July 2000 Issue 10

Field ExchangeEmergency Nutrition Network

Pellagra outbreak, AngolaKosovar refugees eat cakeRelief evaluation, WajirCurrency devaluation, Congo

occurred in Kosovo, it is obvious that withenough political commitment the Kuito outbreakcould prove to be an ‘end-chapter’ in a longhistory of preventable disasters.

This edition of Field Exchange also carries anevaluation by Oxfam of their emergencyintervention in response to drought and floodbetween 1996-8 in Wajir district, Kenya. A keyfinding of the evaluation was that the most cost-effective component of the intervention, whichincluded provision of general rations, livestockrestocking and food for work, was the cash forwork project. This finding is potentially verysignificant.

There has been a long, albeit largely theoretical,debate about whether the provision of cash ratherthan food in emergencies would be a more cost-effective form of intervention. Food aid stilldominates in emergencies (80% in the currenthorn of Africa appeal). Cash could be providedas payment for work (cash for work) or simply inplace of the general ration. Advantages of cashprovision would be that large quantities of fooddo not have to be procured and moved longdistances while the cash would allow recipientsfreedom to purchase other essential commoditiesapart from food e.g. fuel, shelter, water, livestockfodder and service crippling debt repayments.Shipping and other transactional costs amount toroughly 60% of food aid costs, while anestimated 50% of food aid is sold soon afterdelivery. Another potential advantage is that cashprovision would inject effective demand intocollapsing local markets. There are howevercertain unknowns with this type of intervention:the effect on security in conflict situations, theeffect on gender resource control i.e. it may beeasier for women to control donated foodresources than cash. It is also unclear whether theinjection of large quantities of cash into a foodscarcity situation would lead to inflation.Equally, unclear is the extent to which donorgovernments would be happy to furnishhumanitarian agencies with cash for distributionto individuals rather than cash which is tied tothe purchase of food aid sometimes within thedonor country. What is clear is that furtherstudies are necessary and long overdue.

Finally, it is with a certain amount of regret thatwe publish Field Exchange’s first anonymousarticle. To date agencies have been particularlyopen and transparent and have shown theircommitment to learning through endorsing thepublication in Field Exchange of articles writtenby their staff about field level experiences. Theseaccounts have highlighted both positive andnegative aspects of agency intervention. In thisinstance however the agency did not want to berecognised through this article in view of thesensitivity of the programme. The author hastherefore edited the article in such a way so asthe agency and country programme cannot beidentified. The article contains valuable lessons,which should be documented and available toanyone establishing a Therapeutic FeedingProgramme.

Editors,

Fiona O’ReillyJeremy Shoham

Dear Readers,

Over the past ten years large-scale outbreaks ofpellagra have only occurred amongst populationsdependent on emergency food aid. The mostrecent outbreak in Kuito, Angola highlighted inthis edition of Field Exchange is the largest sincethe outbreak in Malawi among Mozambicanrefugees in the early nineties. UnfortunatelyPellagra is not the only micronutrient deficiencydisease to have been reported amongst food aiddependent populations in recent years. Therehave also been epidemics of scurvy, beri-beri,angular stomatitis and severe anaemia. Thequestion is, why are these eminently preventablediseases allowed to develop amongst populationsunder international care and protection?

It is not as if we lack policies and strategies toprevent outbreaks or deal with them when theyoccur. Current humanitarian aid policy dictatesthat if an emergency affected population isentirely dependent on the emergency ration,fortified blended foods like Corn Soya Blend(CSB) should be added to the ration to remedymicronutrient shortfalls. In the longer term effortsare to be made to fortify one of the main rationcommodities with micronutrients. So where dothings go wrong?

In the Kuito case, it took several months to agreethat fortified CSB should be added to the generalration after the outbreak of pellagra begun. Itthen took a further six months for the CSB toarrive. The fact that the outbreak in Kuito wasnot predicted - suggests that the assessment ofthe level of dependency on the general ration wasflawed. The subsequent late provision of CSBmay have been due to a variety of factors - cost,logistics or limited availability. Clearly we havenot learnt sufficiently from past ‘outbreak’experiences. The tragedy in Kuito now providesan opportunity to put that right.

The experience of Kuito in conjunction with pastoutbreaks highlight where efforts need to befocused to prevent future epidemics ofmicronutrient deficiency disease. First, theprocess and method of assessment of dependencyon the general ration is often weak andinsufficiently focussed upon micronutrient intake.Review and revision of both the process andmethod is therefore a matter of urgency. Second,there is a need for greater transparency about thedifficulties of obtaining fortified blended foodsfor populations dependent on food aid. This isnot the first time there have been problems inproviding CSB. Potential impediments could beexplored and identified at the start of any givenemergency, and alternative strategies, e.g.fortification of cereals or oil, put in place andready to implement should CSB provision proveproblematic.

It is difficult to think of excuses for pellagraoutbreaks amongst populations receiving foodaid. The fact that the diversity and adequacy ofemergency general rations supplied around theworld seems to depend at least in part, on geo-political factors and cultural affinity betweendonor and beneficiary populations raises the issueof political commitment. Susanne Jaspar’s articleon food rations in Kosovo in this issue, ‘Let themeat cake’, demonstrates yet again the glaringinequities in global food aid. While no-one isseriously advocating the provision of chocolatebars and cake as part of the general ration, as

Field Articles7 Don’t let them eat cake8 Feeding without fear12 A Pellagra epidemic in Kuito,

Angola17 Reflections on food and

nutrition interventions inHuambo

19 Industry: unlikely players inemergency food distribution

3 Research• Effects of breast-feeding:

Implications for Policies on HIVand Infant Feeding

• Is extrusion cooking of blendedfoods really advantageous?

• Currency devaluation impact onnutritional status in Brazzaville,Congo

• Infant Feeding in Emergencies:Recurring Challenges

• China’s great famine 40 yearslater A need for historical closure

• Compliance problems withvitamin pill distributions

9 News• Nestlé and the Code• The management of nutrition in

major emergencies• ACC/SCN Working Group on

Nutrition in Emergencies • Nutritionists, food specialists

and food logisticians wanted• UNICEF builds capacity for

emergencies• New Publication: Children’s

Health in Emergencies

11 Letters

14 Evaluations• Evaluation of the Wajir Relief

programme 1996-98• Evaluation of the Response to

the Montserrat Volcano

16 Agency Profile• Action Contre la Faim (ACF)

21 Revised MSF Nutrition Guidelines

22 People in Aid

23 The Backpage

Contents

month olds and 1.4 for 9-11 month olds). In the firstsix months of life protection against diarrhoea wassubstantially greater than against deaths due to acuterespiratory infection. For second year deaths, thepooled risk ratios from five of the studies rangedbetween 1.6-2.1. Protection was highest whenmaternal education was low.

The researchersrecognised thatobservational studiesof breastfeeding andinfant health may beaffected by a numberof methodologicalproblems includingself-selection, reversecausality, i.e. feeding

changes as a result of the illness, and confounding.An attempt was therefore made in the study to avoidreverse causality by recording breast-feeding beforethe fatal illness episode. It was also recognised thatthe studies used did not employ a uniform protocolfor defining causes of death. Furthermore, most ofthe studies did not provide sufficient information onbreast-feeding patterns (exclusive, predominant, orpartial) to allow a pooled analysis of this variable.

Conclusions and recommendations

The authors of the study recommend that the findingson relative risk should be used in future simulationsof the impact of withholding breastfeeding in HIV-positive mothers. The results will also help assess therisks and benefits associated with breastfeeding forchildren of different ages.

Particular attention is drawn to the higher levels ofprotection seen among less educated women,particularly for deaths between the ages of 6-11months. The results are said to be consistent with thefinding that infant-mortality differentials according tobreastfeeding status are virtually non-existent in moredeveloped countries where maternal education ishigh.

The authors suggest that the main policy issue arisingout of the research is whether or not HIV positivemothers with low levels of schooling and income willbe able to safely feed their infant with breast-milksubstitutes.

3

The recognition that HIV is transmitted throughbreast-milk has raised important questionsabout strategies that promote breastfeeding in

areas of high HIV prevalence. As this question isparticularly relevant to emergency situations wherelevels of communicable diseases are often high, FieldExchange has continued to publish relevant findingson this subject (see Field Exchange 3, 8 and 9).

Theoretical models have been developed to assessthe advantages and disadvantages of breastfeedingfor HIV positive women as well as for women ofunknown HIV status who live in areas of high HIVprevalence. These models have taken into account therisk of transmission through breastfeeding withregard to the age of the infant, the protectionafforded by breast-milk against infectious diseasemortality, the underlying HIV prevalence, and therate of infant and child mortality. However,according to a recent WHO/UNAIDS1 review animportant limitation of these models was the poorquantification of the relative risks for mortalityassociated with lack of breastfeeding. Such modelsused relative risk estimates ranging from 1.3 to 7.9and no model allowed for variable levels ofprotection within the first year of life.

A recent study hasaddressed theprotective effect ofbreastfeedingaccording to the ageand sex of the infant,the cause of death andthe education status ofthe mother.Information on 1223deaths of children

under two years of age was obtained from 8 studiesconducted between 1980-98. It was found thatprotection from breast-milk declined steadily withage during infancy (5.8 for infants <2 months, 4.1 for2-3 month olds, 2.6 for 4-5 month olds, 1.8 for 6-8

Effects ofbreastfeeding:

Implicationsfor Policies onHIV and InfantFeedingSummary of published paper

1 WHO (2000) Effect of breastfeeding on infant and childmortality due to infectious diseases in less developedcountries: a pooled analysis. WHO collaborative study teamon the role of breastfeeding on the prevention of infantmortality. The Lancet, vol 355. February 5th, 2000

Research

“Protection washighest whenmaternal education was low”

“Non–breasfedinfants under 2months werealmost 6 timesmore likely todie”

4

Blended foods prepared by mixing a cerealflour, usually maize flour, with soy flour toget a high protein food with a good balance

of amino acids are widely used in food aidprogrammes. These foods are included inemergency general rations for populations entirelydependent on food aid and also used in selectivefeeding programmes for malnourished individuals.Blended foods are usually pre-cooked by extrusionso that less cooking time is required and to improveshelf-life.

A study1 funded by Nutriset and ANVAR (AgencieNationale de la Valorisation de la Recherche)compared the starch digestibility of a blended foodprepared with and without extrusion cooking.Resistant starch along with soluble and insolubledietary fibres were measured in vitro before andafter extrusion. Starch digestibility was assessed in8 volunteers who ate a test meal with either 100gms of extruded blended flour (EF) or non-extruded (NEF) blended flour cooked for 15minutes at 80 degrees Centigrade in 500 ml ofwater.

Starch digestibility was measured by C13 (radio-active isotope of carbon) enrichment of breathsamples for 8 hours. Concentrations of hydrogen inthe breath were measured during 12 hours to assessbacterial fermentation in the colon.

Results

In vitro (outside the body of a person or animal inconditions created artificially by scientificexperiment), resistant starch and soluble andinsoluble dietary fibres were higher in NEF.However, in vivo (inside the body of a person) C13

excretion was no different for EF and NEF whilehydrogen excretion was significantly higher for EF.Furthermore, feelings of satiety were marginallyhigher with EF. The authors of the study raised thefollowing points:

i) The study was made on only one sample ofblended food prepared from whole maize and soygrains with and without extrusion cooking. It is notknown whether these results would be obtainedwith other types of blended flour especially with alower fibre content.

ii) Cooking for 15 minutes as is commonlypractised in food aid programmes was probablyenough to gelatinise starches present in the NEF tobe well digested in healthy adult subjects.However, the similar starch digestibility of EF andNEF found in the study may not be extrapolated tomalnourished children who often have an impairedstarch digestion.

iii) In malnourished children, excessivefermentation may lead to flatus, bloating orabdominal pain.

iv) The increased satiety following an EF meal wasunexpected. But as the statistical significance of thedifference was border-line, the result needs to beconfirmed by other studies. Nevertheless, areduction of appetite due to a change in fibrestructure and increased colonic fermentation or amechanical effect seems plausible.

In conclusion the authors state that “extrusioncooking of blended flours for porridge preparationdoes not seem to present a major advantage interms of digestibility in healthy subjects. It alsosuggests that extrusion cooking of high fibreblended flour may increase bacterial fermentationin the colon which may also depress appetite.Further studies in malnourished children areneeded to determine whether extrusion is warrantedwhen taking into account its advantages and also itsincreased costs and potential disadvantages”.

1 Meance.S, Achour.L and Briend.A (1999): Comparison ofstarch digestibility of a blended food prepared with andwithout extrusion cooking. European Journal of ClinicalNutrition (1999) 53, pp 844-848

i) These findings do not alter the fact thatextruded blended foods have a longer shelf-lifethan non extruded blended flour (NEF) and:

ii) The lower resistant starch and fibres found invitro in extruded blended flour (EF) may indicatethat these flours require less than 15 minutescooking time to achieve comparable digestibilitywith NEF after 15 minutes cooking of the latter.This may have implications for fuel saving.

Is extrusioncooking ofblended foods reallyadvantageous?Published Paper

Research

Editorial comment

Blended food used in a supplementary feeding programme,Pavarando Camp, Colombia. 1998 H. Timmermans (UNHCR)

5

Research

Currency devaluations can have a dramatic impact onpeoples entitlement and in extreme cases contributeto nutritional crises. Devaluations are often carried

out as part of economic structural adjustment programmespromoted by international organisations like the WorldBank and IMF. International financial assistance in theform of grants or loans from these organisations may becontingent upon recipient countries undertaking economicreforms like devaluation or reducing expenditure in socialsectors. These macro-economic ‘adjustments’ may beimplemented overnight hitting the poorest members ofsociety really hard. Yet, the impact of these initiatives onfood security and resulting nutritional status are rarelymeasured. Recent events in Brazzaville, Congo underlinethe potentially rapid adverse impact devaluations can haveupon nutritional security in developing countries.

The African Financial Community (CFA) franc wasdevalued by 50% on the 12th, January of 1994 in 14 sub-

saharan African countries.A survey1 was conducted in1996 to evaluate changes infeeding practices forinfants, the quality ofcomplementary foods, andthe nutritional status ofchildren and their motherscompared to a surveyundertaken in 1993 prior todevaluation. The 1996

survey was in two districts of Brazzaville where the earliersurvey had been conducted and involved a representativesample of 4206 households with a child aged 4-23 months.

Results

Daily food expenditure increased considerably between1993-6 with numerous households declaring that they hadentirely abandoned certain food that had become tooexpensive, e.g. chicken, bush meat and fresh-water fish.Although breastfeeding and complementary feeding rateshad remained stable the complementary foods given toinfants had declined in quality, e.g. gruels were being madefrom local ingredients rather than imported flours asoccurred previously and therefore had half the energydensity.

The anthropometric indicators showed that young childrenhad undergone a substantial deterioration in theirnutritional status. Between 1993-6 the prevalence ofstunting increased from 12.1% to 15.5% which was highlysignificant. There was also a statistically significantincrease in the prevalence of wasting from 6.0% to 8.8%.The mean body mass index of mothers decreased by 1.28kg/m2. This is significant and corresponds to a weight lossof nearly 3.3 kg in three years for a woman of averageheight. As a consequence the number of women exhibitingthinness (body mass index < 18.5kg/m2) increased verysignificantly from 11.3% to 15.6%.

The authors of the study acknowledge that the impact ofthe devaluation on nutritional status would not only haveresulted from less access to food, but also poorer healthcare and general caring practices as women becameincreasingly engaged in income generation activities tooffset reduced spending power. The authors also concludedthat a more accurate assessment of the specific effects ofthe devaluation on the nutritional status of urbanpopulations would be provided by comparing the resultsobtained here with those in another large capital in theCFA zone.

1 Martin-Prevel, Y et al (2000). Deterioration in the nutritional statusof young children and their mothers in Brazzaville, Congo, followingthe 1994 devaluation of the CFA franc. Bulletin of the World HealthOrganisation, 2000, vol 78, pp 108-116.

Currency devaluationimpact on nutritionalstatus in Brazzaville,Congo

Summary of Published paper

Infant Feeding in Emergencies:

Recurring ChallengesBy Marie McGrath

Published Report

The importance of infantfeeding in emergencies hasbeen highlighted during

recent emergencies in countriessuch as Iraq and Bosnia, wherebreastmilk substitutes arecommonly used. Anecdotalevidence suggests that, in thesesituations, infant feeding practiceshave had a negative impact on childhealth. The 1999 Kosovo crisispresented an opportunity toinvestigate the policy and practiceof agencies involved in thehumanitarian response with regard to infantfeeding.

Field research was carried out in Macedoniabetween 15 June and 31 July 1999 and gathereddata on the following:

1. The availability, awareness and implementationof existing policy instruments and guidelines oninfant feeding in emergencies;

2. The flow of relief items used for infant feedingand any accompanying violations of theInternational Code of Marketing of BreastmilkSubstitutes;

3. The quality of infant feeding interventions;

4. The infant feeding practices of the emergency-affected population.

The methodology included a literature search ofguidelines and policies relating to infant feedingin emergencies, questionnaires for field andheadquarters personnel on infant feeding issuesand structured interviews with key field personnel.In two camps, an infant feeding practice survey(including 24 hour recall) of children 2 years andunder was conducted. The response rates wereaffected by the sudden mass return of refugees toKosovo in June, 1999.

The research found that there was poor awareness,use and implementation of guidelines and policyinstruments among emergency personnel operatingin Macedonia. UN agencies, International andlocal NGOs were all affected. Where guidelineswere observed, this was often as a result ofindividual rather than organisational learning. TheInternational Code was contravened in a numberof ways including the general distribution of infantformula, complementary foods, bottles and teatsand the donation of such products to facilities inthe health care system. A number of factorsconstrained effective implementation of andadherence to MOUs, guidelines and the Code andthese included poor levels of interagency co-ordination and gaps in the applicability of theinstruments themselves.

Infant feeding items reached the emergency-affected population through a wide range ofchannels. Large proportions of the items wereunsolicited donations that passed through anumber of agencies before reaching the affectedpopulation. Lack of co-ordination and monitoringof these items meant that it was very difficult totrace these flows. This situation resulted in a rangeof infant feeding interventions with the affectedpopulation which varied substantially in quality.Mother and Baby Tents were the focus of infantfeeding interventions in camps and the quality of

support given was very variable.Breastfeeding support was rarelyadequate though MBTs oftenprovided infant formula, bottles, andcomplementary foods to mothersand infants. Other interventionsincluded postnatal support inmaternity facilities which was insome cases undermined by thedonation of breastmilk substitutes tothese facilities.

The camp surveys of infant feedingpractice showed that 88% of the 242children surveyed had initiated

breastfeeding. Among infants under 6 months ofage, 60% were exclusively breastfed and 24%predominately breastfed. The main supplementaryitems in infants under six months were water, teaand cow’s milk. Breastfeeding was continued in50% of children aged 12 - 15 months and 22% ofchildren aged 20 - 23 months. The use of liquid orpowdered (non-formula) milk was high. Amonginfants aged 6 - 12 months who were beingbreastfed (60%), 74% were receiving liquid orpowdered milk. Among the remaining infants aged6 - 12 months not being breastfed, all werereceiving liquid or milk powder and none werereceiving infant formula. In Stankovec I camp, thetimely complementary feeding rate for infantsaged 6 - 9 months was 33%. Among childrenreceiving non-milk foods, biscuits were the maincomplementary infant food introduced (67%). InNeprostino camp, 47% of all children 2 years andunder had fed on a bottle in the previous 24 hours.

A negative impact of the crisis on rates ofinitiation of breastfeeding was not identified.However the cohort effect was observed. Amonginfants no longer breastfeeding, a significantlyhigher proportion (81%) aged 6 – <12 monthsstopped breastfeeding before the age of 4 monthsthan among children aged 12 – 24 months (32%)(p=0.001, risk ratio 2.53). Perceived inadequacy ofbreastmilk was the main reason given forcessation in all age groups. The long-termconsequences of a reduction in the duration ofbreastfeeding are unknown but could bedetrimental if access to cow’s milk or water andsanitation conditions decline. The prevalence ofdiarrhoea in children 2 years and under was high(54%). More recent data from Kosovo indicate anincreased prevalence of childhood diarrhoea andARI in the returnee population. For a morevulnerable population in less sanitary campconditions and with fewer international resourcesavailable, the negative consequences on infantmorbidity and mortality of the aid operation mayhave been much greater.

Based on the research findings a number ofrecommendations for policy makers andpractitioners are made. The research report andrecommendations are available in the documentreferenced below.

ReferenceMeeting the nutritional needs of infants duringemergencies: recent experiences and dilemmas – Reportof an International Workshop, Institute of Child Health,London, November 1999. For more information contactAnna Taylor, Save the Children, UK, email:a.taylor@scfuk.org.uk

1 Kosovar Albanian Health Survey Report, IRC, Institute ofPublic Health, Pristina, WHO, CDC, September 1999

“young childrenhad undergone asubstantialdeterioration intheir nutritionalstatus”

6

Research

China’s great famine 40 years laterA need for historical closurePublished Review

Compliance problems with vitamin pill distributionsUnpublished report

Apellagra outbreak hit war affectedKuito town, the capital of BieProvince in Angola in the second

half of 1999 (see article in this issue ofField Exchange, page 12). MSF Belgiumorganised a ‘vitamin B complex’ distributionto all women over the age of 15 years. Theresponse was seen as an emergency measureas other sources of niacin, e.g. ground nuts,CSB and dry fish were not available in theemergency general ration. Women over 15years were targeted due to lack of resourcesto organise a distribution to the entirepopulation. MSF Belgium were howeveraware that although pellagra was diagnosedmost frequently in this demographic group,the entire population was also probablyequally affected. Thirty tablets weredistributed to all women.

MSF Belgium and ICRC conducted anutrition survey1 shortly after thedistribution. Part of the survey was designedto assess compliance with the vitamindistribution. Consumption of the vitaminwas recorded by counting the number of

tablets left in the distributed tablet bags. Awoman was categorised as compliant whenthe number of tablets corresponded to the 30tablets distributed less the number of daysspent since the distribution allowing forthree tablets either way. The survey wasconducted 6-11 days after the distribution.Nine hundred and fifty women wereassessed.

Results

Forty four percent were compliant in thetown and 42% in the camps for IDPs.Compliance was judged to be poor. Severalexplanations were offered for this:

• There was confusion between vitaminsand contraceptive tablets which were onlyto be taken once monthly

• The vitamin tablet appeared to increasefeelings of hunger

• There was a lack of understanding of theconcept of prevention of micro-nutrientdeficiency amongst beneficiaries

• Twenty percent of women had less tabletsthan expected as they shared tablets withother family members or because theytook more tablets than recommended. (Bvitamins are not stored by the body so thatexcess intake does not afford protection)

The authors of the survey report concludedthat:

i) A vitamin B tablet distribution does notappear to be the most effective solution tocontrol a pellagra outbreak.

ii) Targeting women was an emergencymeasure but not satisfactory as all strata ofthe population were probably deficient or atrisk.

iii) Distribution of additional foods rich invitamin B remains the best strategy tocontrol a pellagra outbreak.1 MSF/ICRC (1999) Rapid Nutritional Assessment,Kuito, Province of Bie, Angola, December 1999.Unpublished Field Report. For more informationcontact:Sophie Baquet MSF Belgium. Emai: sophie.baquet@msf.be

Forty years ago China was in themiddle of the world’s largest faminewhere some 30 million people starved

to death (see Field Exchange 8). A review1

article in the British Medical Journaldiscusses how this man-made famine was atthe time largely covered up within Chinaand that even today China has notundertaken an open, critical examination ofthis unprecedented tragedy.

The review traces the origins of the famineto the leadership’s decision to launch the‘Great Leap Forward’ whereby economicdevelopment was to be promoted throughpromoting heavy industry. Based onStalinist ideology tens of millions of ruralpeasants were ordered to mine local depositsof iron ore and limestone, to cut trees forcharcoal and to build simple clay furnacesto smelt metal. Peasants were forced toabandon all private food production.

At the same time fabricated reports ofrecord grain harvests were issued todemonstrate the superiority of communalfarming. These gross exaggerations werethen used to justify the expropriation ofhigher shares of grain for cities and theestablishment of wasteful communal messhalls serving free meals. In reality by thespring of 1959 there was a famine in a thirdof China’s provinces.

The famine showed clear marks of‘omission’, ‘commission’ and ‘provision’.These three processes recur in all modern

man-made famines. The greatest omissionwas the failure of China’s rulers toacknowledge the famine promptly and tosecure foreign food aid. The Chinesegovernment took nearly three years to act.Taking away all means of private foodproduction, forcing peasants intomismanaged communes and continuing foodexports were the worst acts of commission.Preferential supply of food to cities and tothe ruling elite was the deliberate act ofprovision.

The true extent of the famine was notrevealed to the world until the publication ofage distribution data from the country’s firstreliable population census in 1982. Thesedata made it possible to estimate the totalnumber of excess deaths between 1959 and1961, and the first calculations by Americandemographers put the toll at between 16.6and 23 million. More detailed later studiescame up with 23 to 30 million excess deathsand unpublished Chinese materials hint attotals closer to 40 million.

The lack of accuracy is as expected. Alldeath tolls cited for major famines havelarge margins of error. This is true even for

events unfolding amid unprecedentedpublicity. An attempt to discern a coherentpicture of morbidity, mortality andnutritional status during the 1991-2 faminein Somalia, an effort based on 23 separatefield studies, ended in failure. Similarcontroversies surround the recent estimatesof the excess deaths in Iraq attributable toeconomic sanctions after the Gulf war.

The authorhighlights theneed for opendiscussion, moralexamination andhistorical closureand cautions thatif accountingdoes not happensoon, the directmemories ofsurvivors will be

lost and many facts will never be known.The review also points to Westernindifference to the great famine. Eyewitnessstories of refugees who fled to Hong Kongwere widely dismissed and rarely reportedduring the famine years. Incredibly, the1997 edition of the New EncyclopaediaBritannica does not even list the catastrophein its tabulations of famines in the past 200years.

1 Smil.V (1999): China’s great famine: 40 years later.BMJ Volume 319, 18-25th December, pp 1619-1621

“The famine showed clearmarks of omission,

commission & provision”

“The reviewalso points towesternindifference tothe greatfamine”

7

This time last year, I was cooking spaghetti for300 new arrivals at a camp for Kosovarrefugees in Albania. The camp itself, on the

Adriatic coast, was like any overcrowded Europeancamp site: rows of tents, car parks, vendors’ stallsand ice cream vans. I looked at the people I wasabout to feed, and saw plump-cheeked children,heavy men and heavier women. They did not looklike the refugees I was used to, the victims of Africancrises whose skeletal limbs and emaciated figureshaunt television viewers the world over.

I worked as an emergency nutritionist, first inAlbania and later in Macedonia. By July 1999, itbecame clear that the main nutritional problemamongst Kosovars was not undernutrition but obesity.This was confirmed by a nutritional survey inJanuary 2000 in Kosovo, which found that whilstonly 5.3% of adult women were undernourished,23.6% were overweight, and 10.4% were obese.Amongst the elderly (both sexes), 32% wereoverweight and 16% were obese. Nor is obesityrestricted to the Kosovars: a Bosnian doctor workingin Sarajevo recently confirmed that obesity is agrowing problem in Bosnia, too - and that it is moreprevalent now than before the war.

Obesity is associated with hypertension, diabetes andheart disease. Although, the condition has increasedin all European countries in the past ten years, it isparticularly affecting people in the Balkans andEastern Europe. This is probably due to the highintakes of animal products in their traditional diet.Since the war - during which there seems to havebeen a temporary reduction in obesity, these countrieshave witnessed an upward trend.

The international community responds to any disasterwith food aid, and the Kosovo crisis was noexception. However, the quantity and types of foodprovided to some Kosovars, whilst they wererefugees, was exceptional. The UN used the sameprocedures to work out food aid needs as elsewhere,but numerous agencies decided to use private fundsto purchase food. Meanwhile, many donor countriesprovided funding direct to NGOs to buy additionalfoods; and donations - ranging from Mars bars,Italian cakes, pain au chocolat, Turkish delight, aswell as healthier alternatives such as milk, cheese,fruit juice, fresh fruit and vegetables.

Not all refugees received these foods. Some refugeesin Macedonia lived off bread, tinned fish andvegetables for months, and others received almostnothing (for example refugees living with Albanianhosts). Some clearly inappropriate and potentiallyharmful foods found their way to the camps - infantformula and baby foods, for instance, weredistributed there, despite the international codes

against the promotion of such products.

As a nutritionist, my job was to ensure thatpotentially harmful foods were not distributed, and afair distribution of the rest of the food. Given thenumber of agencies involved in the operation, thisproved an almost impossible task.

Nutritional surveys show no significant increase inthe prevalence of undernutrition in Kosovars fromDecember 1998 to January 2000. This could beinterpreted as a successful relief operation, oralternatively, that people had sufficient fat stores todeal with a period of shortage.

Two key questions that emerge from the foodresponse to the Kosovo crisis. First: why was such anemphasis placed on food aid? And second: how canwe justify the provision of high cost food items toEuropeans who were not undernourished when inmost African crises we cannot even provideundernourished populations with a basic survivalration.

Food aid forms part of the basic package of reliefinterventions to any emergency affected population.Handing out food to hungry people also providesgood images for the media. The problem is, when thepublic is kept in the dark about the real needs of therefugees, as it was during the Kosovo crisis, well-meaning people end up sending often inappropriategifts.

It is true that Kosovar refugees were cut off fromtheir normal sources of food supply and needed foodaid. Nutritionists usually recommend food rationsthat are culturally acceptable. This alone would havejustified a different food ration for Kosovars than forEthiopians. But did it justify chocolate and cake? Theissue is one of equity and impartiality. Ashumanitarians, we claim to provide assistance on thebasis of need. The aid community did not do this in1999, when the need was clearly greater in placessuch as Somalia, Sudan and Angola.

It is difficult to be truly impartial in responding toemergencies. It is not surprising that westernindividuals feel greater compassion for victims of acrisis that is closer to home. Governments and NGOs,however, have a responsibility to respond accordingto need if they claim to be “humanitarian”. As forfamine victims elsewhere, I am sure they heard aboutthe response to the Kosovo crisis, and I hope thatthey will demand their Mars bars, Turkish delight andcake. I doubt they will get it.

Don’t let them eat cake

By Susanne Jaspars

Susane Jaspers is a Nutritionistspecialising in emergency nutrition,

food aid and food security. This article is based on herexperiences in Albania and

Macedonia where she found Kosovarrefugees suffering from obesity not

malnutrition.

This article first appeared in the New Statesman, on 15 May2000. For subscriptions, phone 00-44-207-592-3626 (orfreephone in the UK: 0800-731-8496).

KUKES/ALBANIA – © P. PIETERSE (CONCERN)

REFUGEE CAMP/KRUME – © P. PIETERSE (CONCERN)

Field Article

8

Field Article

Feeding without fearAnonymous

This is a story to illustrate thathowever experienced you are, there isalways the chance that you will find

yourself in a situation that you are notprepared for, and that you do not feelqualified to deal with. Unfortunately, this isthe nature of disasters, and the humanitariansystem in which we work. It is also a storywhich shows that with the right support,determination, energy and common sense,you can probably do it. Moreover, you mayhave to, because there will be no one else.In my case, I ended up re-organising atherapeutic feeding programme for adults,when I thought I was going to do a foodsecurity assessment. I had no recentexperience of therapeutic feeding, certainlynot of adults, and have no medicalbackground. Whilst obviously it would havebeen better to have someone qualified andexperienced in therapeutic feeding, I thinkthat in the end, we did a fairly good job.

Last year, I went to Central Africa to do afood security assessment of people recentlydisplaced by fighting in a nearby region. Atleast that is what I thought I was going todo. I had also been asked to take a quicklook at the therapeutic feeding programme.The nutritionists at the agency’sheadquarters wanted to be re-assured thatthe correct procedures were being followed.Before my departure, however, there wereno major concerns.

In my 15 years experience of working as anemergency nutritionist, I have often advisedon and co-ordinated feeding programmes.On occasion, I also had to teach the basicsof therapeutic feeding, so I was aware of therecent developments and new guidelines forthe treatment of severe malnutrition. Itherefore felt I could review the programme,but not manage the feeding of severelymalnourished individuals. The last time Ihad any direct involvement in therapeuticfeeding was in 1987, when we used to givemothers of severely malnourished children atake home ration of DSM, oil, and sugar tofeed their children in the afternoons.

When I visited the feeding programme, Iknew just about enough to realise that therewere several problems with the proceduresused in the programme. Problems rangedfrom the actual treatment of severemalnutrition, to ones related to theorganisation and management of theprogramme. The programme wasimplemented by highly motivated nationalstaff, who had received some training infeeding programmes during earlier conflictrelated displacement in 1997. The situationin 1999 was very different however. Themajority of the severely malnourished hadoedematous malnutrition, something thatwas not seen before in the area concerned.Also, the prevalence of severe acutemalnutrition was much higher in 1999 thanin 1997.

So we were in a serious situation, with veryhigh levels of severe, oedematous,malnutrition in adults, and no agency fieldstaff who knew how to deal with it. Afterone week of frantic phone calls toheadquarters, I was finally told there was noone with experience of therapeutic feeding

who could come to assist, and “if you haveto save lives, you save lives.”

This is what saved us (and them):

• The presence of other agencies who wererunning therapeutic feeding programmes.

• Very supportive headquarters staff.

• Availability of the new WHO guidelineson the treatment of severe malnutrition

• Knowledge of related public health issues,e.g. the need for immunisation, adequatewater supply, sanitation, etc., as well asthe necessity of adequate general rationsfor the family.

• Dedicated international and nationalnurses within the organisation.

• My previous experience in themanagement and organisation of feedingprogrammes, e.g. issues of crowd control,number of beneficiaries per centre, recordkeeping, weight monitoring, follow-up,etc.

• The realisation that as long as your centreis well organised enough to monitorpeople individually, you can try thingsout, and adjust feeding regimesaccordingly.

• The realisation that no one will die fromone bowl of porridge.

• The realisation that you can talk tomalnourished adults. They can tell youhow they feel and if their condition isgetting better or worse.

Without doubt, the other agencies and theWHO guidelines were the most crucial inhelping us re-organise the programme.However, some innovation was necessary.We did not have the modified ORS formalnourished people (ReSoMal), nor did wehave the F-75 therapeutic milk for phase 1of therapeutic feeding. We modified normalORS immediately for oedematous cases, by

adding 2 litres of water instead of 1 litre,and adding 50 g of sugar. The headquartersnutritionist suggested a modification of F-100 therapeutic milk. By adding morewater, as well as oil and sugar, we loweredthe protein content whilst keeping theenergy content at 100 kcals/100 ml. Thisbecame known by everyone as “specialmilk.” Immunisation of children wasanother immediate priority, as was therecruitment of health staff specifically forthe feeding programme.

All feeding beneficiaries were screened, todetermine whether they should be intherapeutic or supplementary feeding. Thesewere then separated in different shelters forfeeding, and given different colouredbracelets. On the first day of the newtherapeutic feeding, every adult was askedon entry, whether their oedema had gotbetter or worse in the last few days. Peoplewith very severe oedema, or whose oedemagot worse, were put in phase 1, and received“special milk” for at least three daysaccording to their body weight.Arrangements were made to weigh peopleon “special milk” on a daily basis. If theiroedema was going down over these days,they were allowed to eat solid meals as wellthe following day, but were closelymonitored. We knew this was not strictlyaccording to protocols, but it was difficult tokeep adults on a milk only diet for morethan 3 days. Not only did they find this veryboring, but also, they had really lookedforward to eating their traditional food uponcoming home.

Amazingly, our re-organisation and newfeeding regime worked. It was one of themost satisfying experiences in myprofessional life to have people tell me theiroedema was going down after a couple ofdays on “special milk.” It seems strangenow, but when we started, I honestlythought we would kill someone with a bowlof porridge that was too high in protein fora severely malnourished person. I laterrealised, that even if someone should nothave received porridge yet, and theircondition deteriorated, we would soon knowabout it, and could adjust their feedingregime.

This brief description cannot possiblyreflect the often chaotic and hectic firstweek of re-organisation. Of course therewere many more things to do than writtenhere; new registers, attendance sheets,organising regular weighing, follow-uppeople who did not lose their oedema or didnot gain weight later, follow-up ofdefaulters, medical examination andtreatment of sick people, screening of newarrivals, registration of new arrivals forgeneral rations, etc., etc. It wasn’t perfect,but I think I can honestly say we improvedsome people’s lives, and perhaps even theirchances of living, at least for a little while.

“Without doubt, the otheragencies and the WHOguidelines were the mostcrucial in helping us re-organise the programme”

9

The newly published WHO manual ‘Management ofnutrition in major emergencies’1 replaces the 1978edition, and reflects scientific and conceptual advances in

understanding the prevention, causes and treatment ofmalnutrition in emergencies. It reflects the input of a wide rangeof individuals and agencies.

One of the major conceptual advances incorporated in themanual is that emergency management is viewed as a multi-sectoral venture; ministries and departments of local governmentneed to plan and work together for emergency prevention,preparedness, response and rehabilitation. Safeguarding thenutritional status of the population also requires a holistic andproactive approach, which implies more than food distributionand health protection. Action is called for in the areas ofenvironment, population, economic and human development,land and water management, production and trade, services,human rights, governance, empowerment and growth of civilsociety.

The book covers the concepts, principles, and precise measuresneeded to ensure adequate nutrition in both the relief phase andthe subsequent rehabilitation and development phases.

There are seven chapters. The first, on meeting nutritionalrequirements, explains the importance of nutritional assessmentas a fundamental tool for calculating food needs, monitoring theadequacy of food access and intake, and ensuring adequateprocurements. The chapter also sets out recommendations formean daily per capita intakes of energy and protein and formicronutrients and other specific nutrients. The major nutritionaldeficiencies are covered in chapter two, which includes detailedinformation on the signs, symptoms, prevention, and treatmentof protein-energy malnutrition, iron-deficiency anaemia, vitaminA deficiency, iodine deficiency disorders, beriberi, pellagra, andscurvy. Chapter three describes the methodology for measuringmalnutrition. Information includes target audiences forassessment, advice on body measurements and clinical indicators

of malnutrition, and precise instructions for conducting rapidnutritional surveys, individual screening, and nutritionalsurveillance.

Chapter four provides a detailed guide to the planning,organisation, and delivery of general feeding programmes.Topics covered include basic requirements for suitable foodcommodities, principles of good organisation and co-ordination,and the composition of a general ration calculated to meet thepopulations’ minimum requirements for energy, protein, fat, andmicronutrients. Guidelines for selective feeding programmes arepresented in chapter five, which covers both the supplementaryfeeding of vulnerable groups and the therapeutic feeding ofindividuals suffering from deficiency diseases.

In view of the close link between infectious diseases andmalnutrition, chapter six offers advice on the organisation ofservices to ensure priority immunisations and to monitor andtreat each of twelve infectious diseases commonly seen indeveloping countries. The book concludes with advice on theplanning, administration, and logistics of emergencypreparedness and response programmes, emphasising the need todetect vulnerability to nutritional deficiencies and monitor earlywarning indicators.

The essential purpose of this manual is to help build nationalcapacities and human resource development within the country.Thus, the manual could be used as a framework for developingteaching modules and training programmes.

1 ‘Management of Nutrition in Major Emergencies’ is available on requestfrom Marketing and Dissemination, World Health Organisation, 1211 Geneva27, Switzerland. The price of the book is Sw.fr. 72 (US $64.80), indeveloping countries Sw.fr. 50.40.

1 Management of Nutrition in Major Emergencies, Geneva, World HealthOrganisation (in collaboration with UNHCR, International Federation of RedCross and Red Crescent Societies, and World Food Programme), 2000.

The management of nutrition in major emergencies

NutritionWorks and International Health Exchange are setting up aspecialist register for food and nutrition specialists. The registerwill support recruitment to food and nutrition posts for the

following agencies as well as for IHE’s wider client base:

• The World Food Programme,• Action Against Hunger,• Concern Worldwide,• Oxfam,• Save the Children Fund.

If you have expertise in any of the following areas, and are available foreither long or short-term postings or consultancies we would like to hearfrom you: public nutrition, nurse/nutrition, food security, food aid, foodlogistics.

Both emergency and development expertise is required. Jobs may includethe management or implementation of food distribution and feedingprogrammes (therapeutic and supplementary), food security assessments,nutritional surveys, project planning and evaluations.

For further information and an application form, please contact Patrick Brooke,International Health Exchange, London SE1 7AE, UK. Tel: 00-44-207-620-3333 Email:pat@ihe.org.uk

News

Nutritionists, food specialists and food logisticians wanted

New publicationCChhiillddrreenn’’ss HHeeaalltthh iinn EEmmeerrggeenncciieess::pprraaccttiiccaall gguuiiddeelliinneess ffoorr hheeaalltthh wwoorrkkeerrss

Produced as a special supplement to HealthlinkWorldwide’s popular international newsletter ChildHealth Dialogue, this publication will provide a

unique audience of mainly indigenous health anddevelopment workers with up-to-date, practicalinformation on appropriate policies and procedures tofollow in the event of an emergency occurring in their area.Written in clear, easy to understand language, it explainswhat health workers can do in the early stages of anemergency. It describes how management and preventionof childhood illnesses such as diarrhoea and malaria differsin emergency situations, the basics about malnutrition inemergencies and how to work with communities and otherorganisations.

Single copies are free to indigenous organisations indeveloping countries. For others the cost is £2.50/US$5 andincludes postage. Bulk copies are also available free toorganisations that are able to distribute the publicationthrough their own channels.

For further information contact Coral Jepson, Healthlink Worldwide,Cityside, 40 Adler Street, London 1E 1EE. Telephone: 0207 539 1570;Fax: 0207 539 1580 or visit our web site; http://www.healthlink.org.uk

10

News

ACC/SCN Working Group onNutrition in Emergencies

Excerpts fromWorking Group

ReportThe ACC/SCN held its 27th Session

at the World Bank in WashingtonDC last April. About 60 participants

from NGOs, bilateral and UN agency werepresent for the afternoon meeting of theWorking Group in Emergencies. Theagenda included, among other topics, anupdate on research work amongmalnourished adults and nutritionalproblems faced by infants in emergencies.

Update on Adult Malnutritionprogrammes and research inBrazzaville and Burundi Carlos Navarro, ACF-F Action Contre La Faim)

Dr. Navarro presented a broad overview ofsome of the problems encountered whentrying to treat severely malnourished adultsin Burundi and Congo-Brazzaville, whereACF is undertaking an analysis of itsoperational (nutritional) programmes. Theproject in Burundi has been operatingsince 1994 and at least 1,000 persons permonth (including 700 adults) have beentreated in 5 Therapeutic Feeding Centres(TFCs) in two provinces. The programmein Brazzaville began in July 1999, and hastreated approximately 600 patients permonth, including 400 adults, in 3 TFCs.The objective of the presentation was topresent some of the operational dilemmasthat arise.

Emergency nutrition interventions aimingto address adult malnutrition, arebecoming increasingly common practice inemergencies and there continues to be anenormous demand for information ondiagnostic criteria, and protocolspecifications.

In summary, the following issues werehighlighted as operational problems inACF programmes:

Criteria for assessment of acute adultmalnutrition

• The inappropriateness of Body Mass Index(BMI) for assessing acute malnutrition (“aprogressive loss”) in emergencies, asopposed to chronic malnutrition (a “steadystate” of malnutrition), is increasinglyrecognised. Despite ongoing ambiguitiesregarding cut-offs, MUAC and clinicaloutcomes are used more frequently asassessment tools for admission criteria incurrent operations.

• The inability to stand has been identifiedas a very good prognostic tool to predictmortality in malnourished adults. Ways toidentify this functional deterioration bymeasuring strength are currently beingexplored.

• Preliminary findings have shown severelymalnourished individuals recover well insupplementary feeding interventions.Those admitted with BMI<16 haverecovery rates of at least 50% and thoseadmitted with BMI between 16 and 17have recovery rates greater than 90%.Current research is focusing on the follow-up and outcomes of the remaining 50%.

Medical management of patients in TFCsThe high prevalence of both acute andchronic disease among malnourishedadults poses a serious challenge in themanagement of adult malnutrition. Thedesign of therapeutic feeding for adults

must take into consideration someimportant medical issues. These include:

• In adults, severe malnutrition beyond acertain threshold is almost alwaysaccompanied by medical complications;

• Acute diseases such as diarrhoea do notnecessarily contribute to malnutrition inadults to the same extent as in children,instead malnutrition is often associatedwith, or is the consequence of, a chronicand debilitating disease such as chronichepatic and cardiac complications, whichare more prevalent in adults. Case by casediagnosis is essential and either referralservices or hospital facilities should beprovided. It is important to recognise thatmedical and nutritional problems bothneed addressing.

• Staff working in therapeutic nutritioncentres may not have sufficient medicalskills, or may not be appropriately trainedto address severe adult malnutrition.

An agency that wants to assist severelymalnourished adults may therefore need toconsider a complete revision of thestrategy, objectives, training, and othermeans (including human) it usually puts inplace to cope with severe malnutrition inemergencies.

Oedema and refeeding oedema• The differential diagnosis of famine

oedema in adults is complicated by thehigh prevalence of other diseases (cardiacinsufficiency, cirrhosis, etc.). Furthertraining and guidelines, adapted for staff inemergency TFCs need to be developed.

• Large numbers of patients have beenidentified with re-feeding oedema or havefailed to reduce levels of oedema despiteappropriate diagnosis and treatment. Thisis most likely due to inappropriate foodsbeing consumed e.g. those with high saltor low protein content or both.

Treatment considerations• Treatment with the same protocols

proposed for children (with changes in thequantities per kilo) have been found to bevery satisfactory. Weight gains, duration ofstay and success rates may be as high asthose for children.

• Acceptability and adherence to atherapeutic diet is more challenging foradults, in particular the refusal of a puremilk based diet remains a constraint.Alternatives to milk (with the samenutritional properties) are currently beingexplored.

HIV/AIDs• In both Brazzaville and Burundi, ACF has

reported that a high prevalence of thepatients admitted to the TFCs are HIVpositive. Despite this, recovery rates andother indicators (weight gain, duration ofstay) do not seem to be affected,suggesting that HIV positive malnourishedadults do recover as well as HIV negativeadults.

• The impact of the high prevalence of HIVrelated malnutrition in adults and itstherapeutic management is not wellunderstood. Research into HIV andmalnutrition in emergencies is urgentlyrequired, however the complexity of thetopic, and the ethical and operationalproblems presented make it extremely

difficult for any agency to conduct suchresearch.

Social considerations• Adults have a caring role in the family, are

the source for food and revenues, and theactors of reconstruction, socialrepresentation, etc. Separating them fromtheir social environment may havedeleterious consequences for theirlivelihoods and their ability to cope with,or recover from their current situation.Shorter-term treatment and ambulatorytreatment may be appropriate strategies foraddressing these issues.

• In locations where malnutrition relatedmortality is high among adults indirectsocial problems may also arise. InBurundi, many children have becomeorphans. ACF and its partners in Burundiare actively involved in taking care oforphans, and also in reuniting them withtheir surviving relatives.

Nutritional problems faced byinfants in emergencies Prof. Michael Golden, University of Aberdeen

Prof. Golden outlined a number ofimportant problems/issues regarding infantnutrition. Issues about the inclusion ofinfants in nutritional surveys were coveredin an article post-script written by ProfGolden in Field Exchange 9* and so willonly be cursorily dealt with here. Themain points about infants in nutritionalsurveys made in the presentation were that:

• Infants are not systematically surveyed.• Current selection criteria for surveys often

only include children above 6 months andlonger than 65 cm so that there is aselection bias.

• There are no established cut-off points orcriteria for infants less than six months todefine severe malnutrition (and admissioninto TFCs).

• The weighing scales and length boardscurrently provided by UNICEF areinsufficiently accurate to screen andmanage high-risk infants.

Additional points raised by Golden aboutinfant nutrition in emergencies includedthe following:

• Currently F100, diluted to lower the renalsolute load and osmolarity, is usedempirically to re-feed infants. There havebeen no studies on alternative diets for theseverely malnourished infant.

• Rehabilitating the severely malnourishedinfant whilst maintaining lactation raises anumber of serious difficulties. Severelymalnourished infants:− do not cry and, because they do notcomplain or show hunger, are neglected(this is not abuse),− lack strength and therefore are not ableto suck effectively or stimulate milkproduction,− have a very high mortality risk.

• A technique to support lactation, known assupplemental suckling, has been developed(see Field Exchange 9).

Mother’s diet• Breastfeeding mothers need a nutrient-

dense balanced diet. Mothers with type 1deficiencies (not associated with maternalanthropometric change) can have breast-

* ‘Comment on:Including infants in

nutrition surveys,experiences in Kabul

city’, Field Exchange 9,March 2000, pp16-17

News

milk which can lead to death or severeand irreversible defects in their infants.

• Clinical deficiencies of Vitamin K andD, iodine, thiamine, cobalamine,pyridoxine appear in breast-fed infantsbefore their mothers. Deficiencies ofselenium, Vitamin E and A and folatecan appear in both child and mother atthe same time, although data areinconclusive. Type 2 nutrients arepreferentially preserved in breastmilk,while Type 1 levels will fluctuate inbreastmilk.

• In order to have a healthy infant (andmother) the breastfeeding mother’s dietmust contain all 40 essential nutrients.

Recommendations of theWorking Group to the ACC/SCNfor action

Adult malnutrition Clarify issues relating to adultmalnutrition including its definition,and operational interventionguidelines. Disseminate thisinformation as widely as possible toagencies in need of support andguidance.

Infant feeding issues Liaise with the Breastfeeding andComplementary Feeding WorkingGroup in taking responsibility forfurther development of the operationalguidance, management of theconsultative process and coordinationof dissemination. Improve the trainingof humanitarian staff on infant feedingpractice. Advocate for the need ofexperts on infant feeding issues to bepresent at all emergencies from theoutset.

For further information or full report contactthe ACC/SCN c/o World Health Organisation,20 Avenue Appia 1211 Geneva 27 Switzerland.phone: + 41-22-791 04 56 fax: + 41-22-79888 91 EMail: accscn@who.inthttp://www.unsystem.org/scn/

Due to the increased frequency with whichcountries find themselves thrust into asituation of instability, UNICEF has

decided to mainstream its emergency responsecapacity into it’s regular country programmingprocess. Whether due to civil strife, insurgencies,warfare, or natural disasters such as drought,earthquakes and floods, UNICEF country officesacross the globe increasingly find themselveshaving to respond to emergency situations.

In keeping with the roles and responsibilitiesoutlined in the memorandum of understandingdeveloped with WFP, UNICEF need to undertakea number of activities following the declaration ofan emergency. Instead of reacting after the fact,UNICEF offices are now expected to be able toproactively respond in emergency situations.

Amongst the responses from UNICEF officesexpected in an emergency situation, the nutritionrelated ones are now considered a priority.UNICEF expects its offices to be able to lead aprocess of assessment and monitoring of thenutrition situation. In addition UNICEF should beable to source and deliver emergency supplies,including special foods for therapeutic feeding ofseverely malnourished children and micronutrientsupplements as appropriate.

In order for UNICEF to meet these expectations aseries of training sessions are being planned tocreate the required capacity. Initial emphasis willbe given to the Sub-Saharan Africa region.Capacity building efforts will be carried out incoordination with those of WFP.For further information contact Ludmilla Lhotska, UNICEFNutrition section New York, e-mail: llhotska@unicef.org

UNICEF buildscapacity foremergencies Dear Field Exchange,

Where have we gone wrong? Why is it that whenfood supplies get stretched, NGO and internationalstaff still think of infant formula rather thansupplementing the diets of the lactating mothersaffected.

I am currently in Mongolia, following the “dzud”,(a serious snow emergency) that has claimed thelives of some 2.4 million animals to date. The“mass starvation” predicted by the UN in March,has thankfully not happened but there are anumber of families that have seen theirvulnerability increase as their only means ofsurvival has gone.

In a recent co-ordination meeting, where I believeI was the only nutritionist in attendance (in fact Ithink I am probably the only nutritionist involvedin the emergency response here) one INGO,reported back from their recent trip to an affectedarea about the poor water quality, lack of fuel,and the loss of livestock. The INGO announcedthat due to the loss of livestock they would bepurchasing infant formula to feed the vulnerablechildren. Another INGO is currently shipping incontainers full of infant milk and othercommodities.

There is no evidence of lactation failure, and noevidence that malnutrition rates in young infantsare being affected by the dzud. What is actuallyhappening is that mothers are spending long hourschasing animals across the steppe and aretherefore tired.

SCF UK carried out a nutritional assessment inone of the 6 most affected provinces, the onlyNGO to actually carry out a formal assessment.We found that the incidence of acute malnutritionwas very low, less than 2 % while the incidence ofchronic malnutrition was almost the same as thatfound in the 1999 national nutrition survey (about12.5% underweight and 24.6% stunted).

It seems that once again the easy option is indanger of being chosen. This opens up a wholenew issue for those of us that work in nutrition.We have raised awareness for emergencyorganisations, but in a place like Mongolia, whereemergencies rarely happen, most staff aredevelopment orientated working in long termprojects but have had to respond to sporadicemergencies as the only people on the groundwith resources at the time. The majority of staffare often nationals with health qualifications;nutritionists are few and far between and the onesthat are, certainly here, are involved in researchonly. The “Infant Feeding in Emergencies”document1 certainly had not reached here althoughits now been linked to the UN DMT web site sothat interested parties can gain access to it. .

We have a whole new audience that we need toinform and as disasters inevitably occur in ‘new’areas we need to make haste. To give them credit,once the dangers of infant formula had beenexplained to this particular NGO, plans wererapidly altered. I hope that in other situations thereare informed nutritionists on hand to spread theword.

Emma Roberts

SCF Nutritionist.

Mongolia

1 ‘Infant Feeding in Emergencies: Policy Strategy andPractice’ A report by the IFEG. Produced by and availablefrom the ENN at a cost of £3 per copy.

Letters

11

Nestlé and the Code

Aformer employee of Nestle has publicisedinternal company documents that he saysprovide evidence that the company has

breached the international code on marketingbreast milk substitutes. The documents arereproduced in a report published by an NGOwhich campaigns for the "rational use ofmedication in Pakistan". The report highlightsNestle's donation of gifts to doctors as a rewardfor promoting its products, a practice outlawed bythe code. Other alleged violations include directmarketing of products to mothers and theprovision of free supplies of breast milksubstitutes.

Mr Francois-Xavier Perroud, vice president ofNestle, denied allegations of mal-practices statingthat “As anywhere in the world, Nestlesmarketing of breast milk substitutes in Pakistan isin line with the WHO code and if errors occurthen they are promptly corrected”BMJ Volume 320, 19th February 2000, pp 468

12

Field Article

Angola has been at war for more than 20 years. Asecond peace process, initiated at the end of 1994lasted until 1998 when conflict resumed. Since late

98, more than one hundred thousand people living in Biéprovince (in the central high plateau of Angola) have fledconflict and sought asylum around Kuito town (the provincialcapital of Bié). The population of Kuito town andsurrounding area has been estimated at 155,000, with about110,000 Internally displaced people (IDPs) currentlysheltered in various sites around the town. Kuito iseffectively now an enclave due to the high level of militaryactivity in the area and is known to be one of the heaviestmined cities in the world.

With little potential for food production by the localpopulation and the numerous displaced people living inKuito, most of this population are completely dependent onWFP (World Food Programme) rations. Small agriculturalfields and seeds have been allocated to the displacedpopulation but harvests are generally poor and insufficient.The purchasing power of the resident population has rapidlydecreased due to inflation and the activities of most tradershad been reduced due to the war.

MSF Belgium has been present in Bié province since the endof 1989. MSF’s work has included operating feeding centresand supporting Kuito general hospital. At the end of July1999 the first cases of pellagra were diagnosed in Kuito. Thismarked the beginning of the largest pellagra outbreakdocumented in the world for displaced or refugee populationssince the outbreak in Malawi in 1990 when more than 18,000cases of pellagra were reported among Mozambicanrefugees.

Case definition

The case definition for diagnosis of pellagra used in Kuitowas dermatitis on two different and symmetrical sitesexposed to sunlight or what is know as a cassal’s necklace(see photo).

These classical skin lesions only seem to occur more often inolder persons. Furthermore, individuals that do not gooutdoors, i.e. are not exposed to sunlight, do not get the skinlesions either. Although the triad of dermatitis, diarrhoea, anddementia is distinctive, these symptoms do not occur in everypatient. The earliest manifestations do not include dermatitisand in one third of florid cases dermatitis is the only sign.

The outbreak and the response

Local health professionals in Kuito know about pellagra, butonly a few cases a year are seen. From July 1999, a marked

increase in cases was seen and the phenomena rapidlybecame epidemic.

Between August 99 and January 2000, 898 cases of clinicallydiagnosed pellagra were seen in the hospital (see graph).Once the diagnosis was confirmed patients were referred tothe supplementary feeding centre where they received astandard protocol of nicotinamide 50 mg (adults = 3 x 2tablets/day for 15 days; children = 3 x1 tablet/day over 15days), vitamin B complex tablets, and a supplementary rationof CSB and dry fish.

The data showed that 83% of pellagra cases were female andthat 85% of cases were over 15 years of age. Sixty sixpercent of cases were IDPs (Table 1a). The attack rates at theend of November were 2.6/1,000 inhabitants. Attack rates byage and sex are given in Table 1b.

It should be noted that the attack rate only reflects dermatitiscases reported at the treatment centres by passive detectionand therefore probably underestimates the true attack rate.

A Pellagraepidemic inKuito, AngolaBy Sophie Baquet and Michelle van Herp

Sophie Baquet is theheadquarter nutritionist inMSF Belgium and Michel vanHerp, Headquartersepidemiologist in MSF

Belgium. This article is based on fieldvisits to Kuito between August 1999 andMarch 2000 and from field reports. Thereis also a contribution from Jeremy Shohambased on a recent review of pellagra inemergencies carried out on behalf of WHO.

Classical skin lesions - Cassal’s necklace. © P. Delchevalerie

13

Field Article

The general ration provided by humanitarianagencies was meant to ensure an intake of 1800kilocalories per person. The commodities were maizeflour, pulses, oil and salt. The logistical constraints tosupplying the food ration regularly in Kuito wereconsiderable as almost everything had to come in byair. The target groups for the general ration wereIDPs and others identified as vulnerable in theresident population (under five, pregnant andlactating, and disabled persons). From November1999, families with malnourished children were alsoincluded as vulnerable, as well as families withpellagra cases.

Between April and December 99 general food rationsprovided an average of 8 mg niacin per person perday. From November dried fish (a niacin rich food)was distributed to pellagra cases and their families aswell as to individuals attending feeding centres andtheir families. This was seen as a preventive measure.

In view of the fact that the general food distributiondid not provide enough niacin, and other sources likeCSB were not yet available in the ration until June2000, a distribution of vitamin B complex tablets toall women aged 15 and over was organised as anemergency response by MSF and other humanitarianagencies in December 1999. The target group waschosen only because of lack of resources to organisea distribution to the entire population Thirty tabletswere distributed to all women. A nutritional survey conducted in December 1999assessed compliance with intake of vitamin B

Distribution by sex male: ...............................98 (17%)female: ..........................473 (83%)

Distribution by age < 15 years: ......................86 (15%)≥ 15 years: ....................485 (85%)

Distribution by residential status resident: ........................196 (34%)displaced: .....................372 (66%)

IDPs Resident Total pop.n = 110,000 IDPs n = 130,000 inhab. n = 240,000 pop.

Male < 15 y 0.8 / 1,000 0.5 / 1,000 0.65 / 1,000≥ 15 y 1.4 / 1,000 0.6 / 1,000 1.0 / 1,000

Female < 15 y 1.2 / 1,000 0.4 / 1,000 0.8 / 1,000≥ 15 y 10.2 / 1,000 4.5 / 1,000 7.1 / 1,000

Total 3.4 / 1,000 1.5 / 1,000 2.4 / 1,000

Note: first cases of the epidemic have not been included as data are not available.

Table 1a: Distribution of pellagra cases per main demographic characteristic,1999, n = 571 cases, MSF.

Table 1b: Attack rates per main demographic groups, n = 571 cases, 1999, MSF

complex tablets by counting the number of tabletsleft in the distributed bag after a set number of days.The survey found low compliance.

It was concluded that a vitamin B tablet distributioncampaign did not seem to be the most effectivesolution to control a pellagra outbreak. Furthermore,targeting women with tablets was an emergencymeasure, but not a satisfactory option, as all strata ofthe population were probably deficient in niacin.

At a multi-agency meeting held in January 2000 itwas agreed that the general ration should besupplemented with CSB (rather than groundnuts asthe latter lacks riboflavin and pyridoxine both ofwhich are necessary for the conversion of tryptophaninto niacin) and that the priority group for receivingthe expanded ration should be the displaced.Consensus was also reached that the possibility ofincluding vulnerable residents should also beinvestigated.

Discussion

By January 2000 a number of important issues andlessons about the outbreak and response had beenidentified at multi-agency meetings and throughdiscussion with knowledgeable experts.

i) Although an average intake of 15-20 mg of niacinper person per day prevents pellagra for all agegroups, this applies to healthy individuals. However,as people had been subsisting on the deficient formany months body stores would have been depleted

in response to infection and other metabolic stressesso that it was critical to increase body stores to staveoff overt deficiency. Also, the majority of thepopulation in Kuito were exposed to malaria,diarrhoea and an increased risk of other infectionsand therefore may have had a greater requirement.

ii) The fact that the general ration was deficient inmany nutrients including all those implicated inpellagra led to the conclusion that CSB would be thebest food supplement to improve the intakes of awide range of nutrients. Groundnuts and beans,although rich in niacin, have relatively low levels ofriboflavin and pyridoxine which are both required toconvert tryptophan to niacin.

iii) There was uncertainty about the amount of niacinin maize - food composition tables show muchvariability. It is therefore important to advocate for‘nutrient content’ labelling of maize so that it ispossible to determine more accurately the amount ofsupplement to include in the ration to make up forany niacin shortfall.

iv) Although the case definitions used ensured thatthe diagnosis was not in doubt, the actual numberswith niacin deficiency in the population were grosslyunderestimated. Children would be eating the samediet as adults and have the same proportionaterequirements for niacin, but would not necessarilyshow the skin lesions of pellagra - they may getdiarrhoea. Classical signs are much less common inyoung children than in adults.

PELLAGRA OUTBREAK IN KUITO FROM 07/1999 TO 05/2000 Weekly evolution of new cases in hospital consultation

0

10

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40

50

60

70

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30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9

weeks

nu

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er o

f n

ew c

ases

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)

-10

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Resident Cases

IDP Cases

Total Cases

Distribution of Vitamin B

Number of Pellagra Casesadmitted in the SFC, Kuito,1999, MSF. Right Y axisrepresents total pellagracases.Left Y axis representsresidents & IDP casesseparately.

Pellagra is caused by Niacin(Nicotinic acid) deficiency. Thecondition can be fatal and is oftenassociated with other vitamin Bdeficiencies. Niacin (vitamin B3)is a water-soluble vitamin widelydistributed in plant and animalfood but in very small amounts.

Rich sources of niacin includegroundnuts, fish, meat and pulses. Thebody can synthesise niacin from theamino acid tryptophan.

The recommended daily requirementsrange from 13 to 15 mg nicotinic acid

equivalent for women and 16 to 19 mg for men. Duringpregnancy and lactation an additional 2 and 5 mg nicotinicacid respectively are required. For infants and children, 6and 11 mg daily are recommended, respectively.

The initial clinical features of pellagra are non-specific andinclude anorexia, prostration, weight loss, headache and aburning sensation in the mouth. The fully developedsyndrome, described by the “three D’s” consists ofdermatitis, gastrointestinal symptoms (diarrhoea), andfinally mental impairment (dementia). Eventually the fourth‘D’ can occur - death.

Niacin deficiency was endemic and often epidemic amongpoor population in Europe and USA until the middle of the20th Century. It was first reported 250 years ago andfollowed the introduction of maize (low in niacin comparedto other cereals) to Europe from the Americas.

Niacin deficiency is now endemic at very low levelsamongst the rural poor in Africa where maize is theprincipal cereal. Examination of rural health centre recordsmay show a few cases – especially during the ‘hungryseason’. However, outbreaks of pellagra have only occurredin recent years amongst emergency affected populations.The limited epidemiological data available from theseemergencies indicate that it affects principally adults,particularly women. When a niacin and/or tryptophan –deficient diet is consumed, the lead-time for developingsigns of pellagra is about 2 to 3 months.

Reminder about pellagra

The pellagra casedefinition wasdermatitis on twodifferent andsymmetrical sitesexposed to sunlight.© P. Delchevalerie

14

Evaluation of the WajirRelief programme 1996-98Published Evaluation

OXFAM (UK and Ireland) were engaged inrelief work in Wajir District of Kenyafrom September 1996 until October 1998.

The interventions were a response to the droughtsof 1996/7 and the El Niño floods of 1998.OXFAM published the findings of an externalevaluation1 of their response in April 1999. Thisevaluation drew on the experiences of their staff,other agency and government staff and on theviews of beneficiaries.

Wajir district is populated by a largely pastoralistpopulation. Successive droughts had led todepletion of livestock herds and increasingdestitution. Available data on child malnutritiondemonstrated a severe crisis. OXFAM respondedby organising one of the largest relief operationsever mounted in Wajir District. Over the two yearperiod OXFAM spent £4,612,029 on reliefcomponents. It delivered over 21,000 tons ofmaize 16,000 tonnes of beans and 500 tonnes ofoil.

Although the programme was continuous, it canbe broken down into two distinct phases:

i) The response to the drought starting with athree month drought mitigation project in thesouth and parts of the west extending to the wholedistrict except a 15 km radius around Wajir town(where the Kenyan government were providingrelief) and winding down by October 1997;

ii) The response to the El Niño floods with arelief programme from December 1997 to August1998 which became a recovery programmeending in October 1998.

Overall the evaluation demonstrated the timelinessand high quality of the relief response deliveredby OXFAM to the rural population of Wajirduring the drought and floods of 1996-8.However, there were problems:

i) there was a tendency to plan and submitproposals for only 3 months. This appears to havebeen due to a reluctance by DfID to commit tolonger term food purchase as their preferredoption was to encourage WFP to provide relieffood;

ii) the planning phase consistently under-estimated the number of beneficiaries eligible forrelief food. As a result the ration had to be cut andthe food shared more thinly.

Main findings of the evaluation

OXFAM used a system of relief food distributionwhereby the district was divided into fivelivelihood zones, each with a different recoverypackage. This approach was appropriate andworked well.

OXFAM registered women as beneficiaries ofrelief resources. Although more managementintensive than other distribution approaches, itwas a price worth paying for a more efficient andequitable means of distribution.

The relief food became a critical component ofthe diet and the dramatic fall in malnutrition ratesduring 1997 over a period of about five monthswas probably due to the combined results of therelief operation and of good rains in April/May1997.

The food distribution also stabilised food priceshelping pastoralist purchasing power. This benefit

was especially critical for Wajir town which wasless well served by the relief operations due tosmaller distributions of maize by the GoK. Thispresented a dilemma for OXFAM as many of thepoorest and most vulnerable lived in the town butit would not have been appropriate to shoulder thegovernments responsibility and replace their reliefoperations with an NGO one.

The coverage of 90% of households reported inJuly 1997 was exceptional and the operation wasconsistently rated by beneficiaries as one of themost successful the district had experienced. The impact of the floods was sudden and extreme.During the first few months of 1998 when theroad network was severely disrupted, the fooddistribution was life-saving. OXFAMsupplemented the meagre government relief rationin Wajir town with Unimix and high energybiscuits.

As Wajir district began to recover from droughtand flood OXFAM altered their approach andinstigated a series of recovery interventions toassist vulnerable households as food relief waswithdrawn. A financial analysis of the four typesof intervention demonstrated the costs andbenefits associated with each. It cost Ksh 525 todeliver one ration of food relief. In order toprovide similar benefits, i.e. the equivalent of onemonthly ration, restocking with goats cost Ksh712, restocking with oxen Ksh 480 and cash forwork Ksh 450.

The cash for work scheme made the most impact,allowing households to clear their debts, buyessential items and invest in small-scale incomegenerating activities.

Restocking interventions also provided benefits torecipients but sheep and goats did not achieve thelevels of production anticipated. The result wasthat this became an expensive means oftransferring assets to poor households. Restockingwith oxen and provision of seeds would havemade a significant impact if the short rains of1998 had not failed.

The on-going development programmeundoubtedly suffered from the legacy of the large-scale relief programme. It dramatically changedthe perception of OXFAM in the district, whichnow tends to be seen as a ‘free hand out resourcerich’ relief agency. OXFAM’s ability to turn theimage around and re-establish itself as adevelopment agency will depend partly on thetime lag before another emergency operation.

OXFAM exploited its comparative advantage asan international NGO with strong field basedoperations by identifying and responding early tolocalised food stress and mobilising fast as theemergency developed and changed. However, thesuccess of its response was highly dependent onfunding provided by one bilateral donor -DfID.The lengthy procedures that WFP must follow tolaunch an appeal and deliver food to Kenya meantthat the first WFP deliveries to Wajir arrived 9months after OXFAM had started the reliefoperation and four months after the GoKsemergency declaration.

1 Buchanan-Smith. M and Barton.D (1999); Evaluation ofthe Wajir Relief Programme (1996-98). Oxfam, Oxford OX27DZ, England.

Evaluations

There were many possible explanations for thehigh prevalence of pellagra amongst females over15 years of age; demographic profile, differenthealth seeking behaviour, different sunlightexposure (men go bare chested so will not getcassals necklace in sunlight), real dietarydifferences, different clinical expression of illnessand hormonal differences.

v) In the longer term a more appropriate solutionshould be found than supplementing the generalration with fortified CSB. Strategies used insimilar situations have included fortification ofthe maize in local mills and commercialfortification of maize in country or in the countryof origin.

Update on situation

A second vitamin B distribution was carried outat the end of February/March 2000. This wastargeted to everyone in Kuito and implemented asCSB had as yet to be included in the generalration. As can be seen from the graph, the numberof cases of pellagra began to decline markedly inFebruary and March. This was probably due to acombination of factors, i.e. the vitamin tabletsdistribution, a diversified WFP ration (includinggroundnuts), less sunshine and a small harvest.However, as can also be seen from the graph,pellagra cases were beginning to reappear againby the end of April. Although WFP had beenpromising the delivery and addition of CSB to thegeneral ration since early in 2000 none had beendistributed in the general ration by the end ofMay 2000.

Conclusions and recommendations

This epidemic underscores once more thevulnerability of food aid dependent population tomicro-nutrients deficiency diseases such aspellagra (an easily preventable nutritionaldeficiency).

Despite international nutrition officialrecommendations, relief programmes failed toprovide the minimum recommended dailyallowances (RDA) of essential micronutrients toKuito’s vulnerable population.

Although it was recognised that niacin rich foodsneeded to be urgently added to the general ration,this proved not to be possible. In the event niacinrich foods (dried fish and CSB) were onlytargeted through feeding centres. It was unclearwhether this occurred as a result of logisticaldifficulties, or due to inadequate provisioning of,or access to CSB. In any event given the currentpolicy of ensuring adequate micro-nutrient intakefor populations totally dependent on food aidthrough the provision of fortified blended foods,established in the most recent WFP/UNHCRMOU, questions need to be asked about why thiswas not possible during the Kuito emergency.There is also an issue (which may well relate tothe lack of supply or access to CSB) about onlytargeting niacin rich supplements to pellagracases and malnourished children and theirrespective families. This curative strategy isarguably unethical. In a situation where there is aclear public health emergency of large proportionit should surely be incumbent upon theinternational community to prevent further casesof this disease occurring and provide niacin richfood to the whole population.

Many observers and experts believe that thereneeds to be a review of the diagnostic criteria forpellagra. In this case relying on narrowdermatologically based diagnostic criteria mayhave obscured a high prevalence in otherdemographic groups (i.e. it wasn’t just womenover 15 years of age who were suffering). In theevent due to lack of resources, this led to aninitial vitamin tablet distribution to adult femalesonly.

15

The UK Department for InternationalDisasters (DfID) commissioned anevaluation1 of the British government

response to the Montserrat volcanic emergencybetween July 1995 and November 1998. Theisland of Montserrat is a British GovernmentOverseas Territory. The volcanic eruption whichbegan in July 1995 devastated Montserrat. Bythe 26th of December 1997, when the mostextreme explosive event took placeapproximately 90% of the resident population(over 10,000) had to relocate at least once withover two thirds of the population leaving theisland. Virtually all the important infrastructureof the island was destroyed or put out of use forthe short to medium term. The private sectorcollapsed and the economy became largelydependent on British Aid.

Evaluation Findings

Overall, the disaster response by Britishgovernment was considered a success with only19 confirmed fatalities and hardly anymeasurable increase in communicable diseaseand physical ill health. Throughout theemergency, which involved four majorevacuations at little notice, everyone had a roofover their head and no one went hungry.However, the success has to be qualified by lesssatisfactory aspects of the response and itsconsequences.

Following evacuations in December 1995 andagain in April 1996 relief food was distributedto support those relocated to the north whetherresident in shelters or private housing. Rationswere intended to supply one main meal a day.They consisted primarily of long-life tinnedfoods and where locally donated suppliesallowed, fresh fruit and vegetables. The

approximate numbers receiving food rationsranged between 3,500 and 4,600. Overall theration distribution appears to have been wellorganised. However, people also needed incomesupport for other essential expenditures. Also,the administrative costs of direct distributionwere extremely high.

Plans were put forward to refocus the form ofassistance from June 1996 within three monthsof the final evacuations of the South. TheGovernment of Montserrat elected for a FoodVoucher Scheme, broadened to include all foodsand basic toiletries and exchangeable in localshops. The scheme reduced the burden oforganising supply and delivery. It also provideda way of supporting the fragile private retailsector. It offered an opportunity to broaden theeligible population beyond evacuees in sheltersto include other evacuees outside the shelters aswell as safe zone residents who had lost theirjobs because of the evacuation.

The assistance scheme was further adaptedwhen vouchers were replaced in December1997 by cheques to the same value that couldbe cashed at banks and supermarkets. Thischange appeared to be a pragmatic response topressures from beneficiaries wanting freedom touse the assistance in a more flexible way tomeet general expenditure, including rents. Itwas also a response to the heavy administrativeburden of the voucher system on staff involvedin the programme. Pre-registration wasundertaken with a view to rationalisingbeneficiary lists as in September 1997 it wasestimated that nearly all of the on-islandpopulation were in receipt of the voucher.During 1997, it had been decided that therewould be a social welfare review to movetowards more targeted forms of benefits for

more narrowly defined groups based on meanstesting. This process had still not beencompleted by September 1999.

Evaluation Conclusions

The evaluation authors concluded that theprovision of relief during the initial evacuationswas appropriate and timely in providing arudimentary safety net. The switch to a voucherscheme was a practical, and probablyappropriate, development when it became clearthat people would be remaining in the north ofthe island indefinitely and that large numberswere still in need of some form of assistance.Substantial savings in transaction costs weremade in the move from rations to vouchers.However, the introduction of an exchangeablevoucher was partly based on the desire toextend the categories receiving support. In viewof the subsequent problems of targeting, a morerapid move to some form of income supportmight have been appropriate. Generally, unlessthere are specific reasons in favour of morerestricted food assistance, purely monetarytransfers are preferable on grounds of flexibilityand minimising transaction costs for allinvolved.

Senior Monteserratian officials suggestedinformally that had there been a needsassessment, up to 20% of the beneficiaries inlate 1998 would have been removed from thelists. Potentially the most serious criticism ofthe voucher scheme and its successor was thatthey fostered a dependency culture amongstsome of those remaining on the island

1 Clay. E et al (1999) An Evaluation of HMG’s Responseto the Montserrat Volcanic Emergency. EvaluationReport EV635, December 1999.DfID, 94 Victoria St,London SW1 5JL. Email: enquiry@dfid.gov.uk

Evaluation of the Response to the Montserrat VolcanoPublished Evaluation

© JIM DEMPSTER

Evaluations

16

Agency Profile

During my efforts to fix up a meeting with ACF’sD.G in Paris, I had been asked to be very clearabout how much time I would need as he would

be squeezing me in between urgent meetings. In a way Iexpected nothing less from the busy head of a largeinternational NGO and was therefore pleasantlysurprised when Jean Luc introduced me into his office ina relaxed manner and proceeded to give me a couple ofhours of his afternoon to answer my questions beforegetting back to work at 5pm!

Jean Luc Bodin began his professional career workingfor MDM and IFRC in Karamoja between 1979-82. Hesubsequently went to work for AICF1 in Chad in 1982and then moved into a field post with MSF France inEthiopia. He returned to France in 1987 having spent 8years in the field. AICF then proposed that he work as avolunteer in Paris. “At the time there were only 5 staff atHQ covering four country missions,” Jean Lucremembered having to share one phone between 3people.

AICF were founded by a group of French ‘intellectuals’,authors and other public figures in 1979 whose conceptfor the agency was a sort of ‘Amnesty International’ forcombating hunger. The main aim of AICF was tosensitise the French public to the need to fight globalhunger and starvation and to engender a belief that theproblem could be tackled with their help and work.AICF committees were set up in many cities in France.Their role was to fund-raise and sensitise the localcommunity. However, following the experience inEthiopia in 1984 it became obvious that AICF lackedoperational capacity for this type of emergency andneeded to ‘scale-up’ in terms of resources and staff.During this period (1987-91) AICF expanded rapidly butalso began to work more in the development sector, e.g.seed programmes in Kordofan, income generatingprojects in Pakistan and Madagascar and land transferprogrammes in the Philippines.

Jean Luc was made director of operations in 1991 andsoon after AICF’s Board decided the organisationurgently needed to rationalise its work and specialise inone or two emergency sectors only. This was partly asAICF was spreading itself too thinly and also as therewas no real coherence between the organisation’s nameand what it was doing. It was also hoped that thisstrategy would make it easier to raise funds. It wasdecided to focus on the emergency nutrition and watersectors.

Two technical specialists were taken on to help with thistransformation and AICF began to develop expertise inselective feeding programme interventions. During thisperiod (1992) links with INSERM (a governmentadvisory centre) led to the formation of the InternationalConsultative Scientific Committee whose role was toadvise AICF on technical matters in the nutrition domainand also to initiate research through AICF emergencyprogramme infrastructure. Field trials of F100 in AICFprojects came about through this linkage. AICF alsodeveloped a water and sanitation expertise at about thesame time. Subsequently, AICF have strengthened theirinstitutional capacity to deal with medical aspects oftherapeutic feeding programmes and more recentlydeveloped a food security capacity.

Since taking up the DG post three years ago Jean Luchas put a lot of effort into improving the marketing ofACF to the French public. The proportion of ACFfunding that comes from the public purse is very low(just under 25%) – especially compared to larger NGOslike MSF or OXFAM. It was felt dependence on a fewlarge donor organisations for funding could compromiseautonomy. ACF hopes eventually to get to a positionwhere 50% of revenue comes directly from the Frenchpublic. Jean Luc’s view is that “MSF’s success in gettingpublic donations is due to their greater involvement inadvocacy work which in turn makes them more publiclyvisible.”

When asked whether ACF had ever found themselves ina difficult political or ethical position, Jean Luc repliedthat this had indeed happened on a number of occasions.For example, ACF had pulled out of DPRK at thebeginning of this year because their food aid appeared tobe siphoned off by government and was not reaching thechildren it was intended for. Then there was theexperience in South Sudan, where AICF had beenconcerned about the consistently high levels of wasting(13-18%) recorded in Labone camp and wanted to do asocio-economic survey to establish whether food aid wasbeing diverted from intended beneficiaries. Notsurprisingly, the authorities asked them to leave.

Jean Luc gave an example of the type of conflict that canarise between humanitarian ideals and the need to satisfypotential funders but where ACF managed to hold fast.This occurred in Afghanistan where the UN/OCHA haddeveloped a strategic framework for influencing Talibanpolicies - especially with regard to women. ACF’s viewwas that this translated into sacrificing short-term

Action Contre la Faim (ACF)Interview by Jeremy Shoham

Name Action Contre la Faim

Address rue Niepce, 75014 Paris, France

Telephone +33 (1) 43 35 88 88

Fax +33 (1) 43 35 88 55

Email acf@acf.imaginet.fr

Internet http://www.acf-fr.org

Year formed 1979

Director Jean Luc Bodin

Overseas staff 194 expat / over 4,000 local

HQ staff 63

Annual Budget 263 Million FFrancs

1 AICF changed their name to ACF in 1996 as itwas realised that AICF did not convey theorganisation’s intentions or purpose very readily tothe French public and nor was it very consistentwith the names of the other partners, ActionAgainst Hunger in the US and UK and AccionContra el Hambre in Spain. Thus the ‘I’ forinternational was dropped.

ACF personnel discussing a crop production at harvest (West Africa)

17

Field Article

Angola has been at war for almost 3 decades.This has had a profound influence at alllevels of the country’s infrastructure:

economic, social, public, commercial, political andmilitary. There had been massive inflation ofconsumer prices, averaging over 1000% in theperiod 1994–98.1 Almost half the country’s 11million population live in urban centres, partly toavoid insecurity in rural areas.

Fighting had resumed in December 1998, and wasconcentrated in the central Planalto region of thecountry, in and around Huambo Province. Theresulting displacement, together with the economicimpact of the unrest led to the current emergencyprogramme.

The scale of SCF’s emergency operation inHuambo had increased markedly since December1998, mostly as a result of concerns about the foodand nutritional situation of the town’s inhabitants –displaced and latterly residents. The IDPs fell intotwo broad groups: camp residents (about 30,000)and those dispersed in the local bairos (about100,000).

SCF’s emergency operations included:

i) a General Food Distribution Programme, andii) a Supplementary Feeding Programme

General Ration Programme

SCF were an implementing partner of WFP for thegeneral ration programme. At the time of my visitthe programme was undergoing several changeslinked to servicing the expanded case–load ofresidents and non–camp IDPs. WFP had finallyacceded to repeated SCF requests to expand foodaid support.

In the period June 1999 to January 2000 the totaldistribution by ICRC and WFP/SCF amounted to14% of estimated food requirements.2 TheNovember nutrition survey in Huambo hadindicated a global malnutrition rate of 13.8%.

On arrival it appeared that coordination of the foodaid programme had been weak. One manifestationof this was the discrepancy between ICRC andWFP approaches. ICRC gave a ration of 6kg ofmaize per person whereas WFP provided anythingup to a full ration of 12kg maize, 1.8kg beans, 0.75

Kg oil and 0.15kg salt. In contrast to WFP, ICRCdid not employ targeting criteria in the belief thateverybody had been equally affected by theconflict. This served to confuse relations withGovernment authorities, through whom all agenciesworked to ensure a co–ordinated, planned responseto the population’s food needs. Althoughgeographical areas of responsibility were clearlydemarcated between ICRC and SCF, the rationalefor ration variations was not clear.

WFP planned a monthly food distribution of1,500MT of food aid involving food for work,general ration distributions and supplementaryfeeding programmes in Huambo Municipality. Incontrast ICRC had a monthly programme of3,000MT food, distributed entirely through generalrations, for people living outside HuamboMunicipality, plus 3 bairos in Huambo (Aviacao,Fatima and San Luis).

One serious limitation of WFP’s operation inHuambo had been the lack of forward planning; allactivities were carved out in one–month chunks,with little analysis of needs/responses beyond that.Undoubtedly, this was partly a result of pipelineconstraints, but more transparency as to theseconstraints would have eased rapport with the otheragencies. It meant that SCF could not guaranteebeneficiaries rations beyond a month or informthem in sufficient time about what their rationentitlement was going to be. But perhaps evenworse was the fact that this lack of informationundermined relations with the secretaries andcommunities of the various bairos.

At the time of my visit WFP appeared to berevising their activities largely sparked by amission from Rome which revealed problems in thefood distribution programme.

Targeting rations when the need for foodaid support is ubiquitous

SCF’s registration procedure for the general rationprogramme in October employed two broad criteriafor exclusion from non–camp distributions: salariedemployment (including army, police, civil securityforces, government workers etc.) and evidence ofcommercial activity (business people rather thanpetty traders). As some households were therefore

Reflections on food andnutrition interventionsin HuamboBy Lola Goselow

This article is based on a field trip madeby Lola Gostelow (SCF HQ emergencyadvisor) to the SCF programme in Huamboprovince, Angola in November 1999. Theaim of the visit was to review activitiesand future plans as well as work with theteam on technical aspects of the food and

nutrition programme. The article provides a snapshotdescription of SCF’s emergency food and Nutritionintervention at the time. It also shows how mid-termprogramme reviews can strengthen interventions.

humanitarian ideals for longer-term political ones andstruck a deal with the Taliban in 1998 to open upselective feeding programmes in Kabul. They were onlythe second agency to sign an agreement with theTaliban. This did however, make it very difficult forACF to get funds for the programme, strengthening JeanLuc’s resolve to increase agency financial autonomyfrom major donors. In Jean Luc’s words ‘its OK fordevelopment programmes to be influenced by politicalor foreign policy purposes, but not humanitarian aid’.

Apart from ACF Paris, there is also an ACF in the UKand one in the US since 1985 (both called ActionAgainst Hunger) and an ACF Spain (ACH) in Madrid.The four offices have a co-operation agreement but areall legally independent. However, only ACF in Paris isso far financially self-supporting although ACF - UK(AAH) expects to be this year.

There were three main reasons for setting upinternational offices:

i) to improve capacity to lobby or influence other donorgovernments, e.g. the capacity for advocacy in Spainand the US are now considered to be good given stronglinkages with the Spanish government and US senate;

ii) to improve access to human and technical resourcesand expertise that may exist in other countries;

iii) to increase access to financial resource in otherdonor countries.

At the end of our meeting Jean Luc re-iterated that hismain wishes for the future were for greaterindependence financially and less political constraints inACF’s work.

I met Chris Daniel’s (the recently appointed ACFTechnical Co-ordinator) prior to leaving theorganisation. We chatted a bit and Chris told me howrecently revised EU funding arrangements (the EUprovides about 50% of ACF’s funding) were makingsome people in ACF cautious about ACF moving backinto rehabilitation and development programmes eventhough this makes sense from a food securityperspective. Apparently ECHO now generally providesfunds for only the first 12 months of an emergency andthen DG VIII takes over responsibility. However, DGVIII may well take a year and a half to consider afunding request, and funding is rarely allowed to beused for funds spent before a proposal is approved withthe result that ACF needs to provide interim fundingafter 12 months for longer lasting emergencies andparticularly for programmes that involve rehabilitation.

I left the ACF offices in Paris thinking about thebalancing act key decision makers in humanitarianNGOs have to perform in order to survive while at thesame time maintaining the political and professionalintegrity of their agency. Institutional flexibility andadaptation seem to be the name of the game.

ACF – Nurse feeding a malnourished infant in a TFC in SierraLeone

18

Field Article

not eligible, disputes emerged and grievances wereoften directed at SCF. At the time of my visit thedecision had been taken to postpone futuredistributions until the Government had formallyagreed to the criteria proposed and communicatedthis agreement to all bairo administrators.

WFP Huambo subsequently criticised these criteria astoo broad. A meeting was convened in November toreview the criteria used and plan for a re–registrationexercise. WFP tabled a list, on which criteria couldbe based. The list included:• elderly (>55 years) head of households• disabled head of households• salaried workers• family income (the idea of a 45 million Kwz

poverty line was discussed) • nutritional status• agricultural activity and farm income

Lengthy discussions ensued amongst the agencies,during which it was agreed that there was a need forrealism about the sorts of information that it wouldbe possible to collect with some confidence, or whichcould be verified independently of interviews. Thefinal outcome of the meeting was that three sets ofcriteria for exclusion from non–camp distributionswere to be considered in making a decision abouteligibility for a food ration and that backgroundinformation on the beneficiaries should also becollected (see table).

It was anticipated that the background informationwould be useful for the general monitoring of thesituation in Huambo and for getting a basic profile ofthe population for use in future non–emergencyprogramme planning.

Thus, the decisions making process regarding receiptof a food ration would be as follows:

There was a great deal of discussion and uneaseabout these criteria, not least because it could beexpected that the vast majority of households wouldhave some ‘other income’ apart from a salary. Indeed,those with no other income would arguably have diedby now, since the general ration would not have metall nutritional needs. However, there was quite a lotof pressure from WFP to ‘tighten’ the criteria used, asthey felt it was unacceptable to see well–dressedpeople arrive for food at a distribution; they wantedto exclude the ‘obvious’ cases of inappropriateregistration. The point was made that while the

revised criteria might reduce inappropriateregistrations, it would also markedly increase thelikelihood of missing people who truly neededsupport. WFP maintained that we should progresswith these ‘new’ criteria, and review the programmein January 2000.

In January another SCF advisor visited Huambo toconduct a brief appraisal of food security in Huambo.He concluded that the total food supply to the citywas less, probably very substantially less, than wasrequired by the population for adequate subsistence(the November nutrition survey in Huambo hadindicated a global malnutrition rate of 13.8%). Inaddition there was no evidence for any easilyidentified household characteristic, other thanpossession of an affluent residence in the concretecity, which allowed discrimination between thosewho were in need of food distribution and those whowere not. In other words the proportion of the generalpopulation who were able to meet their food needsfrom their own economic activities was so small as tonegate any advantage from targeting. Following theserecommendations WFP reinstated a generaluntargeted food distribution which was finallyrunning smoothly in April 2000. The general fooddistribution ceased for all non–IDPs in May as aresult of the WFP/FAO Crop assessment whichconcluded that the recent harvest would meetpeople’s food needs for two months. Preliminaryresults from the May survey showed global levels ofmalnutrition to be 10%.

The discussions, disagreements and arrival atconsensus over targeting, registration andmanagement of the distribution system took almost 6months. We have to ask ourselves at what cost?

The Supplementary feeding programme

There were a total of 13 supplementary (8 SCF, 2Concern, 3 ADDRA) and 6 therapeutic feedingcentres. Entry criteria for all SFCs were similar:children up to 12 years of age, below minus twostandard deviations (equivalent to approximately80%) of the median weight–for–height (WFH). SCFcentres had used low MUAC as an alternative entrycriterion to admit cases who were not below theWFH cut off but looked malnourished. It washowever agreed that this practice would be stopped.This would help more rigorous monitoring as onlyWFH is used after admission to evaluate progress anddecide on discharge.

Supplementary feeding in the context of theoverall general ration.

Registration records in some centres showed thatthose attending were coming from nearby bairosrather than the immediate vicinity: For example,approximately 65% of the caseload in the Aviacaocentre come from Kalamanda, where SCF had onlymade one general distribution in the past.The ration given at the centres was 1,400kcal perchild or carer per day (two porridge meals wereprovided at around 9.30am and 1.30pm). This wasquite generous and reflected the concern about thelack of general ration at the time the programme wasestablished. It was decided that the ration could bereduced for children aged below three years. Thus,instead of the 200ml porridge, the under three yearolds would receive 150ml, or approximately 1050kcal per day. Also, no second helpings would begiven to older children. In this way, it was hoped thatthe ‘supplementary’ aspect of the feeding programmecould be strengthened so that children would realisethat they also needed to eat outside the feedingcentre.

In addition, out of the 4,000 or so registered in theSCF feeding programme, about one third were carersaccompanying children below 2 years of age thatwere travelling long distances to come to the centre.The carers received the same ration as the children.We discussed the possibility of reducing theirallocation to one meal.

The feeding programme team were planning a rapidassessment to examine the proportion of childrenattending the feeding centres whose families hadreceived a general ration in the last two months. Thisenquiry was intended to help guide any futuredecisions about the size of the ration for children andcarers. It was also hoped that it would shed light onwhether those children who had been attending forseveral months came from families who received noother food aid.

Attendance Issues

Data from feeding centres were showing a clearpattern of non–attendance for about two weeksfollowing a food distribution. But, once the food athome ran out, children would return for feeding. Acorollary was that there were a significant number ofchildren who had been attending the programme forseveral months but who had yet to recover. Twoadditional staff were recruited in each of the centresin order to trace children. With these additional staff,it was hoped that families could beencouraged/supported to continue sending theirchildren for feeding in order to ensure full andspeedy recovery. It was also hoped that such contactwould help provide information about some of theconstraints that families were facing with regard toparticipating in the feeding programme and thedecision–making processes they go through.

There were regular weighing days (2 per week percentre) with the bulk of admissions and dischargesoccurring on these days. It was therefore of littlesurprise that attendance on weighing days had beendropping as children sought to avoid discharge!Consequently, it was agreed that the weighing dayswould be varied, and any children who missed theweighing day would be monitored on their first dayof return.

Improving Psychological Care

Another new cadre of staff employed were playorganisers (two per centre), to promote mentalstimulation and developmental activities with thechildren as a complement to the physical care theywere receiving. Such activities are an importantaspect of the success of a feeding programme, andthere is evidence that length of stay is reduced whenplay and other activities are combined with thefeeding. These new staff were about to be trained bya church group on techniques to care for childrenwho had been psychologically injured.

Lessons Learnt

Although not explored in detail during my visit, a keyissue which emerged and that would hopefully betaken forward by the team, was the need to improvethe quality of documentation of our programmes.With this in mind, it was recommended that all teamscompile key documentation relevant to theirprogramme: lessons learned, monitoring formats,staffing issues, guidelines on approaches or protocols,rationale for any major decisions made, etc. Theseneeded to be compiled on paper and disk, and storedin a clear, accessible location (in Huambo, Luandaand London).

For example:

• In the general ration programme, there wereimportant experiences of targeting, ration selection,timing, distribution methodologies, monitoring etc.which needed to be captured for future reference.

• In the nutrition programme, lessons aboutinformation for registration, the need for individualrecord cards for each child, formats for reportingthe monitoring statistics, the final protocols etc.constituted important experiences which would helpinform the implementation of any future feedinginterventions.

It was vital that we should not have to begin againfrom scratch (as was the case for this programme).

Salaried worker?

Any other income?

Child in feedingCentre?

Receive rationNo ration

yes

yes

yes

no

no

no

Background Information

Residence status; arrival dateand place of origin for IDPs

Family demography (includingany disabled members)

Source of income (formal orinformal sector, type of tradeetc)

Number of children in feedingcentres and name of centre(s)

Farming activities

Criteria for exclusion fromnon-camp distributions

Salaried workers

Households with anyincome

Households with nochildren at feeding centres

19

The destruction brought by the violence ofHurricane Mitch from October 26-27th of l998has been well documented. No country was

harder hit than Honduras, a nation of 5.8 million.Eighteen thousand people died, 1.4 million weremade homeless, 600,000 displaced. It was the worstnatural disaster to hit Central America in 200 years.By the time the 180-MPH winds had subsided threequarters of the Honduran agriculture sector was inruins and 80% of its infrastructure destroyed. Mitchwas not only wind, it was rain. Rain of almostbiblical proportions. Deforestation, leading towholesale erosion. There was nothing to stop thetorrents of water as they roared down the mountainsinto the valleys. Rivers rose l4 feet in hours sweepingaway all before them.

Honduras, like most third world nations wassingularly ill equipped to cope with this wrath ofnature. Corruption, a lack of resources, a military thatwas then a law unto itself meant that anythingresembling a disaster or crisis plan was non-existent.There were no standby reserves of food or drinkingwater and no caches of medical supplies. There wasjust a hope that the storm would pass. It didn’t and aninefficient and overwhelmed civil authority foundthat it could not cope.The problem of organising any form of a relief effortwas further hampered by terrain. Honduras is mainlymountains sliced by a series of rivers. With themajority of bridges down and many roads washedout, getting food, medical supplies and water to theaffected population became a logistical nightmare.

However, as I found out there were some unlikelyadministrative and logistical structures that were ableto fill the vacuum and provide the foundation for arelief effort. I say unlikely, as these were the huge

agricultural companies of United Fruit (ChicitaBananas) and Standard Fruit (Dole).

Dole’s major operational and administrative hub isthe third largest city in Honduras, La Ceiba on thenorthern coast of Honduras. From there it controls itshuge plantations that stretch among the coastal planeand down the rich fertile land of Aquan valley.Nature determined where the plantations and villageswould be, it also determined that it was thoseplantations and villages that would take the brunt ofthe storm. The rivers like the Aquan, The Cangrejal(which bisected La Ceiba) and the Bonita becameterrible water bulldozers, smashing all that were intheir path. As the water receded, little remained.Those towns and villages that survived were buried infour to six feet of mud. Drinking water was astinking cocktail of drowned animals, sewage androtting food. The usual conveyors of disease, fliesand mosquitoes added to the misery. Some villagesthat survived the worst had to be evacuated becauseof the fears of a malaria or dengue fever outbreak.People flooded into the town seeking shelter,straining already meagre resources.

Faced with this catastrophe, the civil administrationallocated some municipal buildings as temporaryshelter. However the immediate problem was foodand water, not only supplies but also a distributionmechanism. The central government had little tooffer. Politics demanded that the capitol Tegucigalpagot first call on resources. The area also benefitedfrom the presence of the large American Base atPalmerola. This meant that the Southern part ofHonduras was an American sphere in terms of aidafter Mitch, leaving little for the rest of the country.Overall the area around La Ceiba was not faring well.The 4th Infantry regiment of the Honduran Army

Peter Guy Silverman is the ombudsman for CityTV,Toronto. He has recorded the needs and reliefefforts for a variety of organisations. Thesedocumentaries have been aired on CityTV.This article is based on a mission Peter undertookwith the Canadian Disaster, Assistance andResponse Team (DART) at La Ceiba. Their missionwas to provide immediate medical, engineeringassistance and drinking water. Dole (a commercialfruit company) provided the DART with a base ofoperations at its facility at Sonaguara as well asfirst hand knowledge of the area.

Industry: unlikely players inemergency food distributionBy Peter Silverman

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20

seemed unable to respond, unlike the units in thecapital that did take part in rescue and relief. TheAirforce with its usual elan deployed threehelicopters to haul food and water over the mountainsto now isolated villages. It was a band aid operation.I can attest that rains and cloud made the missions‘seat of the pants.’ Canadian helicopter crews thoughtwe were mad to fly with the Hondurans citing a lackof maintenance. In the end all three machines weregrounded or crashed.

However bleak the picture an unlikely source of helpdid emerge, Standard Fruit, Dole. More aware thanthe civil authorities, Dole had started preparations inanticipation of the Hurricane, though like everyoneelse they did not suspect its magnitude. Dole, throughits local administration, started buying up - in thewords of one of its managers - “every bean andkernel of rice we could get our hands on.” The reasonwas, to avoid prices rocketing as a result of shortagesand speculation. Once the storm ended, Dole shiftedto aiding the relief effort. It was well equipped to doso. The company established a distribution centre atits concentrate plant in La Ceiba at Pinanta. The firstpriority was to sort and distribute food that wasarriving by air from Canada, Mexico and the US. Thefirst people to get help through the system were thedisplaced living in temporary shelters in La Ceiba.Kids from the Marzapan private school (on Doleproperty) initially helped with the distribution, laterlocal volunteers joined in. However, the unfortunatelack of community and the fault line between richand poor meant that this reservoir of good deeds soondried up. Dole ended up having to do most of thework. Dole did have certain assets, An integratedlogistical system and the resources to make it worki.e. ships’ containers (which it allocated to anyorganisation which needed to transport reliefsupplies), a port facility at Cortez, trucks, a

warehouse, forklifts, labour, computers and anadministrative structure. Its staff knew the area andspoke Spanish and usually English. And it hadcontacts. Contacts that persuaded a US NationalGuard Air Force unit to fly C-130s loaded with foodinto La Ceiba.

The system as it evolved insured that the distributionwas transparent and the food got to those who neededit. At the warehouse, large numbers of men andwomen, most getting paid ‘food for work’ would sortand bag the different food items. Each family wouldreceive a large bag, usually weighing 50lbs of basicnecessities, and if available some ‘luxury items.’ Thebasics were rice, flour, cooking oil, powdered milkand bottled water. The luxury items were cannedfoods, like tuna or coffee. Sometimes clothing wouldbe included. Once bagged, the food was then donatedto a vetted organisation that had to prove itslegitimacy, and the need of its constituency. Most ofthe recipients were church groups who were runningthe food for work programmes. I was at thewarehouse and watched as trucks and pick-upsarrived for the bags. Each was carefully scrutinisedby Maria San Martin, a Dole manager assigned tosupervise the programme. She did not hesitate todeny anyone who could not produce the requireddocumentation. Dole also demanded proof of deliveryto the legitimate recipients. Each person receiving abag, usually for a family, had to produce theirnational ID, (picture and fingerprint) and sign for thebag. In one of the poor Barrios I watched as hundredsof mainly women, many clutching children, wouldwait patiently for their name to be called to receive abag. There seemed to be an almost desperate intensityto ensure honesty and equality in the distributionprocess. But it was also accepted that people wouldbarter or sell certain items. A tacit realisation thatindividuals and families have different needs.

The other element of Dole’s relief programme wassupplying food for field kitchens in villages wherebasic cooking equipment had been destroyed. Againit was a local functioning organisation, usually achurch one, that ran the kitchen and controlled thedistribution. I recall in one village near Boca a line ofwomen and children clutching tin plates and mugswaiting with stoic endurance to obtain a meagreration, and plastic bags of water from the CanadianArmy Disaster Assistance and Response Team(DART)

There were some hiccups. A large donation fromTexas of flour was shunned. It was wheat, not cornand unsuitable for making tortillas, or at leastHonduran tortillas. This was solved by a Dole cookwho worked out a recipe that could utilise the flour.A large donation of vacuum packed coffee inChristmas designed packaging was not greeted withenthusiasm. Not because of the Santa Claus but theHondurans simply felt the coffee wasn’t that good.

My own impression of the Dole effort based on threelengthy trips to Honduras (and watching similaroperations in other parts of the world) is thatregardless of the organisation, food relief after amajor disaster is a complex business and not one foramateurs.

Regardless of Dole’s motives which were not allaltruistic (public image played a part) it had themachinery to do the job. A separate computer drivencommand centre was set up with a staff of 8 to keeptrack of the containers with relief supplies. Dole alsohad an international radio communications networkand cell phones. Private industry in this incidentshowed that it not only had the logistical resourcesand equipment to do the job but also the businessacumen to ensure it was done efficiently andeffectively.

Field Article

“food relief after a majordisaster is a complexbusiness and not one foramateurs”

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Guidelines

The MSF nutrition guidelines for use inemergencies have recently been revised. Thenew guideline will be available in January 2001.

The main changes to the guidelines occur in thesections on i) analysis of food insecurity situations, ii)the relation between assessment of food insecurity andnutritional interventions, and iii) the treatment ofsevere malnutrition.Field exchange will highlight theserevisions in three consecutive articles. This first articlesummarises key points in the new section on:

Analysis of a food insecure situation

The new nutrition guidelines adopt an inter-disciplinary approach to assessment and advocatesusing the UNICEF conceptual framework for analysisso that the assessment focuses on food security, healthand care.

The new guidelines define three sequential stages inthe transition from food security to famine. These areelaborated below. Every situation is different. Thespeed with which the stages progress from one toanother can vary greatly depending on the nature (orthe origin) of the crisis, its context, the range of copingstrategies that are adopted, and the aid that isdelivered.

People adopt a range of strategies (copingmechanisms) to cope with reduced access to food. Inthe latter stages of the process, coping mechanismsbecome exhausted so that the priorities of theindividual and community shift towards survival.

Stage 1 – Food insecurity: ‘insurancestrategies’

During this first stage, the responses developed by thepopulation are reversible and in principle do notdamage future productive capacity.

People anticipate problems and adopt insurancestrategies planned in advance to minimise the effectsof food shortages, enhance productive capacity andpreserve their productive assets. People’s responses arecharacterised by diversification of activities, longerwork hours and focussing on increasing income andlimiting expenditures. The caring capacity for the non-productive members of the community (elderly,children, sick) will be reduced. For example when menmigrate to the city for temporary work, womenbecome the head of the household and have more workand therefore less time to care for children. People alsoreduce their food intake, without this immediatelybeing a threat to health. Therefore an increased level ofmoderate malnutrition may be seen.

Stage 2: Food crisis: ‘crisis strategies’

The responses in the next stage ‘food crisis’ are lessreversible as households are forced to use strategiesthat reduce their productive assets and threaten theirfuture livelihoods.

At this stage, the households or individuals are obligedto develop new strategies to meet their food needs. Allsurpluses have been sold and all potential forincreasing resources by diversification of activitieshave been exhausted. People have to sell goods that areessential for their future livelihoods. Additionally,economising on health and water resources results in apoor health environment which can be made worse bygradual migration of the skilled and educated of thecommunity (nurses, teachers etc.)In a food crisis, the prevalence of acute global andsevere malnutrition as well as mortality ratesassociated with them, is elevated. An increased risk ofmortality in moderately malnourished individuals canbe attributed to a deterioration of the healthenvironment, which increases the risk of infections.

Stage 3: Famine: distress strategies

Famine is the last stage of this process. In nearly allcases, it is linked to war and conflict. It ischaracterised by excess mortality and highmalnutrition in all the age groups of the population,complete destitution, social breakdown and distress

migration as people abandon their homes in search offood. All coping mechanisms have been completelyexhausted. The people are dependent on food aid forimmediate survival. Famine situations can result from inadequate reliefassistance during the food crisis stage. Reliefassistance has been too little, too late, not welltargeted, not well organised or co-ordinated and oftendiverted. This is frequently linked to seriousconstraints such as high levels of insecurity or lack ofpolitical commitment (at international, national orlocal level).The combined effects of insufficient food intake andpoor health environment are important factors leadingto famine and death among moderately and severelymalnourished people. In fact, the majority of deaths (inabsolute number) occur amongst individuals who arenot severely malnourished. One of the main underlyingcauses of famine mortality is deterioration in the healthenvironment. In addition to an adequate provision offood, access to curative health care, environmentalsanitation and shelter can avert many deaths.

Analysis

An assessment should try to locate a deteriorating foodand nutrition situation on the continuum of movingfrom food security to famine. The table below helps to determine the stage of theprocess of moving from food insecurity to famine.Each stage will not necessarily show all characteristics,but the table helps to illustrate which stage a situationhas reached and in what direction the situation is likelyto develop.

Interventions

Locating a situation on the food security/faminecontinuum helps identify the most appropriate type ofintervention.In a food insecurity situation the focus of interventionsshould be on preservation of livelihoods to preventpeople sliding into food crisis and famine, e.g. food forwork. Early warning systems are crucial at this stage.Support can be given to existing health structures toshore up treatment of individual cases of severemalnutrition.In a food crisis situation it is crucial to prevent furthermovement along the continuum by ensuring enoughfood. E.g. general food distribution. As the socialcaring systems comes under pressure provisionsshould be made to support special vulnerable groups,e.g. elderly, orphans, under five’s in general. Selectivefeeding programmes like therapeutic feeding centresand supplementary feeding centres can be installed.Health care systems and water resources may alsorequire support. In a famine situation, the primary goal is to ensuresurvival, to reduce mortality. The major focus is ongeneral food distributions, supplementary feedingprogrammes, blanket feeding, and therapeutic feedingand mortality surveillance.

In the next issue Field Exchange there will be a further articlebased on revisions to the MSF guidelines. This article willelaborate further on choice of nutritional strategies andprogramme designs in relation to context.

Revised MSFNutritionGuidelines by Saskia van der Kam, MSF Holland,Senior Nutritionist

Coping mechanisms (household level)

Insurance strategies• reversible coping • Preserving productive assets• Reduced food intake, etc.

Crisis strategies• irreversible coping• Threatening future livelihood • Sale of productive assets,

etc.

Distress strategies• no coping• Starvation and death• No more coping mechanisms

Stage of food insecurityprocess

Food insecurity

Food crisis

Famine & death

Stages of Food insecurity, coping mechanisms1

Mortality rate

Population movements

Global malnutrition rate

Mortality related to moderatemalnutrition

Severe malnutrition rate

severe malnutrition in adults

Livelihood changes

Selling of capital assets

Activity diversification

Reduction of expenditures

Food availability

Food accessibility

Dependence on food aid

Reduction in caring practices

Food insecurity

Normal

Seasonal migration

could be increased

Low

Low

Low

Temporary

none or very limited

Normal or slightly increased

Reduced

Normal or slightly decreased

Slightly reduced

Low

Low

Food crisis

Increased or high

Population displacement +/-

Increased

Elevated

Moderate or high

Low/moderate

irreversible

Important

Increased +++

Reduced +++

Reduced

Reduced

High or moderate

Moderate or high

Famine

Extremely high

Distress migration

Extremely high

High

High

High

Complete destitution

Exhausted or very limited

Exhausted or limited

No more possibility to reduce

Rare or none

Severely reduced or none

Complete

High

Specific characteristics of food insecurity, food crisis and famine

Increase resources:• crop diversification for farmers• livestock diversification for pastoral populations, sale

of excess livestock, long distance grazing • sale of non productive assets (utensils, jewellery,

charcoal, furniture) • labour migration (search for temporary employment in

towns)• diversification of informal economic activities• loans• prostitution

Decrease expenditures:• reduction of food intake (reduced meal frequencies

and smaller quantities eaten)• change in diet (consumption of wild foods, cheaper

foods etc.)• reduction of expenditures on health care (and water

purchase) • reduction of social support to the community,

(relatives and neighbours)• reduction of time available for care

Examples of insurance strategies

Increase resources:• sale of productive assets (tools, seeds, livestock)• massive slaughtering of livestock• mortgaging of farmland or house • sale of farmland, house, sale of land rights, harvest

rights, • exchange of livestock for staple food

Breakdown in social structures:• prolonged migration, men do not return from seasonal

migration or are enrolled in armies.• further cuts in use of water, firewood and health

services• community structures (mutual help systems) collapse • Skilled and educated people (health staff) migrate• decrease of community funds for funerals and

weddings• reduction of support to the non-productive members

of households (small children, elderly, disabled) • marginalisation of non-productive individuals,

(orphans, beggars, etc.)

Example of crisis strategiesfor a settled population

1 inspired by H.Young, S. Jaspars. Nutrition Matters. Intermediate Technology publication, London. 1995.

22

People in Aid

From Left:Yvonne Grellety(Consultant), Anne Ralte (FANTA,Washington DC), Mike Golden(Aberdeen University)and Anne-SophieFournier (AAH NewYork)

From Left:Mary Lung’aho (CRS/Linkages, Washinton)and Rebecca Norton (IBFAM, Geneva)

From Left:Pieter Dijkhuizen (WFP, Rome)and Brad Woodruff (CDC, Atlanta)

Top from leftLeft: Andrew Tomkins (UCL, UK), Rita Bhatia (UNHCR Geneva)Andrew Seal (UCL, UK).Right: Milla McLachlan (World Bank WashingtonDC), Rita Bhatia, Richard Jolly Outgoing ChairACC/SCN, New York) Sonya Rabeneck (ACC/SCNGeneva), Mike Golden (Aberdeen University)Namanga Ngongi (Chair ACC/SCN).

Second row from leftLeft: Chris Daniell (ACF, France) and CarlosNavarro-Colorado (ACF, France) Right: Namanga Ngongi, Milla McLachlan andRichard Jolly.

On the left, from leftSonya Rabeneck and Arabella Duffield. AnnaliesBorrel.

The ACC/SCN held its 27thsession at the World Bankin Washington DC last April.The session report isavailable at:http://acc.unsystem.org/scn/or email: accscn@who.int

The Emergency Nutrition Network (ENN) grew outof a series of interagency meetings focusing on food andnutritional aspects of emergencies. The meetings were hostedby UNHCR and attended by a number of UN agencies, NGOs,donors and academics. The Network is the result of a sharedcommitment to improve knowledge, stimulate learning andprovide vital support and encouragement to food and nutri-tion workers involved in emergencies. The ENN officiallybegan operations in November 1996 and has widespread sup-port from UN agencies, NGOs, and donor governments. Thenetwork aims to improve emergency food and nutrition pro-gramme effectiveness by:

• providing a forum for the exchange of field level experi-ences

• strengthening humanitarian agency institutional memory • keeping field staff up to date with current research and

evaluation findings• helping to identify subjects in the emergency food and

nutrition sector which need more research

The main output of the ENN is a quarterly newsletter, FieldExchange, which is devoted primarily to publishing field levelarticles and current research and evaluation findings relevantto the emergency food and nutrition sector.

The main target audience of the Newsletter are food andnutrition workers involved in emergencies and those research-ing this area. The reporting and exchange of field level expe-riences is central to ENN activities.

The ENN is located in the Department of Community Healthand General Practice, Trinity College, Dublin, Ireland.

The TeamFiona O’Reilly is the ENN Co–ordinator, and FieldExchange co–editor. Fiona has been involved inthe area of nutrition, health and development forthe past 10 years, half of which has been spentworking in emergency situations.

Jeremy Shoham is co–editor for Field Exchangeand the ENN technical consultant. Jeremy hasbeen working in the area of emergency food andnutrition for the past 15 years.

Kornelius Elstner works part time with the ENN.

Suzy Lyons works part time for the ENN while she is under-taking an MSc in Community Health in Trinity College Dublin.

23

The Backpage

Field Exchange

UNHCR

The

supported by:

GENEVA FOUNDATIONto protect health in war

EditorsFiona O’ReillyJeremy Shoham

Layout & WebsiteKornelius Elstner

Contributors for this issueSophie BaquetLola GostelowSusanne JasparsSaskia van der KamMarie McGrathPeter Silverman

Thanks for the Photographs to:Anne Kellner (UNHCR)Sherri Dougherty (WFP)Ed Clay (ODI)Vinciane Verougstraete (MSF)Chris Daniells (ACF)Pieternella Pieterse

On the coverWFP Relief Food Convoy. L. DeMatteis(WFP)

As always thanks for the Cartoon to:Jon Berkeley, who can be contactedthrough www.holytrousers.com

Special thanks to Professor JohnKevany, Jean Long and Deirdre Handyfrom Trinity College for assistance andsupport for the ENN.

Cartoon Corner by Jon Berkeley

Emergency Nutrition NetworkDepartment of Community Health & General PracticeUnit 2.5, Trinity Enterprise Centre,Pearse Street, Dublin 2, Ireland

Tel: +353 1 675 2390 / 843 5328Fax: +353 1 675 2391e–mail: foreilly@tcd.iewww.tcd.ie/enn