of these children was not done with a nutritional lens. We therefore secured funds externally to provide enough feeds. We hired a cook and an extra nurse and a care assistant to form a nutrition team – the existing nurses were already too thin on the ground. So we had some form of a nutrition team. I also formulated porridge which was almost equivalent to F100 (a feed used for malnourished children in the rehabilitation phase of treatment). We also started providing nutritious family foods for these children. Hence from children having almost nothing, they now had enough milk with high protein and energy porridge for rehabilitation, and adequate family food given once a day. Nutrition education sessions and follow up after discharge were done.
After implementing these interventions were there improvements?
Yes. From our records, case fatality reduced to 10 per cent. For me that was a major improvement. It meant about half of these deaths were prevented. Also, we realised that children who were treated and discharged did not come back again malnourished, which meant that we prevented the recurrence of malnutrition. The education sessions also made a difference. The mothers were able to make the porridge we used on the ward at home. Every time mothers came for follow up reviews, they were full of smiles, because they were proud to come back and show us a healthy child. This already is a sign that hope to the once hopeless women was restored.
What are you doing now?
Currently, I am studying for a PhD at the University of Southampton. My research area is broadly on the treatment and prevention of malnutrition. I am specifically looking at the overall structure and systems in the management of acute malnutrition in Uganda, and how these can be improved.
How do you see the future regarding addressing malnutrition in Uganda?
We must not rely on donor feeds or funds. They do not come on time and can stop coming. It is just not sustainable. We should be creative and formulate feeds from locally available foods that are also well accepted by communities, like our specially formulated porridge. I know there is currently ready to use therapeutic food (RUTF) being used in some places, but this has problems. People should be able to think outside the box and know what to do when RUTF funding ceases.
Work like that I did in Uganda is always a challenge. Mothers have other children to look after and are not willing or able to stay with one admitted malnourished child. We need to strengthen the community-based management approach. This would ensure that children stay in the hospital for as short a time as possible and are then treated as outpatients with family foods and RUTF if appropriate or needed.
I believe in building capacity of health workers to identify, treat and prevent malnutrition in children. Currently, the guidelines for management are not fully followed because of lack of understanding to some extent. In my experience treating and preventing electrolyte imbalance has mostly been ignored. Therefore capacity building in the form of training should be looked at seriously in order to sustainably address malnutrition in Uganda.
Thank you Florence for sharing these experiences. There is a lot to learn.
Building capacity in Africa
I am recently back from Windhoek, Namibia, attending an African Nutrition Leadership Programme follow-up workshop on grant writing. The Republic of Namibia is in southern Africa with its western border in the Atlantic Ocean. It shares land borders with Angola and Zambia to the north, Botswana to the east and South Africa to the south and east. It gained independence from South Africa on 21 March 1990, following the Namibian War of Independence. Its capital and largest city is Windhoek. Namibia is a small but beautiful country. It is a popular destination for tourists interested in wildlife, desert scenery and traditional African cultures.
From Hosea Kutuka International Airport to Windhoek, I observed the beautiful scenery of Namibia. Whilst in Windhoek I visited some interesting places, including Parliament where I saw the statue of Hosea Kutako. The picture below is of some colleagues and me in front of Hosea Kutako's statue. I will like to tell you a bit about him because I like history. Chief Hosea Kutako was a Namibian nationalist leader who lived from 1874 to 1970. With his colleague the Rev Michael Scott, he organised petitions to the United Nations which eventually led to the recognition of Namibia's status as a sovereign country under colonial control by South Africa. He was also instrumental in the independence of Namibia from colonial rule. Read more about him at http://www.thefullwiki.org/Hosea_Kutako.
As mentioned, my reason for going to Namibia was to learn about writing effective and successful grant applications. The aim of the four-day workshop was to equip young African nutritionists like me with the skills of grant proposal writing in order to increase our success rates for winning grants.
I know what you are thinking. Namibia is a long way to go for a grant writing workshop! But this meeting was special in several ways. There were facilitators who have been successful in receiving substantial grants, there to share their experiences with us. There were resource people from grant-giving bodies who shared with us why grant applications are normally unsuccessful and what to do to increase our chances. But most of all, participants had the time to actually write or continue with applications they have been working on, with support.
Most academic professionals are buried in activity upon activity, especially those who teach, and it is really hard to find the time to write for publication and to apply for grants. When asked what our expectations were, the first person who spoke said she wanted to leave the workshop with a complete or near complete grant proposal. As can be seen below, participants got right down to work on their proposals, supported with help from the facilitators and resource people.
The key phrase I took from the training was 'be detailed'. This means making sure every aspect of the application is adequately and carefully covered, including budgeting. Small things like word count, fonts, margins, and so on, are not trivial. There are reasons why they are set that way. If two applicants have done everything right except the fact that one used the wrong margins, the other may be selected. Also, if too many applications are received, apparently trivial things could be the basis for rejecting some.
Meet eligibility criteria
More generally, I learnt that grant bodies will only fund projects that meet their objectives. It is a waste of time to send applications on topics outside these objectives. Eligibility in terms of location for the activity such as country, type of activity, type of organisations which can apply, funding objectives and size of grants are very important. If the funding is for X amount, do not ask more. If you need more to reach your funding target, you can look for the rest from other sources.
Importantly, look through websites of grant bodies where you may find information on current projects being funded, grant writing hints specific for the organisation, frequently asked questions, and common mistakes made, and guidelines for completing application forms.
Were our expectations met? I believe so. Participants who left the meeting with completed proposals usually had arrived with half completed proposals and so were able to complete them with the guidance given. Those of us who did not leave with ready to submit proposals, left with clearer ideas and knowledge of the way forward. All participants also left with an expansion of our networks, and so are the opportunities for future collaborative activities between and within countries.
Energy, passion, and...
I asked a friend who comes to mind when she thinks of leadership. She mentioned Mother Teresa (above) and Nelson Mandela.
What do we need to effectively address nutrition issues in Africa? I am sure if we create a forum to discuss this, we would have diverse opinions and tons of information. What do I think? To me three areas are vital: evidence, passion – and leadership. By 'evidence' I mean knowing the extent of the problem. This we do know to a large extent. We know that in Africa both undernutrition and overnutrition are major issues. We can describe the length, breadth, depth and height of these issues. This does not mean research should stop or we should stop describing the problem. I say this with caution because you may say, enough of describing what everyone knows. You have a good point.
'Passion' means zeal and fervour, or more mildly put,desire and longing. We must have enough passion to see that problems really are addressed. We must have enough passion to persevere and persist. But passion and evidence are not enough. A good friend of mine always makes me laugh when he tells me that many ladies who are obese or overweight know this and know the consequences, that is, the evidence. Many of these also desire or long to lose a kilo or twenty But few actually get there. Why? Evidence and desire alone are not enough.
The third factor for making a difference is leadership. We must learn how to lead our own selves, and Africa. This is why I like to write about leadership and commending those who put their efforts in mentoring more people to be nutrition leaders for Africa. If we combine leadership with evidence and passion then we have all the ingredients – which also need to be in the right proportions and mixture – to be effective change agents.
Look out for more on my thoughts on leadership in my next column. I will write about my speech on leadership at the Living Legends Award ceremony during the 2009 International Congress on Nutrition in Bangkok.
Acknowledgement and request
You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.
Please cite as: Annan R [Column] Experiences; treating malnutrition in Uganda, building capacity for grant writing, and other items. Website of the World Public Health Nutrition Association, January 2011. Obtainable at www.wphna.org
The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.
This column is reviewed by Geoffrey Cannon.
Funders of the Namibia workshop were the North West University, Potchefstroom, South Africa), the Global Alliance for Improved Nutrition (GAIN), Sight & Life, and the Nestlé Foundation. Thanks also, to the resource people who reviewed our proposals and provided guidance for improvements. Special thanks to the African Nutrition Leadership Programme, who have seen the need to build enough capacity in Africa in order to address our own issues, through grants for nutrition research and interventions. This is crucial to promoting sustainable health and nutrition well-being, and making our continent strong.