field exchange - enn · or interpret, e.g. livestock status or collection of wild foods. value...

November 1999 Issue 8

Field ExchangeEmergency Nutrition Network

Targeting in KosovoOne Hundred Years of FamineEthiopia: Targeting Errors Burundi: ACF Evaluates TFPs

Special Focus: Food Aid Targeting

Dear Readers,

Land-mark dates like a new millennium often make us think about thepast as well as the future. Field Exchange 8 is also in reflectivemood and includes a specially written article that re-visits some ofthe worst man-made famines of the last hundred years. This piece,which was mainly written by Fiona Watson, is based on eye-witnessaccounts and contains harrowing and emotive snap-shots of European,Asian and African famines spanning the entire century.

This last Field Exchange of the millennium is also a special focusedition. Recent emergencies in southern Sudan, Angola and Kosovohave once again raised the practical and political difficulties oftargeting food aid to the forefront of humanitarian agency agendas.Field Exchange 8 carries a special focus editorial on targeting aswell as summaries of two recent studies on targeting emergency foodaid in eastern Africa. There is also a study on using copingstrategy information as a proxy for identifying food insecurehouseholds in Greater Accra, Ghana. UNHCR has contributed an articleabout working through local implementing partners during the Kosovocrisis. The piece describes and examines the targeting strategiesused to reach the most needy returnees with food aid followingrepatriation from the camps. A list of key references on targetinghas been included at the end of the newsletter.

Other field articles include one written by Pippa Coutts on thedevelopment of a food information system by SCF in Darfur, WestSudan and the critical importance of understanding the local economyin order to monitor food security through this system. Pippa Howellof Action Aid has contributed an article ‘Between a Rock and a HardPlace’ about issues arising from working as a World Food Programme(WFP) implementing partner with Internally Displaced Persons (IDPs)in Western Uganda. The article describes the tensions that arise dueto conflicting community expectations and donor policies andculminates in suggestions as to how to reduce points of conflictbetween different stakeholders. Laura Phelps and Caroline Wilkinsonhave written an article describing the poor infant feeding practicesin Kosovo and Macedonia, many of which pre-dated the recentemergency, and highlighting the potential for further deteriorationduring the emergency.

There are two emergency programme evaluations included in this FieldExchange. One is a review of the Oxfam response to floods inBangladesh in 1998 and the other is an evaluation of the ACFimplemented selective feeding programme in Burundi in 1998.

The ENN team hopes to be out and about in ‘the field’ in the newyear. Hopefully, we will meet some of you and encouragecontributions on a range of subjects. Thanks to all of you for yourinvolvement with the ENN and please continue to write in withletters, articles and any ideas for special focus editions.

In the meantime all the very best and happy New Year to you.

Editors,

Fiona O’ReillyJeremy Shoham

Contents

3 Special Focus on Targeting

20 One hundred years of famine – a pause for reflection

Field Articles5 Protecting production in Africa’s

forgotten war10 Grounding Food Security

Monitoring in an Understandingof the Local Economy

12 Increasing Protein to Poultry15 Challenges for humanitarian

response in Kosovo24 Between a Rock and a Hard

Place? Responding to IDP FoodNeeds in Uganda

27 Infant Feeding Practices:Observations from Macedoniaand Kosovo

6 Research• Food aid targeting in Ethiopia• Infant feeding and HIV

transmission• Ready to use therapeutic food

for treatment of marasmus• Alternative food security

indicators• Food aid targeting in East Africa

13 News• International Public Nutrition

and Emergencies: The Potentialfor Improving Practice

• Nutrition in Relief andEmergencies short Course

• MSF welcomes Nobel supportfor peoples’ right tohumanitarian assistance

• Summary of the Meeting of theWorking Group on Nutrition inEmergencies

• Kerubino Dies• WFP plane crash

19 Agency ProfileEpiCentre

26 Evaluations• Summary of the Oxfam Review

of Bangladesh flood response• Evaluation of the Impact of the

ACF Therapeutic FeedingProgramme in Burundi

30 People in Aid• Tomas dispenses dental

treatment in the bush of SouthSudan

31 Resources on food aid targetingin emergencies

31 The Backpage

Dear Readers

You may have noticed that the issue number on the cover of the last FieldExchange was wrong... it was meant to be number seven, not six.Also, Jeremy’s profile was way out of date, he no longer runs the EmergencyNutrition MSc. at the Public Health Nutrition Unit, London School of Hygiene andTropical Medicine. It is now organised by Claire Schofield.

We would like to apologise, for any incovenience these errors may have caused.

Yours,

Kornelius Elstner

Erra

ta

ENN, Field Exchange, November 99 —

Special Focus on Targetingby Jeremy Shoham

The recent spate of reports and articles ontargeting emergency food aid shows theresurgence of interest in this subject. This is

not however a new subject. During the Sahelianfamine of 1984-5 many international aid agencies putconsiderable effort into collecting information to helptarget food aid across the region. The reasons givenfor targeting at that time were the same as currentjustifications, i.e. the desire to:

• reach only those in need of food aid or sometimesthose most in need given scarce food aid or logisticresources;

• avoid creating dependence by over-supplying foodaid;

• limit disruption to the local economy through over-supply, e.g. through an effect on market prices.

In some emergency situations targeting (whichinvolves excluding some of the population from foodaid assistance) will not be attempted as it will beobvious that the whole population is in need (e.g.Somalia 1992-3). In these cases the emphasis will beon how to reach all with necessary food aid so thatdifferent food distribution mechanisms may beemployed e.g. general distributions, soup kitchens,supplementary feeding.

One of the main findings of a review of the targetingexperiences of the 1980s was that the types ofinformation used to inform targeting decisions had

changed from previous decades. Previously targetedprogrammes had mainly relied on data on agriculturalproduction and impact of food deficits on nutritionalstatus. More recently, needs assessments and foodinformation systems have increasingly used data onpopulation/household access to food, income sourcesand types of survival strategy employed by theaffected populations to inform targeting decisions.This shift in methodology appears largely to reflectthe gradual adoption of Sen’s model of famine, e.g.that famine results from failure of entitlement ratherthan of food supply.

Targeting once again appears to be a majorpreoccupation of aid agencies and governments. Inthe famine in southern Sudan last year much effortwas made to design emergency feeding programmeswhich would target the neediest. The experiencestriggered a number of reports and articles on thesubject (see Field Exchange Feb. ‘99 ). For thepurposes of this special focus article we willdistinguish three stages of targeting:

• at the national level (stage 1) governments, donorsand national early warning systems are involved indecisions to identify and prioritise areas in need offood aid (often called geographic targeting) and inthe design of appropriate interventions, At this levelinformation systems are central to targetingdecisions

• at the sub-national level (stage 2) there is a furtherrefinement of geographic targeting in which localgovernment and implementing agencies decide onthe distribution within the region or district tocommunity or village level. This is also usuallybased on some form of information system.

• at the beneficiary level (stage 3) household orindividual recipients are selected by administrativesystems, e.g. through village committees orhousehold surveys or through the mechanism ofdistribution, i.e. the choice of mechanism such asfood for work or school feeding determines whogets the food.

Targeting cannot be attempted without informationon food security, i.e. food and income sources andcoping capacity, at the regional, sub-regional orhousehold level.

Stage 1 and 2 targeting are rarely easy. In somesituations there are no existing food informationsystems or assessments with baseline data againstwhich to compare current information. Furthermore,certain types of information are difficult to quantifyor interpret, e.g. livestock status or collection of wildfoods. Value judgements may also need to be made,e.g. should charcoal production or sale of livestockassets be counted or discounted as resources. If theview is that charcoal production denudes theenvironment while sale of key livestock assets

Special Focus

X marks the spot for the foodair-drops in South Sudan (WFP1998, F. Pagetti )

— ENN, Field Exchange, November 99

undermines long-term viability, then food or incomederived from these resources may not be included inassessing the degree of self-sufficiency of apopulation or group. This in turn affects theassessment of overall food needs of acommunity/population. Stage 2 targeting can also beextremely problematic from the point of view of localpolitical pressures, especially where programmes areimplemented by local government rather than outsideagencies. Nevertheless, in spite of these difficultiesthere seems to be an increasing ground-swell ofopinion that the greatest gains in targeting efficiencycan be made by improving information systemswhich inform decisions about geographic targetingrather than by refining intra-community targetingsystems (stage 3).

The jury on intra-community targeting (stage 3) isstill out. In the famines of the early 1980sexperiences were mixed. An Oxfam evaluation reportfrom the Red Sea Province in 1984 concluded thatefforts to target by household were thwarted by theBeja nomad view that food aid resources should beshared equally amongst all households irrespective ofsocio-economic status. This contrasted withexperiences in South White Nile province in northernSudan where household level targeting appeared to beaccepted by the community. More recently, efforts toestablish distribution committees in southern Sudanwhich identified and targeted the most vulnerablehouseholds were largely unsuccessful as oncemonitoring agencies had left the distribution site, aredistribution would take place with food often beingshared rather than targeted. In contrast, villagecommittees established in Central Tanzania during1998/9 to distribute food aid to drought affectedhouseholds were apparently successful in identifyingand targeting the most needy households. In thisinstance the committees in conjunction with thecommunity established their own eligibility criteria. Itcould be argued that certain identifiable factorsdetermine the success of one programme and thefailure of the other (see Community ManagedTargeting of Emergency Food Aid: Does it EverWork?, Field Exchange 7, July 99). One factor whichcan ‘de-rail’ outsider attempts to implement intra-

community targeting is that outsider perceptions ofvulnerability are often substantially different to thoseof local communities. Local political structure anddynamics are also key factors in determining thefeasibility of intra-community targeting and shouldform a critical component of any needs assessment. Ithas recently been argued by some observers that inalmost all situations of food crisis, fair and needsbased intra-community targeting is effectivelyprecluded by political processes within communities.

Another factor which may account for the variationin successes of intra community targeting, is theseverity of the crisis affecting the community. Theremay be a point of severity beyond which targetingwill not work in any community.

While the mechanism of food distribution cansupport certain forms of targeting, there aredifficulties and uncertainties connected with eachtype of mechanism which make it difficult torecommend one type of intervention over another .

For example, one rationale for Food For Workprogrammes (FFW) is that such programmes self-select the neediest members of a community.However, recent findings in Ethiopia calls this intoquestion as it appears that households with mostlabour to spare may willingly participate in the work.Cash for work (CFW) is also being increasinglyadvocated amongst some parties, especially as thisform of intervention would be cheaper since bulkfood aid does not have to be moved long distancesand it would stimulate/encourage local/regionalmarkets. However, there has been very little empiricalstudy on CFW projects and it is possible that theseprogrammes ‘self-target’ even fewer needyhouseholds than FFW. Also, CFW may prove moregender divisive than FFW while in situations ofconflict the injection of cash may increase insecurity.

Distributing food aid through existing infrastructure,e.g. school feeding or MCH clinics, is a means toreach a demographic target group, but these may notnecessarily be the most needy, e.g. only the better offmay go to school or be near enough to attend health

centres. Furthermore, targeting food aid tohouseholds on the basis of a child’s nutritional status(as often occurs through MCH programmes) maytarget households with care or health problems thatresult in malnutrition, rather than the most foodinsecure households.

Market interventions, i.e. putting food aid on to themarket in order to reduce prices and increaseavailability, would also on the face of it appear to bea cost-effective self-targeted intervention. In theory,the quantity of food that would need to be releasedonto a market to substantially reduce prices would befar less than the quantity of food needed to feed alarge population through a general ration programme.However, the experience of managing marketinterventions in emergencies has been extremelymixed and have shown that this type of interventionrequires great expertise and commitment fromgovernment.

It seems obvious that if it is thought appropriate ordesirable to target food aid in a given context, thefeasibility and means of such a strategy should beassessed. This would have implications for the designand methodology of food security assessments.

In most situations it should be possible to classify thecircumstances or factors where certain forms oftargeting are appropriate and feasible. This is,however, a domain where we lack guidelines or goodpractice reviews.

Looking back at the past 15 years, it appears thatthere has been little headway in defining when andhow to target emergency food aid. Yet there has beensubstantial documented experience of attempts totarget food aid resources. Perhaps we are now in aposition to begin the process of identifying thosecircumstances which indicate a predispositiontowards one form of targeting rather than another andto move towards producing guidelines for field stafffaced with this most difficult and responsibleprogramming decision.

Special Focus

SUDAN (WFP/A. JOE)

Still bearing the brunt of a 30-year civil war,millions of Angolans are facing severe food andfuel shortages, artillery attacks on many of the

main cities, and the terror of being caught betweentwo warring forces.

There are now more than one million internallydisplaced people in Angola, two-thirds of who arewomen and children, according to the United NationsChildren’s Fund. Hundreds of thousands of Angolansface severe malnutrition, disease and death, and theintensifying civil war shows no prospects for any realpeace process to begin.

Donor activity has been so low that Kofi Annanhimself appealed to the international donorcommunity in June to “urgently support humanitarianactivities in Angola to avoid a massive humantragedy.”

But donor response - from across the globe - remainsinadequate, partially because of the hopelessness ofthe Angolan situation, but also because the world’sattention these past few months has been fixed on theBalkan crisis.

Though the Angolan government sells oil to foreigncompanies it spends much of this money was spenton arms and remains heavily in debt. So health andeducation go by the board. Soldiers on both sides liveoff the land and the people: forcing people to givefood, stealing crops, hijacking vehicles. Neither sidewill back down. All roads are unsafe, with ambushescommon: in two separate attacks, humanitarian aidworkers in well-identified vehicles were brutallyslain.

Most of the countryside is under UNITA control,with the government holding the besieged cities,flooded with more than a million people who havefled unsafe rural areas. UNITA continues to inflictdamaging attacks on government forces. Food, fuelsand just about everything else are scarce in theprovincial cities, since they can be supplied only byair. High prices put food and other commodities outof reach for most ordinary Angolans. In UNITA heldareas where agriculture and trading have come to anabrupt halt, virtually nothing is available aside fromsubsistence farming products. Most of the harvest istaken by the UNITA troops. People are kept insideUNITA areas by terror force and, of course, landmines. Some people who have fled the UNITAonslaught have come out wearing clothes made oftree bark.

CARE International has had to re-work its longer-term development projects to provide emergencyassistance to those in immediate need. It continues itshealth, agriculture and humanitarian mine actionprojects, mostly in Kuito, the provincial capital ofBié Province in Angola’s Central Planalto region. Butthe situation is so bad that our teams are restricted to

working within about tenkilometres of Kuito town.Currently over 72,000 displacedpeople are crowded into Kuitotown, with hundreds morearriving every day. To reduce thepressure on the town, CAREInternational is currently workingwith local agencies to designate‘safe zones’ within a 10km radiusof Kuito town to move peopleinto temporary accommodation.

Using supplies from the WorldFood Programme (WFP) CAREfed about 50,000 internallydisplaced people in May. DuringJune and July we were only ableto feed children, the sick and thevulnerable from among thosedisplaced. In August we fed72,000 using partial WFP rations- but even the full WFP rationmeets only 60 percent of people’sdietary needs and currently there are no supplies oftwo essential foods - lentils and oil. World FoodProgramme food stocks and funds for its transport arenot adequate to meet needs in Kuito, nor in any otherpart of Angola.

Focus on LandminesIt is impossible to estimate the number of mines inAngola. Even conservative guesses put it atsomewhere around the 20 million mark. It remainsone of the most heavily-mined countries in the world.These hidden killers are a legacy of a 30-year civilwar. More mines are planted every day by both sidesof the conflict and continue to kill and maim ordinaryAngolans every day. Already some 70,000 Angolansare believed to have lost limbs as a result of landmineexplosions but the threat of death or serious injurybecomes even greater as a growing number ofdisplaced people risk wandering into unmarkedminefields in unknown territory. Women and children are in constant risk of death orinjury due to landmines whilst foraging for food andfirewood on the outskirts of the town. Lack of food isforcing people - often women - to venture further outof the city limits in the search for wild roots, leaves,small animals and fuelwood which they need to sellin order to buy household essentials.

CARE International would never have becomeinvolved in landmines clearance and awareness workhad mines not been cited as the main obstacle todevelopment. Their presence has prevented ruralrefugees from returning home and beginning theirwork on their farms once again.

The focus of our landmines work remains on freeingup land to return it to community use. Removing ordestroying every known mine is simply too great a

task for CARE’s teams, so sites where landminesmight be planted are surveyed, mapped and, wheremines and explosives ordnance are found, markedclearly. This way people know where it’s safe tofarm, graze cattle and fetch water.

This year alone our teams have trained almost 5,000people in mine awareness, destroyed or marked over100 mines or unexploded ordnance, and assessed fourcamp sites and surrounding agricultural land fortemporary but safe resettlement of internallydisplaced people.

As an integral part of this programme, agricultureactivities have been initiated for up to 15,000displaced farm families. Work is under way with thegovernment of Angola in order to allocate qualityarable land on the outskirts of Kuito. To boost thisprogramme CARE has distributed seeds and handtools, and provided technical assistance to helpimprove harvests.

Nearly all of the above activities face fundingconstraints due to lack of donor interest, especiallythe CARE-Angola Humanitarian Mine ActionProject.

The project is a successful model for the integrationof demining and mines awareness with health andagriculture programmes; yet the future funding of thisgroundbreaking work remains uncertain. The layingof new mines by both sides in the civil war, whichautomatically eliminates some potential donors,explains only part of this.

For more information contact: Anthony Robbins, CAREInternational UK,8-14 Southampton Street, London WC2E 7HA,England. e-mail: [email protected]

Protecting productionin Africa’s forgottenwarBy Anthony Robbins, CARE International UK

Field Article


TOB

Y P

ET

ER

S:A

NG

OLA

95

Research


Based on data from a nationally representativesurvey of 4166 farm households by the GrainMarket Research project in June 1996, a

recent study* examined the efficiency of food aidtargeting in rural Ethiopia. Targeting was defined as‘restricting the coverage of an intervention to thosewho are perceived to be most at risk in order tomaximise the benefit of the intervention whilstminimising the cost’. A key finding was that therewas not a significant association between householdfood insecurity (defined as food availability of lessthan 1680 kcals per capita per day) and food aidreceipts delivered during the 1995/6 emergencyprogramme (either free food or food for work).Household food security was defined on the basis ofhousehold food availability (e.g. own production,anticipated purchases, food exchanges received etc, ).Four factors were found to contribute to ‘targetingerror’:

i) The primary beneficiaries of food aid werehouseholds at the extremes in terms of foodavailability, e.g. those with the least and thosewith the most food available. This pattern seemedto hold across numerous regions of the country.

ii) A large number of female and aged heads ofhouseholds received food aid, irrespective of theirfood needs. The food security strategy and thebeneficiary selection criteria used by several keyNGOs involved in the distribution of food aidfavour female and aged heads of households.However, the study found households headed bywomen and those over 60 years were no less foodsecure than those headed by men or youngerfarmers.

iii) An inability of the food aid system to reachhouseholds outside the historically deficit areas.The strongest determinant of food aid receipt wasthe number of years in the past that householdsreceived food aid. This was largely because yearsof food aid reflect the progressive build-up of theinstitutional capacity in the food aid deliverysystem over time, i.e. personnel, contacts and

knowledge of the area, offices, trucks andinstitutional reputation.

iv) There was a disproportionately largeconcentration of food aid in the region of Tigrayregardless of household food needs. There mayhave been several reasons for this:• Tigray is historically a food deficit area and

therefore has had a significant investment ininstitutional capacity.

• Tigray has large numbers of community baseddevelopment projects and public workprogrammes that are implemented as food forwork activities. Many food secure householdsbenefit from these programmes.

The authors of the study also suggested that just asthere may be pressures at the community level todirect the flow of food aid to non-needy households,regional biases may be the result of politicalinfluences and other pressures on the food aiddelivery system.

A number of conclusions were drawn from thisstudy:

i) There needs to be greater flexibility in food aiddelivery systems so that food shortages in otherareas of the country with less infrastructure andinstitutional mechanisms can be addressed.

ii) Area targeting at woreda (sub-district) levelshould be more emphasised. Efficient areatargeting has a greater likelihood of reachingvulnerable households (possibly at lower cost)than does household level targeting.

iii) The guidelines and criteria used for identifyingthe most vulnerable households need to be re-assessed. The current focus on women and theelderly is not an effective way to target foodinsecure households. Indicators that reflecthousehold food availability per adult equivalentmay help improve targeting efficiencies.

iv) Ways need to be found to assist local level foodaid administrators resist pressures and incentivesto distribute food aid to the more food securehouseholds.

References*Food Aid Targeting in Ethiopia; A Study of who needs it andwho gets it. Clay D., Molla D. and Habtewold D. (1999). FoodPolicy 24 pp391-409.

Food aidtargetingin EthiopiaSummary of published paper

Food Distribution, Ethiopia ‘95 (WFP/P. Cenini)


Research

The observation that mother-to-childtransmission by HIV-1 infected women canoccur through breastfeeding has resulted in

policies that recommend avoidance of breastfeedingby HIV-1 infected women in the developed worldand under specific circumstances in developingcountries. Studies have been able to show that infantsuninfected at 3-6 months of age are still at risk ofbecoming infected through breastfeeding. Previousstudies from Durban, South Africa have shown thatthe highest overall rate of vertical transmission was inexclusively breastfed children (39%) and the lowestin never-breastfed infants (24%) with no evidence ofa duration effect in the exclusively breastfed group.However a recent Lancet article1 asserts that analysesof HIV-1 transmission via breastmilk are flawedbecause they have failed to account for the effects ofdifferent types of breastfeeding practices. The articleis based on a study which prospectively examinedinfant feeding practices of 549 HIV-1 infectedwomen who were part of a vitamin A interventiontrial in Durban, South Africa. The proportion ofHIV-1 infected infants at one day, one month and at3 months were compared in three different feedinggroups, exclusively breastfed, mixed fed and formulafed. HIV-1 infection was defined by a positive RNA-PCR test.

Results of the studyThe risks of HIV-1 transmission associated with non-exclusive breastfeeding seem to be substantial,exclusive breastfeeding does not seem to convey anyexcess risk of HIV-1 transmission over formulafeeding.

Exclusively breastfed infants were less likely to beinfected at three months than were those receivingmixed feeding or those never breastfed. Similarpercentages of exposed infants in the three feedinggroups had evidence of infection at birth - about 6% -but differences in vertical transmission had emergedby one month and had become larger by the time thebabies were 3 months old. At 3 months, 18.8% of156 never breastfed children were estimated to beHIV-1 infected compared with 21.3% of 393breastfed children, however this result was notstatistically significant. The estimated proportion ofinfants HIV-1 infected by 3 months was significantlylower for those exclusively breastfed to 3 monthsthan for those who received mixed feeding before 3months (14.6% versus 24.1%). The authors of thestudy suggest the following:

• that the virus acquired during delivery could havebeen neutralised by immune factors present inbreastmilk but not in formula feeds. Breastmilkcontains non-specific immune factors that haveantiviral and anti-HIV-1 effects in vitro, and that,

• the fact that mixed feeding carries the highest riskis not surprising because the beneficial immunefactors of breastmilk are probably counterbalancedby damage to the infants gut by contaminants orallergens in mixed feeds.

The authors conclude that a possible recommendationis for exclusive breastfeeding with early weaning andthat there is an urgent need to supplement existinginadequate data on HIV-1 transmission throughbreastfeeding.

An editorial2 in the same edition of the Lancet makesthe following points about this research study.

If the increase in the percentage infected reflectsbecoming infected around the time of delivery thetrend in the never breastfed group (6.4% at birth to14.8% at one month to 18.8% at three months) likethe increasing trend in the mixed feeders group issurprisingly protracted. Furthermore why was thereonly a small increase in the proportion infected in thebreastfeeding group at 1 month (from 6.8% at birth to8.7%) but a much steeper increase at 3 months (to

14.6%). The absolute increases in percentage infectedwere similar for the three groups between 1 monthand 3 months and the real difference seems to haveoccurred in the first month of life. In the editorial it isquestioned whether this finding suggests a protectiveearly effect of exclusive breastfeeding?

If HIV-1 infected women choose to breastfeedperhaps they should refrain from giving any otherfoods, at least for the first 3 months. In view of therisk of late postnatal transmission through breastmilkafter 3-6 months, and because introduction of otherfoods becomes more frequent as the infant gets older,women could then be advised to consider early andabrupt weaning. But it is premature to base public-health guidelines on the basis of the results of thisone study, and further research is urgently required toconfirm and elucidate the findings.

References1Influence of infant feeding patterns on early mother to childtransmission of HIV-1 in Durban, in South Africa: a prospectivecohort study. Coutsoudis. A et al, The Lancet, vol 354, August7th, 1999.2Infant feeding and HIV-1 transmission - Editorial in Lancet,Vol 354, August 7th, 1999, pp 442-443

Infantfeeding and HIVtransmissionSummary of Published paper

MOZAMBIQUE (WFP/R. MAASS)


The second edition of fieldexchange carried a short pieceon the development of a ready to

use therapeutic food (RUTF) referredto then as Therapeutic Spread for thetreatment of marasmus. This productwas developed as a substitute for F100to be used where unhygienic conditionscreated a risk of F100 becomingcontaminated. F100 which containsdried skimmed milk is ideal forbacterial growth and therefore has to beprepared before each meal and used byexperienced staff. In certain settingsproper use of F100 may not always befeasible or advisable. The RTUFsubstitute, which was developed inFrance, complies with the F100formula except that part of the DriedSkimmed Milk (DSM) has beenreplaced with lactoserum andgroundnut paste. This eliminates theneed for dilution with water. Testsshowed that bacteria failed to grow onthis product.

A recent letter in the Lancet* gives theresults of a study by ACF and theChadian ministry of health on 20severely malnourished children (<70%weight for height and over 12 monthsof age) without oedema fed with

RUTF. The primary aim of the studywas to determine whether childrenconsumed the appropriate amounts ofenergy during this phase of theirrecovery. The children were onlyincluded in the study after they hadbeen gaining weight rapidly for at leastthree days on F100. During the studyalternative F100 feeds were replacedby the RUTF. Children were fed bytheir mothers who were asked not to‘force feed’ the child. The study foundthat the caloric intake with thecombined feed was the same as when

the children were exclusively fed F100.

The researchers concluded that RUTFmight be useful in contaminatedenvironments or where residentialmanagement is not possible, e.g.during a war or disaster. It might alsobe useful for treatment at home or incentres without a kitchen. The use ofRUTF could increase cost-effectivenessand coverage of nutrition rehabilitationprogrammes. However, the authorscaution that RTUF has not been testedin infants (in whom an assured water

intake is more critical) or in cases ofoedematous malnutrition, and may notbe appropriate for children withinfection. Thus, wide promotion of thisnew diet is premature in settings wherethe use of standard protocols ispossible. Nonetheless, the bottom lineis that RTUF does appear to obviateproblems of quality control andbacterial contamination.

References*Ready to use therapeutic food for treatmentof marasmus. Briend. A, et al, The Lancet, Vol353, May 22nd 1999

Research

Ready to usetherapeutic foodfor treatment ofmarasmusSummary of published letter

Severely malnourished child eats crudeporridge mix before the development ofspecialised therapeutic foods. Chad ‘85(WFP/C. Gartung)

Research


The FEWS (Famine Early Warning System)project for the Greater Horn of Africa recentlycommissioned a review on food aid targeting*

in East Africa with the aim of improving the targetingof emergency food aid in response to droughtinduced slow onset food crises in Tanzania, Ugandaand Kenya. The reviewer spent three weeks in eachcountry in discussions with agency staff at capitalcity level and in selected food insecure areas. Reliefoperations during the year of 1997/8 were taken as areference period to focus discussion.

Main findingsTanzania:• The information systems were patchy and over

focused on balance sheets of grainproduction and consumption.

• A broader framework to take account of theeconomy and coping capacities in different areasneeds to be integrated into the relief needsassessment process.

• Government directives on targeting athousehold/individual level are more developed thanin the other two countries. However problems withtheir implementation point to a need for a review offood aid policy in general and more detailedtraining and support for local government in foodinsecure areas.

Uganda:• There is a virtual absence of information systems to

detect and assess potential food crises. • In the medium to long term a decentralised Early

Warning System (EWS) in selected districts may beneeded. In the short term FEWS should focusassistance on the development of the institutionaland analytical framework for inter-agencyassessment missions which are even moreimportant than usual in a context of limitedmonitoring information.

Kenya:• Kenya has multiple sources of food security

information and generally reliable data but thelinkage between available information and targetingdecisions is weak. Support is recommended for theNational Drought Management Secretariat whichcould provide a link by compiling and comparinginformation from vulnerable districts and ensurethat it reaches the right people.

The report discusses a number of major cross-cuttingissues for all three countries.

i) Information systems: Analysis gaps rather thandata gaps are evident. Weak links between availableinformation and targeting decisions are areas wheresignificant but relatively low-cost improvementscould be achieved. One suggested approach is todevelop agreed methodologies and procedures forinter-agency needs assessment missions in advance ofemergencies Such missions are very influential indetermining the scale and initial targeting design ofrelief operations, yet relatively little technical workhas been done on their method and on ensuring that

all available information is accessible and used bythem. There is also a need for decentralised EWScapacity in selected food insecure areas in order tointegrate analysis of vulnerability and copingcapacity information.

ii) Targeting Mechanisms: Each mechanism has itsadvantages and limitations. Free food distributionsshould be supplemented or partially replaced by FoodFor Work, school feeding or other types ofprogramme where capacity exists, but are likely toremain an important element in large scaleoperations. Needs assessment missions shouldinclude an assessment of targeting possibilities at theearliest stage of response planning. The choice of lesspreferred commodities as a targeting measure appearsto have limited potential in emergency situations. Nosuccessful examples were found during the study.

iii) Comparative Cost-Effectiveness: There is nostraight-forward correlation between the type oftargeting method and cost-effectiveness. Quality ofmanagement and planning are probably moreimportant determinants of cost-effectiveness. Freedistributions are not necessarily more expensive thanother mechanisms, thought they do tend to be largerscale.

iv) Market based approaches: Limited use was madeof these. Carefully designed direct interventions(such as emergency livestock purchase in pastoralistareas) can help to limit relief needs, but probably amuch greater potential for minimising food aid lies inthe promotion of efficient private sector markets. Thecontrasting experience during 1997/8 of Kenya(where private commerce filled a large part of thefood gap) and Tanzania (where the markets werepartly restricted and were much less successful inequalising and filling food shortages) illustrates thecritical importance of the economic and policyenvironment to food security.

v) Local government targeting: In all three countriesa similar pattern of constraints and problems withlocal government targeting were identified. Capacityand resource limitations are a major factor, but it alsoappears inherently more difficult (largely for politicalreasons) for government institutions rather than foroutsiders to systematically select and exclude areasand population groups at each level of theadministrative hierarchy.

vi) Drought versus flood: While drought inducedfood crises are by far the most important cause ofrelief needs in East Africa and therefore the focus ofinformation and response systems, the impact of theEl Nino floods (especially in Kenya) have usefullyconcentrated attention on the need for disasterpreparedness to include an element of flexibility andreadiness for the unexpected.

References*Food aid targeting in East Africa, Kay Sharpe, March 1999:Consultancy report for FEWS project, REDSO/USAID, PO Box66613, Nairobi,Kenya

Food aid targetingin East AfricaConsultancy Report

In an effort to construct a series of alternative foodsecurity indicators researchers have conducted astudy* on the ‘frequency’ and ‘severity’ of coping

strategies in 559 households in Greater Accra,Ghana. Through focus group discussion a simple setof questions was derived and agreed upon identifyingthe most common coping behaviours used byhouseholds in times of food shortage. Thesebehaviours/strategies were then ranked or weightedfor severity. The combination of the frequency withwhich these strategies were used and the perceiveddegree of severity associated with such a strategyresulted in a simple quantitative score. The higher thecomposite score, the more coping strategies reported,and the more food insecure the household. Forexample, for one of the composite indicators a scoreof 18 was equivalent to relying on two moderatelysevere coping strategies for more than half of thedays in the month prior to the survey. As expectedthe average number of times a particular copingstrategy was employed decreased with the severity ofthat strategy. Purchase of cheaper foods was the mostcommon strategy, rationing money to buy street foodwas the second most common and mothers or adultsreducing intake was the third. Skipping meals forwhole days was the least frequent overall andborrowing was the second least frequently reported.

Cut-off points for these composite indicators werebased on the percentile position of the indicator inthe overall distribution of respondent scores. Twopercentiles were used (60th and 70th percentile).These cut-off points were then used to identifyhouseholds at risk of food insecurity.

The coping strategy indicator scores were thencompared with more standard measures of foodsecurity/insecurity for each household including aconsumption, a poverty and a nutritional benchmark.Analysis showed that the coping strategy indices donot identify the same households as food insecure asthe benchmark indicators.

The authors of the study then made the assumptionthat the best benchmark measure with which tovalidate their newly derived indicators of foodinsecurity would be a composite of caloricavailability (< 2320 kcals) and more than 50-60% ofthe household budget being devoted to food. Analysisshowed that there was a stronger correlation betweenthose households identified as food insecure by thecoping strategy composites and this ‘gold standard’than with the individual benchmark indicators. Otheradvantages proposed by the authors for copingstrategy indicators over the more traditionalbenchmark indicators were that:

• they offer detailed information and a morecomplete picture about decisions and behaviourinvolving trade-offs and vulnerability

• the measures are much less time consuming andless expensive in terms of data collection andanalysis than the benchmark indicators.

References*Alternative food security indicators; revisiting the frequencyand severity of coping strategies. Maxwell. D., et al. FoodPolicy 24 (1999), pp 411-429

Alternativefood securityindicatorsSummary of published paper

Field Article


Information systems which regularly monitor foodsecurity are used to predict which populationswill suffer acute food stress in a given event,

climatic or man-made. Typically these systemscombine a variety of indicators which are trackedover time, and are used to estimate food aid needsand to target the assistance. However, interpretingwhat the changes in these indicators mean anddistinguishing which geographic area is most likelyto be affected by any change, whether political orenvironmental or economic, can be very difficultwithout a thorough understanding of the dynamics ofthe rural economy. The case of North Darfur, Sudan,provides a good example of this.

Much of Darfur, in the far west of Sudan, is a vastsandy plain of goz soil, which supports thick fields ofmillet after the annual two or three months of rain. InDarfur there is a great diversity in livelihoods. Thereare more than 90 ethnic groups in a province of overone million people who basically follow farming orherding modes of life. But in order to survive thefrequent drought that affects the area, communitieshave variously exploited several niches to diversifytheir sources of income and access to food so thatthey aren’t simply dependent on one kind ofagriculture or livestock herd.

This diversity has set a challenge for the variousagencies promoting food security within the area.One of these is Save the Children (UK), who afterthe 1991/92 famine in Darfur set up a foodinformation and early warning system with the aim

of providing information which could predict anapproaching food crisis and assist agencies inplanning appropriate interventions. The foodinformation system (FIS) conducted bi-annual villageand households assessments, based around a cropassessment, nutritional survey of children andmonthly market monitoring. During theseassessments, the Darfur team visited pastoral, agro-pastoral and sedentary farming people with the samequestionnaire. However, the team, who wereextremely knowledgeable about Darfur rural life, feltthat the information was not assisting them properlyto describe and differentiate communities. It hadlimited value in picking out the geographic areasfacing the greatest food stress.

What was required was baseline information in orderto interpret the indicators of food stress. Therefore in1998/99 the Darfur Food Information System usedthe household food economy approach to compilesuch a baseline for the region. Through this process ithas identified a dozen different food economy areaswithin which households have similar livelihoods andare affected by comparable risks and problems. Ineach area the differing importance of various foodand income sources has been quantified, and wealthdifferences have been analysed between poorer,medium and better-off types of household.

The baseline has highlighted how farmers cope withpoor production years. For instance, there are threefood economy areas in Kutum Province. One ofthem, the northern pastoral area, is populated by the

This article was written by PhilippaCoutts of The Food Economy Group,

using an illustration from Darfurand work of Yousif Abubaker, AbdelRahmin Nor Hussein and Mohamed

Salih of SCF’s Food InformationSystem.

Grounding Food Security Monitoring in an Understanding of the Local Economy:

Understanding differences – and making a difference

“Livestock prices are affected by livestocknumbers and conditions”

Field Article


Zaghawa people. The Zaghawa are known for theirlarge mixed livestock holdings, whilst the productionof millet is relatively unimportant and mosthouseholds typically harvest less than 200kg/annum.But the Zaghawa have always harvested a largequantity of wild grains. They are also a mobilepeople: in the dry season the men typically migratewith the livestock and women go to Kebkabiya orSouth Darfur to work on the grain harvest duringNovember to January. The women’s cash and grainpayments are brought home to be consumed by thefamily during the agricultural season later in the year.The Zaghawa are also known for their strong kinshipsolidarity and in poor years, for example whenlivestock prices are low and some families arestruggling, support will be given by better-offhouseholds to the poor.

In Um Keddada, by contrast, the levels of rainfall arehigher so that the area planted with millet is largerand the production levels are greater - up to2000kg/annum in a good year. The major ethnicgroup living in this area is the Berti, who aretraditionally sedentary farmers practising mixedcultivation and animal husbandry. In a year of goodcrop production ‘medium’ households can produceenough grain to meet their annual food needs. Amajor strategy employed by households to cope withbad production years is the storage of grain fromgood years. In addition, households increase theamount of grain they purchase from the market, andthey earn the cash to do this through a combinationof the sale of livestock and local agricultural labour.In most cases, both the male and female householdmembers work locally within Um Keddada province.This is in contrast to the Zaghawa who have tomigrate further for work and where the men arepredominantly involved in animal husbandry andtrade rather than agricultural labour.

The differences in the way households live in normalyears, and the labour, grain and livestock marketsthey use, mean that different factors have to be takeninto account when monitoring their food security.From this baseline understanding it has been possibleto identify what type of information should begathered to monitor households access to food, in thedifferent food economies, and when and where itshould be gathered.

From this baseline understanding it has been possibleto identify what risks or shocks are most likely toadversely affect the food security of the area. This isnot just drought. As markets are very important to thefood security in Darfur, a loss of access to a marketcan seriously affect household food security. Forinstance in 1997 the pastoralist people of Malhacould not reach Humra in Kordofan due to tribalclashes, and the price of livestock in their localmarkets declined. This had an immediate affect ontheir short term food security. The price of livestockin Darfur is largely determined by the export trade.Most of Darfur’s livestock is driven the great distanceto Khartoum, from where it is sold on to SaudiArabia. In 1997 lack of cash amongst traders withinSudan and restrictive government export policieslimited the number of livestock that were bought forsale overseas and the price in Darfurs marketsdeclined.

Once we get a proper understanding of the majorsources of food and income, the principal factorsaffecting food security become apparent and anappropriate monitoring system can be designed.

For the pastoral economies in northern Darfur thefollowing are the major factors identified as affectinghousehold food security, and the suggested indicatorswhich should be monitored to predict or perceive achange from normal:

1. A major source of food is market purchase, andthe major source of income for this is the sale oflivestock, particularly sheep. Hence, livestocknumbers, their condition and sale price needs tobe monitored. To predict and understandsignificant changes in price the following needsto be monitored:• Access of the pastoralists to their major

markets. This is affected by insecurity.• The overseas demand for sheep. This is affected

by competition in these markets and theGovernment of Sudan’s export policies.

• Livestock to grain terms of trade. This isaffected by the price of livestock and grain,millet in particular, which is in turn affected bythe source of supply of the millet. In a goodharvest year when the supply is local the priceis low.

2. Livestock prices are also affected by livestocknumbers and condition. To monitor this andpredict any severe crises, the patterns ofmovement of livestock should be monitored tosee if they change from normal. Insecurity,rainfall , pasture and water availability shouldalso be monitored. Monitoring incidence of

disease outbreak is also vital.

3. Another major source of income is wage labouron the farms of neighbouring areas. Theavailability and terms of trade for this are affectedby the harvest in that area and by the competitionfor work, which depends on the harvestthroughout Darfur: in poor years more peoplelook for work.

4. Wild grains are the other major source of food.The availability of these should also bemonitored.

ConclusionThe Darfur case shows that the more thorough ourunderstanding of the local economy and the way itfits into the large dynamics of the political and socialeconomy, the greater is our ability to monitor foodinsecurity accurately. This monitoring can thenprovide information on both the risks faced byhouseholds and effectiveness of their copingstrategies.

For further info contact: Philippa Coutts,19 Pitts Road,Headington, Oxford OX3 8BA, England. e-mail:[email protected]

“Wild grains are the other major source of food. The availability of these should also be monitored”

Field Article


Chickens are unable to manufacture 10 necessaryamino acids or the B vitamins.1 They thereforerequire a diet high in protein. In addition, they

require fats and carbohydrates, and cannot exist onhigh fibre diets. When NGOs or the FAO have taken arole in the improvement of family poultry farming inthe developing world, the diet endorsed is varied,comprised of grains and tubers “for energy” (millet,sorghum, maize, sweet potatoes, and even cassava);meals for protein (sunflower cake, fish meal, cottonseed cake, maize germ, soya cake, meat and bonemeal) and vegetables “for vitamins” (green grass,green kale, and cabbage)2 and green seaweed.3 Thegrains are given as a supplement to foraging4 withmillet recommended as the best grain for proteinsupplementation in chickens. Where these areunavailable, leaf meals have been used,5 and recentresearch suggests that the seeds of the Croton tree arevaluable in supplying necessary oils and proteins.1 Inthe search for less expensive, natively available foodfor chickens, recent studies suggest that tobacco seedcakes,6 or even molasses from sugar cane residue,7 canbe reasonably and productively utilised, and that mealfrom azolla, snails or rice polishings are comparable tomaize-soybean meal diets.8

In Haiti, however, farmersoften are unable to purchaseany form of supplementationfor their poultry, relying onthe birds to forage forthemselves. In addition, wateris seldom if ever madeavailable, as the labour to do sowhere there is not a readilyaccessible source, precludes it. Wherethe daily wage is $1.00 US, and the localmedical fee $1.50, high quality feed is a luxury. Theresult is poor production from the poultry both ineggs and meat. During the course of participatingwith Habitat for Humanity in Les Cayes, Haiti, wedeveloped a solution to the vexing problem of how toincrease protein intake to poultry where there isneither sufficient labour to care for them, norfinancial resources to provide high quality feed forthem. The land thereabouts is steeply sloped, butmostly cleared and grassy, with a few trees, and someshrubs and bushes at the foot. The heat and humidityare high. Chickens are left to find forage whereverthey wander. They are thin, muscular and do notcontribute greatly to the diet. The project was to build

a house of two rooms; the kitchen and toilet would beoutside the building. The materials were locally madeconcrete blocks. The site was compacted clay,laboriously dug by hand for the footings. In the

course of constructing the home, we stackedthe concrete blocks at the foot of the

slope leading to the site for easyaccess. While the house site and

the surrounding grassy areawere extremely hot with littleshade, the concrete bricksprovided an environmentthat was cool and moist. Itbecame attractive,therefore, as a habitat for avariety of arthropods and

small vertebrates. Thechickens soon learned to

gather when the blocks wereremoved. The forage provided

them with a plentiful and varieddiet, high in fats and protein. Insects

compare favourably with beef in thesenutrients.9 One-hundred grams of caterpillars, forexample, provide 28.2 gms of protein, 35.5 mg ofiron, and 10.8 mg. of three major B vitamins, while100 gms of lean, ground beef provides 27.4 gms ofprotein, only 3.5 mg. of iron, and a total of just over6 mgs. of the three B vitamins. This means ofincreasing nutrient for chickens requires one or a fewconcrete blocks, bricks, or large stones. The forageunderneath would provide an important source ofprotein and fats to make a significant difference insize, weight and quality of eggs and meat. Thismethod has the advantage of requiring no assistancefrom any organisation, nor reallocation of finances toenhance flock value.

Increasing Protein to Poultry

Frances D. Burton (University of Toronto at Scarborough, Dept. of Anthropology) and PeterG. Silverman (Ombudsman, CITY TV, Toronto)

Poultry can be an important source of food following drought andcrop failure. Unfortunately, reduced staple crop production also affectsthe chickens so that they become scrawnier and less able to produceeggs thereby detracting from their potential contribution tohuman diet. The article below suggests one ratherinnovative means by which the nutrition of poultry maybe safeguarded in times of drought and foodscarcity. Eds

For further information contact: Frances Burton, University of Toronto atScarborough, 1265 Military Trail, Scarborough, Ontario M1C 1A4, Canada.e-mail: [email protected]

References:1 Thijssen, Rik. Croton megalocarpus, the poultry-feed tree: how localknowledge could help to feed the world. Domestication andcommercialization of non-timber forest products in agroforestrysystems. Non-Wood Forest Products 9. Food and AgricultureOrganization of the United Nationshttp://www.fao.org/docrep/w3735e/w3735e00.htm

2 Sonaiya, E.B. Rural family poultry in Kenya. INFPD Newsletter Vol. 8No. 3.http://www.fao.org/WAICENT/FaoInfo/Agricult/AGA/AGAP/infpd83.htm

3 Zahid, P.B., Aisha, K., Ali, A., 1995. Green seaweed as component ofpoultry feed. Bangladesh Journal of Botany. 24:(2)153-156 (DEC)

4 Dieng, A., Guèye, E.F., Mahoungou-Mouelle N. M. and and A. Buldgen,1999. Effect of diet and poultry species on feed intake and digestibilityof nutrients in Senegal. INFPD Newsletter Vol. 8 No. 3.[INTERNATIONAL NETWORK FOR FAMILY POULTRY DEVELOPMENT].http://www.fao.org/WAICENT/FaoInfo/Agricult/AGA/AGAP/infpd83.htm

5 Donkoh, A., Atuahene, C.C., Poku-Prempeh, Y.B., and I.G. Twum, 1999.The nutritive value of chaya leaf meal (Cnidoscolus aconitifolius (Mill.)Johnston): studies with broiler chickens. Animal Feed Science andTechnology.77:(1-2)163-172 (FEB 15)

6 Gonzalez, L.M., Lonwo, E., Perez, N., Gonzalez, J.L., and O. Gutierrez.1992. Evaluation of Tobacco Seed Cake as Protein-source in PoultryDiet. Cuban Journal of Agricultural Science 26:(2)171-175. (July)

7 Waliszewski, K.N., Romero, A., and V.T. Pardio. 1997. Use of canecondensed molasses solubles in feeding broilers. Animal Feed Scienceand Technology.67:(2-3)253-258 (July).

8 Ali, Ma, and S. Leeson. 1995. The Nutritive-value of some IndigenousAsian Poultry Feed. Animal Feed Science and Technology. 55(3-4)227-237. (Oct).

9 Lyon, Wm. F. Insects as Human Food HYG-2160-96. http://www.ag.ohio-state.edu/~ohioline/hyg-fact/2000/2160.html

...wondering about crudemortality rates among spiders?

Frances on location in Les Cayes, Haiti

News


Aworkshop was organised by the FeinsteinInternational Famine Center in June this year.This workshop provided a forum for both

technical and non-technical representatives of NGOs,UN, governments and academic institutions toconsider the potential of using a Public Nutritionapproach to tackle nutritional problems in complexemergencies.

Workshop proceedingsThe first day of the workshop focussed on theconceptual issues related to the role and significanceof malnutrition in emergencies and speakersaddressed issues relating to malnutrition andvulnerability and the responsibilities within theinternational humanitarian system for addressingnutritional problems. The discussions in the plenarysession raised a number of issues to do with the valueof a Public Nutrition approach in tackling some ofthe concerns. Participants agreed that the commonmisconception about the scope of nutrition among thewider humanitarian system tends to give it a narrowfocus on malnutrition and feeding people. Thisinability to take account of the wider determinants ofmalnutrition is a constraint to improving programdesign and impact. There was a difficult and at timescontentious discussion where participants who weredrawn from a range of backgrounds had to come to acommon understanding of Public Nutrition and itsapplicability to emergency situations. Once there wasgreater clarity on the conceptual issues, the focus ofthe workshop shifted towards operational matters.

Presentations on the second day included operationaltools and frameworks that are currently used byagencies and have a direct impact on nutrition.Representatives from UNHCR, UNICEF and WFPpresented the memoranda of understanding betweenkey UN agencies.

Six case-study presentations also illustrated thevarious components of a Public Nutrition approach,

including in-depth assessment, analysis, programdesign and constraints of using the approach(Concern Worldwide, Helpage International, CareInternational, Action contre la Faim, UNHCR andNutritionWorks).

Workshop outcomesMost key decisions about nutrition in emergenciesare made by non-nutritionists. Hence participantsagreed on the necessity of raising levels of awarenessand understanding amongst senior policy-makers andall actors in the humanitarian sphere, about theimpact of their actions on nutrition. Recommendedstrategies for achieving this included:

1. Developing better multi-sectoral workingrelationships and strengthening relationships withdonors and key decision-makers in thehumanitarian system. Such a relationship should be based on theknowledge that individual components of a PublicNutrition approach are not viewed as competingpriorities.

2. Institutional learning, training and capacitybuilding, particularly in relation to institutionsbased in developing countries and building uponinitiatives such as the Sphere project. Appropriatetraining and education curricula and relatedmaterials were felt to be needed for both specialistand non-specialist staff working in food andnutrition related programmes at all operationallevels. Information was seen to be central to theprocess of institutional learning, education of themedia, and informing key decision-makers withinthe donor community. The papers presented at theworkshop, plus an overview of the proceedings,are published as a special issue of the DisastersJournal, which may be ordered using the formincluded in this Newsletter, or ordered directlyfrom Blackwell Publishers Journals (108 CouleeRoad, Oxford OX4 1JF, UK or 350 Main Street,Malden, MA 02148, USA).

International Public Nutrition and Emergencies:The Potential for Improving Practice

Workshop summary by Anuradha Harinarayan, Feinstein International Famine Center, Tufts University

What is Public Nutrition?

Public Nutrition is a broad-based problem-solvingapproach to addressing nutritional problems ofpopulations or communities. In contrast to clinicalnutrition, the emphasis is shifted from theindividual to the population level, and from anarrow set of technical interventions to a widerange of strategies, policies and programs tocombat malnutrition.

Public Nutrition recognises that food insecurity isonly one of the determinants of malnutrition inemergencies, and interventions need to addressboth the health and social environment to have animpact on malnutrition. Public Nutrition is distinctfrom Public Health in a few key ways - PublicHealth tends to approach nutritional problem-solving using a medical, disease prevention model,which rarely takes account of public policy infood-related fields outside of health, likeeconomics, trade or agriculture. This distinction ishighly relevant to Public Nutrition in emergencies,where Public Health strategies fall short of takingaccount of the wider social, economic and politicaldeterminants of access to food, relevant publicpolicies and community and individual strategiesfor dealing with food insecurity. Additionally, aPublic Nutrition approach makes explicit theimpact of the political, economic and healthenvironment on a family’s ability to care for itsmembers and itself.

This approach requires that a context specificanalysis of the types and causes of malnutritionform the basis of decision-making at all stages ofthe project cycle including, planning and designingprogrammes, implementation, monitoring andevaluation.

Nutrition in Reliefand Emergenciesshort Course

Merlin and International Health Exchange (IHE)will be running a second short course on‘Nutrition in Relief and Emergencies’ between

the 19th-21st of January 2000. The course is being run inconjunction with NutritionWorks (a partnership of sixindependent nutritionists who have extensive publicnutrition experience in the regions of sub-Saharan Africa,Asia, Eastern Europe and the Middle East) and is aimedat doctors, nurses and other health personnel who havelittle formal training in nutrition. The course will also beof value to nutritionists and dieticians who have noprevious overseas experience of relief programmes. Asyet the venue is undecided but those interested in thecourse should contact Ben at IHE on 00 44171 620 3333.

October 15 1999. The internationalmedical relief organisationMédecins Sans Frontières (MSF),

was today awarded the internationalNobel Peace prize in Oslo. The awardhonours the work of all national andinternational MSF relief workers bringingmedical assistance in around 80countries, over 20 of which are inconflict.

“As entire families are chased from theirhomes in East Timor and as thousandsmore people are targeted in conflictsaround the world which don’t make thehead-lines, this Nobel prize is animportant high level confirmation of thefundamental right of ordinary people tohumanitarian assistance and protection”said Dr James Orbinski, MSF’sInternational Council President.

MSF welcomesNobel support forpeoples’ right tohumanitarianassistanceInternational medical relieforganisation awarded NobelPeace Prize

The 26th ACC/SCN meeting was held from the8th to 15th of April in Geneva. The WorkingGroup on Nutrition in Emergencies, made up

of NGO, bilateral and UN agency members and somemembers of the AGN, met to discuss nutritionalissues in emergencies on Sunday April 11th. Two ofthe agenda items were the evolution of nutritionresponses in emergencies since 1976 and the impactof the recent crisis in Southern Sudan on adolescentsand adults.

Dr. Mike Toole (Macfarlane Burnet Centre forMedical Research, Australia) gave an overview of thetrends in nutrition assistance programmes inemergencies between 1976 and 1999. Dr. Tooleprefaced his presentation by saying that although thequality of nutritional assistance has improvedconsiderably in the last two decades, some problemsstill persist such as the continuing outbreaks of micronutrients deficiency disorders. Furthermore, therapidly changing geopolitical context had raised newchallenges in the provision of adequate food aid.

Key milestones in nutritional assistance inemergencies were identified and summarised.

These included the following:

• Nutrition assessment surveys routinely began to useanthropometry making comparisons with theWHO/CDC/NCHS reference population during therefugee crises of the late 1970s, specifically theinflux of Laotians, Vietnamese and Cambodianrefugees into Thailand

• During the early 1980s in Somalia and Ethiopiaoutbreaks of scurvy and measles in refugee campsdemonstrated inadequacies in the range of nutrientsin refugee diets and that communicable diseaseprogrammes were critical in the prevention ofexcess mortality among malnourished children.

• During the late 1980s acute malnutrition persistedin many refugee camps highlighting fooddistribution mechanisms as a key factor inemergency response.

• The term “complex humanitarian emergency” wascoined following the international response to thedisplacement of Kurds from northern Iraq. Thelessons learned during this emergency included: thepotential impact of diarrhoea on the nutritionalstatus of previously well-nourished populations; thedangers associated with displacement of apopulation where prevalence of breast feeding islow and the impact of local food trade in preventingmicro nutrient deficiency diseases.

• Following the dissolution of the Soviet Union, anumber of economic crises occurred, mostsignificantly in the former Yugoslavia. In thesesettings, children were not found to be asvulnerable to nutritional disorders as the elderly,particularly those surviving on fixed pensions inurban situations in cold climates.

• During the 1990s, armed conflicts in Somalia andsouthern Sudan led to severe famines, whereextremely high rates of malnutrition were reported(all age groups were affected including adults). Theneed to standardise nutrition assessment methodsand to improve the assessment and management ofadult and adolescent malnutrition was highlightedduring this period.

Some unresolved issues which urgently need to beaddressed were summarised as: assessment andmanagement of acute malnutrition in adolescents andadults; prevention of vitamin C deficiency in largeAfrican food aid dependent populations and themanagement of anaemia among severelymalnourished children.

Dr. Peter Salama (Medical co-ordinator foremergencies, Concern Worldwide) presentedbackground information and a case study to highlightthe ongoing lack of attention to adult and adolescentmalnutrition in nutritional emergencies.

The experience of Somalia (1992-93) and Angola(1993-94) led to recognition of the need to developanthropometric indices and treatment protocols foradult malnutrition. A case study was presented on thesituation in Ajiep, Bahr el Ghazal in southern Sudanin 1998. In this situation where there were some 18NGOs operating over 50 Supplementary FeedingProgrammes (SFPs) and 21 Therapeutic FeedingProgrammes (TFPs), not one of these programmeswas tailored for adolescents and adults. Concernestablished adult and adolescent therapeutic andsupplementary feeding programmes. Two keyconclusions that were drawn from the presentationwere: (i) that towards the end of a severe famine,adult and adolescent malnutrition is frequently asignificant health problem and (ii) that with thecorrect treatment and management of malnutrition,even the most emaciated individuals can survive.

Dr Salama recommended that there was a need for (i)programmes to target adult and adolescentmalnutrition and that these conditions should besystematically investigated as part of any reliefresponse and (ii) an inter-agency working group onadult and adolescent malnutrition in order to:

• further standardise eligibility criteria and treatmentprotocols in selective feeding programmes for thisdemographic group

• establish survey methodologies for determiningprevalence of adult and adolescent malnutrition andpopulation prevalence cut-offs

• determine an operational research agenda.

The SCN agreed that it would take on responsibilityfor following-up specific recommendations on adultand adolescent malnutrition.

For further information contact: ACC/SCN, 20 Avenue Appia,1211 Geneva 27, Switzerland. e-mail: [email protected]: http://www.unsystem.org/accscn/


Summary of the Meeting of the Working Group on Nutrition inEmergencies

by Annalies Borrel

AWFP-chartered aircraft crashed 15 km northof Pristina on 12 November, killing all 24passengers and crew aboard. The Pristina-

bound plane which departs daily from Rome wasexpected to arrive at its destination at 11:30. Thelast radio contact with the plane was at 11:15. Uponlearning of the news of the plane's disappearance,WFP contacted KFOR in Pristina to begin a searchand rescue mission. The plane was located later onFriday evening. WFP set up a crisiscommunications room at its Rome headquarters todeal with the various aspects of the crisis.

Below is the complete list of passenger names, allof whom worked for UN agencies, aid organisationsor government agencies. Three of the passengerswere WFP staff.

Bazzoni, Roberto Italian Caritas Sardinia

Biocca, Paola Italian WFP

Curry, Andrea Irish GOAL

Davoli, Velmore Italian Gruppo Volontariato Civile

Evens, Nicolas Ian Philip British Tearfund

Faisal, Abdulla Kenya UNV

Gavino, Marco Italian UNMIK

Lay, Kevin British Tearfund

Liuzzi, Raffaella Italian Boyden

Martinez-Vasquez, Miguel Spanish UNMIK

Martinez, Jose Maria Spanish UNMIK

Mirshahidul, Alam Bangladeshi UNMIK

Perez Fortes, J. Spanish UNMIK

Powell, Richard Walker Australian WFP

Rowan, Daniel Canadian Canadian Government

Samer, Thabit Iraqi WFP

Sarro, Paola Italian Terre des hommes

Scotti, Laura Italian AiBi

Sircana, Antonio Italian Caritas Sardinia

Zecchi, Carlo Italian Gruppo Volontariato Civile

Ziegler, Julia German International Crisis Group

Maccaferro, Andrea Italian Air Operator Balmoral

Canzolino, Antonio Italian Air Operator Balmoral

Piazza, Katia Italian Air Operator Balmoral

WFP Executive Director Catherine Bertini publiclyoffered condolences to the family members andfriends of all the victims.

The WFP air bridge from Rome to Pristina forKosovo operations staff will resume regular flightson 16 November.

From: WFP Emergency Report. For further informationcontact: Deborah Hicks <[email protected]>

News

WFP plane crashInformation as of 13 November

Kerubino Dies

On the 15th of September last Reuters Kenyareported the death of Sudanese rebel leaderKerubino Kwanyin Bol. The warlord who

is thought to have fired the first shot in Sudan's 16-year civil war was reported, by family, to have diedafter being wounded in faction fighting. Kerubinowas one of the founders of the Sudan People'sLiberation Army (SPLA) which since 1983 hasbeen fighting the Islamist Khartoum governmentfor political and religious freedoms for the mainlyChristian and animist south. But, like other rebelcommanders, he shifted his allegiances severaltimes. For three years he held sway over his homeregion of northern Bahr el Ghazal with a terrorcampaign which culminated in last year's faminewhich killed an estimated 60,000 people.


The tragic events leading to the expulsion of800,000 Albanian Kosovars between Marchand June 1999 during the Nato air-campaign

are well known. The speed at which the majority ofrefugees returned in the month following the signingof the Peace Agreement was just as remarkable. Theinitial UN assessment mission in May 1999,estimated that 600,000 people had remained withinthe province throughout the war. Of these, 50% hadbeen internally displaced; half of this group had beenon the move for more than one month, living mainlyin the open in forests or mountains with little accessto food or clean water and sanitation facilities. Thetestimony of refugees fleeing Kosovo reported thatthe Serbian forces had limited the access of the urbanpopulation to food.

Current population estimates indicate that the totalpopulation living in Kosovo is approximately1,600,0001 with approximately 90% of Albanianshaving returned but with a simultaneous exodus ofthe majority of the Serbian population (75,000). Thepre-war rural population accounted for 63% of thepopulation with 37% being urban2. There are anestimated 2,000 villages across 29 municipalities allof which have an urban centre. Despite efforts toprovide protection for the remaining minoritypopulations, their exodus continues. The need for theprovision of food and non-food items to the entirepopulation is acute as they work to rebuild their lives.

Currently over 200 humanitarian organisations aredelivering emergency assistance in the form of food,medical care, shelter, water and sanitation, largelyunder the co-ordination of UNHCR. One of the mainfailings of the international community has been the

failure to make maximum use of the parallelstructures e.g. health and education structures, whichhad developed within the Kosovo-Albanian traditionof self-organisation. One of these structures was theMother Theresa Society (MTS). This articlehighlights some of the challenges that both the localcommunity-based MTS structure and theinternational community have faced in deliveringemergency food aid and non-food items through analready existing ‘assistance’ mechanism.

Food assistance before the crisis The Mother Theresa Society (MTS) was founded in1991, as a “charitable and humanitarian society” inresponse to the change in strategy of the Yugoslavgovernment towards Kosovo. Many Kosovar-Albanians (and other ethnic groups) no longer hadaccess to state welfare and medical structures. MTSorganised itself into 44 branch and 636 sub branchoffices with the objective of providing welfareassistance3 to the poorest of those residing in Kosovoi.e. ‘social cases’. Providing assistance for 50,000‘social cases’ in February 1998, MTS was by far thelargest local NGO. Other local organisations such asthe Yugoslav Red Cross also provided assistance,although they were perceived to be targeting theSerbian population. At the time of the evacuation ofhumanitarian organisations prior to the Nato bombingin March 1999, MTS had become the principlevehicle for distributing humanitarian aid to waraffected persons in Kosovo. Many of the estimated4,000 - 6,000 activists4 were targeted by the Serbforces while others fled to Albania, Macedonia andelsewhere. With the cessation of fighting theseactivists returned and resumed their efforts withremarkable speed. MTS now serves a caseload of 1.1

million and takes charge of around 80% of food andnon-food items. With the 1998 beneficiary caseloadincreasing twenty-two fold, the MTS network hasbeen under ever increasing strain to continue to meetthe needs of the beneficiaries as well as the reportingrequirements of international donors and NGOs.MTS faces many challenges which, as expressed byMTS activists themselves and members of thePartnership Project, (a UNHCR funded project whichaims to support MTS as they adapt to the newsituation5), are summarised later in the article.

The current situation: assessment, deliverymechanisms and targeting of food aid (June14th to September 1999) During June and early July, under the co-ordinationof UNHCR, eight international NGOs were identifiedto be the main implementing partners (IPs) ofUNHCR and WFP for the distribution of food aid andnon-food items. It was agreed that, for co-ordinationpurposes each of the IPs would be responsible forfood distribution in each of the designated Areas ofResponsibility (AORs). Food assistance would bedelivered, where feasible, through a local distributingpartner (DP)6. As part of the initial response in thefirst two months of the emergency, a blanket fooddistribution to a target population of approximately1.7 million7 people throughout Kosovo wasprovided8. During August, 18.3 Metric Tonnes offood aid was distributed through the main food aidpipelines; 85% of the estimated food needs of 21.7Metric Tonnes. During the early stages of theresponse in early July, a rapid Food Economyassessment was undertaken jointly by WFP and FAO,primarily to develop an analysis of medium-termfood aid needs and to explore ways in which food aid

Challenges for humanitarian response in KosovoAnnalies Borrel, Rita Bhatia and Anna Young

This article looks at challenges inKosovo with specific reference todelivering food assistance throughlocal distribution mechanisms.Annalies Borrel is currently workingas a consultant with UNHCR asFood and Nutrition Co-ordinator inKosovo and Rita Bhatia, the UNHCRnutritionist from Geneva was onmission between June-August 1999in Kosovo. Anna Young is workingwith ‘Mercy Corps International asProject Manager for the‘Partnership Project’.

Field Article

Houses inhabited by gypsies in northern town of Mitrovica,Kosovo, set on fire by returning Kosovars (UNHCR/R. LeMoyne)


Field Article

could promote the normalisation and reconstructionof the Kosovo economy. In addition, a Food SecuritySurvey, including an anthropometric survey, wasundertaken by Action Against Hunger (AAH) duringthe month of July. Results of the survey indicatedthat the nutritional status of the under-five populationhad not deteriorated significantly since December19989.

However, the food security assessments confirmedthat the crisis had a significant impact on the foodsecurity situation of a large proportion of thepopulation living in Kosovo. Production of winterwheat (planted in October and harvested in June/July)was most severely affected in the northwesternmunicipalities and less severely affected in thesoutheast of the province. The rural population hadbeen severely affected by loss of harvest ofvegetables, beans and maize since the massivepopulation displacement (March-April) prevented theplanting of these crops. Furthermore, the looting andslaughter of livestock particularly cattle, wassignificant. On this basis it was estimated that inthose rural areas most severely affected, 80% of foodaid needs would need to be met through food aid. Inthe towns where little infrastructural damage hadtaken place, such as Pristina and Prizren, it wasanticipated that the urban trade and business sectorwould recover rapidly10. In the urban areas wheremore significant damage has occurred, the percentageof population requiring food assistance will mostlikely remain quite high i.e. 65%11.

The findings from the Food Economy assessmentestimated that approximately 900,000 people (anestimated 53% of the population) should be targetedfor food aid assistance from mid-September throughthe winter. Food assistance would be geographicallytargeted according to two main factors, cropproduction and infrastructural damage. However, withover 1.3 million people registered to receive food aidby the end of August, the question remained as to“how the food aid would be targeted?” An exhaustiveprocess to define beneficiary selection criteria fortargeting at community level was carried out. Fourcategories of beneficiaries (see box) were defined andranked in order of priority.

Although the process of defining eligibility criteriahad been participatory in nature, it is widely acceptedthat the criteria were not entirely satisfactory. Themain areas for concern were:

• The number of beneficiary numbers from the‘bottom-up’ community based targeting exercisewould be greater than the ‘top-down’ 900,000figure

• The selection criteria appeared to focus too muchon structural damage rather than ‘access to food’and other food security factors

A strategy for implementing the selection criteria,based on the following principles, was proposed byWFP:

• The ceiling figure of 900,000 beneficiaries wouldstill be respected

• A compromise figure, between the geographicaland community-based targeting systems, would beused (by taking the average and applying anadjustment factor) as the final figure for targeting ineach area

• The order of priorities would be respected i.e. thosefalling in Category I would receive before CategoryII etc.

• The system needed to be understood by all playersand needed to be applied immediately withoutfurther information collection and analysis.

There were still some outstanding concerns:

• Where food was inadequate to address the needs ofall categories, some of the most vulnerable withrespect to access to food, would not receiveassistance i.e. those in Category III and IV.

• The obligation to adhere strictly to the order ofpriorities and not share rations was not necessarilythe usual (acceptable) practice of the community.

• The top down geographical targeting was not basedon accurate population data and had most likelyunder-estimated the significant rural to urbandisplacement.

• The appropriateness of the selection criteria for thenon-Albanian populations had not been adequatelyconsidered.

• The categories, as outlined in the criteria, could notrealistically capture the significant knowledge andskills that were so fundamental to the community-based distribution system.

In this context, a task group was set up to monitor theimplementation of the selection criteria. The purposeof the task group was not to identify whether or notthe NGOs and food distribution system partners werefailing to rigorously apply the targeting criteria, butrather to better understand how the targeting processwas being implemented in practice, to identifyproblems and to use the opportunity to learn from thecommunity-based system12.

Challenges facing local distribution partnerssuch as MTSStrains on the voluntary ethos of the networkMTS activists worked for 9 years without monetarycompensation for their work. During 1991 to 1998,engagements with the society and associated workcommitments were limited to a few hours a week. Bythe autumn of 1998 activists at the branch were

working full time coordinating between sub-branches, headquarters and the plethora of NGOsestablishing themselves in Kosovo. Furthermore,since the return to Kosovo the vast increase incommodity distribution has meant that communitylevel activists at the sub-branch level are alsoworking full time. A short-term solution has beenfound by compensating a select number of activists at

Selection Criteria for the Distribution ofHumanitarian Food Aid in Kosovo

1. Families without shelter whose houses havebeen badly or totally destroyed.

2. Internally displaced families (IDP) - peoplewho are unable to return to their homes due tothe emergency situation and are currentlyliving with a host family or in a communitycentre and do not have access to food.Families hosting IDPs are eligible to receive aration.

3. Persons who are permanently unable togenerate an income and have no access toother financial support nor to food, such as theelderly and handicapped

4. Social cases such as single parent households,families with low socio-economic status andhouseholds whose members are unemployed.

Returnees arrive at their heavily damaged homesin Mistrovica, Kosovo (UNHCR/R. LeMoyne)

Field Article

all the levels of the society. In the future whenworkloads decrease, MTS will need to return to avolunteer network, streamline its personnel ordevelop other projects to sustain itself.

Large number of agencies operating in KosovoAt the time of writing there are more than 200hundred agencies operating in Kosovo, many of themproviding relief supplies to the Kosovar population.This has inevitably led to a lack of coordination notonly among international agencies, but specificallyamong the local distributing partners, such as MTSwho are often not informed about deliveries to theirnetwork. This inevitably has undermined theindependence and strength of a localised community-based organisation. Given the reality that localagencies will continue their work when internationalagencies begin to significantly reduce their presence,more attention should be paid to the negativeimplications of the international community failing tofully recognise and respect local structures.

Re-establishing after the conflictDuring the evacuation it was uncertain whether or notMTS as an institution would survive events. Uponreturn, the network re-established itself withremarkable speed in many areas of Kosovo. Thecapacity to re-establish so rapidly is one of manyindicators of the strength of the network, especiallyconsidering the tragic personal crises many of theactivists were facing themselves. The Red Cross hasalso re-established itself.

Donor accountabilityThere is an obvious need for a large degree ofaccountability in situations where commodities aredelivered as humanitarian aid. MTS has a highlydeveloped system of distribution logs and rationcards, which was refined in 1998 and continued afterthe bombing. The challenge now lies in collating this

information, since the large majority of the entriesare being carried out manually. The process ofestablishing a computer database is a gradual one.However, MTS is working hard to meet therequirements of the donor community which is basedon a mutual understanding of the importance ofrecord keeping.

Accountability to local communityInevitable delays in pipeline deliveries which lead toirregular distributions, are often blamed on MTS whothemselves, are often ill informed as to the broaderpicture of the mechanisms of large scale aid delivery.Additionally, when NGOs deliver directly to onevillage (often luxury ‘one off’ commodities such astoys, food parcels etc.) without informing MTS, othervillages perceive MTS to be favouring certain areas.In contrast, an MTS sub-branch or branch would tryto allocate commodities between villages accordingto those most in need. WFP, UNHCR and the IPshave partially addressed this issue by attempting toincrease coordination and mutual support andestablishing targeting criteria jointly.

IdentityGiven the current undetermined status of Kosovo,national bodies are under political pressure to alignthemselves with potential political parties. This isperhaps particularly relevant to MTS since thenetwork delivers such a substantial amount ofcommodities. Inevitably, the commodities lendauthority to those controlling them. MTSheadquarters has clearly stated that the network willremain politically non-aligned. However, at thecommunity level this issue at times, can lead to sometension between the self-elected civil administration,political groups and MTS. In most cases this hasbeen resolved through negotiation and a generalacceptance that MTS is the most qualified andexperienced network to handle the commodities.


View of the Cegrane refugee camp inMacedonia (UNHCR/H.J. Davies)


Relationship between international and localagenciesThe relationship between international and localagencies is often (as elsewhere in the world) one ofuneasy interdependence. Without the cooperation oflocal distribution partners, the humanitarian reliefeffort would be severely hindered. Local distributionpartners are on the other hand frequently dependenton international agencies for resources. However,often there is mutual distrust with internationalagencies doubting figures given and the decisionstaken by distribution partners and the distributionpartners lacking confidence in the internationalcommunity to access and deliver sufficientcommodities in a timely manner.

Addressing the needs of multi-ethnic groupsIn some areas where atrocities had been carried outspecifically against MTS activists, it remainsdifficult13 for MTS to provide welfare assistance tonon-Albanian communities, specifically the Serbianpopulations. In some cases, non-Albanian ethnicgroups have refused to accept assistance from theMTS network. For many of the MTS activists, theindividual loss and trauma suffered as a result of thewar has been enormous and will inevitably affecttheir ability to support all communities in theimmediate future.

Challenges facing the internationalcommunity The opportunity to work with local distributingpartners, such as MTS, from the outset of theemergency, was a relatively unique one. It didhowever present certain challenges

Systems and protocolsIn the beginning, there was some reluctance by theinternational organisations, particularly by those whohad not worked in Kosovo prior to the crisis, toconsider the local MTS as an integral part of theoverall food distribution system. Different agencieshad their own protocols, monitoring systems, formsetc. and were keen to implement their own systems,which in some situations conflicted with that of thelocal community-based distribution system.

Local staff recruitment The national staff members who were employed bythe international agencies did not have suitableexperience. They were often young individuals, welleducated, spoke English and were recruited from the

urban areas14 rather than from local ruralcommunities. This sometimes gave rise to difficultiesbetween the usually much older, more experiencedlocal volunteers who were working with MTS.

International staff skillsThe international staff, employed by the agencies forthe distribution, did not necessarily demonstrate theskills required for the type of approach that wasconsidered so important in developing a constructiverelationship with the local community-baseddistribution system.

Monitoring roleAn important component of the internationalagencies’ role was that of monitoring. This created anumber of challenges. Firstly, a code of conduct wasnecessary to ensure that the monitoring was carriedout using a discrete, respectful and constructiveapproach. Secondly, rather than carrying out thedistributions themselves, the agencies were expectedto focus on issues of monitoring at the householdlevel, such as; coverage, access to the ration, fooduse, vulnerability factors and the communityperception of nutritional vulnerability. The need todevelop monitoring skills, procedures and means touse the monitoring information was relevant to allagencies.

Measuring ‘nutritional vulnerability’The community-based targeting system did notalways accord with international agency perceptionsof nutritional vulnerability. The system relied oncommunity knowledge of vulnerability which wassensitive to detail and changes, and captured anumber of complex factors affecting nutritionalvulnerability - a concept that international agenciescould not necessarily ‘measure’ quantitatively.

Using a ‘capacity-building’ approach The professional capacity of the local distributionsystem varied from one area to the next. In mostcases it was necessary for agencies to take a‘capacity-building’ approach to food distributions.While under enormous pressure to ‘get the job done’,it was certainly challenging for agencies to providethe necessary support and not undermine othercapacity building activities provided by thepartnership project.

Identifying alternative distribution partnersWhere the MTS distribution system was not working

e.g. in some non-Albanian ‘enclaves’, the agenciesneeded either to identify an alternative partner orcarry out the distribution themselves. In cases wherean alternative partner was deemed appropriate e.g.Orthodox Church or local village committee,significantly more time and resources needed to beallocated to training and building systems foraccountability etc.

Co-ordination with KFORThe distribution systems established in Kosovoinvolved a number of different agencies working inclose partnership, namely UNHCR, WFP, anImplementing Partner (international) and aDistribution Partner (local). In addition, KFOR, theUN Peace keeping Mission for Kosovo, was yetanother element to take into consideration in thedistribution system. The extensive network of KFORpersonnel in villages, with their enthusiasm toprovide food and other humanitarian assistance to thepopulation, sometimes created misunderstandings andconfusion among the partners. While their presencewas recognised as important in identifying gaps inaid provision these well-intentioned efforts wereoften cause for misunderstandings.

Joint planning and information sharing Information flow from MTS headquarters to theextensive number of sub-branches has at times, beenvery slow. This undermined the ability of agencies toco-ordinate shared planning and take timely action.Given the obvious differences in resources that theinternational and local agencies were working with,this limitation was understandable. Despite theseconstraints, agencies recognised that it was importantto continue to make efforts to facilitate and carry outjoint planning.

ConclusionsDespite the difficulties and constraints experiencedby both the international agencies and distributionpartners, the relief effort in Kosovo has demonstratedthat it is possible to work with local partners from theoutset of an emergency. In these contexts however,there is still a need for ‘emergency food distributionagencies’ to develop a ‘community-approach’ to fooddistributions with a focus beyond ‘logistical relief’.

The need to target food aid to those who most need itis a legitimate one. The Food Economy approach isone method that is based on a sound analysis and canprovide a framework for identifying geographic

Field ArticleReturnees going to Medvec,

Kosovo (UNHCR/R. Chalasani)


differences in food needs. Community-managedtargeting is undoubtedly, in many situations, aneffective way of reaching the most vulnerable. Thiscase study has shown that where both targetingmechanisms are applied, the process of reconcilingthem can be challenging. The process needs to bemanaged carefully and sensitively otherwise it maybe the cause of grave misunderstandings andpossibly even create conflict at the community level.

The international community and local distributionpartners must now together, assess the effectivenessof the targeting process. Adequate resources, skillsand time must be allocated to monitoring the impactof the implementation of the selection criteria.Mechanisms such as: establishing a task group, thedevelopment of monitoring skills and activities ineach of the agencies and adopting a learningapproach with local distribution partners, arefundamental to this next stage.

The full implications for a community-basednetwork such as MTS of the presence of, andinteraction with such a large international communityin a crisis situation, still has to be realised. A follow-up evaluation of the impact of the relief effort onlocal NGOs, such as MTS, will be important inenhancing understanding and the future role of acommunity-based approach to emergency food reliefprovision.

Footnotes1 UNHCR/KFOR, September 19992 It is likely that there has been a shift towards urbandisplacement due to dramatic destruction in the rural areas,increased employment opportunities and access to food. 3 MTS also had a medical sector providing parallel primaryhealth care throughout Kosovo. This will not be discussed inthis article. 4 Community ‘contact’ persons5 The Partnership Project has been funded for a year now inrecognition of the demands placed upon the MTS society. Itaims to support the society by providing financial and

material resources to the network in conjunction with trainingand technical support.6 In most, but not all situations, the DP is MTS.7 With the objective to reach 80% of the population. 8 The monthly food basket, which aimed to provide2,300kcal, was made up of wheat flour, beans oil, sugar andcanned meat. Due to logistical constraints, this completefood basket was rarely fully provided during the early stagesof the emergency. 9 In December 1998, global malnutrition was 2.0% and inJune 1999 was 3.1% (-2 z-score weight for height) amongunder fives (Action Against Hunger Nutrition Surveys). 10 Prior to the war, when Albanian employment in the formalsector was restricted resulting in the urban (and to a lesserextent) rural Kosovar Albanian economy being fuelled byremittances from abroad, Mother Theresa Society wasassisting 30% of the population. 11 Mark Lawrence, Food Economy Assessment of KosovoProvince, July 1999. 12 This process is currently under way with the aim to makeany changes to the criteria by the end of October. 13 In many situations MTS is delivering assistance to non-Albanian populations. 14 Furthermore, these well-educated persons were oftenemployed as interpreters, drivers and monitors - removingthem from potential positions in rebuilding their ownstructures.

For more information contact: Annalies Borrel, 829 CourtenayDrive NE, Atlanta, GA 3036, USA. email: [email protected]

Vincent Brown is the co-ordinator for the MSFPSP (populations in precarious situations)residential training course for MSF field staff

which is held twice yearly. He works forEPICENTRE the agency responsible for running thecourse. As a regular participant of the paneldiscussion on emergency food aid needs assessmentsand interventions which forms a component of thecourse, the ENN thought it time to find out a littlemore about EPICENTRE on behalf of FieldExchange. I therefore set up an interview withVincent at the most recent PSP course in Lacanauwhich is about 45 minutes drive from Bordeaux inFrance. A delayed flight meant that I arrived quitelate in Lacanau. Vincent looked tired (it was near theend of the two week PSP course) so I felt a littleguilty interviewing him in the late evening when Iimagine he would have much preferred to unwindwith a drink. Nonetheless, Vincent was typicallyenergetic, enthusiastic and warm in answering myquestions.

EPICENTRE was set up in 1986 by anepidemiologist called Alain Moren who had beenworking for MSF France for several years. Alan wasvery interested in public health epidemiology andafter studying in Johns Hopkins University and a twoyear stint as an epidemiological information officer inCDC was asked by MSF France to create an appliedepidemiology unit in Paris. This unit (EPICENTRE)was to undertake three main activities - training,applied research and ‘consultations’. Although initialfunding was entirely from MSF France, it wasunderstood that within approximately 5 years

EPICENTRE should become roughly 50% self-financed. EPICENTRE is located in the samebuilding as MSF France and now boasts a staff of 15people in Paris comprising medical epidemiologists,computer specialists and administrative support.EPICENTRE also has three field posts headed bysenior medical epidemiologists in Kampala, Kinshasaand Abidjan.

EPICENTRE activities include the following:

Research and Consulting: EPICENTRE developsapplied research projects aimed at improving healthprogrammes while a team of public health andepidemiology experts are available to requestingagencies and countries. EPICENTRE are routinelyinvolved in disease outbreak investigations,epidemiological studies (prevalence studies, clinicaltrials, risk measures), setting up and evaluating healthinformation systems, computerising these systems,evaluation of health programmes and rapidepidemiological assessments. This work may be donefor any branch of MSF on demand, or outsidecontracting agencies.

EPICENTRE are also involved in up to 22 weekstraining for MSF staff each year. There are twoweeks of training specifically in nutrition andvaccination each year while nutrition also forms amodule of the biannual PSP course.

Vincent described how research ideas and proposalsare usually jointly conceived by MSF France andEPICENTRE but that on-going operational demandson EPICENTRE, i.e. evaluations, assessments, etc ,do limit time to press ahead with research ideas. Healso explained how some research takes a long timeto set up, especially clinical trials, and that these mayinvolve lengthy discussions with ethical committeesat national or international level.

Nevertheless, applied research comprises one third ofEpicentre activities with over 20 research projectsplanned for the year 2000. Examples of Epicentreresearch activities include:

• a review of epidemic thresholds of meningitisduring outbreaks in Sahelian Africa

• an assessment of the impact of routine antibiotic

regimens on acutely malnourished childrenadmitted to therapeutic feeding centres.

• assessing admission criteria for adults insupplementary feeding programmes

• an evaluation of the efficacy of different drugcombinations in the treatment of malaria.

I asked Vincent what he believed EPICENTRE’sgreatest achievement had been to date. He said that ithad to be the development and use of appliedepidemiology as a tool to assess/evaluate ongoingprogrammes. He then started to explain how this toolwas now being developed by EPICENTRE todocument violence and advocate for its cessation.Recently, EPICENTRE had carried out representativeepidemiological surveys on Kosovar refugees inMontenegro and Albania on the extent of violencecommitted against the individual. This informationwas then shared ‘at international level’.

The following morning at breakfast, Vincent provideda few more details about the PSP course. Heexplained that MSF staff needed to have had 12-18months field experience before they could beaccepted on the course and that applicants only hadto pay for subsistence. He also said that given howeach course of 36 students usually had between 15-20nationalities with huge variations in length of fieldexperience, it was remarkable how well they got on.

The atmosphere on the PSP course always seems tome to be uniquely multi-cultural and vibrant. It alsostruck me how the creation of a semi-autonomousresearch/technical support group by an emergencyhumanitarian agency is a fairly unique initiative.Operational emergency aid agencies generate somuch experience and data in the course of their work,yet undertake very little research during the course ofthese activities. This is mainly due to competing andhigher priority operational demands on agency staff.Those of us who are more research minded oftenreflect on the wasted opportunity to conduct vitalresearch. EPICENTRE appear to have found amechanism whereby emergency programmes can beutilised as project sites for important research. It istherefore perhaps surprising that there are not moreexamples of this kind of institutional arrangementbetween an operational emergency agency andresearch/technical support unit.

Address 8, rue Saint-Sabin, 75004 Paris

Telephone 00 33 1 40 21 28 48

Fax 00 33 1 40 21 28 03

Email [email protected]

Formed 1986

Name of Director Dominique Legros

Overseas staff 3

HQ staff 15

Epicentre budget 2 million US$/year (approx)

EpiCentreInterview with Vincent Brown. By Jeremy Shoham

Agency Profile

Field Article


As the millennium draws to a close, memoriesof the appalling man-made famine insouthern Sudan last year are hard to erase.

Even as this issue of Field Exchange goes to press,thousands of Angolans teeter on the edge ofstarvation; pawns in a long and brutal civil war overwhich they have little control. Famines have occurredwith monotonous frequency throughout the 20thcentury despite enormous technological, economicand social advances - the Ukraine famine in the1930s, the Bengal and Dutch famines of the 1940s,the great China famine of the 1950s, Biafra in thelate 1960s, famines in Bangladesh, Ethiopia, Somaliaand Sudan in the 1970s-90s. There are many others,though perhaps lesser known. What most of thesefamines have in common is a shared cause; they wereall created by man. Some of the man-made faminesof this century are described below. The accounts arestark, harrowing and shameful. Yet their causes andimpact bear striking similarities to the famines oftoday.

We have included these accounts in the last issue ofField Exchange for the millennium not to createpessimism as we move into another century, but tohelp us pause and reflect on how far we have comebut how little has really changed. We can only hopethat as our children look back over the famines of the21st century that they will see less of the hand ofman than has been evident in famines during thesepast hundred years.

The allied blockade of Germany: March 1915to 1918The allied blockade of Germany began on 11 March1915 at the outbreak of the First World War. Neutralships bound for Germany were apprehended at sea,escorted into British or French ports and detained,effectively giving the Allies long-range control ofGerman commerce. By September 1916, the Britishfleet was single handedly intercepting an average of135 merchant ships every week.

As a result of the blockade, conditions withinGermany deteriorated. Unemployment stood atbetween 20 and 40 per cent, and although theGovernment provided 10.5 Deutsche Marks per weekto a family of four in which no one was employed,the benefit of the payment was eroded by soaringinflation. The supply of food declined and rationingwas instituted. The diet in Germany was initiallyreduced to bread and potatoes. Failure of the potatocrop in 1916 led, however, to turnips replacingpotatoes as the principal staple, and the particularlysevere winter of 1916-17 was dubbed the ‘turnip-winter’. The daily bread ration, which had beenestablished at 225 grams per person per day in 1915,fell to 160 grams in 1917 with dough made from 55per cent rye flour, 35 per cent wheat flour and 10 percent substitutes. As conditions got worse, the ryeflour was replaced by turnips. Only the very young,

invalids, expectant mothers and the elderly werepermitted milk.

Food prices increased as did the queues for rations.As one observer noted: “the daily bread was now aluxury”. The collective weight of the Germanpopulation plummeted sharply. The incidence ofactual starvation was reported to be particularly highin jails, asylums, and other institutions where inmatesonly had access to an unsupplemented food ration.Cases of tuberculosis (TB), rickets, influenza,dysentery, scurvy, keratomalacia and hunger oedemabecame rife. TB was reported to be the major causeof death, but was initially limited largely to theelderly. As the disease spread, however, TB began toaffect adults and young children whiledeterioration of hygienic standardscontributed to the spread of disease.

The human toll was enormous.The number of deaths inGermany increasedfrom 88,235 in1915 to 293,760 in1918. This increasewas despite a dropin the birth ratefrom 30 per 1000 to15 per 1000between 1914 and1919. Mortalityincreases wereparticularly highamong children andthe elderly. The deathrate of childrenbetween the ages of1 and 5 years roseby 50 per cent andamong childrenfrom 5 to 15 yearsby 55 per cent.

The SovietFamine: 1932-1934In 1928, Stalin launchedhis first five-year plan,which was an ambitiousattempt to boostindustrialisation in the SovietUnion. The plan was to doublesteel output and triple both pig ironand tractor production within five years.The investment for industrialisation was to comefrom the agricultural sector through collectivefarms. The aim was to create modern ‘socialist agro-towns’ which would produce massively increasedyields. The collectivisation campaign, which beganin 1929, was violent, brutal and sudden. Overnight,small peasant holdings were merged into collectives;giant farms covering as much as 247,000 acres.

One hundred years offamine – a pause for reflectionThis piece was written by Fiona Watson, Institute of Child Health - NutritionWorks with contributions from the editors

Millennium Special

Wages were abolished and a system of work pointsestablished, which were paid as a share of thecollective’s output.

The peasants violently resisted collectivisationthrough armed rebellions, and destroying crops andlivestock. Stalin’s response was draconian. Allcollective land, agricultural produce andimplements were declared state property andanyone guilty of destroying or damaging them wasto be shown no mercy. Peasants were forbidden toleave the countryside without permission while richpeasants (kulaks) were expelled and killed or sentto labour camps. Agricultural production fell by 40per cent. Nevertheless, from 1931 to 1933, theforcible seizure of grain was re-introduced and theSoviet Union doubled grain exports to raise hardcurrency to buy equipment needed forindustrialisation.

Famine ensued. On average, the peasants were leftwith a third less grain than they had between 1926and 1930. The food shortages were most acute inthe Soviet Union’s richest grain-growing areas,including the Ukraine. The Ukraine was particularlyhard hit because Stalin initiated a campaign to crushUkrainian nationalism and the rebellious Cossacks,who truthfully reported the existence of famine. In1931, Stalin allowed relief grain to be delivered toall regions except the Ukraine.

The terrible spring of 1932 was superseded by theeven more terrible spring of 1933. Vasily Grossman,a Soviet writer recorded:

“When the snow melted true starvation began.People had swollen faces and legs and stomachs.They could not contain their urine...And now theyate anything at all. They caught mice, rats,sparrows, ants, earthworms. They ground up bonesinto flour, and did the same thing with leather andshoe soles; they cut up old skins and furs to makenoodles of a kind and they cooked glue. And whenthe grass came up, they began to dig up the rootsand ate the leaves and the buds, they usedeverything there was; dandelions, and burdocks andbluebells and willowroot, and sedums and nettles...”

An eyewitness noted that: “...the fertile Ukrainiansoil was covered with human corpses...I saw howspecial brigades gathered the corpses from thestreets and houses, and carted them to commongraves, or simply threw them in ravines.” TheItalian Consul in Kharkov, the capital of Ukrainereported that there was: “a growing commerce inhuman meat” and that people in the countrysidewere killing and eating their own children. Theauthorities responded by distributing posters thatread: ‘EATING DEAD CHILDREN ISBARBARISM’. People knew that there was food inthe cities and desperately tried to flee thecountryside. In Kharkov in 1932, the policerecovered 250 corpses every morning from therailway station.

Despite the massive scale of the famine, adeliberate conspiracy of silence was enforced anddoctors were forbidden to disclose on deathcertificates that the deceased had starved to death.Figures on the number of people who died duringthe famine in Ukraine are difficult to determineaccurately. Estimates vary between 5 and 8 millionequivalent to between 10 to 25 per cent of the entirepopulation of the Ukraine.

The Ukrainian famine finally ended in 1934 whenStalin ordered a stop to the forced seizure of grain,and allowed each household to have a small plot ofland on which to grow vegetables and raise a cow, apig and up to ten sheep.

The Warsaw Ghetto: November 1940 to July1942

The Germans invaded Poland in September of 1939.By October of 1940, they had confinedapproximately 380,000 Jews in a 3.5 square milearea of Warsaw that normally housed about160,000. In March 1941, the population reached apeak of 445,000, representing about 30 per cent ofthe Warsaw population. The area was surrounded bya 10 foot high wall and was sealed off on 15November 1940. Jews were forbidden to go outsidethe area without permission on penalty of beingshot on sight and no contact with the outside worldwas allowed. The Germans calculated that theycould destroy the population in the Warsaw Ghettoin nine months through mass starvation and theaccompanying infectious diseases.

Rationing in Poland had begun in December 1939.By 1941, the official ration provided 2,613 kcalsper day for Germans in Poland, 699 kcals for Poles,and 184 kcals for Jews in the ghetto. Whilst thesevere food shortage affected the whole of Warsaw,those outside the ghetto were able to trade withfarmers. Inside the ghetto access to food was muchworse. The poor hygiene within the ghetto re-ignited typhus and an epidemic flared up. A furtherhardship was the cold. In December 1941, the Nazisrequisitioned all furs for their soldiers at theRussian front. The electricity supply to the Ghettowas cut off for extended periods and the practice ofsleeping in clothes facilitated the spread of typhusthrough lice.

People of all ages began to die in droves. BetweenNovember 1940 and June 1942, doctors workinginside the ghetto recorded a total of 70,381 deathsof which 18,237 were due to starvation, 2,509 totyphus and the remaining to ‘unknown’ causes,though this was usually believed to be starvation.This was equivalent to a Crude Death Rate (CDR)of approximately 125 deaths per 1,000 of thepopulation per year. There was a seasonal patternwith higher death rates during the cold wintermonths than the summer.

One observer gives a harrowing account of thedesperation within the Ghetto:

“People of all ages died in the streets, in shelters, inhomes, and in hospitals. Wdowinski used to walkabout one kilometre from his home to CzysteHospital, and often saw six to ten bodies lying inthe street each day. Night-time created a specialhazard because: ‘... even the most courageous orinsensitive lost their nerve when, in the darkness ofthe night, they happened to accidentally step onsome soft object that turned out to be a cadaver’.Those found dead on the street usually had not diedthere. The family commonly removed a body fromtheir home onto the street, after removing allevidence of identity. In that way, they might be ableto use the extra ration card for a few days...mothershid dead children under beds for days in order toreceive a larger food ration.”

Because the Jews were able to smuggle some foodinto the Ghetto, the Germans were unable to starveall the inhabitants. Mass deportation of Jews in theGhetto to the gas chambers in the exterminationcamps of Treblinka and Auschwitz began on 22July 1942 and the Ghetto was finally razed to theground in May 1943.

The siege of Leningrad: September 1941 toJanuary 1944In September 1941 Leningrad was surrounded byGerman forces and the order issued to “tighten upthe blockade and level the city to the ground byshelling from the air”. During the 900 days of the

PH

OTO

GR

AP

H B

Y K

OR

NE

LIU

S E

LST

NE

R -

DU

BLI

N ‘9

9


Millennium Special

siege, there was incessant aerial bombing andshelling from long-range guns. The winter of 1941 to1942 was particularly severe and the coldest in morethan a century. A lack of fuel had reduced the powersupply, badly affecting heating and restrictingcooking, the water and sewerage systems weredamaged by shelling and there were increasing foodshortages.

Supplies could not be airlifted in because of theactivities of the Luftwaffe though some provisionscould be brought in by lorry across the iced-overLake Ladoga. The ration of bread, which was 500grams for manual workers and 300 grams for‘mental’ workers in September 1941, fell to an alltime low in December 1941 of 250 grams for manualworkers and 125 grams for ‘mental’ workers(equivalent to a maximum of about 438 kcals to 875kcals per day) supplemented with a meat ration ofbetween 75 and 150 grams per month and smallamounts of sugar, fat, potatoes and other vegetables.Not only were the rations small, but the nutritionalvalue of the bread was low, consisting of “about one-half defective rye flour, the rest being substitutessuch as cellulose, malt, and bran”. The populationgrew some food in parks and gardens, but werereportedly reduced to eating rats, glue from furniturejoints and wall paper.

Lyudmila Anopova, who was a child during the siegedescribed her experience of the winter of 1941 to1942 as follows:

“... all the provisions in the town were burned - andwith them all traces of the old life. Famine descendedupon Leningrad... That was the beginning of theworst winter in living memory. They cut off the water

supply. The Neva was close by, only 500 metersaway. But how could we reach it? We lowered

sledges, saucepans and milk churns from thefourth floor. We made our way slowly to theNeva, across the snowdrifts, and scooped upfreezing water from the ice holes... Thewindows are boarded up with plywood. It’sdark everywhere. The only warmth is in thekitchen by the iron stove, and a tiny wick isburning on the table. It’s just a twisted pieceof cloth dipped in oil... I’m hungry every

moment of the day. Provisions are soldon ration books. We have to stand in

a long queue at the shop onKirovsky Prospect. For our sixration books we get a littlemillet, some dry onion, now andagain a piece of frozen meat.We stand there for hours. Weare frozen but we wait andsuffer in silence. In themorning, we do not have thestrength to get up... I have noneed to dress. We sleep in ourovercoats.”

Weight loss was estimated to beup to 33 per cent of pre-starvation weight while scurvy,pellagra and night blindness hadall appeared by the end of thewinter. Diseases such as dysentery,bronchopneumonia and tuberculosiswere rampant and a typhus epidemicstarted but was controlled. Estimatesof deaths attributable to starvationduring the siege range from 630,000to 1 million out of a pre-war

population of 2.5 million,equivalent to a crude death

rate of between 112 and 178per 1,000 of the populationper year.

The Chinese Famine: 1958 to 1962

China has traditionally been a ‘land of famine’. Theextent of the 1958-62 famine dwarfed previousfamines, however, and yet it remained a secret forover 20 years. The scale of the famine only becameinternationally known in the mid-1980s whenAmerican demographers were able to examineChinese population statistics. The findings wereshocking: at least 30 million people had starved todeath making it the worst famine in human history.

The great Chinese famine took place during Mao’sGreat Leap Forward which was launched in January1958. The ‘two generals’ that Mao said wouldmodernise China were steel and grain production.Mao, therefore, initiated a crash industrialisationprogramme, in which steel output would be doubledor trebled within a year. The entire country set upsmelters to create steel in backyard furnaces.Everyone had to meet a quota by handing over theirmetal possessions ranging from bicycles, ironbedsteads and door knobs to iron griddles, woks andpans. To fire the furnaces, huge numbers of trees hadto be cut down. The lumps of metal which emergedfrom the backyard furnaces were to be used in themechanisation of agriculture. Unfortunately theyturned out to be useless.

Enforced collectivisation of agriculture and theobligatory procurement of grain harvests at lowprices by the state had been started in the mid-1950s.In 1958, ‘people’s communes’ were established,private plots abolished and communal kitchens setup. State grain procurements were also increased aswere grain taxes on peasants. Mao drew up an eight-point blueprint for all Chinese agriculture whichevery farmer had to follow. The results weredisastrous including the campaign to reduce pests.The whole country was turned out to make a noise,beating drums and pans, to prevent sparrows fromlanding anywhere until they fell down dead withexhaustion. Without the birds to prey on them,however, insects multiplied causing damage to crops.

The situation was exacerbated during the period 1959to 1961 by several natural disasters. As a result,agricultural production dropped dramatically anddespite wildly exaggerated claims of bumper harvestsreported by Party cadres, there were huge foodshortages. Per capita grain supply fell from 307kg/year in 1956 to 235 kg/year in 1961 while thedaily food energy availability fell to an estimatednational average of 1,535 calories in 1960.

By the autumn of 1958, conditions, especially in thepredominantly rural areas of the northern provinces,had begun to deteriorate drastically. The grain in thecollective granaries began to run out and food fromthe collective kitchens became sparser and sparser.Leaves, ground corn stalks, wild grasses and anythingelse that the peasants could gather were added to thecommunal pot.

In the autumn of 1959, the grain harvest dropped byat least 30 million tonnes over that of 1958, butofficials reported that it was much higher. The stateprocurement target was set at 40 per cent of totaloutput and in many places the entire harvest wasseized together with all livestock, vegetables and cashcrops. Party leaders were sent to villages to searchfor hidden grain reserves. The peasants were notpermitted to cook at home and the ‘internal passport’was introduced banning peasants from travellingwithout permission. It was a brutal and violentcampaign.

One of the famine survivors was Mrs Liu whorecalled the winter of 1959-60:

“On the muddy path leading from her village, dozens


Millennium Special

of corpses lay unburied. In the barren fields therewere others; and amongst the dead, the survivorscrawled slowly on their hands and knees searchingfor wild grass seeds to eat. In the ponds and ditchespeople squatted in the mud hunting for frogs andtrying to gather weeds. It was winter, and bitterlycold, but...everyone was dressed only in thin andfilthy rags tied together with bits of grass and stuffedwith straw...Sometimes she saw her neighbours andrelatives simply fall down as they shuffled through thevillage and die without a sound... The dead were leftwhere they died because... no one had the strength tobury them... She remembered, too, the unnaturalsilence. The village oxen had died, the dogs had beeneaten and the chickens and ducks had long ago beenconfiscated by the Communist Party in lieu of graintaxes. There were no birds left in the trees, and thetrees themselves had been stripped of their leavesand bark. At night there was no longer even thescratching of rats and mice, for they too had beeneaten or had starved to death.”

Out of 300 people who had lived in Mrs Liu’s villageat the start of the famine, only 80 survived.

China’s leaders appeared to have been unaware of theseverity of the famine until it was too late to preventa catastrophe. Grossly exaggerated harvests werereported and those brave enough to suggest that therewas a problem were labelled as ‘right-wingopportunists’. As a result, China continued to exportgrain while the famine raged. Over a three yearperiod from 1958, China doubled grain exports andcut imports of food. It was only in 1961 that Chinastopped exporting grain and international supplies ofgrain were called on to compensate for foodshortages inside the country.

Sudan: 1998 South Sudan has been embroiled in war since 1983and experienced a number of famines since then.The 1988 famine was responsible for an estimated250000 deaths in Bahr El Ghazal alone. The 1998famine, like the 1988 famine, was man made andresulted in an estimated 60,000 deaths. This time theinfluence of one man in particular was significant:Commander Kerubino Kuanyin Bol. Thisgovernment-

backed warlord and his army inflicted terror andcaused massive displacement in Northern Bar ElGhazal (NBEG), his home province, for the threeyears preceding the famine. Though other factorscontributed to the crisis in NBEG, it was theactivities of Kerubino and the hostilities in andaround Wau, Gogrial, Abyei and Aweil that providedthe shock that pushed the region over the brink.

Ajiep (the epicentre of the famine) suffered fromchronic insecurity for several years after Kerubinodefected from the SPLM (Southern PeoplesLiberation Movement) in 1994. An estimated 70 percent of the population were forced out of their homesand families lost their productive assets such aslivestock. Humanitarian agencies operating in thearea had to evacuate staff and programmes weredisrupted as a result of military raids in April 1998.This was followed by a further raid in May in whichan estimated 300 citizens were killed and 7 thousandhead of cattle were stolen. The devastation caused bythe military action came on top of two consecutiveyears of drought, which not only affected crop yieldsbut had an adverse impact on other important foodsources such as wild foods, fish, and grazing land forlivestock.

On 4th February 1998, just 6 days after the outbreakof renewed hostilities and the initial movement ofpeople had begun, the Government of Sudan (GOS)imposed a blanket suspension of Operation LifelineSudan (OLS) flights to the BEG and Lakes Region.The flight ban came at the most critical moment ofthe OLS response. The flight ban was lifted on the26th February when the GOS granted clearance tofour airstrips. Rather than improving thehumanitarian situation, however, this very limitedclearance actually exacerbated the crisis by turningeach of these locations into an ‘aid magnet’ drawingpopulations in throughout the region in search offood. The influx of people quickly overloaded localand OLS capacity, created tensions between the hostand displaced populations, and set a precedent fordisplaced groups moving from location to location insearch of food. As these were the most vulnerablemany died on route. Many others died when theyreached a location and were not selected in thetargeting process for humanitarian aid.

By March 1998 there was a sharp slide in thenutritional status in NBEG. By May the famine was

‘visible’ with media images showing thousands ofsouthern Sudanese starving and close to death. ByJuly, the famine was advanced with many in thehumanitarian assistance community describingthe emergency and its scale as one of the worstthey had ever witnessed. A number of agenciesadmitted for the first time that the scale of theproblem was overwhelming their capacityand that they were not coping.

In August surveys showed that theprevalence of acute malnutrition in manyareas of the region was as high as 70 to

80 per cent while crudemortality rates

reached up to 69.7/10,000/day in some places and upto 121 deaths per day in Ajiep. Estimates of thepopulation in need of food aid rose monthly from250,000 in January 1998 to 1,000,000 in August1998. Agencies were forced to reduce the admissioncriteria for severely malnourished as feeding centrescould not cope with the numbers arriving fortreatment.

Mothers were suspected of withholding food fromtheir children so that the child would be eligible fortreatment at centres and the family would receive thegeneral ration given to the family of admittedchildren. Parents were temporarily ‘abandoning’ theirchildren so that they would be accepted in carecentres for unaccompanied minors. Agenciesattempted to target the ‘most’ vulnerable with thescarce resources available although in a situationwhere everyone was vulnerable this just did notwork.

By September 1998, the relief programme had scaledup considerably with large quantities of resourcesbeing delivered (almost 10,000 metric tonnes permonth). By November early signs of improvementwere evident and by December the situation whilefragile was stabilising in many areas.

In October 1998 the communities were beginning toask questions as to whether it had done anything tobe ashamed of. Particular stories were being told andanalysed to see where the society had let down theindividuals or individuals had let down the values ofsociety, one such story follows.

“A man set out in June with his two sons to return tohis home area, but on arrival found that there wereno food distributions going on there. He thereforedecided to return with his sons to the nearest placewhere he could receive food - Acongcong - but on theway the father died. The elder of the two brotherswas faced with the threat that all male members ofthe family could die if they stayed so that the lineagewould also perish (riar) - a fate worse than death. Hetherefore decided that the best thing to do would beto abandon his younger brother, who was slowinghim down, with his father’s corpse and continue toAcongcong alone at least to make sure that hesurvived. When he reached Acongcong, a team wasdispatched to try and find the child, but while it wasaway the older boy died. It seemed that the lineagehad perished after all, until the team returned with

the younger child, stillalive.


Millennium Special

UNICEF/R. CHALASANI

Many international NGOs make a long termcommitment to communities with whomthey are engaged in development

programmes. Increasingly, crises such as conflict aswell as drought or floods disrupt the lives of thesecommunities and also development activities. Whensuch crises occur, the NGO will want to respond tothe communities’ needs and, with its existingresource base and local knowledge and contacts, isusually well placed to do so. For the same reasons,such NGOs may be seen as suitable implementingpartners by agencies such as the World FoodProgramme (WFP). By taking on this role, however,NGOs may find themselves being squeezed betweenthe policies of the donor agency and the expectationsof the community members. When food deliveriesare unreliable or the food basket is locallyinappropriate, the NGOs relations with thecommunity may be negatively affected, and staff mayfeel they are not responding adequately to people’sneeds.The following example raises questions both as to thebest way to respond to locally displaced people’sneeds, and how to optimise NGO/WFP collaboration.

In July 1997 in Bundibugyo, western Uganda,ActionAid responded to the needs of peopledisplaced by rebel activity, initially with a temporaryshelter and health/hygiene programme. The localRed Cross was distributing food on behalf of WFP inthe initial phase. Relying on a few local volunteers,their logistical capacity was severely constrained.Part of the area was difficult to access due tocontinuing insecurity. In August, WFP haddiscussions with ActionAid - whose developmentprogramme had been established since 1993 - toimplement the second phase of food distributions tosome 70,000 people over a six month period.

At this stage, ActionAid local staff in Bundibugyohad no experience of working in emergencyconditions, although they received support and

training from Kampala. This was the first majorexperience of an emergency for the wholecommunity. Many people were severely traumatised,both by the violent nature of the crisis but also by theloss of assets and means of production. Some peoplewho fled to the town and trading centres had neverbefore left their mountain villages.

Pipeline Problems The NGO registered IDPs, worked with camp leadersto involve beneficiaries in distribution tasks andinformed the camps when food would be delivered.One of the first problems to be faced was an erraticdelivery schedule. This was partly caused by thedeteriorating state of the road and bridges, and badweather conditions. Deliveries also sometimesarrived with only part of the expected rations. Thisled some beneficiaries to think that the NGO wasgiving more food to some camps than others. Such

Between a Rock and a Hard Place?Responding to IDP Food Needs in Uganda


“The food was timely, but laterbecause of breaking bridges foodstarted delaying. At differentcamps the amount of food wasnot the same, this resulted incomplaints.”

Camp leader, Kirumya camp

“Posho was delivered more thanbeans, which forced people to sellsome posho to get more beans tomake sauce.”

Food scoopers, Bumado camp

Philippa Howell is the Research &Programme Learning Officer in theEmergencies Unit, of ActionAidbased in UK. This article which shehas contributed describes importantissues arising from working as aWFP implementing partner withinternally displaced persons (IDPs)in Western Uganda. The articledraws from a review of theBundibugyo food distribution whichthe author carried out in 1998.

Field Article

Bundibugyo - July 1999 by Amanya Michael Ebye, ActionAid Uganda

rumours were fuelled more easily than mightbe expected, given the social breakdown, fearand insecurity caused by the displacement.Communications were also more difficult thanusual, since local leadership structures hadbeen dispersed. The inconsistency in itemsdelivered resulted in people having to sellsome of the rations to buy other food items.In particular, deliveries often consisted ofcereal and oil, without any pulses.

The food sales led local authorities to suspectNGO staff of selling food. The frustrationexperienced by the NGO staff, already stressedby working exceptionally long hours torespond to the emergency, resulted in difficultcommunications between them and the localWFP representatives. With no priorknowledge of the way in which WFP operated,and little understanding of their logistics andtransportation constraints, staff felt themselvesto be squeezed between the expectations of thecommunity on the one hand and the perceivedbureaucratic rigidity of the UN on the other.

Unfamiliar Food BasketAnother issue which caused friction betweenthe community and the NGO was the contentsof the food basket. The community’s normaldiet is based predominantly on root vegetablesand matoke. The cereal component of theration was mostly white maize. Most people inBundibugyo were not familiar with maize anddid not know how to cook it. Those who didwere only familiar with posho (maize flour),whereas most of the rations were delivered aswhole maize grains. There are several reasonswhy distributing maize grains in Bundibugyowas inappropriate:

• Whole maize takes a long time to cook anduses large amounts of water and fuel.

• Women did not know how to prepare it, e.g.to soak it to reduce cooking.

• Maize grains carry a social stigma, beingserved in boarding schools and prisons.

• There was no grain mill on the Bundibugyoside of the Rwenzori mountains, and there islittle or no tradition or knowledge of handgrinding.

• Differentiated needs were not taken intoaccount: whole grains are very difficult forelderly people and young children to chew.

Many people reported stomach pains anddiarrhoea due to the change in diet. The cerealwas often unpopular to the extent that both

posho and maize grains would be sold orexchanged for local food. Those from thedistant villages in particular wanted the‘mountain food’ that they were used to. Wholemaize sold at low prices resulted in profits fortraders who could transport it, grind it and re-sell it as flour.

Practical issues aside, the delivery ofunfamiliar or unpalatable food raises ethicalquestions. The Code of Conduct require us to“respect custom and culture” and the Spherefood aid standards state that local acceptabilityand preparation should be considered incommodity selection. This should be possiblein a relatively small-scale local displacementwhere markets are still functioning to areasonable extent.

Are There Viable Alternatives?Emergency projects always have to deal withunforeseen events, and to a great extent thenegative effects of delays and alterations canbe offset by clear communication mechanismsand transparent NGO/community relations.The difficulties in this case may have beenexacerbated by the relative inexperience ofstaff and local authorities, combined with thepoliticised nature of localised displacementand a traumatised, largely dysfunctionalcommunity. However, the displacement hasnow become long term, although notnecessarily stable.

The experience therefore raises somequestions. Are externally-sourced foodpackages (over which the NGO has nocontrol) the best way in which an NGO canmeet the needs of locally displacedcommunities? If there is still a reasonablyfunctioning local market, alternative meansmight be:

• buying food locally. This would support thelocal economy both in terms of commoditiesand transport. It would be culturallyappropriate; supportive to socio-economicrecovery; less likely to threaten goodworking relations with local leaders; andmore likely to encourage ‘ownership’ andgreater participation of beneficiaries in needsassessment and implementation.

• giving cash. This would enable beneficiariesto meet a range of needs according to theirown priorities, promoting dignity andempowerment through choice. At presentthis option is usually considered onlythrough employment-based responses.

Another way, is for NGOs with valuable localknowledge to use this to influence WFP policyand practice. NGOs already well-establishedin a project area have access to information onlocal livelihoods and social norms whichshould result in a high awareness of differentpeople’s needs and priorities. This shouldallow more appropriate and flexibleemergency responses. There is evidence thatWFP is willing to listen and learn from NGOs.For instance, there appears to be increasingacknowledgement of the benefits ofcommunity-managed programmes. The natureof the WFP/NGO partnership also offersopportunities for improvement. Earlier thisyear, staff from Bundibugyo, and others fromKenya also implementing WFP food aid,invited WFP regional staff to a programmelearning workshop. Many issues andchallenges raised by the two experiences were

discussed, and it was realised that moreregular discussions (perhaps even staffexchanges) could improve communicationsand an understanding of each others’approaches and agendas. A joint action planfor future partnership was agreed. Inparticular, we all felt field operations wouldbenefit from early introductions anddiscussions between WFP and NGO staff,especially if a joint assessment is not takingplace. Sharing field offices could also improvecommunications. This would help to clarifyroles, responsibilities and procedures, andencourage the early resolution of problems.

What is crucial, if we are to ensure that thefood delivery system benefits the recipientsrather than the donors, is for NGOs todocument and articulate clearly the pitfalls andchallenges they encounter: for instance, casestudies of the effects of an inappropriate foodbasket. This kind of detailed information iswhat WFP staff need in their turn to influenceinternational donor policy. It is currently theattitudes of donors that constrain WFP tomaking long, complicated shipments ofcommodities from one part of the world toanother, rather than using its resources topromote local production and purchasing offood.

No doubt this kind of advocacy will be mostpowerful when NGOs pool their experienceand present a co-ordinated approach as to thebest way to use UN resources to fulfilbeneficiaries’ needs. If other NGOs havesimilar or different experiences relevant to theissues raised here, we would encourage themto share and publish.

contact for further information: Philippa Howell,Emergencies Unit, ActionAid,


“Maize flour was exchangedor sold to get bananas,rice, sweet potatoes.”

Bundimulangya camp

“We gave five cups ofposho for a bunch ofmatoke, because it was thefood we wanted.”

Bubukwanga camp

“People did not know howto cook maize meal andwere getting diarrhoea.”

Union camp

Field Article

Bundibugyo camp, Uganda

Between July and October last year Bangladeshsuffered severe flooding regarded as the worstin living memory: two-thirds of Bangladesh

was affected resulting in widespread disruption anddamage to homesteads and crops. The OxfamBangladesh Office (OBO) responded to the crisis bysupporting flood relief and rehabilitation activities incharland (river eroded areas) through eight corepartners (non-government). Oxfam also supportedlong-standing partners to deliver health services, foodsupplements and livelihood support in other severelyaffected urban and rural areas.

Oxfam commissioned a review* of this programmewhich was carried out over a two-week period. Itfocussed on three key areas: targeted fooddistribution, supplementary feeding and emergencyhealth services.

Some of the main findings of the review that relate tothe targeted food distribution and follow uprehabilitation activities were as follows: activities inthe relief phase of the flood response programmeincluded targeted distribution of food and non-fooditems and a supplementary feeding programme.

The rehabilitation phase involved a continuation ofthe above as well as:

• Provision of interest free loans• Cash-for-work • Agricultural rehabilitation support

Targeted food distributionCore partner organisations, because of their long-standing work in disaster preparedness andmanagement with char communities, were quicklyable to update the ongoing ‘distressed persons list’(DPL) which groups households according to pre-defined criteria for poverty and vulnerability inrelation to flood impact and food insecurity. The criteria were:

• Severely flood affected• Level of household food stocks (< 4 days, 5-10

days and 10 days)

• Employment status i.e. landless householdsnormally dependant on daily paid labour givenpriority

• Female headed household• Pregnant and lactating mothers • Households with malnourished children • Disabled • Elderly

Although food distribution was primarily determinedby the level of contingency funding immediatelyavailable to OBO and the capacity of the partners topurchase and distribute food, the DPL was the basisfor targeting initially limited food assistance.

During the flood, it was apparent that access to food,although limited, was possible. Markets werefunctioning and fishing was being widely practiced(there was an abundance of fish in the early stage ofthe flood). OBO decided therefore to distribute foodparcels containing approximately 80% of calorierequirements (based on Kcal requirement of 2,100per day) over a three week period. The food parcelalso contained essential non-food items and Taka 100cash for the purchase of other food and non-fooditems. Households with pregnant and lactatingmothers were given additional food support of 1 litreof oil and where possible, pumpkins.

Initially, 15,000 families were targeted in core partnerareas during August. In September, funding for50,000 more parcels was proposed which includedtargeting households in long-standing partner areas(urban and rural). Food parcel distribution continuedthroughout the rehabilitation phase giving a final totalof 130,219 parcels distributed.

It was clear from meetings with beneficiaries thatthere was a high level of perceived transparencywithin the food distribution programme. Thecommunity based disasters committee worked withcore partners in the identification of households forfood targeting and were closely involved in fooddistribution. Those who received priority targetingwere also those viewed by the communities to bemost poor and food insecure

Loan taking

All women participating in the discussions reportedhaving to take out consumption loans within 10-15days after the flood. Loan taking followed strategiesto reduce food consumption and requestingfood/financial help from less affected relatives orcommunity members. According to Helen KellerInternational (HKI), loans were taken by over 50% ofthose affected by the floods and this was significantlyhigher among vulnerable households (defined aslandless and dependent on daily wage labour). Loantaking is a coping strategy normally adopted in the‘lean’ seasons. During the flood however, this wasmore a crisis strategy as the value of the loans takenwas much higher, the proportion of households takingloans increased and the levels of interest repaymentwere exorbitant (up to 200%). The timing and limitedinitial coverage of the response could have been animportant contributing factor to the high levels ofloan taking.

During the rehabilitation phase, OBO responded tothe high level of loan taking by assisting 8,000households with access to interest free loans (averageof £45) to re-start income generation activities. Thiswas targeted at group-members of core-partneragencies only because of the need to ensurerepayment schedules. In recognition of thislimitation, OXFAM also assisted mainly non-groupmembers with cash for work. Over 31,000 people(mainly women) were paid at the rate of Taka 60(£0.75) per day for re-building activities. Pregnantand lactating women were also targeted through thisactivity and were given only very light work.

The review concluded that overall, the response byOBO and core-partners to the health and nutritionproblems arising from the 1998 floods reflected avery high level of commitment, motivation andorganisation enabling them to respond effectively tothe demands placed on them. The responseundoubtedly helped to protect the short and long termlivelihoods of those assisted.

References*Oxfam Bangladesh ,Emergency Flood Relief andRehabilitation Programme, Health and Nutrition Review,DRAFT, Carmel Dolan, Consultant


SummarSummaryyofof the Oxfthe OxfamamRReevieview ofw ofBangBangladeshladeshffloodloodrresponseesponse

Evaluations

Food Distribution in Bangladesh‘98 (WFP/T. Haskell)


Poor breast-feeding and infant feeding practicesare well known to have adverse consequencesfor the health and nutritional status of children,

which in turn have consequences for the developmentof the child both physically and mentally. An increasein morbidity in turn impacts heavily on public healthexpenditure.

Inappropriate infant feeding practices in the Balkanshave been observed for some years. Although Kosovois generally recognised as a breast feeding society,the rate of exclusive breast-feeding pre-emergencywas extremely low and the introduction ofcomplementary fluids and foodstuffs was commonwithin the first 2 months of life1. These poorpractices were recently confirmed by the infantfeeding surveys undertaken in Macedonia in June of19992 and July of 1999 in Kosovo.3

In 1997 the UNICEF MICS1 survey showed that only12.2% of children were breast-fed exclusively until 4months. More recently the combined NutritionalAnthropometric, Child Health and Food SecuritySurvey in 1998 showed that 25.6% of breast feedingmothers did not continue feeding past 3 months.4

During the recent Kosovo crisis a survey in theMacedonia refugee camps found that 23% of infantsunder 4 months received neither breast milk nor asuitable breast milk substitute.5

Following the influx of breast milk substitutes duringthe crisis, WHO led an information findingconsultation in Macedonia6. Findings showed thatthere was little clear documentation about the infant

formula that was imported into the country during theconflict and the supply of infant formula grosslyoutweighed the need. This document reports thatinfant formula was given on request to mothers whoself presented to health workers, often in the absenceof breast-feeding counselling or lactation support.

Prior to the conflict a reported 76.8% of childrenbreast fed for more than 3 weeks4 while post conflict71.5% were reported to breast feed for more than 3weeks.3 It should be noted that both of theses figuresreflect mixed not exclusive breast feeding.

It appears that the following factors have had thegreatest effect on breast feeding and weaningpractices in the Kosovar population:

• Many mothers (44.3%), cited insufficient milk asthe reason for cessation of breast feeding4 prior toand during the conflict.

• There has been very little support from healthprofessionals, whether national or international, andvery minimal breast-feeding counsellingimmediately after birth. Furthermore the activepromotion of re-lactation and support to motherswith difficulties in breast feeding has been verylimited.

The influx of humanitarian aid to the region and theabsence of co-ordinated control of breast milksubstitutes, meant that infant formula and specialisedbaby foods were handled directly by humanitarianorganisations who in many cases lacked the technicalknowledge about their correct use. The donation of

Evaluations

As a result of concerns expressed about theusage of infant formula and a need for moreinformation regarding weaning practices duringand after the conflict in Kosovo, Action AgainstHunger-UK began to examine infant feedingpractices in the area and found that someaspects of infant feeding were extremely poor.Furthermore, the emergency had led to asituation where some of these poor practiceswere likely to be exacerbated. At the sametime, the crisis provided an opportunity forAAH-UK to collaborate with WHO and UNICEF instrengthening health structures in order toimprove infant feeding. This article was writtenby Laura Phelps and Caroline Wilkinson. Lauraand Caroline have worked for AAH-UK inKosovo as nutritionist and nutrition co-ordinatorsince June 1999.

ACF and ECHO (European CommissionHumanitarian Office) undertook a jointevaluation of the ACF therapeutic feeding

programme in Burundi in November 1998. The natureof the emergency in Burundi meant that there were anumber of factors which had a critical bearing on theoutcome of the programme. Although the situation hadimproved greatly by the time the evaluation wasundertaken, the constraints were primarily related tothe very insecure period of 1996/7. These included thefollowing:

• humanitarian staff and beneficiaries regularly facedsecurity incidents

• humanitarian organisations were denied access tobeneficiaries in the community

• Therapeutic Feeding Centres (TFCs) only providedday care due to insecurity at night and as staff did notwant to stay

• the embargo on Burundi had caused large priceincreases and restricted imports of key commoditiesfor humanitarian agencies and the general population

• ACF had problems in locating well trained andqualified staff

• food aid flows were restricted and irregular• the vast majority of the population were farmers - yet

had limited access to land.

The main findings of the evaluation were as follows.

Strengths• treatment in the centres was of high quality • mortality rates were acceptable (less than 10%)

although it had taken more than one and a half yearsto achieve these rates

• weight gain was on average more than 8gm/kg/day• between June and October an estimated 5000 lives

had been saved in the TFCs• local staff had been trained and would be able to

work in national structures following ACF’s eventualdeparture

Weaknesses• it was impossible to obtain information on the

coverage of the programme as there were nopopulation data or nutritional survey information

• there was little knowledge or information about whathappens to individuals following discharge andreasons for relapse

• for most situations the degree of integration withnational structures would be considered insufficient.However, in the Burundi context this may not be an

appropriate judgement• donor funding for the programme has been on short-

term contract (3 months) making it very difficult toplan ahead

• the targets established for therapeutic feedingprogrammes in the Sphere guidelines are not whollyachievable in the Burundi context and may not beappropriate

• the degree of participatory planning with thecommunity has been insufficient

RecommendationsThe following were amongst the recommendations inthe evaluation:

• to strengthen integration with national healthstructure, e.g. establish withdrawal criteria anddivision of responsibilities during phase out

• improve capacity to treat adult malnutrition• to re-evaluate the roles of the Sphere guidelines*

within TFCs and their limitations in highly insecureenvironments.

References

*Humanitarian charter and minimum standards in disasterresponse, ISBN 92-9139-049-6 (First edition 1998. Geneva)

Evaluation of the Impact of the ACF Therapeutic Feeding Programme in Burundi

Infant Feeding Practices:Observations from Macedonia and Kosovo

Field Article

powdered milks, and also to a certain extent locally-procured pre-prepared complementary foods has ledto the distribution of these products during and postcrisis in the camps and through the health units inKosovo. Donated powered milks and complementaryfoods were distributed without being properlytargeted and without appropriate labelling inAlbanian or another suitable language. The use of alltypes of foods for infants, (including cows’ milk andpre-prepared weaning foods) within the refugeepopulation has been uncontrolled and untargeted.

A recent survey7 assessed infant feeding practicesfollowing the return of refugees to Kosovo in July1999 (standard 30 x 30 cluster sampling). Themethodology involved retrospective questioning ofmothers of children between 6-18 months of age, andkey informant discussions. All mothers (total of 922)were questioned on breast feeding practices whileonly 219 mothers were questioned on weaningpractices. The following are some of the key findingsfrom this study.

Breast-feedingTwenty-five percent of women do not start to breastfeed until 24 hours or more after birth. Lateintroduction to the breast has implications for breastfeeding success, low colostrum intake and bondingbetween mother and child. Interestingly there appearsto be a trend towards stopping breast feeding earlierin younger children; of the 18 month olds only16.7% had stopped at 6 months or before, comparedwith 23.6% of the infants that were 6 months old atthe time of the survey. Key informant discussionsconfirmed that younger women are breast feeding fora shorter length of time than their mothers did,although the reasons for this were not established.

Infant FormulaTwenty-four percent of infants aged 12 months orunder received infant formula (no pre-war baselinedata), 25.5% of their mothers were unable to read theinstructions. Fifteen percent of infants received bothbreast milk and infant formula. Following donationsby humanitarian organisations and multinationalcompanies, national doctors and food distributionagencies (both national and international) were seento be prescribing/donating infant formula for motherswho report problems breast feeding, many withoutcounselling or lactation support. A continued supplywas not always assured so the family either had topurchase this expensive product or swap it for anaccessible alternative. The options available are farfrom ideal as, six month’s supply of infant formula isequal to an average family’s bread expenditure for 6weeks.8 Key informant discussions suggest that if themothers could not afford to continue with formulathat they changed to diluted cows’ milk with addedsugar. In cases where there was an adequate supplyof formula, often mothers did not have theknowledge or facilities for hygienic preparation.Both practices may potentially result in an increasedincidence of diarrhoea due to either uncleanwater/preparation facilities or due to an immatureinfant gut. Diarrhoea is a significant problem inKosovo, confirmed by WHO weekly epidemiologicalbulletins which report that up to a third of childrenaged 5 years or under are presenting with waterydiarrhoea.

Cows’ milkSixty-eight percent of infants drink cows’ milk on adaily basis before 6 months of age. The number ofcows killed during the conflict (62%) negativelyaffected the availability of milk. Children under theage of 2 years, were prioritised for receipt of cows’milk when in short supply.

Frequency of breast feeds may be compromisedwhen other feeds, such as cows’ milk, is given,


The International Code of marketing of Breastmilk substitutes

In 1979, WHO and UNICEF organised an international meeting on infant and youngchild nutrition. One of the recommendations made was that there should be aninternational code of marketing of infant formula and other products used asbreastmilk substitutes. Member states of WHO and other groups/individuals who hadattended the 1979 meeting, including representatives of the infant food industry, werethen involved in a consultative process which culminated in the production of theInternational Code. This Code was endorsed by the World Health Assembly in 1981 ina Resolution which stressed that the Code is a “minimum requirement” to be enacted“in its entirety” by all countries.

The Code sets out the responsibilities of the infant food industry, health workers,national governments and concerned organisations in relation to the marketing ofbreastmilk substitutes, feeding bottles and teats as well as information regarding theuse of these products. Since 1981, subsequent WHA Resolutions have been passedwhich aim to strengthen and clarify the Code. These Resolutions have the same statusas the Code itself and should be read with it.

The most important parts of the Code, which relate to infant feeding in emergencies,are:

The Aim“The aim of this Code is to contribute to the provision of safe and adequate nutritionfor infants, by the protection and promotion of breastfeeding, and by ensuring theproper use of breast-milk substitutes, when these are necessary, on the basis ofadequate information and through appropriate marketing and distribution.”

The Scope The Code applies to any product which is marketed or otherwiserepresented as a partial or total replacement for breastmilk, and to feeding bottles andteats. Only certain products are suitable as breastmilk substitutes, but many otherunsuitable products (such as baby cereals, baby drinks and follow-on formulas) fallunder the scope of the Code when they are marketed inappropriately.

AdvertisingNo advertising of above products to the public.

SamplesNo free samples to mothers, their families or health care workers.

Health care facilitiesNo promotion of products i.e. no product displays, posters or distribution ofpromotional materials. No use of mothercraft nurses or similar company-paidpersonnel. No free or low-cost supplies.

Health care workersNo gifts or samples to health care workers. Product information must be factual andscientific.

SuppliesNo free or low-cost supplies of breastmilk substitutes to maternity wards andhospitals. (The 1994 Resolution states that they should not be in any part of the healthcare system).

InformationGovernments have the responsibility to ensure that “objective and consistentinformation is provided on infant and young child feeding”. Such information shouldnever promote or idealise the use of breastmilk substitutes and should includespecified points. It should also explain the benefits and superiority of breastfeedingand the costs and hazards associated with artificial feeding. Manufacturers shouldprovide only scientific and factual information to health workers and should neverseek contact with mothers.

LabelsProduct labels must clearly state the superiority of breastfeeding, the need for theadvice of a health worker and a warning about health hazards. No pictures of infants,or other pictures idealising the use of infant formula.

ProductsUnsuitable products, such as sweetened condensed milk, should not be promoted forinfants. All products should be of high quality and take account of the climatic andstorage conditions of the country where they are used. Manufacturers and distributorsshould comply with the Code INDEPENDENTLY of government action to implementit. NGOs have a responsibility to report any violations to governments and tomanufacturers.

Excerpt from “Infant Feeding Report in Emergencies, policy, strategy and practice, May 1999(Available from the ENN)

Field Article

resulting in a reduced supply of breast milk to thechild. Introduction of cow’s milk before 4-6 monthshas implications for renal damage as it has anosmolar load greater than the excretory capacity oftheir immature kidneys (although, a third of themothers did dilute the milk). More importantly, cows’milk is probably a significant contributor to the highincidence of diarrhoea reported in young infants, as aresult of early introduction to an undeveloped gut. Itappears from the key informant discussions thatcows’ milk is seen as a good substitute for breastmilk at any age. Another problem with cows’ milk isthe low iron content, which make it a poor weaningfood, especially if taken in large volumes when itcould displace other foodstuffs.

TeaNinety-five percent of infants have had tea introducedby the age of 12 months. Tea is commonly givenfrom the age of 2-3 months old in bottles with sugaradded. The poly-phenol content of tea contributes tothe inhibition of iron absorption; an even moreserious problem when the overall diet of a majorityof children aged 6-12 months would appear tocontain insufficient iron. This needs furtherinvestigation and will be included in the next survey,planned for November/December 1999.

Sugar added contributes to the development of dentalcaries at a very young age. Tea should not normallybe given until at least 2 years of age for thesereasons, but 90% of infants under 1 year receive teaon a daily basis. Tea does not appear to be given forhealth reasons, although it is advocated by theKosovar doctors for both treatment of diarrhoea, andas a night time drink in two major hospitals inKosovo.

Biscuits and cakesBy 6 months 78.6% of infants were eating biscuits,92% of these on a daily basis, and 7.5% on a weeklybasis. A majority of infants in Kosovo are weanedonto biscuits and cows’ milk, which may or may notbe mixed with extra sugar. The biscuits available arenutritionally poor and provide inadequate vitaminsand minerals. In addition, this product is often startedat 3-6 months and as a wheat-containing product thisis too early for introduction. The infant’s intestine isnot sufficiently developed until 6-8 months to dealwith the protein type, and the child may haveproblems digesting the wheat, which can result indiarrhoea. Kosovar doctors/nurses and hospitals bothdirectly and indirectly support biscuits byrecommending them or giving them to childrenduring their in-patient stay.

Fruit and Vegetables:Generally the intake of both fruit and vegetables isvery low (43% of infants 6-18 months, 66% on adaily basis) and not in line with complementary foodguidelines. It is recommended that fruit andvegetables should be introduced at 4-6 months as theinitial complementary food, especially as theyprovide important vitamin C, which helps in theabsorption of iron. Most of the mothers in the keyinformant discussions stated that they felt fruit was agood weaning food for infants, but the cost wasprohibitive, especially in this time of food insecurity.However, it must be noted that vegetables would bejust as beneficial to the child and it would seem thatsome vegetables (potatoes, cabbage) are available toeven the poorest families5.

On a broader level, the results of the Food SecuritySurvey5 indicate that the differences between a mealnow and what was classed as a ‘normal’ meal pre-conflict is primarily a reduction in meat followed byfresh vegetables and milk. Fruits, cheese and yoghurtwere the next most commonly mentioned items to bereduced in the diet. This is an especially worrying

trend for the winter-time as the diet in the wintermonths is known to be less diverse than the summerdiet and access to these foods is likely to be evenmore problematic this winter. Micro nutrient intakesare a particular concern in light of the results of theinfant feeding survey and the practices previouslydiscussed.

ConclusionsComplementary Feeding practices Kosovo-widegenerally do not follow internationally acceptedrecommendations. They are potentially contributingto the reported high incidence of diarrhoea and irondeficiency anaemia in children under 18 months ofage. These practices could, however, be significantlyimproved upon over time through a widespreadinformation programme.

The issue of exclusive breast feeding appears to be aneducational one, as the introduction of tea, cows’milk and biscuits to children under 6 months hasreportedly only occurred in the last 20 years, and hasoccurred in response to marketing, availability andinappropriate health advice. Kosovo is such a childorientated society that when mothers and healthprofessionals are able to make an informed decisionthen in our limited experience, their practices change.The dissemination of this information to healthprofessionals and throughout the community will be alengthy process, but the initial stages are promising.

It is essential that breast-feeding is pro-activelysupported and fully endorsed by internationalorganisations working in the emergency and post-emergency stage. However it must be recognised thatthere are situations where breast-feeding is not anoption, and where safe alternatives need to befacilitated. Accurate preparation of infant formula isessential for correct usage. This is dependent on clearinstructions in the appropriate language and adequateresources within the household to ensure goodhygiene.

For the use of complementary foods, however, thereare times when humanitarian organisations are left ina dilemma. The question remains, when targeting andmonitoring of food distributions cannot be carried outbut it is clear that families have limited or no accessto appropriate complementary foods for infants -provide commercial infant foods and risk potentialmisuse or deny the population in question theseproducts?

Broad untargeted distributions are inevitable, but theyrequire a quick response in terms of advice andpractical suggestions to minimise potential damage tothe infant population, both in the short term health ofthe child and longer term orientation of practices inthe population. Action Against Hunger-UK arecurrently working in collaboration with UNICEF,UNHCR and WHO to disseminate clear policyguidelines for breast milk substitutes in Kosovo,which became law from November 1st 19999. Forimported goods we suggest that they are labelled inthe appropriate language, with specific informationabout their use. This labelling also offers theopportunity for a health promotion message to targetthis potentially vulnerable group.

The nutrition programme for Action Against Hunger-UK, in the coming year will include breast feeding /infant feeding education from the tertiary to primaryhealth care structures in 15 municipalities throughoutKosovo. This will be a co-ordinated programme withUNICEF in line with the Baby Friendly Initiative atthe tertiary level and a community based approachutilising the ‘train the trainer’ model and linking inwith women’s group initiatives at the secondary andprimary health care level.


Bibliography• Breast feeding: How to support success, Copenhagen, WHO

Regional Office for Europe, 1996• Infant Feeding in Emergencies: A guide for mothers. WHO

Regional Office for Europe, revised 1997.• Ten successful steps to breast feeding; Infant feeding in

Emergencies, Nutrition Unit, Copenhagen, WHO RegionalOffice for Europe, revised 1997.

• Re-Lactation: Review of experience and recommendationsfor practice, WHO Department of Child and AdolescentHealth Development, 1997

• Infant Feeding in Emergencies: Policy, Strategy and Practice.Report of the Ad Hoc Group on Infant Feeding inEmergencies, May 1999.

For further information please contact Laura Phelps orCaroline Wilkinson, at [email protected] [email protected] contact Frances Mason, Nutrition and Food SecurityAdvisor, Action Against Hunger-UK on Tel: 0171 831 5858, [email protected]

Footnotes1 UNICEF Multiple Indicator Cluster Survey. Federal Republic

of Yugoslavia, Institute of Public Health of Serbia andMontenegro (Belgrade 1997)

2 UNHCR, Action Against Hunger, Macedonian IMCH, UNICEF(June 1999) Nutrition and Health Survey of KosovarRefugees in camps in Macedonia

3 Action Against Hunger-UK, (July 1999) Infant Feeding andWeaning Practices in Kosovo, Federal Republic ofYugoslavia

4 Action Against Hunger, Mercy Corps International, UNICEF(December 1998) Nutritional Anthropometric, Child Healthand Food Security Survey. Kosovo, FR Yugoslavia.

5 UNHCR, Action Against Hunger, Macedonian IMCH, UNICEF(June 1999) Nutrition and Health Survey of KosovarRefugees in camps in Macedonia.

6 Forsyth.V., WHO consultant, (July 1999) Report of the WHOinfant feeding consultancy to the Former Yugoslav Republicof Macedonia and Albania.

7 Action Against Hunger, Anthropometric Nutritional & InfantFeeding and Weaning Survey, Kosovo 15-27th July 1999

8 Calculated from the average costs of 6 popular InfantFormulas at urban prices and compared to figures takenfrom the Action Against Hunger, Food Security Survey,Kosovo 12-26th July 1999

9 Breast milk substitutes are products that replace breastmilk up to the age of 6 months and includes infantformula and specialised feeding products.

Field Article

Borton, J & Shoham, J (1989, March). Experiencesof Non-Governmental Organisations in the targetingof emergency food aid. Report of a Workshop, ODI.

Clay, D, Molla, D and Habtewold, D (1999). FoodAid Targeting in Ethiopia; A Study of who needs itand who gets it. Food Policy 24 pp391-409

De Waal, A (1988). Famine early warning systemsand the use of socio-economic data. Disasters, 12(1),

Harragin, S (1998, June). The Southern SudanVulnerability Study. SCF (UK).

Jaspars, S (1998) Responding to the Crisis in Congo-Zaire: Field Exchange No 3, pp12-14

Jaspars, S (1999, April 12). Targeting and distributionof food aid in SPLM controlled areas of SouthSudan.

Jaspars, S and Shoham, J (1999) Is it possible totarget the vulnerable - with special reference tocommunity based targeting, Disasters 23 (4) in press

Jaspars, S, & Young, H (1995, December). GeneralFood Distribution in Emergencies, from NutritionalNeeds to Political Priorities. London: Good PracticeReview 3. Relief and Rehabilitation Network. ODI.

Keen, D (1991). Targeting emergency food aid: thecase of Darfur in 1985. In: To Cure all Hunger; Foodpolicy and food security in Sudan. Ed. Maxwell. ITpublications.,

Sharp, K (1998, September). Between relief anddevelopment; targeting food aid for disasterprevention in Ethiopia. Relief and RehabilitationNetwork, (Network paper 27).

Sharp, K (1999) Food aid targeting in East Africa,

March 1999: Consultancy report for FEWS project,REDSO/USAID

Slim, H & Mitchell, J (1990). Towards CommunityManaged Relief; A case study from Southern Sudan.Disasters, 14(3),

Shoham, J (1999) An evaluation of the communitymanaged emergency feeding programme in Singidaand Dodoma regions of Central Tanzania in 1998/9,DFID East Africa

Shoham, J and Giama, S (1991) The role of socio-economic data in early warning and targeting. Paperprepared for FAO/IGADD workshop on the role ofdata in nutritional emergencies, Nairobi, Kenya

Watson, F (1998) Reconstruction in Bosnia:Implications for Food Security and the Future ofFood Aid. Field Exchange 3, pp 23-25

Tomas Murray is a 25year old dentist fromGrange in CountyWaterford who recentlyspent some time workingalongside aid workersfrom the relief anddevelopment agencyGOAL in South Sudan.

People in Aid


For the people in the more remote areas Tomaswas the first dentist they had seen in their lives.Tomas found that in general the people of

South Sudan have low levels of dental decay and gumdisease due to their tradition of good brushing usingchewed sticks and, more importantly due to the lackof sugar in their diet.

Despite this low level of decay the people do have ahigh level of pain and infection because any decaypresent is left untreated and becomes the centre ofchronic infection. Antibiotics can deal with thesituation in the short term but, unless the offendingtooth is extracted, the pain will return.

Tomas’ visit to South Sudan was undertaken to assessthe dental needs of the population, to carry outroutine extractions where necessary, to look at waysof improving dental care and to gain information tofacilitate future visits by dentists.

Working in the shade of a tree performing extractionsamong the Dinka and Neur tribes Tomas wassurprised to find that the vast majority of adults had

had their front bottom teeth removed. This was doneas part of a ritual performed on both male and femalechildren when they get to the age of 14. Ninety-threepercent of the patients treated had had this done.

This ritual is thought to have originated in the dayswhen the people of South Sudan were regularly takenas slaves. Those captives with teeth missing wereseen as unhealthy and certainly less valuable and sowere often released. The practice continues today butnow the lack of front teeth has come to be seen as asign of beauty.

It was noted also that women had more dental diseasethan men. Of the 167 patients treated by Tomas in histwo and a half weeks, 104 were females, 59 malesand the number of patients under the age of 10 wasjust 4.

Each day during his stay in South Sudan Tomaswould travel to one of the outlying villages, set up amakeshift dentist’s chair in the shade of a tree andoffer his services to anyone that needed treatment.The range of treatments offered was of necessity

limited to extraction of teeth which were causingpain.

“To carry out more complicated procedures such asfillings or root treatments would be very difficulthowever. It would also be of little use as the majorityof teeth that were taken out were in such a brokendown state that the only option, even in a westernclinic, would have been extraction.”

Sterilisation of instruments was of the utmostimportance as otherwise fatal diseases could bespread through the population. Following cleaning allinstruments were put in boiling water over a woodfire for 30 minutes and then placed in a coldsterilisation fluid for a further 30 minutes.

For continuation of this kind of treatment Tomassays: “The ideal would be for a local person with amedical background to be trained to extract teethwith a local anaesthetic”.

Tomasdispensesdentaltreatment in the bush of South Sudan

Resources on food aid targeting in emergencies

Tomas in Action (GOAL - ‘99)

The Emergency Nutrition Network (ENN)grew out of a series of interagency meetings focusing onfood and nutritional aspects of emergencies. The meetingswere hosted by UNHCR and attended by a number of UNagencies, NGOs, donors and academics. The Network is theresult of a shared commitment to improve knowledge, stimu-late learning and provide vital support and encouragement tofood and nutrition workers involved in emergencies. The ENNofficially began operations in November 1996 and has wide-spread support from UN agencies, NGOs, and donor govern-ments. The network aims to improve emergency food andnutrition programme effectiveness by:

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

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

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

nutrition sector which need more research

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

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

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

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

Jeremy Shoham is co-editor for Field Exchange andthe ENN technical consultant. Jeremy has beenworking in the area of emergency food and nutri-tion for the past 15 years.

Kornelius Elstner works part time with the ENN.


The Backpage

Field Exchange

UNHCR

The

is currentlyfunded by:

GENEVA FOUNDATIONto protect health in war

EditorsFiona O’ReillyJeremy Shoham

Layout & WebsiteKornelius Elstner

Contributors for this issueAnthony RobbinsPhilippa CouttsFrances D. BurtonAnnalies BorrelAnna YoungRita BhatiaFiona WatsonPhilippa HowellLaura PhelpsCaroline WilkinsonAnuradha Harinarayan

Thanks for the Photographs to:Anne Kellner (UNHCR)Sherry Dougherty (WFP)CARE InternationalGOAL

On the coverRoma Community members on themove in search of safety fromretaliating Kosovars. Kosovo, June ‘99(UNHCR/R. LeMoyne)

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

Thanks to the Department ofCommunity and General Practice,especially Professor John Kevany,Trinity College for support for thisproject.

Cartoon Corner by Jon Berkeley

Emergency Nutrition NetworkDepartment of Community Health & General PracticeTrinity College, 199 Pearse Street, Dublin 2, Ireland

Tel: 353 1 608 2676 / 843 5328Fax: 353 1 670 5384e–mail: [email protected]: www.tcd.ie/ENN

field exchange - enn · or interpret, e.g. livestock status or collection of wild foods. value...

Documents