Childhood Malnutrition: An Overview of Pediatric Starvation and Institutional Corruption in Developing Countries
By: Ashley Zhu
Healthy equity in developing countries has introduced a chronically unjust burden to populations in countries consistently associated with extremely high rates of infectious disease and lack of adequate medical care. Poor infrastructure, unclean water, and little food leave them especially vulnerable to the lethality of infectious, non-communicable diseases (Orach, 2009).
Malnutrition – specifically, complicated severe malnutrition (CSM), also known as severe acute malnutrition (SAM) – is one of the most troubling health problems, affecting over 16 million children in low- and middle-income countries (Wen, 2022).
Patients with CSM show a number of clinical danger signs, including infections or inability to sufficiently feed, and are disproportionately located in developing regions. Despite World Health Organization (WHO) guidelines, which lists antibiotics and therapeutic feeding to treat severe malnutrition cases, inpatient mortality of children with CSM ranges from 8 to 25% in African hospitals, indicating that current methods are largely insufficient (Orach, 2009).
Figure 1. Stunting (abnormally low height for a child’s age), wasting (abnormally low weight for a child’s given height), and underweight (abnormally low weight for a child’s given age) are the indices used to measure undernutrition. According to data drawn from the global epidemiology study, undernourished children are heavily concentrated in Africa and Asia, while the Americas and Europe showed the lowest prevalence.
Though inadequate supply of basic macronutrients (i.e. protein, carbohydrates, and fat) is the basic contributor to malnutrition, chronic diseases also play a key role in protein-energy malnutrition – a term that describes the striking imbalance between nutrient supply and bodily requirements (Müller, 2005). Diarrhea-producing illnesses are particularly prevalent in developing countries, causing increased metabolic requirements and decreased nutrient absorption (Müller, 2005). Additionally, loss of subcutaneous fat, which reduces a child’s ability to store water and regulate body temperature, causes rapid dehydration and risk of hypothermia (Müller, 2005). The more deadly manifestations of protein-energy malnutrition cause the degeneration of the liver and heart: when accompanied by edema – deadly buildup of fluid in the body’s tissues – severe malnutrition can lead to cardiac failure (Müller, 2005).
In particular, children are vulnerable to post-discharge mortality (PDM), which affects developing countries almost as acutely as in-patient deaths. Malnutrition-related variables, such as clinically diagnosed malnutrition and low mid-upper arm circumference (MUAC), were the strongest predictors of PDM (Nemetchek, 2022). Furthermore, children who died in the following post-discharge period showed evidence of elevated inflammatory and endothelial cellular responses, suggesting undetected exposure to bacterial products when clinically judged to be stable (Njunge, 2022). A study that examined children from four Kenyan towns showed that, in addition to heightened inflammation, children with SAM showed deranged metabolism – for example, abnormal levels of the hormone leptin, which plays a key role in immune homeostasis, directly associated with mortality (Njunge, 2022).
The ever-present issue of malnutrition as it relates to childhood mortality exposes the insufficiency of current global health initiatives. Not only are medical facilities in developing countries severely lacking in resources, but their health systems are also extremely corrupt and tend to intensify the poverty experienced by lower classes (Orach, 2009). An estimated $455 billion out of the $7.35 trillion spent on global health care annually is lost to fraud and corruption, and more than 140,000 annual deaths in children under the age of five can be traced to corruption (National Academies of Sciences, Engineering, and Medicine, 2018). A 2012 study surveyed a cohort of Ugandan participants, who shared their perspectives on the fraudulent behaviors of the healthcare sector. They reported misappropriation of funds – both government funds and grants from donor agencies – as well as lack of transparency and accountability in government policy decisions (Bouchard, 2012). Additionally, theft and resale of drugs and medical equipment has left many doctors depleted of supplies, making it very difficult to affordably treat patients (Bouchard, 2012).
Figure 2. The flowchart from the Journal of the Pakistan Medical Association demonstrates interplay between public and private institutions, ultimately showing how different forms of corruption lead to the ruin of a country’s healthcare systems.
Increased transparency has shown to improve reform efforts in many cases. Transparency in medical supply pricing resulted in a 50 percent decline in price variation across hospitals, and reference pricing for pharmaceuticals in Ukraine addressed the collusion that had resulted in an annual loss of $100 million out of their $250 million budget (National Academies of Sciences, Engineering, and Medicine, 2018). Furthermore, theft and bribery have been shown to decrease when medical professionals are paid wages that are proportional to their education and training: this would require better innovation and allocation of each country’s healthcare budget, like using profits from private surgeries to raise funds for public services (Bouchard, 2012). With so many deaths occurring after discharge and continued hospitalization of CSM patients, it is critical that effective interventions are developed to reduce corruption and address the neglected causes of childhood mortality.
References
Wen, B., Njunge, J. M., Bourdon, C., Gonzales, G.B., Gichuki, B.M., Lee, D., Wishart, D.S., Ngari, M., Chimwezi, E., Thitiri, J., Mwalekwa, L., Voskuijl, W., Berkley, J.A., Bandsma, R.H. (2022). Systemic inflammation and metabolic disturbances underlie inpatient mortality among ill children with severe malnutrition. Science Advances, 8(7). American Association for the Advancement of Science. Retrieved February 24, 2022, from https://www.science.org/doi/10.1126/sciadv.abj6779
Njunge, J. M., Gwela, A., Kibinge, N. K., Ngari, M., Nyamako, L., Nyatichi, E., Thitiri, J., Gonzales, G. B., Bandsma, R., Walson, J. L., Gitau, E. N., & Berkley, J. A. (2019). Biomarkers of post-discharge mortality among children with complicated severe acute malnutrition. Scientific reports, 9(1), 5981. Retrieved February 23, 2022, from https://doi.org/10.1038/s41598-019-42436-y.
Orach C. G. (2009). Health equity: challenges in low income countries. African health sciences, 9(Suppl 2), S49–S51. Makerere University Medical School. Retrieved February 23, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877288/#R8
Nemetchek, B., English, L., Kissoon, Niranjan, Ansermino, J.M., Moschovis, P.P., Kabakyenga, J., Fowler-Kerry, S., Kumbakumba, E., Weins, M.O. (2018). Paediatric postdischarge mortality in developing countries: a systematic review. BMJ Open, 8(12). BMJ. Retrieved February 24, 2022, from https://bmjopen.bmj.com/content/8/12/e023445.info
Müller, O., Krawinkel, M. (2005). Malnutrition and health in developing countries. Canadian Medical Association Journal, 173(3), 279–286. CMAJ. Retrieved March 8, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1180662/?report=classic
Bouchard, M., Kohler, J. C., Orbinski, J., & Howard, A. (2012). Corruption in the health care sector: A barrier to access of orthopaedic care and medical devices in Uganda. BMC international health and human rights, 12, 5. https://doi.org/10.1186/1472-698X-12-5
National Academies of Sciences, Engineering, and Medicine. (2018). The Critical Health Impacts of Corruption. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25152.
Images
Ssentongo, P., Ssentongo, A.E., Ba, D.M., Ericson, J.E., Na, M., Gao, X., Fronterre, C., Chinchilli, V.M., Schiff, S.J. (2021). Global, regional and national epidemiology and prevalence of child stunting, wasting and underweight in low- and middle-income countries, 2006–2018. Scientific Reports. Springer Nature. Retrieved March 10, 2022, from https://doi.org/10.1038/s41598-021-84302-w
National Academies of Sciences, Engineering, and Medicine. (2018). The Critical Health Impacts of Corruption. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25152.
