November 2003 Issue 20

• Microfinance Project in Rwanda• Thiamine Deficiency in Angola• Destitution in Ethiopian Highlands• Hidden Famine in Madagascar

• Microfinance Project in Rwanda• Thiamine Deficiency in Angola• Destitution in Ethiopian Highlands• Hidden Famine in Madagascar

contents

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Editorial

Field ArticlesLessons From a MicrofinancePilot Project in Rwanda.Border Closures and Nutrition inGaza.Postscript: Malnutrition onPolitical Grounds.Targeted Food Distribution toWomen and Children in NorthernAfganistan.Suspected Thiamine Deficiencyin Angola.

ResearchComparison of the efficancy of asolid ready-to-use food and aliquid, milk based diet in treatingsevere malnutrition.Infant formula distribution innorthern Iraq.postscript: Infant formula distribution in northern Iraq, By WFP.What triggers humanitarianIntervention?Destitution in Ethiopia’sNortheastern Highlands.Famine Avoided Despite Droughtand ‘Zud’ in MongoliaGovernment versus NGO efficiency, Bangladesh.Women’s Contributions toReducing MicronutrientDeficiencies.Hidden Famine in Madagascar.Implementation of WHOGuidelines on the Managementof Severe Malnutrition in SouthAfrica and Ghana.

News & ViewsVitaGoat. Antiretroviral Therapy andNutrition.Justwrite.Local production of Plumpy’nut.Training course on ageing inAfrica.New FAO/WHO manual on livingwell with HIV/AIDS.Facing up to the storm. INASP Health Directory2003/2004.HIV-positive mothers in Ugandareturn to breastfeeding.Caring for Severely MalnourishedChildren: book review.Debate on the Management ofSevere Malnutrition.Debate on the Management ofSevere Malnutrition: A Response

Letters

EvaluationMSF Holland in Afghanistan.

Agency ProfileTerre des hommes.

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I stood perplexed in the bomb blastedshell of what had previously functioned asthe regional children’s hospital in Somalia’scapital, Mogadishu. It was 1991, Somaliawas a country gripped by the most brutal ofcivil wars. Benadir Hospital, Mogadishuacted as a therapeutic feeding centre for mal-nourished children. I had just been presen-ted with a new admission, a tiny and mal-nourished infant of about two months of age- Zenab I think her name was. Apparentlyher mother was severely injured and figh-ting for her life in another hospital in thecity, after the family home had been hit by ashell. Zenab was accompanied by a youngaunt who had no children of her own. Iremember feeling ill-equipped to deal withZenab or others like her. She fell outside thestandard guidelines for the treatment ofsevere malnutrition that we had establishedin the centre. She was ‘supposed’ to be bre-astfed and therefore protected from malnu-trition. But clearly breastfeeding was not anoption here. There were not many likeZenab at the time in Mogadishu but therewere some. I remember the correct, but notvery helpful, public health message ‘breastis best’ resounding in my ears. Everything Ihad learned told me that to buy formula(even if it was available) for this infant wasnot the right thing to do. I also rememberthinking ‘how come I don’t know what to dowith this case – someone somewhere musthave been in this situation before and whatdid they do?'

Field Exchange was established to helpfield workers like me in similar situations.By providing a forum for sharing field expe-riences, the hope was that Field Exchangewould allow challenges and lessons to becaptured rather than lost and that guidelineswould, as a result, become more contempo-rary and better reflect the field reality. It wasalso hoped that a publication like FieldExchange would help expose ‘experts’ andresearchers to greater field reality.

Twelve years on and much has changed.Significant advances have been made in thefood and nutrition sector of emergency res-ponse. Field Exchange has attempted tokeep its audience up to date. However, thereare still many areas where there is inconclu-sive research and where there is insufficientconsensus and guidance. For example, inspite of all the advances in the managementof severe malnutrition as well as in thera-peutic foods, consensus among experts onhow to manage young severely malnouris-hed infants has yet to be achieved (seeDebate on the Management of SevereMalnutrition, page 16).

There are also times when the need todemonstrate consensus seems to stifledebate and advance. It appears that in somesituations, ‘experts’ would rather ignorefield experiences (that often fail to meet rigo-rous research design standards due to theemergency context) which may call into

question aspects of current guidelines. Thismay be done in order to ensure there is con-sensus between guidelines, out of a legiti-mate concern that those in the field will beconfused if there is more than one message.Whatever the reason, I believe FieldExchange has a responsibility to report inde-pendently, encourage debate and advance.This is not always easy and there have beenseveral occasions where the ENN has comeunder considerable pressure not to publishwhat was seen as controversial debate orsensitive information.

Readers of Field Exchange will also beaware of the lack of unanimous guidance onsupporting safe infant feeding strategies inemergency affected areas, where bottle andmixed feeding is common. This situationmay partly reflect the blind adherence to‘dogma’ and the fear that recommendinganything other than breastfeeding will openthe flood gates for the formula industry whowill then go on to win ‘the battle against thebreast’. The assessment findings on infantfeeding in Iraq (page 6) highlight how, forpolitical reasons, formula milk is part of thegeneral ration distribution. Though this con-travenes best practice and negativelyinfluences the prevalence of breastfeeding,there is a lack of clear practical guidance onappropriate interventions in such a context.

The experience contrasts with recent fin-dings from Uganda (page 15), where HIV-positive mothers whom, after counselling,chose to use formula were not able to accessthe commodity. Both situations leave a lot tobe desired if safe and appropriate infant fee-ding is to be achieved. Some agencies andinstitutions are working on this issue butmore research is required. I commend theinteragency ‘core group on infant feeding inemergencies’ for their strident efforts todevelop practical guidance for field practicein this area.

In the absence of conclusive research, thesharing of programmatic experience is vital.Field workers need to ‘keep it real’, write inand describe the actual problems which arebeing encountered and the measures takento overcome these, so that appropriate gui-dance can follow. Technical experts need tobe open to debate and allow field experienceto influence guidance and policy. They needto be pragmatic and develop guidelines forsituations which actually occur e.g. wherebreastfeeding is not an option. More thananything, child well being should be thefocus of efforts to improve practice.

So what happened to Zenab? The fact isI made the best of a difficult situation –something field workers often have to do. Iscoured through the limited resources avai-lable to me, mainly from Oxfam feeding kitsor what hadn’t been looted from the agenc-y’s office and eventually found a ‘home-made BMS recipe’. Zaneb survived, mainlyas a result of the care provided by her aunt,but did not grow very well. Today I wouldmanage cases like this differently, thanks tothe guidelines that have been produced andwork done in this area resulting largely fromthe sharing of field experiences.

As this is my last issue of Field Exchangeas ENN director, I would like to thank theInteragency Group of Nutritionists responsi-ble for conceiving of the ENN and suppor-ting it’s work over the years. I wish MarieMc Grath and Jeremy Shoham every successin continuing the ENN and Field Exchange.

Fiona O’ReillyMother with malnourished childern in BenadirHospital, Mogadishu, Somalia, 1991

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In 2001, Concern initiated a 3-year actionresearch project on microfinance, funded bythe Department for InternationalDevelopment-UK, and involving qualitative

research in Angola, Cambodia, Mozambique andRwanda. Informed by the findings of this four-country study2, since 2002 Concern has been sup-porting the development of an innovative micro-finance service, Abazamukana, in Rwanda,which was recently evaluation

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Microfinance in conflict Our knowledge of how, and indeed if, microfi-

nance can work in war-affected environmentshas, until the end of the 1990’s, been very limited.In the past, microfinance in war-affected coun-tries has often consisted of short-term, poorlyplanned, rushed interventions by organisationsunder pressure to disburse funds quickly, usingstaff that has no expertise in microfinance.Clients have been provided with relatively largeloans for long loan periods, to inject capital intothe household economic activities.Unfortunately, these strategies and tactics havegenerally proved inappropriate, resulting in inef-fective lending mechanisms, over-indebtednessof clients, poor repayment rates (significantlyless than 98%), and low outreach. This has beenpartly due to diversion of loans to wealthier ormore powerful members of the community, and

an over-emphasis on credit at the expense ofsavings and other services.

History of microfinance in RwandaRwanda today is a relatively peaceful and sta-

ble country. Although people are very poor, ruralmarkets are dynamic and organised and attractbuyers and sellers from urban as well as ruralareas. There has been very little restriction placedon microfinance organisations (MFOs) by thegovernment of Rwanda and overall, this has pro-bably encouraged more non-governmental orga-nisations (NGOs) to get involved in microfinancethan if there were exacting regulation. Despitewhat appears to be a fairly enabling environ-ment, however, only 0.3% of the population haveaccess to NGO microfinance services. With littlecompetition and the highest population densityin Africa, why has the entire NGO sector onlyattracted, on average, 2,900 clients per year since1994? There are, of course, many causes but thereare two particularly important constraints tomicrofinance. First, skills and education levelsare very low, with 91% of the workforce engagedin agriculture, 80% of secondary teachers unqua-lified and less than one-half of civil servants withsecondary education. Without skills, it is difficultto make use of financial services and without ski-lled microfinance staff, it is difficult to rapidlyexpand a MFO. Secondly, social capital has been

gravely damaged by the genocide. It createdmany sub-divided groups in Rwandan societyand reduced the prevalence of traditional practi-ces like gift giving, exchange, mutual assistance,collective action and protection of the vulnera-ble. Individuals are less open to joining microfi-nance groups when social capital remains soseriously damaged.

Project planningComplementing the findings of the four-

country research in 2001, the Abazamukanaintervention was also developed using marketresearch in Rwanda. As well as identifying ahigh population density (>300 persons /sq km),this preparatory market research provided a cri-tical insight into the market environment, in par-ticular:

• Clients disliked travelling to, and spendingtime in, group meetings and were willing to paymore for an individualised service.• The majority (83%) of potential clients werewilling to pay at least 5% interest per month onindividual short-term loans (but individual loanswere costly and risky to provide). • Clients appeared to have less respect for NGOmanaged microfinance initiatives following thepost-war emergency relief years, when loanswere disbursed but not collected.

Lessons From aMicrofinance PilotProject in Rwanda

By Tamsin Wilson

One of the legacies of conflict in Rwanda is poorer social cohesion.As a result micro-finance initiatives have not fared well. The typeof micro-finance project described below relies more on individualparticipation than traditional models and has therefore proved tobe a valuable tool in addressing post-emergency food insecurity.(Ed)

Tamsin Wilson is an independent microfinance consultant. She co-ordinated Concern Worldwide’s qualitative research on microfi-nance in Angola, Mozambique, Rwanda and Cambodia, and nowprovides technical support to the Rwandan microfinance pro-gramme.

The contribution of Concern Worldwide in producing this article isgratefully acknowledged.

This article describes Concern Worldwide’s experiences in develo-ping and managing an innovative microfinance project,Abazamukana 1 , in Rwanda.

What is microfinance?Microfinance is the provision of banking services such assavings, credit and money transfer to poorer people who cannotaccess ordinary mainstream banking services. Microfinance canbe provided by specialist microfinance organisations (MFOs), bybanks that downscale to reach the poor, by moneylenders,Credit Unions and by community-based organisations. Post-con-flict microfinance sits on the edge of the mainstream microfi-nance sphere but it should not be considered a separate disci-pline.

Field Article

Mugina marketplace which is

transformed into aplace of great acti-vity on the weekly

market day

A bicycle repairerin Mugina marketwho is workingwith his third loanfromAbazamukana

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Steve Townsend, Concern. Rwanda

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• Clients needed to respond immediately tobusiness opportunities and could not wait a longtime for loans to be approved.• Many clients disliked the conventional arran-gement whereby all members of a group gua-ranteed the loan of a fellow member, and wererequired to repay the loan if the borrower couldnot.• Clients could not afford the minimum savingsbalances and collateral requirement of the localCredit Union.

The weekly market was the focal point forthousands of local and city buyers and sellers,and would be a good location for a branch forcash transactions.

Project designThe design of Abazamukana and its products

responded directly to the results of the marketresearch. The poor image of NGOs in the area,who were well known for giving loans and notcollecting repayments effectively, alertedConcern to the need to present Abazamukanadifferently to its predecessors. One approachwould have been to create a wholly communityowned and managed MFO, with little outsideinvolvement. However, the approach chosen byConcern was to present Abazamukana as a per-manent, professional and commercial bankingservice provider for poorer people. It rented anoffice in the market place, with a shop front verylike others in the area, and aimed to project aserious, professional image.

Abazamukana’s first branch was established inthe busy market square, offering innovative andflexible loan and saving products for indivi-duals, rather than groups. Clients could depositmoney in their savings account and withdrawmoney as frequently as they needed, simply byvisiting the branch. Loans were made availablefor short periods of a few weeks or months andrepayment was normally weekly.

As there were no group meetings, the organi-sation depended heavily on the credit agentswho made several visits to every client in theirown home, to build up a good relationship andmutual understanding before the first loan wasdisbursed. Because the credit agent and thebranch manager approved loans, rather than acommittee, clients normally knew in less than aweek if their loan application had been success-ful. Repeat clients with excellent repaymentrecords over the previous three loan cyclessimply went to the branch and could immedia-tely obtain a repeat loan of the same size as thelast. Instead of group-based collateral, loanswere guaranteed by a combination of 20%savings and a personal guarantee from a closefamily member who became responsible for theloan in case of default.

The credit agents did not carry any cash.Clients called in person at the branch to make allcash transactions, which meant that creditagents were not a target for theft when they tra-velled in the communities. Credit agents sub-mitted completed loan applications to thebranch and a separate cashier disbursed loans tothe client.

The more flexible loan product saved time forthe client but was more expensive forAbazamukana to provide. Therefore, the loaninterest rate (of normally less than four months)was much higher than other MFOs in the area.For the first two loan cycles, 10% interest permonth was charged. For subsequent loans, withclient credit record established, the interest ratedropped to 5% interest per month. In contrast,the savings product did not create any incomefor Abazamukana, and therefore did not attractany interest. In the event that Abazamukanabecomes a regulated MFO in the future, there isgood potential to on-lend funds held, thus allo-wing savings interest to be paid.

Field Article

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

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Strengths Weaknesses

Repayment rates improved when the loan gua-rantee was developed to include 20% of theloan deposited in the savings account prior toloan disbursal, and a personal guarantee froma close family member.

The initial loan guarantee, consisting of charac-ter assessment and social pressure applied bylocal committees, was not a large enoughincentive for clients to repay

Abazamukana remains closely connected andtotally dependent upon Concern. It was unsuc-cessful in distancing itself from Concern pro-bably because Concern vehicles are used fortransport, expatriate staff visit the project andfor some time, the Concern logo appeared onthe client passbooks.

Short-term loans at high interest rates workwell until clients delay repayments and theinterest due builds up to un-manageable pro-portions.

Clients do not deposit large amounts of savingsin their accounts because they are scared thatthe NGO Concern, like its predecessors, willone day leave and there is a chance that theymight not get their savings back.

The savings product is perceived to be forricher people as there is a mistaken impressionthat the poor can’t save. In other countries ithas been proven that even beggars can save.

Some people, including a few community lea-ders, have taken loans without any intention ofrepaying. Furthermore, they have activelyencouraged others not to repay the so-called‘American money.’

By not actively targeting women, the microfi-nance service was used more by men. Of thefew people that hadn’t made a single on-timeloan repayment, 70% were men, whereas ofthose with a 95% repayment rate, or better,70% were women.

Motorbikes, rather than 4x4 vehicles, are themost appropriate means of transport for theMFO as they keep costs low and suggest thatthis isn’t a ‘normal’ NGO project.

Repayment rates fell sharply when there weredelays in getting the motorbikes for creditagents and the organisation continued to dis-burse loans without any means of following uprepayment.

Clients like the individual loan and savings pro-ducts. In the first nine months, 1,000 peoplebecame clients of Abazamukana.

By hiring an accountant, Abazamukana hasbeen able to develop transparent accountingsystems.

The loan product is perceived to be for thepoorest.

Situating the branch in the busy market squarehas meant that Abazamukana catches a lot of‘passing trade’, especially on market days.

Clients prefer to have credit agents visitingthem in their houses rather than them atten-ding group meetings. In a recent satisfactionsurvey, the majority of clients stated thatAbazamukana’s loan was the cheapest in thearea despite the fact that based on interestrate alone, it is the most expensive. Theiranalysis of the cost included non-financialcosts like travel to meetings, attendance atmeetings, and time spent waiting for loanapproval.

Even though this is a pilot project,Abazamukana was designed as if it werenecessary for the organisation to become self-sufficient. This has had a positive influence onthe attitude of credit agents and cashiers, andon strategic decisions made by management.

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1‘Abazamukana' is Kinyarwandan for ‘Slowly, slowly, weprogress together’2Wilson, T. (2002) Microfinance during and after armedconflict: Lessons from Angola, Cambodia, Mozambiqueand Rwanda. http://www.postconflictmicrofinance.org3Wilson, T. and Kidney, I. (2003) Concern WorldwideRwanda: Abazamukana Mid-term Review Report.Internal document.

Strengths and weaknessesIn general, where Abazamukana strayed

from the basic principles that underpin micro-finance it has experienced problems, andwhere it has adhered to them it has been suc-cessful. The greatest challenge has been crea-ting the conditions for clients to wish to repaytheir individual loan, in the absence of thetried and tested group guarantee mechanism.A combination of factors have been emplo-yed, including the alternative guaranteemechanism (20% compulsory savings and apersonal guarantee), good education andclose follow-up by staff, easy access to futureloans if the last ones have been repaid, and theorganisation projecting the image of a seriousand permanent microfinance provider.

Lessons learnedPoor people will pay market rates of interest

for a service that they value, and the cost ofthe savings or credit product is less importantthan its accessibility and convenience. Time isa precious commodity to poor people andthey will pay more for a product that savesthem time. Charging market rates of interesthelps to create a microfinance service that cangrow over time to help more people.

Individual loans can work, especially inareas where social capital has been eroded,but they are more risky than group-basedloans. They require a combination of suppor-ting factors, including close follow-up of latepayers the day after their repayment falls due,an effective alternative guarantee, support ofcommunity leaders and the incentive offuture loans to encourage repayment.

Good personnel are the single most impor-tant factor influencing the success of an MFO.Although staff are difficult to recruit in war-affected areas, an MFO like Abazamukanashould have a professional microfinancemanager and a professional accountant.Without this, the chances of success are signi-ficantly diminished.

Sustainability should be planned from thebeginning. Whereas it is normally expectedthat MFOs will achieve self-sufficiency in 5-7years, it may take a few years longer in harshpost-conflict environments. In the interest ofsustainability, some necessary decisions maybe unpopular with clients – it is impossible tomeet all demands.

In-depth market research should be conduc-ted before the MFO is designed, since war-affected situations are quite different to placeswhere microfinance is normally found.However, while microfinance products mustbe adapted to their environment, they shouldalways adhere to basic microfinance princi-ples.

Poorer people need encouragement andincentives to believe that they should be put-ting away a few coins a week as savings. Theyalso need to believe that their money is safe. IfNGOs do not have a background and techni-cal expertise in microfinance and a commit-ment to remaining in emergency relief coun-tries in the medium to long term to supportthe microfinance services that they have esta-blished, they should not become involved inmicrofinance operations.

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

The World Health Organisation (WHO)recommends a liquid, milk-based diet(F100) during the rehabilitation phase ofthe treatment of severe malnutrition.

However, a dry, solid, ready-to-use food (RTUF)that can be eaten without adding water, thus eli-minating the risk of water-sourced bacterial con-tamination, has recently been developed. Thisfood is obtained by replacing part of the driedskim milk used in the F100 formula with peanutbutter. RTUF is at least as well accepted by chil-dren as is F100, and its availability has raised thepossibility of treating severely malnourishedcases in the community. However, since the effi-cacy of RTUF has never been tested in a contro-lled trial, its recommendation for extensive usein the community might be premature. Theobjective of a recent study in Senegal was tocompare the efficacy of RTUF and F100 in pro-moting weight gain in malnourished children.

The open-labelled, randomised trial took placein a therapeutic feeding centre attached to a cli-nic2 in Dakar, Senegal, that is attended by poorfamilies. Recruitment and follow-up were con-ducted between March and September 2001, thepeak season for malnutrition. Eligible childrenwere identified by the study physician, based onanthropometric criteria.

A total of 70 severely malnourished Senegalesechildren, aged between 6 and 36 months, wereselected. Each was randomly allocated to receivethree meals containing either F100 (n = 35) orRTUF (n = 35), in addition to the local diet. Mostof the children (27 in F100 group, 29 in the RTUFgroup) were fed by their mothers, while theremainder (n=14) were fed by another memberof the family. All efforts were made to have chil-dren fed ad libitum. Breastfed children wereoffered their meals after being breastfed.

Data from 30 children in each group were avai-lable for analysis. The main findings were:• The mean daily energy intake in the RTUFgroup was 808 ± 280 kJ3 /kg/day (95% CI: 703.8,912.9) and in the F100 group was 573 ± 201 kJ/kg /day (95% CI: 497.9, 648.7, p<0.001). • The average weight gains in the RTUF andF100 groups were 15.6 g/kg/d (95% CI: 13.4,17.8) and 10.1g/kg/d (95% CI: 8.7, 11.4), respec-tively (p<0.001). • The difference in weight gain was greater in

the most wasted children (p< 0.05). • The average duration of rehabilitation was 13.4days (95% CI: 12.1, 14.7) in the RTUF group and17.3 days (95% CI: 15.6, 19.0) in the F100 group(p<0.001).

These results suggest that RTUF, given in asupervised setting, is superior to F100 in promo-ting weight gain during the rehabilitation phaseof the management of severe malnutrition. Theauthors of the study recommend that furtherwork be undertaken to measure the effectiveness(in terms of weight gain) of RTUFs consumed athome. Weight gain at home is likely to be lowerthan that in a controlled setting since the RTUFmight be shared with siblings and will be consu-med with less supervision. Yet, achieving a rapidweight gain is not as important at home as it is ina residential treatment unit, for economic, social,and familial reasons. Also, the lower risk of crossinfection from other children in a family settingmakes a rapid recovery less important. A lowerweight gain seems acceptable during home-based treatment; even so, the weight gain obser-ved in the current study was over ten times theweight gain of well-nourished children of thesame age.

The authors reflect that if effectiveness studiesof RTUF and of its locally produced equivalentsin a community setting yield positive results, thewidespread use of these foods could change theway we treat severe malnutrition.

1El Hadji Issakha Diop, Nicole Idohou Dossou, Marie

Madeleine Ndour, André Briend, and Salimata Wade

(2003). Comparison of the efficacy of a solid ready-to-use

food and a liquid, milk-based diet for the rehabilitation of

severely malnourished children: a randomised trial. Am J

Clin Nutr 2003;78:302–7.2 Dispensaire Saint Martin, Rebeuss, Dakar, Sénégal3 Conversion of kJ to kcal: kJ x 0.2388 = kcal

Comparison of the Efficacy of a SolidReady-to-Use Food and a Liquid, Milk-Based Diet in Treating Severe MalnutritionSummary of published research1

Kwashiorkor case, before and after management using RUTF (oedema resolved). NutritionalRehabilitation Centre (Dispensaire Saint Martin), Senegal 2001

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inputs and improved local economy.The current distribution of the general ration is

scheduled to continue until November 22,20033 . One general ration supplies about 2200 kcal perperson per day and is usually distributed on amonthly basis (a 3-monthly food ration was dis-tributed before the war started). For the last tri-mester of pregnancy and the first four monthsafter delivery, a woman receives an additionalration of 1 kg sugar (from WFP)4 and HighProtein Biscuits (from UNICEF). A family withan infant below 1 year of age receives an additio-nal ration of 3.6kg infant formula (8 tins permonth), 0.9 kg complementary infant food, 1 barof soap and 0.5kg detergents.

Infant formula distributionSince 1997, the distribution of infant formula

in NI has increased from 1.8 kg to 3.6 kg permonth. A recent survey in NI found a high per-centage of bottle-fed infants (64%), rangingfrom 51% (0-2 months) to 69% (9-11 months),and representing a 25-30% increase sinceAugust 1996 5. Correspondingly, exclusive breas-tfeeding rates were low, at 7% for infants aged0-6 months. Between 6 and 9 months, just overhalf (53.4%) of infants received complementaryfood in addition to breastfeeding, despite theirinclusion in the ration (currently 0.9 kg/month).The most commonly reported health problemswere diarrhoea and acute respiratory infections6.

According to information from beneficiaries,the current distribution system is inadequate.Infant formula No. 1 (suitable from birth to 6months), No. 2 (follow-on formula, six monthsonwards) and Cerelac (a commercial weaningfood) are given on a monthly basis to each infantduring the first year of life, sometimes irrespec-tive of his/her age7. The instructions on theinfant formula are written in English and Arabiconly and not in Kurdish language, even then51% of the women in NI are illiterate. No ackno-wledgement or advice is given on the use of dif-ferent formula by age - if mothers have no kno-wledge about this difference in the compositionof breast milk substitutes, or have no possibilityto exchange the tins with relatives or neighbours,infant feeding is very likely to be greatly inade-quate.

The presence of infant formula in the food bas-ket continues to discourage mothers from breas-tfeeding. In addition, it is frequently mixed withunclean water, available in limited quantitiesand handled under extremely hot conditions.Consequently, bottle-feeding coupled withinadequate water and sanitation facilities is amajor contributing factor to infant malnutrition,morbidity and mortality, especially for thoseliving in remote areas where there is limitedaccess to medical facilities.

Reports of health institutions suggested anassociation between severe malnutrition amonginfants and the high prevalence of bottle-feedingin NI. For example, in Erbil governorate, 44.7%of severely malnourished admissions werebelow the age of 6 months, of whom none wereexclusively breastfed, nearly one-third (30.7%) ofthe infants were exclusively bottle-fed and 69.3%recieved mixed feeding (bottle and breastfee-ding)8. Furthermore, institutional based data andvisits to four different paediatric wards revealedseveral limitations in the management of severemalnutrition. These included lack of therapeuticmilk and modified oral rehydration solutionduring the initial stage of treatment and lack ofawareness about the importance of a rehabilita-tion phase. Education on infant feeding practicewas also lacking. During visits by the assessor,mainly undiluted ORS - sometimes mixed withtherapeutic milk - was offered by feeding bottlesfor severely malnourished children with diar-rhoea. Mothers continued to offer mixed or bot-tle-feeding during their stay in the hospital asthey did before admission. Many of the motherswith children admitted in paediatric wards belie-ved that they did not have enough breast milk.

A UNICEF study in NI (2002)9 revealed that51.1% of doctors and health staff have not yetheard about the concept of exclusive breastfee-ding.

RecommendationsThe following recommendations were made

as a result of the assessment:

The untargeted distribution of infant formula isinappropriate. Strategies to protect and supportbreastfeeding are urgently required. Breast milksubstitutes should only be distributed to infantswhere the individual need is specifically establis-hed. The current system is, undoubtedly, contri-buting to infant morbidity and malnutritionrates, in a region ill equipped to deal with theconsequences.

Worryingly, plans to meet infant feeding needsafter November 2003 are not confirmed. A newfood distribution system, targeting vulnerablegroups according to predefined social/healthand nutrition-related criteria such as young chil-dren, pregnant and breastfeeding mothers,elderly and disabled people is needed, ratherthan a blanket distribution of food to the wholepopulation.

Training of medical personnel is urgently nee-ded in promotion of exclusive breastfeeding andthe management of severe malnutrition.

For further information, contact: Dr. VeronikaScherbaum, email: scherbau@uni-hohenheim.de,or Mrs. Sabine Wartha, Caritas Austria, email:S.Wartha@caritas-austria.at, or Geke Verspui,Cordaid, email: Geke.Verspui@cordaid.nl

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Between 19th June and 12th July, 2003, anutrition and mother and child healthassessment was carried out in NorthernIraq (NI), commissioned by Caritas

Austria and Cordaid Netherlands. Focusing onthe needs of those in the Kirkuk and Mosul areas(both internally displaced people (IDP) andreturnees), the objectives of the consultancyincluded an assessment of the situation of thelocal hospitals and the health centres in terms ofcoverage and treatment of malnourished chil-dren, and an estimation of the impact of the ces-sation of the Oil for Food (OFF)2 programme onthe malnourished. The investigations werebased on a collection of qualitative and quantita-tive data, including epidemiological health andnutrition indicators (where available), institu-tion-derived data and qualitative informationfrom interviews with staff and beneficiaries. Thissummary focuses on the observations and con-cerns regarding the inclusion of infant formulain the general food ration.

Oil for food (OFF) Since 1996, the World Food Programme (WFP)

has been responsible for the distribution of foodaid to the northern regions, as provided by theGovernment of Iraq (GOI) under UNSCR 986distribution plans. The significant improve-ments in both chronic and acute malnutrition inNI since 1996 can be related to the cumulativeeffect of improved household food security (con-tinuous distribution of food rations via OFF),implementation of an OFF-associated targetednutrition programme (TNP), increased health

Infant FormulaDistribution inNorthern IraqSummary of assessment1

Research

1Final Report, Nutrition/Mother and Child HealthConsultancy in Northern Iraq, 19/6 – 12/7/2003, Dr. Veronika Scherbaum, on behalf of Caritas Austria andCordaid Netherlands.2 A Memorandum of Understanding (MOU) was signed in1996 between the United Nations (UN) and theGovernment of Iraq (GOI). The UN Security CouncilResolution (SCR 986) permitted the GOI the export of $2billion of petroleum every 6 months and the use of therevenues to import items related to basic humanitarianneeds of the population. 3 Source: WFP nutritionist in Suleimanyiah, Northern Iraq4At the time of the assessment, WFP provided 1kg sugarand 4kg of oil (substituted with pulses when oil not availa-ble) to this group. This ration has since been revised to 2kgoil, 1.02kg cheese, 1kg milk (18 September 2003).5 UNICEF, 1996 multiple indicator cluster survey – Iraq,results from Northern governorates.6 UNICEF-Northern Iraq and the Regional Ministries ofHealth & Social Affairs. Nutritional status of children inautonomous Northern Governorates (Dohuk, Erbil andSuleimanyiah) of Iraq, data collected November 2002,report 23 March 2003.7 The ration scale of infant formula (3.6 kg per month) wasplanned by the Iraqi Trade ministry, and is not a standardscale of the WFP programme. Source: WFP Nutritionist,Suleimanyiah, Northern Iraq.8 Directorate of Health data from Erbil NutritionRehabilitation Centre, n=144, Jan to March, 2003.9 UNICEF-Northern Iraq (2002) KAP survey on exclusivebreastfeeding among doctors and health staff.

Returnees in a rural area of Dibaga sub-districtin Erbil governorate, Northern Iraq, 2003

Mother breastfeeding, Northern Iraq, 2003

Veronika Scherbaum

Ver

onik

a Sch

erbau

m

7

Infant FormulaDistribution inNorthern IraqBy the World Food Programme(WFP)

Given the considerable reference to WFP activi-ties in this assessment, WFP were invited tooffer their perspective.

There are a number of points whichthe WFP would like to raise, in lightof the assessment findings fromIraq. Under the oil for food (OFF)

programme, the Ministry of Trade (MOT)has been responsible for procurement of allfood commodities including infant for-mula. WFP is responsible for the distribu-tion in Northern Iraq only and not in thecentre and the south. Following the war in2003, WFP is facilitating the procurement ofall commodities already negotiated by theMOT.

With regard to targeting infant formula Iand II by age, this issue was also raised bythe WFP and United Nations Office of theHumanitarian Coordinator for Iraq(UNOHCI) food observers in 1997/98,when the Government of Iraq was respon-sible for procuring and distributing thefood ration. As part of WFP’s observationmandate, WFP analysed the nutrient con-tents of formula-I and formula-II distribu-ted in Iraq in 1998 (over 60 brands) and didnot find significant difference in contents ofthe two formulas. Following a request foradvice posted on Ngonut1 , personal com-munication from two nutritionists/profes-sors suggested the differences reflectedmarketing stunts rather than any real diffe-rence in nutrient profile. WFP, therefore,saw no reason to advocate for pursuance ofthe expensive, and almost impossible, taskof identifying infants below and above 6months of age and then plan, procure,transport, and distribute different milks tosuch a large, and changing, population on amonthly basis.

Breast milk substitutes should only be dis-tributed to infants where the individualneed is specifically established - this isinternationally agreed upon policy. DespiteWFPs consistent advice against the blanketdistribution, the MOT has not agreed toexclude infant formula from the generalration. This is to avoid any disquiet that islikely to occur when an established ration isreduced/modified in the prevailing politi-cal situation in Iraq, especially given thediscontent shown in 1996 when infant for-mula was removed from the ration by thegovernment. At present, UNICEF is tryingto develop a strategy for targeted distribu-tion, in collaboration with the Ministry ofHealth and Ministry of Trade.

Regarding plans for after November 2003,WFP is mandated by the UN resolution totake the responsibility of PublicDistribution System of Food untilNovember. After that it becomes the res-ponsibility of the Coalition ProvisionalAdministration (CPA) whose plans are notyet available.

1 Ngonut was a forum of email exchange betweennutritionists, since replaced by Nutritionnet(www.nutritionnet.net)

Postscript Research

It is commonly assumed that mas-sive media coverage of a humanita-rian crisis will lead to increasedallocations of emergency funds.

This is often referred to as the ‘CNNeffect’. A recent study has examined thevalidity of this assumption.

The hypothesis of the study is thatthree main factors, working either inconjunction or individually, determinethe volume of assistance. These are theintensity of media coverage, the degreeof political and security interests thatdonors have in a particular region orcountry where a crisis occurs, and theinstitutional framework and strength ofthe network of humanitarian organisa-tions involved in the country or regionconcerned.

In the study, four case-study compari-sons are made. The first examines theIndian cyclone of October 1999 and theMozambique floods of late-January2000. The remaining three comparisonsdeal with complex emergencies andinvolve Angola, Sudan, the Balkans, theDemocratic People’s Republic (DPR) ofKorea, and Afghanistan.

Data on the level of media coverageand volume of emergency assistancewere collected for each case study.Media sources were two major televi-sion channels in Denmark, as well as 23leading newspapers; United Kingdom(5), Germany (3), France (3), Italy (2),the United States (7), Spain (1) andDenmark (2). Financial data were deri-ved from OCHAs 2 and ECHOs 3 data-bases. Data on level of media coveragewere collected for selected periods oftime, namely at three month intervalsduring the central years.

Data were also gathered about thescope and severity of the unfoldingemergency situation and the need foroutside assistance. Attempts were madeto judge the number of people affectedand/or the need for food assistance. Forthe India and Mozambique comparison,figures were compiled from theCRED/OFDA4 database. For the othersituations, figures were derived fromthe relevant UN consolidated inter-agency appeals (CAP) and mid-yearCAP updates. Other sources of dataincluded World Food Programme/Food and Agricultural Organisationfood aid needs estimates. It was notpossible to derive any quantifiable indi-cators for level of stakeholder commit-ment to a given crisis, thus this part ofthe analysis is built upon qualitativejudgements.

Apart from the India - Mozambiquecomparison, none of the other caseslead to an ‘unambiguous confirmation’that media attention is the most signifi-cant explanation as to the amounts ofemergency aid going to specific crises.For example, the conspicuous differen-

ces in aid allocations to Angola, Sudanand Kosovo in 1999 were undoubtedlyalso a result of immense vestedEuropean political and security inte-rests in Kosovo. The authors of thestudy claim that the massive internatio-nal emergency assistance to Kosovobecame one of a number of crisis mana-gement tools used by Western powersin their warfare against the Serbs. Theymake the same claim about Afghanistanafter September 11th where here, secu-rity concerns were at the forefront sothat the sudden massive level of inter-national assistance became an instru-ment for crisis management. Similarlyin North Korea, donor interests - ormore specifically security concerns -were paramount. In the words of theauthors, “it seems difficult to explainthe relatively high level of emergencyassistance to a Communist one-partystate with extremely limited mediaaccess and very meagre possibilities foraid evaluation”.

The authors also assert that even cri-ses that are largely ignored by themedia may very well uphold a substan-tial, albeit insufficient, level of emer-gency assistance - either because thereare significant donor interests in thearea or because the stakeholder com-mitment is long-lived and strong.Sudan and Angola are held up as exam-ples of this, where humanitarian net-working and continuous lobbying bywell co-ordinated United Nations agen-cies and international non-governmen-tal organisations are prevalent.

The study concludes that media atten-tion is no more crucial than donor inte-rests in mobilising international resour-ces for humanitarian crises. Rather thecase seems to be that the media play acrucial role only when there are no vitalsecurity issues at stake, namely when ahumanitarian crisis occurs in a place oflittle strategic importance to aid-fun-ding governments.

The authors also suggest that naturaldisasters and complex emergencieshave a greater tendency to become ‘for-gotten crises’ when major aid donorshave no particular security interestsvested in the afflicted regions. In suchcases, two factors may very well deter-mine the volume of emergency aid thatis allocated - the presence and strengthof humanitarian stakeholders in theregion, and the curiosity and persis-tence of the international press.

What Triggers HumanitarianIntervention?Summary of published paper1

1 Olsen G, Cartensen N and Hoyen K (2003).Humanitarian Crises: What determines the levelof emergency assistance? Media coverage,donor interests and the aid business. Disasters,2003, 27 (2); pp 109-1262 Office for the Co-ordination of HumanitarianAffairs (OCHA)3 European Commission HumanitarianOrganisation (ECHO)4 Centre for Research on the Epidemiology ofDisasters (CRED)/Office of United StatesForeign Disaster Assistance (OFDA)

8

Working with a number of localpartners, the Institute ofDevelopment Studies (IDS) andSave the Children UK (SC UK)

have recently published a report on destitutionin Ethiopia’s north eastern highlands. Thebackground for the study was conflicting evi-dence over whether poverty in rural Ethiopiawas increasing, as well as a growing concernthat diversion of increasing volumes of interna-tional assistance, to meet emergency appealsand annual food deficits, was displacing inves-tment to address the underlying causes of chro-nic food insecurity.

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

• What is destitution?

• How do people become destitute?

• How many people in Wollo are destitute?

• Is destitution in Wollo increasing?

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

Destitution was defined as a state of extremepoverty that results from the pursuit of unsus-tainable livelihoods, meaning that a series oflivelihood shocks and/or negative trends orprocesses erode the asset base of already poorand vulnerable households until they are nolonger able to meet their minimum subsistenceneeds. They lack access to the key productiveassets needed to escape from poverty andbecome dependent on public and/or privatetransfers.

Fieldwork-based data were collected duringthe dry season months of November 2001 toMarch 2002. A household questionnaire wasdesigned and administered to a stratifiedmulti-stage random sample of over 2,000 hou-seholds. The questionnaire included sectionson household demographics, livelihood activi-ties, ownership of and access to productiveresources, migration, participation in social ins-titutions, access to formal and informal trans-fers, achievement of basic needs, and a self-assessment of household well-being.

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

i) To facilitate self-assessment, householdswere asked “are you unable to meet the house-hold’s needs by your own efforts and unable tosurvive without support from the communityor government?” In response to this, 14.6%households were classified as destitute, overhalf (54.9%) were classified as vulnerable, and30.6% were considered to have viable liveliho-ods.

ii) Seventeen indicators of destitution wereassessed, with cut-off points for each indicatorapplied. The proportion of households classi-fied as destitute in terms of a single indicatorranged from 4.2 to 41.1%, with an average of19.4%.

iii) A composite destitution index, combining

Destitution in Ethiopia’sNortheastern HighlandsSummary of unpublished report1

Research

Counting housholds

A blacksmith and a potter

Mapping urban linkages

Kay Sharpe

Kay Sharpe

Kay Sharpe

the 17 single indicators, was scaled andweighted using principal components analy-sis. Overall, 95% of the 310 self-assessed des-titute fell in the bottom 40% of households, asranked by the destitution index. The 293 hou-seholds that satisfied both these criteria weredefined as destitute (13.8%), and much of thesubsequent analysis was based on comparingthis distinct group against the larger sample.

The study found that destitution in Wollo isgendered. One in three female-headed house-holds, compared to one in twelve male-hea-ded households, was destitute. Destitute hou-seholds were more likely to be smaller thanaverage – more than half of all single-personhouseholds were destitute – contradicting thecommon assumption that the poorest house-holds tend to be large, with high dependencyratios. Labour constraints were also highlysignificant determinants of destitution. In thisstudy, two-thirds of destitute households hadno able-bodied males.

Respondents were asked to categorise them-selves at four points in time - ten years ago,two years ago, one year ago and at time ofinterview. This showed that the proportion ofdestitute had increased nearly threefold overthe past 10 years, from 5.5% to 14.6%, whilevulnerable households had increased evenmore dramatically from 17% a decade ago, to55% in 2001/2.

The analysis found that carrying capacity isthe main cause of destitution – too many peo-ple trying to make a living from too little land.The poorest households in Wollo facedresource constraints of all kinds - land, lives-tock, labour, credit, inputs - which inhibitedtheir ability to construct viable livelihoodsand left them highly vulnerable to shocks thatcould push them over the edge at any time.Dependence on rain-fed agriculture, forexample, exposes rural communities to recu-rrent livelihood shocks following rain failure.Idiosyncratic shocks are another source ofdestitution, i.e. loss of adult males throughdivorce or widowhood, or major healthshocks like HIV/AIDS.

The authors of the study concluded that forthe labour constrained destitute, little can beadvocated except more comprehensive andeffective safety nets or social protection trans-fers, although these are expensive and logisti-cally complex to administer. For the workingdestitute, enhancing their access to produc-tive resources is arguably the only feasibleway of reversing processes of impoveris-hment, phasing out chronic dependence onfood aid and empowering poor households toachieve sustainable livelihoods. Access can beimproved, not only through asset ownership,but also community ownership. Support toboth farming and the rural non-farm eco-nomy is essential. This requires market inte-gration, investment in infrastructure andsmall town development. Proximity to smalltowns provides a clear route out of destitutionand vulnerability for rural households andcommunities in the catchment area.Recommendations, therefore, fall into twocategories, those that promote enhancedaccess to assets and those that promote moreproductive livelihoods.

9

1 Sharp K, Devereux S and Amare Y (2003).Destitution in Ethiopia’s northeastern highlands(Amhara National Regional State). IDS, SC-UKEthiopia. A policy research project funded by DFID.April 2003

Research

Nomadic herding remains at the coreof Mongolian society, employing asignificantly larger proportion of thepopulation than any other economic

activity. A series of liberalising reforms between1989 and 1992, sparked by the breakdown of theSoviet Union and a termination of subsidies, ledto the privatisation of the herd collectives (neg-dels) and the wholesale transfer of livestock andother assets to private ownership, mainly byindividual herders. Services, formerly providedfor free, were mostly either discontinued ormade available only at a cost. As a result, use ofthese services contracted or collapsed. Thenumber of herding households more than dou-bled from 69,000 in 1989 to 154,000 in 1993, asnewly unemployed city-dwellers sought to takeadvantage of the privatisation of negdel herdswhile fleeing food and job shortages in urbanareas. Cash shortages in the countryside led tothe reappearance of a barter economy and asharp decline in the consumption of purchasedfoods in favour of self-provisioning.

A recently published article based on fieldresearch in two districts of Bayankhongor pro-vince Mongolia, examines how famine has beenavoided amongst the population against a back-drop of ‘Zud’, despite the increased risk asso-ciated with this form of subsistence. Zud deno-tes any one of a range of winter conditionswhich threaten livestock survival, such as unu-sually abundant snowfall, the formation of animpenetrable ice layer over pastures, or a lack ofsufficient winter fodder following a summerdrought or due to soil compaction by grazinganimals. In the past decade, Zud winters in 1993and 1997 were followed by an unprecedentedthree-year sequence of dry summers and extre-mely harsh winters between 1999-2002.Weakened by inadequate summer feeding andlacking sufficient supplementary feed, severalmillion animals died each winter in blizzardsand temperatures as low as 50 degrees belowzero in some areas. Overall, the national herdsize decreased from 33.6 million in 1999 to about25.1 million in April 2002.

Between 1999 and 2002, the number of lives-tock in the study area declined by 65% in onedistrict and 22% in the other, as a result of Zud.Over two weeks, 14 herding households, mostof whom had suffered heavy livestock losses,were interviewed in each district about copingstrategies employed, help received and reco-very prospects. Additional information wasobtained by consulting statistics and intervie-wing officials and NGO staff at state, provincial,and district levels.

Why was there no famine?One reason posited by the authors is the exis-

tence of democracy. Mongolia has had an activedemocratic system since 1989, with a powerfulelected parliament containing representatives ofseveral parties, an active opposition and a freepress. The devastating impacts of the droughtsand Zuds of 1999-2002 have been debated atlength in parliament and in the newspapers.The government has been open about what washappening and within the limits of its resources,has acted effectively.

Another reason is the behaviour of herders.Winter preparation by herders has been impor-tant. Although the lack of milking animals hada significant impact on food quality, winter foodstores - augmented by borrowing - ensured thatfor most herder households, the real impact ofanimal losses on livelihoods was delayed. Goodincome from cashmere sales filled the gap in1999-2000. When cashmere and other livestockproducts income crashed after 2000, herders tur-ned to alternative sources, relying particularlyon pensions and other social insurance benefitsas well as on assistance from family andpatrons, to maintain a minimum level of con-sumption while conserving their remainingherd. Extra loans were sought, as was supple-mentary income in farming, gold mining andcasual jobs. In 2000, some households benefitedfrom generous relief and restocking.

However, the authors caution that after threeZuds in as many years, each following adrought summer, the capacity of some house-holds may be stretched to near collapse. Oneindication of this is the recent increase in childmalnutrition in Bayankhongor province, whichdoubled between December 2001 and May 2002.While most households had sufficient food atthe end of 2002 derived from a bundle of foodand income sources, many are extremely vulne-rable and are likely to face severe difficulties aswinter stores run out, new loans are not availa-ble and old ones cannot be repaid.

In a broader sense, coping in terms of main-taining a sustainable livelihood has failed formany households. For poor households withsmall herds and little prospect of acquiringmore animals, herding no longer yields enoughto provide for long-run subsistence. Realisingthis, many herders, particularly in the Gobiregion, are considering migration to cities inorder to find non-herding employment. Manyhave already done so and nationally the ruralpopulation has decreased, for the first timesince transition, by 7.6% over the past 2 years.

Others who either do not want to migrate orare constrained by lack of funds, obligations tocare for elderly parents in the countryside, orowing to the absence of city-based family orfriends, are seeking alternative sources ofincome in or near their home districts.

The authors conclude that for many house-holds, the losses of the last winter have trigge-red the beginning of ‘coping failure’ and thenecessity to switch from ‘coping’ to ‘adaptation’– moving from short-term responses to tempo-rary food shortages, to permanent changes inthe ways in which food is acquired. Unlike far-mers, herders with too few animals cannot hopethat a single good year will restore them to eco-nomic health. If another Zud occurs before her-ders have had an opportunity to re-build theirresource bases, the resulting increase in foodinsecurity and economic and social upheavalfor affected households may well be far morewidespread.

Famine Avoided DespiteDrought and ‘Zud’ in MongoliaSummary of published paper1

1 Siurua, H and Swift, J (2002). Drought and Zud but nofamine (yet) in the Mongolian herding economy. IDSBulletin vol 33, no 4, 2002

The Bangladesh Integrated NutritionProgramme (BINP) was adopted toimprove the nutritional status of thepopulation, especially of women and

children, through community based nutritioninterventions. The community based nutritioncomponent focuses on growth monitoring ofchildren, dissemination of nutrition-relatedinformation and supervised supplementary fee-ding of target women and children inCommunity Nutrition Centres (CNCs) at villagelevel. The government has adopted the NationalNutrition Programme (NNP) based on experien-ces and lessons learned from the BINP, andintends to provide a similar mix of services tothose being delivered under the BINP. Scaling upthe activities to the whole country will costapproximately 150 million dollars a year.

The BINP experimented with two models ofdelivery, one using government managementstructures and the second using non-governmen-tal organisations (NGOs) working in the localcommunity. A recent study has compared theefficiency of the government of Bangladesh(GOB) and NGO management in the provision ofnutrition services and involved a detailed cos-

ting to estimate cost of delivering nutrition servi-ces from the CNCs. The number of individualsenrolled, the number actually participating in theprogramme, and person-days of service delive-red were used as effectiveness measures.

Thirty-five CNCs were randomly selected fromfive BINP areas, of which 21 were in GOB-runareas and 14 in NGO-run areas. The cost of pro-viding nutrition services per enrolee wasUS$24.43 for GOB-run CNCs and US$29.78 forNGO-run CNCs.

The analysis implies that the NGO facilities arenot more efficient in the delivery of nutrition ser-vices when cost per person/days of service deli-vered is considered. One potential criticism ofthis type of comparison is that it assumes enrol-ment and participation without looking intopotential mis-targeting. If the expected enrol-ment is calculated by using prevalence of malnu-trition rates found by the BINP, it is clear thatenrolment rates were lower in GOB facilities andhigher in NGO facilities than otherwise expectedfor rural Bangladesh. However, enrolment doesnot equal participation. Re-estimating the cost-effectiveness measures with expected enrolment

numbers makes the NGO facilities even less effi-cient compared to GOB facilities.

On average, the BINP delivered food supple-mentation of 480 kcals per participant at a cost ofabout US$0.25 per day. Allowing for administra-tion and management costs, the actual food costbecomes US$0.20 per participant per day. If theproject were to use this amount of money to buyrice from the local market, the calorie content ofthe rice would be more than 2000 kcals. Unlessthe food supplementation process generatesother types of benefit, such a high level of costcannot be justified. The study authors concludethat even if other benefits such as nutrition edu-cation and community involvement are genera-ted, policy makers should compare a program-mes’ relative efficiency and effectiveness with itsseparable components, to determine whetherconcentrating on specific components will gene-rate higher levels of social benefits per dollarspent.

1 Mahmud Khan, M and Ahmed, S (2003). Relative effi-ciency of government and non-government organisationsin implementing a nutrition intervention programme – acase study from Bangladesh. Public Health Nutrition; 6(1), pp 19-24, 2003

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

Summary of published paper1

and health and develop interventions based onthat diagnosis. The author suggests that as indi-viduals realise their power to make decisions,lay claim to resources and exercise freedom ofchoice, they may engage the very institutionsthat created and perpetuated differential powerdynamics. Thus, the “power and technology”pathway will lead to more sustainable nutritionoutcomes.

The Thailand and Peru studies took a total of 9and 16 months respectively, while the other stu-dies took between 9 and 18 months. Even moreremarkable was the time needed for the nutri-tion-specific intervention in Peru, taking a merefour months to implement and demonstrateequivalently significant results. The authors sug-gest that the relative efficiency and effectivenessof the Peru and Thailand studies probablyreflects ‘who’ made the decisions. In the Peruand Thailand cases, women applied their enhan-ced skills to make decisions about which pro-blems they needed to address and how to solvethem, including the types of resources they nee-ded and means to access them. The developmentprofessionals served as facilitators and technicalresources, not as the primary decision-makers.In contrast, the decision-makers in the other stu-dies were the research team. While communitymembers, including women, provided informa-tion to the technical specialists and participatedin the intervention trials, their decisions werelimited to the choice of whether or not to adopta technology or modify a practice.

The authors state that although care must begiven to drawing conclusions from this retros-pective analysis, it should not be a surprise thatinvesting in women’s decision-making powerand expanding their freedom of choice was anefficient and effective way to achieve results

10

Research

Anumber of agencies have adopted‘gender sensitive’ policies, which aimto strengthen the role of women incontrolling intervention resources in

emergencies. The rationale for such policies isthat empowerment of women will contribute toimproved impact of the intervention. The fin-dings of a recent study in non-emergency situa-tions lend some support to this approach. (Ed)

The International Centre for Research onWomen, with partners in Ethiopia, Kenya,Tanzania, Peru and Thailand, implemented anintervention research programme to find ways tostrengthen women’s contributions to reducingmicronutrient deficiencies. The trial interven-tions focused on:

• Improving women’s skills and knowledge infood production, processing and preparationmethods and feeding practices, to improve vita-min A intake in Ethiopia.• Promoting the adoption of new varieties ofbeta-carotene-rich sweet potatoes by women far-mers in Kenya and encouraging their consump-tion to improve vitamin A intake.• Increasing women’s access to, and utilisationof, a modified solar drying technology to incre-ase year-round availability of vitamin A-richfoods in Tanzania.• Strengthening women’s skills in decision-making, problem solving and management toimprove quality of services in Peruvian commu-

nity kitchens and improve iron status of kitchenmembers and other consumers.• Strengthening women’s problem-solving andleadership skills to organise community-basedinterventions and so reduce vitamin A, iron andiodine deficiencies in rural Thailand.

All five country interventions achieved signifi-cant nutrition outcomes and succeeded in rea-ching their nutrition objectives in less than 18months. The approaches appear to have achie-ved objectives in two specific ways – first interms of entry point and second, in terms of deci-sion-makers. The Ethiopia, Kenya and Tanzaniastudies began by addressing women’s practicalresource needs as they related to food produc-tion, care and feeding practices. The Thailandand Peru studies began by strengthening wome-n’s capabilities as problem solvers, decision-makers and community leaders, followed bydevelopment of nutrition specific interventionsthat addressed women’s practical resourceneeds.

The two approaches are described in the articleas the ‘power and technology pathway’ and the‘technology’ pathway. The entry point for thetwo-step power and technology pathway streng-thens individual capabilities to solve problems,take decisions and lead their communities. Thispathway merges with the ‘technology’ pathwaywhen the decision-makers identify the practicalresources needed to improve access to food, care

Women’s Contributions to ReducingMicronutrient DeficienciesSummary of published research1

1 Johnson-Welch, C (2002). Explaining nutrition outcomesof food-based interventions through an analysis of wome-n’s decision-making power. Ecology of Food and Nutrition,41, pp 21-34, 2002.

vious policies and not to put the changing policiesat risk. Surprisingly the famine was hidden notonly to the press, but also to economists workingat that time on the economic reforms. It is arguedin the paper that had the press been free to reportthe case, and had economists been properly infor-med of the situation, public ‘coping mechanisms’could have been put in place.

Little is known of the situation in rural areas.However, the mortality increase seen among chil-dren in the capital over the 1975-86 period, with apeak in 1985-6, was also visible in the nationally

representative sample of the Demographic andHealth Surveys, in both urban and rural areas.

The author concludes that improved informationtechnology, as well as more integrated markets inMadagascar, makes another famine of this naturequite unlikely in the future.

11

The political economy of an urbanfamine in Madagascar is the subjectof a recently published article. Thefamine occurred in the capital city,

Antananarivo, between 1985-86 but remai-ned hidden for a long time, eventuallyuncovered by analysing the demographicdata of registered deaths in the city.

Antananarivo lies in the highlands of cen-tral Madagascar and in 1985 had a popula-tion of approximately 577,000 people. Forthe period 1976-95, the mortality data recor-ded for the city showed a typical famine in1985-6, where mortality levels increasedmarkedly, and life expectancy fell from 59.4years in 1975, to 49 years in 1986. The mor-tality increases bore all the characteristics ofa famine - a strong relative increase amongchildren, especially 5-9 year olds, andyoung adults, particularly young men aged20-34 years old. In absolute terms it wasestimated that about 7,600 persons died in1985-6 in excess of baseline mortality levels,about half of whom were children under 15years of age, with a small excess of boys.Adults aged 15-59 years comprised one-third of excess deaths, nearly three-quarters(74%) of whom were men. The remainingdeaths were amongst the elderly, again witha higher male mortality. These figures implythat 1.3% of the population died because offamine, a rate that compares with someother ‘mild’ famines. However, the mainevidence that this was a famine lies in the‘causes of death’ profile, which is especiallyclear for young adults. Mortality from mal-nutrition (starvation) among adults hardlyexisted before 1984 and after 1988, whereasit showed a huge peak in 1986.

The explanation for the Antananarivofamine appears quite clear. Rapid deregula-tion of rice prices and rice markets, follo-wing a long period of strict state regulation,led to a rapid increase in the price of rice,the staple food of the large majority of apoor population. The poorest could notcope with the increasing cost of what cons-tituted 80% of their food intake.Furthermore, poverty had been increasingin Madagascar over the period precedingthe crisis and started to decrease only tenyears later, after 1996.

Beyond market failure and institutionalfailure (i.e. lack of government policies tooff-set the rice price inflation), several otherfactors may have played a role in thefamine. The geographical isolation of thecapital city in the highlands, together with avery poor road system, may have contribu-ted to market segmentation, already aggra-vated by the lack of incentives to rice far-mers during the 1972-84 period as a result ofthe state controlled economy. The changingeconomic situation during 1984-6 created amarket trap with effects similar to those of ablockade - rice was available in the countryor could easily be imported, but peoplecould not access it because of a lack of enti-tlement. If people had commanded higherincomes or had access to credit, they wouldhave been able to survive the crisis.

The Madagascar famine seems to havebeen ‘hidden’ from the start, probably in anattempt to hide the major failures of pre-

1 Garenne, M (2002). The political economy of an urbanfamine. IDS Bulletin, vol 33, no. 4, 2002

Hidden Faminein MadagascarSummary of published paper1

Research

A market in Tulear, Madagascar(c) IRD - Base Indigo. Photo by Vincent Simmonneaux, 1998

Comparisons aside, some would still regard the18% fatality rate from severe malnutrition at bothhospitals during the study period as unacceptablyhigh, considering the guidelines target mortalityrates of 5-10%. Guideline components that werenot implemented or sustained may have been cru-cial to achieving further decreases in case-fatalityrates. Furthermore, guideline practices believed tobe in place may have been implemented inconsis-tently or poorly in reality. Also, the influence ofHIV on malnutrition mortality was not measuredspecifically. The primary cause of death in somecases was probably advanced acquired immuno-deficiency syndrome (AIDS), in which case thedeaths would not have been preventable.

Hospital staff questioned the evidence base ofsome of the guideline components and felt that theevidence behind certain recommendations – suchas the single approach for managing marasmusand kwashiorkor, feeding frequencies, routineantibiotics, and requirements of micronutrientsother than vitamin A, folic acid and zinc – wasinadequate. Documentation of the technical basisof these specific recommendations, or research toprovide the necessary evidence, would promotewider acceptance of the guidelines.

The study intentionally selected two general hos-

pitals that seemed to have a good chance of imple-menting the guidelines. Although the findingscannot be generalised to all small hospitals inAfrica, the study gives an idea of what may ormay not be feasibly implemented with a minimumof intervention. It is difficult to predict whethersimilar African hospitals would have the samesuccess in improving care management practicesby following the guidelines, particularly withoutexternal consultant support. Conversely, moreintensive input and support might allow imple-mentation of all components of the guideline butwith less assurance of sustainability.

The authors of the study concluded that widerimplementation of the guidelines in similar set-tings is possible but that the guidelines could beimproved by including additional information onhow to adapt specific components to local situa-tions. Furthermore, additional information is nee-ded about certain components of the guidelinesand their impact on mortality.

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1 Deen J et al (2003). Implementation of WHO guidelines onmanagement of severe malnutrition in hospitals in Africa.Bulletin of World Health Organisation, 2003, 81 (4), pp 237- 2422 Management of severe malnutrition: a manual for physi-cians and other senior health workers. WHO, 1999

Summary of published research1

In the past, Field Exchange has addressed issuesfaced by international humanitarian agencies inphasing out emergency therapeutic feeding pro-grammes and leaving behind improved and sus-tainable capacity for treatment of severe malnu-trition. The study summarised below providesadditional evidence that at least in non-emer-gency situations, improved and sustainablepractices can be promoted (Ed).

The study set out to investigate theproblems, benefits, feasibility andsustainability of implementingWorld Health Organisation (WHO)

guidelines on the management of severemalnutrition 2. A postal questionnaire wassent to 12 African hospitals inviting them toparticipate. Five hospitals were evaluatedand two were selected to take part in thestudy - a district hospital in South Africa(Battor Hospital) and a mission hospital inGhana (Mapulaneng Hospital). At an initialvisit, an experienced paediatrician revie-wed the situation in the hospitals and intro-duced the principles of the guidelinesthrough a participatory approach. During asecond visit about six months later, the pae-diatrician reviewed the feasibility and sus-tainability of the introduced changes andhelped find solutions to problems. At a finalvisit after one year, the paediatrician reas-sessed the overall situation.

Implementation of most of the main prin-ciples of the WHO severe malnutrition gui-delines was feasible, sustained over a one-year period, and affordable to the institu-tions (see table 2). Although relativelylabour intensive, the process was successfulbecause hospital staff were involved inplanning the changes from the outset, logis-tical limitations were acknowledged andlocal modifications to the generic approachwere developed. The success can also beattributed to the enthusiasm of the residentpaediatricians and the follow up by the visi-ting paediatrician. As the resources forimplementation came from the hospitalbudgets (except for a supply of mineral andvitamin pre-mix), financial sustainability islikely.

Whether the WHO guidelines, once imple-mented, are effective is another importantand relevant question. At Battor, the morta-lity was unchanged, possibly because diag-noses of severe malnutrition were more pre-cise during the study year - this is suppor-ted by a decrease in the number of admis-sions classified as severely malnourishedfrom 81 at the beginning, to 39 during thestudy. At Mapulaneng, the mortality hal-ved. This may have been because all casesof severe malnutrition, not only those withcomplications, were admitted, as suggestedby the increase from 29 cases pre-study to125 cases during the study. Also, the studywas not blinded so some bias in the repor-ting may have occurred during the studyyear.

Research

Triage, urgent assess-ment and management

Feasible andsustained

Battor and Mapulaneng Hospital

Table 1 Summary of the feasibility and sustainability of the main components of the WHO guidelines for the management of severely malnourished children

• Routine admission of all severely mal-nourished children• Using key signs, oedema of both feet orsevere visible wasting, for the diagnosis• Measurement of height and calculationof weight-for-height• Measures against hypoglycaemia, e.g.early feeding on admission, nasogastrictube feeding when necessary• Measures against hypothermia, e.g.blankets, heaters, keeping the childrendry• Restricting the use of intravenous fluidsonly to those with shock or severe dehy-dration• Preparation and use of starter (75kcal/100 ml) and catch-up (100 kcal/100ml) formulae• Delaying the administration of supple-mental iron

• Allowingmothers to staywith the chil-dren all day andnight

• Routine admi-nistration of oralantibiotics tothose withoutcomplications

Feasible withadaptation orspecial provi-sion

Frequent feeding, all day and night Supplemental electrolytes, minerals, andvitamins

Routine administrationof antibiotics to thosewithout complications

Feasible, butimplementedinconsistentlyornot sustained

• Measurement and recording of feeding• Daily measurement and charting ofweights• Transition from starter (75 kcal/100 ml)to catch-up (100 kcal/100 ml) formula

Not feasible • Preparation and use of rehydrationsolution for the severely malnourished(ReSoMal)• Calculation of weight gain in g/kg/day• Target case-fatality rate of 5–10%

Allowing mothers tostay with the childrenall day and night

Triage, urgentassessmentand manage-ment

Category Mapulaneng Hosptial Battor Hospital

Implementation of WHOGuidelines on theManagement of SevereMalnutrition in SouthAfrica and Ghana

Dietitian interacting with ward nurse atMapuleng hospital, Northern Province,South Africa 2002

Rehabilitated child at Catholic hos-pital, Battor, Volta Region, Ghana2001

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AntiretroviralTherapy andNutrition technical guidance1

Access to antiretroviral drugs (ARVs)is increasing among people livingwith HIV/AIDS (PLWHA) in deve-loping countries, as a result of

local, national, and international efforts.Issues related to antiretroviral therapy (ART)in resource limited settings have becomeincreasingly relevant to PLWHA, caregivers,service providers, and programmers. Draftedby the Food and Nutrition TechnicalAssistance Project (FANTA), a technical notenow provides information and guidance on

the food and nutrition implications of ART andhow to manage these in resource limited set-tings.

Managing the interactions between ART andfood and nutrition is a critical factor in the extentto which the therapy is effective in slowing theprogression of HIV/AIDS and improving thequality of life of PLWHA. In resource limited set-tings, many PLWHA lack access to sufficientquantities of nutritious foods, which poses addi-tional challenges to the success of ART.Programmes working with people taking ARTmay need to strengthen human capacity toaddress nutritional issues, establish linkages toprogrammes addressing food and nutritionissues, and incorporate information about drug-food interactions into communication materials,staff training and orientation, and supervisionsystems.

This technical note summarises the types ofARVs commonly used, offers a framework forunderstanding drug-food interactions, describeskey issues and steps for managing ARV-food

interactions, identifies areas of knowledgegaps, and lays out the specific food andnutrition implications of ARVs commonlyused in resource limited settings.

While the document focuses on ART, itnotes that individuals infected with HIVhave special nutritional needs, irrespectiveof whether they use ART. Furthermore,although access to ART in developing coun-tries is increasing, the majority of PLWHAstill do not have access to ART.

1Food and Nutrition Implications ofAntiretroviral Therapy in Resource LimitedSettings - DRAFT, Tony Castleman, EleonoreSeumo and Bruce Cogill, FANTA, June 2003

The document is available online atwww.fantaproject.org or email:fanta@aed.org

13

Looking beyond short term feeding solu-tions, Malnutrition Matters is a non-pro-fit organisation dedicated to providingsustainable, affordable and locally avai-

lable food technology solutions for malnutrition.Staff have been involved in food technology pro-jects in over 30 countries, although the emphasishas been in the regions of the Former SovietUnion, in Africa and in India. Most recently,Malnutrition Matters has developed a comple-tely non-electric, versatile food processingsystem called VitaGoat improving upon pre-vious systems (SoyCow and VitaCow) whichboth require a reliable supply of electricity.

The VitaGoat system comprises of a pressure-cooking vessel, a bicycle-powered grindingsystem, an energy-efficient steam generator anda mechanical press. The system can process soy-beans into soya-milk and derivatives, as well as

If you find writing a chore, perhaps knowwhat you want to say, but not how to say it,or feel you need to polish your writing skills,then JustWrite may be what you need.

Developed by the not-for-profit organisationFahamu, JustWrite is an online course on effec-tive writing, which can help individuals to buildup effective writing skills over a period of a fewweeks. It provides health workers with anopportunity to develop effective writing skillswithout absenting themselves from work, andbenefit from extensive professional guidance.The course is ideal for anybody producing anysubstantial piece of writing, such as an advocacydocument, paper for publication, or researchreport.

The course takes three intensive weeks andcombines study material, stimulating interactiveexercises, lively online discussion with yourfellow participants and individual tuition. Studyis broken down into daily hour-long slots,making the course suitable for those in full time employment.

A specially designed CDROM is provided con-taining all the study materials, including interac-tive exercises and assignments. It also containssections on grammar, punctuation and stylisticissues - together with a reading list and guides tofurther study. You can be anywhere in the worldto benefit from this course, you only need accessto a computer and email.

The cost of the course is currently £300 sterling.For participants from developing countries whoare without sponsorship, the fee will be negotia-ble. For further details on course dates and aregistration pack, write to Hilary Issac, email:jw-info@fahamu.org

With bases in the UK and South Africa, Fahamuis a not-for-profit organisation that aims to sup-port progressive social change in the souththrough using information and communicationtechnologies. For further information, see onlineat http://www.fahamu.org.uk

micro-enterpriseresponds tomalnutrition

VitaGoat fruits, vegetables and cereals into aqueous solu-tions or juices, soups, purees, and gruels. Thereis no food wastage with the processing. The‘Okara’ residue from the soya processing is avai-lable for breads, as additions to other foods, orcan be used as animal feed. Using only its bicy-cle grinder, the VitaGoat can also grind dry cere-als and grains to produce flour, and meal, andprocess nuts into pastes or ‘butter’ such as pea-nut butter. It can also grind roasted coffee.

The VitaGoat can be used in a number of set-tings including humanitarian projects, social ins-titutions (hospitals, schools, etc) and sustainablemicro-enterprises. The technology also facilitatesthe development of projects for processing andpreserving foods and can for example be usefulin situations of seasonal ‘glut’ where waste canoccur due to lack of local markets or processingoptions, e.g. mangos and tomatoes.

Launching in October, the projected localselling price should be under US$2,000 whentechnology-transfers are completed. Thereafter,construction, training and parts for the systemswill be provided locally. The system will at firstundergo a six-month pilot programme test inpartnership with Africare in Guinea, Chad andMozambique. After this, it is intended to transferresponsibilities for the VitaGoat to manufactu-rers in two or more African locations. Similarinitiatives are planned for other regions, inclu-

ding Latin America, and South and South-EastAsia, when appropriate sponsors and NGO part-ners are identified.

For further information, contact: MalnutritionMatters, 498 Rivershore Cres, Ottawa, ON,CanadaK1J 7Y7, email: matters@malnutrition.org, tel: 1 613 446 0205 , fax: 1 613 446 2072.See online at http://www. malnutrition.org

an online course ineffective writing

News & Views

VitaGoat system, left to right: steam boiler,cooker with press, cycle grinder

JustWrite

By Frank Daller,Vice-Presidentof Malnutrition Matters.

Malutrition Matters

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The French company, Nutriset, hasbeen involved in projects aimed atestablishing local production ofPlumpy’nut - a ready-to-use food

product (RTUF) employed in feeding pro-grammes for the management of severemalnutrition. Plumpy’nut can also be usedas a nutritional supplement for childrenand adults.

The product was originally developed inpartnership with the IRD (Institut deRecherche pour le Développement) and hasbeen jointly patented by Nutriset/IRD. Thepractical value of this product – especiallyin situations where there are few trainedstaff available and in home-treatment pro-grammes - has meant that it has been adop-ted by a number of non-governmentalorganisations (NGOs). A wide variety ofstakeholders have been interested in localproduction in order to make access toPlumpy’nut more sustainable.

Experience with local productionThe first project to attempt local produc-

tion of Plumpy’nut was in Senegal, in part-nership with the University of Dakar andthe ITA (Institute for Food Technology) inDakar. Production is currently taking placewithin the university and a comparativestudy is being carried out into the effective-ness of locally produced Plumpy’nut com-pared to the product manufactured inFrance. The aim of the project is to promote

Local Production of Plumpy’Nut By Anne-Laure Glaisner andBeatrice Simkins, Nutriset

HelpAge International are planning a training course on Ageing in Africa, to run between 23- 27February, 2004 and based in Nairobi, Kenya.

Aimed at mid-level or senior programme managers, social and healthcare professionals, seniorgovernment officers, or those simply with an interest in ageing issues, topics to be coveredinclude:• Demographic situation and socio-economic implications for Africa• HIV/AIDS and its impact on older people• Gender dimension of ageing• Poverty • Research and Policies on ageing

A course fee of US$400 is chargeable for those requiring accommodation and US$150 for thosewho make their own arrangements.

For more information, contact HelpAge International at email: helpage@africaonline.co.ke

Local production in Malawi, 2002 Distribution of Plumpy sauce in a plate of rice, Madagascar in 1996

small-scale local production in each feeding cen-tre so as to increase the availability of the pro-duct in a way that it can become an integral partof public health programmes in Senegal.

A second project, which developed out of theconcerted action of a number of NGOs, is under-way in Malawi. In December 2002, Nutrisetcarried out a technical audit in the field to iden-tify a potential local producer. The product andthe manufacturing process have been adapted tolocal conditions, taking into account the availa-bility of raw materials, production equipmentand packaging. A licence was granted to themanufacturer, free of charge, for the productionand sale of Plumpy’nut in the socialwork/humanitarian sector. In order to ensureproduct quality, Nutriset supplies the essentialminerals and vitamins used in the form of a pre-mix. This premix is sold to the NGOs who willbe using the final product, and it is delivered forprocessing to the local manufacturer. A secondvisit is planned for October 2003.

A third project has been the initiative of a smallfood company in Lubumbashi, DemocraticRepublic of the Congo. The idea held threeattractions for the company: helping to meet anincreasingly pressing local need, a means todiversify its production, and becoming moreinvolved in the ‘social fabric’ of the region. InJune 2003, Nutriset and its project partnerscarried out a technical audit and market study.Funding is currently being sought. Nutriset willprovide the company with technical support andwill ensure staff training for production and

quality management. A licence for the produc-tion and sale of Plumpy’nut to the humanitariansector will be granted free of charge. However,the company is also planning to develop a simi-lar product for distribution on the local market.This product will be distinguished fromPlumpy’nut by its name, its formula and its pac-kaging. Nutriset will also help in the design anddevelopment of this product.

These three projects show that the process ofsetting up local production of Plumpy’nut can-not be standardised and will depend on localconditions. Furthermore, the most critical aspectof setting up local production is establishingquality management. Conscious of its role as lea-der in this type of project, Nutriset is planning toset up an experimental production line reprodu-cing, as far as possible, the manufacturing con-ditions encountered in developing countries.The purpose of this is to help staff understandmore precisely the problems local producershave to deal with, in order to help them findsolutions. Licencing Plumpy’nut local producersis another key area for quality control. A licenceeffectively becomes a quality guarantee forNGOs and other users.

For further information, contact Anne-LaureGlaisner, Research and development,or Beatrice Simkins, International communica-tion and development, email: nutriset@nutri-set.fr, NUTRISET - BP 35 – 76770, Malaunay,Francetél : +33 (0)2 32 93 82 8)fax : +33 (0)2 35 33 14 15http://www.nutriset.fr/

Training Course on Ageing in Africa

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NutrisetNutriset

The International Network for theAvailability of Scientific Publications(INASP) has launched the online INASP-Health Directory 2003/2004. The

Directory is a networking tool for building pro-fessional relationships and sharing information,and a reference for those who are seeking techni-cal and financial support. Listings include 240international organizations and programmesworldwide that are working to improve access toinformation for health professionals in develo-ping and emerging countries. Each entry givesfull contact details and a short description ofrelevant activities.

Presented in two parts, part 1 includes orga-nisations that provide health information, whilepart 2 describes organisations that support book,library and information development, includinga section on health.

The INASP-Health Directory 2003/2004 is sup-ported by Exchange, a networking and learningprogramme on health communications for deve-lopment (http:// www.healthcomms.org). Available free of charge at http://www.inasp.info/pubs/healthdir/, it is

designed to complement 'INASP Health Links',the internet gateway to selected websites forhealth professionals, medical library communi-ties, publishers, and NGOs in developing andtransitional countries (see online athttp://www.inasp.info/health/links/con-tents.html)

The Directory is also available on CD-ROM(thanks to e-TALC), and a limited number ofprinted copies will be available free of charge tomedical libraries in developing countries.

For comments, suggestions for improvement,and recommendations for newentries, contact Neil Pakenham-Walsh at email:health@inasp.info

HIV/AIDS are described and recommendationsgiven on foods and eating habits to meet theserequirements. The manual also explains how toaddress the nutritional aspects of HIV-relatedconditions. Practical recipes using locally availa-ble foods are suggested, as well as some simplehome remedies for easing some of the problemspeople with HIV/AIDS may experience.

The manual consists of:i) Guidelines, with accompanying informationand explanations, intended for use by:• Health service providers and other extensionworkers, as well as those involved at the nationaland community level in the many differentaspects of counselling and home-based care• Community based organisations working withpeople with HIV/AIDS who need informationfor programming and counselling purposes• Planners in the health, social and nutrition ser-vices so they can develop national or local gui-delines for nutritional care and support for peo-ple living with HIV/AIDS • International agencies that support nationaland community-based support programmes for

people with HIV/AIDS

ii) Summary sheets that can be used as han-douts, listing the main points for each key topic.

The summary sheets and leaflets are specifi-cally for use by people who are living withHIV/AIDS or who are caring for a person livingwith HIV/AIDS, who want to be better infor-med.

The annexes contain:• further technical information• suggested recipes for home treatments andfoods for different conditions• forms to monitor food intake and weight• sources of literature and information on insti-tutions providing support for people living withHIV/AIDS.

15

An increasing number ofmothers with HIV in Ugandaare breastfeeding their babiesafter UNICEF stopped dona-

ting free infant formula, according to arecent news piece published in theLancet.

Under the prevention of mother-to-child HIV transmission (PMTCT) project,between 2000 and 2002, UNICEF dona-ted infant formula for HIV-positivemothers who, on counselling, chose touse formula rather than breastfeed theirnewborn infants. However, according toUNICEF in Uganda, they found thatthose who were in need did not haveaccess to formula, and since it wasexpensive, it was not sustainable.Nationally, only 32% of the HIV-positivemothers opted for formula feeding. Theremainder chose to breastfeed eitherbecause of stigma, or their living condi-tions made formula feeding risky. Evenamong those who chose formula, manywere breastfeeding at night for conve-nience.

Ministry of Health (MOH) figures werenot available as to how many mothershad reverted to breastfeeding. At one ofthe urban sites, Nsambya, while 50% ofthe women formula fed their childrenlast year, this has now dropped to lessthan 20%.

Uganda’s Child Health Commissionerhas expressed concerns that the reducedavailability of infant formula will slowefforts to reduce mother-to-child HIVtransmission. However, the MOH is fin-ding it difficult to respond to requests toprocure infant formula, given the limitedresources available and many other basicantenatal needs that remain unmetwithin the health system.

FAO and WHO have recently produced amanual on nutritional care and supportfor people living with HIV/AIDS, called‘Living well with HIV/AIDS’. The

manual aims to provide practical recommenda-tions for a healthy and balanced diet for peopleliving with HIV/AIDS in countries or areas witha low resource base. It aims at improving nutri-tion in a home-based setting. It is also applicableto people with HIV/AIDS in hospitals and otherinstitutional settings, including hospices.

The food requirements of people with

1 Further information and a full text version ofthe manual is available online at the WHO web-site http://www.who.int/disasters, and at theFAO website at http://www.fao.org

New FAO/WHOManual on LivingWell with HIV/AIDS1

News & Views

HIV-PositiveMothers inUganda Return to Breastfeeding

Facing up to theStorm Recently produced by Christian Aid,

Facing up to the Storm is a disastermanagement book which looks at howlocal communities can cope with disas-

ter, and the potential for community-basedapproaches to disaster management. Originalcase studies, based on first-hand experiencesfrom Orissa and Gujarat in India, show howpeople, even in the poorest parts of the develo-ping world, can survive disasters if they areinvolved in all aspects of managing disastersfrom response to prevention. This approach dif-fers greatly from the top-down, government-ledapproach experienced by most communities andfrom the practice of most governments andmany agencies.

The book is available to download athttp://www.christianaid.org.uk/storm. A limited number of hard copies are availablethrough the UK suppliers, tel:+44 (0)8700 787788 or by international mailorder, email : vhai@vsnl.com,Attention: Megha Sharma, tel: ++ 91 11 26518071/2 (India)

Seedling nurseries will help replantIndia’s devastated east coast after the1999 Orissa cyclone destroyed over amillion trees.

INASP Health Directory 2003/2004

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Summary of published research1

1 News, The Lancet, vol 36, no.9383, 16 Augest 2003.

The last issue of Field Exchange reported onthe publication of a new book ‘Caring forSeverely Malnourished Children’ by AnnAshworth and Ann Burgess. The book des-

cribes how to manage severely malnourished chil-dren in hospitals and other health units with inpa-tient facilities. Due to criticisms of the content byProf. Mike Golden, the authors, TALC and thepublisher together agreed to have the book revie-wed. Three independent experts in the field wereasked to address the following questions:

1. Does the book deviate from WHO guidelines ontreatment of severe malnutrition. 2. If so would these deviations be detrimental tochildren's health. 3. Does the book provide the information requiredfor health workers to manage severely malnouris-hed children successfully.

The findings of the reviewers were as follows;

Does the book deviate from WHO guidelines?Only minor changes were noted. i) The use of a larger daily dose of folic acid i.e.2.5mg instead of the recommended 1 mg ii) The option of using 2% magnesium sulphatewhen CMV or the electrolyte/mineral solution isunavailableiii) The option of using crushed Slow-K tabletswhen CMV or potassium chloride solution is una-vailableiv) Advocating the use of metronidazole.

Would these deviations be detrimental to chil-dren's health?

All reviewers agreed that these would not bedetrimental. The first three are alternatives to theformulations advised by WHO and relate to theavailability of suitable preparations, so that thequestion is about whether it is preferable to givesomething or nothing. Their conclusion was that apragmatic choice to provide a formulation that isavailable is appropriate. Concerns over whether alarger dose of folic acid interferes with antifolateantimalarial drugs like Fansidar are addressed bythe reviewers. There is no firm evidence of an effectbut the consensus is that there is ongoing debateand well designed studies are needed to furtheraddress the issue of dosage and risk of malaria.

The WHO guidelines state that the use of metro-nidazole is accepted practice in many units and thereviewers agreed that it is effective in treating smallbowel overgrowth (SBO). There is some discrepancyamong the reviewers as to the importance attachedto SBO in malnutrition.

Does the book provide the information requiredfor health workers to manage severely malnou-rished children successfully?

All reviewers answered this question in the affir-mative. One concluded the book “is an excellentsummary of optimal management under prevailingconditions”. Another stated “the manner in whichthe book is set out is helpful, and meets the need fora book more orientated to nurses and healthcareworkers than the WHO manual”. A third stated thatthe book “is far superior to any other options avai-lable and provides in clear language an approachwhich would improve the care of children in gene-ral and the care of severely malnourished childrenin particular”.

This book is available at a subsidised low price(£3.15 + postage) only from Teaching-aids At Lowcost (TALC), PO Box 49, St Albans, Herts. AL1 5TX,United Kingdom (info@talcuk.org). The book is alsoavailable on CD ROM which in addition includes acomprehensive guide for trainers 'Improving theManagement of Severe Malnutrition' and the TALCslide set 'Treatment of Severely MalnourishedChildren'. The combined cost of the book + CD is£4.50 + postage. The book is also available fromMacmillan country offices and through local books-hops. For contact details of local offices, please seewww.macmillan-africa.com/Contacts.

16

Over the past six months, ENN has been a party to debate regarding technical aspects of themanagement of severe malnutrition. We believe that transparency and information sharingleads to clarity not confusion, and so wish to share the following key areas of debate. Thisarticle was circulated pre- publication to those involved, who were invited to respond in theform of a letter for inclusion in the same issue of Field Exchange.

Caring for SeverelyMalnourishedChildren: Book Review

News & Views

In May 2003, a new publication, Caringfor severely malnourished children,Ashworth and Burgess, 2003 1 , met withsome technical criticism from Professor

Mike Golden in the form of a book critiquesubmitted to ENN, and circulated to thepublishers and supporting agencies (seeField Exchange 19, pp 19). In response, areview by independent experts was co-ordi-nated by TALC and the findings of thereview are summarised in this issue of FieldExchange 2. Through this process it emergedthat issues raised in the original book criti-que primarily concerned aspects of the 1999WHO guidelines on the management ofsevere malnutrition3 and consequently, sub-sequent publications which reflect theseguidelines, e.g. Ashworth/Burgess 2003.Drawing on a number of sources, we wereable to determine where there is some con-sensus over potential challenges to the 1999WHO guidelines and other derivativepublications. Largely based on the originalcritique, the following key areas of debatehave emerged.

Management of severe malnutritionin infants less than six months

The 1999 WHO guidelines do not specifi-cally extend to include malnourishedinfants under six months of age. Differencesin field approaches to managing malnouris-hed infants under six months have alreadybeen highlighted by the ENN - a recentstudy by ENN and GIFA (Geneva InfantFeeding Association) to support technicaltraining material on infant feeding in emer-gencies, concluded that an urgent consulta-tion by technical experts and field practio-ners was required to achieve consensus onthe management of severe malnutrition inyoung infants4.

In the ENN/GIFA study, the most signi-ficant areas of contention were the role ofbreastfeeding, and the choice of therapeuticfeed (if any) to use in managing young, mal-nourished infants.

The majority of guidelines/field proto-cols reviewed relied on breastfeeding (ifnecessary supported by supplementary suc-kling) to treat young infants. In contrast,WHO draft guidance available to the reviewadvised that breastfeeding could not berelied upon, and that the first priority is the-rapeutic feed to ensure infant survival. Thisposition is echoed in the recently published‘Caring for Severely MalnourishedChildren’ (Ashworth and Burgess, 2003).

The WHO draft guidance recommendgiving supplementary therapeutic milkbefore each breastfeed. This is contrary tothe supplemental suckling technique5 andexpert breastfeeding recommendations,where breastmilk is always offered first6 .

The WHO draft guidance recommend theuse of F75 during stablisation and fullstrength F100 during recovery of infantsunder six months. Argument against the useof full strength F100 in infants under sixmonths revolves around water balance andrenal function in young malnourishedinfants (see Field Exchange 19)7. Instead, thecritique considers diluted F100 the formulaof choice for young malnourished infants,while F75 and infant formula are consideredsafe to use but less pragmatic options. TheAshworth/Burgess publication recom-

mends using a “starter formula” which islikened to F75. However the starter formula-tion given is of higher osmolarity than stan-dard F75, which, it has been argued, mayprecipitate osmotic diarrhoea.

Management of severe oedemaThe Ashworth/Burgess publication

recommends energy intake of 75 kcal/kg/din the initial treatment of children withsevere oedema. The critique argues that, inpractice, the degree of oedema is overesti-mated by clinicians, particularly the inexpe-rienced, and nowhere warrants a reductionin intake from 100 to 75 kcal/kg/d.Overestimation of oedema will lead tounderfeeding, which may not necessarilycontribute to increased mortality, but delaysprogress and recovery. The critique alsoquestions the evidence base for prescribingreduced energy intake in severe oedemacases.

Diarrhoea and dehydration Management of diarrhoea and dehydra-

tion has been identified as one of the mostcontentious and difficult issues in the mana-gement of severe malnutrition. The 1999WHO guidelines recommend using 50 –100ml Resomal for each stool loss for chil-dren under 2 years, which, the critiqueargues, risks providing dangerous amountsof sodium and over re-hydration.

Blood transfusionsThe 1999 WHO guidelines state that very

severe anaemia can cause heart failure andspecifies that children with very severeanaemia need a blood transfusion. The criti-que argues that heart failure due to anaemia(where the peripheries are warm, the pulsefull and the heart overactive) is uncommonin the malnourished child. Other forms ofheart failure are common and lead to bre-athlessness with a weak, rapid pulse, whichoften coincide with anaemia. Further, heartfailure due to fluid overload is always asso-ciated with a fall in haemoglobin (so calleddilutional anaemia). These may mislead theinexperienced clinician. Giving a bloodtransfusion in these circumstances is hazar-dous, with evidence to suggest it shouldonly be considered in the first 24 hours oftreatment. Furthermore, fluid shifts andelectrolyte imbalance during treatment8,which occur more rapidly with modern the-rapeutic feeds, make children much morevulnerable to therapeutic errors – inappro-priately transfusing to correct a dilutionalfall in haemoglobin is, the critique warns,usually fatal.

AntibioticsThe 1999 WHO guidelines recommend the

use of cotrimoxazole as first line antibiotictreatment, where there are no signs of infec-tion or complications. The critique suggeststhat since nearly all severely malnourishedchildren have small bowel bacterial over-growth (SBO)9, oral amoxicillin is preferablesince (unlike cotrimoxazole) it is activeagainst SBO. This alleviates the need to usemetronidazole for SBO suppression, recom-mended in the Ashworth/Burgess publica-tion (2003).

The evidence baseWhile these issues are derived from field

experience and documentation not readily

Debate on the Management of SevereMalnutritionby Marie McGrath, Fiona O’Reilly and Jeremy Shoham (ENN).

Debate on the Management of Severe Malnutrition : A Response

accessible, they do represent current thinking,often controversial, in addressing severe malnutri-tion. Gaps in evidence are also partly due to thedifficulties of conducting operational research inemergencies. Certainly, individuals and agenciesshould bear some responsibility in sharing andwriting up their experiences and findings.However there is also a sectoral responsibility topromote and support this process, and a technicalresponsibility to consider this informal evidencebase when developing or updating guidelines.

Differing and convincing opinions on practiceexist between, and are recognised by, the expertsthemselves. Yet alternative approaches to mana-ging malnutrition can sometimes suggest conflic-ting opinions when, in reality, there are none. Forexample, the perspective of the clinician may pre-sent an entirely different viewpoint and set of prio-rities than the public health expert, more concer-ned with the population at large. However, con-flicts and errors can arise when approaches encro-ach on one another, without involving the “expertother”. Thus, simplifying complex clinical manage-ment, targeted at the majority of health workersbut without careful clinician input, risks sugges-ting that such treatment is easy to administer andmay be open to error. Equally, basing guidance-for-all on the management of the clinical complexitiesof individual cases, useful for specialist and expe-rienced practioners, risks alienating many of thoseworking in the field who need simple, practicaland pragmatic advice that will, on balance, domost good and least harm to the majority. There isroom for all approaches, but a collaborative effortand consultation is required to make this work.

The way forwardThe production of the 1999 WHO guidelines,

has, without doubt, improved morbidity and mor-tality and the care of the severely malnourished,which may be substantially attributed to standar-disation of care. Initiatives to improve the accessi-bility of standard guidance to those with fewresources and limited support are long overdueand welcomed.

Although published in 1999, the current WHOguidelines were first drafted in 1992 - many of theareas of contention stem from field practices andexperiences over the past 10 years. Given the ever-changing face and challenges of emergency nutri-tion, guidelines need to be managed as working,“living” documents. The technical issues summari-sed here suggest the need for a formal review ofthe evidence base of the 1999 WHO guidelines forthe management of severe malnutrition. Such areview process needs to include a mechanism toengage with field practioners, and should take intoaccount the largely informal evidence base that isguiding current field practice. Updating and revi-sion of guidelines takes time. Where there are iden-tified gaps in recommendations, interim guidance -generated through expert consultation, for exam-ple - could be considered. This, in turn, could betied in with the review process, e.g. valid for agiven period. The WHO, as lead technical agency,would be well placed to initiate this process.

For further information about this piece, or tocontribute views, opinions or data related to thisissue, contact fiona@ennonline.net ormarie@ennonline.net

17

1 Ashworth A and Burgess A, 2003. Caring for severely mal-nourished children. Published by Macmillan, supported byTeaching aids At Low Cost (TALC), funded by the US Agencyfor International Development (USAID) through the Food andNutrition Technical Project (FANTA) of the Academy forEducational Development (AED), 20032 News, Caring for severely malnourished children: bookreview, Field Exchange 20.3 Management of severe malnutrition: a manual for physiciansand other senior health workers. WHO, 19994 ENN/GIFA Project, summary of presentation, Field Exchange19, p285 Field Exchange 9, Infant feeding in a TFP, p7, Mary Corbett6 Infant Feeding in Emergencies, Module 1 for emergencyrelief staff. Draft material developed through collaboration of:WHO, UNICEF, LINKAGES, IBFAN, ENN and additional contri-butors. March 20017 Diet and renal function in malnutrition, Summary of presen-tation, Field Exchange 19, p248 Wharton BA, Howells GR, McCance RA. Cardiac failure inkwashiorkor, Lancet 1967; 2;384-3879 Unpublished data. Eva Lamm. Breath hydrogen excretion inchildren when malnourished and during recovery. MSc report,University of Uppsala, 1998

BackgroundMany individuals and organisations, inclu-ding NGOs, have contributed to the improvedtreatment of children with severe malnutrition,but case-management remains very poor inmost hospitals in developing countries andmany children die as a result. Children withsevere malnutrition are usually treated at dis-trict hospitals (i.e. at the first-referral level) butmedical and nursing students are usually trai-ned in tertiary hospitals and they may gothrough their entire training without havingmanaged a severely malnourished child orbeen taught best-practice. The WHO manual1

and the more recent WHO-IMCI guidelines2

aim to fill the knowledge gap about how tocare for severely malnourished children. TheAshworth & Burgess book3 follows the WHOguidelines and is part of this endeavour. It des-cribes in simple terms what to do and why,and is primarily for nurses, clinical officers andmedical assistants working in poorly-resour-ced hospitals. The WHO Training Course4 tea-ches practical skills as well as knowledge, andhospital teams from over 20 countries havebeen trained in the last two years. Some natio-nal training courses have been held and moreare planned.

Although the WHO manual and WHO-IMCI guidelines differ only slightly, the latterreflect an international consensus of opinion asto what constitutes ‘best practice’ for first-refe-rral hospitals. Ministries of Health are adop-ting the international guidelines, and medicaland nursing schools are being encouraged andenabled to include the guidelines in their curri-cula. Case fatality rates are beginning to fall,but it will need the combined efforts of manypeople to scale-up existing efforts.

Management of infants less than sixmonthsThere are two concerns regarding the severelymalnourished young infant: i) immediate wel-fare of the child (stabilisation with F75 andcatch-up, with continued breastfeeding) ii)long-term welfare of the child at home (espe-cially breastfeeding). Stabilisation of the childhas to have priority on admission to ensuresurvival and return of appetite and strength.Diluted F100 is discouraged for the stabilisa-tion phase because its potential renal soluteload and sodium and lactose contents are morethan twice those of F75. Thus F75 is more sui-ted metabolically for stabilising severely mal-nourished infants than diluted F100. In thecatch-up phase, diluted F100 may be prefera-ble to full-strength F100 for very young infants(<4m) but this has not been tested. A randomi-zed trial is being planned. In rapid growth,although F100 has a higher potential renalsolute load than diluted F100, solutes are chan-neled into new tissue and do not need to beexcreted by the kidney.

Although supplemental suckling has beenreported as successful, this is not always thecase. This technique requires considerable sup-port and supervision and when implementedas part of routine hospital care, the results arevariable. For example in Afghanistan, manyinfants had no weight gain for weeks with thistechnique. More data are needed before anyconclusion can be made about the role of sup-plemental suckling in the care of severely mal-nourished infants.

In the Ashworth & Burgess book, F75 iscalled 'starter formula' because experience sho-wed that a 'functional' name was more mea-ningful to indigenous health workers. Wefound mistakes were made when it was calledF75 as some health workers misinterpret F75 tomean 'give 75ml'.

Management of severe oedemaIn the stabilisation period, the target energyintake is 100kcal/kg body weight/day, and‘per kg body weight’ is referring to metaboli-cally-active tissue mass. The weight of seve-rely oedematous children does not reflect theirtrue tissue mass as their weight is elevated byoedema fluid. The WHO-IMCI WorkingGroup took a figure of 20% as being a reaso-nable estimate of the proportion of weight dueto oedema fluid in children with severeoedema (i.e. oedema of the feet, legs, hands,arms and face). So for severely oedematouschildren, the guidelines advise 100ml/kg/dayof F75 instead of 130ml/kg/day (roughly a20% reduction) which will lead to a dailyenergy intake of approximately 100kcal/kgoedema-free body weight/day. This achievesthe target intake without risking heart failurefrom sodium and fluid overload. It is not‘underfeeding’, as the intake /kg trueweight/day is met.

Diarrhoea and dehydrationChildren with profuse watery diarrhoea canbecome dehydrated if no action is taken toreplace the lost fluid. WHO suggests 50-100mlof ReSoMal as a guide after each watery stool.This is consistent with data from theInternational Centre for Diarrhoeal DiseaseResearch, Bangladesh, where the typical rangefor stool loss is 50-100ml/watery stool. TheCentre treats many hundreds of severely mal-nourished children with diarrhoea each yearand stool collections are made for every child.Most hospitals and TFCs have no provisionfor measuring stool losses and so replacementvolumes will always be a matter of judgementas stool losses vary, but a guide of 50-100ml isreasonable given the large body of evidencefrom Bangladesh.

Blood transfusionsThere is no divergence of views. Very severeanaemia may not be common but when itdoes occur action is required. The WHOmanual and guidelines define the circumstan-ces when a blood transfusion is needed anddescribe appropriate treatment. Repeat trans-fusions should not be given even if the hae-moglobin level stays low and this is stated inthe WHO-IMCI guidelines. The risk of heartfailure from fluid overload is stressed in theWHO manual and guidelines, and actions toavoid fluid overload are described.

AntibioticsThe choice of antibiotics for first-referral hos-pitals was guided by effectiveness, availabi-lity, and cost. The need for flexibility due tolocal patterns of pathogen resistance wasrecognised.

Way forwardIf there are robust new data that challenge thetreatment practices advocated by WHO thenthese should be placed in the public domainand reported in a manner that will allow scru-tiny and peer review. Divergent protocolscause confusion and distrust among healthworkers, and weaken the message. We shouldall speak with one voice. No new data havebeen published or presented to WHO thatchallenge the guidelines. There is, however, agrowing body of evidence to show their effec-tiveness.

By Professor Ann Ashworth, London School of Hygiene and Tropical Medicine

1 Management of severe malnutrition: a manual forphysicians and other senior health workers.WHO,1999.2 Management of the child with a serious infection orsevere malnutrition. Guidelines for care at the first-referral level in developing countries. WHO, 2000. 3 Caring for severely malnourished children. AshworthA, Burgess A. TALC, 2003.4 Training course on the management of severe malnu-trition. WHO, 2002.

News & Views

18

The political situation in the Gaza Strip has resulted in ahigh level of international media attention. The vulnera-bility of the Palestinian people is easy to see by walkingthrough the streets of the overpopulated Gaza Strip,

especially in the refugee camps. Population density is estimatedat 3,278 individuals per square kilometre, one of the highest inthe world. The 362 square kilometres of the Gaza Strip are inha-bited by 1,196,591 Palestinians, with one-quarter of the landoccupied by less than 5,000 Israeli settlers who began arriving in1967. The Israeli settlers consume the majority of undergroundwater, which is derived from the coastal aquifer. More than 66%of the Gaza Strip population are refugees who lost their home-land ‘Palestine’ when Israel was formed in 1948.

Poverty has drastically increased over recent years, whileIsraeli activities continue to undermine the already poorresource situation of the Palestinian National Authority (PNA).Poverty and poor access to employment have been most res-ponsible for an alarming deterioration in the nutrition andhealth status of Palestinians, affecting more than 65% of theGaza Strip population. Local, national and international organi-sations have implemented well-intentioned interventions inorder to address existing food and nutritional problems.However, the quality and relief focus of this work has, on occa-sion, drawn criticism, particularly with regard to sustainability.

Ard El Insan Palestinian Benevolent Association (AEI) is thePalestinian counterpart of the Swiss organisation Terre deshommes (Tdh). Many international organisations4 contribute toAEI to support its activities in advocacy, child and family healthand community nutrition. Recognising the interdependence ofnutrition with health and other sectors, AEI undertakes avariety of preventive and curative health care activities, as wellas work aimed at improving the nutrition and food situation ofthe Palestinian people, especially during stress periods.

Border Closures andNutrition in Gaza

By Dr. Adnan Al-Wahaid

Dr. Al-Wahaidi is a paediatri-cian based in the GazaStrip. Originally working forTerre des hommes since1987, he is now MedicalDirector of Programming forits Palestinian successor,Ard El-Insan. The continued support ofTerre des hommes, KarimRida Saed Foundation-UK,Medical Aid For Palestinians-UK, ECHO and the SwissGovernment is gratefullyacknowledged.

This article describes the nutritional and health consequences ofthe closure system in Gaza, as experienced by a paediatricianworking there.

Dear ENN,Further to your article on the technical debate regarding the

management of severe malnutrition, I wish to offer some contex-tual information to the development of the World HealthOrganisation (WHO) guidelines, and agency field protocols.

Initial guidelines for the treatment of malnutrition, written in the1970s in Jamaica, were published by the Pan American HealthOrganisation (PAHO) and subsequently by the World HealthOrganisation (WHO) in the 1980s. They were based upon practiceat the tropical medicine research unit (TMRU) in Jamaica, treatingsmall numbers of children (about 50 children a year). The resear-chers, clinicians and staff were all highly trained and had ampleaccess to sophisticated instruments, literature and funds. Theywere ‘overstaffed’ to facilitate research measurements, which allo-wed labour intensive individual treatment to be given. The guide-lines were not even implemented in the paediatric wards next tothe unit where they were written.

Non-governmental organisations (NGOs) and agencies usedthe practical guidelines published by Medecins sans Frontieres(MSF) - in most hospitals no generally accepted guidelines werebeing used. In the early 1990s, when I drafted the current WHOguidelines , I simplified them as much as I thought safe. The bigstep was to formulate the diets, instead of giving individual ingre-dients by weight of child. Nevertheless, the basis of the manage-ment was the experience of a research ward.

The draft guidelines were given to the NGOs in 1994. ActionContre le Faim (ACF) took these draft guidelines, wrote practicalprotocols based upon the principles and provisions, and persua-ded Nutriset to start to produce the diets commercially. Their pro-tocols have since been adopted by most NGOs. These NGOs havenow treated many hundreds of thousands of children using theguidelines and have amassed an enormous body of data, informa-tion and experience. For example, in Burundi from January 1999 toDecember 2001, 80,419 severely malnourished patients’ characte-ristics and outcomes were entered into the national database, coor-dinated and maintained by UNICEF. The main expertise in appl-ying the protocols and the effects of their variation now lies withthe NGOs. However, in most places the data are not systematicallycollected or analysed. Yvonne Grellety made a very detailed analy-sis of over 10,000 patients from 13 countries in Africa.Interestingly, she confirmed, en masse, the importance of the oldphysiological data showing the sensitivity of these children tosodium and their propensity to develop heart failure in severaldifferent situations and analyses.

The original draft guidelines have been treated as a ‘livingdocument’ that has gone through an evolutionary process – likecomputer software, we no longer use dos 3.1 (the operatingsystem used for the original draft). The analyses, together with fre-quent field evaluations, in many different contexts and countries,shows where the critical points in the protocols lie and where dif-ficulties of training, understanding, application and scale arise inpractice, particularly in resource limited situations or emergencies.This has resulted in a number of changes in both detail andemphasis. The modified protocols are greatly simplified. Theyare relatively easy to apply in the field by nurses and nurse-assis-tants. The results being obtained are, in some places, as good orbetter than those obtained in the research ward in Jamaica. It isrelatively easy to get good results from an adequately resourced,dedicated team in a research setting, it is quite a different matterto maintain good results in routine service. Nevertheless, at anational scale the results are a success story. The mortality rate(2000/2001) for Angola was 6% (3,976 deaths, 66,165 discharges)and 5% (3,552 deaths, 74,759 discharges) in Burundi. The currentdata for Ethiopia appear to have an even lower motality rate, withthe best centres reporting around 1% mortality.

The main changes are of emphasis. Some aspects we thoughtwere vital fifteen years ago are now known to be either minor orin some cases detrimental. Conversely, other aspects that were notemphasised were omitted, or compromises made in the originalguidelines are now seen to be critical. The aspect of emphasis andapproach is far from trivial. It determines where resources aredirected when they are limited.

The challenge is to find a mechanism for both translating thisvery extensive body of knowledge into internationally endorsedguidelines within a reasonable time span, and to create a proce-dure for regularly updating the guidelines so that they are not out-dated or used to produce derivative training material years later,when the State of the Art has moved on.

YoursProfessor Mike GoldenEmail: mike@pollgorm.net

Letters Field Article

19

they are deprived of adequate storage facili-ties for fresh foods. Resulting dependence ondry food rations and canned alternatives, inaddition to poor quality water, are direct cau-ses of micronutrient deficiencies like irondeficiency anaemia and rickets.

This tragic situation has dramatically affec-ted the nutritional and health status of thePalestinian people. Contributing factors tomalnutrition include poverty, poor infrastruc-ture, low levels of sanitation and high levelsof food insecurity. Vulnerable groups such aschildren and pregnant or lactating women arecompromised further as a result of inade-quate nutritional supplementation, leading tohigher risk of stillbirths, premature deliveriesand low birth weight babies. Chronic nutritio-nal deprivation is adversely affecting themajority of the Gaza Strip children and othervulnerable groups, ensuring a legacy of poorhealth status as well as impaired physical andmental development.

Nutritional status of Palestinian children The deterioration in nutritional status of

Palestinian children has become well recogni-sed at both national and international levels.Results of a nutrition survey carried out inAugust 2002 2 found 13.2% of children in theGaza Strip suffering from acute malnutrition.This compares unfavourably with surveyfigures from 1995, where only 5.7% of chil-dren under 5 years were acutely malnouris-hed (<-2SD of the reference weight forheight)3. More recently in March 2003, provi-sional findings from a study by AEI andAccion contra el Hambre (Madrid) indicateconsiderable food insecurity and economicvulnerability in the Gaza population4.

AEI activitiesThe main target groups of AEI are those

living in the most needy areas, those whoreside near the Israeli settlements, and areassubjected to military Israeli incursions.Alongside relief and medical care, commu-nity health programmes have been developedwhich include intensive breastfeeding coun-selling plus health and nutrition education.This approach aims to increase people’s capa-city to cope with the ever increasing nutritio-nal and health demands, while working clo-sely with the Ministry of Health and otherhealth providers to incorporate longer termnational nutrition strategies.

AEI have four operational centres in Gaza- one at Nusseirat middle camp, one inKhanyounis and Rafah, one in the south andone in the north (Jabalia camp of refugees).The community health team operate as twomobile groups, one in the north and anotherin the south, and comprises 24 communityhealth workers. These work in support of thecentre-based activities and outreach servicesinto more inaccessible areas.

Each operational centre comprises: • a medical and nutritional assessment unit • a growth monitoring unit (GMU) which

Food security in the Gaza StripPalestinians are well known for being gene-

rous. Their hospitality is, to some degree,measured by the variety of foods served totheir guests. However, nowadays, peoplepartly define their grinding poverty in termsof no longer being able to serve their guests adiverse meal. The population is now depen-dent on rations or food donations from out-side. The loss of self-sufficiency, and absenceof land that allows choice of food, creates astrong sense of indignity. These difficulties arecompounded by political and military actions,which can result in border closures and demo-lition of houses, crops and gardens.

Most people in the Gaza Strip buy theirfood from the market since they lack land forcultivation. Although there are many types offood in the market, supplies are irregular.Unemployment has reached catastrophiclevels in the Gaza Strip (more than 60%). Thishas translated into very limited purchasingpower for food. Dependency ratios haveincreased dramatically and in many families,food purchase is sacrificed for other urgentneeds such as treatment of diseases or payingback debts and loans. Other factors whichconstrain access to food include difficulties inimporting/exporting goods due to disruptedlogistics caused by Israeli activities, prolon-ged sieges, curfews, border closures, roadblockades and the direct impact of militaryoperations, incursions or raids.

The lack of capacity to cook food on a dailybasis is another big problem, often caused byinability to buy the gas or fuel, which is moreexpensive in the Gaza Strip and the West Bankthan in any of the surrounding countries.People are therefore forced to borrow the fuelor borrow cash for fuel purchase. There arealso numerous occasions when fuel or gascannot be imported into Gaza, or may noteven be allowed tobe conveyed fromone area to anotherinside the GazaStrip, simply bec-ause of border closu-res lasting fromhours up to severaldays. Electricity sup-plies are also proble-matic due to thepoor infrastructure,resulting from deca-des of ‘disabling’Israeli regulationsand the completedependency onIsrael. Poor house-holds cannot pay thebills and may lackrefrigerators. Hence

"AEI have four operational centres in Gaza, where they work closely with the Ministry of Health and other health providers toincorporate longer term national nutrition strategies"

Field Articleprovides follow-up of severely and modera-tely malnourished children, and nutritioneducation• a special care unit for specific nutritionaltreatment, such as nutritional anaemia, coeliacdisease, and rickets • a breastfeeding counselling unit, formothers who present with breastfeeding diffi-culties.

During 2002, 8,163 new cases were managedat the centres, of which 6,750 were undernou-rished and/or anaemic children. Overall, 40%of new cases (n=3265) were assessed at themedical and nutritional assessment unit, 589cases (7.2%) in the special care unit, 604 cases(7.4%) in the GMU and 16.4% (n=1344) in thebreastfeeding counselling unit. In the commu-nity, 3,116 undernourished children were trea-ted in the same period.

The unprecedented magnitude of thehealth/nutrition and socio-economic pro-blems currently seen in the Gaza Strip has ledto an expansion and strengthening of AEI ser-vices. New staff members have been recruitedand more activities have been directed to thedeprived areas and locations where life hasbecome extremely difficult due to Israeli mili-tary activities, e.g. Rafah, Beit-Hanoun, andareas close to the settlements. However, ourcapacity remains stretched, while a combina-tion of food insecurity and safety problemscontinues to pose enormous challenges to theMinistry of Health and non-governmentalorganisations (NGOs). Many of the challen-ges to food security and nutrition, includingthe role of the Israeli ‘occupation’, the safetyof Palestinians and the deteriorating foodnutritional situation, were raised in a UNmeeting ‘food as a human right’, attended byAEI and Palestinian NGOs in Gaza in July2003.

Concerns for the futureContinued and prolonged food deprivation

will clearly lead to further deterioration in thenutritional situation of Palestinian childrenand other at risk groups. This will in turn leadto higher morbidity, e.g. respiratory tractinfections, diarrhoeal diseases and intestinalparasites and resulting mortality. Unless stepsare taken to ameliorate the situation, this willhave significant and unacceptable nutritionand health implications for future generationsof Palestinians.

For further information, contact: AEI, email:aei-pal@hally.net or Mr. Khalil Marouf ,Tdh,e-mail: khalil.marouf@tdh.ch

1 Contributors to AEI include Medical Aid forPalestinians UK (MAPUK), Karim Rida SaidFoundation UK (KRSF), Terre des hommes,ECHO, NPA, IRFAN Canada and IBFAN 2 Nutrition survey, Johns Hopkins UniversitySchool of Public Health, Gaza, August 20023 Nutrition survey, Terre des hommes, 19954 Nutrition survey, Accion contra el Hambreand AEI, March 2003

Dr. A

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Dr. A

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MethodsTwo external consultants with back-

grounds in nutrition and health under-took the evaluation. Field work took placein Kabul, Herat and Kandahar whereinterviews were carried out with MSFHproject staff , personnel from INGOs, localNGOs, UN agencies, and MoPH staff. Theconsultants also attended a regionalworkshop in Ashgabad and a medical co-ordination day in Amsterdam. Phoneinterviews were conducted with staff inQuetta, Pakistan while a number of MSFHstaff no longer involved in the programmewere interviewed in London andAmsterdam.

20

Last year, MSFH Holland (MSFH)commissioned an evaluation of theiractivities in Afghanistan betweenMay 2000 and May 2002. The eva-luation set out to:

i) understand MSFH’s role inAfghanistan and how MSFH adaptednutritional and health programmesin a rapidly changing political andoperational context in the culturalsetting of Afghanistan

ii) examine how MSFH used itsproximity in the region to witnessviolations of humanitarian principlesand law and how MSFH positioneditself in its advocacy work.

This summary of the evaluation fin-dings concentrates of the first ofthese objectives.

Summary of Evaluation1

The last three years have witnesseda severe deterioration in the rela-tionship between Israel and thePalestinians in the Occupied

Territories. Civilians in both societiesbecame victims of appalling acts of vio-lence, betrayed by their leaders who areunable to courageously initiate an alterna-tive. While this is true, we believe thatIsrael, both because it is already a well-established and powerful state, andbecause it is the Occupying Power, bearsthe responsibility to initiate an end to thehostilities. It is also clear that as long asIsrael retains control of the OccupiedPalestinian Territories – it is responsible forthe well being of all people under its con-trol. Poverty is a direct result of the closu-res system and therefore Israel is accounta-ble for the impaired welfare of thePalestinian residents of the OccupiedTerritories. In our clinics in the West Bankwe encountered similar situations to thosedescribed by Dr. Adnan Al-Wahaidi. Wewere struck by the high level of bed wet-ting in the 7-12 year old age group. We alsoencountered cases of diarrhoea due to badwater, and problems in child developmentdue to malnutrition.

Physicians for Human Rights (PHR) -Israel was established in 1988 as a non-par-tisan, non-profit organisation. It bringstogether volunteer health workers andhuman rights activists who work againstabuses of human rights in general, andchampion the right to health in particular.Its members and staff attach deep signifi-cance to close cooperation with Palestiniancivil society, human rights activists andmedical organisations and workers. In ourmedical and human rights work we striveto construct, even if on a small scale, analternative to that of violence and hostility,thus showing that such an alternative ispossible.

PHR-Israel has been prevented fromentering the Gaza Strip for three yearsnow, refused by the Israeli security appa-ratus on the grounds of our staff's personalsafety. However, our experience in theWest Bank, where we have been conduc-ting mobile clinics every Saturday in coo-peration with various Palestinian healthNGOs for the past 14 years, shows that ouractivity is welcomed and appreciated.

Our work in the Gaza Strip is thereforeseverely restricted. We keep in close con-tact with human rights and health organi-sations, campaigning and advocating forthe freedom of movement of medical staffand patients both on an individual case-by-case basis, in emergency cases, and alsoon a collective basis regarding policies ofentry and exit. We also monitor the treat-ment of prisoners and detainees from Gazawho are held in Israel away from theirfamilies. We then disseminate the informa-tion to our public. Israel has now resumedfull control of the Occupied Territories,

1 The Mission Report 11-19 August, of Ms. CatherineBertini, UN Personal Humanitarian Envoy of theSecretary-General, states her appointment was inresponse to– among other things – "a request fromPrime Minister Sharon of Israel to the Secretary-General to assist in addressing humanitarian needsarising from the ongoing Israeli-PalestinianConflict…" (p. 1).2 World Bank, Twenty Seven Months – Intifada,Closures and Palestinian Economic Crisis, AnAssessment, May 2003, p. xi.3 see footnote 2, p. xiv.4 an essential condition or element5 see footnote 2, p. xvii.

Malnutrition on Political Grounds

Based in Israel, Hadas Ziv works forthe organisation Physicians forHuman Rights – Israel, and is ProjectDirector for the Occupied Territories.

Postscript

By Hadas Ziv

and exerts total authority over the every-day lives of Palestinian residents. At thesame time, the Israeli government prefersto contact foreign and international organi-sations and ask them to provide humanita-rian assistance to the Palestinian residentsof the Occupied Territories 1.

Israel's regime of severe restrictionsimposed on freedom of movement withinthe West Bank and Gaza Strip - as well asbetween the two, and between them andthe outside world - has severely affectedthe Palestinian economy, causing deterio-ration in their standard of living, nutritionand health. According to the World Bank"the second year of Intifada witnessed afurther steep decline in all Palestinian eco-nomic indicators. By the end of 2002, RealGross National Income (GNI) had shrunkby 38 percent from its 1999 level. Poverty– defined as those living for less thanUS$2.1 dollar per day – afflicts approxima-tely 60 percent of the population”2. Theeffects of these indicators on health are evi-dent: "the health status of the Palestinianpopulation has deteriorated measurably.Real per capita food consumption hasdropped by up to a quarter when compa-red to 1998 levels.”3 The effects are espe-cially visible on women and children withhigher levels of malnutrition and anaemia.The decline in economic activity leads to asteep fall in tax payment, which in turncauses a growing inability of thePalestinian Authority to supply basic ser-vices, let alone develop its infrastructure.Although invaluable to the lives ofPalestinians, international assistance isproblematic, since it addresses a situationto which the solution can only be political.

"The sine qua non 4 of economic stabilityand recovery is the lifting of closure in itsvarious forms, and in particular internalclosure. As long as Palestinian internal eco-nomic space remains as fragmented as it istoday, and as long as the economy remainssubject to extreme unpredictability andburdensome transaction costs, the revivalof domestic economic and Palestinian wel-fare will continue to decay”5.

As long as the occupation continues, theState of Israel's commitment to providesuch assistance is both a moral and legalconcern.

Evaluation

MSF Holland inAfghanistan

response capacity of other agencies.

MSFH placed too much confidence in rapidMUAC assessments which it saw as a viablealternative to weight for height surveys.Rapid MUAC assessments found alarmingrates of Global Acute Malnutrition (GAM)which were not the case where weight forheight surveys were undertaken. Similar pre-valences of GAM were not identified in a limi-ted number of surveys reviewed where bothindicators were measured. The correlationbetween weight for height measurements andMUAC requires further analysis in this settingbefore MUAC can be used with confidence inplace of weight/height to define prevalence ofmalnutrition. Trend analysis was also affectedby assessments carried out on changing popu-lations and using varying age and height cut-offs.

The high dependency on expatriate staffwith sometimes limited experience and shortcontracts, for project management led to lackof continuity of approach. The difficultiesexperienced by MSFH in human resourcemanagement were often related to inability tofill positions by expatriates. Yet MSFH's expe-rience has shown that management capacitycan be accessed locally.

At the time MSFH did not have policieswhich addressed some of the issues that arisein connection with working in the type of lon-ger-term health crisis that exists inAfghanistan. Such a context raises issues onproject management, how to work with,through or independently of local partnersand infrastructure, the degree of dependenceon expatriate staff, coherence of health strate-gies and methods of withdrawing from pro-grammes. Arguably, this absence of policy ledto a modus operandi that was not alwaysappropriate for the context.

Key recommendations The evaluation contained a number

of recommendations related to theabove findings. Key recommenda-tions that related specifically to nutri-tion and food security aspects of theprogramme were as follows;

• MSFH could further clarify itspolicy and strategy on implementa-tion of general food distributionsbased on an analysis of past expe-rience and the internal debate on thisissue that has taken place over thepast decade. This clarified policyshould set out options on what to doin circumstances where food insecu-rity is severe and undermining MSFHhealth programmes.

• MSFH could increase capacity tosupport epidemiological analysis inareas of operation as well as compe-tence in integrating food security,health status and nutritional statusanalysis.

• Unless the current consensus chan-ges (as evidenced by new research)MUAC assessments and surveysshould be treated with the appro-priate caution.

21

1 O’Reilly F., Shoham J. MSF Holland inAfghanistan Mission Evaluation: May 2000-May2002

MSFH implemented traditional emergencyfeeding programmes in a number of open set-tings partially to collect data which would beuseful in advocacy but also to prevent severemalnutrition. However, there was limitedevidence of ‘alarming’ levels of malnutritionand traditional feeding programmes werefound to be inappropriate to the cultural set-ting so that eventually these were either dis-continued or adapted (e.g. mobile SFP).

Thorough investigation of outcomes interms of malnutrition and mortality was notrigorously undertaken by MSFH. Howeverwhere other agencies managed to undertakethorough representative investigation morta-lity was found to be high and related to dise-ase while levels of malnutrition were lowerthan expected in the context of a food crisis.

There was a considerable need withinAfghanistan for credible information on howthe drought was impacting the health andnutrition of the population. As a healthagency with historical capacity in nutritionthe evaluators suggested that MSFH couldhave capitalised more on their comparativeadvantage in the health sector by analysingand highlighting the health component of thecrisis and by focussing their interventionsmore fully on the health sector, i.e. investingmore resources in further strengthening andexpanding health programmes and integra-ting nutrition components (where necessary)into these health programmes. Also MSFHwas well placed in the regional paediatricward to strengthen and support health infor-mation systems and analysis and strengthenlinks in referring clinics, however this was notdone. This may have been a better option thanfocussing on a sector (food aid) where MSFHwere dependent upon the commitment and

Limitations of the evaluationLimitations included lack of a central

repository for reports and information on theprogramme. Much information was lost ormisplaced during the evacuation. The highstaff turnover meant that most MSFH interna-tional staff connected to the programme overthe time period in question were no longer inAfghanistan at the time of the field visit norwere many key personnel from other INGOsand UN agencies present during the periodunder question.

FindingsWithin a context of the appalling health sta-

tus of women and children and poor accessto basic health facilities in Afghanistan, thefocus of MSFH’s operational activities wasaffected by ‘what the Taliban would allow’,security , a developing drought induced foodcrisis, lack of reliable information and howMSFH perceived its role (i.e. whether itshould focus on needs arising out of crisis,human rights monitoring, or health needs ofthe most vulnerable). Over the time period inquestion the focus changed from improvinghealth care access in rural areas to focusing onhealth needs in cities and eventually to safemotherhood in remote areas.

MSFH’s primary analysis of the impact ofthe drought was in keeping with many otheragencies, i.e. that there was a developing foodcrisis, which required emergency food andnutrition interventions. Although MSFH’sperception was that a General FoodDistribution (GFD) was the most appropriateresponse, staff were conflicted about whetherMSFH should take on an implementing role.Ultimately the decision was taken (based onmany factors and previous experience) thatMSFH would not ‘do’ GFDs. MSFH thereforefocused on advocating for improved GFDand later implemented Blanket FoodDistributions (BFDs) as stop gap measures.Although much of the advocacy work wasimportant, MSFH were largely unable toinfluence or affect the mobilisation of GFDsin areas where they were implementing BFDs.

Evaluation

Weighing supplementary rations, Mazlak IDP camp,Herat 2002

Kandahar, Afghanistan, 2002

Fiona O'Reilly

Fiona

O'R

eilly

22

Targeted FoodDistribution to Womenand Children in NorthernAfghanistan

By Regine Kopplow, Concern Worldwide

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

Concern Worldwide has been operational in northeastAfghanistan since 1998, following an intervention inresponse to the earthquakes that struck the northernpart of the country. With a landscape of high mountains

and narrow lush plains, north-eastern Afghanistan is an extre-mely remote area and access to many villages is only possible onfoot or by donkey/horse. Poverty is a major issue. Water for irri-gation is scarce, access to markets severely limited, and almostall the population are involved in subsistence agriculture.

Between 1999 and 2001, Concern assistance targeted ruralwater supply, health education, and shelter rehabilitation. In thesecond half of 2001, Concern began to assist and support IDP(internally displaced persons) settlements in Takhar provinceand extended its FFW (food for work) infrastructure projects toBaghlan province. By 2002, Concern began to adopt a longer-term strategy, reflected in the programming approach in Rustaqdistrict, an area with a population of 167,455 people. Here, themany villages surrounding the relatively large market town ofRustaq are hampered by poor land consisting mainly of rock for-mations, with little arable potential. In Rustaq district, commu-nity based organisations were established, through whichConcern began to address food security needs. The early FFWand FoodAC (food for asset creation) projects were replaced bycommunity based agricultural activities such as seed distribu-tions, seed banks and livestock vaccination, water projects toprovide safe drinking water and irrigation systems, as well asinfrastructure projects to construct roads, bridges and dams witha voluntary community component.

Nutrition and food securityFollowing three years of drought, a food security and nutri-

tional assessment by Concern in December 2001 showed alar-ming results. Although the sample size was small (100 house-holds in 7 villages), it indicated that there were pockets of greatneed that required immediate intervention to prevent death, dis-placement and destitution. Women seemed particularly affected.In the surveyed villages, 36.5% of the females measured, had aMUAC (mid-upper arm circumference) <215mm, indicatingchronic severe malnutrition, and a further 27% had a MUAC<230mm, suggesting a high risk of becoming malnourished. Incomparison, malnutrition rates (MUAC <125mm) for childrenaged 1 to 5 years were 10.1%. Meanwhile, the 2001 WFP VAM2

report suggested that 60% of the population in Rustaq districtwere drought affected and required food assistance until the endof June 2002.

In response, Concern intervened to assist and support mal-nourished vulnerable families in Rustaq district. Aiming to meetimmediate basic food needs, the project objectives 3 includedprovision of:• a balanced food basket for the malnourished to improve theirnutritional status before/over winter• fortified food (BP5) to malnourished children and severelymalnourished women to improve their nutritional statusbefore/over winter.

TargetingThe project operated in two main phases. Phase One (August

to December 2002) targeted 12 villages, while Phase Two(December 2002 to April 2003) targeted a further 16 villages. The28 targeted villages were located between 5 and 35km fromRustaq town. The average population was 122 households pervillage, of which 9% constituted vulnerable groups, e.g. elders,disabled, unaccompanied children, returnees or female-headedhouseholds. Overall, 24 of the 28 villages were wholly depen-dent on rain-fed agriculture.

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

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

Regine Kopplow is a senior nutrition advisorwith Concern, working in Afghanistan sinceApril 2002. Previous field experiencesinclude Namibia and Sierra Leone.

Field Article

One of the project villages, 300 families, 100% rain-fed agriculture onland 1700m above sea level, 15km away from the district capital with it’sbazaar and health facilities. Saqawa. September 2002

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MUAC screening WH pre-intervention9 WH post-intervention2127 306 2752.3% 2.0% 0.4%12.8% 13.1% 6.9%

15.1% (n=320) 15.1% (n=46) 7.3% (n=20)

nSevereModeratGlobal acute

Children 6-59 months and MUAC ≥124 mm

Table 2 Prevalence of acute malnutrition in children pre and post intervention

Classification

23

and drought, the recent earthquake, exhaustedcoping mechanisms and empty food stores, theaim was to supply 100% of calorie need(2100kcal/day/person).5 6 Monthly famil rationsconsisting of 45kg wheat, 45kg rice, 10kg driedbeans and 5kg vegetable oil, provided an indivi-dual daily intake of 2156 kcal, 60.5g protein and33.7g fat.

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

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

MUAC screening MUAC cut-off points were identified after a

thorough review of nutrition surveys conductedin Afghanistan by different agencies, and cross-checking during screenings at the start of theproject. MUAC, BMI and WH (% of the median)criteria used in screening and nutritional survei-llance, are outlined in table 1.

Village MUAC screening of women and chil-dren identified rates of malnutrition necessita-ting immediate intervention. From 2127 childrenscreened, 12.9% were moderately malnourishedand 2.3% severely malnourished (15.1% globalacute malnutrition). Malnutrition rates were notevenly distributed in children, most notably, • the prevalence of global acute malnutritionwas highest in children aged 12 to 23 months(37.2%) followed by children aged 24 to 35months (28.4%). • under 48 months of age, girls had higher ratesof global acute malnutrition than boys. • of those who were classified as severely mal-nourished (n=48), 39% comprised infants under1 year of age.

From a population of 2734 women screened,moderate malnutrition rates were particularlyhigh (39.6%). The overall prevalence of severemalnutrition was 1.0%. Women aged between 20to 29 years had the highest prevalence of bothmoderate (38%) and severe malnutrition (0.9%).Among malnourished women aged 20-29 years(MUAC £220mm), 17% were pregnant and41.5% breastfeeding. Meanwhile, half (50%) ofthose aged 15-19 years were pregnant (26.9%)and/or breastfeeding (23.1%).

Weight-for-height (WH) and body massindex (BMI)

Amongst children with a MUAC £124, the vastmajority (85%) had a WH ≥80%. Similarly, overhalf (64%) of the women classified as malnouris-hed using MUAC had a normal/overweightBMI (≥18.5). Using BMI, only 31% of womenregistered in the programme were classified asmoderately malnourished (BMI ≥16<18.5)8.Conversely, the proportion classified as severelymalnourished (BMI <16) increased. Comparedto women with a normal BMI (≥18.5 <25) andMUAC ≤220, the severely malnourished groupwere older (39y versus 34y), taller (1.55m versus1.52m) and had an average BMI of 14.98, andMUAC of 192mm (BMI 20.22, MUAC 209 in nor-mal BMI group).

Impact of monthly food rationAfter five months of food distribution, all

Phase One beneficiaries were reassessed usingBMI (women) or WH (children). Prevalence ofmoderate and severe acute malnutrition fell toacceptable levels amongst children (see table 2). However global acute malnutrition rates remai-ned unacceptably high for women (28%), whilesevere malnutrition rates halved but remained

elevated (2.4%), (see table 3). It should be notedthat the statistical significance of these findingswas not tested.

Impact of BP5 distributionBP5 biscuits were distributed to 207 children

and 37 women over a four week period. Allwomen and children receiving BP5 were weig-hed before, weekly during, and 6 weeks after theintervention. During the distribution, the nutri-tional status of both women and children impro-ved. However amongst children, nutritional sta-tus declined once supplementation ceased (seefigure 1 ). Since different entrance criteria wereused for the children in Phase One and Two, chil-dren entering Phase Two had a lower startingWH than those in Phase One. Children in PhaseTwo, with an average WH of 77.5%, showed avery rapid response to the 4 weeks of BP5 sup-plementation, reaching a higher WH than PhaseOne (starting WH 88.4%). However, six weeks

after the last BP5 ration, the Phase Two WH haddropped to 86.9%.

Since only women in Phase Two received theBP5 supplement, it was possible to compare theirimprovement in nutritional status betweenPhase One and Two. With BP5 supplementation,the mean body weight increased by an average2.7kg (36.6kg to 39.3kg) and the improvementswere maintained 6 weeks following cessation ofsupplementation (see figure 2). However, thesame gain was found in the group without BP5supplementation (36.1kg to 38.8kg). It should benoted that participation in the final weight moni-toring was only 50% for the non-BP5 supple-mented group.

Women’s nutritional vulnerabilityThe limited impact of the interventions on

women can, at least in part, be explained bythose longer-term factors underpinning nutritio-nal vulnerability of Afghan women. The cultural

Field Article

MUAC screening BMI pre-intervention10 BMI post-intervention2734 808 7491.0% 5.1% 2.4%39.6% 30.9% 25.6%

40.6% (n=1110) 36.0% (n=291) 28.0% (n=210)

Table 1 Classification of malnutrition by anthropometry

Classification

SevereModerate Global acute

Children 6-59 m Women ≥ 15 years

MUAC WHmm %

MUAC BMI mm %

<185 <16≥185 ≥220 ≥16<18.5

≥220 <18.5

<110 <70≥110≥124 ≥70<80

≥124 <80

Table 3 Prevalence of acute malnutrition in women pre and post intervention

Classification Women ≥15 years and MUAC ≥220 mm

Boy on a donkey in Saqawa village, the normal transport facility, Saqawa. September 2002

nSevereModerateGlobal acute

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9 MUAC prevalence rates refer to the total population, while weight-for-height figures refer to the sub-groupof the population with MUAC ≤124.10 BMI prevalence rates refer to the sub-group of the female population with a MUAC ≤ 220 and excludeswomen pregnant and/or lactating (infant under one year). See footnote 8.

Figure 2: Mean BMI of women under BP5 treatment (n=37)

16.4

16.2

16

15.8

15.6

15.4

15.2

15

14.8

14.6

before BP5 4 weeks 6 weeks afterafter BP5 last BP5

Figure 1: Mean weight-for-he ight ratio for children under BP5treatment (n=207)

95

90

85

80

75

70

phase 1 phase 2 phase 1+2

before BP5 after 4 weeks BP5 6 weeks after last BP5

24

1 Emergency Complementary Food Supplies To DroughtAffected Vulnerable Populations in Afghanistan, Ref:605/11285/CON 08 02, 17 April 2002-30 April 2003,Concern Worldwide2 World Food Programme/Vulnerability Analysis Mapping 3 The project had other key objectives and activities rela-ting to health and nutrition education, and hygiene whichare not included here but are detailed in the main report(see footnote 1)4 Body Mass Index (BMI) is calculated as weight (kg) divi-ded by height squared (metres)5 This meets Sphere standard on food aid requirements.6 In effect, this meant that the project provided a general,rather than complementary, food ration.7 Slightly different BMI cut-off points were used for severemalnutrition in women for surveillance (BMI<16) compa-red to BP5 distribution (BMI≤16). As various standardsexist, a cut-off point was accepted at the beginning of theproject, which was later revised as the project progressed.8 All pregnant women (12%) and those breastfeedinginfants under six months (7.8%) were excluded from thiscomparative analysis. Thus, 219 women (19.8%) of thetotal group (n=1110) were not included. Of the remaining891 eligible for measurement, 808 women were availableand BMI calculated. 11 The Cormic Index assesses the relative contribution ofthe trunk and legs to stature. It is calculated as the ratioof sitting height (SH) to standing height (H) SH/H andexpressed as a percentage. A means of standardising BMIusing Cormic Index has been proposed, for both males(BMI =0.78(SH/S)-18.43) and females (BMI=1.19(SH/H)– 40.34), and detailed in the RNIS supplement,Assessment of nutrition status in emergency affectedpopulations, Collins S, Duffield A, Myatt M, July 2000. Seeonline at http://www.validinternational.org/tbx/docs/ACF88.pdf

and social consumption patterns within the hou-sehold do not favour women in terms of dietaryquantity or quality. Culturally, it is less accepta-ble for women to move out of the confines of thevillage than men. Consequently, there are feweropportunities for women to improve the qualityof their diet, through purchasing or consumingvitamin/protein rich foods during visits to themarket, for example. Similarly, access to healthsystems is reduced by this restricted movement.There is also poorer access to health education ata time when there appears to be considerablyless transfer of inter-generational knowledge,especially in the rural areas. Finally, pregnancypatterns suggest insufficient time for nutritionalrecovery between births.

Conclusions, recommendations and les-sons learnt

A discrepancy was found between estimatedmalnutrition levels using different indicators.Amongst children, the vast majority who hadbeen classified as acutely malnourished usingMUAC, did not fulfil weight-for-height criteria.Only one-third of the women deemed modera-tely malnourished using MUAC, were classifiedas such using BMI criteria. On the contrary, theprevalence of severe malnutrition in women washigher using BMI criteria. Women, overall, appe-ared ‘unusually’ shorter than men. While wehave no clear explanation for these observations,contributing factors may include phenotype, aswell as chronic malnutrition and many earlypregnancies influencing female developmentand body stature. Also, the inclusion of adoles-

cents (10-19 years as defined by WHO) in ourcomparison, and the lack of standard BMI cut-off points for this group, may influence interpre-tation of population-based figures. Ultimately,these findings highlight that MUAC cut-offpoints for malnutrition need to be further revie-wed in Afghanistan. Further research may beneeded on the Cormic Index11 to obtain morereliable anthropometric reference data of Afghanadults.

BP5 is a compact energy rich food with easystoring, transporting, distribution and prepara-tion character. The acceptability is high.However in our intervention, the full weightgains were not sustained in children. Amongstwomen, weight gains were sustained althoughthese were similar to those who had not beensupplemented. Though interpretation of respon-ses amongst women is limited due to incompletedata, it would be valuable to investigate how,and the extent to which, the factors contributingto the long-term nutritional vulnerability ofAfghan women impacted the effectiveness ofBP5 distribution. The experience also illustratesthe need for clear education and training on therationale, use and constraints of BP5, for both thebeneficiary and the community.

In some of the targeted villages, Concern hasbeen implementing community-based interven-tions that are at risk of being undermined by freefood distributions. The use of high-energy BP5with a likely quick impact strengthens this ten-dency. Even when beneficiaries receive the

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

Our findings highlight that nutrition surveysin Afghanistan should include women. Focusingexclusively on children, and even pregnantwomen in the third trimester does not reflect theentire dimension of malnutrition in the country.Considering the prevalence of early and fre-quent pregnancy and the potential implicationsfor maternal and infant nutritional status,addressing the needs of Afghan women is all themore critical.

For further information, contact RegineKopplow at email: Regine.Kopplow@gmx.de, orafghanistan@concern.ie

mea

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88.490,6 90,7

77,5

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16.3 16.3

Girls in one of the project villages observing sceptically the screening process. Rustaq/north-eastAfghanistan. March 2003

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Philippe explained how Tdh is a child-focu-sed agency whose two main pillars of work are“operational and advocacy.” He outlined threemain sectors of Tdh work, which are maternaland child health (MCH) and nutrition, childrenin difficult circumstances, e.g. street kids, andchild rights, such as fighting against child traf-ficking. Rebecca explained how there arecurrently seven specialist advisors at HQ. As thenutrition advisor, she advises the desks, part-ners and delegations on request. She is only thesecond nutrition advisor in the organisation, thefirst one being appointed four years ago.

In the past, Tdh nutrition programmes weremainly selective feeding, e.g. supplementaryand therapeutic feeding. Nowadays, these acti-vities are often coupled with education andhealth interventions. According to Philippe,“there has been an evolution towards a moreintegrated and holistic approach, with greaterfocus on community based interventions overthe past five years. The idea is to listen to thecommunity more and not give out ready mademessages”. Rebecca explained how the empha-sis is now on greater integration of nutritionprogrammes into existing mother and childhealth programmes, so that improved treatmentof malnutrition becomes longer-term and sus-tainable. Rebecca also stressed that Tdh are notan organisation like Medecins sans Frontieres,who are able to rush into emergencies and hit

the ground running. Tdh lack thecapacity for this and only reallywork effectively where they havelong-term experience and local kno-wledge.

Philippe reasoned that as Tdh isa small NGO, it has to specialise inareas like improving inadequatematernal and child caring practicesor improving health services (at thedistrict level). It, therefore, has littlecapacity for food security work andwill team up with other agenciesthat have complementary abilities.Also, as a small agency, Tdh tend towork at health district rather thannational level. While the agencyalways attempts to integrate pro-grammes into local public healthsystems, this can be a problem inmore remote areas where healthsystems are not working well. Thetemptation is then to set up Tdh’s

mission deciding how to distribute moniesamongst the various NGOs.

Tdh now operates in 30 countries. In 2000,there were 43 country programmes, but this hasslowly been reduced as country situations haveimproved - Tdh moved out of Bosnia two yearsafter the war ended, for example. If Tdh moveinto a new country, they will usually phase outgradually from another programme.

Tdh was formed in 1960 following the ‘war ofdecolonisation’ in Algeria. This war had a pro-found effect in France and French speakingSwitzerland, raising awareness for many of theextensive problems in developing countries.Tdh continues to work in Algeria to this day,typifying how the agency tends to becomeinvolved in a country following an emergencyand then stay on to undertake longer-term deve-lopment work. This pattern has recurred incountries like Vietnam, Bangladesh (followingpartition), Ethiopia, Rwanda, and Kosovo.However, there is no institutional split withinTdh between emergencies and development. Infact, the very first emergency co-ordinator wasonly employed in 2003.

Tdh is a relatively small non-governmentalorganisation (NGO) - the budget in 2002 was amodest 22.7 million euro. Approximately 83% ofthe revenue comes from private donations andthe remainder from public funds,e.g. the Swiss government deve-lopment agency and decentralisedgovernment at canton and com-mune level. The cantons hold adevelopment budget, which a‘federation of NGOs’ allocate tomembers. Tdh have workinggroups in the 23 Swiss cantons –approximately 2,500 volunteers inall. The volunteers support Tdhthrough fund-raising and profilebuilding, e.g. events in shoppingcentres. Tdh is also a member ofthe Tdh alliance, which has tenmembers (the principal ones beingGermany, Switzerland and Italy).As Tdh funding sources arediverse, their funding base is rela-tively stable. For emergencies,most funds come from a centrali-sed body called ‘Swiss Solidarity’.This body generates fundsthrough the media, with a com-

25

Agency Profile

Interview by Jeremy Shoham

NameAddress

TelephoneFaxInternet SiteYear FormedSecretary GeneralOverseas Staff

HQ StaffAnnual Budget

Terre des hommes,Tdh En Budron C8, 1052

Le Mont sur Lausanne,Switzerland

+41 21 654 66 66+41 21 654 66 77

www.tdh.ch1960

Peter Brey24 expatriateand 800 local

9022.7 million euro

(expenditure in 2002)

Tdh feeding centre, Haiti. 1999

Tdh feeding centre, Haiti. 1999

F ield Exchange interviewed PhilippeBuchs, joint head of the Terre des hommes (Tdh)programmes department, and Rebecca Norton,headquarters (HQ) nutrition advisor based inLausanne, Switzerland. Philippe has worked forTdh for 20 years (most of his working life). Fiveyears of this has been spent in the field and theremainder at HQ. His background is in politicalscience. Rebecca has been a nutritionist at TdhHQ for almost three years.

26

The conflict between the governmentof MPLA (Popular Movement for theLiberation of Angola) and the ‘rebel’forces of UNITA (National Union for

the Total Independence of Angola) has beenongoing for more than 25 years. In February2002, the leader of UNITA was killed and aceasefire signed by the warring parties.Despite the cessation of hostilities, and thefact that humanitarian agencies have beenable to move more freely, access to particularareas continues to be a serious problem.

Medecins Sans Frontieres (MSF)-Spain hasbeen working in Angola since 1989, carryingout emergency and post-emergency inter-ventions. For months before the end of theconflict, MSF teams in Caala and Matala hadbeen receiving information on a locationcalled Chipindo, where, allegedly, the popu-lation had been confined with virtually nofreedom of movement and hardly any assis-tance being provided by the authorities, des-pite enormous need. Many of the inhabitantsof Chipindo had come from the north-eas-tern and eastern parts of the Huila province– areas formerly under the control of therebels. Chipindo, itself, had been underUNITA control for over 13 years until itcame under government control in March2001. The area lacked any infrastructure andwas effectively a military base. In order forthe military to have control over this displa-ced population, no one was allowed to leavewithout the express permission of high-ran-king military officials.

Suspected ThiamineDeficiency in AngolaBy Manuel Duce, Dr. Josep M. Escriba, Dr. Cristina Masuet, Dr.Paula Farias, Dr. Elena Fernandez and Dr. Olimpia de la Rosa

Dr. Paula Farias, Dr. Elena Fernandez and Dr. Olimpia de la Rosaare all medical doctors currently working in emergency situa-tions with MSF. The support of Pilar Perez Vico (documentalist),Simone Rocha (advocacy) and Dr. Gloria Bassets (director ofthe medical department), in the preparation of this article isacknowledged and appreciated

This article describes MSF-Spain’s field expe-rience in the detection and management of a sus-pected outbreak of beriberi in Angola.

Rapid assessmentAccess to Chipindo had been impossible for

humanitarian organisations since the resump-tion of the war at the end of 1998. Following the2002 ceasefire, an MSF team were able to con-duct a rapid assessment in Chipindo on April27th and 28th, 2002, although roads were inse-cure and difficult to travel and the airstrip wasmined.

The assessment team found between 14,000and 18,000 people, most of who had arrived inChipindo between May and September 2001.Using MUAC screening, the prevalence of glo-bal acute malnutrition was 30% and severeacute malnutrition was 15%, in children aged 6-59 months.

Later, in August 2002, MSF- Spain conducteda mortality survey using systematic sampling. Atotal of 449 families and 2,193 individuals wereincluded. Crude mortality rate (CMR) andunder five mortality rate (U5MR) were calcula-ted for the period 15th October 2001 (start ofrainy season) to August 2002:• CMR 4.7/10000/day (95% CI 4.1-5.3)• U5MR 15.2/10000/day (95% CI 12.5-18.0)

Most mortality occurred between October2001 and March 2002 (76.8%). Overall, malnu-trition was reported as the main cause of death(42.1% of all deaths). Malnutrition affected allage groups, particularly those under 15 yearsold (42.3% of all deaths occurred in this agegroup). This might be linked to the fact that thearea was affected by a measles epidemic inFebruary 2002.

Suspected cases of beriberiIn response to the initial assessment and with

Manuel Duce is currently theHQ nutritionist at MSF-Spain.Prior to this, he worked for11 years in the field, mainlyfor MSF in Africa, Asia, LatinAmerica and the Caribbean.

Josep M. Escribà is a medi-cal doctor, who currently isworking as the HQ epidemio-logist.

Cristina Masuet is a medicaldoctor, currently working asa volunteer with MSF in epi-demiology and nutrition.

own programme independently. Rebeccaidentified difficulties in holding onto goodstaff as a problem. Tdh are putting a lot ofeffort into training local nutrition and healthstaff but the good ones tend to be snapped upby the better paying agencies.

Two other ‘nutritional’ challenges arefaced by Tdh, according to Philippe. First, thesmall size of the agency with only one nutri-tionist (supported by a public health doctor)means that local teams have a lot of auto-nomy, but not always a lot of support fromHQ. As a result, Tdh try and work in net-works of other agencies in order to obtainsupport from elsewhere, when needed.Secondly, too little emphasis has been placedon the psychosocial components of malnutri-tion. The emotional and social environmentof families needs to be addressed much more.This is also very important in emergencies.Tdh are currently involved in operationalresearch in Nepal, which started in 2001, loo-king at psychosocial factors leading to mal-nutrition. The research is very much basedon listening to mothers and then providingappropriate counselling. Results from thestudy show how long it takes to provide thenecessary psychosocial support and traincommunity people in taking on this role. Thestudy report and a film of the study ’Downby the river – listening to mothers’ are nowavailable (see news section of this issue).

Rebecca went on to outline the followingnew developments and initiatives in thenutrition sphere:• Greater emphasis on integrating nutritionprogrammes within existing Mother andChild Heath programmes.• Providing more psychosocial support forfamilies with malnourished children.• Strengthening capacity to provide breas-tfeeding counselling - the first Tdh breastfee-ding counselling course will be held in Africathis year.• Collating and disseminating key lessonslearnt/best practice, and providing this inthe form of a knowledge managementsystem with software to field staff. It is hopedthat this will be available by the end of 2004.

When asked about the specific strengthsand uniqueness of Tdh, Philippe made anumber of points. Tdh are present when anemergency arises (as they work in emergencyprone countries) so they know the culture,region and people. Prior knowledge is criticalin the early stages of emergency response.They are a very ‘grass roots’ agency andknow their partners and their abilities well.Most of these partners are local NGOs, themajority of whom have been helped by Tdhto establish themselves as an NGO. By hel-ping the institutional development of partnerNGOs, this engenders a deep relationshipwith partners of shared culture and tradition.Tdh attempts to be flexible and not imposeready made solutions – field staff have adecentralised approach and Tdh will alwaysaim to add value to a project rather than justfund, i.e. they take part in project planning.

When asked to describe the ‘culture’ of hisagency, Philippe commented that, in manyregards, it was a ‘typical Swiss entity’- “theSwiss government has been politically stable,since 1959 and very much consensus driven.Tdh has no political affiliation and advocatesbased on what it sees in the field, rather thanideology or global theories. With some excep-tions - being openly against the recent war inIraq, for example - Tdh does not make politi-cal statements. It is an agency which basesprogrammes on field reality and trying tochange reality where necessary”. Rebecca’sresponse to the same question was that Tdhis a very people-oriented agency andnowhere is this better epitomised than in theexcellent way in which staff are treated.

Agency Profile Field Article

Male <15 y 17 3,970 4.28/1,000

=15 y 5 4,851 1.03/1,000

Female <15 y 15 4,130 3.63/1,000

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

100

90

80

70

60

50

40

30

20

10

00 5 10 15 20 25 30 35 40

100

90

80

70

60

50

40

30

20

10

00 5 10 15 20 25 30 35 40

Total 51 18,000 2.83/1,000

27

first cases of beriberi, no general food distribu-tion had been implemented in the area.

A total of 52 suspected cases of thiamine defi-ciency, with a mean age 21.3 years 3 (ranging 4months-82 years), were treated and observed.Those under 15 years of age proved most at risk,accounting for 61.6% (n=32) of all cases. Twelvecases were in children under five years of age,and 36.5% (n=19) in those over 15 years. Overall,there was no significant difference in incidencebetween males (42.3%, n=22) and females(57.7%, n=30). However, in those over 15 yearsold, females were almost three times more sus-ceptible to beriberi. As yet there is no proven

explanation for this difference. Based on the WHO classification, seven

patients (13.5%) showed dry or neuritic beriberi(decreased reflexes or touch, algesic (pain-rela-ted) and/or motor disorders) while nearly one-third (30.8%, n=16) demonstrated a wet or car-diac beriberi (heart failure or oedema). Twenty-eight patients (53.9%) demonstrated a mixedberiberi, and one four month old infant (1.9%) anaphonic beriberi. Half of the suspected cases(53.8%, n=28) had at least two or moresigns/symptoms that affected different organicsystems, and thirty-five patients showed neuro-logical signs. Table 2 includes an outline of the

Figure 2 Time (days) from start of thiaminetreatment to disappearance of oedema,heart failure and motor symptoms

improved access, on the 3rd of May 2002, MSFSpain opened a therapeutic feeding centre (TFC)and supplementary feeding centre (SFC) inChipindo. During the first days of operation, 384children under five years of age and 60 adoles-cents and adults were admitted to the TFC,while 668 children and 468 adolescents andadults were admitted to the SFC. As some of thepatients in the TFC had a combination of highoutput heart failure, leg oedema and polyneuro-pathy, beriberi was suspected and thiamine(vitamin B1) treatment was initiated.

Categorisation1 and treatment protocols forberiberi were based on WHO 2 recommendations(see box). Since laboratory facilities were notavailable, it was impossible to confirm defi-ciency of thiamine biochemically. Therefore, inorder to confirm the disease and the efficacy ofthe treatment, a monitoring form was developedto follow the progress of patients during thecourse of treatment. It is important to note thatas these protocols were initiated at the start of anemergency intervention, and given the conside-rable demands on staff and resources, the fin-dings of the study have limitations and shouldbe viewed with some caution.

Those affected by thiamine deficiency inChipindo had been eating an extremely limiteddiet. Patients reported that the first symptoms ofthiamine deficiency appeared after they hadbeen reduced to eating “batata dolce” (sweetpotato) with wild leaves as their main food fortwo months. With little potential for food pro-duction, most of this population were comple-tely dependant on food aid rations. However,donor response to the emergency was slow andgeneral food rations were implemented verylate. At the time that the field team detected the

Suspected cases of beriberi, TFCChipindo. May/June 2003

Field Article

Table 1 Beriberi attack rates for main demographic groups

Frequency of Total population** Attack ratesberiberi (n)*

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

Table 2 Clinical characteristics and recovery time of beriberi cases

Clinical Total affected Group recovery Median timecharacteristics to recovery

%* (n) %** (n) days (range)

Neurological Motor

Touch

Pain

Reflexes

65.4 (34)

23.1 (12)

17.3 (9)

5.8 (3)

79.4 (27)

100 (12)

33.3 (3)

33.3 (1)

6 (1-31)

3 (1-14)

15 (5-31)

4 (4-5)

Cardiac Oedemas

Heart failure

61.5 (32)

28.8 (15)

81.3 (26)

73.3 (11)

10.5 (1-38)

4 (1-21)

Other Loss of voice

Gastrointestinal

5.8 (3)

3.8 (2)

66.7 (2)

50.0 (1)

5 (3-5)

18 (5-31)

*Percentage of affected patients by overall sample** Recovery percentage of affected patients by groupForty-one patients (78.8%) were treated using prescribed thiamine dosages for treatment ofmoderate beriberi, and 11 patients (21.2%) were treated using dosages for severe beriberi(nine of whom demonstrated motor deficits and oedema).

Figure 1 Time (days) from start of thiaminetreatment to disappearance of beriberisymptoms

Rec

over

y Pr

obab

ility

Time (days)

Global Beriberi

Rec

over

y Pr

obab

ility

Time (days)

OedemaHeart FailureMotor Symptoms

Man

uel

Duce

Man

uel

Duce

Man

uel

Duce

28

clinical characteristics of this sample. Overall, median recovery time was 15 days (6 to 31 days).

Recovery rates and median time (days) for disappearance of speci-fic clinical symptoms (recovery) are shown in table 2. Our results,reflected in figures 1 and 2, are comparable with those reported inthe literature, i.e. heart failure is the first symptom that responds totreatment, followed by motor signs and oedema respectively.

Ten people died (19%) during the intervention. Seven deaths (3girls and 4 boys) were among those under 16 years of age. Of these,four cases had wet beriberi (3 boys and 1 girl) and three cases hadmixed beriberi (1 boy and 2 girls). In addition, three adult womendied, two with mixed beriberi and one with wet beriberi.

Conclusions and lessons learnedIt is usually assumed that beriberi only occurs amongst popula-

tions consuming rice as their main staple. Our experience showsthat this is not always the case. If untreated, thiamine deficiencyleads to death and in Chipindo, mortality rates were high even withtreatment. This may have been due to other complicating factors,such as measles, diarrhoeal disease, acute respiratory infections andmalaria commonly found in this population. Unfortunately, theseother factors were not assessed.

It was difficult to estimate the magnitude of the problem in thearea. Less than 1% of the population was suspected of having vita-min B1 deficiency (and treated). This constitutes a ‘mild’ publichealth problem as defined by WHO. However, as the symptoms ofmild thiamine deficiency are vague and can easily be attributed toother problems, the magnitude of the problem may actually havebeen greater.

As clinical manifestations of beriberi are easily confused withmany other diseases, beriberi can be diagnosed most successfully bycombining an assessment of the clinical symptoms with a dietaryhistory suggestive of a low thiamine intake. Moreover, this studyhas shown that evidence of vitamin B1 deficiency can be confirmedwith the disappearance of clinical signs under treatment. Other stu-dies have had similar results4. However it remains likely that some‘unidentifiable’ groups had sub-clinical deficiency diagnosis. It istherefore important to continue efforts to develop field-friendlymethods for the biochemical assessment of thiamine deficiency.

It is clear that when people depend entirely on emergency foodrations, they are prone to developing a wide range of micronutrientdeficiencies. These deficiencies are, in the main, both predictableand preventable. However, the international humanitarian commu-nity continues in failing to prevent the occurrence of outbreaks suchas we experienced in Angola. We, therefore, have to ask the ques-tion, what is it we need to do to prevent such outbreaks occurringin the future?

For further information, contact Manuel Duce at email:manuel_duce@barcelona.msf.org, or Josep Escriba at email:josepm_escriba@barcelona.msf.org

1 Up to eight clinical symdromes related to lack of vitamin B1 have been descri-bed. See Golden M. Diagnosing beriberi in emergencies, Field Exchange 182 WHO. Thiamine deficiency and its prevention and control in major emergencies.WHO/NHD, 19993 The age of one patient is unknown, hence n=51 for age-related data 4 Ahoua L, Etienne W. Epidemie de beri beri a la maison d’arret et de correctiond’Abidjan. Epicentre/Medecins Sans Frontieres, 2003

Field Article

A guide to thiamine deficiency and beriberiCase definitionBeriberi is a clinical syndrome that arises insidiously as a result of severe,prolonged deficiency of dietary thiamine. In the early stages, it is charac-terised by anorexia, malaise and weakness of the legs, frequently withparasthesia, there may be slight oedema and palpitations. The disordermay persist in the chronic state or may, at any time, progress to an acutecondition characterized by either cardiac involvement with oedema, orby peripheral neuropathy, or a combination of the two.

DiagnosisLaboratory facilities are required to assess thiamine status through bio-chemical assays (blood thiamine, urinary thiamine excretion, bloodpyruvate and lactate, transketolase activity).

Source of thiamine (vitamin B1)Thiamine is present in almost all plant and animal tissue although mostsources contain low concentrations of the vitamin. Body storage of thia-mine is minimal and it has a high turn over rate. Therefore a continuoussupply of the vitamin is needed.

The major causes of thiamine deficiency include:• Inadequate diet (when the diet consists mainly of white (milled)

cereals, including polished rice and starchy staple foods such tubers) • Inappropriate cooking methods• Consumption of food containing thiaminases or antithiamine factors

(e.g. fermented fish, tea leaves)• Poor absorption• Increased metabolic demand

Categories of beriberiIn adults, characteristics of wet and dry beriberi include:

Thiamine deficiency can also occur in infants. Three main types of infan-tile thiamine deficiency are classified:

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

Infantile thiamine deficiency: 25-50 mg of thiamine slowly administeredintravenously followed by a daily intramuscular dose of 10 mg for oneweek. This is followed by 3-5 mg of thiamine per day orally for at leastsix weeks

Critically ill adults: 50-100 mg thiamine administrated slowly intrave-nously, followed by 3-5 mg of thiamine per day orally for at least sixweeks.

Source: Thiamine deficiency and its prevention and control in majoremergencies WHO/NHD 999.13, WHO 1999

• swelling (oedema)• increased heart rate

(tachycardia)• lungs usually clear• enlarged heart related to• no cyanosiscongestive

heart failure

• pain• tingling, or loss of sensa

tion in hands and feet(peripheral neuropathy)

• muscle wasting with lossof function or paralysis ofthe lower extremities

• loss of ankle and kneereflexes.

Wet beriberi Dry beriberi

Cardiologic or pernicious form

Pseudo meningiticform

Aphonic form

• peak prevalencein 7-9 monthsold infant

• nystagmus (involuntary eyemovement)

• muscle twitching

• bulging fontanelle

• convulsions andunconsciousness

• peak prevalencein 4-6 month old infants

• initially hoarsecry until no sound is prodcedwhile crying

• restlessness,oedema, breathlessness and death

Chipindo town

• peak prevalence in breastfed babies of 1-3months of age

• colic, restlessness, anorexia,vomiting

• oedema, cyansisand breatlessnesswith signs of heartfailure leading todeath

Man

uel

Duce

People in AidCTC workshop

A three day workshop was held by CONCERNWorldwide and Valid International on theCommunity Therapeutic Care (CTC) approach toaddressing malnutrition in emergencies, inDublin, Ireland between 8th-10th of October.Bringing together interested agencies, key acade-mics and donors, the aim was to discuss and deve-lop strategies and policies to harmonise the futureimplementation of CTCs. The proceedings of thisworkshop will be prepared and disseminated by theENN.

29

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

Isabelle Sauguet(Nutriset),

Steve Collins(ValidInternational),

Anne Callanan (WFP)

Jeya Henry (Brookes Uni, Oxford), Bruce Cogill(FANTA)

Abdallah Eisa (SC Sudan), Arabella Duffield(ENN)

Carlos Navarro (ACF), Mary Corbett (DCI)

Clockwise from top:• Mike Golden (Ind), Tahmeed Ahmed (ICDR'B)

• Anne Callanan (WFP), Fiona O’ Reilly (ENN) • Anna Taylor (SC UK), Mark Manary

(University ofWashington)

• El Hadji Issakha Diop (University of Dakar),Salimate Wade (Universityof Dakar) Anne Nesbitt(Queen Elizabeth Hospital,Malawi)

• Paul Rees-Thomas (Concern), Chris Brasher (MSFFrance)

• Yvonne Grellety (Ind), Jeremy Shoham (ENN)

• Montse Saboya (MSF France), Sophie Baquet(MSF Belgium)

30

People in AidPSP course

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

Thirty-six people took part in the course

Group picture:36 participants of the PSP + permanent team

Permanent team: Isabelle Beauquesne, Johanne Sekkenes,Catherine Bachy, Gloria Puertas, Brigg Reilley

Sub-Group:Sophie Baquet, Joseph Leberer, Cecile Chapuis,Juncal Gonzalez, Janet Raymond and Johanne Sekkenes

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

Cec

il D

une

The Emergency Nutrition Network (ENN) grew outof a series of interagency meetings focusing on foodand nutritional aspects of emergencies. The mee-tings were hosted by UNHCR and attended by anumber of UN agencies, NGOs, donors and acade-mics. The Network is the result of a shared com-mitment to improve knowledge, stimulate learningand provide vital support and encouragement tofood and nutrition workers involved in emergencies.The ENN officially began operations in November1996 and has widespread support from UN agen-cies, NGOs, and donor governments. The networkaims to improve emergency food and nutrition pro-gramme effectiveness by:• providing a forum for the exchange of field level

experiences• strengthening humanitarian agency institutional

memory • keeping field staff up to date with current rese-

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

and nutrition sector which need more researchThe main output of the ENN is a quarterly newslet-ter, Field Exchange, which is devoted primarily topublishing field level articles and current researchand evaluation findings relevant to the emergencyfood and nutrition sector. The main target audience of the Newsletter are foodand nutrition workers involved in emergencies andthose researching this area. The reporting andexchange of field level experiences is central to ENNactivities.

The TeamFiona O’Reilly (Field Exchangeproduction editor) and JeremyShoham (Field Exchange technicaleditor) are both ENN directors

Marie McGrath is a qualified paediatric die-tician/nutritionist, working previously withMerlin and carrying out research with SCUK.

Deirdre Connell is currently the ENN parttime administrator.

Royal Danish Ministry of Foreign Affairs

GENEVA FOUNDATIONto protect health in war

Editorial teamDeirdre HandyMarie McGrathFiona O’ReillyJeremy ShohamD e s i g n Orna O’Reilly/BigCheeseDesign.comW e b s i t eKornelius ElstnerContributors for this issue

Thanks for thephotographs to:

On the coverMugina marketplace,Rwanda,Steve Townsend, Concern

The ENN is a company limited by guarantee and nothaving a share capital. Company registration number: 342426ENN directors:Fiona O’Reilly, Jeremy Shoham, Dr. Shane Allwright

supported by:

We would liketo draw your atten-tion to the fact thatthis is the last issueof Field Exchange inphase three of theENN. Sadly, thiscoincides with thedeparture of our

colleague, Fiona O’Reilly, who is retiringfrom the ENN as co-director. Fiona and Iestablished the ENN in Trinity College,Dublin at the end of 1996. As a resident ofDublin, it fell to Fiona to establish the officeand deal with all practicalities related torunning a publication as well as the otheractivities that the ENN have become increa-singly involved with over the years. Fionamanaged many of these tasks single-han-dedly and had to learn a huge variety ofskills ‘on the hoof’. These included desktoppublishing, financial accounting, companylegal affairs and staff management. Fionahas made many invaluable contributions tothe ENN. Most notable amongst these hasbeen the development of a unique presenta-tional style for Field Exchange, which is theenvy of many other publications. Fiona hasalso insisted on establishing procedures,which ensured that information in FieldExchange was corroborated and correctlyattributed. She effectively became the ‘politi-cal editor’ in that she ensured that poten-

Back Page

A personal word from the core group membersFiona has had a long-standing involvement

and commitment to the issue of infant andyoung child feeding. She brought to the groupher varied experience with emergency issues,was a source of energy and ideas and was pas-sionate about what she believed – sparks some-times flew before we reached an agreement! Butthis was tempered by a willingness to listen and

tially sensitive pieces were thoroughly verifiedand opportunities given for others to presenttheir views. The fact that we have never beeninvolved in litigation (so far) is largely due toFiona’s developed ‘political antennae’.

Fiona has also been enormously influential inthe area of infant feeding in emergencies, whereENN has been an active member of a core groupof agencies involved in developing trainingmaterial for field workers. Fiona’s ever practicaland pragmatic approach, and insight into fieldreality has greatly contributed to field-friendlyguidance. No doubt Fiona will remain engagedwith this work in the future, however her contri-bution so far is marked by some words from thecore group members below.

The ENN owes Fiona a considerable debt ofgratitude. We wish her every happiness and suc-cess in her future career.

Jeremy Shoham(editor)

Kornelius Elstnerhas been a centraland invaluablemember of the ENNteam over the pastfive years. Korneliushas been responsible

for the design and layout of FieldExchange as well as the design and main-tenance of the ENN website. ButKornelius's input did not stop there-aswell as sorting out all things to do withcomputers and IT, 'K's perfectionist ten-dencies and linguistic excellence meantthat he often found himself picking uperrors in Field Exchange content andcorrecting the editors grammar! Havingrecently completed his computer sciencedegree Kornelius is embarking on acareer in the IT business. We wish himevery success in the future.

From the Editor

Fiona O’Reilly

learn – to participate in the discussion,debate and challenge.

Ultimately, Fiona gets things done,does not beat about the bush and goesstraight to the point, no matter how cha-llenging, difficult or sensitive it may be. Abreath of fresh air, we look forward to hercontinued involvement – there is noescape!

31

Tamsin WilsonManuel Duce Dr. Josep M. EscribaDr. Cristina MasuetPaula FariasElena FernandezOlimpia de la RosaDr. Adnan Al-WahaidAnne-Laure GlaisnerBeatrice SimkinsHadas ZivProfessor Mike GoldenRegine KopplowProfessor Ann AshworthWFPVeronik ScherbaumFrank Daller

Jacqueline DeenVincent SimmonneauxEl Hadji Issakha DiopHien Lam DucSteve Townsend Chris Op ReisCecil DuneManuel DuceNutrisetVeronika ScherbaumDan CharlishTdhRegine KopplowTamsin WilsonChristian AidMalutrition MattersMichel GarenneKay SharpeCatherine Bachy