Responding to Malnutrition in Sierra Leone

Every other Friday in Kono District, Sierra Leone, the quiet, serene campus of Wellbody Clinic’s birth waiting home erupts with noise. Women chat. Toddlers squeal. A wood fire crackles. And a metal grinding machine whirs as it blends together buckets of sesame seeds, rice, dried fish, beans, salt, and sugar—creating a highly-nutritious mix to be cooked into a porridge and fed to the crowd of caregivers and their children, who are suffering from malnutrition.

Malnutrition is a daily threat in Sierra Leone, where 76% of people live on less than $3.20 per day and food insecurity is high. The resulting health impacts are devastating and long-term: As a result of poor nutrition and starvation, nearly one-third of children younger than five suffer from stunting, or impaired growth, that can permanently damage cognition and overall physical health.

Since PIH began its work to strengthen Kono’s health system, combating malnutrition has been a priority. In addition to launching the inpatient feeding program at Koidu Government Hospital, which provides intensive care to malnourished children, PIH-supported clinicians established the severe acute malnutrition program at Wellbody to treat and support children on the brink of needing inpatient care.

But these initiatives, while critical, left out children experiencing a specific kind of malnutrition: moderate acute malnutrition. Children with moderate acute malnutrition were classified as sick, but were not considered sick enough to be enrolled in and benefit from the severe acute malnutrition program.

So in 2019, PIH established a new program to catch these kids at risk of falling through the cracks: the moderate acute malnutrition program (MAM). In the years since, that program has been expanding malnutrition treatment, providing support to hundreds of families in Kono each year and ensuring that children have access to the care they need to restore their health.

Now well into its second year, the MAM program has proven prescient, as food insecurity and malnutrition have been on the rise throughout the COVID-19 pandemic. While Sierra Leone has recorded comparatively low rates of COVID-19 infections and deaths, the virus’ ripple effects have, unsurprisingly, proven serious and long-lasting in the country’s context of extreme poverty, few formal safety nets, and already rising food prices.

According to one study, 67% of Sierra Leonean households have seen their incomes decrease from last year, as three-day lockdowns enacted throughout the pandemic caused catastrophic losses for families surviving on daily wages. Relatedly, between June and August of this year, nearly 2 million people—a quarter of the population—fell into the category of severely food insecure.

In the face of this mounting injustice, now, more than ever, equitable malnutrition care is essential. Below, spend an afternoon in Kono at a MAM feeding session and learn how the program works:

Although starving, malnourished children show little interest in food. They also suffer from symptoms like fatigue, limited growth, and a weakened immune system, making other illnesses easier to contract and harder to heal from.

Clinicians at Wellbody screen their pediatric patients for malnutrition by measuring their upper arm circumference and taking their z-score—a comparison between their weight and the weight of a healthy child their same height. Those who meet the criteria of malnutrition are enrolled in the either the severe acute malnutrition or the MAM program. They’re also tested for malaria and respiratory viruses and given amoxicillin, deworming medication, and vitamin A tablets, to ensure the absence of other underlying infections and to boost their immune system.

The MAM program lasts six weeks, by which time the vast majority of toddlers regain their health with feeding support and family nutrition education. In the program’s first year, 61% of children gained weight, with an average weight gain of more than two pounds.

Every two weeks, children and their caregivers in the MAM program gather at the clinic to prepare mass amounts of homemade Bennimix—a blend of entirely local ingredients, provided by PIH, that contain the carbs, protein, calcium, and iodine children need to restore their health and nutrition. The mix is named after the sesame seeds it contains, which are called benni in Krio, the most widely spoken language in Sierra Leone.

To make Bennimix, Wellbody staff and caregivers of enrolled children sift through the ingredients—rice, sesame seeds, fish, beans, iodized salt, and sugar (for taste)—and feed them into a metal grinder to blend them together.

Some of the Bennimix is saved to cook into a porridge that day, as a demonstration for caregivers on how to create these specialized meals at home—from how to measure the ingredients to how long to let the porridge simmer.

“When they go back home, they’re going to apply what we’re teaching them—how to prepare the food, how to cook it properly,” says Mariama Mansaray, a Wellbody Clinic nurse who oversees the nutrition department and leads MAM feeding sessions. “It’s reducing malnutrition across the district, and drastically reducing relapse cases.”

Enough Bennimix is made for every family to take home a two-week supply, ensuring children have the daily nutrients they need to recover.

Mansaray calls caring for children “her calling.”

“Since I was a little girl, I had this vision of taking care of children,” she says. “We have a lot of orphans in the program—referrals from the special care baby unit [at nearby PIH-supported Koidu Government Hospital] and directly from communities of babies who have lost their mothers. I have a special passion for these children since I, too, am an orphan. They say ‘She who knows it, feels it.’”

Mansaray has more kids in her care than ever before. Last year at PIH-supported facilities in Kono, nearly 800 children received treatment for malnutrition, the last step of which is enrollment in the MAM program.

The steady growth of the MAM program is a testament to not only how widespread the problem of malnutrition is in Sierra Leone, but also to the program’s success. Women whose children have been discharged from the program and have regained their health often promote the MAM program to their friends and neighbors—leading to a line of patients actively seeking enrollment.

“When they see this program is very good, that their child is well fed, they go back and bring their neighbors who are going through the same constraints,” says Mansaray.

And the program has served to build community among some of Kono’s most marginalized, isolated people—often, teenage and single mothers.

“She [the mother] will tell you, ‘I don’t have anything. I’m just giving my child glucose powder,’” Mansaray says. “We try to let them know that all is not lost. We, the nurses, are encouraging them, talking to them as equals, receiving them with open arms. They’re happy to be around the other women.”

At the beginning of each session, Mansaray leads a health talk covering early childhood nutrition, including the benefits of breastfeeding, what to add to a child’s diet as she grows older, and how to access ingredients without going to the market, such as through gardening and fishing.

But recognizing that, for many caregivers, it is an extreme lack of material resources—not knowledge—that prevents their child from eating, Mansaray and Wellbody staff take note of each family’s health and economic status and refer the most vulnerable to PIH’s social support program.

Through this additional form of care, families receive money to continue buying the ingredients they’ve learned about, plus clothing, toiletries, and goods to sell for profit, helping them start small trading businesses and get back on their feet financially.

In this way, the MAM program also acts as referral center, connecting families with other forms of support beyond nutrition. Mansaray also often directs young mothers to the adolescent and youth-friendly services clinic at Koidu Government Hospital, where they can get specialized health care as well as educational and career counseling.

By the end of each session, the hustle and bustle of children playing, women cooking, and clinicians teaching calms as everyone comes together for one final activity: eating. Caregivers feed the Bennimix porridge to their children, taking a spoonful for themselves here and there and unlocking the healing power of sharing a meal.