November 2003 Issue 20

•• MicrofinanceMicrofinance ProjectProject inin RwandaRwanda •• ThiamineThiamine DeficiencyDeficiency inin AngolaAngola •• DestitutionDestitution inin EthiopianEthiopian HighlandsHighlands •• HiddenHidden FamineFamine inin MadagascarMadagascar Editorial contents I stood perplexed in the bomb blasted question aspects of current guidelines. This Field Articles shell of what had previously functioned as may be done in order to ensure there is con- sensus between guidelines, out of a legiti- Lessons From a Microfinance the regional children’s hospital in Somalia’s 3 capital, Mogadishu. It was 1991, Somalia mate concern that those in the field will be Pilot Project in Rwanda. was a country gripped by the most brutal of confused if there is more than one message. 18 Border Closures and Nutrition in civil wars. Benadir Hospital, Mogadishu Whatever the reason, I believe Field Gaza. acted as a therapeutic feeding centre for mal- Exchange has a responsibility to report inde- • Postscript: Malnutrition on nourished children. I had just been presen- pendently, encourage debate and advance. This is not always easy and there have been Political Grounds. ted with a new admission, a tiny and mal- nourished infant of about two months of age several occasions where the ENN has come 22 Targeted Food Distribution to - Zenab I think her name was. Apparently under considerable pressure not to publish Women and Children in Northern her mother was severely injured and figh- what was seen as controversial debate or Afganistan. ting for her life in another hospital in the sensitive information. 26 Suspected Thiamine Deficiency city, after the family home had been hit by a Readers of Field Exchange will also be in Angola. shell. Zenab was accompanied by a young aunt who had no children of her own. I aware of the lack of unanimous guidance on remember feeling ill-equipped to deal with supporting safe infant feeding strategies in 5 Research Zenab or others like her. She fell outside the emergency affected areas, where bottle and standard guidelines for the treatment of mixed feeding is common. This situation • Comparison of the efficancy of a severe malnutrition that we had established may partly reflect the blind adherence to solid ready-to-use food and a in the centre. She was ‘supposed’ to be bre- ‘dogma’ and the fear that recommending liquid, milk based diet in treating astfed and therefore protected from malnu- anything other than breastfeeding will open severe malnutrition. trition. But clearly breastfeeding was not an the flood gates for the formula industry who • Infant formula distribution in option here. There were not many like will then go on to win ‘the battle against the Zenab at the time in Mogadishu but there breast’. The assessment findings on infant northern Iraq. were some. I remember the correct, but not feeding in Iraq (page 6) highlight how, for • postscript: Infant formula very helpful, public health message ‘breast political reasons, formula milk is part of the distribution in northern Iraq, is best’ resounding in my ears. Everything I general ration distribution. Though this con- By WFP. had learned told me that to buy formula travenes best practice and negatively • What triggers humanitarian (even if it was available) for this infant was influences the prevalence of breastfeeding, not the right thing to do. I also remember there is a lack of clear practical guidance on Intervention? thinking ‘how come I don’t know what to do appropriate interventions in such a context. • Destitution in Ethiopia’s with this case – someone somewhere must Northeastern Highlands. have been in this situation before and what The experience contrasts with recent fin- • Famine Avoided Despite Drought did they do?' dings from Uganda (page 15), where HIV- and ‘Zud’ in Mongolia positive mothers whom, after counselling, Field Exchange was established to help chose to use formula were not able to access • Government versus NGO field workers like me in similar situations. the commodity. Both situations leave a lot to efficiency, Bangladesh. By providing a forum for sharing field expe- be desired if safe and appropriate infant fee- • Women’s Contributions to riences, the hope was that Field Exchange ding is to be achieved. Some agencies and Reducing Micronutrient would allow challenges and lessons to be institutions are working on this issue but Deficiencies. captured rather than lost and that guidelines more research is required. I commend the would, as a result, become more contempo- interagency ‘core group on infant feeding in • Hidden Famine in Madagascar. rary and better reflect the field reality. It was emergencies’ for their strident efforts to • Implementation of WHO also hoped that a publication like Field develop practical guidance for field practice Guidelines on the Management Exchange would help expose ‘experts’ and in this area. of Severe Malnutrition in South researchers to greater field reality. Africa and Ghana. In the absence of conclusive research, the Twelve years on and much has changed. sharing of programmatic experience is vital. 13 News & Views Significant advances have been made in the Field workers need to ‘keep it real’, write in food and nutrition sector of emergency res- and describe the actual problems which are • VitaGoat. ponse. Field Exchange has attempted to being encountered and the measures taken to overcome these, so that appropriate gui- • Antiretroviral Therapy and keep its audience up to date. However, there are still many areas where there is inconclu- dance can follow. Technical experts need to Nutrition. sive research and where there is insufficient be open to debate and allow field experience • Justwrite. consensus and guidance. For example, in to influence guidance and policy. They need • Local production of Plumpy’nut. spite of all the advances in the management to be pragmatic and develop guidelines for • Training course on ageing in of severe malnutrition as well as in thera- situations which actually occur e.g. where breastfeeding is not an option. More than Africa. peutic foods, consensus among experts on how to manage young severely malnouris- anything, child well being should be the • New FAO/WHO manual on living hed infants has yet to be achieved (see focus of efforts to improve practice. well with HIV/AIDS. Debate on the Management of Severe • Facing up to the storm. Malnutrition, page 16). So what happened to Zenab? The fact is • INASP Health Directory I made the best of a difficult situation – something field workers often have to do. I 2003/2004. There are also times when the need to demonstrate consensus seems to stifle scoured through the limited resources avai- • HIV-positive mothers in Uganda debate and advance. It appears that in some lable to me, mainly from Oxfam feeding kits return to breastfeeding. situations, ‘experts’ would rather ignore or what hadn’t been looted from the agenc- • Caring for Severely Malnourished field experiences (that often fail to meet rigo- y’s office and eventually found a ‘home- Children: book review. rous research design standards due to the made BMS recipe’. Zaneb survived, mainly emergency context) which may call into as a result of the care provided by her aunt, • Debate on the Management of but did not grow very well. Today I would Severe Malnutrition. manage cases like this differently, thanks to • Debate on the Management of the guidelines that have been produced and Severe Malnutrition: A Response work done in this area resulting largely from the sharing of field experiences. Don Redding 18 Letters As this is my last issue of Field Exchange as ENN director, I would like to thank the 20 Evaluation Interagency Group of Nutritionists responsi- • MSF Holland in Afghanistan. ble for conceiving of the ENN and suppor- ting it’s work over the years. I wish Marie 25 Agency Profile Mc Grath and Jeremy Shoham every success in continuing the ENN and Field Exchange. • Terre des hommes. Fiona O’Reilly 29 People in Aid Mother with malnourished childern in Benadir Hospital, Mogadishu, Somalia, 1991

2 Field Article Lessons From a Microfinance Pilot Project in Rwanda

By Tamsin Wilson Concern. Rwanda Townsend, Steve

Mugina market Tamsin Wilson is an independent microfinance consultant. She co- place which is ordinated Concern Worldwide’s qualitative research on microfi- transformed into a nance in Angola, Mozambique, Rwanda and Cambodia, and now place of great acti- provides technical support to the Rwandan microfinance pro- vity on the weekly gramme. market day The contribution of Concern Worldwide in producing this article is gratefully acknowledged. This article describes Concern Worldwide’s experiences in develo- ping and managing an innovative microfinance project, Abazamukana 1 , in Rwanda.

One of the legacies of conflict in Rwanda is poorer social cohesion. A bicycle repairer As a result micro-finance initiatives have not fared well. The type in Mugina market of micro-finance project described below relies more on individual who is working with his third loan participation than traditional models and has therefore proved to from be a valuable tool in addressing post-emergency food insecurity. Abazamukana Steve Townsend, Concern. Rwanda (Ed)

n 2001, Concern initiated a 3-year action an over-emphasis on credit at the expense of gravely damaged by the genocide. It created research project on microfinance, funded by savings and other services. many sub-divided groups in Rwandan society the Department for International and reduced the prevalence of traditional practi- Development-UK, and involving qualitative History of microfinance in Rwanda ces like gift giving, exchange, mutual assistance, Iresearch in Angola, Cambodia, Mozambique and Rwanda today is a relatively peaceful and sta- collective action and protection of the vulnera- Rwanda. Informed by the findings of this four- ble country. Although people are very poor, rural ble. Individuals are less open to joining microfi- country study2, since 2002 Concern has been sup- markets are dynamic and organised and attract nance groups when social capital remains so porting the development of an innovative micro- buyers and sellers from urban as well as rural seriously damaged. finance service, Abazamukana, in Rwanda, areas. There has been very little restriction placed 3 which was recently evaluation . on microfinance organisations (MFOs) by the Project planning government of Rwanda and overall, this has pro- Complementing the findings of the four- Microfinance in conflict bably encouraged more non-governmental orga- country research in 2001, the Abazamukana Our knowledge of how, and indeed if, microfi- nisations (NGOs) to get involved in microfinance intervention was also developed using market nance can work in war-affected environments than if there were exacting regulation. Despite research in Rwanda. As well as identifying a has, until the end of the 1990’s, been very limited. what appears to be a fairly enabling environ- high population density (>300 persons /sq km), In the past, microfinance in war-affected coun- ment, however, only 0.3% of the population have this preparatory market research provided a cri- tries has often consisted of short-term, poorly access to NGO microfinance services. With little tical insight into the market environment, in par- planned, rushed interventions by organisations competition and the highest population density ticular: under pressure to disburse funds quickly, using in Africa, why has the entire NGO sector only staff that has no expertise in microfinance. attracted, on average, 2,900 clients per year since • Clients disliked travelling to, and spending Clients have been provided with relatively large 1994? There are, of course, many causes but there time in, group meetings and were willing to pay loans for long loan periods, to inject capital into are two particularly important constraints to more for an individualised service. the household economic activities. microfinance. First, skills and education levels • The majority (83%) of potential clients were Unfortunately, these strategies and tactics have are very low, with 91% of the workforce engaged willing to pay at least 5% interest per month on generally proved inappropriate, resulting in inef- in agriculture, 80% of secondary teachers unqua- individual short-term loans (but individual loans fective lending mechanisms, over-indebtedness lified and less than one-half of civil servants with were costly and risky to provide). of clients, poor repayment rates (significantly secondary education. Without skills, it is difficult • Clients appeared to have less respect for NGO less than 98%), and low outreach. This has been to make use of financial services and without ski- managed microfinance initiatives following the partly due to diversion of loans to wealthier or lled microfinance staff, it is difficult to rapidly post-war emergency relief years, when loans more powerful members of the community, and expand a MFO. Secondly, social capital has been were disbursed but not collected.

What is microfinance? Microfinance is the provision of banking services such as savings, credit and money transfer to poorer people who cannot access ordinary mainstream banking services. Microfinance can be provided by specialist microfinance organisations (MFOs), by banks that downscale to reach the poor, by moneylenders, Credit Unions and by community-based organisations. Post-con-

Steve Townsend, Concern. Rwanda Townsend, Steve flict microfinance sits on the edge of the mainstream microfi- nance sphere but it should not be considered a separate disci- pline.

3 Field Article

• Clients needed to respond immediately to business opportunities and could not wait a long Strengths Weaknesses time for loans to be approved. • Many clients disliked the conventional arran- Clients like the individual loan and savings pro- Repayment rates fell sharply when there were gement whereby all members of a group gua- ducts. In the first nine months, 1,000 people delays in getting the motorbikes for credit ranteed the loan of a fellow member, and were became clients of Abazamukana. agents and the organisation continued to dis- required to repay the loan if the borrower could burse loans without any means of following up not. repayment. • Clients could not afford the minimum savings balances and collateral requirement of the local Repayment rates improved when the loan gua- The initial loan guarantee, consisting of charac- Credit Union. rantee was developed to include 20% of the ter assessment and social pressure applied by The weekly market was the focal point for loan deposited in the savings account prior to local committees, was not a large enough thousands of local and city buyers and sellers, loan disbursal, and a personal guarantee from incentive for clients to repay and would be a good location for a branch for a close family member. cash transactions. Even though this is a pilot project, Abazamukana remains closely connected and Project design Abazamukana was designed as if it were totally dependent upon Concern. It was unsuc- The design of Abazamukana and its products necessary for the organisation to become self- cessful in distancing itself from Concern pro- responded directly to the results of the market sufficient. This has had a positive influence on bably because Concern vehicles are used for research. The poor image of NGOs in the area, the attitude of credit agents and cashiers, and transport, expatriate staff visit the project and who were well known for giving loans and not on strategic decisions made by management. for some time, the Concern logo appeared on collecting repayments effectively, alerted the client passbooks. Concern to the need to present Abazamukana differently to its predecessors. One approach Clients prefer to have credit agents visiting Clients do not deposit large amounts of savings would have been to create a wholly community them in their houses rather than them atten- in their accounts because they are scared that owned and managed MFO, with little outside ding group meetings. In a recent satisfaction the NGO Concern, like its predecessors, will involvement. However, the approach chosen by survey, the majority of clients stated that one day leave and there is a chance that they Concern was to present Abazamukana as a per- Abazamukana’s loan was the cheapest in the might not get their savings back. manent, professional and commercial banking area despite the fact that based on interest service provider for poorer people. It rented an rate alone, it is the most expensive. Their office in the market place, with a shop front very analysis of the cost included non-financial costs like travel to meetings, attendance at like others in the area, and aimed to project a meetings, and time spent waiting for loan serious, professional image. approval. Abazamukana’s first branch was established in the busy market square, offering innovative and Situating the branch in the busy market square Short-term loans at high interest rates work flexible loan and saving products for indivi- has meant that Abazamukana catches a lot of well until clients delay repayments and the duals, rather than groups. Clients could deposit ‘passing trade’, especially on market days. interest due builds up to un-manageable pro- money in their savings account and withdraw portions. money as frequently as they needed, simply by visiting the branch. Loans were made available The loan product is perceived to be for the The savings product is perceived to be for for short periods of a few weeks or months and poorest. richer people as there is a mistaken impression repayment was normally weekly. that the poor can’t save. In other countries it has been proven that even beggars can save. As there were no group meetings, the organi- sation depended heavily on the credit agents By hiring an accountant, Abazamukana has Some people, including a few community lea- who made several visits to every client in their been able to develop transparent accounting ders, have taken loans without any intention of own home, to build up a good relationship and systems. repaying. Furthermore, they have actively mutual understanding before the first loan was encouraged others not to repay the so-called disbursed. Because the credit agent and the ‘American money.’ branch manager approved loans, rather than a committee, clients normally knew in less than a Motorbikes, rather than 4x4 vehicles, are the By not actively targeting women, the microfi- week if their loan application had been success- most appropriate means of transport for the nance service was used more by men. Of the ful. Repeat clients with excellent repayment MFO as they keep costs low and suggest that few people that hadn’t made a single on-time records over the previous three loan cycles this isn’t a ‘normal’ NGO project. loan repayment, 70% were men, whereas of simply went to the branch and could immedia- those with a 95% repayment rate, or better, tely obtain a repeat loan of the same size as the 70% were women. last. Instead of group-based collateral, loans were guaranteed by a combination of 20% savings and a personal guarantee from a close family member who became responsible for the loan in case of default. The credit agents did not carry any cash. Clients called in person at the branch to make all cash transactions, which meant that credit agents were not a target for theft when they tra- velled in the communities. Credit agents sub- mitted completed loan applications to the branch and a separate cashier disbursed loans to the client.

The more flexible loan product saved time for Concern. Rwanda Townsend, Steve the client but was more expensive for Abazamukana to provide. Therefore, the loan interest rate (of normally less than four months) was much higher than other MFOs in the area. For the first two loan cycles, 10% interest per month was charged. For subsequent loans, with client credit record established, the interest rate dropped to 5% interest per month. In contrast, the savings product did not create any income for Abazamukana, and therefore did not attract any interest. In the event that Abazamukana becomes a regulated MFO in the future, there is good potential to on-lend funds held, thus allo- wing savings interest to be paid.

Meat seller in Mugina market who has taken two loans from Abazamukana.

4 Research

Strengths and weaknesses In general, where Abazamukana strayed from the basic principles that underpin micro- finance it has experienced problems, and where it has adhered to them it has been suc- cessful. The greatest challenge has been crea- Comparison of the Efficacy of a Solid ting the conditions for clients to wish to repay their individual loan, in the absence of the Ready-to-Use Food and a Liquid, Milk- tried and tested group guarantee mechanism. A combination of factors have been emplo- Based Diet in Treating Severe yed, including the alternative guarantee mechanism (20% compulsory savings and a Malnutrition personal guarantee), good education and Summary of published research1 close follow-up by staff, easy access to future loans if the last ones have been repaid, and the organisation projecting the image of a serious and permanent microfinance provider.

Lessons learned he World Health Organisation (WHO) the most wasted children (p< 0.05). • The average duration of rehabilitation was 13.4 Poor people will pay market rates of interest recommends a liquid, milk-based diet (F100) during the rehabilitation phase of days (95% CI: 12.1, 14.7) in the RTUF group and for a service that they value, and the cost of 17.3 days (95% CI: 15.6, 19.0) in the F100 group the savings or credit product is less important the treatment of severe malnutrition. THowever, a dry, solid, ready-to-use food (RTUF) (p<0.001). than its accessibility and convenience. Time is a precious commodity to poor people and that can be eaten without adding water, thus eli- minating the risk of water-sourced bacterial con- These results suggest that RTUF, given in a they will pay more for a product that saves supervised setting, is superior to F100 in promo- them time. Charging market rates of interest tamination, has recently been developed. This food is obtained by replacing part of the dried ting weight gain during the rehabilitation phase helps to create a microfinance service that can of the management of severe malnutrition. The grow over time to help more people. skim milk used in the F100 formula with peanut butter. RTUF is at least as well accepted by chil- authors of the study recommend that further dren as is F100, and its availability has raised the work be undertaken to measure the effectiveness Individual loans can work, especially in (in terms of weight gain) of RTUFs consumed at areas where social capital has been eroded, possibility of treating severely malnourished cases in the community. However, since the effi- home. Weight gain at home is likely to be lower but they are more risky than group-based than that in a controlled setting since the RTUF loans. They require a combination of suppor- cacy of RTUF has never been tested in a contro- lled trial, its recommendation for extensive use might be shared with siblings and will be consu- ting factors, including close follow-up of late med with less supervision. Yet, achieving a rapid payers the day after their repayment falls due, in the community might be premature. The objective of a recent study in Senegal was to weight gain is not as important at home as it is in an effective alternative guarantee, support of a residential treatment unit, for economic, social, community leaders and the incentive of compare the efficacy of RTUF and F100 in pro- moting weight gain in malnourished children. and familial reasons. Also, the lower risk of cross future loans to encourage repayment. infection from other children in a family setting The open-labelled, randomised trial took place makes a rapid recovery less important. A lower Good personnel are the single most impor- weight gain seems acceptable during home- tant factor influencing the success of an MFO. in a therapeutic feeding centre attached to a cli- nic2 in Dakar, Senegal, that is attended by poor based treatment; even so, the weight gain obser- Although staff are difficult to recruit in war- ved in the current study was over ten times the affected areas, an MFO like Abazamukana families. Recruitment and follow-up were con- ducted between March and September 2001, the weight gain of well-nourished children of the should have a professional microfinance same age. manager and a professional accountant. peak season for malnutrition. Eligible children Without this, the chances of success are signi- were identified by the study physician, based on anthropometric criteria. The authors reflect that if effectiveness studies ficantly diminished. of RTUF and of its locally produced equivalents in a community setting yield positive results, the Sustainability should be planned from the A total of 70 severely malnourished Senegalese children, aged between 6 and 36 months, were widespread use of these foods could change the beginning. Whereas it is normally expected way we treat severe malnutrition. that MFOs will achieve self-sufficiency in 5-7 selected. Each was randomly allocated to receive years, it may take a few years longer in harsh three meals containing either F100 (n = 35) or post-conflict environments. In the interest of RTUF (n = 35), in addition to the local diet. Most sustainability, some necessary decisions may of the children (27 in F100 group, 29 in the RTUF 1El Hadji Issakha Diop, Nicole Idohou Dossou, Marie be unpopular with clients – it is impossible to group) were fed by their mothers, while the Madeleine Ndour, André Briend, and Salimata Wade meet all demands. remainder (n=14) were fed by another member (2003). Comparison of the efficacy of a solid ready-to-use of the family. All efforts were made to have chil- food and a liquid, milk-based diet for the rehabilitation of In-depth market research should be conduc- dren fed ad libitum. Breastfed children were severely malnourished children: a randomised trial. Am J ted before the MFO is designed, since war- offered their meals after being breastfed. Clin Nutr 2003;78:302–7. affected situations are quite different to places 2 Dispensaire Saint Martin, Rebeuss, Dakar, Sénégal where microfinance is normally found. Data from 30 children in each group were avai- 3 Conversion of kJ to kcal: kJ x 0.2388 = kcal However, while microfinance products must lable for analysis. The main findings were: • The mean daily energy intake in the RTUF be adapted to their environment, they should 3 always adhere to basic microfinance princi- group was 808 ± 280 kJ /kg/day (95% CI: 703.8, ples. 912.9) and in the F100 group was 573 ± 201 kJ /kg /day (95% CI: 497.9, 648.7, p<0.001). Poorer people need encouragement and • The average weight gains in the RTUF and incentives to believe that they should be put- F100 groups were 15.6 g/kg/d (95% CI: 13.4, ting away a few coins a week as savings. They 17.8) and 10.1g/kg/d (95% CI: 8.7, 11.4), respec- also need to believe that their money is safe. If tively (p<0.001). NGOs do not have a background and techni- • The difference in weight gain was greater in cal expertise in microfinance and a commit- ment to remaining in emergency relief coun- El Hadji Issakha Diop tries in the medium to long term to support the microfinance services that they have esta- blished, they should not become involved in microfinance operations.

For further information, contact Tamsin Wilson on email: Tamsinwilson@btopen- world.com

1‘Abazamukana' is Kinyarwandan for ‘Slowly, slowly, we progress together’ 2Wilson, T. (2002) Microfinance during and after armed conflict: Lessons from Angola, Cambodia, Mozambique and Rwanda. http://www.postconflictmicrofinance.org Kwashiorkor case, before and after management using RUTF (oedema resolved). Nutritional 3Wilson, T. and Kidney, I. (2003) Concern Worldwide Rehabilitation Centre (Dispensaire Saint Martin), Senegal 2001 Rwanda: Abazamukana Mid-term Review Report. Internal document.

5 Research

inputs and improved local economy. A UNICEF study in NI (2002)9 revealed that The current distribution of the general ration is 51.1% of doctors and health staff have not yet scheduled to continue until November 22,20033 . heard about the concept of exclusive breastfee- One general ration supplies about 2200 kcal per ding. person per day and is usually distributed on a monthly basis (a 3-monthly food ration was dis- Recommendations Infant Formula tributed before the war started). For the last tri- The following recommendations were made mester of pregnancy and the first four months as a result of the assessment: Distribution in after delivery, a woman receives an additional ration of 1 kg sugar (from WFP)4 and High The untargeted distribution of infant formula is Protein Biscuits (from UNICEF). A family with inappropriate. Strategies to protect and support Northern Iraq an infant below 1 year of age receives an additio- breastfeeding are urgently required. Breast milk Summary of assessment1 nal ration of 3.6kg infant formula (8 tins per substitutes should only be distributed to infants month), 0.9 kg complementary infant food, 1 bar where the individual need is specifically establis- of soap and 0.5kg detergents. hed. The current system is, undoubtedly, contri- buting to infant morbidity and malnutrition Veronika Scherbaum Infant formula distribution rates, in a region ill equipped to deal with the Since 1997, the distribution of infant formula consequences. in NI has increased from 1.8 kg to 3.6 kg per month. A recent survey in NI found a high per- centage of bottle-fed infants (64%), ranging Worryingly, plans to meet infant feeding needs from 51% (0-2 months) to 69% (9-11 months), after November 2003 are not confirmed. A new and representing a 25-30% increase since food distribution system, targeting vulnerable August 1996 5. Correspondingly, exclusive breas- groups according to predefined social/health tfeeding rates were low, at 7% for infants aged and nutrition-related criteria such as young chil- 0-6 months. Between 6 and 9 months, just over dren, pregnant and breastfeeding mothers, half (53.4%) of infants received complementary elderly and disabled people is needed, rather food in addition to breastfeeding, despite their than a blanket distribution of food to the whole inclusion in the ration (currently 0.9 kg/month). population. The most commonly reported health problems were diarrhoea and acute respiratory infections6. Training of medical personnel is urgently nee- ded in promotion of exclusive breastfeeding and According to information from beneficiaries, the management of severe malnutrition. the current distribution system is inadequate. Infant formula No. 1 (suitable from birth to 6 For further information, contact: Dr. Veronika months), No. 2 (follow-on formula, six months Scherbaum, email: [email protected], onwards) and Cerelac (a commercial weaning or Mrs. Sabine Wartha, Caritas Austria, email: food) are given on a monthly basis to each infant [email protected], or Geke Verspui, during the first year of life, sometimes irrespec- Cordaid, email: [email protected] tive of his/her age7. The instructions on the infant formula are written in English and Arabic only and not in Kurdish language, even then 51% of the women in NI are illiterate. No ackno- Mother breastfeeding, Northern Iraq, 2003 wledgement or advice is given on the use of dif- ferent formula by age - if mothers have no kno- wledge about this difference in the composition of breast milk substitutes, or have no possibility to exchange the tins with relatives or neighbours, infant feeding is very likely to be greatly inade- quate.

The presence of infant formula in the food bas- ket continues to discourage mothers from breas- tfeeding. In addition, it is frequently mixed with etween 19th June and 12th July, 2003, a unclean water, available in limited quantities nutrition and mother and child health and handled under extremely hot conditions. eronika Scherbaum assessment was carried out in Northern Consequently, bottle-feeding coupled with V Iraq (NI), commissioned by Caritas inadequate water and sanitation facilities is a Returnees in a rural area of Dibaga sub-district BAustria and Cordaid Netherlands. Focusing on major contributing factor to infant malnutrition, in Erbil governorate, Northern Iraq, 2003 the needs of those in the Kirkuk and Mosul areas morbidity and mortality, especially for those (both internally displaced people (IDP) and living in remote areas where there is limited returnees), the objectives of the consultancy access to medical facilities. included an assessment of the situation of the local hospitals and the health centres in terms of Reports of health institutions suggested an coverage and treatment of malnourished chil- association between severe malnutrition among 1Final Report, Nutrition/Mother and Child Health dren, and an estimation of the impact of the ces- infants and the high prevalence of bottle-feeding Consultancy in Northern Iraq, 19/6 – 12/7/2003, 2 Dr. Veronika Scherbaum, on behalf of Caritas Austria and sation of the Oil for Food (OFF) programme on in NI. For example, in Erbil governorate, 44.7% Cordaid Netherlands. the malnourished. The investigations were of severely malnourished admissions were 2 A Memorandum of Understanding (MOU) was signed in based on a collection of qualitative and quantita- below the age of 6 months, of whom none were 1996 between the United Nations (UN) and the tive data, including epidemiological health and exclusively breastfed, nearly one-third (30.7%) of Government of Iraq (GOI). The UN Security Council Resolution (SCR 986) permitted the GOI the export of $2 nutrition indicators (where available), institu- the infants were exclusively bottle-fed and 69.3% billion of petroleum every 6 months and the use of the tion-derived data and qualitative information recieved mixed feeding (bottle and breastfee- revenues to import items related to basic humanitarian from interviews with staff and beneficiaries. This ding)8. Furthermore, institutional based data and needs of the population. 3 summary focuses on the observations and con- visits to four different paediatric wards revealed Source: WFP nutritionist in Suleimanyiah, Northern Iraq 4At the time of the assessment, WFP provided 1kg sugar cerns regarding the inclusion of infant formula several limitations in the management of severe and 4kg of oil (substituted with pulses when oil not availa- in the general food ration. malnutrition. These included lack of therapeutic ble) to this group. This ration has since been revised to 2kg milk and modified oral rehydration solution oil, 1.02kg cheese, 1kg milk (18 September 2003). Oil for food (OFF) during the initial stage of treatment and lack of 5 UNICEF, 1996 multiple indicator cluster survey – Iraq, results from Northern governorates. Since 1996, the World Food Programme (WFP) awareness about the importance of a rehabilita- 6 UNICEF-Northern Iraq and the Regional Ministries of has been responsible for the distribution of food tion phase. Education on infant feeding practice Health & Social Affairs. Nutritional status of children in aid to the northern regions, as provided by the was also lacking. During visits by the assessor, autonomous Northern Governorates (Dohuk, Erbil and Government of Iraq (GOI) under UNSCR 986 mainly undiluted ORS - sometimes mixed with Suleimanyiah) of Iraq, data collected November 2002, report 23 March 2003. distribution plans. The significant improve- therapeutic milk - was offered by feeding bottles 7 The ration scale of infant formula (3.6 kg per month) was ments in both chronic and acute malnutrition in for severely malnourished children with diar- planned by the Iraqi Trade ministry, and is not a standard NI since 1996 can be related to the cumulative rhoea. Mothers continued to offer mixed or bot- scale of the WFP programme. Source: WFP Nutritionist, effect of improved household food security (con- tle-feeding during their stay in the hospital as Suleimanyiah, Northern Iraq. 8 Directorate of Health data from Erbil Nutrition tinuous distribution of food rations via OFF), they did before admission. Many of the mothers Rehabilitation Centre, n=144, Jan to March, 2003. implementation of an OFF-associated targeted with children admitted in paediatric wards belie- 9 UNICEF-Northern Iraq (2002) KAP survey on exclusive nutrition programme (TNP), increased health ved that they did not have enough breast milk. breastfeeding among doctors and health staff.

6 Postscript Research Infant Formula Distribution in What Triggers Humanitarian Northern Iraq Intervention? By the World Food Programme (WFP) Summary of published paper1 t is commonly assumed that mas- ces in aid allocations to Angola, Sudan Given the considerable reference to WFP activi- sive media coverage of a humanita- and Kosovo in 1999 were undoubtedly ties in this assessment, WFP were invited to rian crisis will lead to increased also a result of immense vested offer their perspective. allocations of emergency funds. European political and security inte- IThis is often referred to as the ‘CNN rests in Kosovo. The authors of the effect’. A recent study has examined the study claim that the massive internatio- here are a number of points which validity of this assumption. nal emergency assistance to Kosovo the WFP would like to raise, in light became one of a number of crisis mana- of the assessment findings from The hypothesis of the study is that gement tools used by Western powers Iraq. Under the oil for food (OFF) three main factors, working either in in their warfare against the Serbs. They Tprogramme, the Ministry of Trade (MOT) conjunction or individually, determine make the same claim about Afghanistan has been responsible for procurement of all the volume of assistance. These are the after September 11th where here, secu- food commodities including infant for- intensity of media coverage, the degree rity concerns were at the forefront so mula. WFP is responsible for the distribu- of political and security interests that that the sudden massive level of inter- tion in Northern Iraq only and not in the donors have in a particular region or national assistance became an instru- centre and the south. Following the war in country where a crisis occurs, and the ment for crisis management. Similarly 2003, WFP is facilitating the procurement of institutional framework and strength of in North Korea, donor interests - or all commodities already negotiated by the the network of humanitarian organisa- more specifically security concerns - MOT. tions involved in the country or region were paramount. In the words of the concerned. authors, “it seems difficult to explain With regard to targeting infant formula I the relatively high level of emergency and II by age, this issue was also raised by In the study, four case-study compari- assistance to a Communist one-party the WFP and United Nations Office of the sons are made. The first examines the state with extremely limited media Humanitarian Coordinator for Iraq Indian cyclone of October 1999 and the access and very meagre possibilities for (UNOHCI) food observers in 1997/98, Mozambique floods of late-January aid evaluation”. when the Government of Iraq was respon- 2000. The remaining three comparisons sible for procuring and distributing the deal with complex emergencies and The authors also assert that even cri- food ration. As part of WFP’s observation involve Angola, Sudan, the Balkans, the ses that are largely ignored by the mandate, WFP analysed the nutrient con- Democratic People’s Republic (DPR) of media may very well uphold a substan- tents of formula-I and formula-II distribu- Korea, and Afghanistan. tial, albeit insufficient, level of emer- ted in Iraq in 1998 (over 60 brands) and did gency assistance - either because there not find significant difference in contents of Data on the level of media coverage are significant donor interests in the the two formulas. Following a request for and volume of emergency assistance area or because the stakeholder com- advice posted on Ngonut1 , personal com- were collected for each case study. mitment is long-lived and strong. munication from two nutritionists/profes- Media sources were two major televi- Sudan and Angola are held up as exam- sors suggested the differences reflected sion channels in Denmark, as well as 23 ples of this, where humanitarian net- marketing stunts rather than any real diffe- leading newspapers; United Kingdom working and continuous lobbying by rence in nutrient profile. WFP, therefore, (5), Germany (3), France (3), Italy (2), well co-ordinated United Nations agen- saw no reason to advocate for pursuance of the United States (7), Spain (1) and cies and international non-governmen- the expensive, and almost impossible, task Denmark (2). Financial data were deri- tal organisations are prevalent. of identifying infants below and above 6 ved from OCHAs 2 and ECHOs 3 data- months of age and then plan, procure, bases. Data on level of media coverage The study concludes that media atten- transport, and distribute different milks to were collected for selected periods of tion is no more crucial than donor inte- such a large, and changing, population on a time, namely at three month intervals rests in mobilising international resour- monthly basis. during the central years. ces for humanitarian crises. Rather the case seems to be that the media play a Breast milk substitutes should only be dis- Data were also gathered about the crucial role only when there are no vital tributed to infants where the individual scope and severity of the unfolding security issues at stake, namely when a need is specifically established - this is emergency situation and the need for humanitarian crisis occurs in a place of internationally agreed upon policy. Despite outside assistance. Attempts were made little strategic importance to aid-fun- WFPs consistent advice against the blanket to judge the number of people affected ding governments. distribution, the MOT has not agreed to and/or the need for food assistance. For exclude infant formula from the general the India and Mozambique comparison, The authors also suggest that natural ration. This is to avoid any disquiet that is figures were compiled from the disasters and complex emergencies likely to occur when an established ration is CRED/OFDA4 database. For the other have a greater tendency to become ‘for- reduced/modified in the prevailing politi- situations, figures were derived from gotten crises’ when major aid donors cal situation in Iraq, especially given the the relevant UN consolidated inter- have no particular security interests discontent shown in 1996 when infant for- agency appeals (CAP) and mid-year vested in the afflicted regions. In such mula was removed from the ration by the CAP updates. Other sources of data cases, two factors may very well deter- government. At present, UNICEF is trying included World Food Programme mine the volume of emergency aid that to develop a strategy for targeted distribu- /Food and Agricultural Organisation is allocated - the presence and strength tion, in collaboration with the Ministry of food aid needs estimates. It was not of humanitarian stakeholders in the Health and Ministry of Trade. possible to derive any quantifiable indi- region, and the curiosity and persis- cators for level of stakeholder commit- tence of the international press. Regarding plans for after November 2003, ment to a given crisis, thus this part of WFP is mandated by the UN resolution to the analysis is built upon qualitative 1 take the responsibility of Public Olsen G, Cartensen N and Hoyen K (2003). judgements. Distribution System of Food until Humanitarian Crises: What determines the level of emergency assistance? Media coverage, November. After that it becomes the res- Apart from the India - Mozambique donor interests and the aid business. Disasters, ponsibility of the Coalition Provisional 2003, 27 (2); pp 109-126 comparison, none of the other cases 2 Administration (CPA) whose plans are not Office for the Co-ordination of Humanitarian lead to an ‘unambiguous confirmation’ yet available. Affairs (OCHA) that media attention is the most signifi- 3 European Commission Humanitarian cant explanation as to the amounts of Organisation (ECHO) 4 Centre for Research on the Epidemiology of emergency aid going to specific crises. Disasters (CRED)/Office of United States For example, the conspicuous differen- Foreign Disaster Assistance (OFDA) 1 Ngonut was a forum of email exchange between nutritionists, since replaced by Nutritionnet (www.nutritionnet.net)

7 Research

orking with a number of local partners, the Institute of Destitution in Ethiopia’s Development Studies (IDS) and Save the Children UK (SC UK) Whave recently published a report on destitution Northeastern Highlands in Ethiopia’s north eastern highlands. The background for the study was conflicting evi- Summary of unpublished report1 dence over whether poverty in rural Ethiopia was increasing, as well as a growing concern that diversion of increasing volumes of interna- tional assistance, to meet emergency appeals and annual food deficits, was displacing inves- tment to address the underlying causes of chro- nic food insecurity.

The study area encompassed three zones of Amhara National Regional State, formerly known as Wollo province. Of a population tota- lling approximately 4.5 million, 90% were rural dwellers and engaged in smallholder agricul- ture as their primary occupation. Funded by the Department for International Development (DFID), the study set out to provide answers to the following questions:

• What is destitution?

• How do people become destitute?

• How many people in Wollo are destitute?

• Is destitution in Wollo increasing?

• What are the most appropriate policy mea- sures to address destitution in Wollo?

Destitution was defined as a state of extreme poverty that results from the pursuit of unsus- tainable livelihoods, meaning that a series of livelihood shocks and/or negative trends or Kay Sharpe processes erode the asset base of already poor A blacksmith and a potter and vulnerable households until they are no longer able to meet their minimum subsistence needs. They lack access to the key productive assets needed to escape from poverty and become dependent on public and/or private transfers.

Fieldwork-based data were collected during Kay Sharpe Mapping urban linkages the dry season months of November 2001 to March 2002. A household questionnaire was designed and administered to a stratified multi-stage random sample of over 2,000 hou- seholds. The questionnaire included sections on household demographics, livelihood activi- ties, ownership of and access to productive resources, migration, participation in social ins- titutions, access to formal and informal trans- fers, achievement of basic needs, and a self- assessment of household well-being.

In order to determine numbers of destitute, three approaches were used.

i) To facilitate self-assessment, households were asked “are you unable to meet the house- hold’s needs by your own efforts and unable to survive without support from the community or government?” In response to this, 14.6% households were classified as destitute, over half (54.9%) were classified as vulnerable, and 30.6% were considered to have viable liveliho- ods.

ii) Seventeen indicators of destitution were assessed, with cut-off points for each indicator applied. The proportion of households classi- fied as destitute in terms of a single indicator

Kay Sharpe ranged from 4.2 to 41.1%, with an average of Counting housholds 19.4%.

iii) A composite destitution index, combining

8 Research the 17 single indicators, was scaled and weighted using principal components analy- sis. Overall, 95% of the 310 self-assessed des- Famine Avoided Despite titute fell in the bottom 40% of households, as ranked by the destitution index. The 293 hou- seholds that satisfied both these criteria were Drought and ‘Zud’ in Mongolia defined as destitute (13.8%), and much of the 1 subsequent analysis was based on comparing Summary of published paper this distinct group against the larger sample.

The study found that destitution in Wollo is gendered. One in three female-headed house- holds, compared to one in twelve male-hea- ded households, was destitute. Destitute hou- seholds were more likely to be smaller than average – more than half of all single-person Another reason is the behaviour of herders. households were destitute – contradicting the omadic herding remains at the core Winter preparation by herders has been impor- common assumption that the poorest house- of Mongolian society, employing a significantly larger proportion of the tant. Although the lack of milking animals had holds tend to be large, with high dependency population than any other economic a significant impact on food quality, winter food ratios. Labour constraints were also highly Nactivity. A series of liberalising reforms between stores - augmented by borrowing - ensured that significant determinants of destitution. In this 1989 and 1992, sparked by the breakdown of the for most herder households, the real impact of study, two-thirds of destitute households had Soviet Union and a termination of subsidies, led animal losses on livelihoods was delayed. Good no able-bodied males. to the privatisation of the herd collectives (neg- income from cashmere sales filled the gap in dels) and the wholesale transfer of livestock and 1999-2000. When cashmere and other livestock Respondents were asked to categorise them- other assets to private ownership, mainly by products income crashed after 2000, herders tur- selves at four points in time - ten years ago, individual herders. Services, formerly provided ned to alternative sources, relying particularly on pensions and other social insurance benefits two years ago, one year ago and at time of for free, were mostly either discontinued or as well as on assistance from family and interview. This showed that the proportion of made available only at a cost. As a result, use of these services contracted or collapsed. The patrons, to maintain a minimum level of con- destitute had increased nearly threefold over number of herding households more than dou- sumption while conserving their remaining the past 10 years, from 5.5% to 14.6%, while bled from 69,000 in 1989 to 154,000 in 1993, as herd. Extra loans were sought, as was supple- vulnerable households had increased even newly unemployed city-dwellers sought to take mentary income in farming, gold mining and more dramatically from 17% a decade ago, to advantage of the privatisation of negdel herds casual jobs. In 2000, some households benefited 55% in 2001/2. while fleeing food and job shortages in urban from generous relief and restocking. areas. Cash shortages in the countryside led to The analysis found that carrying capacity is the reappearance of a barter economy and a However, the authors caution that after three the main cause of destitution – too many peo- sharp decline in the consumption of purchased Zuds in as many years, each following a drought summer, the capacity of some house- ple trying to make a living from too little land. foods in favour of self-provisioning. holds may be stretched to near collapse. One The poorest households in Wollo faced Arecently published article based on field indication of this is the recent increase in child resource constraints of all kinds - land, lives- research in two districts of Bayankhongor pro- malnutrition in Bayankhongor province, which tock, labour, credit, inputs - which inhibited vince Mongolia, examines how famine has been doubled between December 2001 and May 2002. their ability to construct viable livelihoods avoided amongst the population against a back- While most households had sufficient food at and left them highly vulnerable to shocks that drop of ‘Zud’, despite the increased risk asso- the end of 2002 derived from a bundle of food could push them over the edge at any time. ciated with this form of subsistence. Zud deno- and income sources, many are extremely vulne- Dependence on rain-fed agriculture, for tes any one of a range of winter conditions rable and are likely to face severe difficulties as example, exposes rural communities to recu- which threaten livestock survival, such as unu- winter stores run out, new loans are not availa- rrent livelihood shocks following rain failure. sually abundant snowfall, the formation of an ble and old ones cannot be repaid. Idiosyncratic shocks are another source of impenetrable ice layer over pastures, or a lack of In a broader sense, coping in terms of main- destitution, i.e. loss of adult males through sufficient winter fodder following a summer drought or due to soil compaction by grazing taining a sustainable livelihood has failed for divorce or widowhood, or major health animals. In the past decade, Zud winters in 1993 many households. For poor households with shocks like HIV/AIDS. and 1997 were followed by an unprecedented small herds and little prospect of acquiring three-year sequence of dry summers and extre- more animals, herding no longer yields enough The authors of the study concluded that for mely harsh winters between 1999-2002. to provide for long-run subsistence. Realising the labour constrained destitute, little can be Weakened by inadequate summer feeding and this, many herders, particularly in the Gobi advocated except more comprehensive and lacking sufficient supplementary feed, several region, are considering migration to cities in effective safety nets or social protection trans- million animals died each winter in blizzards order to find non-herding employment. Many fers, although these are expensive and logisti- and temperatures as low as 50 degrees below have already done so and nationally the rural population has decreased, for the first time cally complex to administer. For the working zero in some areas. Overall, the national herd since transition, by 7.6% over the past 2 years. destitute, enhancing their access to produc- size decreased from 33.6 million in 1999 to about 25.1 million in April 2002. tive resources is arguably the only feasible Others who either do not want to migrate or way of reversing processes of impoveris- Between 1999 and 2002, the number of lives- are constrained by lack of funds, obligations to hment, phasing out chronic dependence on tock in the study area declined by 65% in one care for elderly parents in the countryside, or food aid and empowering poor households to district and 22% in the other, as a result of Zud. owing to the absence of city-based family or achieve sustainable livelihoods. Access can be Over two weeks, 14 herding households, most friends, are seeking alternative sources of improved, not only through asset ownership, of whom had suffered heavy livestock losses, income in or near their home districts. but also community ownership. Support to were interviewed in each district about coping both farming and the rural non-farm eco- strategies employed, help received and reco- The authors conclude that for many house- holds, the losses of the last winter have trigge- nomy is essential. This requires market inte- very prospects. Additional information was red the beginning of ‘coping failure’ and the gration, investment in infrastructure and obtained by consulting statistics and intervie- wing officials and NGO staff at state, provincial, necessity to switch from ‘coping’ to ‘adaptation’ small town development. Proximity to small and district levels. – moving from short-term responses to tempo- towns provides a clear route out of destitution rary food shortages, to permanent changes in and vulnerability for rural households and Why was there no famine? the ways in which food is acquired. Unlike far- communities in the catchment area. One reason posited by the authors is the exis- mers, herders with too few animals cannot hope Recommendations, therefore, fall into two tence of democracy. Mongolia has had an active that a single good year will restore them to eco- categories, those that promote enhanced democratic system since 1989, with a powerful nomic health. If another Zud occurs before her- access to assets and those that promote more elected parliament containing representatives of ders have had an opportunity to re-build their productive livelihoods. several parties, an active opposition and a free resource bases, the resulting increase in food press. The devastating impacts of the droughts insecurity and economic and social upheaval and Zuds of 1999-2002 have been debated at for affected households may well be far more 1 Sharp K, Devereux S and Amare Y (2003). length in parliament and in the newspapers. widespread. Destitution in Ethiopia’s northeastern highlands (Amhara National Regional State). IDS, SC-UK The government has been open about what was 1 Siurua, H and Swift, J (2002). Drought and Zud but no Ethiopia. A policy research project funded by DFID. happening and within the limits of its resources, famine (yet) in the Mongolian herding economy. IDS April 2003 has acted effectively. Bulletin vol 33, no 4, 2002

9 Research Government versus NGO efficiency, Bangladesh

Summary of published paper1 It is often assumed that during emergencies, nutrition and food interventions can be more efficiently managed by NGOs than by government. A recent study on an integrated nutrition programme in Bangladesh may challenge this assumption, even though the programme was conducted in a non-emergency setting. The study also found that the supplementary feeding component of the intervention was very costly in terms of providing calories. Given the limited data in the public domain on the costs (and cost-efficiency) of emergency supplementary feeding programmes, the findings may be of interest to emergency programme planners - Ed

he Bangladesh Integrated Nutrition ting to estimate cost of delivering nutrition servi- numbers makes the NGO facilities even less effi- Programme (BINP) was adopted to ces from the CNCs. The number of individuals cient compared to GOB facilities. improve the nutritional status of the enrolled, the number actually participating in the population, especially of women and programme, and person-days of service delive- On average, the BINP delivered food supple- Tchildren, through community based nutrition red were used as effectiveness measures. mentation of 480 kcals per participant at a cost of interventions. The community based nutrition about US$0.25 per day. Allowing for administra- component focuses on growth monitoring of Thirty-five CNCs were randomly selected from tion and management costs, the actual food cost children, dissemination of nutrition-related five BINP areas, of which 21 were in GOB-run becomes US$0.20 per participant per day. If the information and supervised supplementary fee- areas and 14 in NGO-run areas. The cost of pro- project were to use this amount of money to buy ding of target women and children in viding nutrition services per enrolee was rice from the local market, the calorie content of Community Nutrition Centres (CNCs) at village US$24.43 for GOB-run CNCs and US$29.78 for the rice would be more than 2000 kcals. Unless level. The government has adopted the National NGO-run CNCs. the food supplementation process generates Nutrition Programme (NNP) based on experien- other types of benefit, such a high level of cost ces and lessons learned from the BINP, and The analysis implies that the NGO facilities are cannot be justified. The study authors conclude intends to provide a similar mix of services to not more efficient in the delivery of nutrition ser- that even if other benefits such as nutrition edu- those being delivered under the BINP. Scaling up vices when cost per person/days of service deli- cation and community involvement are genera- the activities to the whole country will cost vered is considered. One potential criticism of ted, policy makers should compare a program- approximately 150 million dollars a year. this type of comparison is that it assumes enrol- mes’ relative efficiency and effectiveness with its ment and participation without looking into separable components, to determine whether The BINP experimented with two models of potential mis-targeting. If the expected enrol- concentrating on specific components will gene- delivery, one using government management ment is calculated by using prevalence of malnu- rate higher levels of social benefits per dollar structures and the second using non-governmen- trition rates found by the BINP, it is clear that spent. enrolment rates were lower in GOB facilities and tal organisations (NGOs) working in the local 1 higher in NGO facilities than otherwise expected Mahmud Khan, M and Ahmed, S (2003). Relative effi- community. A recent study has compared the ciency of government and non-government organisations efficiency of the government of Bangladesh for rural Bangladesh. However, enrolment does in implementing a nutrition intervention programme – a (GOB) and NGO management in the provision of not equal participation. Re-estimating the cost- case study from Bangladesh. Public Health Nutrition; 6 nutrition services and involved a detailed cos- effectiveness measures with expected enrolment (1), pp 19-24, 2003

and health and develop interventions based on that diagnosis. The author suggests that as indi- viduals realise their power to make decisions, Women’s Contributions to Reducing lay claim to resources and exercise freedom of choice, they may engage the very institutions Micronutrient Deficiencies that created and perpetuated differential power dynamics. Thus, the “power and technology” pathway will lead to more sustainable nutrition 1 Summary of published research outcomes.

The Thailand and Peru studies took a total of 9 and 16 months respectively, while the other stu- dies took between 9 and 18 months. Even more number of agencies have adopted nity kitchens and improve iron status of kitchen remarkable was the time needed for the nutri- ‘gender sensitive’ policies, which aim members and other consumers. tion-specific intervention in Peru, taking a mere to strengthen the role of women in • Strengthening women’s problem-solving and four months to implement and demonstrate controlling intervention resources in leadership skills to organise community-based equivalently significant results. The authors sug- Aemergencies. The rationale for such policies is interventions and so reduce vitamin A, iron and gest that the relative efficiency and effectiveness that empowerment of women will contribute to iodine deficiencies in rural Thailand. of the Peru and Thailand studies probably improved impact of the intervention. The fin- reflects ‘who’ made the decisions. In the Peru dings of a recent study in non-emergency situa- All five country interventions achieved signifi- and Thailand cases, women applied their enhan- tions lend some support to this approach. (Ed) cant nutrition outcomes and succeeded in rea- ced skills to make decisions about which pro- ching their nutrition objectives in less than 18 blems they needed to address and how to solve The International Centre for Research on months. The approaches appear to have achie- them, including the types of resources they nee- Women, with partners in Ethiopia, Kenya, ved objectives in two specific ways – first in ded and means to access them. The development Tanzania, Peru and Thailand, implemented an terms of entry point and second, in terms of deci- professionals served as facilitators and technical intervention research programme to find ways to sion-makers. The Ethiopia, Kenya and Tanzania resources, not as the primary decision-makers. strengthen women’s contributions to reducing studies began by addressing women’s practical In contrast, the decision-makers in the other stu- micronutrient deficiencies. The trial interven- resource needs as they related to food produc- dies were the research team. While community tions focused on: tion, care and feeding practices. The Thailand members, including women, provided informa- and Peru studies began by strengthening wome- tion to the technical specialists and participated • Improving women’s skills and knowledge in n’s capabilities as problem solvers, decision- in the intervention trials, their decisions were food production, processing and preparation makers and community leaders, followed by limited to the choice of whether or not to adopt methods and feeding practices, to improve vita- development of nutrition specific interventions a technology or modify a practice. min A intake in Ethiopia. that addressed women’s practical resource • Promoting the adoption of new varieties of needs. The authors state that although care must be beta-carotene-rich sweet potatoes by women far- given to drawing conclusions from this retros- mers in Kenya and encouraging their consump- The two approaches are described in the article pective analysis, it should not be a surprise that tion to improve vitamin A intake. as the ‘power and technology pathway’ and the investing in women’s decision-making power • Increasing women’s access to, and utilisation ‘technology’ pathway. The entry point for the and expanding their freedom of choice was an of, a modified solar drying technology to incre- two-step power and technology pathway streng- efficient and effective way to achieve results ase year-round availability of vitamin A-rich thens individual capabilities to solve problems, foods in Tanzania. take decisions and lead their communities. This • Strengthening women’s skills in decision- pathway merges with the ‘technology’ pathway 1 Johnson-Welch, C (2002). Explaining nutrition outcomes making, problem solving and management to when the decision-makers identify the practical of food-based interventions through an analysis of wome- resources needed to improve access to food, care n’s decision-making power. Ecology of Food and Nutrition, improve quality of services in Peruvian commu- 41, pp 21-34, 2002.

10 Research Hidden Famine in Madagascar

Summary of published paper1

he political economy of an urban famine in Madagascar is the subject of a recently published article. The famine occurred in the capital city, TAntananarivo, between 1985-86 but remai- ned hidden for a long time, eventually uncovered by analysing the demographic data of registered deaths in the city.

Antananarivo lies in the highlands of cen- tral Madagascar and in 1985 had a popula- tion of approximately 577,000 people. For the period 1976-95, the mortality data recor- ded for the city showed a typical famine in 1985-6, where mortality levels increased markedly, and life expectancy fell from 59.4 years in 1975, to 49 years in 1986. The mor- tality increases bore all the characteristics of a famine - a strong relative increase among children, especially 5-9 year olds, and young adults, particularly young men aged 20-34 years old. In absolute terms it was estimated that about 7,600 persons died in 1985-6 in excess of baseline mortality levels, about half of whom were children under 15 years of age, with a small excess of boys. Adults aged 15-59 years comprised one- third of excess deaths, nearly three-quarters (74%) of whom were men. The remaining deaths were amongst the elderly, again with a higher male mortality. These figures imply that 1.3% of the population died because of famine, a rate that compares with some other ‘mild’ famines. However, the main evidence that this was a famine lies in the ‘causes of death’ profile, which is especially clear for young adults. Mortality from mal- nutrition (starvation) among adults hardly existed before 1984 and after 1988, whereas it showed a huge peak in 1986.

The explanation for the Antananarivo famine appears quite clear. Rapid deregula- tion of rice prices and rice markets, follo- wing a long period of strict state regulation, led to a rapid increase in the price of rice, the staple food of the large majority of a poor population. The poorest could not cope with the increasing cost of what cons- tituted 80% of their food intake. Furthermore, poverty had been increasing in Madagascar over the period preceding the crisis and started to decrease only ten years later, after 1996.

Beyond market failure and institutional failure (i.e. lack of government policies to off-set the rice price inflation), several other factors may have played a role in the famine. The geographical isolation of the capital city in the highlands, together with a very poor road system, may have contribu- ted to market segmentation, already aggra- (c) IRD - Base Indigo. Photo by Vincent Simmonneaux, 1998 vated by the lack of incentives to rice far- A market in Tulear, Madagascar mers during the 1972-84 period as a result of the state controlled economy. The changing vious policies and not to put the changing policies representative sample of the Demographic and economic situation during 1984-6 created a at risk. Surprisingly the famine was hidden not Health Surveys, in both urban and rural areas. market trap with effects similar to those of a only to the press, but also to economists working blockade - rice was available in the country at that time on the economic reforms. It is argued The author concludes that improved information or could easily be imported, but people in the paper that had the press been free to report technology, as well as more integrated markets in could not access it because of a lack of enti- the case, and had economists been properly infor- Madagascar, makes another famine of this nature tlement. If people had commanded higher med of the situation, public ‘coping mechanisms’ quite unlikely in the future. incomes or had access to credit, they would could have been put in place. have been able to survive the crisis. Little is known of the situation in rural areas. The Madagascar famine seems to have However, the mortality increase seen among chil- been ‘hidden’ from the start, probably in an dren in the capital over the 1975-86 period, with a 1 Garenne, M (2002). The political economy of an urban attempt to hide the major failures of pre- peak in 1985-6, was also visible in the nationally famine. IDS Bulletin, vol 33, no. 4, 2002

11 Research

Implementation of WHO Guidelines on the Jacqueline Deen Management of Severe Jacqueline Deen Malnutrition in South Africa and Ghana

Summary of published research1 Dietitian interacting with ward nurse at Rehabilitated child at Catholic hos- Mapuleng hospital, Northern Province, pital, Battor, Volta Region, Ghana South Africa 2002 2001

In the past, Field Exchange has addressed issues Comparisons aside, some would still regard the pitals that seemed to have a good chance of imple- faced by international humanitarian agencies in 18% fatality rate from severe malnutrition at both menting the guidelines. Although the findings phasing out emergency therapeutic feeding pro- hospitals during the study period as unacceptably cannot be generalised to all small hospitals in grammes and leaving behind improved and sus- high, considering the guidelines target mortality Africa, the study gives an idea of what may or tainable capacity for treatment of severe malnu- rates of 5-10%. Guideline components that were may not be feasibly implemented with a minimum trition. The study summarised below provides not implemented or sustained may have been cru- of intervention. It is difficult to predict whether additional evidence that at least in non-emer- cial to achieving further decreases in case-fatality similar African hospitals would have the same gency situations, improved and sustainable rates. Furthermore, guideline practices believed to success in improving care management practices practices can be promoted (Ed). be in place may have been implemented inconsis- by following the guidelines, particularly without tently or poorly in reality. Also, the influence of external consultant support. Conversely, more he study set out to investigate the HIV on malnutrition mortality was not measured intensive input and support might allow imple- problems, benefits, feasibility and specifically. The primary cause of death in some mentation of all components of the guideline but sustainability of implementing cases was probably advanced acquired immuno- with less assurance of sustainability. World Health Organisation (WHO) deficiency syndrome (AIDS), in which case the Tguidelines on the management of severe deaths would not have been preventable. The authors of the study concluded that wider malnutrition 2. A postal questionnaire was implementation of the guidelines in similar set- sent to 12 African hospitals inviting them to Hospital staff questioned the evidence base of tings is possible but that the guidelines could be participate. Five hospitals were evaluated some of the guideline components and felt that the improved by including additional information on and two were selected to take part in the evidence behind certain recommendations – such how to adapt specific components to local situa- study - a district hospital in South Africa as the single approach for managing marasmus tions. Furthermore, additional information is nee- (Battor Hospital) and a mission hospital in and kwashiorkor, feeding frequencies, routine ded about certain components of the guidelines Ghana (Mapulaneng Hospital). At an initial antibiotics, and requirements of micronutrients and their impact on mortality. visit, an experienced paediatrician revie- other than vitamin A, folic acid and zinc – was wed the situation in the hospitals and intro- inadequate. Documentation of the technical basis 1 Deen J et al (2003). Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. duced the principles of the guidelines of these specific recommendations, or research to Bulletin of World Health Organisation, 2003, 81 (4), pp 237 through a participatory approach. During a provide the necessary evidence, would promote - 242 second visit about six months later, the pae- wider acceptance of the guidelines. 2 Management of severe malnutrition: a manual for physi- diatrician reviewed the feasibility and sus- The study intentionally selected two general hos- cians and other senior health workers. WHO, 1999 tainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reas- Table 1 Summary of the feasibility and sustainability of the main components of the sessed the overall situation. WHO guidelines for the management of severely malnourished children

Implementation of most of the main prin- Category Battor and Mapulaneng Hospital Mapulaneng Hosptial Battor Hospital ciples of the WHO severe malnutrition gui- delines was feasible, sustained over a one- Feasible and • Routine admission of all severely mal- Triage, urgent assess- • Allowing year period, and affordable to the institu- sustained nourished children ment and management mothers to stay • Using key signs, oedema of both feet or with the chil- tions (see table 2). Although relatively severe visible wasting, for the diagnosis dren all day and labour intensive, the process was successful • Measurement of height and calculation night because hospital staff were involved in of weight-for-height planning the changes from the outset, logis- • Measures against hypoglycaemia, e.g. • Routine admi- tical limitations were acknowledged and early feeding on admission, nasogastric nistration of oral local modifications to the generic approach tube feeding when necessary antibiotics to • Measures against hypothermia, e.g. those without were developed. The success can also be blankets, heaters, keeping the children complications attributed to the enthusiasm of the resident dry paediatricians and the follow up by the visi- • Restricting the use of intravenous fluids ting paediatrician. As the resources for only to those with shock or severe dehy- implementation came from the hospital dration • Preparation and use of starter (75 budgets (except for a supply of mineral and kcal/100 ml) and catch-up (100 kcal/100 vitamin pre-mix), financial sustainability is ml) formulae likely. • Delaying the administration of supple- mental iron Whether the WHO guidelines, once imple- mented, are effective is another important and relevant question. At Battor, the morta- Feasible with Frequent feeding, all day and night Routine administration lity was unchanged, possibly because diag- adaptation or Supplemental electrolytes, minerals, and of antibiotics to those special provi- vitamins without complications noses of severe malnutrition were more pre- sion cise during the study year - this is suppor- ted by a decrease in the number of admis- Feasible, but • Measurement and recording of feeding sions classified as severely malnourished implemented • Daily measurement and charting of from 81 at the beginning, to 39 during the inconsistently weights study. At Mapulaneng, the mortality hal- or • Transition from starter (75 kcal/100 ml) not sustained ved. This may have been because all cases to catch-up (100 kcal/100 ml) formula of severe malnutrition, not only those with complications, were admitted, as suggested Not feasible • Preparation and use of rehydration Allowing mothers to Triage, urgent by the increase from 29 cases pre-study to solution for the severely malnourished stay with the children assessment 125 cases during the study. Also, the study (ReSoMal) all day and night and manage- was not blinded so some bias in the repor- • Calculation of weight gain in g/kg/day ment ting may have occurred during the study • Target case-fatality rate of 5–10% year.

12 News & Views

fruits, vegetables and cereals into aqueous solu- ding Latin America, and South and South-East VitaGoat tions or juices, soups, purees, and gruels. There Asia, when appropriate sponsors and NGO part- is no food wastage with the processing. The ners are identified. By Frank Daller,Vice-President ‘Okara’ residue from the soya processing is avai- of Malnutrition Matters. lable for breads, as additions to other foods, or For further information, contact: Malnutrition can be used as animal feed. Using only its bicy- Matters, 498 Rivershore Cres, Ottawa, ON, micro-enterprise cle grinder, the VitaGoat can also grind dry cere- CanadaK1J 7Y7, responds to als and grains to produce flour, and meal, and email: [email protected], malnutrition process nuts into pastes or ‘butter’ such as pea- tel: 1 613 446 0205 , fax: 1 613 446 2072. nut butter. It can also grind roasted coffee. See online at http://www. malnutrition.org The VitaGoat can be used in a number of set- ooking beyond short term feeding solu- tings including humanitarian projects, social ins- VitaGoat system, left to right: steam boiler, tions, Malnutrition Matters is a non-pro- titutions (hospitals, schools, etc) and sustainable cooker with press, cycle grinder fit organisation dedicated to providing micro-enterprises. The technology also facilitates sustainable, affordable and locally avai- the development of projects for processing and Llable food technology solutions for malnutrition. preserving foods and can for example be useful Staff have been involved in food technology pro- in situations of seasonal ‘glut’ where waste can jects in over 30 countries, although the emphasis occur due to lack of local markets or processing has been in the regions of the Former Soviet options, e.g. mangos and tomatoes. Union, in Africa and in India. Most recently, Malnutrition Matters has developed a comple- Launching in October, the projected local tely non-electric, versatile food processing selling price should be under US$2,000 when system called VitaGoat improving upon pre- technology-transfers are completed. Thereafter, vious systems (SoyCow and VitaCow) which construction, training and parts for the systems both require a reliable supply of electricity. will be provided locally. The system will at first undergo a six-month pilot programme test in The VitaGoat system comprises of a pressure- partnership with Africare in Guinea, Chad and cooking vessel, a bicycle-powered grinding Mozambique. After this, it is intended to transfer system, an energy-efficient steam generator and responsibilities for the VitaGoat to manufactu- a mechanical press. The system can process soy- rers in two or more African locations. Similar beans into soya-milk and derivatives, as well as initiatives are planned for other regions, inclu- Malutrition Matters

the food and nutrition implications of ART and interactions, identifies areas of knowledge Antiretroviral how to manage these in resource limited set- gaps, and lays out the specific food and tings. nutrition implications of ARVs commonly Therapy and used in resource limited settings. Managing the interactions between ART and Nutrition food and nutrition is a critical factor in the extent While the document focuses on ART, it to which the therapy is effective in slowing the notes that individuals infected with HIV 1 progression of HIV/AIDS and improving the have special nutritional needs, irrespective technical guidance quality of life of PLWHA. In resource limited set- of whether they use ART. Furthermore, tings, many PLWHA lack access to sufficient although access to ART in developing coun- quantities of nutritious foods, which poses addi- tries is increasing, the majority of PLWHA tional challenges to the success of ART. still do not have access to ART. Programmes working with people taking ART ccess to antiretroviral drugs (ARVs) may need to strengthen human capacity to 1Food and Nutrition Implications of is increasing among people living address nutritional issues, establish linkages to Antiretroviral Therapy in Resource Limited with HIV/AIDS (PLWHA) in deve- programmes addressing food and nutrition Settings - DRAFT, Tony Castleman, Eleonore loping countries, as a result of issues, and incorporate information about drug- Seumo and Bruce Cogill, FANTA, June 2003 Alocal, national, and international efforts. food interactions into communication materials, Issues related to antiretroviral therapy (ART) staff training and orientation, and supervision The document is available online at in resource limited settings have become systems. www.fantaproject.org or email: increasingly relevant to PLWHA, caregivers, [email protected] service providers, and programmers. Drafted This technical note summarises the types of by the Food and Nutrition Technical ARVs commonly used, offers a framework for Assistance Project (FANTA), a technical note understanding drug-food interactions, describes now provides information and guidance on key issues and steps for managing ARV-food

f you find writing a chore, perhaps know A specially designed CDROM is provided con- what you want to say, but not how to say it, taining all the study materials, including interac- or feel you need to polish your writing skills, tive exercises and assignments. It also contains JustWrite then JustWrite may be what you need. sections on grammar, punctuation and stylistic I issues - together with a reading list and guides to Developed by the not-for-profit organisation further study. You can be anywhere in the world an online course in Fahamu, JustWrite is an online course on effec- to benefit from this course, you only need access tive writing, which can help individuals to build to a computer and email. effective writing up effective writing skills over a period of a few weeks. It provides health workers with an The cost of the course is currently £300 sterling. opportunity to develop effective writing skills For participants from developing countries who without absenting themselves from work, and are without sponsorship, the fee will be negotia- benefit from extensive professional guidance. ble. For further details on course dates and a The course is ideal for anybody producing any registration pack, write to Hilary Issac, email: substantial piece of writing, such as an advocacy [email protected] document, paper for publication, or research report. With bases in the UK and South Africa, Fahamu is a not-for-profit organisation that aims to sup- The course takes three intensive weeks and port progressive social change in the south combines study material, stimulating interactive through using information and communication exercises, lively online discussion with your technologies. For further information, see online fellow participants and individual tuition. Study at http://www.fahamu.org.uk is broken down into daily hour-long slots, making the course suitable for those in full time employment.

13 Nutriset Nutriset Local production in Malawi, 2002 Distribution of Plumpy sauce in a plate of rice, Madagascar in 1996 Local Production of Plumpy’Nut

By Anne-Laure Glaisner and Beatrice Simkins, Nutriset

small-scale local production in each feeding cen- quality management. A licence for the produc- he French company, Nutriset, has tre so as to increase the availability of the pro- tion and sale of Plumpy’nut to the humanitarian been involved in projects aimed at duct in a way that it can become an integral part sector will be granted free of charge. However, establishing local production of of public health programmes in Senegal. the company is also planning to develop a simi- Plumpy’nut - a ready-to-use food lar product for distribution on the local market. Tproduct (RTUF) employed in feeding pro- A second project, which developed out of the This product will be distinguished from News & Views grammes for the management of severe concerted action of a number of NGOs, is under- Plumpy’nut by its name, its formula and its pac- malnutrition. Plumpy’nut can also be used way in Malawi. In December 2002, Nutriset kaging. Nutriset will also help in the design and as a nutritional supplement for children carried out a technical audit in the field to iden- development of this product. and adults. tify a potential local producer. The product and the manufacturing process have been adapted to These three projects show that the process of The product was originally developed in local conditions, taking into account the availa- setting up local production of Plumpy’nut can- partnership with the IRD (Institut de bility of raw materials, production equipment not be standardised and will depend on local Recherche pour le Développement) and has and packaging. A licence was granted to the conditions. Furthermore, the most critical aspect been jointly patented by Nutriset/IRD. The manufacturer, free of charge, for the production of setting up local production is establishing practical value of this product – especially and sale of Plumpy’nut in the social quality management. Conscious of its role as lea- in situations where there are few trained work/humanitarian sector. In order to ensure der in this type of project, Nutriset is planning to staff available and in home-treatment pro- product quality, Nutriset supplies the essential set up an experimental production line reprodu- grammes - has meant that it has been adop- minerals and vitamins used in the form of a pre- cing, as far as possible, the manufacturing con- ted by a number of non-governmental mix. This premix is sold to the NGOs who will ditions encountered in developing countries. organisations (NGOs). A wide variety of be using the final product, and it is delivered for The purpose of this is to help staff understand stakeholders have been interested in local processing to the local manufacturer. A second more precisely the problems local producers production in order to make access to visit is planned for October 2003. have to deal with, in order to help them find Plumpy’nut more sustainable. solutions. Licencing Plumpy’nut local producers A third project has been the initiative of a small is another key area for quality control. A licence Experience with local production food company in Lubumbashi, Democratic effectively becomes a quality guarantee for The first project to attempt local produc- Republic of the Congo. The idea held three NGOs and other users. tion of Plumpy’nut was in Senegal, in part- attractions for the company: helping to meet an nership with the University of Dakar and increasingly pressing local need, a means to For further information, contact Anne-Laure the ITA (Institute for Food Technology) in diversify its production, and becoming more Glaisner, Research and development, Dakar. Production is currently taking place involved in the ‘social fabric’ of the region. In or Beatrice Simkins, International communica- within the university and a comparative June 2003, Nutriset and its project partners tion and development, email: nutriset@nutri- study is being carried out into the effective- carried out a technical audit and market study. set.fr, NUTRISET - BP 35 – 76770, Malaunay, ness of locally produced Plumpy’nut com- Funding is currently being sought. Nutriset will France pared to the product manufactured in provide the company with technical support and tél : +33 (0)2 32 93 82 8)fax : +33 (0)2 35 33 14 15 France. The aim of the project is to promote will ensure staff training for production and http://www.nutriset.fr/

Training Course on Ageing in Africa HelpAge International are planning a training course on Ageing in Africa, to run between 23- 27 February, 2004 and based in Nairobi, Kenya. Aimed at mid-level or senior programme managers, social and healthcare professionals, senior government officers, or those simply with an interest in ageing issues, topics to be covered include: • Demographic situation and socio-economic implications for Africa • HIV/AIDS and its impact on older people • Gender dimension of ageing • Poverty • Research and Policies on ageing A course fee of US$400 is chargeable for those requiring accommodation and US$150 for those who make their own arrangements. For more information, contact HelpAge International at email: [email protected]

14 News & Views

HIV/AIDS are described and recommendations people with HIV/AIDS given on foods and eating habits to meet these requirements. The manual also explains how to ii) Summary sheets that can be used as han- New FAO/WHO address the nutritional aspects of HIV-related douts, listing the main points for each key topic. conditions. Practical recipes using locally availa- Manual on Living ble foods are suggested, as well as some simple The summary sheets and leaflets are specifi- home remedies for easing some of the problems cally for use by people who are living with 1 people with HIV/AIDS may experience. HIV/AIDS or who are caring for a person living Well with HIV/AIDS with HIV/AIDS, who want to be better infor- The manual consists of: med. i) Guidelines, with accompanying information and explanations, intended for use by: The annexes contain: AO and WHO have recently produced a • Health service providers and other extension • further technical information manual on nutritional care and support workers, as well as those involved at the national • suggested recipes for home treatments and for people living with HIV/AIDS, called and community level in the many different foods for different conditions ‘Living well with HIV/AIDS’. The aspects of counselling and home-based care • forms to monitor food intake and weight Fmanual aims to provide practical recommenda- • Community based organisations working with • sources of literature and information on insti- tions for a healthy and balanced diet for people people with HIV/AIDS who need information tutions providing support for people living with living with HIV/AIDS in countries or areas with for programming and counselling purposes HIV/AIDS. a low resource base. It aims at improving nutri- • Planners in the health, social and nutrition ser- tion in a home-based setting. It is also applicable vices so they can develop national or local gui- to people with HIV/AIDS in hospitals and other delines for nutritional care and support for peo- 1 Further information and a full text version of institutional settings, including hospices. ple living with HIV/AIDS the manual is available online at the WHO web- • International agencies that support national site http://www.who.int/disasters, and at the The food requirements of people with and community-based support programmes for FAO website at http://www.fao.org

ecently produced by Christian Aid, Facing up to the Facing up to the Storm is a disaster management book which looks at how HIV-Positive Storm local communities can cope with disas- Rter, and the potential for community-based Mothers in approaches to disaster management. Original case studies, based on first-hand experiences Uganda Return to from Orissa and Gujarat in India, show how people, even in the poorest parts of the develo- Breastfeeding ping world, can survive disasters if they are involved in all aspects of managing disasters Summary of published research1 from response to prevention. This approach dif- fers greatly from the top-down, government-led approach experienced by most communities and n increasing number of from the practice of most governments and mothers with HIV in Uganda many agencies. are breastfeeding their babies after UNICEF stopped dona- The book is available to download at Ating free infant formula, according to a http://www.christianaid.org.uk/storm. recent news piece published in the A limited number of hard copies are available Lancet. Christian Aid/Dan Charlish through the UK suppliers, tel: Seedling nurseries will help replant +44 (0)8700 787788 or by international mail Under the prevention of mother-to- India’s devastated east coast after the order, email : [email protected], child HIV transmission (PMTCT) project, 1999 Orissa cyclone destroyed over a Attention: Megha Sharma, tel: ++ 91 11 2651 million trees. between 2000 and 2002, UNICEF dona- 8071/2 (India) ted infant formula for HIV-positive mothers who, on counselling, chose to use formula rather than breastfeed their newborn infants. However, according to UNICEF in Uganda, they found that those who were in need did not have INASP Health Directory 2003/2004 access to formula, and since it was expensive, it was not sustainable. Nationally, only 32% of the HIV-positive he International Network for the designed to complement 'INASP Health Links', mothers opted for formula feeding. The Availability of Scientific Publications the internet gateway to selected websites for remainder chose to breastfeed either (INASP) has launched the online INASP- health professionals, medical library communi- because of stigma, or their living condi- Health Directory 2003/2004. The ties, publishers, and NGOs in developing and tions made formula feeding risky. Even TDirectory is a networking tool for building pro- transitional countries (see online at among those who chose formula, many fessional relationships and sharing information, http://www.inasp.info/health/links/con- were breastfeeding at night for conve- and a reference for those who are seeking techni- tents.html) nience. cal and financial support. Listings include 240 international organizations and programmes Ministry of Health (MOH) figures were worldwide that are working to improve access to not available as to how many mothers information for health professionals in develo- had reverted to breastfeeding. At one of ping and emerging countries. Each entry gives the urban sites, Nsambya, while 50% of full contact details and a short description of the women formula fed their children relevant activities. last year, this has now dropped to less than 20%. Presented in two parts, part 1 includes orga- nisations that provide health information, while Uganda’s Child Health Commissioner part 2 describes organisations that support book, has expressed concerns that the reduced availability of infant formula will slow library and information development, including The Directory is also available on CD-ROM a section on health. efforts to reduce mother-to-child HIV (thanks to e-TALC), and a limited number of transmission. However, the MOH is fin- printed copies will be available free of charge to ding it difficult to respond to requests to The INASP-Health Directory 2003/2004 is sup- medical libraries in developing countries. ported by Exchange, a networking and learning procure infant formula, given the limited resources available and many other basic programme on health communications for deve- For comments, suggestions for improvement, lopment (http:// www.healthcomms.org). antenatal needs that remain unmet and recommendations for new within the health system. Available free of charge at entries, contact Neil Pakenham-Walsh at email: http://www.inasp.info/pubs/healthdir/, it is [email protected] 1 News, The Lancet, vol 36, no.9383, 16 Augest 2003.

15 News & Views Caring for Severely Debate on the Management of Severe Malnourished Malnutrition Children: Book Review by Marie McGrath, Fiona O’Reilly and Jeremy Shoham (ENN). he last issue of Field Exchange reported on Over the past six months, ENN has been a party to debate regarding technical aspects of the the publication of a new book ‘Caring for management of severe malnutrition. We believe that transparency and information sharing Severely Malnourished Children’ by Ann leads to clarity not confusion, and so wish to share the following key areas of debate. This Ashworth and Ann Burgess. The book des- article was circulated pre- publication to those involved, who were invited to respond in the Tcribes how to manage severely malnourished chil- form of a letter for inclusion in the same issue of Field Exchange. dren in hospitals and other health units with inpa- tient facilities. Due to criticisms of the content by n May 2003, a new publication, Caring mends using a “starter formula” which is Prof. Mike Golden, the authors, TALC and the for severely malnourished children, likened to F75. However the starter formula- publisher together agreed to have the book revie- Ashworth and Burgess, 2003 1 , met with tion given is of higher osmolarity than stan- wed. Three independent experts in the field were some technical criticism from Professor dard F75, which, it has been argued, may asked to address the following questions: IMike Golden in the form of a book critique precipitate osmotic diarrhoea. submitted to ENN, and circulated to the Management of severe oedema 1. Does the book deviate from WHO guidelines on publishers and supporting agencies (see The Ashworth/Burgess publication treatment of severe malnutrition. Field Exchange 19, pp 19). In response, a recommends energy intake of 75 kcal/kg/d 2. If so would these deviations be detrimental to review by independent experts was co-ordi- in the initial treatment of children with children's health. nated by TALC and the findings of the severe oedema. The critique argues that, in 3. Does the book provide the information required review are summarised in this issue of Field practice, the degree of oedema is overesti- for health workers to manage severely malnouris- Exchange 2. Through this process it emerged mated by clinicians, particularly the inexpe- hed children successfully. that issues raised in the original book criti- rienced, and nowhere warrants a reduction The findings of the reviewers were as follows; que primarily concerned aspects of the 1999 in intake from 100 to 75 kcal/kg/d. WHO guidelines on the management of Does the book deviate from WHO guidelines? Overestimation of oedema will lead to severe malnutrition3 and consequently, sub- Only minor changes were noted. underfeeding, which may not necessarily sequent publications which reflect these contribute to increased mortality, but delays i) The use of a larger daily dose of folic acid i.e. guidelines, e.g. Ashworth/Burgess 2003. progress and recovery. The critique also 2.5mg instead of the recommended 1 mg Drawing on a number of sources, we were questions the evidence base for prescribing ii) The option of using 2% magnesium sulphate able to determine where there is some con- reduced energy intake in severe oedema when CMV or the electrolyte/mineral solution is sensus over potential challenges to the 1999 cases. unavailable WHO guidelines and other derivative iii) The option of using crushed Slow-K tablets publications. Largely based on the original Diarrhoea and dehydration when CMV or potassium chloride solution is una- critique, the following key areas of debate Management of diarrhoea and dehydra- vailable have emerged. tion has been identified as one of the most iv) Advocating the use of metronidazole. Management of severe malnutrition contentious and difficult issues in the mana- Would these deviations be detrimental to chil- in infants less than six months gement of severe malnutrition. The 1999 dren's health? WHO guidelines recommend using 50 – The 1999 WHO guidelines do not specifi- 100ml Resomal for each stool loss for chil- All reviewers agreed that these would not be cally extend to include malnourished dren under 2 years, which, the critique detrimental. The first three are alternatives to the infants under six months of age. Differences argues, risks providing dangerous amounts formulations advised by WHO and relate to the in field approaches to managing malnouris- of sodium and over re-hydration. availability of suitable preparations, so that the hed infants under six months have already question is about whether it is preferable to give been highlighted by the ENN - a recent Blood transfusions something or nothing. Their conclusion was that a study by ENN and GIFA (Geneva Infant The 1999 WHO guidelines state that very pragmatic choice to provide a formulation that is Feeding Association) to support technical severe anaemia can cause heart failure and available is appropriate. Concerns over whether a training material on infant feeding in emer- specifies that children with very severe larger dose of folic acid interferes with antifolate gencies, concluded that an urgent consulta- anaemia need a blood transfusion. The criti- antimalarial drugs like Fansidar are addressed by tion by technical experts and field practio- que argues that heart failure due to anaemia the reviewers. There is no firm evidence of an effect ners was required to achieve consensus on (where the peripheries are warm, the pulse but the consensus is that there is ongoing debate the management of severe malnutrition in full and the heart overactive) is uncommon and well designed studies are needed to further young infants4. in the malnourished child. Other forms of address the issue of dosage and risk of malaria. In the ENN/GIFA study, the most signi- heart failure are common and lead to bre- The WHO guidelines state that the use of metro- ficant areas of contention were the role of athlessness with a weak, rapid pulse, which nidazole is accepted practice in many units and the breastfeeding, and the choice of therapeutic often coincide with anaemia. Further, heart reviewers agreed that it is effective in treating small feed (if any) to use in managing young, mal- failure due to fluid overload is always asso- bowel overgrowth (SBO). There is some discrepancy nourished infants. ciated with a fall in haemoglobin (so called among the reviewers as to the importance attached The majority of guidelines/field proto- dilutional anaemia). These may mislead the to SBO in malnutrition. cols reviewed relied on breastfeeding (if inexperienced clinician. Giving a blood Does the book provide the information required necessary supported by supplementary suc- transfusion in these circumstances is hazar- for health workers to manage severely malnou- kling) to treat young infants. In contrast, dous, with evidence to suggest it should rished children successfully? WHO draft guidance available to the review only be considered in the first 24 hours of All reviewers answered this question in the affir- advised that breastfeeding could not be treatment. Furthermore, fluid shifts and 8 mative. One concluded the book “is an excellent relied upon, and that the first priority is the- electrolyte imbalance during treatment , summary of optimal management under prevailing rapeutic feed to ensure infant survival. This which occur more rapidly with modern the- conditions”. Another stated “the manner in which position is echoed in the recently published rapeutic feeds, make children much more the book is set out is helpful, and meets the need for ‘Caring for Severely Malnourished vulnerable to therapeutic errors – inappro- a book more orientated to nurses and healthcare Children’ (Ashworth and Burgess, 2003). priately transfusing to correct a dilutional workers than the WHO manual”. A third stated that The WHO draft guidance recommend fall in haemoglobin is, the critique warns, the book “is far superior to any other options avai- giving supplementary therapeutic milk usually fatal. lable and provides in clear language an approach before each breastfeed. This is contrary to Antibiotics the supplemental suckling technique5 and which would improve the care of children in gene- The 1999 WHO guidelines recommend the expert breastfeeding recommendations, ral and the care of severely malnourished children use of cotrimoxazole as first line antibiotic where breastmilk is always offered first6 . in particular”. treatment, where there are no signs of infec- The WHO draft guidance recommend the This book is available at a subsidised low price tion or complications. The critique suggests use of F75 during stablisation and full (£3.15 + postage) only from Teaching-aids At Low that since nearly all severely malnourished strength F100 during recovery of infants cost (TALC), PO Box 49, St Albans, Herts. AL1 5TX, children have small bowel bacterial over- under six months. Argument against the use United Kingdom ([email protected]). The book is also growth (SBO)9, oral amoxicillin is preferable of full strength F100 in infants under six available on CD ROM which in addition includes a since (unlike cotrimoxazole) it is active months revolves around water balance and comprehensive guide for trainers 'Improving the against SBO. This alleviates the need to use renal function in young malnourished Management of Severe Malnutrition' and the TALC metronidazole for SBO suppression, recom- infants (see Field Exchange 19)7. Instead, the slide set 'Treatment of Severely Malnourished mended in the Ashworth/Burgess publica- critique considers diluted F100 the formula Children'. The combined cost of the book + CD is tion (2003). £4.50 + postage. The book is also available from of choice for young malnourished infants, Macmillan country offices and through local books- while F75 and infant formula are considered The evidence base hops. For contact details of local offices, please see safe to use but less pragmatic options. The While these issues are derived from field www.macmillan-africa.com/Contacts. Ashworth/Burgess publication recom- experience and documentation not readily 16 News & Views accessible, they do represent current thinking, often controversial, in addressing severe malnutri- Debate on the Management of Severe tion. Gaps in evidence are also partly due to the difficulties of conducting operational research in Malnutrition : A Response emergencies. Certainly, individuals and agencies should bear some responsibility in sharing and By Professor Ann Ashworth, London School of Hygiene and Tropical Medicine writing up their experiences and findings. However there is also a sectoral responsibility to Background Management of severe oedema promote and support this process, and a technical Many individuals and organisations, inclu- In the stabilisation period, the target energy responsibility to consider this informal evidence ding NGOs, have contributed to the improved intake is 100kcal/kg body weight/day, and base when developing or updating guidelines. treatment of children with severe malnutrition, ‘per kg body weight’ is referring to metaboli- Differing and convincing opinions on practice but case-management remains very poor in cally-active tissue mass. The weight of seve- exist between, and are recognised by, the experts most hospitals in developing countries and rely oedematous children does not reflect their themselves. Yet alternative approaches to mana- many children die as a result. Children with true tissue mass as their weight is elevated by ging malnutrition can sometimes suggest conflic- severe malnutrition are usually treated at dis- oedema fluid. The WHO-IMCI Working ting opinions when, in reality, there are none. For trict hospitals (i.e. at the first-referral level) but Group took a figure of 20% as being a reaso- example, the perspective of the clinician may pre- medical and nursing students are usually trai- nable estimate of the proportion of weight due sent an entirely different viewpoint and set of prio- ned in tertiary hospitals and they may go to oedema fluid in children with severe rities than the public health expert, more concer- through their entire training without having oedema (i.e. oedema of the feet, legs, hands, ned with the population at large. However, con- managed a severely malnourished child or arms and face). So for severely oedematous flicts and errors can arise when approaches encro- been taught best-practice. The WHO manual1 children, the guidelines advise 100ml/kg/day ach on one another, without involving the “expert and the more recent WHO-IMCI guidelines2 of F75 instead of 130ml/kg/day (roughly a other”. Thus, simplifying complex clinical manage- aim to fill the knowledge gap about how to 20% reduction) which will lead to a daily ment, targeted at the majority of health workers care for severely malnourished children. The energy intake of approximately 100kcal/kg but without careful clinician input, risks sugges- Ashworth & Burgess book3 follows the WHO oedema-free body weight/day. This achieves ting that such treatment is easy to administer and guidelines and is part of this endeavour. It des- the target intake without risking heart failure may be open to error. Equally, basing guidance-for- cribes in simple terms what to do and why, from sodium and fluid overload. It is not all on the management of the clinical complexities and is primarily for nurses, clinical officers and ‘underfeeding’, as the intake /kg true of individual cases, useful for specialist and expe- medical assistants working in poorly-resour- weight/day is met. rienced practioners, risks alienating many of those ced hospitals. The WHO Training Course4 tea- Diarrhoea and dehydration working in the field who need simple, practical ches practical skills as well as knowledge, and Children with profuse watery diarrhoea can and pragmatic advice that will, on balance, do hospital teams from over 20 countries have become dehydrated if no action is taken to most good and least harm to the majority. There is been trained in the last two years. Some natio- replace the lost fluid. WHO suggests 50-100ml room for all approaches, but a collaborative effort nal training courses have been held and more of ReSoMal as a guide after each watery stool. and consultation is required to make this work. are planned. This is consistent with data from the The way forward Although the WHO manual and WHO- International Centre for Diarrhoeal Disease IMCI guidelines differ only slightly, the latter The production of the 1999 WHO guidelines, Research, Bangladesh, where the typical range reflect an international consensus of opinion as has, without doubt, improved morbidity and mor- for stool loss is 50-100ml/watery stool. The to what constitutes ‘best practice’ for first-refe- tality and the care of the severely malnourished, Centre treats many hundreds of severely mal- rral hospitals. Ministries of Health are adop- which may be substantially attributed to standar- nourished children with diarrhoea each year ting the international guidelines, and medical disation of care. Initiatives to improve the accessi- and stool collections are made for every child. and nursing schools are being encouraged and bility of standard guidance to those with few Most hospitals and TFCs have no provision enabled to include the guidelines in their curri- resources and limited support are long overdue for measuring stool losses and so replacement cula. Case fatality rates are beginning to fall, and welcomed. volumes will always be a matter of judgement but it will need the combined efforts of many Although published in 1999, the current WHO as stool losses vary, but a guide of 50-100ml is people to scale-up existing efforts. guidelines were first drafted in 1992 - many of the reasonable given the large body of evidence areas of contention stem from field practices and Management of infants less than six from Bangladesh. experiences over the past 10 years. Given the ever- months Blood transfusions changing face and challenges of emergency nutri- There are two concerns regarding the severely There is no divergence of views. Very severe tion, guidelines need to be managed as working, malnourished young infant: i) immediate wel- anaemia may not be common but when it “living” documents. The technical issues summari- fare of the child (stabilisation with F75 and does occur action is required. The WHO sed here suggest the need for a formal review of catch-up, with continued breastfeeding) ii) manual and guidelines define the circumstan- the evidence base of the 1999 WHO guidelines for long-term welfare of the child at home (espe- ces when a blood transfusion is needed and the management of severe malnutrition. Such a cially breastfeeding). Stabilisation of the child describe appropriate treatment. Repeat trans- review process needs to include a mechanism to has to have priority on admission to ensure fusions should not be given even if the hae- engage with field practioners, and should take into survival and return of appetite and strength. moglobin level stays low and this is stated in account the largely informal evidence base that is Diluted F100 is discouraged for the stabilisa- the WHO-IMCI guidelines. The risk of heart guiding current field practice. Updating and revi- tion phase because its potential renal solute failure from fluid overload is stressed in the sion of guidelines takes time. Where there are iden- load and sodium and lactose contents are more WHO manual and guidelines, and actions to tified gaps in recommendations, interim guidance - than twice those of F75. Thus F75 is more sui- avoid fluid overload are described. generated through expert consultation, for exam- ted metabolically for stabilising severely mal- ple - could be considered. This, in turn, could be nourished infants than diluted F100. In the Antibiotics tied in with the review process, e.g. valid for a catch-up phase, diluted F100 may be prefera- The choice of antibiotics for first-referral hos- given period. The WHO, as lead technical agency, ble to full-strength F100 for very young infants pitals was guided by effectiveness, availabi- would be well placed to initiate this process. (<4m) but this has not been tested. A randomi- lity, and cost. The need for flexibility due to local patterns of pathogen resistance was For further information about this piece, or to zed trial is being planned. In rapid growth, recognised. contribute views, opinions or data related to this although F100 has a higher potential renal issue, contact [email protected] or solute load than diluted F100, solutes are chan- Way forward [email protected] neled into new tissue and do not need to be If there are robust new data that challenge the excreted by the kidney. 1 Ashworth A and Burgess A, 2003. Caring for severely mal- treatment practices advocated by WHO then Although supplemental suckling has been these should be placed in the public domain nourished children. Published by Macmillan, supported by reported as successful, this is not always the Teaching aids At Low Cost (TALC), funded by the US Agency and reported in a manner that will allow scru- for International Development (USAID) through the Food and case. This technique requires considerable sup- tiny and peer review. Divergent protocols Nutrition Technical Project (FANTA) of the Academy for port and supervision and when implemented cause confusion and distrust among health Educational Development (AED), 2003 as part of routine hospital care, the results are 2 workers, and weaken the message. We should News, Caring for severely malnourished children: book variable. For example in Afghanistan, many review, Field Exchange 20. all speak with one voice. No new data have 3 Management of severe malnutrition: a manual for physicians infants had no weight gain for weeks with this been published or presented to WHO that and other senior health workers. WHO, 1999 technique. More data are needed before any 4 challenge the guidelines. There is, however, a ENN/GIFA Project, summary of presentation, Field Exchange conclusion can be made about the role of sup- 19, p28 growing body of evidence to show their effec- 5 plemental suckling in the care of severely mal- Field Exchange 9, Infant feeding in a TFP, p7, Mary Corbett tiveness. 6 Infant Feeding in Emergencies, Module 1 for emergency nourished infants. relief staff. Draft material developed through collaboration of: In the Ashworth & Burgess book, F75 is 1 Management of severe malnutrition: a manual for WHO, UNICEF, LINKAGES, IBFAN, ENN and additional contri- called 'starter formula' because experience sho- physicians and other senior health workers. butors. March 2001 WHO,1999. 7 wed that a 'functional' name was more mea- Diet and renal function in malnutrition, Summary of presen- 2 Management of the child with a serious infection or tation, Field Exchange 19, p24 ningful to indigenous health workers. We severe malnutrition. Guidelines for care at the first- 8 Wharton BA, Howells GR, McCance RA. Cardiac failure in found mistakes were made when it was called referral level in developing countries. WHO, 2000. kwashiorkor, Lancet 1967; 2;384-387 F75 as some health workers misinterpret F75 to 3 Caring for severely malnourished children. Ashworth 9 Unpublished data. Eva Lamm. Breath hydrogen excretion in mean 'give 75ml'. A, Burgess A. TALC, 2003. children when malnourished and during recovery. MSc report, 4 Training course on the management of severe malnu- University of Uppsala, 1998 trition. WHO, 2002.

17 Letters Field Article

Dear ENN, Border Closures and Further to your article on the technical debate regarding the management of severe malnutrition, I wish to offer some contex- Nutrition in Gaza tual information to the development of the World Health Organisation (WHO) guidelines, and agency field protocols. By Dr. Adnan Al-Wahaid Initial guidelines for the treatment of malnutrition, written in the 1970s in Jamaica, were published by the Pan American Health Organisation (PAHO) and subsequently by the World Health Organisation (WHO) in the 1980s. They were based upon practice at the tropical medicine research unit (TMRU) in Jamaica, treating Dr. Al-Wahaidi is a paediatri- small numbers of children (about 50 children a year). The resear- cian based in the Gaza chers, clinicians and staff were all highly trained and had ample Strip. Originally working for access to sophisticated instruments, literature and funds. They Terre des hommes since were ‘overstaffed’ to facilitate research measurements, which allo- 1987, he is now Medical Director of Programming for wed labour intensive individual treatment to be given. The guide- its Palestinian successor, lines were not even implemented in the paediatric wards next to Ard El-Insan. the unit where they were written. The continued support of Non-governmental organisations (NGOs) and agencies used Terre des hommes, Karim Rida Saed Foundation-UK, the practical guidelines published by Medecins sans Frontieres Medical Aid For Palestinians- (MSF) - in most hospitals no generally accepted guidelines were UK, ECHO and the Swiss being used. In the early 1990s, when I drafted the current WHO Government is gratefully guidelines , I simplified them as much as I thought safe. The big acknowledged. step was to formulate the diets, instead of giving individual ingre- dients by weight of child. Nevertheless, the basis of the manage- ment was the experience of a research ward. The draft guidelines were given to the NGOs in 1994. Action Contre le Faim (ACF) took these draft guidelines, wrote practical protocols based upon the principles and provisions, and persua- ded Nutriset to start to produce the diets commercially. Their pro- tocols have since been adopted by most NGOs. These NGOs have now treated many hundreds of thousands of children using the guidelines and have amassed an enormous body of data, informa- tion and experience. For example, in Burundi from January 1999 to December 2001, 80,419 severely malnourished patients’ characte- ristics and outcomes were entered into the national database, coor- dinated and maintained by UNICEF. The main expertise in appl- ying the protocols and the effects of their variation now lies with the NGOs. However, in most places the data are not systematically collected or analysed. Yvonne Grellety made a very detailed analy- sis of over 10,000 patients from 13 countries in Africa. Interestingly, she confirmed, en masse, the importance of the old physiological data showing the sensitivity of these children to sodium and their propensity to develop heart failure in several different situations and analyses. The original draft guidelines have been treated as a ‘living document’ that has gone through an evolutionary process – like computer software, we no longer use dos 3.1 (the operating system used for the original draft). The analyses, together with fre- This article describes the nutritional and health consequences of quent field evaluations, in many different contexts and countries, the closure system in Gaza, as experienced by a paediatrician shows where the critical points in the protocols lie and where dif- working there. ficulties of training, understanding, application and scale arise in practice, particularly in resource limited situations or emergencies. This has resulted in a number of changes in both detail and he political situation in the Gaza Strip has resulted in a emphasis. The modified protocols are greatly simplified. They high level of international media attention. The vulnera- are relatively easy to apply in the field by nurses and nurse-assis- bility of the Palestinian people is easy to see by walking tants. The results being obtained are, in some places, as good or through the streets of the overpopulated Gaza Strip, better than those obtained in the research ward in Jamaica. It is Tespecially in the refugee camps. Population density is estimated relatively easy to get good results from an adequately resourced, at 3,278 individuals per square kilometre, one of the highest in dedicated team in a research setting, it is quite a different matter the world. The 362 square kilometres of the Gaza Strip are inha- to maintain good results in routine service. Nevertheless, at a bited by 1,196,591 Palestinians, with one-quarter of the land national scale the results are a success story. The mortality rate occupied by less than 5,000 Israeli settlers who began arriving in (2000/2001) for Angola was 6% (3,976 deaths, 66,165 discharges) 1967. The Israeli settlers consume the majority of underground and 5% (3,552 deaths, 74,759 discharges) in Burundi. The current water, which is derived from the coastal aquifer. More than 66% data for Ethiopia appear to have an even lower motality rate, with of the Gaza Strip population are refugees who lost their home- the best centres reporting around 1% mortality. land ‘Palestine’ when Israel was formed in 1948. Poverty has drastically increased over recent years, while The main changes are of emphasis. Some aspects we thought Israeli activities continue to undermine the already poor were vital fifteen years ago are now known to be either minor or resource situation of the Palestinian National Authority (PNA). in some cases detrimental. Conversely, other aspects that were not Poverty and poor access to employment have been most res- emphasised were omitted, or compromises made in the original ponsible for an alarming deterioration in the nutrition and guidelines are now seen to be critical. The aspect of emphasis and health status of Palestinians, affecting more than 65% of the approach is far from trivial. It determines where resources are Gaza Strip population. Local, national and international organi- directed when they are limited. sations have implemented well-intentioned interventions in The challenge is to find a mechanism for both translating this order to address existing food and nutritional problems. very extensive body of knowledge into internationally endorsed However, the quality and relief focus of this work has, on occa- guidelines within a reasonable time span, and to create a proce- sion, drawn criticism, particularly with regard to sustainability. dure for regularly updating the guidelines so that they are not out- Ard El Insan Palestinian Benevolent Association (AEI) is the dated or used to produce derivative training material years later, Palestinian counterpart of the Swiss organisation Terre des when the State of the Art has moved on. hommes (Tdh). Many international organisations4 contribute to Yours AEI to support its activities in advocacy, child and family health Professor Mike Golden and community nutrition. Recognising the interdependence of Email: [email protected] nutrition with health and other sectors, AEI undertakes a variety of preventive and curative health care activities, as well as work aimed at improving the nutrition and food situation of the Palestinian people, especially during stress periods.

18 Field Article

they are deprived of adequate storage facili- provides follow-up of severely and modera- ties for fresh foods. Resulting dependence on tely malnourished children, and nutrition dry food rations and canned alternatives, in education addition to poor quality water, are direct cau- • a special care unit for specific nutritional ses of micronutrient deficiencies like iron treatment, such as nutritional anaemia, coeliac deficiency anaemia and rickets. disease, and rickets This tragic situation has dramatically affec- • a breastfeeding counselling unit, for ted the nutritional and health status of the mothers who present with breastfeeding diffi- Palestinian people. Contributing factors to culties. malnutrition include poverty, poor infrastruc- During 2002, 8,163 new cases were managed ture, low levels of sanitation and high levels at the centres, of which 6,750 were undernou- of food insecurity. Vulnerable groups such as rished and/or anaemic children. Overall, 40% children and pregnant or lactating women are of new cases (n=3265) were assessed at the compromised further as a result of inade- medical and nutritional assessment unit, 589 quate nutritional supplementation, leading to cases (7.2%) in the special care unit, 604 cases higher risk of stillbirths, premature deliveries (7.4%) in the GMU and 16.4% (n=1344) in the and low birth weight babies. Chronic nutritio- breastfeeding counselling unit. In the commu- nal deprivation is adversely affecting the nity, 3,116 undernourished children were trea- majority of the Gaza Strip children and other ted in the same period. vulnerable groups, ensuring a legacy of poor The unprecedented magnitude of the health status as well as impaired physical and health/nutrition and socio-economic pro- mental development. blems currently seen in the Gaza Strip has led to an expansion and strengthening of AEI ser- Nutritional status of Palestinian children vices. New staff members have been recruited The deterioration in nutritional status of and more activities have been directed to the Palestinian children has become well recogni- deprived areas and locations where life has sed at both national and international levels. Food security in the Gaza Strip become extremely difficult due to Israeli mili- Results of a nutrition survey carried out in tary activities, e.g. Rafah, Beit-Hanoun, and Palestinians are well known for being gene- August 2002 2 found 13.2% of children in the rous. Their hospitality is, to some degree, areas close to the settlements. However, our Gaza Strip suffering from acute malnutrition. capacity remains stretched, while a combina- measured by the variety of foods served to This compares unfavourably with survey their guests. However, nowadays, people tion of food insecurity and safety problems figures from 1995, where only 5.7% of chil- continues to pose enormous challenges to the partly define their grinding poverty in terms dren under 5 years were acutely malnouris- of no longer being able to serve their guests a Ministry of Health and non-governmental hed (<-2SD of the reference weight for organisations (NGOs). Many of the challen- diverse meal. The population is now depen- height)3. More recently in March 2003, provi- dent on rations or food donations from out- ges to food security and nutrition, including sional findings from a study by AEI and the role of the Israeli ‘occupation’, the safety side. The loss of self-sufficiency, and absence Accion contra el Hambre (Madrid) indicate of land that allows choice of food, creates a of Palestinians and the deteriorating food considerable food insecurity and economic nutritional situation, were raised in a UN strong sense of indignity. These difficulties are vulnerability in the Gaza population4. compounded by political and military actions, meeting ‘food as a human right’, attended by which can result in border closures and demo- AEI activities AEI and Palestinian NGOs in Gaza in July 2003. lition of houses, crops and gardens. The main target groups of AEI are those Most people in the Gaza Strip buy their living in the most needy areas, those who Concerns for the future food from the market since they lack land for reside near the Israeli settlements, and areas Continued and prolonged food deprivation cultivation. Although there are many types of subjected to military Israeli incursions. will clearly lead to further deterioration in the food in the market, supplies are irregular. Alongside relief and medical care, commu- nutritional situation of Palestinian children Unemployment has reached catastrophic nity health programmes have been developed and other at risk groups. This will in turn lead levels in the Gaza Strip (more than 60%). This which include intensive breastfeeding coun- to higher morbidity, e.g. respiratory tract has translated into very limited purchasing selling plus health and nutrition education. infections, diarrhoeal diseases and intestinal power for food. Dependency ratios have This approach aims to increase people’s capa- parasites and resulting mortality. Unless steps increased dramatically and in many families, city to cope with the ever increasing nutritio- are taken to ameliorate the situation, this will food purchase is sacrificed for other urgent nal and health demands, while working clo- have significant and unacceptable nutrition needs such as treatment of diseases or paying sely with the Ministry of Health and other and health implications for future generations back debts and loans. Other factors which health providers to incorporate longer term of Palestinians. constrain access to food include difficulties in national nutrition strategies. importing/exporting goods due to disrupted AEI have four operational centres in Gaza For further information, contact: AEI, email: logistics caused by Israeli activities, prolon- - one at Nusseirat middle camp, one in [email protected] or Mr. Khalil Marouf ,Tdh, ged sieges, curfews, border closures, road Khanyounis and Rafah, one in the south and e-mail: [email protected] blockades and the direct impact of military one in the north (Jabalia camp of refugees). operations, incursions or raids. The community health team operate as two The lack of capacity to cook food on a daily mobile groups, one in the north and another 1 Contributors to AEI include Medical Aid for basis is another big problem, often caused by in the south, and comprises 24 community Palestinians UK (MAPUK), Karim Rida Said inability to buy the gas or fuel, which is more health workers. These work in support of the Foundation UK (KRSF), Terre des hommes, expensive in the Gaza Strip and the West Bank centre-based activities and outreach services ECHO, NPA, IRFAN Canada and IBFAN than in any of the surrounding countries. into more inaccessible areas. 2 Nutrition survey, Johns Hopkins University People are therefore forced to borrow the fuel School of Public Health, Gaza, August 2002 or borrow cash for fuel purchase. There are Each operational centre comprises: 3 Nutrition survey, Terre des hommes, 1995 also numerous occasions when fuel or gas • a medical and nutritional assessment unit 4 Nutrition survey, Accion contra el Hambre cannot be imported into Gaza, or may not • a growth monitoring unit (GMU) which and AEI, March 2003 even be allowed to be conveyed from one area to another inside the Gaza Strip, simply bec- ause of border closu- res lasting from hours up to several days. Electricity sup- plies are also proble- matic due to the poor infrastructure, resulting from deca- des of ‘disabling’ Israeli regulations and the complete dependency on Israel. Poor house- Dr. Adnan A Al-Wahaidi Dr. holds cannot pay the Adnan A Al-Wahaidi Dr. bills and may lack "AEI have four operational centres in Gaza, where they work closely with the Ministry of Health and other health providers to refrigerators. Hence incorporate longer term national nutrition strategies"

19 Postscript Evaluation

Malnutrition on Political Grounds

By Hadas Ziv

Based in Israel, Hadas Ziv works for the organisation Physicians for Human Rights – Israel, and is Project Director for the Occupied Territories.

he last three years have witnessed and exerts total authority over the every- a severe deterioration in the rela- day lives of Palestinian residents. At the tionship between Israel and the same time, the Israeli government prefers Palestinians in the Occupied to contact foreign and international organi- Territories. Civilians in both societies sations and ask them to provide humanita- became victims of appalling acts of vio- rian assistance to the Palestinian residents lence, betrayed by their leaders who are of the Occupied Territories 1. unable to courageously initiate an alterna- tive. While this is true, we believe that Israel's regime of severe restrictions Israel, both because it is already a well- imposed on freedom of movement within established and powerful state, and the West Bank and Gaza Strip - as well as MSF Holland in because it is the Occupying Power, bears between the two, and between them and the responsibility to initiate an end to the the outside world - has severely affected hostilities. It is also clear that as long as the Palestinian economy, causing deterio- Afghanistan Israel retains control of the Occupied ration in their standard of living, nutrition Summary of Evaluation1 Palestinian Territories – it is responsible for and health. According to the World Bank the well being of all people under its con- "the second year of Intifada witnessed a trol. Poverty is a direct result of the closu- further steep decline in all Palestinian eco- res system and therefore Israel is accounta- nomic indicators. By the end of 2002, Real ble for the impaired welfare of the Gross National Income (GNI) had shrunk Palestinian residents of the Occupied by 38 percent from its 1999 level. Poverty Territories. In our clinics in the West Bank Last year, MSFH Holland (MSFH) – defined as those living for less than commissioned an evaluation of their we encountered similar situations to those US$2.1 dollar per day – afflicts approxima- activities in Afghanistan between described by Dr. Adnan Al-Wahaidi. We tely 60 percent of the population”2. The May 2000 and May 2002. The eva- were struck by the high level of bed wet- effects of these indicators on health are evi- luation set out to: ting in the 7-12 year old age group. We also dent: "the health status of the Palestinian i) understand MSFH’s role in encountered cases of diarrhoea due to bad population has deteriorated measurably. Afghanistan and how MSFH adapted water, and problems in child development Real per capita food consumption has nutritional and health programmes due to malnutrition. dropped by up to a quarter when compa- in a rapidly changing political and red to 1998 levels.”3 The effects are espe- operational context in the cultural Physicians for Human Rights (PHR) - cially visible on women and children with setting of Afghanistan Israel was established in 1988 as a non-par- higher levels of malnutrition and anaemia. ii) examine how MSFH used its tisan, non-profit organisation. It brings The decline in economic activity leads to a proximity in the region to witness together volunteer health workers and steep fall in tax payment, which in turn violations of humanitarian principles human rights activists who work against causes a growing inability of the and law and how MSFH positioned abuses of human rights in general, and Palestinian Authority to supply basic ser- itself in its advocacy work. champion the right to health in particular. vices, let alone develop its infrastructure. This summary of the evaluation fin- Its members and staff attach deep signifi- Although invaluable to the lives of cance to close cooperation with Palestinian dings concentrates of the first of Palestinians, international assistance is these objectives. civil society, human rights activists and problematic, since it addresses a situation medical organisations and workers. In our to which the solution can only be political. medical and human rights work we strive to construct, even if on a small scale, an "The sine qua non 4 of economic stability alternative to that of violence and hostility, and recovery is the lifting of closure in its thus showing that such an alternative is various forms, and in particular internal possible. closure. As long as Palestinian internal eco- nomic space remains as fragmented as it is PHR-Israel has been prevented from today, and as long as the economy remains entering the Gaza Strip for three years subject to extreme unpredictability and now, refused by the Israeli security appa- burdensome transaction costs, the revival ratus on the grounds of our staff's personal of domestic economic and Palestinian wel- safety. However, our experience in the fare will continue to decay”5. West Bank, where we have been conduc- ting mobile clinics every Saturday in coo- As long as the occupation continues, the peration with various Palestinian health State of Israel's commitment to provide NGOs for the past 14 years, shows that our such assistance is both a moral and legal activity is welcomed and appreciated. concern. M ethods Our work in the Gaza Strip is therefore Two external consultants with back- severely restricted. We keep in close con- grounds in nutrition and health under- tact with human rights and health organi- took the evaluation. Field work took place sations, campaigning and advocating for 1 in Kabul, Herat and Kandahar where the freedom of movement of medical staff The Mission Report 11-19 August, of Ms. Catherine Bertini, UN Personal Humanitarian Envoy of the interviews were carried out with MSFH and patients both on an individual case- Secretary-General, states her appointment was in by-case basis, in emergency cases, and also response to– among other things – "a request from project staff , personnel from INGOs, local Prime Minister Sharon of Israel to the Secretary- NGOs, UN agencies, and MoPH staff. The on a collective basis regarding policies of General to assist in addressing humanitarian needs entry and exit. We also monitor the treat- arising from the ongoing Israeli-Palestinian consultants also attended a regional ment of prisoners and detainees from Gaza Conflict…" (p. 1). workshop in Ashgabad and a medical co- 2 World Bank, Twenty Seven Months – Intifada, who are held in Israel away from their Closures and Palestinian Economic Crisis, An ordination day in Amsterdam. Phone families. We then disseminate the informa- Assessment, May 2003, p. xi. 3 see footnote 2, p. xiv. interviews were conducted with staff in tion to our public. Israel has now resumed 4 an essential condition or element Quetta, Pakistan while a number of MSFH 5 full control of the Occupied Territories, see footnote 2, p. xvii. staff no longer involved in the programme were interviewed in London and Amsterdam.

20 Evaluation

MSFH implemented traditional emergency response capacity of other agencies. feeding programmes in a number of open set- tings partially to collect data which would be MSFH placed too much confidence in rapid MUAC assessments which it saw as a viable Fiona O'Reilly useful in advocacy but also to prevent severe malnutrition. However, there was limited alternative to weight for height surveys. evidence of ‘alarming’ levels of malnutrition Rapid MUAC assessments found alarming and traditional feeding programmes were rates of Global Acute Malnutrition (GAM) which were not the case where weight for found to be inappropriate to the cultural set- height surveys were undertaken. Similar pre- ting so that eventually these were either dis- valences of GAM were not identified in a limi- continued or adapted (e.g. mobile SFP). ted number of surveys reviewed where both indicators were measured. The correlation Thorough investigation of outcomes in between weight for height measurements and terms of malnutrition and mortality was not MUAC requires further analysis in this setting rigorously undertaken by MSFH. However before MUAC can be used with confidence in where other agencies managed to undertake place of weight/height to define prevalence of thorough representative investigation morta- malnutrition. Trend analysis was also affected lity was found to be high and related to dise- by assessments carried out on changing popu- lations and using varying age and height cut- ase while levels of malnutrition were lower offs. than expected in the context of a food crisis. The high dependency on expatriate staff There was a considerable need within with sometimes limited experience and short Afghanistan for credible information on how contracts, for project management led to lack the drought was impacting the health and of continuity of approach. The difficulties nutrition of the population. As a health experienced by MSFH in human resource agency with historical capacity in nutrition management were often related to inability to the evaluators suggested that MSFH could fill positions by expatriates. Yet MSFH's expe- have capitalised more on their comparative Kandahar, Afghanistan, 2002 rience has shown that management capacity advantage in the health sector by analysing can be accessed locally. and highlighting the health component of the crisis and by focussing their interventions At the time MSFH did not have policies more fully on the health sector, i.e. investing which addressed some of the issues that arise more resources in further strengthening and in connection with working in the type of lon- Limitations of the evaluation expanding health programmes and integra- ger-term health crisis that exists in Limitations included lack of a central ting nutrition components (where necessary) Afghanistan. Such a context raises issues on repository for reports and information on the into these health programmes. Also MSFH project management, how to work with, programme. Much information was lost or was well placed in the regional paediatric through or independently of local partners misplaced during the evacuation. The high ward to strengthen and support health infor- and infrastructure, the degree of dependence staff turnover meant that most MSFH interna- mation systems and analysis and strengthen on expatriate staff, coherence of health strate- tional staff connected to the programme over links in referring clinics, however this was not gies and methods of withdrawing from pro- the time period in question were no longer in done. This may have been a better option than grammes. Arguably, this absence of policy led Afghanistan at the time of the field visit nor focussing on a sector (food aid) where MSFH to a modus operandi that was not always were many key personnel from other INGOs were dependent upon the commitment and and UN agencies present during the period appropriate for the context. under question. Fiona O'Reilly Findings Key recommendations Within a context of the appalling health sta- The evaluation contained a number tus of women and children and poor access of recommendations related to the to basic health facilities in Afghanistan, the above findings. Key recommenda- focus of MSFH’s operational activities was tions that related specifically to nutri- affected by ‘what the Taliban would allow’, tion and food security aspects of the security , a developing drought induced food programme were as follows; crisis, lack of reliable information and how MSFH perceived its role (i.e. whether it • MSFH could further clarify its should focus on needs arising out of crisis, policy and strategy on implementa- human rights monitoring, or health needs of tion of general food distributions the most vulnerable). Over the time period in based on an analysis of past expe- question the focus changed from improving rience and the internal debate on this health care access in rural areas to focusing on issue that has taken place over the health needs in cities and eventually to safe past decade. This clarified policy motherhood in remote areas. should set out options on what to do in circumstances where food insecu- MSFH’s primary analysis of the impact of rity is severe and undermining MSFH the drought was in keeping with many other health programmes. agencies, i.e. that there was a developing food crisis, which required emergency food and • MSFH could increase capacity to nutrition interventions. Although MSFH’s support epidemiological analysis in perception was that a General Food areas of operation as well as compe- Distribution (GFD) was the most appropriate tence in integrating food security, response, staff were conflicted about whether health status and nutritional status MSFH should take on an implementing role. analysis. Ultimately the decision was taken (based on many factors and previous experience) that • Unless the current consensus chan- MSFH would not ‘do’ GFDs. MSFH therefore ges (as evidenced by new research) focused on advocating for improved GFD MUAC assessments and surveys and later implemented Blanket Food should be treated with the appro- Distributions (BFDs) as stop gap measures. priate caution. Although much of the advocacy work was important, MSFH were largely unable to Weighing supplementary rations, Mazlak IDP camp, 1 O’Reilly F., Shoham J. MSF Holland in influence or affect the mobilisation of GFDs Herat 2002 Afghanistan Mission Evaluation: May 2000-May in areas where they were implementing BFDs. 2002

21 Field Article

This article describes the impact of a food distribution programme tar- geting households of malnourished women and children in northern Afghanistan. The observations reflect the challenges of anthropometric measurement in this population, and also raise questions over the effi- cacy of short-term BP5 supplementation programmes. The nutritional vulnerability of Afghan women is also highlighted1 .

oncern Worldwide has been operational in northeast Afghanistan since 1998, following an intervention in response to the earthquakes that struck the northern part of the country. With a landscape of high mountains Cand narrow lush plains, north-eastern Afghanistan is an extre- mely remote area and access to many villages is only possible on foot or by donkey/horse. Poverty is a major issue. Water for irri- gation is scarce, access to markets severely limited, and almost all the population are involved in subsistence agriculture.

Between 1999 and 2001, Concern assistance targeted rural water supply, health education, and shelter rehabilitation. In the second half of 2001, Concern began to assist and support IDP (internally displaced persons) settlements in Takhar province and extended its FFW (food for work) infrastructure projects to Baghlan province. By 2002, Concern began to adopt a longer- term strategy, reflected in the programming approach in Rustaq district, an area with a population of 167,455 people. Here, the many villages surrounding the relatively large market town of Rustaq are hampered by poor land consisting mainly of rock for- mations, with little arable potential. In Rustaq district, commu- nity based organisations were established, through which Concern began to address food security needs. The early FFW and FoodAC (food for asset creation) projects were replaced by community based agricultural activities such as seed distribu- tions, seed banks and livestock vaccination, water projects to One of the project villages, 300 families, 100% rain-fed agriculture on provide safe drinking water and irrigation systems, as well as land 1700m above sea level, 15km away from the district capital with it’s infrastructure projects to construct roads, bridges and dams with bazaar and health facilities. Saqawa. September 2002 a voluntary community component. Chris Op Reis Nutrition and food security Following three years of drought, a food security and nutri- tional assessment by Concern in December 2001 showed alar- Targeted Food ming results. Although the sample size was small (100 house- holds in 7 villages), it indicated that there were pockets of great need that required immediate intervention to prevent death, dis- Distribution to Women placement and destitution. Women seemed particularly affected. In the surveyed villages, 36.5% of the females measured, had a MUAC (mid-upper arm circumference) <215mm, indicating and Children in Northern chronic severe malnutrition, and a further 27% had a MUAC <230mm, suggesting a high risk of becoming malnourished. In Afghanistan comparison, malnutrition rates (MUAC <125mm) for children aged 1 to 5 years were 10.1%. Meanwhile, the 2001 WFP VAM2 By Regine Kopplow, Concern Worldwide report suggested that 60% of the population in Rustaq district were drought affected and required food assistance until the end of June 2002.

Regine Kopplow is a senior nutrition advisor In response, Concern intervened to assist and support mal- with Concern, working in Afghanistan since nourished vulnerable families in Rustaq district. Aiming to meet April 2002. Previous field experiences immediate basic food needs, the project objectives 3 included include Namibia and Sierra Leone. provision of: • a balanced food basket for the malnourished to improve their nutritional status before/over winter • fortified food (BP5) to malnourished children and severely malnourished women to improve their nutritional status before/over winter. Targeting The project operated in two main phases. Phase One (August to December 2002) targeted 12 villages, while Phase Two (December 2002 to April 2003) targeted a further 16 villages. The 28 targeted villages were located between 5 and 35km from Rustaq town. The average population was 122 households per village, of which 9% constituted vulnerable groups, e.g. elders, disabled, unaccompanied children, returnees or female-headed households. Overall, 24 of the 28 villages were wholly depen- dent on rain-fed agriculture.

In the villages, all women aged 15 years and older and children aged between 6 and 59 months were assessed using MUAC. In order to facilitate nutritional monitoring and determine pro- gramme impact, all registered beneficiaries were later assessed using Body Mass Index (BMI)4 for women and weight-for-height % of the median (WH) for children.

All households with at least one person fulfilling MUAC crite- ria (women £220mm and children £124mm) were issued with a ration card. In total, 2734 women and 2127 children under 5 years were screened and 1294 households qualified to receive a monthly dry food ration over a period of 5 months. Based on an average family size of 6 members and given many years of war

22 Field Article and drought, the recent earthquake, exhausted coping mechanisms and empty food stores, the aim was to supply 100% of calorie need (2100kcal/day/person).5 6 Monthly famil rations consisting of 45kg wheat, 45kg rice, 10kg dried beans and 5kg vegetable oil, provided an indivi- dual daily intake of 2156 kcal, 60.5g protein and 33.7g fat.

Over a four-week period, BP5 biscuits (4 bars = 1000kcal) were distributed to selected children in Phase One and Two and women in Phase Two only, in addition to the monthly household ration. For children in Phase One, entry was based on MUAC only (≤124mm) while Phase Two entry included weight-for-height criteria (MUAC ≤124mm and < 80% WH). Entry for women in Phase Two was based on MUAC and BMI criteria (MUAC< 185, and/or BMI ≤16 7 ).

The nutrition team consisted of two female nur- ses, one female translator, two male nutrition workers, one driver and an international female nutritionist.

MUAC screening Chris Op Reis MUAC cut-off points were identified after a Boy on a donkey in Saqawa village, the normal transport facility, Saqawa. September 2002 thorough review of nutrition surveys conducted in Afghanistan by different agencies, and cross- Table 1 Classification of malnutrition by anthropometry checking during screenings at the start of the project. MUAC, BMI and WH (% of the median) Classification Children 6-59 m Women ≥ 15 years criteria used in screening and nutritional survei- llance, are outlined in table 1. Village MUAC screening of women and chil- MUAC WH MUAC BMI dren identified rates of malnutrition necessita- mm % mm % ting immediate intervention. From 2127 children screened, 12.9% were moderately malnourished Severe <110 <70 <185 <16 and 2.3% severely malnourished (15.1% global Moderate ≥110≥124 ≥70<80 ≥185 ≥220 ≥16<18.5 acute malnutrition). Malnutrition rates were not Global acute ≥124 <80 ≥220 <18.5 evenly distributed in children, most notably, • the prevalence of global acute malnutrition was highest in children aged 12 to 23 months Table 2 Prevalence of acute malnutrition in children pre and post intervention (37.2%) followed by children aged 24 to 35 months (28.4%). Classification Children 6-59 months and MUAC ≥124 mm • under 48 months of age, girls had higher rates of global acute malnutrition than boys. MUAC screening WH pre-intervention9 WH post-intervention • of those who were classified as severely mal- n 2127 306 275 nourished (n=48), 39% comprised infants under Severe 2.3% 2.0% 0.4% 1 year of age. Moderate 12.8% 13.1% 6.9% Global acute 15.1% (n=320) 15.1% (n=46) 7.3% (n=20) From a population of 2734 women screened, moderate malnutrition rates were particularly high (39.6%). The overall prevalence of severe Table 3 Prevalence of acute malnutrition in women pre and post intervention malnutrition was 1.0%. Women aged between 20 to 29 years had the highest prevalence of both Classification Women ≥15 years and MUAC ≥220 mm moderate (38%) and severe malnutrition (0.9%). Among malnourished women aged 20-29 years MUAC screening BMI pre-intervention10 BMI post-intervention (MUAC £220mm), 17% were pregnant and n 2734 808 749 41.5% breastfeeding. Meanwhile, half (50%) of Severe 1.0% 5.1% 2.4% those aged 15-19 years were pregnant (26.9%) Moderat 39.6% 30.9% 25.6% and/or breastfeeding (23.1%). Global acute 40.6% (n=1110) 36.0% (n=291) 28.0% (n=210) Weight-for-height (WH) and body mass 9 MUAC prevalence rates refer to the total population, while weight-for-height figures refer to the sub-group index (BMI) of the population with MUAC ≤124. Amongst children with a MUAC £124, the vast 10 BMI prevalence rates refer to the sub-group of the female population with a MUAC ≤ 220 and excludes majority (85%) had a WH ≥80%. Similarly, over women pregnant and/or lactating (infant under one year). See footnote 8. half (64%) of the women classified as malnouris- hed using MUAC had a normal/overweight BMI (≥18.5). Using BMI, only 31% of women elevated (2.4%), (see table 3). It should be noted after the last BP5 ration, the Phase Two WH had registered in the programme were classified as that the statistical significance of these findings dropped to 86.9%. moderately malnourished (BMI ≥16<18.5)8. was not tested. Since only women in Phase Two received the Conversely, the proportion classified as severely BP5 supplement, it was possible to compare their malnourished (BMI <16) increased. Compared Impact of BP5 distribution improvement in nutritional status between to women with a normal BMI (≥18.5 <25) and BP5 biscuits were distributed to 207 children Phase One and Two. With BP5 supplementation, MUAC ≤220, the severely malnourished group and 37 women over a four week period. All the mean body weight increased by an average were older (39y versus 34y), taller (1.55m versus women and children receiving BP5 were weig- 2.7kg (36.6kg to 39.3kg) and the improvements 1.52m) and had an average BMI of 14.98, and hed before, weekly during, and 6 weeks after the were maintained 6 weeks following cessation of MUAC of 192mm (BMI 20.22, MUAC 209 in nor- intervention. During the distribution, the nutri- supplementation (see figure 2). However, the mal BMI group). tional status of both women and children impro- same gain was found in the group without BP5 ved. However amongst children, nutritional sta- supplementation (36.1kg to 38.8kg). It should be Impact of monthly food ration tus declined once supplementation ceased (see noted that participation in the final weight moni- After five months of food distribution, all figure 1 ). Since different entrance criteria were toring was only 50% for the non-BP5 supple- Phase One beneficiaries were reassessed using used for the children in Phase One and Two, chil- mented group. BMI (women) or WH (children). Prevalence of dren entering Phase Two had a lower starting moderate and severe acute malnutrition fell to WH than those in Phase One. Children in Phase Women’s nutritional vulnerability acceptable levels amongst children (see table 2). Two, with an average WH of 77.5%, showed a The limited impact of the interventions on However global acute malnutrition rates remai- very rapid response to the 4 weeks of BP5 sup- women can, at least in part, be explained by ned unacceptably high for women (28%), while plementation, reaching a higher WH than Phase those longer-term factors underpinning nutritio- severe malnutrition rates halved but remained One (starting WH 88.4%). However, six weeks nal vulnerability of Afghan women. The cultural

23 Field Article

necessary training to understand the concept of the intervention, non-beneficiaries only see the quick nutritional improvement. Furthermore, it is common among staff and beneficiaries to call the BP5’s “biscuits”. This engenders a sense that normal biscuits are appropriate foods for chil- dren and endorsed by clinics and NGO’s. In many cases this led to severely malnourished children being exclusively fed with normal bis- cuits. In emergency situations, BP5 seems to be an appropriate supplementary food for short- term interventions, showing a quick impact on malnourished children. However, to reduce the chances of deterioration following the interven- tion, it is vital both to comprehend and concu- rrently address the underlying causes of malnu- trition in the intervention community.

Our findings highlight that nutrition surveys in Afghanistan should include women. Focusing exclusively on children, and even pregnant women in the third trimester does not reflect the entire dimension of malnutrition in the country. Considering the prevalence of early and fre- quent pregnancy and the potential implications for maternal and infant nutritional status,

Cecil Dune addressing the needs of Afghan women is all the Girls in one of the project villages observing sceptically the screening process. Rustaq/north-east more critical. Afghanistan. March 2003 For further information, contact Regine Kopplow at email: [email protected], or and social consumption patterns within the hou- cents (10-19 years as defined by WHO) in our [email protected] sehold do not favour women in terms of dietary comparison, and the lack of standard BMI cut- quantity or quality. Culturally, it is less accepta- off points for this group, may influence interpre- ble for women to move out of the confines of the tation of population-based figures. Ultimately, village than men. Consequently, there are fewer these findings highlight that MUAC cut-off opportunities for women to improve the quality points for malnutrition need to be further revie- of their diet, through purchasing or consuming wed in Afghanistan. Further research may be 1 Emergency Complementary Food Supplies To Drought vitamin/protein rich foods during visits to the needed on the Cormic Index11 to obtain more Affected Vulnerable Populations in Afghanistan, Ref: 605/11285/CON 08 02, 17 April 2002-30 April 2003, market, for example. Similarly, access to health reliable anthropometric reference data of Afghan Concern Worldwide systems is reduced by this restricted movement. adults. 2 World Food Programme/Vulnerability Analysis Mapping There is also poorer access to health education at 3 The project had other key objectives and activities rela- a time when there appears to be considerably BP5 is a compact energy rich food with easy ting to health and nutrition education, and hygiene which are not included here but are detailed in the main report less transfer of inter-generational knowledge, storing, transporting, distribution and prepara- (see footnote 1) especially in the rural areas. Finally, pregnancy tion character. The acceptability is high. 4 Body Mass Index (BMI) is calculated as weight (kg) divi- patterns suggest insufficient time for nutritional However in our intervention, the full weight ded by height squared (metres) recovery between births. gains were not sustained in children. Amongst 5 This meets Sphere standard on food aid requirements. 6 In effect, this meant that the project provided a general, women, weight gains were sustained although rather than complementary, food ration. Conclusions, recommendations and les- these were similar to those who had not been 7 Slightly different BMI cut-off points were used for severe sons learnt supplemented. Though interpretation of respon- malnutrition in women for surveillance (BMI<16) compa- A discrepancy was found between estimated ses amongst women is limited due to incomplete red to BP5 distribution (BMI≤16). As various standards exist, a cut-off point was accepted at the beginning of the malnutrition levels using different indicators. data, it would be valuable to investigate how, project, which was later revised as the project progressed. Amongst children, the vast majority who had and the extent to which, the factors contributing 8 All pregnant women (12%) and those breastfeeding been classified as acutely malnourished using to the long-term nutritional vulnerability of infants under six months (7.8%) were excluded from this MUAC, did not fulfil weight-for-height criteria. Afghan women impacted the effectiveness of comparative analysis. Thus, 219 women (19.8%) of the total group (n=1110) were not included. Of the remaining Only one-third of the women deemed modera- BP5 distribution. The experience also illustrates 891 eligible for measurement, 808 women were available tely malnourished using MUAC, were classified the need for clear education and training on the and BMI calculated. as such using BMI criteria. On the contrary, the rationale, use and constraints of BP5, for both the 11 The Cormic Index assesses the relative contribution of prevalence of severe malnutrition in women was beneficiary and the community. the trunk and legs to stature. It is calculated as the ratio of sitting height (SH) to standing height (H) SH/H and higher using BMI criteria. Women, overall, appe- expressed as a percentage. A means of standardising BMI ared ‘unusually’ shorter than men. While we In some of the targeted villages, Concern has using Cormic Index has been proposed, for both males have no clear explanation for these observations, been implementing community-based interven- (BMI =0.78(SH/S)-18.43) and females (BMI=1.19(SH/H) contributing factors may include phenotype, as tions that are at risk of being undermined by free – 40.34), and detailed in the RNIS supplement, Assessment of nutrition status in emergency affected well as chronic malnutrition and many early food distributions. The use of high-energy BP5 populations, Collins S, Duffield A, Myatt M, July 2000. See pregnancies influencing female development with a likely quick impact strengthens this ten- online and body stature. Also, the inclusion of adoles- dency. Even when beneficiaries receive the at http://www.validinternational.org/tbx/docs/ACF88.pdf

Figure 1: Mean weight-for-he ight ratio for children under BP5 Figure 2: Mean BMI of women under BP5 treatment (n=37) treatment (n=207) 16.4 95 16.2 16.3 16.3 92,2 90 90,6 90,7 91 16 89,9 88.4 15.8 85 86,9 86,2 15.6 80 15.4 77,5 Mean BMI 15.2 75 15 15.2 70 14.8

mean w/h ratio (% of median) mean w/h ratio 14.6 phase 1 phase 2 phase 1+2 before BP5 4 weeks 6 weeks after after BP5 last BP5 before BP5 after 4 weeks BP5 6 weeks after last BP5

24 Agency Profile

F Tdh feeding centre, Haiti. 1999 ield Exchange interviewed Philippe Interview by Jeremy Shoham Philippe explained how Tdh is a child-focu- Buchs, joint head of the Terre des hommes (Tdh) sed agency whose two main pillars of work are programmes department, and Rebecca Norton, “operational and advocacy.” He outlined three headquarters (HQ) nutrition advisor based in Name Terre des hommes,Tdh main sectors of Tdh work, which are maternal Lausanne, Switzerland. Philippe has worked for Address En Budron C8, 1052 and child health (MCH) and nutrition, children Tdh for 20 years (most of his working life). Five Le Mont sur Lausanne, in difficult circumstances, e.g. street kids, and years of this has been spent in the field and the Switzerland child rights, such as fighting against child traf- remainder at HQ. His background is in political Telephone +41 21 654 66 66 ficking. Rebecca explained how there are science. Rebecca has been a nutritionist at Tdh Fax +41 21 654 66 77 currently seven specialist advisors at HQ. As the HQ for almost three years. Internet Site www.tdh.ch nutrition advisor, she advises the desks, part- Year Formed 1960 ners and delegations on request. She is only the Tdh was formed in 1960 following the ‘war of Secretary General Peter Brey second nutrition advisor in the organisation, the decolonisation’ in Algeria. This war had a pro- Overseas Staff 24 expatriate first one being appointed four years ago. found effect in France and French speaking and 800 local Switzerland, raising awareness for many of the HQ Staff 90 In the past, Tdh nutrition programmes were extensive problems in developing countries. Annual Budget 22.7 million euro mainly selective feeding, e.g. supplementary Tdh continues to work in Algeria to this day, (expenditure in 2002) and therapeutic feeding. Nowadays, these acti- typifying how the agency tends to become vities are often coupled with education and involved in a country following an emergency health interventions. According to Philippe, and then stay on to undertake longer-term deve- “there has been an evolution towards a more lopment work. This pattern has recurred in mission deciding how to distribute monies integrated and holistic approach, with greater countries like Vietnam, Bangladesh (following amongst the various NGOs. focus on community based interventions over partition), Ethiopia, Rwanda, and Kosovo. the past five years. The idea is to listen to the However, there is no institutional split within Tdh now operates in 30 countries. In 2000, community more and not give out ready made Tdh between emergencies and development. In there were 43 country programmes, but this has messages”. Rebecca explained how the empha- fact, the very first emergency co-ordinator was slowly been reduced as country situations have sis is now on greater integration of nutrition only employed in 2003. improved - Tdh moved out of Bosnia two years programmes into existing mother and child after the war ended, for example. If Tdh move health programmes, so that improved treatment Tdh is a relatively small non-governmental into a new country, they will usually phase out of malnutrition becomes longer-term and sus- organisation (NGO) - the budget in 2002 was a gradually from another programme. tainable. Rebecca also stressed that Tdh are not modest 22.7 million euro. Approximately 83% of an organisation like Medecins sans Frontieres, the revenue comes from private donations and who are able to rush into emergencies and hit Tdh feeding centre, Haiti. 1999 the remainder from public funds, the ground running. Tdh lack the e.g. the Swiss government deve- capacity for this and only really lopment agency and decentralised work effectively where they have government at canton and com- long-term experience and local kno- mune level. The cantons hold a wledge. development budget, which a ‘federation of NGOs’ allocate to Philippe reasoned that as Tdh is members. Tdh have working a small NGO, it has to specialise in groups in the 23 Swiss cantons – areas like improving inadequate approximately 2,500 volunteers in maternal and child caring practices all. The volunteers support Tdh or improving health services (at the through fund-raising and profile district level). It, therefore, has little building, e.g. events in shopping capacity for food security work and centres. Tdh is also a member of will team up with other agencies the Tdh alliance, which has ten that have complementary abilities. members (the principal ones being Also, as a small agency, Tdh tend to Germany, Switzerland and Italy). work at health district rather than As Tdh funding sources are national level. While the agency diverse, their funding base is rela- always attempts to integrate pro- tively stable. For emergencies, grammes into local public health most funds come from a centrali- systems, this can be a problem in sed body called ‘Swiss Solidarity’. more remote areas where health This body generates funds systems are not working well. The through the media, with a com- temptation is then to set up Tdh’s

25 Agency Profile Field Article own programme independently. Rebecca identified difficulties in holding onto good staff as a problem. Tdh are putting a lot of effort into training local nutrition and health Suspected Thiamine staff but the good ones tend to be snapped up by the better paying agencies. Deficiency in Angola Two other ‘nutritional’ challenges are faced by Tdh, according to Philippe. First, the small size of the agency with only one nutri- tionist (supported by a public health doctor) By Manuel Duce, Dr. Josep M. Escriba, Dr. Cristina Masuet, Dr. Paula Farias, Dr. Elena Fernandez and Dr. Olimpia de la Rosa means that local teams have a lot of auto- nomy, but not always a lot of support from Dr. Paula Farias, Dr. Elena Fernandez and Dr. Olimpia de la Rosa HQ. As a result, Tdh try and work in net- are all medical doctors currently working in emergency situa- works of other agencies in order to obtain tions with MSF. The support of Pilar Perez Vico (documentalist), Simone Rocha (advocacy) and Dr. Gloria Bassets (director of support from elsewhere, when needed. the medical department), in the preparation of this article is Secondly, too little emphasis has been placed acknowledged and appreciated on the psychosocial components of malnutri- tion. The emotional and social environment of families needs to be addressed much more. Manuel Duce is currently the This is also very important in emergencies. HQ nutritionist at MSF-Spain. Tdh are currently involved in operational Prior to this, he worked for 11 years in the field, mainly research in Nepal, which started in 2001, loo- for MSF in Africa, Asia, Latin king at psychosocial factors leading to mal- America and the Caribbean. nutrition. The research is very much based on listening to mothers and then providing appropriate counselling. Results from the Josep M. Escribà is a medi- study show how long it takes to provide the cal doctor, who currently is working as the HQ epidemio- necessary psychosocial support and train logist. community people in taking on this role. The study report and a film of the study ’Down by the river – listening to mothers’ are now available (see news section of this issue). Cristina Masuet is a medical doctor, currently working as Rebecca went on to outline the following a volunteer with MSF in epi- new developments and initiatives in the demiology and nutrition. nutrition sphere: • Greater emphasis on integrating nutrition programmes within existing Mother and Child Heath programmes. • Providing more psychosocial support for families with malnourished children. • Strengthening capacity to provide breas- tfeeding counselling - the first Tdh breastfee- ding counselling course will be held in Africa this year. • Collating and disseminating key lessons learnt/best practice, and providing this in the form of a knowledge management system with software to field staff. It is hoped This article describes MSF-Spain’s field expe- Rapid assessment that this will be available by the end of 2004. rience in the detection and management of a sus- Access to Chipindo had been impossible for pected outbreak of beriberi in Angola. When asked about the specific strengths humanitarian organisations since the resump- and uniqueness of Tdh, Philippe made a tion of the war at the end of 1998. Following the number of points. Tdh are present when an he conflict between the government 2002 ceasefire, an MSF team were able to con- emergency arises (as they work in emergency of MPLA (Popular Movement for the duct a rapid assessment in Chipindo on April prone countries) so they know the culture, Liberation of Angola) and the ‘rebel’ 27th and 28th, 2002, although roads were inse- region and people. Prior knowledge is critical forces of UNITA (National Union for cure and difficult to travel and the airstrip was Tthe Total Independence of Angola) has been mined. in the early stages of emergency response. They are a very ‘grass roots’ agency and ongoing for more than 25 years. In February know their partners and their abilities well. 2002, the leader of UNITA was killed and a The assessment team found between 14,000 Most of these partners are local NGOs, the ceasefire signed by the warring parties. and 18,000 people, most of who had arrived in majority of whom have been helped by Tdh Despite the cessation of hostilities, and the Chipindo between May and September 2001. to establish themselves as an NGO. By hel- fact that humanitarian agencies have been Using MUAC screening, the prevalence of glo- ping the institutional development of partner able to move more freely, access to particular bal acute malnutrition was 30% and severe NGOs, this engenders a deep relationship areas continues to be a serious problem. acute malnutrition was 15%, in children aged 6- with partners of shared culture and tradition. 59 months. Tdh attempts to be flexible and not impose Medecins Sans Frontieres (MSF)-Spain has ready made solutions – field staff have a been working in Angola since 1989, carrying Later, in August 2002, MSF- Spain conducted decentralised approach and Tdh will always out emergency and post-emergency inter- a mortality survey using systematic sampling. A aim to add value to a project rather than just ventions. For months before the end of the total of 449 families and 2,193 individuals were fund, i.e. they take part in project planning. conflict, MSF teams in Caala and Matala had included. Crude mortality rate (CMR) and been receiving information on a location under five mortality rate (U5MR) were calcula- When asked to describe the ‘culture’ of his called Chipindo, where, allegedly, the popu- ted for the period 15th October 2001 (start of agency, Philippe commented that, in many lation had been confined with virtually no rainy season) to August 2002: regards, it was a ‘typical Swiss entity’- “the freedom of movement and hardly any assis- • CMR 4.7/10000/day (95% CI 4.1-5.3) Swiss government has been politically stable, tance being provided by the authorities, des- • U5MR 15.2/10000/day (95% CI 12.5-18.0) since 1959 and very much consensus driven. pite enormous need. Many of the inhabitants Tdh has no political affiliation and advocates of Chipindo had come from the north-eas- Most mortality occurred between October based on what it sees in the field, rather than tern and eastern parts of the Huila province 2001 and March 2002 (76.8%). Overall, malnu- ideology or global theories. With some excep- – areas formerly under the control of the trition was reported as the main cause of death tions - being openly against the recent war in rebels. Chipindo, itself, had been under (42.1% of all deaths). Malnutrition affected all Iraq, for example - Tdh does not make politi- UNITA control for over 13 years until it age groups, particularly those under 15 years cal statements. It is an agency which bases came under government control in March old (42.3% of all deaths occurred in this age programmes on field reality and trying to 2001. The area lacked any infrastructure and group). This might be linked to the fact that the change reality where necessary”. Rebecca’s was effectively a military base. In order for area was affected by a measles epidemic in response to the same question was that Tdh the military to have control over this displa- February 2002. is a very people-oriented agency and ced population, no one was allowed to leave nowhere is this better epitomised than in the without the express permission of high-ran- Suspected cases of beriberi excellent way in which staff are treated. king military officials. In response to the initial assessment and with

26 Field Article

first cases of beriberi, no general food distribu- explanation for this difference. tion had been implemented in the area. Based on the WHO classification, seven A total of 52 suspected cases of thiamine defi- patients (13.5%) showed dry or neuritic beriberi ciency, with a mean age 21.3 years 3 (ranging 4 (decreased reflexes or touch, algesic (pain-rela- months-82 years), were treated and observed. ted) and/or motor disorders) while nearly one- Those under 15 years of age proved most at risk, third (30.8%, n=16) demonstrated a wet or car- accounting for 61.6% (n=32) of all cases. Twelve diac beriberi (heart failure or oedema). Twenty- cases were in children under five years of age, eight patients (53.9%) demonstrated a mixed

e and 36.5% (n=19) in those over 15 years. Overall, beriberi, and one four month old infant (1.9%) an

c u

D there was no significant difference in incidence aphonic beriberi. Half of the suspected cases

l

e

u between males (42.3%, n=22) and females (53.8%, n=28) had at least two or more n

a (57.7%, n=30). However, in those over 15 years signs/symptoms that affected different organic M old, females were almost three times more sus- systems, and thirty-five patients showed neuro- ceptible to beriberi. As yet there is no proven logical signs. Table 2 includes an outline of the

Table 1 Beriberi attack rates for main demographic groups

Frequency of Total population** Attack rates beriberi (n)*

Male <15 y 17 3,970 4.28/1,000 =15 y 5 4,851 1.03/1,000

e

c u Female <15 y 15 4,130 3.63/1,000 D

l

e

u =15 y 14 5,049 2.77/1,000

n

a

M

Total 51 18,000 2.83/1,000

*The age of one patient is unknown. **The population numbers are estimated following the method described in “MSF Refugee Health. An approach to emergency situations”, 1997.

e Table 2 Clinical characteristics and recovery time of beriberi cases

c

u

D

l

e Clinical Total affected Group recovery Median time

u n

a characteristics to recovery M

Suspected cases of beriberi, TFC %* (n) %** (n) days (range) Chipindo. May/June 2003 Neurological Motor 65.4 (34) 79.4 (27) 6 (1-31) Touch 23.1 (12) 100 (12) 3 (1-14) Pain 17.3 (9) 33.3 (3) 15 (5-31) improved access, on the 3rd of May 2002, MSF Reflexes 5.8 (3) 33.3 (1) 4 (4-5) Spain opened a therapeutic feeding centre (TFC) and supplementary feeding centre (SFC) in Cardiac Oedemas 61.5 (32) 81.3 (26) 10.5 (1-38) Chipindo. During the first days of operation, 384 Heart failure 28.8 (15) 73.3 (11) 4 (1-21) children under five years of age and 60 adoles- cents and adults were admitted to the TFC, Other Loss of voice 5.8 (3) 66.7 (2) 5 (3-5) while 668 children and 468 adolescents and adults were admitted to the SFC. As some of the Gastrointestinal 3.8 (2) 50.0 (1) 18 (5-31) patients in the TFC had a combination of high output heart failure, leg oedema and polyneuro- *Percentage of affected patients by overall sample pathy, beriberi was suspected and thiamine ** Recovery percentage of affected patients by group (vitamin B1) treatment was initiated. Forty-one patients (78.8%) were treated using prescribed thiamine dosages for treatment of moderate beriberi, and 11 patients (21.2%) were treated using dosages for severe beriberi (nine of whom demonstrated motor deficits and oedema). Categorisation1 and treatment protocols for beriberi were based on WHO 2 recommendations (see box). Since laboratory facilities were not available, it was impossible to confirm defi- ciency of thiamine biochemically. Therefore, in Figure 1 Time (days) from start of thiamine Figure 2 Time (days) from start of thiamine order to confirm the disease and the efficacy of treatment to disappearance of beriberi treatment to disappearance of oedema, the treatment, a monitoring form was developed symptoms heart failure and motor symptoms to follow the progress of patients during the course of treatment. It is important to note that 100 100 as these protocols were initiated at the start of an 90 emergency intervention, and given the conside- 90 rable demands on staff and resources, the fin- 80 80 dings of the study have limitations and should 70 70 be viewed with some caution. 60 60 Those affected by thiamine deficiency in 50 50 Chipindo had been eating an extremely limited 40 40 diet. Patients reported that the first symptoms of thiamine deficiency appeared after they had 30 30 ecovery Probability ecovery ecovery Probability ecovery R been reduced to eating “batata dolce” (sweet R 20 20 Oedema potato) with wild leaves as their main food for Global Beriberi 10 10 Heart Failure two months. With little potential for food pro- Motor Symptoms duction, most of this population were comple- 0 0 tely dependant on food aid rations. However, 0 5 10 15 20 25 30 35 40 0 5 10 15 20 25 30 35 40 donor response to the emergency was slow and Time (days) Time (days) general food rations were implemented very late. At the time that the field team detected the

27 Field Article clinical characteristics of this sample. Overall, median recovery time was 15 days (6 to 31 days). Recovery rates and median time (days) for disappearance of speci- A guide to thiamine deficiency and beriberi fic clinical symptoms (recovery) are shown in table 2. Our results, reflected in figures 1 and 2, are comparable with those reported in Case definition the literature, i.e. heart failure is the first symptom that responds to Beriberi is a clinical syndrome that arises insidiously as a result of severe, treatment, followed by motor signs and oedema respectively. prolonged deficiency of dietary thiamine. In the early stages, it is charac- terised by anorexia, malaise and weakness of the legs, frequently with Ten people died (19%) during the intervention. Seven deaths (3 parasthesia, there may be slight oedema and palpitations. The disorder girls and 4 boys) were among those under 16 years of age. Of these, may persist in the chronic state or may, at any time, progress to an acute four cases had wet beriberi (3 boys and 1 girl) and three cases had condition characterized by either cardiac involvement with oedema, or mixed beriberi (1 boy and 2 girls). In addition, three adult women by peripheral neuropathy, or a combination of the two. died, two with mixed beriberi and one with wet beriberi. Diagnosis Conclusions and lessons learned Laboratory facilities are required to assess thiamine status through bio- It is usually assumed that beriberi only occurs amongst popula- chemical assays (blood thiamine, urinary thiamine excretion, blood tions consuming rice as their main staple. Our experience shows pyruvate and lactate, transketolase activity). that this is not always the case. If untreated, thiamine deficiency leads to death and in Chipindo, mortality rates were high even with Source of thiamine (vitamin B1) treatment. This may have been due to other complicating factors, Thiamine is present in almost all plant and animal tissue although most such as measles, diarrhoeal disease, acute respiratory infections and sources contain low concentrations of the vitamin. Body storage of thia- malaria commonly found in this population. Unfortunately, these mine is minimal and it has a high turn over rate. Therefore a continuous other factors were not assessed. supply of the vitamin is needed.

It was difficult to estimate the magnitude of the problem in the The major causes of thiamine deficiency include: area. Less than 1% of the population was suspected of having vita- • Inadequate diet (when the diet consists mainly of white (milled) min B1 deficiency (and treated). This constitutes a ‘mild’ public cereals, including polished rice and starchy staple foods such tubers) health problem as defined by WHO. However, as the symptoms of • Inappropriate cooking methods mild thiamine deficiency are vague and can easily be attributed to • Consumption of food containing thiaminases or antithiamine factors other problems, the magnitude of the problem may actually have (e.g. fermented fish, tea leaves) been greater. • Poor absorption • Increased metabolic demand As clinical manifestations of beriberi are easily confused with Categories of beriberi many other diseases, beriberi can be diagnosed most successfully by adults combining an assessment of the clinical symptoms with a dietary In , characteristics of wet and dry beriberi include: history suggestive of a low thiamine intake. Moreover, this study has shown that evidence of vitamin B1 deficiency can be confirmed Wet beriberi Dry beriberi with the disappearance of clinical signs under treatment. Other stu- dies have had similar results4. However it remains likely that some ‘unidentifiable’ groups had sub-clinical deficiency diagnosis. It is • swelling (oedema) • pain therefore important to continue efforts to develop field-friendly • increased heart rate • tingling, or loss of sensa methods for the biochemical assessment of thiamine deficiency. (tachycardia) tion in hands and feet • lungs usually clear (peripheral neuropathy) It is clear that when people depend entirely on emergency food • enlarged heart related to • muscle wasting with loss rations, they are prone to developing a wide range of micronutrient deficiencies. These deficiencies are, in the main, both predictable • no cyanosiscongestive of function or paralysis of and preventable. However, the international humanitarian commu- heart failure the lower extremities nity continues in failing to prevent the occurrence of outbreaks such • loss of ankle and knee as we experienced in Angola. We, therefore, have to ask the ques- reflexes. tion, what is it we need to do to prevent such outbreaks occurring in the future? Thiamine deficiency can also occur in infants. Three main types of infan- For further information, contact Manuel Duce at email: tile thiamine deficiency are classified: [email protected], or Josep Escriba at email: [email protected] Cardiologic or Aphonic form Pseudo meningitic pernicious form form

• peak prevalence • peak prevalence • peak prevalence in breastfed in 4-6 month old in 7-9 months babies of 1-3 infants old infant months of age • initially hoarse • nystagmus (invo • colic, restless cry until no luntary eye ness, anorexia, sound is prodced movement) vomiting while crying • muscle twitching • oedema, cyansis • restlessness, • bulging fontane and breatlessness oedema, breath lle with signs of heart lessness and failure leading to death • convulsions and death unconsciousness

Treatment In cases of mild deficiency, a daily oral dose of 10 mg thiamine is admi- nistrated during the first week, followed by 3-5 mg for at least six weeks. In severe cases the following dosages we used:

Manuel Duce Infantile thiamine deficiency: 25-50 mg of thiamine slowly administered Chipindo town intravenously followed by a daily intramuscular dose of 10 mg for one week. This is followed by 3-5 mg of thiamine per day orally for at least six weeks

Critically ill adults: 50-100 mg thiamine administrated slowly intrave- 1 Up to eight clinical symdromes related to lack of vitamin B1 have been descri- nously, followed by 3-5 mg of thiamine per day orally for at least six bed. See Golden M. Diagnosing beriberi in emergencies, Field Exchange 18 2 WHO. Thiamine deficiency and its prevention and control in major emergencies. weeks. WHO/NHD, 1999 3 The age of one patient is unknown, hence n=51 for age-related data Source: Thiamine deficiency and its prevention and control in major 4 Ahoua L, Etienne W. Epidemie de beri beri a la maison d’arret et de correction emergencies WHO/NHD 999.13, WHO 1999 d’Abidjan. Epicentre/Medecins Sans Frontieres, 2003

28 Isabelle Sauguet (Nutriset), Steve Collins (ValidInternational), Anne Callanan (WFP)

Teshome Feleke (Valid International), Marie McGrath (ENN), Enric Frexia (ECHO), Ana Gerlin Hernandez Bonilla (ICRC)

Jeya Henry (Brookes Uni, Oxford), Bruce Cogill Abdallah Eisa (SC Sudan), Arabella Duffield Carlos Navarro (ACF), Mary Corbett (DCI) (FANTA) (ENN) People in Aid

CTC workshop A three day workshop was held by CONCERN Worldwide and Valid International on the Community Therapeutic Care (CTC) approach to addressing malnutrition in emergencies, in Dublin, Ireland between 8th-10th of October. Bringing together interested agencies, key acade- mics and donors, the aim was to discuss and deve- lop strategies and policies to harmonise the future implementation of CTCs. The proceedings of this workshop will be prepared and disseminated by the ENN.

Clockwise from top: • Mike Golden (Ind), Tahmeed Ahmed (ICDR'B) • Anne Callanan (WFP), Fiona O’ Reilly (ENN) • Anna Taylor (SC UK), Mark Manary (University ofWashington) • El Hadji Issakha Diop (University of Dakar), Salimate Wade (Universityof Dakar) Anne Nesbitt(Queen Elizabeth Hospital,Malawi) • Paul Rees-Thomas (Concern), Chris Brasher (MSFFrance) • Yvonne Grellety (Ind), Jeremy Shoham (ENN) • Montse Saboya (MSF France), Sophie Baquet (MSF Belgium)

29 People in Aid

PSP course

Between 14 and 27 September, the biannual MSF PSP (populations en situation precaire) course was held in Paris, France. Targeting experienced, ideally MSF, medical staff at co-ordination level, the 12 day training included epidemio- logy, vaccination, nutrition, water and sanitation and emer- gencies. Thirty-six people took part in the course

Group picture: 36 participants of the PSP + permanent team

Sub-Group:Sophie Baquet, Joseph Leberer, Cecile Chapuis, Permanent team: Isabelle Beauquesne, Johanne Sekkenes, Juncal Gonzalez, Janet Raymond and Johanne Sekkenes Catherine Bachy, Gloria Puertas, Brigg Reilley Cecil Dune

Regine Kopplow with Nutrition team: Roya translator, Fawzya nurse, Laila nurse, Aslam driver, in front sitting Saber nutrition field worker, Ahmir Khan nutrition field worker with his son Belal. Rustaq Concern field office/north-east Afghanistan, April 2003.

30 From the Editor Back Page

We would like tially sensitive pieces were thoroughly verified learn – to participate in the discussion, to draw your atten- and opportunities given for others to present debate and challenge. tion to the fact that their views. The fact that we have never been Ultimately, Fiona gets things done, this is the last issue involved in litigation (so far) is largely due to does not beat about the bush and goes of Field Exchange in Fiona’s developed ‘political antennae’. straight to the point, no matter how cha- phase three of the Fiona has also been enormously influential in llenging, difficult or sensitive it may be. A ENN. Sadly, this the area of infant feeding in emergencies, where breath of fresh air, we look forward to her coincides with the ENN has been an active member of a core group continued involvement – there is no Fiona O’Reilly departure of our of agencies involved in developing training escape! colleague, Fiona O’Reilly, who is retiring material for field workers. Fiona’s ever practical from the ENN as co-director. Fiona and I and pragmatic approach, and insight into field established the ENN in Trinity College, reality has greatly contributed to field-friendly Dublin at the end of 1996. As a resident of guidance. No doubt Fiona will remain engaged Kornelius Elstner Dublin, it fell to Fiona to establish the office with this work in the future, however her contri- has been a central and deal with all practicalities related to bution so far is marked by some words from the and invaluable running a publication as well as the other core group members below. member of the ENN activities that the ENN have become increa- The ENN owes Fiona a considerable debt of team over the past singly involved with over the years. Fiona gratitude. We wish her every happiness and suc- five years. Kornelius managed many of these tasks single-han- cess in her future career. has been responsible dedly and had to learn a huge variety of Jeremy Shoham for the design and layout of Field skills ‘on the hoof’. These included desktop (editor) Exchange as well as the design and main- publishing, financial accounting, company tenance of the ENN website. But legal affairs and staff management. Fiona Kornelius's input did not stop there-as has made many invaluable contributions to well as sorting out all things to do with the ENN. Most notable amongst these has A personal word from the core group members computers and IT, 'K's perfectionist ten- been the development of a unique presenta- Fiona has had a long-standing involvement dencies and linguistic excellence meant tional style for Field Exchange, which is the and commitment to the issue of infant and that he often found himself picking up envy of many other publications. Fiona has young child feeding. She brought to the group errors in Field Exchange content and also insisted on establishing procedures, her varied experience with emergency issues, correcting the editors grammar! Having which ensured that information in Field was a source of energy and ideas and was pas- recently completed his computer science Exchange was corroborated and correctly sionate about what she believed – sparks some- degree Kornelius is embarking on a attributed. She effectively became the ‘politi- times flew before we reached an agreement! But career in the IT business. We wish him cal editor’ in that she ensured that poten- this was tempered by a willingness to listen and every success in the future.

The Emergency Nutrition Network (ENN) grew out of a series of interagency meetings focusing on food and nutritional aspects of emergencies. The mee- Editorial team tings were hosted by UNHCR and attended by a Deirdre Handy number of UN agencies, NGOs, donors and acade- Marie McGrath supported by: mics. The Network is the result of a shared com- Fiona O’Reilly Jeremy Shoham mitment to improve knowledge, stimulate learning and provide vital support and encouragement to Design food and nutrition workers involved in emergencies. Orna O’Reilly/ The ENN officially began operations in November BigCheeseDesign.com 1996 and has widespread support from UN agen- Website cies, NGOs, and donor governments. The network Kornelius Elstner aims to improve emergency food and nutrition pro- Contributors for this issue gramme effectiveness by: Tamsin Wilson • providing a forum for the exchange of field level Manuel Duce experiences Dr. Josep M. Escriba • strengthening humanitarian agency institutional Dr. Cristina Masuet memory Paula Farias • keeping field staff up to date with current rese- Elena Fernandez arch and evaluation findings Olimpia de la Rosa Dr. Adnan Al-Wahaid • helping to identify subjects in the emergency food Anne-Laure Glaisner and nutrition sector which need more research Beatrice Simkins The main output of the ENN is a quarterly newslet- Hadas Ziv ter, Field Exchange, which is devoted primarily to Professor Mike Golden publishing field level articles and current research Regine Kopplow and evaluation findings relevant to the emergency Professor Ann Ashworth food and nutrition sector. WFP The main target audience of the Newsletter are food Veronik Scherbaum Frank Daller and nutrition workers involved in emergencies and those researching this area. The reporting and Thanks for the exchange of field level experiences is central to ENN photographs to: activities. Jacqueline Deen Vincent Simmonneaux The Team El Hadji Issakha Diop GENEVA FOUNDATION Fiona O’Reilly (Field Exchange Hien Lam Duc production editor) and Jeremy Steve Townsend to protect health in war Shoham (Field Exchange technical Chris Op Reis editor) are both ENN directors Cecil Dune Manuel Duce Marie McGrath is a qualified paediatric die- Nutriset tician/nutritionist, working previously with Veronika Scherbaum Merlin and carrying out research with SC Dan Charlish Royal Danish Ministry UK. Tdh Regine Kopplow of Foreign Affairs Tamsin Wilson Deirdre Connell is currently the ENN part Christian Aid time administrator. Malutrition Matters Michel Garenne Kay Sharpe Catherine Bachy The ENN is a company limited by guarantee and not On the cover having a share capital. Company registration number: 342426 Mugina market place,Rwanda, ENN directors: Steve Townsend, Concern Fiona O’Reilly, Jeremy Shoham, Dr. Shane Allwright 31