by Emily Esmaili
The Ministry of Health of Rwanda recognizes the persistent problem of child malnutrition and its contribution to child morbidity and mortality. As such, it has put into place the National Food and Nutrition Strategic Plan (2013-2018), which aims to eliminate malnutrition in every district in the country. Huye District (Butare) is one with higher levels of poverty and food scarcity than other districts: The Integrated Household Living Conditions Survey (EICV4) carried out in 2013-2014 indicates that Huye district is 8th poorest among the 30 districts in the country (with 32.5% of the population considered as ‘poor’ and 5.7% as ‘extremely poor’). Along with widespread poverty, Huye has exceptionally high rates of child malnutrition and stunting as compared with other districts. It happens that this district also houses the country’s largest university and medical school, as well as one of the largest teaching hospitals.
Centre Hospitalier Universitaire de Butare (CHUB) is the main referral hospital for southern and western districts in Rwanda, as well as one of the two main teaching hospitals in Rwanda. I was stationed at CHUB from February 2014—August 2015, working as Pediatrics Faculty with Yale University and Rwanda Ministry of Health, through a program called Human Resources for Health. Due to the aforementioned high rates of poverty in our catchment area, the majority of our patients were not only malnourished, but also could not afford sufficient food during their hospitalization, which (predictably) hindered their ability to recover and cope with their illnesses. Despite providing the best medical care we could, patients could not meet basic daily nutritional requirements and therefore often had prolonged hospitalizations and difficult hospital experiences.
Children are especially vulnerable to the long-term impacts of malnutrition. Poor neurodevelopmental outcomes are closely linked to early nutrition—starting in the womb. On our wards, manifestations of malnutrition ranged from frustratingly slow recovery from basic childhood illnesses such as pneumonia, to more chronic cases of rickets, to wasting in premature babies from inadequate breast milk (because mothers were themselves too malnourished to produce milk, and could not afford formula). Treating children, and teaching students and residents about pediatric medicine, was exceptionally challenging when such basic needs were not being met.
Overview, Goals, and Objectives
In response to this dire situation, we developed a nutrition program to address nutritional needs in a comprehensive and sustainable way, through a program originally called Farming for Child Health (F4CH). This multi-component program involves providing food for malnourished pediatric patients, breastfeeding mothers, and now surgery patients as well; growing crops and livestock to supply some of the food; and family education about sustainable farming, hygienic food preparation, and healthy, affordable nutrition. The program officially began in May 2015, and owing to its huge success, is now expanding to include patients in Internal Medicine and Obstetrics and Gynecology wards as well. Our ultimate goal is to replicate the program in hospitals throughout Rwanda, pushing towards the goal of eliminating malnutrition through education and self-sustainable agriculture.
F4CH quickly grew into a larger organization, now called Kuzamura Ubuzima (KU), or “Growing Health.” We have partnered with a local NGO, Agaseke k’Urukundo, who farms a large portion of the land surrounding the hospital. The Director General of the hospital granted us ample land to start planting our crops, in partnership with Agaseke. We selected seeds for foods with the highest nutritional value and local availability for cultivation, emphasizing dietary diversity as much as possible. For livestock, we began with pigs, who could recycle the kitchen scraps, produce manure for fertilization, and be sold for additional income—and perhaps eventually supply manure for biofuel as well. In the next few weeks, we plan to bring in dairy goats, which each produce up to 3 liters of nutritious milk, with much less upkeep than cows.
In the hospital’s on-site wood-fueled kitchen, our cook (with the assistance of patients’ families) prepares two meals per day largely from the farm yields: one meal of high-energy porridge (Sosoma, comprised of soy, sorghum, and maize), and one well-balanced lunch (including vegetables, greens, protein, starch, and fats). A typical meal includes rice or potatoes mixed with tomatoes, carrots, onions, peanut powder, and small dried fish; a green leafy vegetable; a boiled egg; an avocado, and a banana. Food staples such as rice, salt, oil, etc. are purchased from local markets.
Beneficiaries are identified by nurses and our project manager, as those with the highest degree of food scarcity. Narrowing the list of those in most need is the project’s most difficult task. We currently feed 30 pediatric patients and 40 surgery patients, and will soon include Internal Medicine and Obstetrics and Gynecology patients as well. We soon plan to conduct a baseline survey to assess the prevalence of food scarcity and malnutrition among hospitalized patients, as well as the impact of hunger upon hospital length of stay. We also plan to conduct ongoing surveys for monitoring, evaluation, and program adjustment as needed.
We have partnered with a Kigali-based NGO called Gardens For Health International (http://www.gardensforhealth.org/) as well as the Catholic University of Rwanda School of Public Health and Human Nutrition, to assist with nutrition education and teaching demonstrations, emphasizing hygienic and nutritious food preparation. In addition, BIOCOOP Rwanda (http://www.biocoop.rw/) supports our agriculture and “farm to fork” activities. We have also partnered with Veterinarians Without Borders (http://vsf-belgium.org) for technical support on best livestock practices. We hope that through these partnerships, patients and families can engage in experiential learning activities to encourage healthy eating and sustainable family farming. Ultimately, we hope to foster long-term behavior change and improved well-being overall.
While initially dependent on private donations, the ultimate goal is for surplus crop and livestock production to generate enough income to meet the costs of farm and program maintenance. Eventually, we hope the farm will be able to feed patients with minimal financial input. Until we reach this goal of self-sustainability, our operating expenses run entirely on donation.
Though still in its nascency, KU has relieved the hunger of numerous patients. Children have been recovering from their illnesses and getting discharged home more quickly, and mothers have once again been able to produce breast milk. Caretakers no longer have to choose between buying medications and buying food. Families and hospital staff have been able to watch the seamless flow from cultivation, to preparation, to proportioning of whole, nutritious foods, meeting a very basic—and vital—need. Many of these successes are owed entirely to team on the ground—especially our Program Coordinator. While her skills range from orchestrating and meticulously documenting all program activities, to rearing piglets and growing mushrooms, the job is quickly growing too large for one person to manage. We are seeking more managerial support as the project continues to expand and flourish.
It was completely gratifying to watch our seedlings grow into food on patients’ plates, and to see a simple warm meal transform a listless child into a lively one. However, what would be even more gratifying would be to know that this modest project, in this one corner of the world, has sown seeds for an enduring solution to hunger in our hospital—and perhaps in other hospitals like ours. We hope that Kuzamura Ubuzima continues to grow, flourish, and thrive—along with the patients it will feed.