November 2001 Issue 14

Field ExchangeEmergency Nutrition Network

Food Security in AfghanistanNutrition Surveillance in SomaliaLong-term refugees in AlgeriaCommunity-base therapeutic care

Contents

Field Articles8 Taking the politics out of resource

allocation: the Kenya experience 12 Nutrition Surveillance in Somalia 19 AAH in Tajikistan: A flexible

response based on analysing thecauses of malnutrition

22 The danger of interpretinganthropometric data out of context

26 Older people, nutrition andemergencies in Ethiopia plus:

28 Post script 28 The dangers of rapid assessment

(reprint)

16 Photo diary• Afghanistan – June 2001

3 Research• Safe infant feeding remains a

challenge: the Balkans experience • Community care: addressing the

management of severemalnutrition

• Utilising the livelihoods approachin food security assessments

• Improved surveillance preventsexcess mortality: the Godeexperience

• Assessing the economic value offortified foods

• Infant Feeding: policies andguidelines

• Area sampling for rapid populationassessment

10 News• Children’s health in emergencies: a

practical approach (CHESS)• Programme Evaluations: where do

you start to learn?• ‘La malnutrition en situation de

crise’a new publication from ACF

• Afghanistan• New IFPRI report

14 Embracing cultures• Whose time is it anyway?

15 Evaluations• Fighting long-term nutritional

deprivation among the Sarahawirefugees

18 Agency Profile• ICRC

21 Letters

30 People in Aid

31 The Backpage

The recently dominant models for UNand NGO interventions in Afghanistanhave been food for work (FFW), food forasset creation (FoodAC), and food foreducation (FFE). FFW programmesconcentrate on projects that require largenumbers of unskilled labourers and lowlevels of capital input. This fits well withthe objective of delivering relief food,with large quantities of food beingdelivered at reasonable cost during aperiod of reduced demand for labour.Targeting may be assumed to bereasonably efficient, with wealthierhouseholds less likely to participate thanpoorer households. However, somevulnerable groups such as householdswith few or no adult male members,nomads, and minority ethnic groups maybe unable to benefit from suchprogrammes. The focus on deliveringfood, rather than on the quality or utilityof the work being done, has led to aconcentration on road building schemesrather than on smaller, community-basedprojects such as the construction ofschools, health posts, improved access topotable water, or the rehabilitation orextension of irrigation schemes.

FoodAC interventions are designed toaddress this problem and may be able toeffect physical improvement in theeducation and health infrastructure but itis unlikely that such improvements canbe fully exploited without continuedsupport. There is the additional problemof a lack of trained staff to work in newand existing schools and health-posts. Atpresent there is a local excess ofinternally displaced educated personssuch as engineers, teachers, and

university lecturers in the NorthernAlliance strongholds. These people couldbe trained to fill these posts as well as totrain other staff but little effort has beenmade to utilise this potentially valuableresource.

FFE has focused on distribution of relieffood and the limited social aim ofincreasing female access to educationusing an incentive ration. There is littledoubt that this has succeeded inincreasing the number of studentsattending school. Increased schoolattendance is not, however, synonymouswith improved access to education.Schools are overcrowded andunderstaffed. Pupil to teacher contacttime has been reduced as many schoolsimplement shift systems to accommodateincreased student numbers and mixed sexstudent cohorts. The FFE model pays thestudents’ families but neglects thepayment of teachers and ancillary staffwho, if complaints by local officials areto be believed, have abandoned theirposts to work in FFW programmes. FFE,therefore, has been superficially effectiveas a means of supporting education buthas, on closer inspection, degraded theperformance of an already impoverishedsystem. Concentration on food deliveryand a narrow definition of whatconstitutes education has led tointerventions such as community-basedliteracy and basic skills tuition beingneglected.

In addition to counter-productivitiesarising from an unimaginative pursuit ofnarrow objectives, there remain questionsabout the ability of the WFP managedsupply lines to meet the needs of existing

This issue of Field Exchange contains a guest editorial on Afghanistan byMark Myatt who worked in Badhakshan and Takhar provinces in North-east Afghanistan in the period leading up to the current conflict. With thehumanitarian crisis in Afghanistan unfolding day by day Mark has chosento focus on intervention needs when the military and security situation haseventually stabilised. If, as seems likely, there will then be need for a largescale aid programme along the lines of the recent Balkan intervention,Mark asserts that the judicious use of food aid could have a significant rolein achieving the wider aims of such an intervention. This will necessitatemodifying the types of food aid programme that have been implemented byhumanitarian agencies in the period leading up to the 11th of September.

Mark is also a co-author with Steve Collins and Gwenola Desplats of anarticle on the nutrition and food security situation in Badakshan Province,NE Afghanistan. Based on a survey carried out in August 2001 Mark et alshow how successive years of drought and increasingly drastic survivalstrategies have bought the population to a point of destitution andimminent famine. The authors caution that donors should not be misledinto thinking that everything is OK given low levels of malnutrition recordedat the time of the survey. These findings mirror those in an article byFitsum Assefa published in the previous Field Exchange which showedthat low levels of wasting recorded in April 2000 were masking an outbreakof scurvy and significant erosion of livelihoods in the southern part ofFaryab province in Afghanistan.

Other articles in Field Exchange 14 cover topics as diverse as the effortsof the Nairobi based Food Security Assessment Unit to strengthennutritional surveillance in Somalia and the work of AAH to bolster nutritionand food security in Tajikistan following civil war and the collapse of theSoviet system of agriculture. Enjoy! (Ed)

Food incentive interventions in post-conflict Afghanistan

By Mark Myatt

3

Research

Arecent article published in Disasters showshow the widespread failure of humanitarianagencies operating in the Balkan crisis to act

in accordance with international policies andrecommendations provides an example of the failureto translate infant feeding policies into practice. Thearticle explores the underlying reasons behind thiswhich included:

i) The weak institutionalisation of policies: Duringthe Kosovo crisis, many agencies with infant feedingpolicies and good practice guidelines did not applythem. Good practice was more dependent on thepresence of individuals with relevant knowledge,interest and experience in infant feeding than on thesystematic communication within the respectiveorganisations of a previously endorsed policy.

ii) The massive quantities of unsolicited donations ofinfant feeding products: A NATO representative inSkopje estimated that during the initial weeks of thecrisis, NATO in Macedonia received and transported3,500 metric tonnes of donated aid of which anestimated 40% was baby food.

iii) The absence of monitoring systems: Monitoringmechanisms were slow to become established duringthe Balkan crisis. The challenge of establishingeffective monitoring for the complex flow of donatedgoods was huge. Given the sheer volume ofdonations, agencies were ill-prepared to establishmonitoring systems that were effective.

iv) Inadequate co-ordination mechanisms: Theunprecedented number of NGOs, donors and bilateralagencies and the quantity of resources directed to thehumanitarian response in the Balkans createdenormous challenges for co-ordinating agencies.

v) The high cost of correcting mistakes: Latedeliveries of UHT (ultra high temperature) milkcontained in rations for refugees repatriating toKosovo meant that the milk was stored in WFPwarehouses in the last three months of 1999 and wasrecognised to be beyond its time limit and thereforeunsafe. However, no agency was willing to incur thecosts of destroying the milk (approximately$500,000). Also, re-labelling milk with appropriatehealth messages was considered too expensive bysome agencies.

Efforts to uphold best practice during the crisis arealso documented. The article identifies actions thatcould be undertaken in advance of, and during, futureemergencies to enhance the application of infantfeeding policies in emergencies. Proposed actionsinclude the following:

• Agencies should take responsibility for ensuringthat their own staff and partner agencies are awareof infant feeding policies and have the capacity toimplement them.

• At the onset of the emergency an appropriateagency must be designated and resourced to co-ordinate infant feeding practice and implementationpolicy.

• Mechanisms for preventing the influx of unsolicitedbilateral donations of inappropriate products needto be explored and established.

• Systematic and comprehensive monitoring systemswhich allow infant feeding products to be trackedthrough the distribution system need to beimplemented in the relevant UN agencies.

• Viable solutions for dealing with inappropriateproducts need to be agreed upon, explicitly statedand endorsed by the humanitarian community.Financial resources should be made available toagencies that recognise the importance ofimplementing good practice and are willing toinvest the time and effort to carry out activitiessuch as the re-labelling of branded infant formulatins for the very small number of infants whoactually require it.

For additional reading on Best practice and policies in InfantFeeding in Emergencies please refer to the Infant Feeding inEmergencies report and training modules, which are availableto download from the ENN website at http://www.ennonline.netor alternatively contact fiona@ennonline.net for furtherinformation.

1 Borrel.A, Taylor.A, McGrath. M, Seal.A, Hormann.E,Phelps.L, and Mason.F (2001): From Policy to Practice:Challenges in Infant Feeding in Emergencies During theBalkan Crisis. Disaster, Volume 25, No 2, June 2001, pp 149-163.

Safe infant feeding remains a challenge:the Balkans experienceSummary of published paper1

programmes. One international NGOhas already felt the need to establishalternative supply lines in order to meetthe requirements of their existingprogrammes.

Agricultural assessments made by theWFP and by NGOs indicate that rainfedagriculture has failed with yields so lowand of such poor quality that manyfarmers have already lost their seedstocks or will be unable to survive thewinter without consuming seed stock.Given the current security situation,already stretched and degraded supplylines, and the need to distribute foodbefore the onset of winter, it is unlikelythat sufficient seed will be distributed intime. This will lead to productionshortfalls in the 2002 harvest. Fooddeficit is, therefore, likely to continueuntil at least summer 2003. Thisprojected deficit means thatinterventions in which food is used asan incentive for participation willremain relevant until at least that time.

Post-conflict reconstruction will be avery different job from simplydelivering food. Careful attention mustbe paid to designing and implementinginterventions that are capable ofmeeting broader aims. FFW andFoodAC may be suitable vehicles todeliver infrastructure improvements butthey cannot address the problem of theongoing support required to makeeffective and sustained use of suchimprovements. UNOs and NGOs with ahumanitarian or emergency focus areshy of committing to long termexpenditure. One solution might be touse food incentive interventions toimplement programmes that may besustained with low levels of input, canbe financed and managed locally, anddo not rely on highly trained staff. Thiscould mean, for example, village healthposts staffed by community healthworkers delivering EPI, MCH, healthpromotion, and basic health care ratherthan district hospitals, or community-based literacy programmes run out ofprimary schools rather than secondaryschools.

The essential basis of any interventionthat uses food incentives is the ability todeliver food. Serious attention must bepaid to this. Supply lines should be builtso that they can compensate forcontingencies such as border closuresand security scares. A diversity ofsources and supply lines managed bymore than one large supplier may benecessary to achieve this.

Inappropriate donations targeted at infants- Kosovo crisis1999 © MARIE MCGRATH

4

Research

The long-held traditional approach to treatingseverely malnourished individuals inemergencies is challenged in a recent

‘viewpoint’ article published in the Lancet. Dr. SteveCollins argues that a therapeutic feeding (TF)centre’s huge requirement for resources, skilled staffand imported therapeutic products makes theoperation very expensive and highly dependent uponexternal support. Furthermore, the centralisedapproach to care with its high staff requirementsundermine local health infrastructure, dis-empowercommunities, and promote the congregation ofpeople and resulting centre-acquired infection. Inaddition, admission of a patient into a TF centrerequires that the carer, usually a mother, leaves thefamily for about 30 days. Absence of a mother wouldbe particularly damaging for younger siblings left athome.

Current practice and limitations

In Collin’s considerable experience over the past 10years, coverage of TF programmes is often lowthereby limiting their overall impact. In a recent tripto Ethiopia where out of a population of 400,000there were approximately 16,000 severelymalnourished children (20% severe wasting), itwould have been necessary to establish 40 TF centresbased on international standards of 100 per feedingcentre. This would have necessitated employing 40skilled centre managers, at least 20 logisticians, 160nurses and 400 carers. In the event, the TF centreprogramme took several months to becomeoperational and never reached this sort of scale.There was a similar picture elsewhere in Ethiopiawith coverage limiting impact of many agency TFprogrammes. By September 2000 many agencies hadfinally started programmes (2 months after the peakof the nutritional crisis). The article also points outthat SPHERE standards do not include indicators forprogramme coverage nor indicators to assess thenegative impacts on health infrastructure andcommunities. Collins advocates Community BasedTherapeutic Care (CBTC) as an alternative.

The components of CBTC

CBTC aims to treat the majority of people withsevere acute malnutrition in their homes. This type ofcare combines the management of malnourishedchildren using outreach workers and the ‘Hearth’method of home-based nutrition education andsupport. The author asserts that the Hearth methodhas been very successful in rehabilitating childrenwith chronic malnutrition in several less developedcountries. The approach uses mothers from thecommunity who are selected on the basis of theirability to raise well-nourished children even in theface of poverty. CBTC would combine these twofeatures and in addition utilise the newly developedReady to Use Therapeutic Food (RUTF), speciallydesigned to treat severe malnutrition in thecommunity. RUTF is nutritionally equivalent to F100but is a paste that patients can eat directly from thepacket. Trials have shown RUTF to be popular andhighly resistant to contamination. It is prepared frompeanuts, dried skimmed milk, sugar and a speciallyformulated mineral and vitamin premix (CMV). Allthe ingredients apart from the CMV are available inthe vast majority of less developed countries.

Phasing in CBTC

The article states that during the first few weeks of anemergency, there is usually little choice but to try tomanage the severely malnourished in the community.Once therapeutic feeding centres become operational,CBTC would then become appropriate for patients inthe rehabilitation phase of treatment. This normallylasts from day 7 until discharge and includes about75% of patients. During rehabilitation a patient’smetabolism has stabilised, appetite has returned andany infections are under control. Treating thestabilised cases through CBTC would greatly reduceneed for TF centres allowing them to be smaller andtherefore quicker to establish.

Experience in Ethiopia shows that a form of CBTCcentre can evolve from dry Supplementary FeedingProgrammes (SFPs) and can then be set up within amatter of days. Currently, in the early stages of an

emergency before TF centres are established peopleidentified as severely malnourished at SFPs will begiven a dry supplementary ration and single dose ofVitamin A, the minimum for clinical management ofa moderately malnourished individual. In Ethiopia itwas relatively easy to provide additional nutritionalsupport, education and systematic medical treatmentto the severely malnourished right from the outset.The severely malnourished were identified by a redwrist band and given a ration of RUTF in addition tothe usual ration for supplementary feeding.Increasing the numbers of staff allowed sufficientcapacity to provide soap and additional medication,e.g. a single dose of mebendazole and measlesvaccination for children. In a full CBTC facility(intensive first phase with community care forrehabilitation phases) they could also be given asingle dose of long acting antibiotic such aschloramphenicol in oil.

Role of the carer

Although not fully explored in an emergency,transition from the ‘intensive SFP’ piloted in Ethiopiainto full CBTC would require identification of‘successful’ mothers, around whom a structuredcommunity treatment and education programmecould be constructed. The mothers of those childrenwho respond well i.e. ‘successful mothers’ could beused as a focus to promote behavioural change inother carers. As in the Hearth method, programmestaff could work with these successful mothers toestablish a simple treatment plan based on thebehaviours that the mothers have already usedsuccessfully. These mothers could then educate othermothers at daily meetings. Initially RUTF wouldhave to be imported but eventually could be madelocally.

Using local clinics and health posts

Ideally, CBTC could operate alongside a therapeuticfeeding centre to which complicated cases couldbriefly be admitted for initial rehydration, antibioticsand to re-establish appetite. Initial experience in

Community care:addressing themanagement ofsevere malnutritionSummary of published paper1

Bedessa TFC, Ethiopia (May 2000)

©P

IET

ER

NE

LLA

PIE

TE

RS

E,

CO

NC

ER

N

5

Research

Ethiopia suggests that with appropriate support, localclinics and health posts can provide this function.Small decentralised stabilisation centres, based inlocal health posts, would reduce the transportproblems associated with centralised feeding centresand help to ‘embed’ the programme within localcommunities. This intervention would also helpensure that some of the emergency funding went intosupporting existing health infrastructure.

Mortality rates

Collins acknowledges the reality that given the usualdelays before implementation and consistent lowcoverage of current TF centres, it is likely that CBTCwill often operate without associated feeding centres.When such centres are not available, people whorequire TF care will be treated through CBTC andwill be exposed to a higher risk of mortality than iftreated in a TF centre. Currently, due to limitedcoverage and people’s inability to access centralisedTF centres the majority of severely malnourishedtend to die in their homes and are not recorded instatistics, at best only appearing as defaulters fromSFPs. Therefore when emergency CBTC is operatingin the absence of ‘stabilisation centres’, reportingstatistics may indicate higher mortality rates than isnormally reported in therapeutic feedingprogrammes, particularly at the initial stages of anemergency.

Research needs

A final point made in the article is that rigorousresearch to compare the impact of CBTC and TFcentre programmes should accompany theintroduction of emergency CBTC programmes andinitially it will be necessary to start with small pilotprogrammes.

For further information contact Dr. Steve Collins at email:steve@validinternational.org

1 Collins.S (2001): Changing the way we address severemalnutrition during famines: The Lancet, Vol 358, August11th, pp 498-501.

The latest Humanitarian Practice Network(HPN) paper produced by ODI describesthe theory and practice of Oxfam GB’s

livelihoods approach to assessing food security inemergencies. This involves assessing the longer-term risks to livelihoods as well as short-termnutritional or life threatening risks.

The first part of the paper describes key conceptsin food security theory in relation to a livelihoodsapproach. The second part of the paper describeshow Oxfam assesses food security.

The authors explain how the types of interventionindicated by the assessment findings may bedetermined by considering two perspectives offood security; first by assessing whether peopleare able to meet their immediate food needs (riskto lives) and secondly by considering thevulnerability and risks faced by differentlivelihood groups and their coping strategies (riskto livelihoods). Interventions are accordinglyidentified, ranging from free food assistance to awide array of livelihood support initiatives, suchas cash-for-work and de-stocking.

The third part of the paper uses case-studies toillustrate how Oxfam has applied its livelihoodsapproach in practice, and how that approach hasbeen adapted depending on the types oflivelihood in question, and the nature of theexternal shock. The case-studies comprise anemergency assessment of the impact of cycloneand floods in Orissa in 1999, a monitoring visitfor Oxfam’s response to drought in Wajir(Kenya) in 2000 and a review of Oxfam’sprogramme for conflict displaced people inUraba (Columbia) in 1999. Food aidpredominated in the largest responses and in theacute phase of emergencies. For smaller scaleresponses or in the less acute phases otherinterventions predominated, e.g. cash for workand agricultural support in Orissa andagricultural and fishing support in Columbia inthe second year of displacement. The relativelysmall scale on which this was done in these casestudies made it feasible to implementmanagement-intensive programmes to promotefood security.

The paper explains how the approach operates ata conceptual level and does not constitute amethodology nor is it unique to Oxfam. Asassessments need to incorporate an analysis ofthe food security of different livelihood groupsand the risks they face, this often means doing amore in-depth assessment than would be the caseif lives alone were in question. Analysis of foodsecurity of different livelihood groups will leadto the identification of different interventions foreach group.

The paper concludes by highlighting keychallenges posed by a livelihoods approach.These include:

i) deciding on the right quantities of food aidand choosing which categories of people totarget. Taking a livelihoods approach toemergency food distributions involves alarger quantity of food aid than when the aimis only to meet immediate food needs. Targetgroups tend to be larger as they includepeople who still have assets. The Wajir casestudy showed that taking a livelihoodsapproach involved targeting almost the entirepopulation. Current nutritional guidelinesonly cover rations for people who have beencut off from their normal food supply and donot offer advice on food aid designed forlivelihood support.

ii) how to combine food and non-foodinterventions effectively, and when to shiftfrom a food to a non-food approach. A largerquestion has to do with when to stopdistributing aid. In the Wajir example, aquestion arose over whether aid should onlystop when herds had recovered to pre-emergency sizes. In some areas decisions tophase out distribution were difficult given thetenuous livelihoods of different groups. Theauthors conclude that further work is neededon this question.

iii) issues to do with neutrality and impartiality,particularly, but not exclusively in complexpolitical emergencies. In conflict situationsespecially, livelihood support may be seen asimpartial. This may also apply to stablesituations. As this support is provided tothose with assets these are not the poorest ormost malnourished or destitute. This may nottherefore accord with principles of aidprovision developed by the West.

One final conclusion from the authors is that alivelihoods approach explicitly acknowledges lifebefore and after the emergency. Rather thanwaiting for an emergency response to evolve intorehabilitation and then preparedness activities,this approach encourages a more searching anddetailed analysis of the impact of food insecurityon peoples lives. Experience has shown that thishas thereby generated response options more inkeeping with the diversity of local needs andoperational scenarios.

1 Young.H, Jaspars.S, Brown, R, Frize. J and Khogali.H(2001): Food Security Assessments in Emergencies: Alivelihoods Approach. Humanitarian Practice NetworkPaper No 36, ODI June 2001

Utilising the livelihoodsapproach in food securityassessmentsA review1

6

Research

In some communities an affordable nutritionallyadequate diet based on local foods may bedifficult to achieve without the introduction of a

low-cost fortified-food supplement. In emergenciesthe addition of a fortified food supplement may berequired to ensure nutritional adequacy of theemergency food aid basket. However, even if the costof food fortification is low, its implementationrequires a strong commitment from localgovernments, food industries and donor agencieswho do not always perceive the benefits of thisapproach. In part, this is because the benefits of foodfortification are not easily quantified in economicterms.

A recent study attempts to show how a mathematicalanalysis known as ‘linear programming’ (LP) ispotentially a powerful tool for identifying a least costnutritionally adequate diet.2 Specifically, LP can beused to work out the cheapest way to introduce afortified food supplement that provides anutritionally adequate diet. The ‘tool’ can alsoprovide an estimate of the expenses saved byfamilies in relation to the sums spent by the donorafter the distribution of a food supplement.

The study, which was based on a food price survey inChad, compared the economic value of two foodsupplements in rural Chad - a traditional blendedflour (maize and cowpea flour, with sugar fortifiedwith a standard mineral and vitamin mix) and anutrient dense spread. The fortification level of thisspread was based on a pilot supplementationprogramme study in Algeria. It was assumed thatthese foods were distributed freely, i.e. as food aid.The resultant savings for a family in providing anutritionally adequate diet for each child wascalculated. The savings were slightly higher for theblended flour. In contrast, the ratio between the

Assessing theeconomic value offortified foodsSummary of published paper1

Improvedsurveillanceprevents excessmortality: theGode experienceSummary of published paper1

Astudy on the epidemiology of the famine inGode district of Ethiopia has just beenpublished. The primary objectives of the

study (which was carried out by SCF USA withsupport from UNICEF and the Centre for DiseaseControl and Prevention) were to estimate mortalityrates, determine the major causes of death andestimate the prevalence of malnutrition amongchildren and adults for the population of Godedistrict. A two-stage cluster survey involving 595households (4032 people) was conducted from July27th to August 1st which included anthropometricmeasurements and 8-month retrospective mortalitydata collection.

The operational scenario

During 1999 data from Early Warning Systems(EWS) in many regions of Ethiopia indicated thatboth food security and the nutritional situation weredeteriorating rapidly. WFP estimated that 10 million

people needed food assistance. The Somali regionwith its largely agro-pastoral and pastoralcommunities had lost a large proportion of theirlivestock due to drought and was the worst affectedarea. In addition, in early 2000, measles cases beganto be reported. It was not until April 2000 however,when media attention began to focus on the town ofGode, that a large scale international humanitarianresponse was triggered. Interventions included foodaid and selective feeding programmes and resulted inpopulations becoming concentrated around majorsites of humanitarian services. In May 2000 someUN agencies reported that the situation, althoughserious, was not a famine and that mortality wasunder control. Later, the WFP claimed that awidespread famine was averted by the rapidhumanitarian response. However, up until the SCFUSA/UNICEF/CDC study there was no data tosupport or refute this statement.

amount saved by the families and the amount spentby the donors is higher for nutrient dense spread thanblended flour because of the higher cost of blendedflour. Each dollar spent by the donor on nutrientdense spread saved US$7.07 for the families, ascompared with US$4.15 for blended flour. In otherwords the nutrient dense spread is more cost-effectivethan the traditional blended flour. These results werenot easily predictable when the costs were comparedin isolation, i.e. prices per kilogram and per quantityof energy contained in each food type.

It was noted that the method should be further refinedby taking into account costs not included in thisexample, such as the cost of targeting fooddistributions, of administrative overheads or oftraining food aid staff. The article concludes that the

method has wide application for evaluating theeconomic benefits of different types of nutrition-intervention programmes including supplementation,fortification and agriculture programmes.

1 Briend.A, Ferguson.E and Darmon.N (2001): Local foodPrice Analysis by Linear Programming: A New Approach toAssess the Economic Value of Fortified Food Supplements:Food and Nutrition Bulletin, vol 22, no 2, pp 184-189

2 Linear programming is a technique that minimises a linearfunction of a set of variables while respecting multiple linearconstraints on these variable. It can therefore be used tominimise the price of a diet while fulfilling constraintsintroduced to ensure a palatable and nutritionally adequatediet based upon Recommended Daily Allowances fordifferent nutrients. The Excel 97 spreadsheet has a LPfunction in all its recent versions. The function is found in the“tools” menu.

CSB distribution in Ethiopia

©P

IET

ER

NE

LLA

PIE

TE

RS

E,

CO

NC

ER

N

Findings of the Study

From December 1999 to July 2000, the CMR inGode was approximately 6 times higher than the pre-famine baseline and 3 times higher than the acceptedcut-off for the definition of the acute phase of acomplex emergency (0.5/10,000/day). Given otherreports it is probable that this reflected the situationin other districts within the zone. Wasting alone or incombination with four major communicable diseases(i.e. measles, diarrhoea, malaria and respiratory tractinfection) was the most common cause of mortalityin Gode district. More than half the deaths were inchildren younger than 5 years.

However, a relatively large proportion of deathsoccurred among children aged 5-14 years whosebaseline mortality rates would be expected to be farlower. These results underscored the importance ofconsidering relative increases in age-specificmortality as well as absolute mortality.

Mortality rates were highest in December 1999 andJanuary 2000 coinciding with the highest rates forfamine related displacement. Both displacement andmortality rates decreased until reaching a low in April2000. After interventions began in Gode (from Aprilto May 2000), more people moved to interventionsites such as Gode town. Communicable diseasescontributed to a significantly higher proportion ofdeaths in the period after major interventions began,suggesting that the population concentration and poorhygiene and sanitation conditions at intervention sitesmay have contributed to disease transmission.

Mortality rates for children under 5 years had beenhigh early on so that prevalence rates for severewasting among children in July 2000 were likely tobe subject to survival bias and thus underestimated.Under such circumstances, the assessment of adultnutritional status may contribute to a betterunderstanding of community nutritional status.

The overall prevalence rates for undernutritionamong adults aged 18-59 years using unadjustedBMI was 1.5-2 times higher than for wasting amongchildren aged 6 months to 5 years (49.3% for adultsusing a BMI cut-off of 18.5 kg/m2 and 29.1% forchildren aged 6-59 months using weight for height<–2 Z scores). If these rates were valid then higherdeath rates amongst adults would have beenexpected. This suggests that the adjusted BMIs (usingthe Cormic Index) calculated in the study provided amore plausible estimate of adult undernutrition(22.7%).

Older persons were frequently left alone during thefamine in Gode as younger adults left home to searchfor suitable pasture or for food aid. The study showeda high prevalence of undernutrition among olderpersons and may partially account for the relatively

large proportion of deaths among this group. Usingadjusted BMIs and a cut off point of 18.5 Kg/m2 anestimated 13% of men and 30% of womenrespectively were undernourished.

Study limitations

There were a number of methodological limitationswith the study. These included:

• households in which all members had died couldnot be included in the study;

• as there was no functioning surveillance systemthere was reliance on verbal reports on morbidity,cause of death and vaccination status of children.

Recommendations:

Most deaths were associated with wasting and majorcommunicable diseases and occurred before thehumanitarian intervention began. The response byhumanitarian partners was delayed and inadequate,consisting primarily of food aid and selective feedingat a few central locations. The intervention may haveincreased disease transmission and mortality byattracting non-immune malnourished people tocentral locations. In such situations less centralisedcommunity based programmes for selective feedingneed to be considered.

Despite low measles vaccination coverage and an on-going measles epidemic from December 1999 to July2000, a measles vaccination campaign with coveragesufficient to stop the epidemic was not implementedin Gode district until August 2000. Measlesvaccination, in combination with vitamin Adistribution is a life-saving intervention that needs tobe implemented immediately in all types of complexemergencies. Vaccination coverage should be above90% and extended to children up to 12-15 years old.2

Nutrition and mortality data should be collected andanalysed during famines. Such data may alsochallenge the assumption that only children under 5are at higher risk. In Gode the lack of anthropometricdata on adults, particularly older persons, resulted inthem not being targeted for selective feedingprogrammes despite their vulnerability.

The use of adjusted BMI is recommended for adultsand allows comparison with international cut-offs.3, 4

Such measurements should be repeated and resultsvalidated against mortality and functional healthoutcomes in other famines and among other ethnicgroups. After this method is further validated, adatabase of baseline mean BMIs and Cormic indicesfor populations regularly affected by famines shouldbe collated for future reference and computersoftware to perform relevant calculations should bedeveloped for field surveys.

Conclusion

No specific international agency has a mandate foroverseeing surveillance systems, designingprogrammes based on such data nor for coordinatinghumanitarian agencies in non-refugee complexemergency affected populations. As a result theseactivities were inadequately performed in the Somaliregion of Ethiopia during this crisis. Ultimatelynational governments are responsible for suchactivities but may lack the resources. In the absenceof structural change in the humanitarian system toaddress this lack of mandate, entirely preventableloss of life is likely to continue to occur on a largescale during complex emergencies.

1 Salama.P, Assefa.F, Talley.L, Spiegel.P, van der Veen.A andGotway.C (2001) Malnutrition, measles, mortality and thehumanitarian response during a famine in Ethiopia: Journalof the American Medical Association, Vol 286, No 5, pp 563-571.

2 Medecins Sans Frontieres. Refugee Health: An Approach toEmergency Situations. London, England, MacmillanEducation Ltd; 1997.

3 See Field Exchange Issue 13 ‘Assessment of adultmalnutrition’ for a summary of the special meeting on thistopic at the SCNs 28th session held in Nairobi, April 2001.

4 Collins S., Woodruff B., Duffield A., Assessment of Adultmalnutrition in emergencies. ACC/SCN July 2000.

7

Research

In 1993 UNICEF compiled a collection of policyand guideline documents relating to the feedingof infants in emergency situations. In June 2000

Save the Children UK, UNICEF and the Institute ofChild Health (ICH) undertook a review of thosedocuments updating the list and identifying thecommon ground that exists among the differentpolicies. The review also analysed the consistency ofthe policy framework, and highlighted importantareas where guidelines are missing or unclear. Anarticle has recently been published which outlines themain issues arising from this review.

The key conclusions indicated that there is a generalconsensus on what constitutes best practice in infantfeeding. However, the lack of clarity in the respectiveresponsibilities of key UN agencies (in particularUNICEF, UNHCR and WFP) over issues relating toco-ordination of activities which affect infant-feedinginterventions constrains the implementation ofsystems to support best practice. While responsibilityfor this function most obviously falls with UNICEF,the existing Memorandum of Understandingsbetween the agencies does not make this explicit,allowing room for alternative scenarios. Otherimportant functions hitherto overlooked by thepolicies and guidelines are the monitoring andcontrol of unsolicited donations of infant feedingitems and the co-ordination of NGO and militaryactivities in infant feeding. Given that many agenciesare potentially involved in supporting infant feedingactivities (from water, logistics, food, health andtransport agencies) the co-ordination function will bechallenging and must therefore be adequatelyresourced.

The authors also conclude that the weak evidencebase on effective and appropriate interventionstrategies for supporting optimal infant feeding inemergencies implies a poor understanding of thepractical tasks needed to support mothers andminimise infant morbidity and mortality. One of themost important gaps in current policies andguidelines is evidence-based practicalrecommendations for promoting and supportingbreastfeeding and supporting the safe use ofsubstitutes when these are necessary. While someimportant experience has been gained in the Balkancrisis by national and international NGOs, there isrelatively little understanding of feasibility of optionsin different emergency contexts including situationswhere there is a high prevalence of HIV/AIDS.

Two recommendations are made:

1. the operational UN agencies primarily UNICEF,should examine the options for improving co-ordination on a range of activities to uphold bestpractice of infant feeding in emergencies;

2. urgent attention needs to be given to developingand supporting operational research in differentemergency contexts on the promotion of optimalinfant-feeding interventions. 1 Seal.A, Taylor. A, Gostelow. L, and McGrath.M (2001).

Review of Policies and Guidelines on Infant feeding inEmergencies: Common Ground and Gaps. Disasters,Volume 25, pp 136-148.

Infant feeding:policies andguidelinesSummary of a review1

In Gode, during the drought of 2000, the majority ofmalnourished children who died (73%) also had anotherdisease such as measles or diarrhoea. Malnutrition alone wasreported as the cause of death for only 27% of children.

Malnutrition can be the most serious public health problem inemergencies and may be a leading cause of death, whetherdirectly or indirectly. Malnourished children (or people) are athigher risk of infection and those who are ill are more likely tobecome malnourished. This pattern is known as the infection-malnutrition cycle.

Source: Causes of death due to wasting, Gode district,Ethiopia Dec ‘99 to Jul ‘00. Salama and Assefa, July 2000.

Wasting + other

Wasting + measles

Wasting + diarrhoea

Wasting alone

33%

18%

11%

38%

Field Article

8

Research

For many decades, the main basis for emergency food aid geographic targetingdecisions taken by the Government of Kenya (GoK) has been district requests.These requests are made to the Famine Allocation Relief Committee (FRC) or

the Permanent Secretary in the Relief and Rehabilitation Department of theGovernment. Requests were made by the District Social Dimensions of DevelopmentCommittee (DSDDC) or in the case of the Arid Land districts1 the District SteeringGroup (DSG). The system has never been transparent and has been critically subjectto political lobbying and media pressure. It is widely acknowledged that politiciansat various levels have perceived the provision of emergency food aid as a resourcethrough which political advantage can be gained and have therefore often ignoredobjective criteria of need.

One key factor which has contributed to the capacity of political lobbyists toinfluence the geographic targeting decision-making process, has been the absencewithin the FRC of a framework for analysing changes in food security. This hasmeant that available data have not been used effectively to inform geographictargeting decisions.

An outcome of the ‘district request’ led system of geographic targeting is that GoKfood rations have been allocated to many districts with some receiving assistance onan almost continuous basis irrespective of crop performance or food availability (seefigures 1 and 2). This has partly contributed to the very small size of rations actuallyallocated through the GoK emergency food distribution system with the result thatextremely food insecure households have had very limited benefit from the GoKprogramme despite the large amounts of money spent. Over the 16 month period ofthe 1996/7 GoK emergency response more than 200,000 metric tons of maize werepurchased and allocated (7% of national maize consumption). Yet in spite of thisenormous expenditure by the GoK, per capita rations of as little as 2kg of maize permonth were frequently recorded. The GoK therefore received very little recognitionor praise for its on-going emergency relief programme and indeed on manyoccasions attracted criticisms from external agencies for the small quantities ofemergency food aid which beneficiaries received.

The targeting system also did not make a distinction between the chronically poor ordestitute and emergency affected populations. Although it is difficult to estimate thenumbers of poor and destitute people who have been targeted by the GoK emergencyrelief programme in the past, it is clear that the chronically poor/destitute have beenconsidered as legitimate beneficiaries of emergency food aid even when there hasbeen no emergency event. Sources in the Ministry of Agriculture have indicated thateven in good years, when maize is being exported, there has been in excess of onemillion recipients of GoK emergency food aid. Analysis of the data on GoK maize

Taking the politics out ofresource allocation: theKenya experienceBy Jeremy Shoham

Jeremy Shoham is co-director of the ENN and editor of FieldExchange. Over the past two years he has been working periodicallyas a consultant for the Government of Kenya, DfID and WFP Kenyahelping to strengthen methods of targeting emergency food aid.

0

10

20

30

40

50

60

Jan

00D

ec 9

9N

ov 9

9O

ct 9

9S

ep 9

9A

ug 9

9Ju

ly 9

9Ju

ne 9

9M

ay 9

9A

pril

99M

arch

99

Feb

99

Jan

99D

ec 9

8N

ov 9

8O

ct 9

8S

ept 9

8A

ugus

t 98

July

98

June

98

May

98

Apr

il 98

Mar

ch 9

8F

eb 9

8Ja

n 98

Dec

97

Nov

97

Oct

97

Sep

t 97

Aug

ust 9

7Ju

ly 9

7Ju

ne 9

7M

ay 9

7A

pril

97M

arch

97

Feb

97

Jan

97D

ec 9

6N

ov 9

6O

ct 9

6S

ept 9

6A

ugus

t 96

July

96

June

96

May

96

Apr

il 96

Mar

ch 9

6F

eb 9

6Ja

n 96

Dec

95

Nov

95

Oct

95

Sep

t 95

Aug

ust 9

5Ju

ly 9

5

Long rain (March - May)

Short rain (Sept. - Oct.)

In the initial phase of an emergency, an immediate assessment ofpopulation size is vital to provide relief workers with the necessary datato plan relief activities. While a head count (census) leading to a

registration is the ideal method of obtaining information on population sizeand composition, such an exercise can often be extremely difficult toimplement especially in the early stages of a large complex emergency. It isnow accepted that as preparations for a census are underway, other strategiesmay be necessary in order to rapidly estimate numbers.2 There are severalapproaches that can be used; mass screening of all children under five yearsof age, counting females above 118 cms, aerial photography, vaccinationcampaigns including information on coverage and using Satellite GeographicSystems GPS. All these methods have advantages and disadvantages whichmust be considered on a case by case basis. In the past decade an approachbased on area sampling in camps has been developed and improved. Thereare two stages. The first is to map the camp by registering all of its co-ordinates. In the second stage the total camp population is estimated bycounting the population living in a limited number of square blocks of knownsurface area and by extrapolating average population calculated per block tothe total camp surface.

A recent study has examined data from six refugee camps in Africa and Asia(between 1992-94), where populations were rapidly estimated within the firstone to two days of arrival using an area sampling methodology. Aftermeasuring all external limits, surface areas were calculated and rangedbetween 1,213,000 and 2,770,000 square metres. In five camps, the averagepopulation per square block was obtained using blocks measuring 25 by 25metres and for another camp with blocks 100 by 100 square metres. In threecamps, different population density zones were defined. The principal aimsof the study were to determine whether population estimates could beobtained rapidly using the method and to identify methodological strengthsand weaknesses.

The study concluded that the area sampling method was efficient inproviding population estimates within one or two days. The validity of themethod could however only be fully evaluated in Liboi camp for Somalirefugees (in Kenya) where a population census conducted a few weeks afterthe assessment estimated the camp population at 45,000 refugees ascompared to the 43,000 figure obtained through the area sampling method.

The study also found limitations with the sampling method. For example,there are issues related to selection of the population density zones and to thenumber of square blocks needed. Stratification3 per density zone is mainlyused as a way to enhance precision. Ideally, a single population density zonecould be considered if the sample was made up of a sufficient number ofsquare blocks (breaking up the camp in smaller, countable areas). However,the number of square blocks sampled varied between different campexperiences and was driven by working conditions and logistical constraints.

The question of selecting the most adequate number and size of squareblocks remained unanswered in the study and merits further research for themethod to be better validated. Number of blocks ranged from five to 26 andthe dimensions varied from 25-100 square metres. Statistical principlessuggest that the higher the number of square blocks selected the moreaccurate the samples representativeness and that selecting a higher number ofsmall blocks would be better than relying on fewer big blocks. The authors ofthe study concluded that the statistical validity of rapid population estimatesshould be tested by comparing results to those of an exhaustive populationcount carried out simultaneously. Furthermore, alternative area samplingmethods such as the ‘T-square’ method’4 might also be considered accordingto the study authors. Such methods have been used in agronomy and rely onthe calculation of the average occupancy area of a unit. As the measurementof only 50 points selected at random are necessary, the method could befaster to implement and thus useful in situations with limited resources.However, the method may be limited by heterogeneity of populationdistribution. This method also therefore needs further testing and validation.

1 Brown. B, Jacquier. G, Coulombier.D, Balandine.S. Belanger.F and Legros. D (2001):Rapid Assessment of Population Size by Area Sampling in Disaster Situations. Disasters,volume 25, No 2, June 2001, pp 164-171.

2 UNHCR (1995): Report of a Workshop on Tools and Strategies in Needs Assessmentand the Management of Food and Nutrition Programmes in Refugee and DisplacedPopulations. Addis Ababa, Ethiopia, 15-21st October 1995.

3 Stratifying implies the division of the target population into distinct sub-groups or ‘layers’i.e. strata, in this case division of the population into sub-groups is based on the densityof the population in that ‘block’.

4 Diggle.p et al (1976). Statistical Analysis of Spatial Point Patterns by Means of DistanceMethods. Biometrics 32: 659-67.

Area sampling for rapidpopulation assessmentSummary of published paper1

1 Arid Lands Resource Management Project

Figure 1: No.of districts receiving GoK maize over time (during this period therewere 68 districts in Kenya)

allocations shows that in some instances when therehas been excellent harvests the number of districtsreceiving food aid has remained more or less thesame (see figure 3).

Political influence within districts

Geographic targeting within districts has also beenhighly politicised. Decisions about the amount offood to be given to each division are taken bymembers of the DSDDC or DSG. The process ofdecision-making bears many similarities to that atnational level.

Political influence on intra-district food allocationshas occurred for many reasons:

i) The District Commissioner has been the finalarbiter of resource allocation and is subject to a highdegree of political lobbying.ii) The district committees (DSDDCs and DSGs)comprised ‘politicians’ as well as technical staff fromline ministries and NGOs (in the case of DSGs). iii) The district committees lacked a clear set ofobjectives for emergency food aid and had noanalytical framework for using the food securityinformation to which they have access. iv) There was very little normative comparison ofdata and no systematic use of baseline informationfrom previous years for comparison.v) There was lack of clarity over whether food aidwas to be used to meet the needs of the chronicallypoor or of those affected by acute emergency events. vi) There were many data gaps e.g. on livelihoodsystems, baseline information on key indicators likeprices or malnutrition data from MCH clinics.

As a result it was often extremely difficult to omitany location or sub-location from food distributions.For example, in Machakos district all 226 sub-locations received emergency food aid between 1998-2000.

Following earlier trips to Kenya connected withemergency food aid planning and provision I wasasked to return in January 2000 on behalf of DfIDand WFP to review the method of GoK emergencyfood aid targeting and to make recommendations for

improvement. Part of my terms of reference involvedlooking at targeting within districts.

My key recommendations (made to the Kenya FoodSecurity Steering Group comprising WFP, GoK andINGOs) for improving targeting at district level wereas follows:

District committees require a clear set of guidelineson the objectives of emergency food aid and meansof targeting food aid commodities.

These guidelines need to specify that:

i) emergency food aid should only be provided forthose livelihood groups affected by a recent shock totheir food system and that the long-term poor shouldnot be recipients of emergency food aid ii) in order to identify and target those affected by arecent emergency event a normative and livelihoodtype analysis must be conducted, i.e. determine howthe indicator levels (prices, crop production, pasture,etc) compare to normal and what the levelsdemonstrate in terms of access to food and incomefor specific livelihood groups. iii) emergency food aid also has a role in protectinglivelihoods and preventing malnutrition andmortality, e.g. it can be used to prevent peopleresorting to survival strategies that undermine long-term viability such as distress sale of key livestock,etc.

In order to institutionalise these guidelines at districtlevel my report recommended a process ofsensitisation at district level through training.

These recommendations for Kenya were by no meansnew. Agencies like Oxfam had supported districtteams in Wajir to adopt and successfully use alivelihood framework for targeting in previous years.Reports from other consultants had also containedsimilar recommendations.2

Capacity building at district level

I returned to Kenya in Jan 2001 to assist in thedistrict level sensitisation and training, this timeworking for the Relief and Rehabilitation Departmentin the Government. The work involved training

9

Field Article

0

10

20

30

40

50

60

70

8099/00

98/99

97/98

96/97

95/96

June May April March Feb Jan Dec Nov Oct Sept August July

0

50

100

150

200

Output (1000 metric tonnes)

1998-991997-981996-971995-96

No. of districts in Eastern Province receiving Food Aid

Top: Masai pastoralist on his way to the market to sell a goat.Middle: key informant interview with Masai women in the Narokdistrict. Bottom: An interview with farmers from Taite-Taucte districtfollowing the 2001 short-rain failure.(All photographs taken by Jeremy Shoham)

Figure 3: Eastern Province: Agricultural Production in 1000MTs and numbers of districts receiving food aid.

Figure 2: Cumulative annual total of districts receiving GoK emergencymaize

10

Field Article

The Active Learning Network foraccountability and performance inthe Humanitarian Sector (ALNAP)

is currently developing training moduleson Evaluation of Humanitarian Action.The modules focus on:

a) general introduction to humanitarianaction evaluationb) how to evaluate humanitarianprogrammes andc) managing and supporting evaluations.

The materials will be piloted by trainingproviders during the next few months.

They will then be accessible on theALNAP website from April 2002. Thedevelopment of the modules is part of arange of ALNAP activities to improve theeffectiveness of the evaluation process inthe humanitarian sector. Further details ofALNAP’s activities can be found onwww.alnap.org

The contact person for the training modules isSara Swords at sara.swords@btclick.com. Formore general inquiries about ALNAP activitiescontact Kate Robertson atk.robertson@odi.org.uk, or write to ALNAP, 111Westminster Bridge Road, London SE1 7JD.

Children’s Health in Emergencies: apractical approach was produced asa 16-page special supplement to

Healthlink Worldwide’s popularinternational newsletter, Child HealthDialogue.

CHESS provides up-to-date and practicalinformation for health and developmentworkers on appropriatepolicies/procedures to follow in the eventof an emergency occurring in their area.Written in clear, easy to understandlanguage, it explains what health workerscan do in the early stages of anemergency, how management andprevention of childhood illnesses such asdiarrhoea and malaria differs inemergency situations, and how they can

work with communities and otherorganisations.

Healthlink Worldwide is seeking to makethis publication as widely available aspossible to individuals and organisationsworking in any type of emergencysituation or wishing to prepare their healthworkers against any such occurrence(whether on a local or national scale).Single copies are free to health workersand individuals in developing countries.For others, the cost is £2.50/US$5.00.Bulk copies (20 copies or more) are alsoavailable free to organisations that areable to distribute the publication throughtheir own channels. For more information contact: HealthlinkWorldwide, Cityside, 40 Adler Street, London E11EE, UK. E-mail: info@healthlink.org.uk

‘La malnutrition en situation de crise’a new publication from ACF

This latest release from Action Contre la Faim drawsfrom ACFs well-recognised experience inaddressing the management of undernutrition in

emergency situations. The manual outlines operationalguidelines for nutritional assessments, nutritionalrehabilitation programmes, practical guides for programmeplanning and implementation. The author, ClaudinePrudhon, has worked with ACF between 1994-2000.

This publication is currently available in French and canbe ordered from Khartala publisher ISBN: 2-84586-170-2Editions, Khartala 22-24 boulevard Arago 75013 Paris andcopies costs € 24.50.Contact Laurence Verdenal for more information at Action Contre laFaim, 4 rue Niepce, 75014 Paris. Tel +33 (0)1 43 35 88 11 or +33(0)1 43 35 88 88 or email: lv@acf.imaginet.fr

An English version, ‘Malnutrition in crisis situations’ will be madeavailable in April 2002.

district level rapid assessment teams3 in the principles of foodeconomy analysis and to help them apply the methodology to thecurrent drought situation and assist in analysing the results. Fourregional training programmes were carried out simultaneously(involving three other trainers) covering 22 districts in Kenya thatwere requesting emergency food aid at the time. This training tookplace over a three week period.

The first week involved working with the district team to identify andlocate major food economy groups in their respective districts and toattribute and quantify food and income sources for each foodeconomy group in a normal year. The results were represented on piecharts as percent of total food and income coming from differentsources. This was then followed by theoretical exercisesdemonstrating how by comparing current food security relatedinformation (e.g. market prices, milk availability, crop production),with baseline values it is possible to estimate and quantify currentaccess to food and income sources and to determine whether there isa food deficit and need for emergency food aid provision. Teams thenwent back to their districts in the second week to collect food securityinformation from District Head Quarters level and through keyinformant interviews at village level for each food economy group.They returned in the third week to analyse the data in relation to eachfood economy group, i.e. to assess food and income sources inrelation to normality and to determine whether there was a fooddeficit for each food economy group. This was not a rigorous trainingin food economy analysis. Furthermore, the limited time for trainingmeant that certain aspects of traditional food economy analysis wereomitted, e.g. stratifying food economy groups into wealth groups.However, the training did provide district government, local NGO andWFP staff with a framework for analysing food security information.This was something that was previously lacking.

The district teams felt that the assessment methods enabled them topresent a coherent assessment of food security and to argue moreconfidently about intra-district food aid needs. The objectivity of theFood Economy assessment framework empowered district teamswhile disempowering politicians on the DSDDCs and DSGs. In short,the district teams embraced the training and worked very hard to usethe tools to come up with credible estimates of food aid needs fortheir respective districts.

Although I was not involved in writing the final report that waspresented to the KFSSG, I understand that WFP and GoK reliedsubstantially on the district team findings to target food aid during2001. This was the first time a standardised framework andmethodology had been used by the GoK to quantify inter and intra-district emergency food aid needs in Kenya. Furthermore, it wasnoted that the final report submitted to the KFSSG recommendedemergency food aid for a lesser number of districts than the initialnumber requesting emergency food aid prior to the assessment by thedistrict teams.

Conclusion

In conclusion, what seems to have occurred in Kenya is that a criticalmass of dissatisfaction was reached with the politically driven systemof emergency food aid targeting that had been operating for severaldecades. This resulted in co-ordinated pressure from key stake-holders for change. Changes have occurred at many levels (see articleby Robin Wheeler in Field Exchange 12). One key development hasbeen the adoption of a framework for analysing changes in foodsecurity (something which has hitherto been absent). This hasprovided a more objective and transparent method of assessingemergency food aid needs for population groups and as aconsequence has reduced political influence on the process ofgeographic targeting. Capacity building has begun at national anddistrict-decision making level. While this article is not championingfood economy analysis as the only framework for food securityassessment and estimating emergency food aid needs, it has aimed tohighlight the contribution an accepted analytical framework can havein de-politicising emergency food aid decision-making. From being acountry with one of the least rigorous methods of defining emergencyfood aid needs, Kenya’s evolving methodology for targetingemergency food aid could now very well become a model for othercountries in the region.

For further information regarding evolving targeting methodologies in Kenyacontact either:Pippa Coutts at the Arid Lands Resource Management Project in the Office of thePresident, Nairobi. (Email: pippac@africaonline.co.ke) or Jeremy Shoham (email:jshoham@easynet.co.uk).

2 Jaspars.S., 1998, ‘discussion Paper. Food aid Strategy for the Kenya EmergencyFloods Operation’ presented at WFP/NGO/GoK meeting on 11th June.Jaspars S. 1998. ‘Final Strategy for Food Distribution in Flood Affected Areas ofEastern, North Eastern Province, Kenya, 6th August

3 Teams comprised staff from government (mainly district agricultural andveterinary officers), NGOs and WFP.

newsProgramme evaluations: where do you start to learn?

Children’s health inemergencies: a practicalapproach (CHESS)

11

News

“If you look at the past year or so, you couldblame the Taliban, but you must look to theroots of the crisis”Anuradha Mittall, Institute for Food andDevelopment Policy, based in Washington.

Aconsolidated UN appeal,launched by Secretary GeneralKofi Annan on September 27th

requested US$584 million. Contingencyplanning figures were forecast at anadditional one and a half millionrefugees that would cross the bordersinto, mainly, Pakistan and Iran. Inresponse the international communityhas been decisive, quick and generous,the US has promised US$320 million,UK $25 million, Italy $7.5 million,Canada $5 million, the EU an additional$4 million, Ireland $2.5 million, NewZealand $400,000, even actress AngelinaJolie contributed a million dollars.

Exactly one month later, there were lessthan 100,000 ‘new’ refugees. There is awide range of factors for thisunexpectedly low number and only thenear future will tell if the worst-casescenario will be reached.

Who is to blame?

The present nutritional, economic andhealth crises in Afghanistan (see alsopage 22) have a very recent historicsource and are not caused by the limitedbombing of Afghanistan or the Talibangovernment. As stated by Joel Charny,vice president for policy for RefugeesInternational, in an interview withReuters news agency on September 26th“Are the Taliban responsible for thecurrent crisis? I could say quite honestlyvery minimally.” According to theSecretary General’s office, the increasesin obstructions to humanitarianprogrammes are linked to the UNsanctions imposed in 2000. “Theserepeated assaults on humanitarian actionbecame more frequent after theimposition of resolution 13331 (2000).”It goes on to say that internal politics inthe Taliban and conflictinginterpretations of the principles ofhumanitarian principles and agencies“must rank alongside the UN sanctionsas contributory causes to the problemsfaced by the humanitarian agencies”.

The reality

As can be seen from the graphs,

Afghanistan and its neighbours havesuffered from the effects of war, droughtand famine for over 20 years. Only asrecently as 1992 there was an estimated6,000,000 Afghan refugees residing inneighbouring countries. Through acombination of Pakistani and Iranianassistance polices, donor support andwork undertaken by NGOs the refugeeswere cared for. Apart from the currentPakistani policy of closing its bordersand given the generous response bydonors and the public and the significantnumbers of established and newlyarrived NGOs there is no reason tobelieve that we will not be able to carefor any new influx of refugees. With theapproaching winter, the possibleescalation of the conflict and theuncertainty of access, the populationmost at risk are the 1.1 million IDPs inthe country. That said, WFP did manageto deliver over 14,000 tons of food to itsbeneficiaries in Afghanistan in October.Their target was 52,000 tons and theyhope to maximise distribution bycontracting more NGOs asimplementing partners for secondarydistributions. The cynical PR exercise oflimited airdrops that were carried outearly in the bombing is certainly not theanswer to overcome the problems ofaccess on the ground.

The NGO response

In the few days following the attacks inNorth Eastern USA, and when it becameapparent that the US were going to carryout military action on Afghan territorythe NGOs launched appeals whilstsimultaneously pleading for restraintfrom the US and its ‘allies’. BothInteraction, which represents a coalitionof American NGOs and its Europeancounterpart ICVA released statementsurging caution and a plea for vulnerableAfghans. All of the larger humanitarianagencies and hundreds of others fromaround the World have deployed orstrengthened their resources and havenow based themselves aroundAfghanistan with some fully operationalin the Northern non-Taliban controlledarea.

Agencies targeted?

Human Rights Watch published a reporton October 18th outlining the increasein attacks on aid agencies by the Taliban

since the bombing began eleven dayspreviously. UNHCR, WFP, OCHA,IOM, MSF, SCA, Islamic Relief andnumerous unnamed demining agencieshave been looted, staff beaten andvehicles stolen. In addition agencieshave become part of the so-called‘collateral damage’ through waywardbombing by the US/UK military. OnOctober 8th the UN funded AfghanTechnical Consultants agencies KabulHQ was hit by a missile killing fourstaff, October the 15th saw a WFPemployee wounded by shrapnel whilstunloading grain at the WFP warehouse,the following day two clearly markedICRC warehouses were destroyedduring daytime air assault and the 26thOctober saw another three ICRCwarehouses in Kabul hit.

As we go to press, the United Front(Northern Alliance) had taken control ofsome 70% of the country. WFP andUnicef had convoys of supplies arriving,IDPs were returning home but securitywas tenuous. The challenge for thehumanitarian community is to mobilisequickly to ensure essential food, shelterand health supplies are moved before thefull onset of winter. Given the monetaryresources made available and the longlead-in time for implementation, surelythis challenge can be met.

AfghanistanChronology of events inAfghanistan

1978 Communist governmentintroduced a deeplyunpopular and massiveagricultural reformprogramme. Somedisplacement to the cities.

1979 Soviet army, at the invitationof the communist governmentmoves in to Afghanistan andinstalls a ‘puppetgovernment’.

1981 Due to the conflict betweenAfghan militia and the Sovietarmy some 1.5 millionrefugees had fled to Pakistan.

1986 Almost 5 million refugees nowscattered in camps all aroundAfghanistan’s neighbouringcountries

1989 The Soviets completewithdrawal of troops leavingbehind a pro-Moscowcommunist regime.

1992 The Mujahideen defeat thegovernment, more than amillion refugees return homewithin the next eighteenmonths. Factional fightingfragments the Mujahideenand Afghanistan slips intoanarchy.

1994 The emergence of the Talibanin Afghanistan.

1996 Taliban takes Kabul sendingthe government into flight.Most of the world do notrecognise new rulers.

1998 UN sponsored talks aim toreach consensus and peacein Afghanistan between thedifferent factions.

2000 For the first time in 10 yearsan increase is reported inrefugee numbers fromAfghanistan. Afghans wereleaving the country due todrought and conflict.

2001 (pre-September 11th) -Refugee and IDP numbers risesharply, WFP launches appeal toassist more then 3.5 million droughtand conflict-affected persons.

Now - 100,000 refugees cross intoPakistan, WFP relaunches appealto target 7.5 million Afghans(resident Afghans, IDPs, andrefugees)

The respected International Food Policy ResearchInstitute (IFPRI) recently published the results of itspredictions of the future of food access and

consumption in a report titled ‘2020 Global Food Outlook:Trends, Alternatives and Choices’.

The 18 page report available at IFPRI website(www.ifpri.cgiar.org), predicts that progress towardseradicating child malnutrition will be slow, and thatmalnutrition will decline by only 20 percent over the next20 years. According to Per Pinstrup-Anderson, directorgeneral of the IFPRI, “ we have the power to change that,with modest alterations to policies and priorities, the rate ofprogress against child malnutrition could be more thandoubled”.

Data were collected and trends analysed using computermodelling to predict consumption patterns, food productionand demand for 16 major food commodities to 2020. Alsotaken into account was the impact of a number of policyactions, including trade liberalisation and expanded

investment in agricultural research, health care andeducation, on food security and nutrition.

On the positive side IFPRI predicts that child malnutritionin China will halve and in Latin America it will benegligible. However, the percentage of children in subSaharan Africa suffering from malnutrition will increase by18%, according to the report.

By modelling different and more positive scenarios, whichwould include a $10 billion per year investment, a 42%reduction in child malnutrition world-wide by 2020 isachievable. IFPRI Senior Research Fellow and co-author ofthe report points out that the investment is “equal to lessthan one week of global military spending”

A more comprehensive examination of the issues has beenpublished by IFPRI in a 206 page book ‘Global FoodProjections to 2020: Emerging Trends and AlternativeFutures’. Please refer to their website (http://www.ifpri.org)for purchasing information.

0

300000

600000

900000

1200000

1500000

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

1990

1988

/89

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

1990

1989

1988

1987

1986

1985

1984

1983

1982

1981

1980

1 The UN General Assembly Resolutionauthorising sanctions against Afghanistandue to Taliban’s refusal to extraditeOsama bin Laden in connection with theAmerican embassy bombings in Africa in1998

New IFPRIreport

Afghan refugees 1980-2001

Afghan repatriation statistics

12

Field Article

Somalia has been without a central governmentfor the past eleven years and has within itsborders a number of areas that are highly

vulnerable in terms of food insecurity. Civilinsecurity, poor infrastructure and inadequate donorsupport have led to low levels of humanitariansupport in the areas of greatest need. The southernand central regions continue to experience a level ofinsecurity that hampers long-term development andpresents daily challenges to organisations involved inproviding humanitarian assistance in the area. Thispaper focuses on the nutrition surveillance project inSomalia and describes some of the successes andchallenges encountered over the past year. It alsoaims to highlight some of the issues related toworking in areas of chronic disaster in the Horn ofAfrica.

The Food Security Assessment Unit

The Food Security Assessment Unit (FSAU),1 iscurrently managed by the UN Food and AgricultureOrganisation (FAO) with funding from the EuropeanCommission (EC) and USAID. It collects, analysesand disseminates information on the overall food andnutrition security situation in Somalia. Althoughbased in Nairobi, plans for decentralisation and theestablishment of bases in four or five areasthroughout Somalia are being developed. A team oftwenty-two field monitors assemble information on arange of indicators such as livestock health, rainfalland crop conditions as well as on issues like security,population movement and the general economy.Through its partners within the SACB (Somalia AidCoordination Body) and local government, analysisand interpretation is undertaken and informationdisseminated through a variety of media. Within theFSAU, interpretation of food security issues has beenstrengthened through the use of the household foodeconomy approach. This approach aims to describehow households access food and essential items innormal times and to understand the influences ofchanges in the wider environment on that access.

Following analysis of this information, the FSAUmakes recommendations on the types of interventionsmost likely to have a positive impact on theavailability and access to food. Suchrecommendations sometimes include food-aid butincreasingly look for alternative options.

In an environment where reports on the humanitariansituation are unclear and sometimes conflicting,decision-makers frequently look to nutritionindicators for guidance in making judgements on theoverall welfare of the population. In recent yearsthere has been an increased interest in understandingissues related to food security and early warningsystems have been developed to try to provideinformation on this. It is unfortunate however thatbecause descriptions of food insecurity are weigheddown with assumptions, conclusions can rarely bedescribed as certain. This contrasts with the reports ofhigh levels of malnutrition and the functionalimpairment that accompanies it. The rate ofmalnutrition therefore provides a clearer and lessambiguous assessment of the seriousness of thesituation. The response of donors to a crisis is heavilydependent on evidence that the problem has alreadyoccurred. Decision-makers increasingly seek the kindof hard evidence produced by good quality nutritionsurveillance information to make judgements on thelevel of impact on the population and on the kinds ofaction needed to be taken.

The Nutrition Surveillance component ofFSAU

Efforts to develop nutrition surveillance activitieshave been undertaken by FSAU since 1995. In 1997,in collaboration with Action Contre La Faim (ACF),an Alert Site Surveillance Network was established.This system, which was largely based on growthmonitoring at clinic level encountered problemsrelated to coordination, support and funding. By2000, little useful information was being produced.Co-ordination of other nutrition surveillance activitiesin Somalia was extremely weak and under constant

criticism from partners within the Somalia Aid Co-ordination Body. Poor co-ordination of the agenciesconducting surveys, lack of standardisation ofapproach and poor methodologies employed byagencies2 were among the weaknesses identified.

In 2000, FSAU sought funding to strengthen thenutrition component of its work with an emphasis onimproving the quality, reliability and coverage of theinformation collection system along with betterinterpretation of nutrition related information. Withfunding from USAID, the current nutritionsurveillance component commenced in September2000 under FAO management. Strong emphasis isgiven to the generation of good quality informationon nutrition and the analysis of this information. Aswell as developing the capacity to collect thisinformation, the system also aims to better utilise theinformation related to growth monitoring andsupplementary feeding and other sources ofanthropometric data generated at health facility level.The response to the project during the first year hasbeen extremely positive and encouraging with boththe requests for assistance and the need for supportproving greater than originally anticipated.

The major aims of this surveillance project are toestablish an efficient and effective nutritionalsurveillance system for Somalia by ensuring that:

• all nutrition surveys and food security assessmentsare undertaken according to standard commonlyaccepted procedures;

• all nutrition data are analysed and interpreted usingrelevant contextual data;

• nutrition related information is disseminated topotential users in appropriate user-friendly formats.

Nutrition surveys

FSAU has not undertaken independent nutritionsurveys believing that surveys should be undertakenby those organisations that already have the capacityto do so and are able to use and respond to thesituation realised through that information. However,

NutritionSurveillancein SomaliaBy Noreen Prendiville

Noreen Prendiville hasbeen involved in health,nutrition and food securityprogrammes in East Africaover the past fifteen yearsand has a special interestin the subject of maternal

health. Currently employed with FAO, shehas also worked with UNICEF, WFP andvarious NGOs.The support of Brian Thompson and MarkSmulders (FAO Rome) in the preparation ofthis article is acknowledged andappreciated.

Nutrition survey in Southern Somalia

B. OWADI, FSAU

13

Field Article

FSAU provides expertise for the planning, trainingand analysis of nutrition surveys and has recentlyacquired additional funding to support partneragencies with inadequate resources. The FSAU hasalso started to play a lead role in the co-ordination ofinteragency surveys, with surveys conducted on morerigorous scientific criteria using unbiased and cleartransparent objectives. This has led to the wideracceptance of results and to more realistic andbroadly supported recommendations. Localgovernment officers, NGOs, UNICEF, CARE andWFP have participated in recent surveys and,together with the communities, have participated inthe analysis, discussion and recommendations. Thisinitiative needs strengthening in a number of ways forexample, by reaching agreement on the roles andcommitments of all partners prior to the survey. Inthe future, it is hoped that routine surveys in ‘normal’times will be implemented and will lead to a betterunderstanding of the underlying problems related tomalnutrition and also provide more realistic base-lines, from which to better judge any deteriorationduring times of crisis.

The current role and perceptions of healthfacility data within the FSAU

While recognising the limitations in the use of datagenerated at health facility level, much time andeffort has been invested by the FSAU in recent yearsin supporting growth monitoring at health centre leveland the development of a database for the analysis ofthat data. The original intended output was thegeneration of nutritional status trends data fromhealth facilities that would allow monitoring ofchanges in nutritional status of the population. Datafrom health facilities collected in this way was notintended for use in isolation but as a stimulus for thequestioning of any changes in malnutrition rates – ora (downward) shift in trends.

However, because the changes in malnutrition trendsrecorded at health facility level can have such a widevariety of causes e.g. population movement, changesin health personnel, absence or availability ofsupplementary food or other supplies, as well asgenuine increases in the number or severity of casescaused by a particular food security or health crisis,the FSAU attaches only limited importance to thesedata in the overall analysis of the food securitysituation. Furthermore, in situations where asubstantial number of children do not present forroutine screening or growth monitoring, theextrapolation of health facility information to thesurrounding population should be attempted withcaution.

On the positive side, through the process ofstrengthening health centre based surveillance, healthfacility personnel are improving their understandingand skills related to the assessment of malnutrition atboth individual and population level. Furthermore,because channels of communication have beenestablished through the FSAU, health centre reportsof worrying trends are followed-up by FSAU who arein a position to cross-check the reports through FieldMonitors and rapid surveys. Feedback to the healthfacilities of the graphs produced with the informationprovided by them has now commenced and isproving to be a useful tool in the promotion of moreaccurate data collection and in the interpretation andanalysis of the trends at health facility level.

In addition to more detailed nutritional surveys andhealth centre data, it was hoped that MUACscreening by FSAU Field Monitors could become avaluable component of nutrition surveillance. In thepast, many of the Field Monitors have rejected thisidea because of the perceived link between nutritionassessments and food aid input which they felt couldcompromise their normally low-key presence in theirareas of responsibility. This concept may yet beintroduced by commencing the activity with FieldMonitors in areas of the country that do not have astrong tradition of food relief.

During the past six months information on nutritional

status generated as part of the FSAU nutritionalsurveillance project has been used as:

• A tool in crisis mitigation through enabling theidentification of appropriate and timely responses toa variety of threats e.g. in Lower Juba during early2000.3

• An indicator of the overall health and welfare ofpopulations in the absence of other healthinformation monitoring systems.

• A key information source for decision makerswithin the humanitarian response body of UNAgencies, NGOs and donors (‘informing the aidresponse’).4

• A food security indicator, demonstrating the impactof a variety of climatic, environmental and politicalinfluences on the population,

• Part of a system for monitoring the impact of reliefinterventions.5

In addition to the above, the project responds to theneeds of other key users of the information:

• The health facility based information providers whoreceive graphic feedback of the data to assist in theanalysis and interpretation of trends in nutritionstatus in the population in the catchment area of thefacility.

• Global nutrition monitoring systems such as theWHO Global Data Base on Child Health andNutrition who regularly request and use informationprovided though the FSAU nutrition project

• Regional information systems for analysis anddiscussion such as the PFEDA (Partners in Foodand Emergency Development Aid) website.

• Partners in neighbouring countries. Frequentcontacts are made with partners in Kenya andEthiopia for exchange of information anddiscussion of common problems.

Regional communication

Exchange of information and discussion of commonproblems between FSAU and partners in Ethiopia andKenya has been useful. This relationship has not beenformalised and the potential exists for greaterdevelopment and institutionalisation of therelationships which have up until now depended uponpersonal contacts. Areas for further developmentinclude the standardisation of nutrition surveymethodology among countries and identification ofspecific information needs with the ultimate aim ofreaching agreement on common programmingapproaches.

Communications have been recently established withneighbouring countries including the followingexchanges:

• From Ethiopia - for information on micronutrient

deficiencies on Ethiopia / Somalia borderpopulations.

• From the FSAU - for information on nutritionsurvey results from Ethiopia/Somalia border areasin order to understand reported high rates inEthiopia compared with relatively little malnutritionon the Somalia side.

• From the FSAU - for information from Ethiopiaregarding relief activities in Ethiopia that appearedto be influencing population movements in borderareas.

• From partners in Kenya - regarding nutritionsurveys in border areas due to lack of access toborder areas inside Somalia (as in the case of NorthEast Province in Kenya and the neighbouringLower Juba and South West Gedo region).

• From organisations in Kenya to share informationand discuss micronutrient deficiencies in NorthEastern Kenya.

• From South Sudan - to share information on theFSAU nutrition surveillance project while in theprocess of establishing a surveillance system there.

Other positive developments in the nutrition sector inSomalia have been:

• The agreement of all partners in the SACB on theuse of standard nutrition survey guidelines. Majordonors have supported this initiative by including itas a condition in their funding contracts.

• The ‘Nutrition Working Group’, which is part ofthe Health Sectoral Committee of the SACB, isused as a forum for reviewing reports and for thedevelopment of recommendations for appropriateaction. This public and critical process of peerreview has significantly improved the quality andtherefore the usefulness of nutrition surveys.

The Role of Nutrition information in EarlyWarning Systems?

Nutritional status is a result and outcome of astressful situation and has been shown to respond in asensitive and timely manner to the intensity andnature of the shock. The fact that a deterioration innutritional status indicates that a problem alreadyexists has led some observers to conclude thatnutritional status is therefore a ‘late warning’, not an‘early warning’ indicator. However, from anoperational early warning point of view ifsurveillance systems are sensitive enough to detectearly changes in nutritional status then such changesmay occur and be discerned before other types of‘change’ are noted, e.g. market prices, unseasonalmigration, etc. This has been shown in manycountries. Nutritional status is not intrinsically a lateindicator in terms of early warning of food crisis aspopulations change dietary patterns early on inresponse to food stress (real or anticipated).

Women pounding maize

M. KAYAD. FSAU

It was late in the afternoon, and I wasdearly regretting my decision to havetemporarily suspended my privileges

(the use of the Land-Cruiser with driver)in order to meet friends in a nearby town.I had been sitting for hours in this dustyand hot African market, staring at thepublic bus that was supposed to take meto my destination. My “Swisshood” wasput under a huge amount of stress: whatkind of country is this where buses onlyleave when they are full? But suddenly,magically, people from all over the placeapproached MY bus - and withinminutes, we were gone. Hurray!However, we stopped 20 minutes latersince it was time to pray!

Different concepts of time are among themost challenging aspects when workingabroad. It’s not that cultures havedifferent notions of “punctuality” it ismore that they perceive and organisetime differently. “You muzungus1 havewatches. We Africans have time...!” -that’s how it was put to a colleague ofmine while he was waiting forinterpreters who were already two hourslate.

The culture of humanitarianorganisations is largely ruled by the morewestern “monochronic” time perception2.“You muzungus have watches ...” time isperceived as linear, precise, tangible, andmeasurable. Things are planned, anddone one after the other. Appointmentsare strictly kept. When taking a train inSwitzerland, I am still amazed at thisidentifiable Swiss feature: unlike Africanbuses, 80% of the trains arrive within oneminute of the schedule! In monochroniccultures, “time is money” - there arestrict deadlines, quarterly reports, timemanagement, and yearly objectives andbudgets. Does this sound familiar to you?

Many countries in which humanitarianswork, are more “polychronic” cultures.“We Africans have time ...”: time isperceived as elastic and relative. Variousactivities may be carried out in parallel.Time commitments are desirable, but notconsidered absolute (“tomorrow ...insh’Allah”). Moreover, schedules aresecondary to relationships. You show youvalue people by giving them time.

I had an appointment with an Iraqiofficial. I was on time, and waited forhim in the lobby. When he finally arrived- eagerly talking with three people - heacknowledged my presence and greetedme. But some other men entered thelobby and engaged a discussion withhim. At the same time he was quicklydealing with a matter involving hissecretary. When the official eventuallyled me into his office, we had a fruitfulbut (for me) difficult meeting, since wewere constantly interrupted by phonecalls and by people popping in. Theserepeated disruptions gradually irritatedme. They also made me feel as if I was

not being taken seriously! Onlyretrospectively did I consider and cometo understand that due to his valuationand perception of relationships and time,it would have been impolite not to dealwith everyone who called or knocked athis door. This fact was confirmed when Ipaid him an unannounced visit a fewmonths later. I was promptly let into hisoffice, even though he was in a meetingwith somebody else already!

But to ease down on schedules or tolearn to take advantage of waiting timesor delays, is only one part of thechallenge, as different ‘time orientations’also have other consequences. How manytimes (in order to measure, register orassist beneficiaries), have I tried - andmostly failed - to have people simply lineup. “It is not that difficult, is it?” It hasfrequently felt like trying to spread adrop of quicksilver that was constantlyreverting to globular form. Often a greatnumber of poles, checkpoints, ropes, andhelpers would be needed to achievesomething resembling a line. No wonderas the notion of lining up is a directresult of applying the westernmonochronic time perspective. Onething, one sequence, one person, orderly,after the other. Have you ever tried tojump a queue in a train station in theUK? I did recently, and can tell you thatorderly sequences have stern defendersthere. If you have ever lined up nicely inIndia to buy a train ticket you’reprobably still waiting, with peoplecontinually passing in front of you.

The influence of ‘time orientation’ onfood preparation can be especiallypertinent for field staff. Duringhousehold assessments in thepolychronic Middle East, I happened toshow up unexpectedly around mealhours: there was always plenty of cookedfood ready irrespective of the time it tookto prepare it, just in case a guest - likeme - would drop by unexpectedly. Inother words, I kept on eating all daylong. In monochronic cultures, there arefewer chances to get invited, since onlythe right quantity of food for thehousehold is prepared. Bad luck for you!

It’s a real eye-opener discovering themany effects different concepts of timehave on how cultures organise theirenvironment and daily life. At the sametime this doesn’t necessarily makemutual understanding any easier.1 Swahili for ‘foreigner’2 See Edward T. Hall, The Silent Language,Anchor Press 1990

Embracing cultures

14

Field Article

Ultimately, it is the sensitivity of the surveillance system whichdetermines whether it is or is not a late indicator. The FSAU is workingtowards establishing a nutritional surveillance system which can detectearly changes in nutritional status at population level.

Cut-off values in surveys: what is ‘normal’ in a countrywhere there is chronic food insecurity

According to pre-1996 reports, the people of Southern and CentralSomalia experienced malnutrition rates of between 10 and 15%6 outsidetimes of crisis. In times of recent crisis (February 2000), thismalnutrition rate has risen above 30%. Surveys with high levels ofglobal malnutrition in Bakool Region have also shown high levels ofsevere7 malnutrition (around 6%), representing a high proportion ofchildren under five that are facing a high risk of death. A high incidenceof diarrhoeal disease and low immunisation coverage for measles furtherincreases this risk.

Despite the fact that South and Central Somalia have enjoyed relativefood security over the past year, the (few) nutrition surveys undertakenseem to hover around total malnutrition rates of around 15% (<-2 Zscores). In the minds of many, numbed by continuously highmalnutrition rates, these kinds of rates have increasingly been acceptedas ‘normal’. A question that then arises is: if we accept a prevalence ofwasting of 15% as ‘normal’, what even more unacceptable and appallinglevel of death and morbidity should be judged to be appropriate fortriggering an intervention.

Trigger levels for action should be determined by two factors; (i) thelevel of functional incapacity caused by malnutrition in terms ofmortality, morbidity, the ability to do work, and to grow and develop and(ii) the level of resources we have available to us; not the level ofdegradation that is considered to be “historically normal” for any onegroup. This is tantamount to double standards. We cannot entertain that acertain level of support be given to one population group but not foranother group in similar circumstances because they have always had itbad. Recognising that situations require a graded response, withresources being directed preferentially to the worst cases or areas ofnutritional deprivation it can be expected that programmers and fieldstaff will have to focus priority attention on those areas that exceedcertain “normative” values. It is clear that in order to address these highrates of malnutrition, all three aspects of food security; availability,access and utilisation need to be addressed in the Horn of Africa.

Challenges for the future

In a country like Somalia, which has been in the grip of a chronicdisaster for many years, the greatest vulnerability and sufferingfrequently occurs in areas of greatest physical insecurity and thereforewhere there is lowest potential for collecting reliable information andmaking appropriate interventions. A question that arises is whether it isacceptable to lower our standards for quality of information and if so atwhat cost? The long-term commitment of the FSAU to strengthen thequality of nutrition information coming out of Somalia is borne out ofthe recognition that nutritional information has a potentially critical rolein terms of advocacy, early warning and impact assessment. However, itis also recognised that nutritional information must always becomplemented by other contextual information to ensure acomprehensive understanding of what such data are telling us.

1 The FSAU was established in 1994 by the UN World Food Programme and USAID.The third project phase, of three years duration, commenced in May 2000 underFAO implementation, and funded primarily by the EC.

2 Shoham.J and Kanyanga.J (1998). Review of the Somalia Food SecurityAssessment Unit. Report for Oxford Policy Management.

3 Interagency nutrition survey was undertaken in Jamame, after which conclusionsand recommendations were discussed with and agreed on with the community andthe main implementing organisations. Decision to distribute food aid and to supportsupplementary feeding for a very specific period was agreed.

4 Information from the nutrition project is frequently used in documents supportingrequests for funding.

5 Levels of malnutrition in and outside times of crisis have provided an input intoexaminations of the likely impact of interventions.

6 Moderate malnutrition; below minus two standard deviations from median weight forheight of reference population.

7 Severe malnutrition; below minus three standard deviations from median weight forheight of reference population and/or nutritional oedema.

Whose time isit anyway?

By Ariane CurdyB.Sc., M.Sc. IntlManagement

Migrating in Northern Somalia

M. NORI. UNA MILK

15

Evaluation

The Saharawi refugee population(approximately 150,000) living in southAlgeria have been in crisis since 1975 when

conflict over the status of Western Sahara or formerSpanish Sahara erupted. This refugee population hasbeen dependent upon international aid for all thistime due in large measure to the harsh desertenvironment in which they have been forced to liveand the resulting lack of food production potential.Efforts to boost food production amongst thispopulation have only had limited success.

Baseline survey findings

In 1997 ECHO financed a baseline survey conductedby CISP2 in collaboration with INRAN.3 This surveyidentified anaemia and growth retardation mostly inwomen and children as emergent problems amongstthe Saharawi refugees due to the long-term impact ofan unbalanced diet. The basic food basket consists ofwheat flour, rice, lentils, sugar and oil, canned fish,canned meat, dried skimmed milk, tea and yeast.However, rations have varied due to interruptions insupply. Access to additional food items has beenlimited and few families can afford to supplementtheir rations. The sandy soil and saline water limitspotential for household vegetable production. Onlyhalf the families surveyed were able to supplementtheir food rations with additional purchased foods.The ration has therefore not contained adequatequantities of iron (49% of RDA), vitamin A (36% ofRDA), zinc, vitamin C (8%) and other nutrientscommonly found in fresh meat, vegetables and fruit.There are also no appropriate weaning foods forchildren between 6 months to one year.

The survey found that approximately 15% of childrenwere born with Low Birth Weight (LBW), i.e. below2,500 grams. Furthermore, 70% of children underfive years were anaemic while 46% were stunted(Height for Age) and 10% wasted (Weight forHeight). In older children an estimated 60% wereanaemic, 31% stunted and 7% wasted. Sixty percentof women of child-bearing age were consideredanaemic and low BMI values were found in 15% ofwomen and 15% of the aged.

Recommendations from the survey findings includedestablishing targeted nutritional interventions toaddress the problem.

Programme initiatives: Pilot SupplementaryFeeding Programmes

In 1998 two pilot efficacy trials were conductedamongst children and infants to examine the benefitsof specially formulated mineral/vitamin fortifiedfoods supplements on the prevention and control ofanaemia and growth retardation. The success of thetrials led to a national supplementation effectivenesstrial covering over 4000 children under the age offive years in all Saharawi refugee camps in 1999. Thegeneral objective of the programme was to measurethe effectiveness of a 3-month targetedsupplementation programme. More specificobjectives were to:

• reduce the incidence of iron deficiency anaemia(IDA) and growth retardation in children aged 6-17months by distributing a fortified rice based flour inthe form of a porridge (RFB-G2);

• reduce the prevalence of iron deficiency anaemiaand growth retardation in stunted children aged 18-59 months by distributing a High Nutrient DensitySpread (HNDS);

• use health dispensaries as a tool for health andnutrition promotion;

• set up an integrated nutrition programmeimplemented by the local health system;

• evaluate the implementation and impact of theintervention for applicability in other similarrefugee settings.

All children under the age of 5 years were screenedat health dispensary level and separated into twogroups; infants 6-17 months (intervention A) andchildren 18-59 months with a height for age less than-2 Z-scores (intervention B). Impact of thesupplementation was assessed by monitoring thenutritional status of children registered at the start ofthe programme and after 3 months ofsupplementation. Food supplements were distributedonce per week at local health dispensaries by MCHstaff. An on-going sensitisation campaign wasimplemented during the entire duration of theprogramme. The results were obtained on 1200children monitored in sentinel dispensaries.

Effectiveness of interventions

Intervention A: After three months meanhaemoglobin (Hb) levels were slightly butsignificantly reduced by minus 0.3 g/dL in infantsbetween 6-17 months. The number with severeanaemia diminished but those with moderate anaemiaincreased. The overall combined prevalence ofanaemia worsened by 5% after supplementation.Mean growth velocity only reached 3 mm/month.Retarded growth was reflected by a worsening of theheight for age Z-score which dropped by 0.2 standarddeviations indicating that linear growth falteringcould not be prevented by the fortifiedsupplementation. The percentage of infants withstunting increased by 10% at the end of theintervention.

Intervention B: Mean haemoglobin levels in stuntedchildren were significantly increased by O.5 g/dLafter three months of HNDS supplementation. Thepercentage of children suffering moderate to severeanaemia dropped by 10%. There was a lowerpercentage of children affected by severe anaemiaand a higher percentage with mild anaemia andnormal Hb levels. The supplementation improvedmean height for age by 0.3 Z-scores and growthvelocity reached 8.9 mm/month. The incidence ofstunting was reduced by 15% mainly among theseverest cases of retarded growth.

Discussion and Conclusions

The poor results of intervention A may have been dueto a number of factors:

i) the fact that a significant proportion of targetedinfants were already showing signs of chronicmalnutrition and hence needed treatment ratherthan preventive levels of micronutrientsupplementation, i.e. higher levels ofsupplementation;

ii) there was a seasonally high prevalence ofdiarrhoea and younger children are moresusceptible to infection;

iii) compliance and acceptability of supplements wasnot optimal.

The rapid worsening of linear growth during thesupplementation period argues for earlier detectionand parallel prevention strategies such as correctinginadequate infant feeding practices and interventionsto prevent intrauterine growth retardation.

In contrast, intervention B reached its aims. Reversalof stunting was achieved in children up to five withremarkable results after the relatively shortsupplementation period. This argues against the agelimit of three years beyond which it is commonlythought that catch-up growth is not feasible.

The trial raised three important questions:

i) To what extent is stunting reversible? The datafrom the study did not allow conclusion. Catchup growth was markedly accelerated in the firstthree months of supplementation but sloweddown afterwards indicating a ‘plateauing off’ ofgrowth velocity.

ii) Is there a later effect on adult height? Maturationshould be followed up in children who hadaccelerated growth compared to those who stayedat low centiles of growth velocity.

iii) Is supplementation that induces catch up growthsafe in individuals exposed to micronutrientdeficiencies since foetal life. By changing thenutritional environment dramatically from onegeneration to another and achieving phenomenalcatch-up the individuals may be metabolicallydisadvantaged ‘by imprinting’ so that they havedifficulty dealing with the new nutritionalenvironment in other ways (diabetes, heartdisease etc.) There may be an optimum rate ofpopulation improvement over time which is lessthan the maximum achievable rate.

Other issues to arise out of the evaluation were asfollows:

Although compliance was very high, the cost of theHNDS may not be sustainable in a long-termstrategy.

Nutritional surveillance is now a well establishedactivity within the refugee supplementationprogramme. The integration of the nutritionintervention into local health systems facilitatedcontact between mothers and health staff and led tomore timely treatment of common diseases.

The sensitisation campaign integrated severalsuccessful outreach strategies involving differentlevels of society. For example, the support of thecommunity at large was greatly enhanced by radiobroadcasts, participatory discussion groups andeducational printed material. Communityinvolvement promoted the sense of ownership of theprogramme and improved mobilisation andparticipation of the beneficiary population. Keycommunity leaders, especially respected women, hada strong influential role to play and their contributionwas increasingly valued throughout the project.

A final conclusion of the authors of the report wasthat vitamin-mineral fortification should beunnecessary where well balanced diets are providedand that provision of a supplementary food shouldnot detract from efforts to provide a full balanceddiet. Consequently, distribution of supplementaryfoods fortified with micronutrients should in mostcases be regarded only as a temporary solution.However, in some situations (including the Saharawirefugees) achieving a well balanced diet may be soproblematic that some form of supplementationprogramme is, at least in the short-term, a necessity. 1 Lopriore. C and Branca.F (2001): Strategies to Fight Anaemia

and Growth Retardation in Saharawi Refugee Children.Internal report, ECHO, CISP and INRAN, Rome 2001.

2 The Comitato Internazionale per lo Sviluppo dei Popoli(CISP) is part of a consortium to better co-ordinate the fieldoperations for the Saharawi refugees.

3 The Italian Institute for Food and Nutrition Research.

Fighting long-term nutritional deprivationamong the Sarahawi refugeesSummary of report1

16

Photo diary

It is June 2001- an email comes in about the Irishagency Concern stepping up their operations inAfghanistan. I had been doing a lot of free-lance

photo work for Concern in the past three years so Iwrite an email back to their head office wondering ifthis means that more photographs and case studiesare also needed. An unexpected ‘yes please’-replymeans I am on a plane out from my ‘base’ in AddisAbaba to Islamabad barely a week after the firstemail came in...

My plane arrives in at 3 AM, a good time for me toadjust to the heat, not so nice for the field staff whowait for me at the airport. A UNOCHA plane takesme across the Hindu Kush to Faizabad the next day.Concern’s Phil Miller is waiting for me by the sideof the airstrip and a briefing starts as soon as we getinto the vehicle.

This three months before the attack on the twintowers in NY, and three months before much of theworld discovered where Afghanistan actually was.Then, there were already many thousands of IDPsliving in Northern Alliance (NA) held territory,ignored by most of the world, with little or no aidreaching them.

Farida, one of the two Afghan women who work forConcern in Faizabad, helps me out as a translator forthe duration of my trip. She provided me withincredible access to women everywhere we went aswell as with great insight into what it is like to be ayoung, educated woman in Afghanistan today. Shestudied at university in Kabul; she wore trousers thenand had male friends. It all ended when the Taliban

AfghanistanJune 2001

By Pieternella Pieterse

started clamping down on people in Kabul, herfather lost his teaching job when the school closedand the family moved north where they originallycame from.

Concern’s work in the Northern Alliance-heldterritory has two target groups; war IDPs anddrought affected populations. In Faizabad and DashtiQala towns we visit the war IDPs. In the Faizabadthere is some relief effort, a number of internationalNGOs have had their offices in Faizabad since the1998 earthquake. In Dashti Qala it is a differentmatter. We find a number of informal IDP campsdotted around the outskirts of the town. There islittle aid available to these people; the frontline isclose so many NGOs have consciously refrainedfrom establishing any presence here. The lack offacilities hasn’t persuaded the IDPs to leave, there isnowhere else to go in this drought stricken area, atleast in the town there is a chance of finding casualemployment or to beg for food. Concern has built alarge amount of latrines in the IDP camps, whichhelp to keep hygiene levels acceptable. Most peopleI spoke to had lived under plastic sheeting throughthe 2000-2001 winter, in the snow. They were aboutto go into a soaring hot summer when I was thereand by now, I guess winter is upon them again.

In the Nuw Abad IDP camp the mood is desperate.We are mobbed by people who want to get theirname on our list. But we have no list... I interviewwomen who were abused and tortured by Talibansoldiers as they attacked their villages in last year’s‘summer offensive’. Many have lost husbands andsons in the struggle, all are ethnic Tajik or Uzbek.

Concern had, before last winter, encouraged localfamilies to take in IDP families, with some success.We visit IDPs who live with host families. In manycases, the local population had seen it as their dutyto take in the IDPs. The host families were helpedby Concern with some food aid and with theconstruction of a latrine in their compounds. Somehost families have now worked out a ‘rent’

agreement but many IDPs are staying for free.

From the war IDPs in Dashti Qala we move on tothe town of Dashtak, the epicentre of the 1998earthquake. On the roads (if you can call them that!)between Faizabad and Dashtak we stop to talk tomen working on road improvement as part of a FoodFor Work project implemented by Concern. Manyare from Dashtak and surrounding areas. I talk towomen about their lives. They feel hopeless. Threeconsecutive years of drought has left them with nofood or livestock on their land and while they areallowed to farm their own land, there is no chance ofthem finding jobs working for others. So they arenot only dependent on aid, they are also dependent,more than ever, on their husbands to work to get thisfood. A number of widows are included in differentfood distributions that run alongside the FFWdistributions but not enough to feed all thevulnerable families. I found many women were notwidowed but simply waiting at home for theirhusbands to return from places where they had goneto look for work. These women had no access toFFW or ‘widow welfare’ rations, but had to beg forfood. One woman had heard that her husband hadbeen spotted in Iraq; another heard her husband hadgone to a town just before the Taliban had attackedit.

On the way back to Faizabad we stop in a villagecalled Begum. Here too drought has turned thesurrounding hills into sand dunes. All women wetalk to are wives of men working on the road, theyhave returned recently. This village was deserted fora year until the road project started. The FFWproject is the only source of income in this area andthese families have returned from their desperatesearches for work in towns 2-3 days walk away. TheWFP rations aren’t very big considering betweenhow many they are shared but still this is the bestdeal around in this drought stricken area where allthe (relative) wealth lies on the Taliban held side ofthe frontline.

Pieternella Pieterse is a free-lancephotojournalist. Based in Ethiopia,she travels extensively throughouteastern and central Africa. Earlierthis year she travelled toAfghanistan with Concern in orderto document the unfoldinghumanitarian crisis.

17

Photo diary

Above: the plains outside the town of Dashti Qala must be one ofthe worst places an IDP population could have settled. Still, lack ofalternatives has forced over 100 families to do so. Too close to thefront line according to some organisations, this large group ofpeople has spent the best part of a year on the dusty, windy, valleyfloor outside the town. Exposed to the elements, children have diedof hypothermia in the winter and as the summer is on its way, manymore are at risk of heatstroke and dehydration.

Below: Zarghuna Sunhanqul and her family have been living on theplains for ten months; under an old tent canvas with the endsbarely touching the ground and side entrances flapping in thewind. Zarghuna, her husband and three of their four children sharethe tiny space, while the eldest daughter and her husband liveunder a sheet of plastic next door.“For the future; I don’t know. Only if the Taliban leaves can we goback. Otherwise we will have to stay here. I cannot imagine how wewill get through another winter here.”

Opposite page, right and below:Drought effected populations along the Puli-Begumroad, Takhar Province

For the past two years, Afghanistan has been hit bythe worst drought in memory. For the large majority,the Afghan population is made up of subsistencefarmers who are solely dependant on what they growon their plots of land. Worst hit were the farmers wholive and plant on land which is not covered by theextensive irrigation systems that are in place in manyparts of Afghanistan.People in the highlands of Takhar only have theseasonal rains to rely on for watering their crops, astheir villages are too far from any rivers to be

irrigated. When the rains failed last year, people hadto resort to selling their livestock and somehousehold goods to buy grain from irrigated land faraway. When their carefully saved up and plantedseeds shrivelled up and died due to this year’s lackof rain, people ran out of ways to cope. Many packedup whatever they had and left their villages. Scores ofdeserted villages were the result of a mass hunger-induced exodus. Recently some people in the areahave been able to come back. Concern started aFood-For-Work (FFW) project at the end of May 2001and many families have taken the chance to movehome to earn a living by upgrading the road thatpasses though their villages.

In the doorway of the army administration building that has beenturned into shelter, stands a frail woman holding a tiny baby.Zemrad the mother, came with her husband and four children fromBoharaq village in Takhar province and like all others in the shelter,fled the Taliban army that captured their homes.“We are poor, we have nothing more to sell. We have received nofood in 5 months. All I do is go begging and ask for scraps of food.My husband just leaves the camp because he can’t stand it.Sometimes he stays away for 2 or 3 days. He sleeps on the streets.He is sick. He wants to go home but we can’t. People are stillfighting.”

Naser Begum is around 40 years old. She lives in one of the tentsalong the river with her four sons. Her face is marked with sorrowand grief. Naser lost her husband in a Taliban bombardment only 10months ago. She is in mourning, but has little time to do so, as shestruggles to make ends meet and to somehow make sure she andher children survive.“First we lived in Lewa camp on the other side of town, but it wasvery crowded. We came here because the river is nearby and atleast we have water. We were in this tent all through the winter. Itwas very cold. It was muddy and sometimes there was snow on theground. The situation is bad. The water from the river is dirty, butwe have no other choice then to drink it. We haven’t received anyfood in 5 months. I sold all the things I had save a few cups andblankets, I have nothing left that I could sell to buy food. I amsending my children out to beg for scraps and that is what we liveon at the moment.”

The Concern road building project has not only drawn the mostrecent drought displaced people back to the villages along theKhana Qa - Dashtak road, it has also drawn back families who leftin 1998 and who have been facing hard times in the town theymoved to.Mumajan Amra is the mother of one such family. In 1998 she lost 8members of her extended family in the earthquake, including her16-year-old son. They moved away to the town of Rustaq where shelooked after her blind husband while her older sons foundemployment to care for the family.The mother of 8 wears a typical ‘city’ outfit, a little different incolour and cut than one is used to in these dusty villages, shestands out a little in the group of Dashtak women she has justrejoined.

Qamargul Saidahir is 31 years old. She lives in the village of Bikhaon the Khana Qa to Dashtak road. Her house is no more than fourlow, mud walls, with what looks like a tent canvas covering the topto keep out the sun and some of the dust. She is shockingly skinnyand sways dizzily as she gets up to shake our hand.“I am sick,” is the first things she says, as if to excuse herself forher skeletal appearance. “As we sit down she sums up what ishappening to her. “My husband has gone away to look for work. Heis in Iran and he has left me and our daughter behind. He hasn’tsent us any food, we haven’t heard from him at all. I am sick, I don’tknow what it is, and I have no money to see a doctor.” Her handstrail in the air and tears roll down her cheeks. “I don’t know what todo anymore. How am I supposed to feed my daughter? How are wegoing to survive?”

IDPs, Now Abad, Dashti Qala, Takhar ProvinceWhen the Taliban advanced on Takhar province in the summer of2000, many civilians fled northeast, to the north of the province,which was, and is, still in hands of the Northern Alliance. The townof Dasthi Qala and its surrounding villages, with its open plainsbecame a popular destination, despite the proximity to the frontline...By June 2001, 3000 families, as many as 20,000 IDPs were living inDashti Qala town and adjacent villages. Luckily, some IDPs foundshelter with host families, living in much more comfortableconditions than the majority of their fellow displaced, who areforced to live in the open in a large and windy plain.

18

Agency Profile

An impromptu visit to colleagues at the ICRCin Geneva proved warm, friendly andinteresting. It left me with the sense that

despite its grand location in the middle of beautifulGeneva, though somewhat isolated from itsoperations, the organisation was anything butremoved from the victims it is mandated to protect.

There is a buzz of energy and commitment within theworking offices of ICRC ... of people just back from‘mission’ or about to go... and a sense of extensiveexperience in the field of international disaster reliefand assistance. The dynamism, casual dress andsmoke filled canteen creates an atmosphere much likeany major operational NGO.

However ICRC is not like any NGO as its head ofrelief operations Geoff Loane explained. ‘ICRCdiffers from other NGOs principally in terms ofmandate. While we are committed to relief assistancethis is in the context of the protection of disasteraffected victims - in other words we are protectionrather than assistance-driven’.

Alain Mourey, ICRC’s Nutritionist at HQ, hasdecades of experience in emergency work. He joinedICRC after graduating from the MSc course inHuman Nutrition at the London School of Hygieneand Tropical Medicine in 1982. Alain has played asignificant role in developing and shaping ICRC’snutrition and assistance policies over the past 19years.

My first question to Alain had to be why ICRC, incontrast to almost every other humanitarian agency,invoked and persisted in using the QUAC stick (basedon a combination of height and mid upper armcircumference) to identify and treat malnutrition incommunities. Alain explained how this came about.Having completed research on anthropometricindicators in a hospital in Geneva he tested out someof his findings in a therapeutic feeding programme inHuambo, Angola in the early 1980s. In thisemergency Alain admitted children to the TFP centrewith severe malnutrition based on clinical criteria ‘Ipicked out children who were undoubtedly severelymalnourished who could benefit from what we had to

offer’. Alain also took height, weight and MUACmeasurements of every child and discovered that if hehad admitted on the basis of weight for heightmeasurements virtually none of the children wouldhave been admitted. This and other similarexperience’s in Uganda, Cambodia, Thailand andEthiopia convinced Alain that using the QUAC stickwas not only quicker in surveys and rapid appraisalsbut also identified the right children for treatment.Weight for height, he points out, is problematicbecause weight can be confounded by medicalconditions such as worm load, inflammation, bowelcontents and water retention. In Ethiopia there was abetter correlation between weight for height andQUAC stick measurements in low land areas wherethere was no infection or worm load.

Alain was keen to broaden the scope of ourdiscussion and pointed out that anthropometry is onlyone tool which may or may not be used in theassessment of the nutritional situation of apopulation. ‘In some cases the situation is patchywith wide variations in nutritional status soantropometry is not helpful while in others everyoneis affected and it’s crazy to target, for example inBurundi everyone is in need.’

Alain explained how ICRC had been forced by thescale and complexity of relief operations of the early1980s to refine its conceptual approach tointerventions on the basis of health problems thatcivilian populations are likely to face in conflict.Alain described the conceptual approach used byICRC known as the “Health Pyramid” as more ‘amatter of common sense’ than anything else. It setspriorities for intervention so as to reduce as quicklyand effectively as possible the risks of morbidity andmortality faced by the victims of armed conflict.Access to food and water is given precedence andhealth services take second place.

Looking back over the last two decades Alainidentified areas where he felt the emergency nutritionsector has advanced and highlighted areas ofstagnation or regression. Unafraid of beingcontroversial, Alain is critical of the Sphere project.He sees the project as contributing to the continuingfragmentation of nutrition into separate andspecialised fields. This is underpinned by the way theSphere project separated Nutrition and Food aid(soon to become Food Security) as two subjects inthe SPHERE handbook. This Alain feels is dangerousand has already had repercussions in the field. Hesays ‘Agencies are specialising so much in narrowfocused responses like therapeutic feeding that theyare beginning to lose sight of the economic and food

Name International Committee ofthe Red Cross

Address 19, Avenue de la Paix,1202 Geneva, Switzerland

Telephone 00 41 22 734 60 01

Fax 00 41 22 733 20 57

Internet site http://www.icrc.org

Year formed 1864

President Mr Jakob Kellenberger

Director-General Mr. Jean-Daniel Tauxe

Overseas staff 1200 approx. expatriatesand thousands of nationalstaff

HQ staff 600 approx.

Annual budget Changing depending onhumanitarian need In 2000a record global budget of1088 millions Sfr.

ICRCInterview by Fiona O’Reilly with Alain Mourey

Key elements of ICRC’s full missionStatement:

• The organisation’s mission arises from the basichuman desire, common to all civilisations, to laydown rules governing the use of force in war andto safeguard the dignity of the weak.

• The organisation has received a mandate fromthe international community to help victims ofwar and internal violence and to promotecompliance with international humanitarian law(IHL).

• The organisation’s activities are aimed atprotecting and assisting the victims of armedconflict and internal violence so as to preservetheir physical integrity and their dignity and toenable them to regain their autonomy as quicklyas possible.

• Through its work the organisation helps toprevent the worsening of crisis and even at timesto solve them.

Family packets distribution toTchetchen refugees in Grozny, 1995

© PAUL GRABHORN (ICRC)

19

Field Article

Tajikistan is the most land locked country in theworld. The country covers 143,100 km2, anarea approximately equivalent to the size of

Greece. The country is split into four majorgeographic zones. Most of the country lies over 3,000metres above sea level.

Political Analysis1

Following the disintegration of the Soviet Union in1991, the newly acquired independence of Tajikistanparadoxically had a destabilising impact on thecountry which is populated by less than 6 millionpeople. The end of the Soviet era marked theoutbreak of a struggle between the five mainregionalist groups in Tajikistan: Leninabadis,Gharmis, Pamiris, Kulyabis and ethnic Uzbek Tajiks.The main cause of the 1992 -1993 civil war was astruggle for control of the resources of the country:land, cotton, and aluminium, as well as for control ofthe government. The war was also motivated by adesire to control the drug traffic network. Tajikistanis the transit route for drug producers in Afghanistan,Pakistan, South East Asia, etc.

In 1992, Russia and Uzbekistan were not satisfiedwith the results of the Tajik elections that gave powerto a democratic-Islamist majority. Therefore, bothcountries were instrumental in the outbreak of civilconflict and were directly militarily involved throughtroops on the ground. Russia and Uzbekistan couldnot take the risk of allowing a pro-Islamistgovernment to become established in Tajikistan thatcould have become a back yard for Uzbek Islamistopposition and could have had a “domino” effect onCentral Asian Republics and on the volatile Muslim

Republics of Russia.

The signing of a peace agreement in June 1997marked the end of Tajikistan’s civil war, whichclaimed over 50,000 lives and caused thedisplacement of 700,000 people. Numerousinternational actors stepped in, e.g. a contact groupconsisting of Russia, Pakistan, Iran and Central AsianRepublics, UNMOT, the OSCE, the InternationalMonetary Fund, the World Bank and the EuropeanCommunity, to encourage the different Tajik partiesto implement the signed peace accord.

During 1999 and 2000, there was significant progressin the implementation of the peace agreement: themilitary wing of the United Tajik Opposition (UTO)was dissolved and former members wereincorporated into government. Nevertheless, theoverall political and security situation remainedfragile. While the risk of resumption of the civil warseems to be relatively low, there are still parties whoremain frustrated by the numerous irregularitiesreported in connection with the campaigns and votingduring the Presidential and Parliamentary elections(respectively in November 1999 and February-March2000). There is a fear that this frustration could yetturn into violence.

Macro-economic situation

Tajikistan had always been the poorest republic in theSoviet Union. The end of the Soviet era resulted inthe cessation of subsidies and the supply of rawmaterials and inputs from Moscow and high rates ofunemployment without any social protection fromcentral government. The post Communist and post-war period in which there has been some movement

AAH in Tajikistan: A flexible response based onanalysing the causes of malnutrition

Frances Mason is Nutrition and Food Security Advisor for AAH-UK. Her pastsix years with the ACF Network has involved work primarily in the Horn ofAfrica, Central Asia, South East Asia and the Balkans. She has previouslyworked with MSF, UNICEF and local organisations in India and Bangladesh.

security context in which malnutrition occursand therefore respond inappropriately. Forexample, NGOs are sometimes unable to step inand fill food gaps when for whatever reasonWFP cannot implement a general distributionprogramme because the NGOs say they cannotdo General rations.’ ‘In this type of situation anisolated therapeutic feeding programme canhave little impact’ Alain exclaimed in dismay.

On the positive side he believes that thenutrition sector has become increasinglyprofessional. For example, Alain stronglysupports the development of food economytools and analytical approaches which havehelped field workers understand the context ofmalnutrition and devise responses accordingly.Furthermore, proponents of this approach, e.g.SCF FSAU, have been able to documentapproaches for others to use. Also the explosionof technology has meant easier dissemination ofadvances. Improved communications has alsofacilitated the coming together of nutritionpersonnel through various networks.’ Notableamongst positive developments has been workby Prof. Mike Golden on type 1 and type 2nutrients and the development of F100 for thetreatment of severe malnutrition.

Alain highlighted a recent important policydevelopment in ICRC. In the early nineties theICRC adopted a resolution aimed at protectingvictims against famine1. This was an importantmove for advocacy purposes but alsooperationally as humanitarian workers had toconcentrate more on the impoverishmentprocess – which leads to the levels ofmalnutrition and destitution associated withfamines. In order to detect impoverishment,methodologies that describe and monitorpeople’s economic behaviour have to be used.The realisation that famines are economicdisasters, which bring about social disruptionbefore becoming health disasters led toprofound changes in research as well as fieldwork. In particular it became clear that copingmechanisms that people use in the face of crisiswere one of the most important factors to takeinto account when deciding on the timing andcontent of humanitarian relief. Sooner or latercoping means surviving at the cost ofimpoverishment and increased vulnerability. Aslong as impoverishment means using reservesput aside as a buffer against hardship it is anormal phenomenon. However, when copinginvolves losing essential assets – in particular,means of production – it becomes extremelydangerous and has to be stopped as soon aspossible. For ICRC the decision to providehumanitarian assistance should come at thispoint. Eventually the realisation took hold thatfood is not the only resource people need tosecure in order to survive. This was particularlyevident in the Soviet Union and formerYugoslavia where ICRC’s experiencedemonstrated the necessity of examiningpeople’s economic circumstances in war as wellas their access to food. This experienceeventually led to the establishment in 1998 ofthe ICRC’s Economic Security Unit.

On leaving the ICRC I realised that my pre-conceptions about the agency may have neededsome revision. The ICRC is not always knownfor a readiness to share information andexperiences with other agencies in the field, Ionce heard their acronym interpreted as - ICouldn’t Really Comment. This however wasnot my impression as Alain seemed eager to talkand share experiences until the very last minuteof our meeting before rushing off for his nestmission... to Angola.1 Resolution no. 13

Mothers with children from feeding centres ©F

RA

NC

ES

MA

SO

N

20

Field Article

towards the establishment of democracy and a free-market economy has failed to live up to theexpectations of the population. Consequently, there isa pervasive nostalgia for the previous system whenthe state assured the provision of food, access to freehealth care, education, pensions and salaries.

The civil war further exacerbated matters and led tothe breakdown of economic networks, loss ofconfidence from investors, deterioration of productiveinfrastructure, and the emigration of professionalsand flight of capital. This led in turn to ‘knee-jerk’policies providing short-term responses to longer-term problems as illustrated within the agriculturalsector.

The collapse of the Soviet agriculturalsystem of production

Prior to the collapse of the Soviet Union the mainsource of livelihoods for rural households was thecollective farm (the kolkhoz) or the state farm (thesovkhoz). Workers on these farms were paid forworking as a member of a brigade which wasresponsible for a particular area of land. The Statetold the kolkhoz what should be produced and inwhat quantity. The workers were paid in relation toproduction targets set by the farm.

Until 1995, the kolkozes were still able to pay theirmembers a small salary despite the fall in productionarising from the breakdown of the centrally plannedeconomy and the effects of the civil war. However,the devaluation of the currency led to the bankruptcyof most of the state and collective farms. Since thistime the farms have been unable to recover andusually have to sell their produce in advance to payoff debts.

The productivity of the kolkhozes has also beenadversely affected by:

• the rupture of supply networks for raw materialsand inputs;

• the destruction, looting and disrepair of buildings,irrigation systems and assets;

• the emigration of specialists; • the control of input supply and marketing by State

monopolies; • the breakdown of control and monitoring leading to

increased corruption and diversion of capital andassets.

Reforms to alleviate poverty

The Government supported by International FinancialInstitutions2 has adopted a policy of aiming to rapidlyincrease economic growth in order to improve theliving standards of the population. The governmenthas based a large part of its agricultural reform policyon the privatisation of land use. In 2000, 450,000hectares of land were cultivated by 17,100 privatefarmers. However despite the law, which states thatany able-bodied citizen of the country has the right tocreate a private farm, access to private land isrestricted to the limited number of people who havethe financial capacity to pay the official andunofficial taxes and to purchase the necessaryagricultural inputs to cultivate large plots.3 At thesame time the banking system is very poor and theopportunities to get loans are extremely low.Therefore, the majority of the population do not‘own’ private farms. Furthermore, all private farmsare obliged to use 65-70% of the land for cottonproduction and according to the farmers, if they donot grow the cotton, the authorities will take back theland.4

Consequently the economic decline in the agriculturalsector continues and there are increasing socialdisparities among the population, which could easilyjeopardise the political and economic stabilisationefforts.

The evolution of humanitarian assistance

Humanitarian interventions began in Tajikistan toaddress the effects of the war through the provisionof material relief assistance to meet the basic and

immediate needs of the population. As the situationchanged so has the form of assistance which hasbecome more focused on strengthening the capacitiesof households, civil institutions and governmentstructures to be more productive and self sufficient.As this transition is taking place, interventions havetended, more and more, to address the impact of theeconomic collapse and transition rather than theconsequences of the civil war.

Nutrition Causal Analysis

An anthropometric survey undertaken by AAH in20005 found that acute malnutrition was identifiedmostly in children between 6 and 36 months of age.Using mean Z-scores, the analysis revealed that acutemalnutrition peaked between 12 and 18 months.There was little evidence of acute malnutrition inchildren over 36 months of age. (In 1999 and 2000respectively, the relative risk of children 6-29 monthsof age having global acute malnutrition was 4.08(3.20<RR<5.19) and 5.66 (4.36<RR<7.35) timesgreater than children aged 30-59 months.

Results of a separate but simultaneously conductednutritional causal analysis suggest that inadequateinfant feeding practices and poor water and sanitationfacilities within the household were the mainunderlying causes of malnutrition amongst childrenunder 5 years. Exclusive breast feeding of children upto 6 months of age was not widespread while earlyintroduction of complementary fluids/foods wasprevalent. The inherent risk of malnutrition due tothese practices was compounded by unhygienichousehold environments. It was found that childmorbidity, in particular the incidence of diarrhoea, isa seasonal phenomenon: prevalence of diarrhoeapeaking during the summer months. This reflects adeterioration in the quality of water consumed. Manyhouseholds report consuming water from irrigationchannels and rivers, the availability of whichconsiderably decreases during the summer. Theincreased incidence of diarrhoea in summer is alsoexplained by inadequate sanitation facilities and anincrease in vector contamination.

The fact that access to, and availability of, qualityhealth care is universally inadequate contributes tothe unnecessary prolongation of disease and increasesthe risk of malnutrition. Poor access to health care isdue to low levels of state input into the health caresystem (14.7% of the national health budget isallocated to primary health care) and also thehousehold environment, which in turn depends ondegrees of poverty and levels of food insecurity.Mothers in households which are food insecure arelikely to spend more of their time out of the housetrying to generate food and/or cash income.Therefore, less time is being spent with youngchildren. Furthermore, expenditure and time spent onhealth and hygiene is less likely to be prioritised.

Food insecurity was identified as a significantproblem. Most of the vulnerable families, in the areasin which Action Against Hunger were workingproduced between 3-6 months worth of food for the

year. The limitations on production are: access toland, access to a functioning irrigation system, accessto good quality agricultural inputs and access to othersources of income. The current drought has onlyaggravated the situation. Preliminary results of aWFP and FAO7 assessment have shown that in 2001there was 44 - 84% of the normal amount of rainfall,the snowfall was lower, and the level of surface wateris 40 - 85% lower than the previous year. Hence foodimport requirements for Tajikistan in 2001 will behigh.

Action Against Hunger (AAH) strategy inTajikistan

Following analysis of the surveys undertaken byAction Against Hunger in 19998 and 20009, AAHdecided to implement both curative and preventivestrategies to combat malnutrition. This involved amulti-sectoral approach. Four crucial sectors wereidentified and activities developed:

1. Treatment of acute malnutrition. Action AgainstHunger opened four therapeutic feeding centres inTajikistan. Each TFC is integrated into existingstate hospital structures. A large number ofsupplementary feeding centres were alsoestablished.

2. Strengthening the health centres capacities inmother and child health care provision. Thisinvolved refresher training of medical personnelfrom medical facilities, distribution of basicmedical equipment to medical facilities and healtheducation at the community level and in schools.

3. Assessing the water and sanitation situation. Thereis a high prevalence of water borne diseases due topoor sanitary environment and limited access todrinkable water.

4. Strengthening food security at the household level.

As noted above, food insecurity was identified as amajor problem for households. AAH realised thatfood security could be significantly improved by:

• optimising crop production on household plotsthrough the rehabilitation and the rationalisation ofirrigation systems and the distribution ofagricultural inputs (the rehabilitation of theirrigation systems allows for an improved usage ofland which is currently either not used to its fullpotential, or may even be left barren),

• increasing access to livestock,• promoting Civil Society initiatives.

Working through community basedorganisations

An example of a Civil society initiative is theCommunity Development Committees (CDCs) whichwere first established in May 1995, by UNHCR incollaboration with the UNDP Peace and ConfidenceBuilding Project. These committees have been usedfor a number of purposes, e.g. supporting peaceconsolidation and confidence building amongst theyouth and the promotion of social and economicintegration of returnees. The CDCs have also beenused to promote food security initiatives.

In 2000 Action Against Hunger became involved with7 CDC programmes aimed at increasing the foodsecurity status of vulnerable families throughlivestock and agricultural credit schemes organisedby CDC-run farms. The specific objectives of theseprogrammes were to:

• reinforce the management and the financialsustainability of the farms,

• enhance the CDCs structures to become reliablelocal NGOs,

• increase the number of beneficiaries of theprogramme,

• develop and reinforce the credit scheme,• create a management structure integrating the

CDCs, the Village Committees and the beneficiaries

Conclusions and Recommendations

Since the Peace Agreement of June 1997, Tajikistanhas made some economic and political progress.

0

2

4

6

8

10

12

14

16

18

Severe (6-29mths)

Severe (6-59mths)

Global (6-29mths)

Global (6-59mths)

ValleysPlainsMountainsPeri-urban

% M

alnu

triti

on

Table 1: Nationwide survey of Tajikistan: AcuteMalnutrition as expressed in Z-Scores.6

21

Letters

However, poverty is still rife. This isprimarily due to limited employmentopportunities which provide adequateincome particularly in agriculture in normalyears. Furthermore, the civil war, combinedwith transition from a centrally planned to amarket economy, has weakened the socialprotection systems. The poorest lack accessto health care, safe drinking water and food.

Economic reforms are infrequent andslowly implemented. There have been a fewfundamental changes but these are mainlyshort-term measures in response to asituation of crisis. The current governmentis trying to keep in place a past systemwhich is still profitable for the“apparatchiks” (members of the communistsystem) while making some small-scalereforms to maintain the IMF and WorldBank support.

The liberalisation of the economy in theagricultural sector, encouraged by westerncountries and financial institutions, mustpass through two main steps: 1)privatisation of the land; 2) theestablishment of a free market. However,the Tajik government is reluctant to beengaged in such economic transition.Therefore the land mostly remains as stateproperty and is farmed by the collectivefarms so the produce, particularly exports,stays under the monopoly control of statefirms.

The current position of the government ishowever in accordance with the wishes ofmost of the population which seems toyearn for the return to the former systemwhere there was certainty that at least basicneeds would be met.

In this context some careful choices have tobe made by the international community.Full-scale return to the former system basedon government assistance and dependencyof the population on state structures is notthe answer. At the same time it is

questionable whether the role of thehumanitarian community should be topromote a western economic system whichcompletely eradicates the current collectivesystem.

The future policies and intervention of theinternational community have to becarefully thought through and defined. Theemphasis is currently being placed onmacro-economic reform and intervention -most notably the promotion of privatisation.The role of humanitarian NGOs like AAHshould be to advocate for full consultationand inclusion of the Tajikistan people in theeconomic reform process and theestablishment of social protection policieswhile adjustment is taking place. Tajikistanhas provided an unusual context forintervention for Action Against Hunger. Theemergency arose out of the collapse of aneconomic and political system and wascompounded by conflict. The experiencehas shown how it is essential that NGOssuch as AAH remain flexible in mounting aresponse based on causal analyses. 1 Tajikistan: The Role of NGOs in Food Security.

Chris Leather, Jean-Michel Grand, FrancesMason. Geopolitics of Hunger. 2000.

2 The World Bank, The IMF, Asian DevelopmentBank.

3 In an assessment undertaken by Action AgainstHunger, 45% of the farmers interviewed admittedthat they had paid between 100,000 and 400,000TR per hectare in addition to the officialregistration fees to get good land to establish adekhan farm.

4 Land Reforms and Farm restructuring, ActionAgainst Hunger, October 2000

5 National Nutrition Survey of Tajikistan: September/ October 2000. Evan McLachlan, Action AgainstHunger, Undertaken in collaboration with MissionEast, World Food Programme, InternationalFederation of the Red Crescent (in partnershipwith the Tajikistan Red Crescent) and GermanAgro Action.

6 Global acute malnutrition is expressed as <-2 z-scores and severe acute malnutrition is expressedas <-3 z-scores and/or nutritional oedema.

7 Report published on WFP / FAO website22/07/01.

8 Nutritional Causal Analysis: Tajikistan. ActionAgainst Hunger, Chris Leather,September/October 1999.

9 Nutritional Causal Analysis: Tajikistan. ActionAgainst Hunger, Morwenna Banham,September/October 2000.

Dear Field Exchange,

Revised MSF nutrition guidelines

We would like to comment on the draft of the newly revised MSFguidelines for the treatment of severe malnutrition (Issue 12, April2001). We appreciate that some practices have to be simplified inemergency settings, especially initially when there is a sudden influxof large numbers of patients, and staff are newly recruited. We areconcerned, however, that the proposed divergence from ‘bestpractice’ will result in unnecessary deaths.

1. Standard diet (one vs two formulas). There are very considerablerisks in simplifying feeding to just one formula (F-100) and failingto give F-75 in the initial phase of treatment (particularly for patientswith oedematous malnutrition). For example, two of us (MG, YG)recently visited two therapeutic feeding centres in Africa wherekwashiorkor is common. The first centre used the MSF protocol withonly F-100 and about 20% of the children died during treatment. Incontrast, in a neighbouring centre which used F-75 as the initialtreatment, only 5% died. We examined some of the newly admittedchildren receiving F-100. The first four children we saw were all inheart failure, which MSF correctly emphasise is a risk when F-100 isfed too early. We have had this experience several times-usually theheart failure is misdiagnosed as pneumonia. A 3-times highermortality was also found among severely malnourished adults fed asingle high protein formula from admission (Collins et al, 1998).

F-100 has too much sodium and protein for the very ill malnourishedpatient, and too high an osmolarity. F-75 was specifically designedto reduce deaths during treatment by taking into account thedamaging effect that malnutrition has on cells and organs. With pre-packaged products, it is not difficult to provide both F-75 and F-100.Thus to make F-75: open one red package and empty into 2 litres ofwater in a red bucket, stir and give according to instructions. For F-100: open one blue package, empty into 2 litres of water in a bluebucket, stir and give according to instructions.

Many NGOs (including ACF, CONCERN, GVC, IMC and ICRC)are already using F-75 and F-100, without encountering thedifficulties or the confusion that MSF fears.

2. Feeding frequency. MSF makes no mention of feeding very illchildren at night in 24 hour care units. Experience has shown thatdeaths often occur at night or early morning conventionally ascribedto hypoglycaemia and hypothermia. These deaths can be preventedby night feeding and such a practice should be included in treatmentrecommendations.

3. Routine treatment with iron MSF advises: ‘Iron with malariatesting’. The meaning of this is not clear, but if it means that ironshould be given routinely, this is contrary to WHO advice which isbased on evidence of higher mortality when iron is given in theinitial phase (Phase 1). In severe malnutrition, reduction in iron-binding transferrin means children are less able to bind all the irongiven to them. Any ‘free’ iron is harmful because it promotesproduction of highly damaging free radicals. Free iron also promotesthe growth of some pathogens, making some infections worse. Thus,iron should never be given during the initial phase of treatment untilthe child has re-synthesised sufficient iron-binding proteins. It shouldbe given only during the rehabilitation phase.

4. Antibiotics. MSF advises that antibiotic treatment for adultsshould be given only if there are signs of infection. This adviceconflicts with WHO recommendations. In severe malnutrition theusual signs of infection, such as fever, are often absent and infectionsremain hidden. Antibiotics should always be given straightaway toall severely malnourished patients, regardless of age.

For the reasons set out above, we do not think that suchcompromised recommendations should be included in a treatmentmanual that has previously had a high reputation and been widelyused. We encourage MSF to reconsider their guidelines.

Yours sincerely

E. C. Schofield and Ann Ashworth, London School of Hygiene andTropical Medicine

Professor M. H. N. Golden,

Dr Y. Grellety. ReferenceCollins S, Myatt M, Golden B. Dietary treatment of severe malnutrition in adults.Am J Clin Nutr 1998; 68: 193-9.

letter

©F

RA

NC

ES

MA

SO

N

22

Field Article

The Concern programme in North EasternAfghanistan (in non-Taliban held areas) hasbeen operational since 1998 in two provinces

Badakshan with a population of 842,702 and Takharwith a population of 883,910. In this area there wasan estimated internally displaced population ofaround 100,000 people. The Concern programmefocused on food security (food distribution and foodfor work projects), water/sanitation and educationalinfrastructure. The rationale for the survey reportedon in this article developed in response to the influxof IDP’s into the area due to the ongoing conflictbetween the Northern Alliance and the Taliban, andalso the ongoing drought conditions, which resultedin crop failure, displacement and general foodscarcity. It was felt that the nutritional status waspoor and an in depth nutrition and food securitysurvey was required to help direct futureprogramming needs.

In August 2001 Concern Worldwide commissionedValid International to conduct a nutrition, health, andfood security assessment in Badakshan Province, NEAfghanistan. The survey used both quantitative andqualitative methods to estimate the prevalence ofacute undernutrition in children and their mothers.The survey also provided information aboutagriculture, household food security/economy, copingmechanisms and information about patterns ofmorbidity and mortality.1

Based on the survey findings, this article argues that,in the absence of context, the results of nutritionalsurveys are almost meaningless. Traditionally,children under five years of age are viewed as asentinel group reflecting the nutritional status of thepopulation. In the Khosh Valley of BadhakshanProvince of NE Afghanistan we found a prevalenceof acute wasting undernutrition of 11.5% (95% CI =8.7%, 14.9%) in children under five using standardcut-off points for weight-for height Z-scores. Takenalone, these figures do not suggest impending orongoing famine. For example, Table 1 compares ourdata with data from two nutritional surveys in Africaboth of which were classified by the RNIS as gradeIII or IV (i.e. no pending or impending disaster).

In this article we describe the circumstancessurrounding the headline prevalence figure anddemonstrate that, when other factors are considered,the people of the Khosh Valley are on the verge offamine.

Choice of indicator

In addition to measuring children under five years ofage, we assessed maternal undernutrition using aMUAC (< 21.5 cm) cut-off point corresponding to aBMI of below 16.0 kg/m2. which defines severechronic adult undernutrition for women. We found21.2% (95% CI = 16.0%, 27.1%) of mothers to beseverely undernourished. Qualitative investigationrevealed preferential feeding of children, withmothers reducing their own intake before reducingthe intake of their children or husbands. This

information was verified by interviewing a variety ofgroups using different methods (in-depth interviewswith mothers and community leaders, focus groupdiscussions with mothers and community leaders,‘natural’ focus group discussions with men atmosques and guest house sites). The qualitative andquantitative results are consistent with each otherindicating that, in this population, prevalence of acuteundernutrition in the traditional sentinel group aloneis not a good choice of indicator for community levelnutritional stress.

Public health environment

Communicable diseases and undernutrition constitutethe principal health problems in the area. Markedseasonal variations were described by communitymembers and health staff. These are summarised inFigure 1.

The public health situation in the Khosh Valley waspoor. Diarrhoea and ARI were the most commoncauses of childhood mortality. Both preventative andcurative services were limited in scope andinadequate. All villages complained of a lack ofpotable water. The water table had droppedconsiderably with recently constructed wells in themiddle of the valley now drying up. Springdischarges were approximately half their usual levels.This had an effect on the quantity of water availablefor irrigation as well as for drinking and hygienepurposes. The lack of potable water was often citedas the cause of diarrhoea but faecal disposal methodswere far from ideal and this, combined with a lack ofwater for washing, is probably as important a causeof diarrhoea as contaminated water.

Diarrhoea and fever were significantly associatedwith acute undernutrition. This finding agrees withother reports that cite diarrhoea as an important causeof undernutrition. Figure 2 illustrates this relationshipusing data from previous nutritional surveysconducted amongst non-displaced populationsthroughout Afghanistan between January 2000 andAugust 2001.

Crops

The rainfed winter and spring wheat crops havefailed for the second consecutive year. The smallquantity of grain harvested was of poor condition,contaminated with smut, and not of seed quality.Yields per unit of seed (i.e. the number of kilogramsof grain harvested for each kilogram of seed planted)ranged between zero and 3.8 averaging 1.4. Yieldsper hectare ranged between zero and 416 kg / hectareaveraging 133 kg / hectare. The irrigated winter andspring winter wheat harvests were also poor due tolack of irrigation water. Yields per unit of seed rangedbetween 1.7 and 17.5 averaging 5.5. Yields perhectare ranged between 292 kg / hectare and 2450 kg/ hectare averaging 940 kg / hectare. The harvest ofbarley, the second commonest staple, was equallypoor. The poor grain harvests over the previous twoyears are reflected in steadily rising cereal prices(Figure 3).

Table 1: Prevalence of under-nutrition in three settings

Location Global Severe Date Source Interpretation

Khosh Valley, Badakshan 12% 3% Sep 2001 Concern / Valid Impending famine

South Sudan (BEG) 18% 1% Oct 1999 MSF-B Stable but vulnerable

Kenya (Dadaab Camp) 16% Dec 1999 MSF-B Stable

The danger of interpreting anthropometric data out of context

0

2

4

6

8

10

12

14

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Glo

bal U

nder

nour

ishe

d (%

)

diarrhoeaseason

diarrhoea season

010000200003000040000

50000600007000080000

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Month

Pric

e (A

fg)

Mark Myatt is a consultantepidemiologist and senior researchfellow at the Institute ofOphthalmology. His areas ofexpertise are infectious disease,nutrition and survey design. He iscurrently working on a rapidassessment procedure fortrachoma prevalence.

Gwenola Desplats is a nutritionistwith an initial background in foodscience. After working in India andBangladesh, she developed aninterest in nutrition in complexemergencies and worked in DRC,Afghanistan and Ethiopia, withACF, Concern, and Save theChildren-US respectively. She is aPhD candidate at Tufts Universityand is undertaking her dissertationresearch in the area of CommunityTherapeutic Care.

Dr. Steve Collins is a NutritionConsultant working for ValidInternational and has worked inmany complex emergenciesfocusing on assessments andestablishing emergency nutritionalinterventions and evaluations. Hisresearch interests include severeadult malnutrition and communitytherapeutic feeding. (Photos ofSteve are welcome!)

Figure 1: Disease calendar

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

ARI ARIWatery diarrhoea

Bloody diarrhoea

MalariaMalnutrition

Figure 2: Global Undernutrition (WHZ) in non-displacedpopulations in Afghanistan, January 2000 - August 2000Sources: ACF, Concern, Focus, MSF, SCF, Solidarite

Figure 3: Trends in wheat prices (Jan 2000 - Aug 2001)

Wheat prices (Afg / Kg) January 2000 - August 2001(Source: WFP, Concern)

1 Nutritional anthropometry, health, food security and agriculture assessment, Concern programme areas northeast Afghanistan,October 2001. Report compiled by Collins S, Myatt M and Desplats G. Available online at http://www.concern.net/

23

Field Article

Potato and onion harvests appeared to have beenreasonably good although farmers reported lowerthan average yields. Harvests of other crops werestrongly dependent upon the area of irrigated landcultivated and the diversity of crops planted. Cropdiversity was low with only a small minority offarmers planting vegetables such as carrots,tomatoes, aubergines, turnips, and pumpkins otherthan in small irrigated areas (kitchen gardens).Production from these areas will be consumed beforethe start of winter.

All farmers interviewed reported planting opiumpoppy. Yields were low, averaging 0.45 Kg perfarming household. Combined with the collapse oflabour markets, this will probably lead to an inabilityto compensate for production shortfalls usingpurchased food.

Figure 4 presents a calendar (May 2000 - July 2002)that provides an estimate of the proportion of foodneeds that will be met by stocks of staple foods. Thepercentage shown on the y-axis of each chartrepresents the percentage of farmers who report thattheir food stocks for a particular staple will besufficient to meet their requirements during aparticular month.

Livestock

Most poorer farmers have already sold their livestockin order to compensate for production shortfalls.Markets operate as a cartel. Livestock prices werelow and wheat prices high. Sale of livestock wasassociated with a reduction of dietary variety due tothe loss of sources of meat, animal fat, eggs, andmilk. Livestock are an important source of winterfuel and for maintaining soil fertility. Livestock saleshave left people with small herds sufficient, onaverage, to provide only 230kg of cereal if sold at thelocal market. This quantity of grain would feed afamily of eight for approximately 2 months. Fodderproduction (winter-feed) has been affected by lack ofwater and it is likely that a fodder shortage will occurduring the winter months. This may seriously affectlivestock with decreased milk yields and may furtherdepress the livestock market reducing the viability ofselling livestock as a coping strategy.

Fruit and wild foods

Fruit was available at the time of the survey and wasan important source of both food and income. Somefamilies gather wild cumin for sale to petty traderswho sell it on at a small profit to traders in themarket towns. Collection and consumption of wildgrasses and vetches was also reported. Both fruit andwild food will not be available during the winter.

Labour

Wage labour (agricultural labour, mining, donkeydriving, service) was a common source of income.Demand for labour is highest during the harvest ofrainfed wheat and barley as well as during the earlierpoppy harvest. Little work has been available. Thesupply of casual labour exceeds demand. Wageslevels were insufficient to meet household foodrequirements. Child labour was a source of familysupport with children ‘leased’ to wealthy persons asservants in return for a ration. Migrant labour wascommon with young men migrating to Pakistan andIran to work and remitting money to their families.Regular seasonal labour migration was also reportedwith male household members travelling to Pakistanto work in the autumn and returning in the spring.Returning workers often return with goods such asclothes and shoes and engage in petty trading.

Other coping strategies

Most people were reducing intake. Usual meal-timeswere kept but solid food was replaced by tea or milk.Reduction in dietary variety was a commonconsequence of the sale of livestock. Preferentialfeeding of children was consistently reported.Although unpopular with the men, both men andwomen reported that mothers preferred to reduce

I r rig a te d W h e a t

%

May Jun Jul A ug Sep Oc t Nov Dec Jan Feb Mar A pr May Jun Jul

05

01

00

R a in fe d W h e a t

%

May Jun Jul A ug Sep Oc t Nov Dec Jan Feb Mar A pr May Jun Jul

05

01

00

I r rig a te d B a r le y

%

May Jun Jul A ug Sep Oc t Nov Dec Jan Feb Mar A pr May Jun Jul

05

01

00

R a in fe d B a rle y

%

May Jun Jul A ug Sep Oc t Nov Dec Jan Feb Mar A pr May Jun Jul

05

01

00

P o ta to e s

Month

%

May Jun Jul A ug Sep Oc t Nov Dec Jan Feb Mar A pr May Jun Jul

05

01

00

0

50

100

150

200

199 9 200 0 200 1

Year

Pric

e (K

g)

Sheep G oats C ows

0

1

2

3

4

5

1999 2000 2001

Year

Dai

ly w

age

(kg

whe

at)

Figure 4: Estimates of the duration of existing food stocks (May 2001 - July 2002)

Figure 5: Trends in livestock (1999 - 2001) Figure 6: Trends in daily wage rates for casual labour (1999 -2001)

Labour prices (Kg Wheat / day worked) 1999 - 2001(Source: WFP, SMU, Concern)

Mark and Gwenola on the road with colleagues in Afghanistan

Livestock prices (Kgwheat/head) 1999 - 2001

(Source: WFP, SMU,Concern)

24

Field Article

their own intake before reducing the intake of theirchildren or husbands.

Borrowing has become increasingly common. Theborrower buys food at between two or three times themarket price that he agrees to repay in cash or grainat a later date, usually after the harvest. The loan issecured against property with irrigated land beingpreferred as security. Food is, therefore, purchased ata multiple of a peak market price that can only bepaid for by sale or transfer of food immediately afterharvest when food prices are likely to be low. Theeffective interest rate may be as high as 350% over athree month period. Defaulting on a loan usuallyleads to seizure of property with the borrower eitherbecoming a sharecropper for the lender or beingdisplaced. Loss of land was frequently cited as areason for displacement with Pakistan and Iran beingmentioned as the preferred destinations.

Sale of land was reported to be a last resort and wasusually mentioned as a prelude to displacement.Land prices are low with irrigated land pricesreported to be between fifty and sixty-five percent of1998 land prices.

Most of the poorer households had already sold theirhousehold goods. The within-village market forhousehold goods is exhausted and the prices offeredfor household assets in market towns were too low toallow this strategy to be anything but a stop-gapmeasure. It is unlikely, therefore, that this will be aviable or important coping strategy to the newlyimpoverished. Capital accumulation is both slow andan hereditary process and this strategy will lead tolong term and continued vulnerability.

Reports of displacement were common.Displacement in Afghanistan is, however,substantially different from displacement in, forinstance, Africa. It takes place before food andincome sources are exhausted and is facilitated by astrong culture of hospitality to travellers. It ispossible that displacement in the face of adverseeconomic circumstances is a common and long-standing coping strategy rather than a crisis strategy.At present it is unclear whether reports ofdisplacement in areas away from the front-linerepresent crisis displacement or coping migration. Itis also unclear what proportion of reports ofdisplacement emanating from UNOs and NGOs referto normal seasonal movements of Hazara and Kuchipeoples rather than to crisis displacement. Morework is required to characterise displacement in theAfghan context. No UN or NGO interventions aretargeted at nomadic groups. These groups may makeup approximately 10% of the population and areknown to be amongst the most economically

Displacement

Sale of land

Kinship support

Petty trading

Wild food

Migrant labour

Casual labour

Child labour

Sale of livestock

Cash crops

Borrowing

Sale of valuables

Normal coping Stress coping Crisis Strategy Status Likely outcomeReduction ofintake

Ongoing Undernutrition.

Sale of livestock Ongoing but livestockprices low. Exhausted formany.

Loss of dietary variety. Undernutrition (loss ofprotein and energy dense foods).Micronutrient deficiencies. Loss of soilfertility. Loss of winter fuel sources leading todeath due to cold and undernutrition due toincreased energy requirements during coldweather and impaired thermoregulationassociated with undernutrition.

Sale of HH goods Exhausted Long term insecurity / vulnerability. Deathdue to cold (sale of bedding and winterclothing). Undernutrition due to increasedenergy requirements during cold weather(sale of bedding and winter clothing) andimpaired thermoregulation associated withundernutrition.

Wild food Exhausted by winter Undernutrition.

Casual labour Ongoing but labour priceslow. Likely to be exhaustedduring winter months.

Daily wages insufficient to purchasesufficient food for a family.

Petty trading Ongoing at capacity butmay become exhausted asgeneral poverty levelsincrease.

Not known.

Borrowing Ongoing Loss of land leading to long term foodinsecurity and eventual displacement.

Child labour Ongoing Loss of labour to family.

Sale of land Ongoing Long term food insecurity. Displacement.

Migrant labour Ongoing Possible loss of ‘brightest and best’ of theyoung male adult generation. Loss ofproductive labour leading to short term foodinsecurity (inability of the family to participatein Food For Work and Food for AssetCreation interventions) and possible longterm vulnerability. Stress on familial andsocial structures.

Cash crops Low yields / prices Loss of expected cash income.

Displacement Ongoing Not known as it is unclear whether‘displacement’ is a coping or crisis strategy.

Figure 7: Identified coping strategies typified by normal,stress and crisis coping

Table 2: Identified coping strategies, their status and likely outcomes

Grain (49%)

Potatoes (1%)

Poppy (8%)

Labour (5%)

Remitted (3%)

Livestock (10%)

Unquantif iedCoping (24%)

(A) Coping 2000

Grain (45%)

Potatoes (1%)

Poppy (5%)

Labour (1%)

Remitted (2%)

Def ic it (46%)

(B) Coping 2001

Grain (45%)

Potatoes (1%)

Poppy (5%)

Labour (1%)

Remitted (2%)

Un-quantif iedCoping 2000 (24%)

Def ic it (22%)

(C) Coping 2001 (Best Case )

Grain (60%)

Potatoes (1%)

Poppy (6%)

Labour (2%)

Remitted (2%)Livestock (17%)

Def ic it (12%)

(D) Crisis 2001

Figure 8: Income calculated as cereal equivalents as proportion of needs for 2000 with projections for 2001

25

Field Article

disadvantaged people in the country.

The identified coping strategies may be viewed aslying along a continuum ranging from normal copingbehaviours (e.g. cash crops, casual labour) throughstress coping behaviours (e.g. borrowing, kinshipsupport) to crisis behaviours (e.g. sale of highlyportable valuables, displacement). Figure 7 and Table2 show identified coping strategies, their status, andlikely outcomes.

Food economy

We performed a basic food economy analysisconverting sources of income and expenditure tocereal equivalents using a purposive sample of 39farmers in the Khosh valley based around the WFPVAM methodology. Figure 8 presents four differentanalyses.

Figure 8 (A) presents the sources of food used by thesample population in 2000. It identifies a gap of 24%that the people filled using one or more of the copingstrategies identified in Table 2.

Figure 8 (B) characterises the same sources of foodfor 2001. In this analysis, the un-specified deficit is22% larger than was accommodated by the copingmechanisms used in 2000. The information from thefocus group interviews presented in Table 2 indicatesthat in 2001 the population has less ability to copeand it is likely that many of these mechanisms arenow exhausted. Even assuming that these copingmechanisms remain intact, the analysis indicates thefarmers have an average food deficit that is at least22% of their annual requirements (see Figure 8 (C)).Given the exhausted state of the coping mechanismsthe actual deficit is likely to be higher.

Figure 8 (D) presents a similar analysis but with theaddition of two crisis strategies. These are strategiesthat remove people’s ability to live in subsequentyears:

1. Any farmers who have remaining cows, sheep orgoats sell them to buy grain.

2. Farmers eat their seed stocks.

If farmers adopt these crisis strategies, theunspecified food deficit drops to 12%. This is lowerthan the un-quantified coping mechanisms employedin 2000 (Figure 8 (A)), indicating that with the saleof most of their essential resources the majority ofpeople will be able to survive the winter. After this,however, they will be incapable of surviving withoutinterventions.

Figure 9 show cumulative frequency plots projectingthe percentage of farmers who will no longer be ableto support household food needs over time given fourdifferent scenarios.

The ‘coping’ line shows the percentage of farmerswho will not be able to feed their families using thesame coping strategies as they did in 2000. ByJanuary 2002 nearly 80% of farmers will haveexhausted their capacity to cope. The ‘crisis’ lineshow the percentage of farmers who will not be ableto feed their families even if they adopt the crisisstrategy presented in Figure 8 (D). In this scenarioapproximately 30% will have exhausted theircapacity to survive even with selling their remainingherds and eating their seed stocks before the end ofJanuary.

At the time of the assessment, it was planned todistribute only 341.5MT of wheat through a FFWscheme. The ‘existing FFW’ line shows the effect ofthis intervention demonstrating that even with thisintervention, over 70% of those surveyed will not beable to find sufficient food for their families withoutselling vital assets. The ‘intervention’ line shows theeffect of a relief distribution meeting 22% of theaverage annual food requirement. With thisintervention, 50% of the families will be able to meettheir food requirements up until the end of January.

Access and humanitarian space

The Khosh valley is a high altitude valleyinaccessible to motorised transport from mid-November until February because of snow. Atpresent, grain is transported via Tajikistan, taking atleast 2 months from time of purchase to time ofdistribution. Even before the start of the war, thisdelay meant that it was unlikely that sufficientquantities of grain could be transported anddistributed before the winter began.

Timing of survey

This survey took place two months after grainharvests at a time when household food stocks shouldhave been at their maximum. Low levels ofhousehold food stocks at this time of year represent afar more serious situation than equivalent storesimmediately prior to harvest. In addition, within threemonths the winter will isolate the valley and lowtemperatures will increase the need for food, fuel andclothing. Indications are that all of these will be inshort supply.

Conclusions

When interpreting nutritional surveys, it is vital toconsider context. In isolation, 11.5% globalundernutrition does not indicate a serious nutritionalsituation. Using this figure alone, it would be difficultto convince a donor to fund immediate emergencynutritional interventions. In the Khosh Valley, bycontrast, the contextual data we collecteddemonstrate that the coping capacity of thepopulation has been exhausted and, in the absence ofimmediate intervention, they face famine.

The overheads for the collection of contextual dataare not great but its collection should be planned inadvance. In retrospect, we made mistakes in thesampling system that we used and this caused somedifficulty in data analysis.2 In future we will collectfood security data using a larger random orsystematic sample. Qualitative data is often seen asbeing somehow ‘second rate’. This need not be thecase if multiple data sources are used and

triangulated with each other and if sampling toredundancy is used.3 In contrast to other disciplinessuch as mental health, emergency nutrition guidelinescovering the collection and analysis of qualitativedata are over-standardised and proscribe a relativelylimited number of data sources and methods of datacollection. Often workers will resort to selectingvarious developmental techniques such asparticipatory rural appraisal (PRA) techniques whichmay not always be applicable or may requireadaptation for the emergency context. We feel thatmore emphasis should be placed upon the collectionand use of qualitative data during emergencynutritional assessments.

Note: This survey took place in August/September 2001and was abruptly interrupted by the terrorist attacks in theUS on September 11th, 2001. This report reflects activitiesand needs at the time of assessment only. For furtherinformation contact Mary Corbett atmary.corbett@concern.ie or contact the authors throughsteve@validinternational.org

2 For example, we used a simple sampling scheme wherebyone ‘rich’, ‘middle’ and ‘poor’ farmer were selected from eachvillage. This meant that the sample was small (39) leading towide confidence limits and also that the rich and middlefarmers were over-represented. We tried to get around thisproblem by weighting each observation during analysis (i.e.so that the data from poor farmers had more weight in theanalysis). Weights were derived from secondary sources, i.e.VAM surveys, but we had no way of validating the weighting.

3 Sampling to redundancy means that once no new informationis being revealed and all potential sources of variation havebeen explored then sampling may cease. In other words allfurther sampling tells you what you already know and istherefore redundant.

Month

Pe

rce

nta

ge

with

out

acc

ess

to fo

od

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

02

04

06

08

01

00

CopingCris isExis ting FFWIntervention

Figure 9: Projected access to food in the Khosh valley

Vanessa Tilstone hasworked for HelpAgeInternational in Ethiopia forthe last 3 years as theCountry Programme Director

and has worked previously inMozambique, Ethiopia, Malawi andBrazil. Dolline Busolo is the RegionalNutritionist for Helpage and has beenbased in Nairobi for the last 2 years.

26

Field Article

This article highlights HelpAge International’swork in researching and promoting the needsof older people in emergencies and in

developing tools for nutritional assessment of olderpeople.1 Using the example of its Ethiopia countrydevelopment programme it focuses on the keydebates and challenges and makes recommendationsfor future action.

The situation of older people in Ethiopia

There is an underlying respect for older people inEthiopia where family and community supportsystems are relatively strong. However, a significantnumber of older people have no family andcommunity support, mainly due to the death ofrelatives or separation caused by famine, war, diseaseand displacement and the weakening of family andcommunity support structures.

Even in family settings, older persons are oftendisproportionately affected in times of drought.Coping strategies are often limited as they may notbe able to travel long distances in search of pasture,water or food or engage in daily labour or otherincome generating activities. They may havedifficulty consuming wild or drought foods. Inaddition, they may also sacrifice themselves in orderto save the lives of other members of the family,either by refusing food, eating last or preferring to beleft behind when families migrate (see Case Study 1).

These situations are usually not identified by aidagencies. Vulnerable older people, particularly thebedridden or itinerant beggars, are not easily visibleand are rarely prioritised for interventions. Untilrecently, nutritional surveys have focused exclusivelyon children under five (see Case Studies 2 & 3).

The Ethiopian government’s policy on food aidtargeting excludes people thought to be over 60 yearsfrom participating in Employment GenerationSchemes (food for work), regardless of their physicalability or ‘real’ age. General food distributions(GFD), if carried out at all, do target vulnerablegroups including older persons but only account for20% of food distributed. In practice older people,particularly women, are often excluded. They areoften not regarded as permanent residents in the areaswhere they presently live as they have moved fromtheir homes due to widowhood, poverty or crises.Supplementary feeding focuses on children underfive years and lactating mothers. Older people are notincluded in this intervention despite the fact that thisgroup often have poorer nutritional status and greatdifficulty digesting the coarse wheat and lentils thatare usually distributed in the GFD.

Assessing older people’s nutritional status

A number of difficulties were experienced promotingthe inclusion of older people in emergencyprogrammes, including a belief that older people arean unproductive group and will always be cared forby relatives, regardless of the food stress. By far thebiggest challenge, however, was the need of furtherresearch on assessment of malnutrition, among adultsand older people.

Initial research by HelpAge Internationalrecommended that armspan be used as a proxy forheight in Body Mass Index (BMI) measurements forolder people. However when the armspan equationswere tested in Ethiopia it was found that there weredifferences from other African populations. A

research project was conducted among the three mainethnic groups and a fourth group which wasparticularly affected by drought. The regressionequations calculated were found to be different foreach of them.

Overall, a number of difficulties were experiencedusing BMI as an indicator of nutritional status (seeTable 1). By far the biggest problem was the need toadjust for Cormic index (Norgan’s correction) whichtakes into consideration the fact that differentphenotypes have different sitting:standing heightratios which will affect their BMIs. This is a complexequation that needs to be derived for each ethnicgroup.

The Mid Upper Arm Circumference (MUAC) wasfound to be a simpler and quicker measurement.MUAC cut-off points had been determined in theinitial research by London School of Hygiene andTropical Medicine (LSHTM), i.e. <22cm for severeand <23cm for moderate malnutrition. However,these are for populations in stable nutritionalsituations and were not found useful for determiningthe need for intervention in emergency situations.Collins et al. had determined lower MUAC cut-offpoints for screening for nutritional interventions inSouth Sudan, where, among the Nuer people, over94% were considered malnourished if BMImeasurements alone were used.

In Ethiopia these cut-off values were found to bevery low and therefore a middle ground, based onAction Contre Faim’s (ACF) experience of

Older people, nutrition andemergencies in EthiopiaBy Vanessa Tilstone

Measurement difficultiesand risk of error

Populations havedifferent phenotypes(body-shapes)

Lack of baselineinformation

Need additionalinformation forinterpretation of findings

• Mathematics required for BMIand regression equation

• Error in height squared • Confounded by famine oedema• Height difficult to measure,

especially in older people• Height derived from a proxy

(demi-span/arm-span), error

• Interpretation affected byphenotype

• Need to determine populationspecific Cormic Index and adjustusing Norgan’s correction.

• Age related changes (BMIdecreases with age, fatredistribution, height decreaseswith age)3

• Normal prevalence rates,seasonal patterns and trendsunknown

• Findings cannot be interpretedin isolation of other information

Table 1Problems using BMI2

Note: BMI is calculated as Weight [kg] ÷ (height [metres])2

©H

ELP

AG

E

Old woman in Borena,Ethiopia (2000)

27

Field Article

therapeutic feeding in Rwanda, was used. This isbeing used in two interventions currently beingsupported by HelpAge International Ethiopia inWerder and Somali region. However, as the casestudies show, there is still much debate about whichcut-off values should be used. A summary of thethree recommendations is outlined in Table 2.

Lessons learnt

There is an increasing acceptance that older peopleare particularly vulnerable in many areas of Ethiopiain times of drought and conflict. A total of ten NGOshave included older people in their nutrition surveysand at least five interventions have been carried out toaddress older people’s needs. For the first time in2001 the national government food appeal mentionedolder people as a priority for supplementary food andthe NGO umbrella organisation, CRDA (ChristianRelief and Development Association), has includedincreasing advocacy for older people as one of theobjectives of its emergency task force.

Research needs

However, more research is required on thevulnerability of older people and nutritionalassessment including:

• Whether BMI measurements need to be adjustedfor sitting height (Cormic index) and its calculationfor various ethnic groups;

• Refinement of MUAC measurements for adults andolder people for severe and moderate malnutritionby relating MUAC to functionality and morbidity;

• More research on how anthropometricmeasurements vary with age;

• Ethnic specific armspan to height ratios to usearmspan as a proxy for height for older people inBMI measurements;

• More research into the vulnerability of older peopleand access to relief interventions in differentregions and contexts;

• Increased awareness within aid agencies of olderpeople’s vulnerability and their right to life.

Nutrition guidelines for older people need to beincorporated into agency guidelines.From experience so far, the main lessons learned are:

• Qualitative information on older people, such asunderlying causes and risks of malnutrition, andchanges in support structures, should besystematically collected during nutritionalassessments. Further data on the effects of food aiduse and intra-household food sharing patterns onolder people are required.

• For rapid assessments where nutritional statuscannot be assessed using sound samplingprocedure, it is more appropriate to collect goodqualitative information rather than taking MUACmeasurements of a small convenient sample.

• The index and the cut-off values used (and thecorrection process if applicable) should always bedefined when reporting prevalence rates.

• Prevalence rates should always be interpreted in thecontext of other information e.g. food security,malnutrition rates among children under five,information on social and community supportstructures.

• Older people need to have access to foods that areeasily digestible and provide adequate amounts ofmicronutrients. Improved access to blended foodsmay fulfil these requirements.

It is hoped that agencies working in Ethiopia andother countries facing humanitarian emergencies andnatural disasters can take up these issues so that olderpeople’s needs are addressed more effectively.

Case Study 1

Coping strategies that discriminate againstolder people, Yabello, Borena Ethiopia 2000-2001 (Vanessa Tilstone, HAI)

In Borena, Southern Ethiopia, during food shortageperiods, older people voluntarily refuse food in orderthat other family members can survive. This practiceis in addition to the normal preferential feeding ofchildren also characteristic in this culture. In 2000,Norwegian Church Aid reported that older peoplewere refusing food, only consuming liquids andconserving energy by resting for long hours. Anutritional survey carried out by HAI in April 2000estimated a prevalence of 54% global malnutritionamong older people (using unadjusted BMI as anindicators (BMI less than 17)). In June 2000, GOALincluded older people in their survey, showing 64%of those assessed with MUAC values less than 23cmusing MUAC.

Despite their widely recognised vulnerability, olderpeople were not prioritised in interventions until May2001, when HAI supported GOAL to implement asupplementary feeding programme focusing on olderpeople. In July 2001, 510 older people, 164 children,and 36 pregnant and lactating mothers wereregistered for supplementary food from Yabello andTeltelle Woredas when they were found to bemoderately or severely malnourished. Criteria foradmission were:

• Reported age over 55 years; or nearest historicalevent.

• Physical signs such as gray hair, wrinkled skin etc.• Cross checking with elders,• MUAC less than 21cm.

Case Study 2

Including older people and adults innutritional surveys: Damot-Wede, Ethiopia,2000 (Kate Sadler, Concern Worldwide)

Concern has been implementing emergency nutritionprogrammes in Damot Weyde since April 2000, whena first survey showed a global malnutrition rate of25.7% among children under five years old. As aresult supplementary and therapeutic programmeswere set up. Reports of sick adults presenting fortreatment led Concern to include adults and olderpeople in their nutrition survey in July 2000 in orderto estimate the extent of the problem.

Data collected included sex, age, oedema, weight,height, sitting-height and MUAC. A measurement forsitting height was taken to determine the CormicIndex (body shape) for the population. The CormicIndex was calculated from the ratio of the sittingheight to standing height. For adults whose heightcould not be measured, no data were collected. Theanalysis used two age categories; 18-49 and >49years. The prevalence of malnutrition was reportedfor observed BMI and adjusted BMI. The adjusted

BMI took into consideration the Cormic Index for thepopulation being surveyed.

The results showed large differences between theprevalence rates reported for observed BMI andadjusted BMI. Using a BMI cut-off of <17kg/m2, theprevalence of malnutrition among younger adults (18-49 years) was 1.7% (adjusted for Cormic Index) and10.7% (unadjusted). The prevalence of malnutritionamong older people (>49 years) was 2.0% and 24.5%for adjusted and unadjusted prevalence ratesrespectively. The large differences in the prevalencerates can be attributed to the fact that the studypopulation has a relatively low Cormic index (longlegs for body stature in relation to trunk length).Therefore without applying the Cormic Indexadjustment factor, the BMI is artificially lowered andresults in a much higher proportion of the populationbeing reported as malnourished. The Cormic Indexfor this population was calculated to be 0.5 comparedto 0.52 for the reference population.

The survey determined that a MUAC cut-off of 18cmidentified a similar proportion of adults with globalmalnutrition to that using an adjusted BMI of <16(severe malnutrition). But further tests are required tosee if the same population groups were affected. Thesurvey also showed that mean BMI and mean MUACvalues significantly decreased with increasing age.

There were a number of additional constraints thatthe survey encountered. These included: (1) sittingheight needed to be monitored closely (very easy tobe inaccurate) and the additional measurementslowed the survey team down considerably; (2) theadjustment process required specific expertise and (3)the sample size of older people was too low.

Case Study 3

Including older people in a SupplementaryFeeding Programme in Bolosso Sore 2000(Laura Phelps, Oxfam-GB)

Many of the older people in Bolosso Sore aremarginalised socially. Chronic health and socialproblems exacerbate their poor nutritional status. Thegovernment DPPC (Disaster Prevention andPreparedness Commission) beneficiary selectioncriteria for gratuitous and Employment GenerationSchemes does not allow for displaced people asbeneficiaries have to be ‘permanent residents’. As aconsequence, Oxfam included older people in theirSupplementary Feeding Programme (SFP).

In November 2000, there were 208 older people(more than 50 years old) registered in the SFP, ofwhich 98% were female. At least 95% of the targetpopulation were living in the urban centres of theworeda. The criteria used for selection was MUAC<18.5 cm. Assessment using BMI showed that noneof the admissions had a BMI <17.0.

An assessment of the causes of malnutrition for olderpeople in Bolosso Sore indicates that this proportionof the population is chronically vulnerable. Many ofthe older beneficiaries in the SFP were widows andthe majority had no access to land. Poor use of foodis exacerbated by physiological problems, especiallysight and dentition difficulties as well as chronicillness. Community support was strong wherefamilies and relative are close by. Once the olderpeople are separated and have to move to new areas,community support was notably poorer. All thewomen were economically unproductive and receivedsmall income from begging outside the church ormarket.

1 Older people in disasters and humanitarian crises: Guidelinesfor best practice (HelpAge International, London, 2000);Suraiya Ismail & Mary Manandhar, Better Nutrition for OlderPeople: Assessment and Action (HelpAgeInternational/London School of Hygiene and TropicalMedicine, 1999).

2 A. Borrel, Report of workshop on addressing the nutritionalneeds of older people in emergencies, November 2000.

3 Ismail & Manandar op. cit.4 Collins, S., Duffield, A. & Myatt, M. Anthropometric

Assessment of Nutritional Status of Adults in Emergency-Affected Populations July 2000 Geneva ACC/SCN.

5 Yvonne Grellety, Personal communication.

Ismail et al. Collins et al. ACF (HAI/LSHTM)3 (July, 2000)4 (Grellety)5

Severe <22.0 cm <16 cm* <20 cmmalnutrition 16-18.5 cm**

Moderate 22.0-23.0 cm 16-18.5 cm 20-21 cmmalnutrition

* with or without clinical/social criteria or** with social/clinical criteria

Table 2MUAC cut-offs for adults

©H

ELP

AG

E

Borena, Ethiopia (2000)

Iwas recently in Northern Darfur, Sudan, where SCF-UKhad employed me to analyse and present data from fivenutritional surveys and combine this with food security /

economy data collected by their early warning system(EWS).1 In my opinion, the data SCF had collected wasexceptional, both in terms of its high quality and its broadhistorical and geographical scope. They had undertaken onecomplete nutritional survey in each of five separate foodeconomy zones, all conducted by well trained teams andimplemented according to internationally recognisedstandards. Detailed food economy and food security datastretching back over ten years supplemented this. Thehistorical records of market prices, terms of trade, harvests,and other sources of income, etc. provided a baseline andenabled the cross-sectional nutritional data to be set incontext. This facilitated a clearer understanding of thesituation.

The results were very worrying; 24% global malnutrition,six months to the next harvest and clear signs that copingcapacities had been exhausted (see graphs). The followingtable outlines the prevalence of malnutrition throughout thestate.

Table 1 - Nutritional status by food economy zone anddisplacement

Normal livelihood patternsThe food economy of Northern Darfur is complex, withpeople depending upon a wide variety of food sources.There is also a wide range of mechanisms that thepopulation employs in order to cope with a variable patternof food security. People farm cereal, raise livestock, collectwild foods, farm cash crops and traditionally migrate to findwork. A strong kinship system, where richer members ofclans support their relatives, cements the copingmechanisms together. Interestingly, local crop production isnot the most significant source of food in any of the 6 foodeconomy zones.

The October 2000 food economy analysis indicated thatthere was a food deficit of 26,057 MT. The deficit wasanticipated to be greatest in the pastoral, goz and tombac

28

Post script

The dangers ofrapid assessmentBy Steve Collins Dr. Steve Collins is a Nutrition Consultant working forValid International. He undertook this assignment onthe request of Save the Children UK and visitedDarfur between 28th April and 13 May 2001. Hespecialises in assessments and setting up emergencynutritional interventions, evaluations and researchingsevere adult malnutrition and community therapeuticfeeding. His previous work experience has includedemergencies in Sudan, Somalia, Angola, Liberia,Burundi, Rwanda, DPRK, Balkans and Haiti.

food economy

zone

sample size

global malnutrition

95%CIsevere

malnutrition95% CI

mean WFH

z-score

Goz 769 31.3 27.2 - 35.5 3.0 1.9 - 4.7 -1.6

Pastoral 760 26.1 22.4 - 29.7 1.7 0.7 - 2.7 -1.5

Non - wadi 750 18.9 15.6 - 22.3 1.1 0.7 - 3.2 -1.3

Jebel 760 20.8 17.8 - 23.8 2.0 0.7 - 3.2 -1.3

Tumbac 740 20.3 17.1 - 23.4 2.7 1.5 - 3.9 -1.2

Displaced 180 26.1 20.0 - 33.3 4.4 2.1 - 8.9 -1.38

Migrationand wage

labourWild foods

Food forwork

Publichealth

environ-ment

Kinshipsupport

Foodstores Coping Market

purchases

Cropproduction

1 El Fasher, Kutum, Mellit, Nyala, El Geneina & Umkeddada

This field article from HelpAgeEthiopia is an excellent example ofwhat can be accomplished in

emergency situations by dedicated, skilledprofessionals. Their description illustratesthe difficulty in bringing the previouslyneglected topic of nutritional status in olderpersons to the attention of responsibleauthorities. The authors are to becommended for sharing their experience inorder that we may all learn more about thisimportant subject.

This article reiterates many of therecommendations regarding the nutritionassessment of adults which were made bythe SCN Working Group on Emergenciesduring a workshop in Nairobi in April 2001.

1

Among the most important recommendationsare that nutrition surveys should never becarried out as the only method of nutritionassessment, without clear objectives, orwithout the will and ability to act on thefindings. Especially for adults, a populationgroup which is not often considered to be themost vulnerable, clear and specific reasons toconduct a survey should exist beforeallocating the necessary money, time,manpower, and other resources. Moreover, tomaximize the usefulness of data collected,survey results must be complemented byqualitative and quantitative informationderived from other sources. A simpleestimate of the prevalence of undernutritionmay demonstrate the existence of a problem,but usually provides little information abouthow to attack the problem.

The HelpAge authors point out many of theconstraints to assessing and addressingundernutrition in adults and older persons,including existing policies, customarypractices, and widely held assumptions ofgovernments and international organisations.Overcoming such barriers often requires harddata, and gathering such data should be animportant component of any emergencyresponse. According to the old adage, whatgets measured, gets noticed.

Although substantial technical gaps existregarding assessment of undernutrition inadults and older people, the HelpAge articleprovides excellent examples of field datacollection and analysis which can serve toexpand our ability to accurately assessnutritional status. One survey cited in thearticle demonstrates the substantial effect onundernutrition prevalence of adjusting body

mass index (BMI) for cormic index. Similarresults have been reported by others.2 Inaddition, this survey identified a MUAC cut-off point corresponding to a BMI <16,indicating severe malnutrition, by comparingthe prevalence rates of undernutrition derivedfrom BMI and MUAC.

Nonetheless, comparison of variousanthropometric indices is insufficient. Asrecommended by both the HelpAge articleand the SCN Working Group onEmergencies, further research needs to bedone to validate the utility of variousanthropometric indices, especially BMI andmid-upper arm circumference (MUAC), inassessing acute undernutrition in adults andolder people. Such validation should includemeasurement of the correlation betweenanthropometric indices and health outcomesand functional capacity, and the ability ofthese indices to identify persons in greatestneed of nutritional support programmes.

The HelpAge article also points out some ofthe difficulties with use of BMI in fieldassessment surveys. Although use of BMI,especially when adjusting for cormic index,is more complex than use of otheranthropometric indices such as MUAC,many of us remember only a few years agowhen humanitarian aid workers routinelyrejected as impractical for field surveys themeasurement of weight and height inchildren < 5 years of age and the calculationof Z-scores. Nevertheless, with training andexposure of personnel to new techniques andthe availability of computers, thismethodology has become standard. In thefuture, measurement of adult stature, sittingheight, and weight, as well as theperformance of the cormic index adjustmentof BMI, will become routine as personnelbecome more familiar with these methods.These new techniques have the potential toprovide much more accurate and detailednutritional information on adults and olderpersons. Standardising and validating thesetechniques will help remove the barrierswhich currently sustain the nutritionalneglect of members of these age groups.

References1 SCN Working Group on Emergencies. Assessment

of adult undernutrition in emergencies: a report ofan SCN Working Group on Emergencies specialmeeting, April 2001. Nairobi, Kenya; 2001.

2 Salama, P, Assefa, F, Talley, L, Spiegel, P, van DerVeen, A and Gotway, CA, Malnutrition, measles,mortality, and the humanitarian response during afamine in Ethiopia. Jama 2001;286: 563-71.

Older people, nutritionand emergencies inEthiopiaBradley A. Woodruff, MD MPH, Medical EpidemiologistInternational Emergency and Refugee Health BranchU.S. Centers for Disease Control and Prevention

NoteThis article was already

published in Field Exchange13, unfortunately due to a

printing problem, the end ofthe article flowed off the page.

Therefore we reproduce thefull text of the article here.We apologise for the error.

food economy zones and among poor households in thesezones. In these three zones, poor households were predictedto not be able to meet over one third of their food needs,indicating a very serious situation.

Erosion of Coping mechanisms in 2001

Crop production

Analysis from the early warning system data indicated thatafter a bumper year in 1998, crop production in both 1999and 2000 was low. This is illustrated in the following graph.In addition to crop failures, the drought caused wide spreadfailure of Koreb, the predominant wild food in Darfur.

Figure 1 - Average crop production in northern Darfur

Market prices

Analysis from data collected in the six principal markets inDarfur indicated a deteriorating situation. All pricesincluded in this report are unadjusted for inflation.

The following graph presents the average market prices ofmillet and goats in the six major markets in Darfur. Themarket price for millet had risen by almost 50% over theprevious four months and in March 2001 was higher thanduring the peak of the hungry season during the crisis in1997. The signs indicated that the rate of increase in milletprices would continue. The animal market had fared slightlybetter and although prices were low they had not yetreached the depths of 1997.

Figure 2 - Millet and goat average prices, 1994 - 20012

Terms of trade between grain and goat were slightly betterthan it was at the peak of the crisis in September 1997, butwere declining rapidly as demonstrated in figure 3:

Figure 3 - Terms of trade between goat and sacks ofmillet, 1994 - 2001.3

In the pastoral food economy zone, market prices areintimately related to the rate of malnutrition, and changes inmarket prices tend to precede changes in malnutrition. Thefollowing graph clearly illustrates this fact.

Figure 4 - the relationship between average market pricesand malnutrition in Malha, 1997-2001

Labour wage rates

The past six months had seen the average wage forlabouring decrease substantially. The concurrent high priceof millet meant that in March 2001, 27 days of labour wererequired to buy one sack of millet, compared to 13 in March1999. Trends in purchasing power in relation to labourpayments are outlined below.

Figure 5 - Daily wage for unskilled labour in towns andrelative purchasing power i.e. daily labour :millet, 1995 - 2001

Kinship and the capacity of the rich to support theirrelatives

Support from family / kin represents the last and mostprofound element in the population’s coping strategy.Information clearly indicated that this final mechanism wasbreaking down. This breakdown was occurring at thebeginning of the hungry season, six months before the nextharvest.

The principle factors undermining coping strategies areillustrated as follows:

Initiating response

On returning to London we approached the donororganisation DfID, to present the findings and a proposal foran intervention aimed at maximising the amount of food aidto be delivered to Darfur before the rains rendered much ofthe state inaccessible. Given the comprehensiveness of theSCF data, I expected a broad agreement on the need foraction and a positive outcome from the discussions. I wastherefore rather taken aback when DfID responded that theSCF data didn’t agree with the findings of another NGO thathad recently conducted a rapid assessment in the state.

Differing methodologies with conflictingassessment results

This other assessment consisted of a team of two expatriatedoctors, a local health assistant and a driver visiting 27locations across a state the size of France in 21 days. Theteam held meetings with the local authorities, visited thehealth facilities, and water points, held discussions withfamilies and screened under-5 children using MUAC (Mid-Upper-Arm Circumference) measurements taken via‘convenience samples’ from groups thought to be at highrisk (e.g. displaced). The team systematically tried to focusits attention on the most vulnerable areas and families withthe aim of describing the situation of the most at-risk ratherthan giving a general picture of the situation. Given theirattempts to focus on the most vulnerable their results weresurprising. Of the 424 children that they measured, only 1%had a MUAC <110mm, 5% was between 110 - 125mm and12.5% between 126 - 135mm. A very different picture to theresults of the SCF surveys.

Rapid assessments and ‘selective’ sampling

A likely explanation for these differences is that theassumption that the displaced are the most vulnerable wasfalse. In Darfur, this assumption was an oversimplificationas, the displaced living around the wadis are those who stillhave cattle remaining, and are in fact the richest segment ofthe population. This clearly illustrates the dangers of rapidassessments and convenience sampling. One erroneousassumption can completely alter the interpretation of thewhole data set.

I recognise that in many situations there may be no time forsystematic sampling and we all at one time or another resortto ‘convenience samples’. Although we are all aware of thebiased nature of these samples and put a “disclaimer” thatthe results cannot be generalised etc., how many of us thencome to believe our own results, especially once they areanalysed and presented in a nice table? This was true of thisrapid assessment in northern Darfur which initially statedclearly that the MUAC results were not “statistics and donot pretend they are representative of the general nutritionalstatus”. Later this position changed in the report to “Even ifthese numbers do not represent statistics, it shows the lowpresence of severely malnourished children even amongpopulations facing very hard condition of life for severalmonths (or years).” I wonder whether the same conclusionswould have been drawn if they had realised that they wereselectively sampling the richer households.

In the field such misleading results are bad enough, they cando even more harm when they filter back to donors as theycan be used to justify political positions. In this case thefindings from this small non-representative sample negatedthe results of a random stratified sample of 3779 childrenusing weight for height measurements and complementedby ten years of involved early warning data. Happily theDfID staff later went to Darfur for themselves and quicklydecided to fund a response.

Valuable lessons highlighted

In my opinion, there are important and simple lessons tolearn from this. Rapid assessment and convenience sampleswill and should continue to form an important element inemergency responses. Often there is no time to wait for aformal survey and to do so would waste precious time anddelay response. However, it is imperative that suchassessments are conducted as broadly as possible (i.e. drawon a wide variety of sources) and the results obtaineddiscussed with others in the field who may have valuablecomplementary insights, knowledge and data. Disseminationand sharing at field level should occur before any reportsfilter back to central offices and thence to donors. Although,statistical and nutritional acumen and intelligence arenecessary elements in any rapid assessment team, thesecannot compensate for local knowledge. A good rapidassessment is one that accesses as broad a cross-section oflocal knowledge as possible. In Darfur, there was a wealthof information available and closer consultation with otheragencies operating in the state, both during and after theassessment, could have prevented much confusion anddelay.

ReferencesSave the Children Fund (UK) and Development andRehabilitation Committee of North Darfur, October 2000Village and Household Survey and Food Needs for 2000/2001Save the Children (UK). How bad does it have to get?. Thenutritional status in N Darfur in the spring of 2001, El Fasherdata from SC-UK EWS/Nutrition Unit, El Fasher, N. Darfurreport compiled by Steve Collins

29

Field Article – Reprint

0

2

4

6

8

10

12

14

1998 1999 2000

year

sack

mill

et /

hous

ehol

d

0

20000

40000

60000

80000

100000

120000

140000

Mar-94 Mar-95 Mar-96 Mar-97 Mar-98 Mar-99 Mar-00 Mar-01

month

pric

e(L

s / 9

0kg

sack

)

march 97 - 55,656

may 97 - 63,450

march 01 65,479

projections August 01 114,000

0

1

2

3

4

5

6

7

Mar-94 Mar-95 Mar-96 Mar-97 Mar-98 Mar-99 Mar-00 Mar-01

month

goat

s / s

ack

of m

illet

projections August 2001 = 6.9 : 1

0%

5%

10%

15%

20%

25%

30%

35%

40%

Sep-97

Feb-98

Sep-98

Mar-99

Sep-99

Mar-00

Sep-00

Mar-01

month

prev

alen

ce o

f glo

bal m

alnu

triti

on

-

10

20

30

40

50

60

70

mill

et p

rice

/ sac

k (L

s *

1000

)

global malnutrition

millet price

0

500

1000

1500

2000

2500

3000

Jan-95 Jan-96 Jan-97 Jan-98 Jan-99 Jan-00 Jan-01 Jan-02

month

aver

age

daily

wag

e(L

s)

0

10

20

30

40

50

60

70

80

90

days

of l

abou

r / s

ack

mill

et

average daily wage projected daily wage

days labour / sack millet projected days labour / sack of millet

Copingis at an

end

Traditionalmigrationdisrupted.Wage rate

low

Cropproduction

failed

Food forwork pipeline

deficit

Even “rich”families’ food

storesexhausted

Richer “kin”have no

resources left

Wild foodsfailed

Marketprices

record highTerm of trade

very low

Rainswill bring

risk ofdiarrhoeaMeasles

risk

2 Dotted lines are projected prices based upon changes overthe previous four months.

3 Dotted line is projected terms of trade based upon rate ofchange during the past four months.

30

People in Aid

Philip Miller (Concern) in Afghanistan. (Pieternella Pieterse, Concern)Participants at the SCN workshop in Nairobi on assessment of adults in emergencies. Top, left to right: Anna Taylor, Bella Duffield, BrianJones and Rebecca Norton. Middle, left to right: Brad Woodruff and wife Liz, Peter Salama and Annalies Borrel. Bottom, left to right: Nick Norgan,Caroline Wilkinson with an ACF employee! (Photographs taken by Fiona O’Reilly)

The fifth Nutrition Training Workshop of The World Food Programme (WFP) washeld in Bangkok from June 11-15. Participants from WFP representing 14 WFPcountry offices primarily in Asia were represented at this workshop. At thesefive-day workshops, staff learn basic concepts of public health nutrition relatedto their work in emergencies and development.

On the right, standing (L to R): Elora Chakma, Tashi Doma, Silvana Guiffrida.Seated (L to R): Melania Gondomartojo, Mahjabeen Masood, VisakhaTillekeratne, Monira Begum

Below (L to R): Visakha Tillekeratne, Mahadevan Ramachandran, Hege Nome

31

The Backpage

Field Exchange The

supported by:

Editorial TeamKillian FordeJoyce KellyJohn KevanyFiona O’ReillyJeremy Shoham

Layout & WebsiteKornelius Elstner

Contributors for this issueSteve CollinsAriane CurdyGwenola DesplatsFrances MasonMark MyattPieternella PieterseNoreen PrendivilleVanessa TilstoneBrad Woodruff

Thanks for the Photographs to:Pieternella Pieterse (Concern)Lucy Deering (Concern)Noreen Prendiville (FSAU)Frances Mason (AAH)HelpAgeGwenola DesplatsIsabelle Kronegg (ICRC)

On the coverWar wounded man in the IDPcamp on the Nuw Abad plains,Afghanistan. By PieternellaPieterse (Concern).

As always thanks for the Cartoon to:Jon Berkeley, who can becontacted throughwww.holytrousers.com

The ENN is a company limited byGuarantee and not having a share capital. Company Registration number: 342426

ENN Directors: Fiona O’Reilly, JeremyShoham, Prof. John Kevany

Pandamonium by Jon Berkeley

The Emergency Nutrition Network (ENN) grew out of aseries of interagency meetings focusing on food and nutritionalaspects of emergencies. The meetings were hosted by UNHCR andattended by a number of UN agencies, NGOs, donors andacademics. The Network is the result of a shared commitment toimprove knowledge, stimulate learning and provide vital supportand encouragement to food and nutrition workers involved inemergencies. The ENN officially began operations in November1996 and has widespread support from UN agencies, NGOs, anddonor governments. The network aims to improve emergency foodand nutrition programme 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 research and

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

sector which need more research

The main output of the ENN is a quarterly newsletter, FieldExchange, which is devoted primarily to publishing field levelarticles and current research and evaluation findings relevant tothe emergency food and nutrition sector. The main target audience of the Newsletter are food and nutritionworkers involved in emergencies and those researching this area.The reporting and exchange of field level experiences is central toENN activities.

The TeamFiona O’Reilly (Field Exchange production editor) andJeremy Shoham (Field Exchange technical editor) are

both ENN directors. Jeremy and Fionaestablished the ENN in theDepartment of Community Health inTrinity College, Dublin in 1996. Earlierthis year the ENN incorporated as a not-for profitcompany limited by garantee.

Joyce Kelly has been working part-time at the ENNsince January 2001 as part of the Field Exchangeeditorial team. She has been involved in health,nutrition and food security programmes for sevenyears. Joyce is leaving the ENN to take up a researchposition within the Irish health system. We are sorryto see her go and wish her all the best.

Kornelius Elstner is responsible for Field Exchangedesign and layout. He is also the ENN I.T.specialist and works part time at the ENN whileundertaking a degree in computer science.

Killian worked part time for the ENN back in 1997.He has since spent the past 3 years working forNGOs and the UN in Eastern Europe and is now backto undertake an M.Phil and help out at the ENN!

UNHCR

GENEVA FOUNDATIONto protect health in war

Royal Danish Ministry of Foreign Affairs

ENN Ltd.The Emergency Nutrition NetworkUnit 2.5, Trinity Enterprise Centre,Pearse Street, Dublin 2, Ireland

Tel: +353 1 675 2390 / 843 5328Fax: +353 1 675 2391e–mail: fiona@ennonline.netwww.ennonline.net