ISSN 1743-5080 (print)November 2005 Issue 26

• Micro-gardening in Uganda

• GIS in nutrition surveys

• Iron deficiency in Argentina

• CBT in Myanmar

1

Over the years, Field Exchange has hadits fair share of criticism to which theeditorial team have always tried torespond positively. More often than

not, we publish critical views in the letters sec-tion. It’s probably true to say that the ENN arein some way reassured by critical emails andletters as it shows that readers care enoughabout the publication to write in. In this issue ofField Exchange, we publish a number of letters(see letters section) which we have activelysolicited in response to criticisms (published inFEx 23 and 24). These concern a purported biasby Field Exchange to publish articles on ‘hightechnology foods’ like RUTF, as well as a poten-tial conflict of interest for the ENN in acceptingfunding from private sector companies involvedin production of foods like RUTF. Further inputand views from our readers on these issueswould be most welcome.

The issue of appropriateness of technical andwestern derived solutions to developing countryproblems is an interesting one. In FEx 26, wehave three field articles which describe pro-grammes or approaches involving some form oftechnology. The technologies range from thevery ‘high tech’, i.e. use of GeographicInformation Systems (GIS), to very ‘low tech’,i.e. micro-gardening. The GIS article by FilippoDibari, Andrew Seal and Paolo Paron providesdetailed guidance on how to apply GIS analysisto conventional nutritional survey data sets, aswell as the benefits, resource needs and con-straints of this tool. The article on micro-gar-dening, provided by ACF-USA, describes an IDPprogramme in Gulu, northern Uganda, involvingmicro-gardening in bags using locally availablematerials and low maintenance systems. Thisform of production, which is especially useful incramped conditions, appears to have been high-ly effective in promoting food security andincreasing consumption of vegetables amongsta highly food insecure population. A third fieldarticle, also written by ACH staff, describes theexperience of using a portable photometer tomeasure red blood cell haemoglobin levels inchildren affected by flooding in the city of SantaFe, Argentina. The authors argue that thedevice provides a valuable means of comple-menting anthropometric data with informationon anaemia - a frequently hidden problem.

In response to another criticism of FieldExchange - about the ‘eurocentric’ nature ofField Exchange photographs (Renzaho, A, Issue23, p17), the ENN commissioned a small-scalereview of past pictures. The piece, written byDorrie Chetty, a senior lecturer in sociology atWestminster University, explores issues of rep-resentation using a cross-section of FieldExchange photographs and certainly providesfood for thought.

There are several other highlights of this issue’sresearch section. A review by the HPG in ODI onthe response to the perceived food crisis inNiger asserts that, in spite of ample early warn-ing, the late response was, in part, due to theview within government and the donor commu-nity that food aid may disrupt markets, encour-age dependency and harm development mech-anisms. These fears appear to have resulted inan extreme reluctance to move from subsidisedfood to free food distribution. Another exampleof ideology prevailing over common sense?

It is worrying that a frequently heard justifica-tion amongst donor agencies for not interveningin crises, or for reducing support in protractedemergencies, is that there is a risk of creatingdependency. Yet, if examined closely, the argu-

ment that poor communities, households andindividuals will stop trying to ‘get ahead’ if inreceipt of a food aid ration for any period of timeseems very questionable. Indeed, recentresearch on dependency, also conducted by HPGand summarised in this issue of Field Exchange,concludes that there is little evidence that reliefundermines initiative or that its delivery is reli-able or transparent enough for people to dependon it. The authors of this study also argue thatin situations where peoples lives and livelihoodsare under acute threat, and local capacities tocope with crisis are overwhelmed, being able todepend on receiving assistance should be seenas a good thing.

This issue’s research section also carries excit-ing new findings based on work by SC UK on theaetiology of kwashiorkor and the potential ofsupplementary feeding programmes to preventits development by treating children with earlysigns of the condition. The findings are impor-tant and challenge a number of previously heldassumptions.

Important infant feeding issues are flagged in arecent paper published in the BMJ. The researchinvestigated infant feeding patterns and risk ofhospitalisation and death in infants under sixmonths of age, in India, Ghana and Peru. Whilethere was no significant difference in death ratebetween exclusively and predominately breast-fed infants, those who were not breastfed wereover ten times more likely to die than predomi-nately breastfed infants. Partially breastfedinfants had an almost two and a half timesgreater risk of death. As well as demonstratinghow critically important it is to consider the riskof not breastfeeding, especially in emergencies,the authors highlight how closer assessment ofinfant feeding practices could help prioritisewhere to target resources in order to maximiseimpact of intervention. In reality, the humani-tarian community rarely adopt such a consid-ered approach to supporting infants in emer-gencies. Assessment of infant morbidity, mor-tality and infant feeding practice in emergenciesis, at best, inconsistent and, more typically,absent. The valuable collation of nutritional sur-vey material by the UN SCN, published in‘Nutrition Information in Crisis Situations’(NICS), does not systematically collect infantfeeding data, or endorse an approach for moni-toring the well-being of infants. Including somesimple, standard indicators on infant and youngchild feeding in early needs assessment and inroutine nutritional surveillance would be a goodstart to resolving the blind spot that currentlyexists. A move by the SCN/NICS (or some otherbody) to seek and collate infant feeding datawould be a welcome development.

Finally, on a completely different matter, theENN are calling for input on the selection oftrustees, in light of the decision to apply for reg-istration as a charity in the UK (see news pieceon p18 for details).

We sincerely hope that you enjoy this issue ofField Exchange.

Jeremy Shoham and Marie McGrath

Any contributions, ideas or topics for futureissues of Field Exchange? Contact the editorialteam on email: office@ennonline.net

From the EditorContentsField Articles

2 Farming in Bags: Micro Gardening in Northern Uganda

16 Prevalence of Anaemia Amongst Young Children in Argentina

25 Community Based Targeting in Myanmar

29 Applying GIS to Nutrition Surveys

4 Research• Study of the Risk Factors for the

Development of Nutritional Oedema in North Kivu, DRC

• Intervention Study on Cases Present-ing Precursor Signs of Kwashiorkor

• Infant Feeding Patterns and Risk of Death

• Neo-Colonialism and ‘Otherness’ Representational Issues in Field Exchange

• SC UK Experiences of Food Security Information Systems

• MUAC Versus Weight-for-Height in Assessing Severe Malnutrition

• Review of Training Opportunities in Nutrition and Food Security

• Antioxidant Role in Preventing Kwashiorkor

• Dependency and Humanitarian Relief• Cash and Vouchers in Emergencies• Nutrition Supplement for People With

HIV

17 News & Views• Care Practices in Emergencies• New Guide on Cash-Transfer

Programming in Emergencies • nutrition - New Publication for

Nutrition in Development• Call for Trustee Nominations for ENN• Review of Operational Guidance on IFE• New CD of IFE Training Materials• European Emergency Food Security

Group (EEFSG) • User Friendly Software to Design Low

Cost Complementary Feeding• Renewed Call to Share Knowledge on

Community Driven Initiatives• New CRED Newsletter on Disasters• Collecting Evidence for Community

Based Treatment of Severe Malnutrition

• WHO Guiding Principles on Feeding Non-Breastfed Infants

• Forum on the Future of Aid• New FANTA Technical Guide on

Measuring Household Food Consumption

• WTO Negotiations on Improving Food Aid

23 Letters27 Evaluation• Evaluation of ECHO Actions in DPRK

28 Agency Profile• Actionaid

33 People in Aid

2

Field Article

The Acholi region of NorthernUganda (Kitgum, Pader andGulu districts) has been affectedby rebel activities since 1986. An

estimated 100,000 people have beenkilled and 20,000 abducted during thisnear twenty year period of crisis. Since1996, the population has been displacedand currently over 90% or over 1.3 mil-lion people are internally displaced(IDPs) in the three districts. Due to theconstant crisis and erratic security situa-tion, access to food, income, and pro-ductive assets for the population hasbecome increasingly difficult over theyears. In particular, access to land isvery limited due to security constraintsand related displacement. Assistancefrom non-governmental organisations(NGOs) and access to the populationhas continually been complicated by theerratic security in the district. The pop-ulation is chronically food insecure,heavily dependent on food aid, faceperiodic lootings and attacks, and isplagued by the effects of poor access tobasic infrastructures (e.g. safe drinkingwater and hygiene facilities).

Work of Action Against Hunger-USAAction Against Hunger-USA (AAH-

USA) has been active in Gulu districtsince 1997, mostly working in nutritionand water and sanitation (WAT/SAN).The majority of the population, estimat-ed at 515,000 people (UNOCHA), areinternally displaced and living in campsthroughout the district.

Food security assessments were com-pleted by AAH-USA in Gulu district in1999 and 2003. As a result of recommen-dations made following the 2003 assess-ment, AAH-USA began a pilot micro-gardening project in two Gulu districtIDP camps in 2004. The project aimed totackle household food insecuritythrough achieving the following aims:

• Decreasing exposure to insecurity by reducing travel times (i.e. to gardens instead of fields)

• Decreasing time spent on gardening duties (e.g. weeding)

• Increasing livelihood and foods security options for households through sales of home produce, by offering planting work for the landless and redundant (including during the dry season), and produc

Micro Gardening inNorthern Uganda

Farming in Bags

By Holly Welcome Radice, Action Against Hunger-USA

The author would like to acknowledge the valuable contributions tothis article of Pamela Atim, Victor Onenchan, and Thomas Ojara, andthe support of Devrig Velly, AAH-USA and Lisa Ernoul, ACF.

Holly Welcome Radice has worked as a food security officer for AAH-USA in Liberia, Uganda, and as programme co-ordinator in Ethiopia.

ing more vegetables for their own consumption.

Project implementationThe project used the basic ideas of

urban agriculture and rooftop farming –containerised planting, using locallyavailable materials, and low mainte-nance systems in small spaces. Theplanting method promoted involvedpolyethylene grain sacks, which areabundant in the camps and not costly.Materials used included loam soil, rocksand a banana stem. The banana stemswere placed in the sacks and filled withrocks. Loam soil was placed around thestem. When the sack was filled withsoil, the banana stem was removedleaving a core area of rocks, whichserved as a watering area. Planting wascarried out around the bag (sides) andon top of it. Some households that hadsmall parcels of land near their com-pounds also planted using traditionalgardening methods. Beneficiaries of theprogramme were recipient householdsof the AAH-USA supplementary feed-ing centres (SFCs) in Opit and Amurucamps. A total of 940 households partic-ipated in the programme.

Micro-gardening activities com-prised training, distribution, and moni-toring. Each camp had a demonstrationgarden near the SFC that was tended bya gardener and hosted the training ses-sions. Training days coincided with thedays the caretakers picked up rations atthe SFC. Groups of up to 40 women(almost all SFC caretakers are women)participated in the training in micro-garden construction, maintenance, andvegetable harvesting. At the end of thetraining, each household received a100kg grain sack, seeds (carrots and achoice of spinach (dodo) or cowpeas(boo)), and an instruction sheet writtenin the local language, Luo. Each house-hold was supposed to plant one garden.The project was kept small-scale inorder to gauge the interest and appro-priateness of the activity before rollingit out.

Gardens were constructed near thebeneficiaries’ household. Soil and rockswere brought from nearby areas and themajority of gardens were built in 2-3days. Fences made of local materials(e.g. thorny bushes, bamboo) were con-

Planting seeds in a micro-garden

ACF-USA staff, Victor Onenchen, watering amicro-garden

Micro-gardening family with bag in bloom

Opit c

amp,

©ACF/

2004

Gulu

, ©

ACF/

2004

Opit c

amp,

©ACF/

2004

ACF-USA staff, Thomas Ojara (middle) making a micro-garden

Ugan

da,

©ACF/

2005

3

dens required, on average, two litres per day inthe dry season) and protecting it from destruc-tion by children and animals. Watering was aparticular problem in Amuru camp wherewater availability was very limited.

The relevance of the project was also demon-strated by the fact that half of the householdshad not been planting vegetables in the previ-ous season before receiving the seeds fromAAH-USA. In addition, vegetable consumptionis generally low. Most households only ate veg-etables 1-3 times a week. The major reasonsgiven for this low consumption were cost andland being too far away, i.e. difficult to cultivateand keep in the home for daily use.

Fifty five percent of micro-gardens that wereobserved were well maintained. However,there was a great contrast between the camps.The gardens in Opit were in better conditionthan those in Amuru. This was related mainlyto the water scarcity in Amuru, where wateringwas carried out sparingly resulting in poorercrop performances.

At the time of the evaluation, 37% of thehouseholds had eaten 6 meals or more fromtheir gardens, with an average of six people tak-ing part in these meals. It should be noted thatat this point, carrots had only just begun to beharvested. As these were the most bulky crop,the final number of meals will be considerablyhigher. Carrots were a big hit. Some parentsstated that the children really enjoyed them andate with more verve when there were carrots inthe meal. AAH-USA conducted training withthe beneficiaries on preparation and cooking ofcarrots. The crowd reaction was excellent with alot of participation, complete with ululations.

None of the households sold the vegetablesproduced in the micro gardens, but 75% indi-cated that if the programme expanded, theywould like to sell, as well as eat, the vegetables.

ConclusionsThe experience of micro-gardening in Gulu

district points to a potentially interesting meansof addressing household food insecurity.Though the project is not a new idea and hasbeen implemented in other displaced settings,there had been no such projects in Gulu districtbefore this one. Although the current micro-gar-den project faced challenges, many of thesecould be addressed by improving the garden-

structed to protect the gardens. Maintenancetook up on average just over 2 hours per week.This included watering, transplanting, fencing,and weeding. AAH-USA food security staffmade weekly visits to the field to monitor thegardens and help troubleshoot for the house-holds.

It is probably fair to say that the initial per-ception of the micro-gardening was that theproject was “strange” and even “a childishthing to be doing”. The Acholi, who are the eth-nic group in Gulu district, are used to garden-ing vegetables in a small area and, in some IDPcamps, there is enough room to have a smallgarden alongside the house. However, garden-ing in a sack had never been seen before.Despite this, the beneficiaries, who were almostexclusively women, were eager to try the newactivity. Many husbands and neighbourslooked on in curiosity. Carrots were also new tomost people, as it is not a traditional Acholicrop.

Success of ‘farming in bags’The results of the micro-gardening project

were assessed through weekly monitoring ofthe gardens’ progress and discussions with thebeneficiaries, observations, and a formal evalu-ation. Overall, micro-gardening was wellreceived. Almost all households who receivedthe garden kit planted a garden. Over 85% ofhouseholds claimed they were satisfied withthe project and 94% wanted to continue withthe activity for more seasons. The main reasonsgiven for wanting to participate in micro-gar-dening included liking the project idea, havingno ‘other’ land to plant, and being able to pro-vide vegetables for their children. Even neigh-bours where impressed, with some 80% ofthose interviewed expressing positive viewsabout the concept of the micro-garden.

A number of advantages were identifiedwith respect to micro-gardening. The proximityof the micro-garden to the compound and theease of maintenance were mentioned most fre-quently. Theft of crops was also reportedly dis-couraged because the micro-gardens can beconstantly monitored. One unexpected advan-tage highlighted was that the micro-gardensdecorate the home.

A few disadvantages of micro-gardens werealso identified. The most significant ones wereproblems related to watering the garden (gar-

ing methods, better targeting and monitoring.

An important attribute of the micro-gardenis that it has offered a new idea to the IDP pop-ulation. After almost 10 years of displacementand very restricted movement, the IDPs in Guludistrict are largely demoralised and lack impe-tus for innovation. While planting in bags wasfirst viewed as childish by many, people arenow really interested. Also, the new vegetablesmay add a lot more interest to household cui-sine.

AAH-USA plan to continue the project,improve it and increase the number of benefici-aries. The pilot project highlighted the need toincrease the size of the gardens for greaterimpact, but at the same time making sure not toover burden households.

Emphasis will be placed on increasing pro-duction in order to promote consumption andsale. In order to do this there will be moredetailed analysis of the types of planting meth-ods promoted, in order to maximise output inreturn for minimal input. Other recommenda-tions include;

• Improve targeting and follow-up: for example, better sensitisation and awareness, ‘home visitor’ staff for monitoring, and systematic monitoring.

• Improve programme inputs: for example, increasing the variety and quantity of seeds,the selection of seeds and the number of bags cultivated per household.

• Improve methods: for example, increasing the variety of methods (intensive farming, container methods), solving problems for seed propagation, achieving greater flexibility (use of bags versus. land), planting for the rainy season, and adding climbing crops.

• Increase frequency and variety of training: for example, running several trainings over the year on gardening, and including more training on food preparation and hygiene.

• Capacity building of staff on micro-garden-ing: for example, more resources being channelled into micro-gardening methods (literature, web sites, in country training).

For further information, contact Devrig Velly,Food Security Coordinator, AAH-USA, email:dv@aah-usa.org

Field Article

Components of a micro-garden Micro-gardens planted in Opit camp

Ugan

da,

©ACF/

2004

Ugan

da,

©ACF/

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Ugan

da,

©ACF/

2004

ProtectiveBarrier

Bag withloamy soil

Crops plantedon the side of

the bag

BaseFoundation

SupportBeams

4

Research

0.00004.50 (2.24, 10.01)

The Democratic Republic of Congo(DRC) in the Great Lakes region ofAfrica has suffered a civil war since1998. Prior to this, in 1994, a large

influx of Rwandans sought refuge in EasternDRC following the genocide. Despite thepotential wealth and fertility of the east of thecountry, rates of severe acute malnutrition areoften high, with kwashiorkor being the pre-dominant form1, 2.

In response to increasing concerns about thishigh prevalence of nutritional oedema, Savethe Children UK undertook a case-controlstudy of the risk factors for the developmentof nutritional oedema in North Kivu, in thenorth eastern part of DRC3. The study was car-ried out in the Masisi Territoire which com-prises of displaced Congolese, returnees andRwandan refugees (many of whom live in vil-lages in eastern Masisi).

MethodData were collected on diet, breastfeeding (forchildren aged 24 months or below only), anddisease. The study dataset consisted of 243cases of nutritional oedema paired with 243matched (i.e. 1:1 matched) controls, aged 6-65months. A sub-set of the data, children aged 24months or below (118 cases of nutritionaloedema paired with 118 matched (ie 1:1matched) controls), included data on breast-feeding which was analysed separately. Dataanalysis using appropriate methods (i.e.paired t-tests, Mantel-Haenszel methods, andconditional logistic regression) was carriedout, controlling for sex, age and socio-economicstatus.

Dietary data were collected on whether certainlisted groups of food items were consumedwithin either the previous 24 hours or the pre-vious seven days. Data were re-coded so thatreported consumption in the previous 7 days(as recorded) included reported consumptionin the previous 24 hours. Associationsbetween the listed food items (and indicesbased upon the reported consumption of thelisted food items) and nutritional oedema arepresented as pairwise associations betweenthe reported consumption of a given food itemand case or control status. This does not con-trol for potential confounding effects in thedata. Hence multiple conditional logisticregression (using the cLOGISTIC programme,an EpiInfo add-in programme4) was subse-quently used, presenting the results as adjust-ed odds rations, their 95% confidence inter-vals, and the p-value for the maximum likeli-hood ratio test statistic. Only those variableswith significant pairwise associations (i.e. p <0.05) were included in the conditional logisticregression model. Non-significant variableswere removed from the model using back-wards stepwise elimination. The remainingsignificant associations are termed independ-ent associations.

Main findingsThe case-control study found positive associ-

Study of the Risk Factors forthe Development ofNutritional Oedema in NorthKivu, DRCBy Mark Myatt and Frances Mason

Table 1 Independent associations with nutritional oedema in children aged 6-24 months

Positive association with nutritional oedema(i.e. an increased risk)

adjusted odds ration(95% confidence interval)

p value

Food Item

if mother is currently pregnant

Negative association with nutritional oedema(i.e. decreased risk of or protection against)

Food stuffs

maize

other cereals

banana/plantain

avocado

sweet potatoes

any foods made with oil/butter/ghee

any food made with sugar/honey

haricot beans

soya beans

sweetened or flavoured water, tea, infusion, or other liquids (including soups and broth)

fever

intestinal parasites

respiratory problems

diarrhoea

Other

having been weaned in the previous 120 days

Infant and child feeding index (ICFI) based on no. of foodgroups reported in previous 7 days

Increasing variety (no. of individual food items reportedconsumed) in the previous 7 days

2.18 (1.03, 4.93)

7.40 (1.63, 33.68)

12.88 (2.65, 62.62)

4.08 (2.19, 8.15)

0.53 (0.28, 0.99)

0.02 (0.01, 0.33)

0.09 (0.02, 0.36)

0.25 (0.08, 0.78)

0.06 (0.01, 0.42)

0.19 (0.05, 0.68)

0.43 (0.20, 0.87)

0.03 (0.00, 0.24)

0.16 (0.05, 0.50)

0.16 (0.03, 0.88)

0.79 (0.70, 0.90)

0.73 (0.60, 0.90)

0.0004

0.0000

0.0072

0.0002

0.0025

0.0083

0.0000

0.0000

0.0071

0.0008

0.0000

2.53 (1.22, 5.24)

2.80 (1.04, 8.67)

0.0015

0.0000

0.0081

0.0205

0.0000

0.0222

having been breastfed in the previous 24 hours

1 In May 2005, SCUK undertook a nutrition assessment inwhich 2.8% severe acute malnutrition was found (95% CI0.8%-4.6%) of which 1.9% was kwashiorkor and 0.1% wasmarasmic-kwashiorkor. 2 UNSCN (2001). Report on the Nutrition Situation ofRefugees and Displaced Populations. RNIS 34.3 Myatt M. (2004). Analysis of data from a matched case-control study of risk factors for the development of nutrition-al oedema in children in North Kivu, Democratic Republic ofCongo. Save the Children UK.4 Dallal GE (1989). "cLOGISTIC: A Conditional LogisticRegression Program for the IBM-PC," The AmericanStatistician, 43, 125.

Disease

0.0318

Other

Mark Myatt is a consultant epidemiologist and senior research fellow at the Division ofEpidemiology, Institute of Opthalmology, University College London. His areas of expert-ise include infectious disease, nutrition, and survey design. He is currently working inSomalia.

This article is based on findings of a report written by Mark Myatt which, in turn, isbased on the findings of research undertaken by Save the Children UK in DRC.

Frances Mason is currently working part time as emergency nutrition advisor for Save theChildren UK. Previously she spent three years as a consultant, following seven years withACF - mainly as head of the nutrition and food security unit in Action Against Hunger UK.

5

ations (i.e. increased risk) between nutritionaloedema and the consumption of soya beansand sweetened or flavoured water, tea, infu-sion, or other liquids (including soups andbroth). These latter fluids are often used forhunger abatement, providing children with ashort-lived energy boost, replacing morenutritious meals and to ‘supplement’ breast-milk in non-weaned infants. Reported con-sumption of sweetened or flavoured water, teaor infusion, or other liquids (including soupsand broth) in the previous seven days wasindependently associated with case or controlstatus in children aged 6-24 months or below.

An increased risk also existed where the moth-er of the oedematous child was currently preg-nant, hence cutting short the period of breast-feeding and potentially the time for childcarepractices, which might otherwise enhance orprotect the infant or young child’s nutritionalstatus. According to a survey Save theChildren undertook in May 2005 5 , it wasrevealed that local beliefs are to stop breast-feeding when a mother becomes pregnant.However, this same survey showed:

• 0-5 months: Exclusive breastfeeding: 62.8% (CI 95%: 56.6-68.9%)

• 6-8 months: Introduction of complementary foods: 84.9% (CI 95%: 77.7-92.1%)

• 6-23 months: Continuation of breastfeed-ing: 78.1% (CI 95%: 72,7-83,4%)

Cases were significantly more likely to havebeen weaned or to have been weaned for alonger period than controls. The data is, there-fore, consistent with earlier weaning in casesthan in controls. Further risk factors includedif the child had suffered a recent episode ofdisease (fever, intestinal parasites, respiratoryproblems and diarrhoea).

The study found a negative association (i.e.decreased risk of or protection against) ofnutritional oedema and the consumption of avaried diet. This particularly included con-suming maize, other cereals, bananas/plan-tain, avocados, sweet potatoes, Irish potatoes,oil/butter/ghee and sugar or honey. Goodinfant and child feeding practices were alsofound to be protective, particularly breastfeed-ing.

In younger children, cases were more likely tobe reported as having had a common child-hood disease (ie diarrhoea, fever, ARI) beforethe onset of oedema (or, for controls, onemonth prior to data being collected) than con-trols. In all children, cases were also more like-ly to have had intestinal parasites (a conditionthat may be more severe in older children) orto have suffered from other (unspecified) dis-eases before the onset of oedema (or, for con-trols, one month prior to data being collected)than controls.

Subsequent (ie conditional logistic regression)analysis of the data revealed that a lack ofdietary diversity (the overall number andpresence or absence of specific food items inthe diet), possibly at particular times of theyear, is associated with oedematous malnutri-tion.

DiscussionThe data indicates that food insecurity, poorsocial care and limited access to public healthare all potentially at play in determining therisk of a child having nutritional oedema.Agriculture and petty trade remain the princi-pal economic activities in the region6. The

main problems faced by the populationinclude limited access to land (a fundamentalcause of inter-ethnic conflict as, over the pastfew decades, poorer households have beenforced off their land by the large landowners),crop disease and ash from the eruption of thevolcano Nyamulagira (both of which haveparticularly affected the production of pota-toes and sorghum). A lack of access to the pre-war markets in Kinshasa and Western Congohas significantly reduced the prices of agricul-tural products since the supply is greater thandemand. The area, therefore, is more cash-poor than food-poor. This particularly affectsthe poorest households who are reliant ontheir own harvest production and are unableto buy more diverse foods in the market. A lack of cash may also reduce access to healthcare - hence increasing the risk of disease - andmay force the child’s carer to find labour, thusfurther reducing time for child care andhousehold food production. Time is alreadylimited, particularly in the mountainousregions of North Kivu where most familiestravel long distances for water (taking up to25% of their time in the day). Many of thesehouseholds have no adequate storage whichmay further contribute to limited availabilityof clean water, resulting in cases of diarrhoea,worms and other intestinal diseases.

The positive association between illness andkwashiorkor suggests that kwashiorkor is partof a broader public health problem. Studies7,8

have shown that the poorest households areunable to purchase necessary items to ensurehealth care and a sanitary environment. In thelatter of these two studies, 65-75% of incomegoes towards expenditure on basic foodsources, reducing the available resources forhealthcare even further than previous years.

For many years, kwashiorkor has beenbelieved to be attributable, at least in part, to adeficiency in anti-oxidant nutrients 9 , resultingin high oxidative stress, primarily as a result ofinfection. The production of anti-oxidantenzymes that can protect the body from theharmful effects of this oxidative stressdepends upon the presence of sufficient traceelements, such as selenium and zinc in thediet. Soya beans, which in the study are foundto increase the risk of nutritional oedema, arehigh in phytic acid which, in turn, can blockthe uptake of essential minerals, includingzinc. Only a long period of fermentation willsignificantly reduce the phytate content ofsoya beans. Soya is currently under promotionin Masisi and is used to make flour for por-ridge and soya milk used in tea, particularlyamongst the poorer households who do nothave access to cow’s milk. Hence, the positiveassociation between consumption of soyabeans and nutritional oedema may be an indi-cator of household food insecurity, as well asthe potential impact of anti-nutrient activity.Soya is also a component of the fortified flour(corn soya blend) given to malnourished chil-dren in feeding programmes.Anti-oxidant nutrients are strongly main-tained in breast milk, which may also con-tribute to the protective nature of good infantfeeding practices, demonstrated by the nega-tive association with nutritional oedema.However, recent research has concluded thatantioxidant supplementation of vitamin E,selenium, cysteine or riboflavin does not pre-vent the onset of kwashiorkor 10 . This studynotes that previous research had entailed com-parisons of biochemical variables in smallgroups of severely ill, malnourished children

5 Save the Children UK (May 2005). Enquête nutritionnelle :Anthropométrie, mortalité et analyse causale de la malnutri-tion; Zone de Santé de Masisi (Province du Nord Kivu) ;République Démocratique du Congo; En collaboration avec lePRONANUT6 King A, Adams L (2000). Household Food EconomyAssessment: Eastern Democratic Republic of Congo. Plainede la Ruzizi Moyens Plateaux Savane, Foret Food EconomyZones of South Kivu Province and Zone Volcanique(Rutshuru) and Zone des Plateaux (Masisi) Food EconomyZones of North Kivu Province. Save the Children UK.7 SC UK (2000). Household Food Economy Assessment:Eastern Democratic Republic of Congo, Food Economy Zonesof South and North Kivu Provinces. Save the Children UK.8 SC UK. DRC Programme (2003). Update of the HouseholdEconomy Analysis of the Rural Population of the PlateauxZone, Masisi, North Kivu, Democratic Republic of Congo.Save the Children (UK).9 Golden MHN (1998). Oedematous malnutrition. BritishMedical Bulletin 1998:54 (No. 2): 433-444.10 Ciliberto H, et al (2005). Antioxidant supplementation forthe prevention of kwashiorkor in Malawian children: ran-domised, double blind, placebo controlled trial. BMJ,doi:10.1136/bmj. 38427.404259.8F (published 25 April2005). See summary in this issue of Field Exchange.

in hospital settings. This new research was aprospective trial investigating the role ofantioxidants in the aetiology of kwashiorkor –hence indicating that antioxidant depletionmay be a consequence rather than a cause ofkwashiorkor.

During the past two years, Masisi has wit-nessed an upsurge of humanitarian interven-tions. Programmes are principally related tothe restoration process and in particular, infra-structure rehabilitation (i.e. building roads,health centres, schools, etc.) and the provisionof basic materials to some of these structures(essential drugs, school materials, etc.).Several agencies have recently initiated live-stock activities. Some agencies have support-ed households to grow soya beans. While thisremains a good source of nutrients (particular-ly protein), it is essential that this be cookedwell to reduce the phytate content.

Future interventions should take into consid-eration the need of the poorer households forcash in order to provide greater dietary diver-sity, access to health care and support to car-ers/mothers to ensure that they can afford totake care of their young children. Other rec-ommendations include:

• Better immunisation, vaccination and promotion of seeking early treatment.

• Diarrhoea control through hygiene promo-tion - protecting water sources and provid-ing effective treatment with oral rehydra-tion solution (ORS), and implementing measures to improve water availability, accesssibility and utilisation. If water is more accessible to the house-hold, it is likely that it may be used for sanitary pur-poses as well as the minimum for drinking and cooking.

• Adequate facilities for dispoal of faeces.• Mass de-worming campaign and helminth

control through hygiene promotion.• Promotion of best weaning practices, prob-

ably within a family-planning programme. • Promotion of best possible infant and child

feeding practices and an emphasis on the inclusion in the diet of foods shown to be protective in this study. The utility of a ‘kitchen garden’ initiative could be investi-gated.

• In the longer-term, access to land and affordable health care–particularly the issue of user fees for the poorest house-holds -must be addressed.

For further information, contact FrancesMason, Nutrition Advisor, Save the ChildrenUK, email:F.Mason@savethechildren.org.uk

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One hundred children from the healthzone of Goma (North Kivu province)aged 15 – 96 months, showing pre-cursor signs of kwashiorkor (bloated

face, discoloured and/or uncurled hair andoedema without signs of indentation), wereadmitted into one of two SFPs for four weeks.These SFPs were sited close to a TFC, henceallowing all cases who developed kwashiorkorduring the study to be immediately referred tothe adjacent TFC.

In the first SFP (Kanyaruchinya), the first 50cases showing the precursor signs of kwashior-kor were admitted into the programme andreceived a supplementary ration2 for 4 weeks,followed by a home visit twice a week.

In the second SFP (Mujda), the first 50 childrenshowing the same precursor signs of kwashior-kor were not admitted into the programme, butsimply placed under observation and moni-tored closely, twice a week, through home visitsover the four week period.

A standard questionnaire was used to collectinformation on the age, sex, weight, height andtype of precursor signs on admission and againat each home visit. This data were analysedusing EpiInfo v.6.04. Only 8% of the childrenenrolled at the start of the study were eligiblefor admission into the SFP based on wasting(weight/height (W/H)). There was a statistical-ly significant difference in W/H z-scoresbetween the two groups at the start of the study(p<0.001), between the two groups at the end ofthe study (p<0.05) and in the interventiongroup before and after the four weeks of inter-vention (p<0.05). There was no significant dif-ference between the two groups in W/H in z-scores in the control group between the startand end of the study.

The cases receiving a supplementary rationwho did not go on to develop kwashiorkor lostthe bloatedness in the face, but the hair signsremained throughout the course of the study. Inthe control subjects, all the pre-kwashiorkorsigns present at the start continued throughoutthe study.

1 Save the Children UK avec la collaboration dueProNaNut (Programme National de Nutrition) (2004),Etude d’intervention sur des sujets presentant dessignes precurseurs du kwashiorkor. Brunet D.2 The ration received was 2.6 kg of maize flour, 500gharicots beans, 210g of oil and 175g of sugar for week1; 700g of CSB, 500g haricot beans, 210g of oil and175g of sugar for weeks 2, 3 and 4. The daily rationequivalent came to 1900 kcal of which 9% was proteinand 31% lipid in week 1 and 975 kcal with 13% proteinand 35% lipid in weeks 2, 3 and 4.

Intervention Study on CasesPresenting Precursor Signs ofKwashiorkor

Dominique Brunet is currently working as a nutritionistwith SC UK. She has 10 years of experience with SCUK, ACF and Oxfam.

In the intervention group receiving the sup-plementary ration, 6% of the cases devel-oped kwashiorkor, compared to 22% of thecases in the control group who did notreceive a ration. Therefore the probability ofdeveloping kwashiorkor amongst childrenwith pre-kwashiorkor signs was lessamongst the children receiving a supple-mentary ration than those without - rela-tive risk of 0.27 (95% CI 0.08, 0.92).

Amongst those that developed kwashiorkorin the intervention group, the nutritionaloedema appeared between days 7–18 ofadmission, averaging at 11 days. In the con-trol group the average was 20 days (appear-ing between 6–30 days).

ConclusionsOf the 100 children participating in thestudy, only 14% developed kwashiorkorduring the course of the four weeks.However, the intervention highlights a con-founding factor in that the supplement pro-vides a protection role in the developmentof kwashiorkor. The majority (92%) of casesdid not have the criteria to enter the SFP(based on wasting) and hence would notnormally be eligible for a supplementaryration. It is important to note that the studyonly continued for four weeks, and henceany further evolution of the cases is notknown after this period.

While the results only partially supporthypothesis one, the second hypothesis isfully supported. The study showed thatthat cases showing precursor signs of kwa-shiorkor and who receive a food ration haveless probability of developing kwashiorkorthan similar cases who do not receive aration.

The conclusions of the study resulted in SCUK proposing to its partner organisations toadmit all cases with precursor signs of kwa-shiorkor into the supplementary feedingprogrammes. It is also recommended thatthis study is repeated in another area/country in which kwashiorkor is prevalentin order to validate the findings.

For further information, contact FrancesMason, Nutrition Advisor, Save theChildren UK, email:F.Mason@savethechil-dren.org.uk

A further study was undertaken by SC UK1

based on two hypotheses:Hypothesis 1: It is possible to develop reliableadmission criteria for children at risk of devel-oping oedematous malnutrition.Hypothesis 2: The admission of these childrenat risk into a supplementary feeding pro-gramme (SFP) will prevent the development ofoedematous malnutrition.

This article is based on a report written byDominique Brunet which was, in turn, basedon the findings of research undertaken by Savethe Children UK in DRC.

Arecently published paper describes asecondary analysis of data from amulticentre randomised controlledtrial on immunisation-linked vitamin

A supplementation. The trial investigatedinfant feeding patterns (exclusive breastfeed-ing, predominant breastfeeding, partial breast-feeding and no breastfeeding) and risk of deathand hospitalisation in infants under six monthsof age.

Altogether, 9424 infants and their mothers (2919in Ghana, 4000 in India and 2505 in Peru) wereenrolled when infants were 18–42 days old intwo urban slums in New Delhi, India, a peri-urban shanty town in Lima, Peru, and 37 vil-lages in the Kintampo district of Ghana.Mother–infant pairs were visited at home every4 weeks from the time the infant received thefirst dose of oral polio vaccine anddiphtheria–pertussis–tetanus (DPT) at the ageof 6 weeks in Ghana and India and at the age of10 weeks in Peru. At each visit, mothers werequestioned about what they had offered theirinfant to eat or drink during the past week.Information was also collected on hospitaladmissions and deaths occurring between theages of 6 weeks and 6 months. The main out-come measures were all-cause mortality, diar-rhoea-specific mortality, mortality caused byacute lower respiratory infections (ALRI), andhospital admissions.

No significant difference was found in the riskof death between children who were exclusive-ly breastfed and those who were predominant-ly breastfed (adjusted hazard ratio (HR) = 1.46;95% confidence interval (CI) = 0.75–2.86). Non-breastfed infants had a higher risk of dyingwhen compared with those who had been pre-dominantly breastfed (HR = 10.5; 95% CI =

Infant FeedingPatterns andRisk of Death Summary of published paper1

Current WHO guidelines recommend that HIV pos-itive mothers should avoid breastfeeding only ifreplacement feeding is acceptable, feasible, afford-able, safe and sustainable, or to breastfeed exclusive-ly but stop as early as possible. In the emergencycontext, meeting these criteria is particularly diffi-cult, especially as HIV status of individual mothersis most likely unknown.The risk of virus transmis-sion through breastfeeding depends on a variety offactors, including the disease status of the mother,whether she exclusively breastfeeds and for howlong. Experts now estimate that on average, for eachmonth of breastfeeding, less than 1% of infants areinfected2. With exclusive breastfeeding, the riskdrops to less than half this level. Any risk of MTCT through breastfeeding and excess morbidity andmortality associated with positive HIV status, needsto be balanced against the risk of excess morbidityand mortality by not breastfeeding, whether aninfant is HIV positive or not. Work from SouthAfrica found that HIV-positive infants who hadnever been breastfed suffered greater morbidity andmortality than HIV-positive infants who had beenbreastfed3. The paper summarised here helps to quan-tify the risks associated with infant feeding choice,and should help both health workers and mothersmake an informed decision about infant feedingchoice.(eds).

By Dominique Brunet and Frances Mason

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5.0–22.0; P < 0.001) as did partially breastfed infants(HR = 2.46; 95% CI = 1.44–4.18; P = 0.001). Diarrhoeaand ALRI were the main causes of death in both non-breastfed and partially breastfed infants. In addition,non-breastfed infants were at substantially higher riskof all-cause hospitalisation (incidence rate ration:3.39%, CI+1.74-6.61, p<0.001) and diarrhoea specifichospitalisation (IRR: 5.59, CI=2.17-14.4, p<0.001). Therisk of ALRI hospitalisation was higher but not signif-icant.

The authors highlight two major implications of theirfindings. First, the extremely high risks of infant mor-tality associated with not being breastfed need to betaken into account when informing HIV-infectedmothers about options for feeding their infants.Second, the finding that the risks of death are similarfor infants who are predominantly breastfed and thosewho are exclusively breastfed suggests that in settingswhere rates of predominant breastfeeding are alreadyhigh, promotion efforts should focus on sustainingthese high rates rather than on attempting to achieve ashift from predominant to exclusive breastfeeding. Incommunities where partial breastfeeding and notbreastfeeding are common, e.g. India and Peru, theimpact of breastfeeding promotion on child survivalcould be much greater and should take into accountpredominant and partial breastfeeding rates. The com-mon practice has been to calculate impact estimates byapplying the risks associated with non-breastfeedingto the prevalence of non-exclusive breastfeeding.

1 Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N,Arthur P. Infant feeding patterns and risks of death and hospitalisationin the first half of infancy: multicentre cohort study. Bull of the WorldHealth Organisation 2005;83:418-4262 Ted Greiner. Personal communication.3 Coutsoudis A et al, 2003. Morbidity in children born to womeninfected with humanimmunodeficiency virus in South Africa: does mode of feeding matter?Acta Pædiatr 2003; 92: 890–895.

Some key breastfeeding indicators

These definitions are based on 24 hour recall in theperiod immediately preceding the questions:

Exclusive breastfeeding: the infant has received onlybreastmilk from his/her mother or a wet nurse, orexpressed breastmilk, and no other liquids or solidswith the exception of drops or syrups consisting onvitamins, mineral supplements ot medicines.

Predominant breastfeeding: the infant’s predominantsource of nourishment has been breastmilk. Howeverthe infant may also have received water and water-based drinks (sweetenend and flavoured later, teas,infusions, etc); fruit juice, ORS solution. Drop andsyrup forms of vitamins, minerals and medicines andritual fluids (in limited quantities). With the exceptionof fruit juice and sugar-water, no food based fluid isallowed under this definition.

Exclusive and predominant breastfeeding togetherconstitute full breastfeeding.

Breastfeeding: the child has received breastmilk(direct from the breast or expressed).

Source: Indicators for assessing breastfeeding practice.Report of an informal meeting, 11-12 June, 1991,WHO_CDD_SER_91.14http://www.who.int/child-adolescent health/New_Publications/NUTRITION/WHO_CDD_SER_91.14.pdf

Field Exchange (FEx) is unique in thehumanitarian sector in that it uses aconsiderable amount of pictorialillustrations to support articles. Part

of the rationale for reviewing past FEx pho-tos was to consider the potential impact ofimages used by the publication on readers,as well as on those represented. In the fastmoving world of global media, visual rep-resentations play an increasingly signifi-cant role. We are bombarded by imagesfrom the moment we wake up in advertis-ing, film, news coverage, etc. In the latter,images are often used as an instantaneousand powerful means of evoking emotionsin the viewer/reader instead of usingreams of text, which may be more time-con-suming to compile and have less of animpact.

The criticism levelled at FEx – that “themajority of pictures imply a situation withwesterners as the ‘master’ while portraying‘indigenous’ as the ‘starved’, ‘powerless’ or‘helpless’” is one that the development

world has been struggling with for overtwo decades. There was a code set up bythe NGO-Liaison Committee regardingrepresentation of the developing worldas far back as 1985. However, thereremain major difficulties in portrayingthe ‘reality’ of victims in any situation, letalone an emergency one where theimpact and urgency of the message canbe crucial to life saving action. ‘Reality’ isnot easily definable, no picture has anobjective meaning – this is achievedthrough negotiation between a readerand the producer/editor of the image. Inthe case of FEx, meaning is achieved viaa relationship between the subjects pho-tographed, the photographer, the editor,and the receiver of the message. To agreat extent, the interpretation of a par-ticular image is very complex and willvary from individual to individual, inthat the reader will read a particularimage by drawing references fromher/his ‘conceptual map’. This map ofreferences will inevitably vary depend-

Neo-Colonialism and‘Otherness’: Representational Issuesin Field Exchange

Dorrie Chetty is a senior lecturer at the Universityof Westminster UK. Her current research interestsinclude gender, development, globalisation andmedia representations.

Image 1. Breastfeedingin Sierra Leone (FEx 13)

By Dorrie Chetty

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This brief review of photographs carried in Field Exchange was prompted by a criticismlevelled at the publication in 2004 ‘that the gallery of pictures accompanying the arti-cles and those presented at the end of each issue is testimony to “neo-colonialism”(Renzaho A, Issue 23, p17). As well as commenting on previous issues, the authormakes some recommendations on images that should be considered by both ENN editorsand those in the field.

References:For guidance on assessing infant feeding practice at apopulation level, see the LINKAGES website athttp://www.linkagesproject.org/tools/m&e.php andMEASURE DHS at http://www.measuredhs.com

For guidance and resources on infant and child feed-ing, including HIV/AIDS and infants in exceptionallydifficult circumstances, see the WHO website: http://www.who.int/child-adolescent-health/NUTRITION/infant.htm

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ing on the reader’s ‘positionality’, e.g. gender,geographical location, political stance andvarious other personal factors. Whilst we mayshare the conceptual map of colonial dis-course, our reading will inevitably be shapedby our positionality within that historicalmap. We may read against the grain of thedominant or the intended readings of the edi-tor - negotiating our own meanings, or wemay be so positioned within the conceptualmap that we do not challenge the dominantreadings.

Reading images in Field ExchangeWe are concerned here with the extent towhich FEx’s use of pictorial support reinforcesor challenges a neo-colonial reading. To thisend, this piece of research has analysed aselection of imagery - a sample of one FieldExchange issue from each year, beginningwith the inaugural issue in 1997, was selectedin order to get a cross-section of images.Acknowledging my own positionality as awoman from an ex-colony, I’ve picked out tworecurring imageries which I consider signifi-cant and which exemplify how we ‘read’images.

Each FEx issue selected contains severalimages of a woman and child, the latter inmost cases at her breast, although sometimesthe child is attached to the woman’s back (anexample from FEx13 is given in image 1).From a Eurocentric reading, in the context ofthe religious imagery of Madonna and child,celebrated by European culture through paint-ings and sculpture, we would assume thewoman to be the mother. Had the child beenwhite and the woman rather plumper, some-one from an ex-colony would have assumedthe woman to be a nursing maid. These areonly two possible readings of the same image,i.e. individuals ‘negotiate’ different readingsdepending on their ‘positionality’. For an edi-tor to ensure a ‘preferred reading’ of an image,s/he needs to have a clear understanding ofthe reader’s conceptual map. There is anassumption that the editor and the readerswould come to the same understanding, shar-ing references from the same conceptual map.Whilst the selection and production of animage may be consciously processed, much ofthe meaning eventually achieved by the read-er occurs at a subconscious level and evokesemotions, using references available toher/him. As images are often used, not just tosupport writing, but sometimes as a code,imagery often uses easily identifiable ‘signi- 1 Renzaho, A, 2004. Field Exchange 23, p17.

Image 3. Mugina market place, Rwanda (Cover of FEx 20)

fiers’. In the development world, women andchildren have historically been identified as vul-nerable groups with programmes focusing onmaternal and child health. It’s not surprising,therefore, that the imagery of a nursing motherhas become a recognisable signifier of ‘need’ and‘vulnerability’. Furthermore, in European cul-ture, women and children have traditionallybeen represented as potential victims, requiringthe protection of their men, particularly against‘strangers’. When a message of victim needs tobe conveyed, an image of a woman and childserves as a short-cut code. Given the focus ofField Exchange – nutritional emergencies andthe fact that many interventions target thisdemographic group for ‘good scientific’ reasons,i.e. women and children are often physiological-ly most vulnerable in food crises, it is inevitablethat there will be many photographs of theseprogramme beneficiaries. At the same time,given the dominant meaning of the mother andchild, such an image is an appealing and power-ful one from which its readers can pull out theirconceptual map and come to similar conclu-sions.

Another recurring imagery in FEx which seemssignificant, particularly from a gender perspec-tive, is that of food aid distributions.Interestingly, the pictures showing sacks of foodaid are usually with males of the communityseemingly in charge of distribution (e.g. in Issue22, p17, see image 2). In contrast, the imagesrelating to collection of fuel and local food pro-duction (e.g. cover of Issue 22) show womenactively engaged in managing these resources.This ‘phenomena’ could be decoded as men areassociated with the control of ‘international/global resources’, whilst women are associatedwith local resources and affairs. There are reso-nances and parallels with the ‘postcolonial’ situ-ation, whereby men were trained to operatemechanised agriculture for cash cropping whilstwomen contributed to the fluctuating, moreinsecure, local food production and consump-tion. This difference in gender imagery seemedto me far more striking than any picture in FieldExchange which may be read as ‘westernersbeing masters and the indigenous as powerless’.

On balance, the variety and quantity of imagesused by FEx showing people from the develop-ing world as active, including women (a strikingexample being the cover of Issue 20, image 3), gosome way to countering the dominant readingof ‘helpless victims from the developing worldneeding the help of westerners’. However,given the absence of varied representations of

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the developing world by the wider mass media,the dominant imagery and reading will remainthat of ‘Enlightened West’ helping ‘The Rest’.

With this in mind, it would be prudent for FExto develop a policy regarding representationalissues, in order to reduce the risk of perpetuat-ing portrayals of the developing world as anundifferentiated homogeneous mass. Crucially,representations used could emphasise parallelsof experiences with the West, thus preventing areading which maintains people from develop-ing countries as ‘distant others’.

A consideration which is often neglected in adiscussion of representations, is the widerimpact they may have upon the subjects used inthe photographs. Even if it is unlikely that thereadership of FEx includes the subjects pho-tographed, the way they ‘could theoretically’read the images should be taken into account.This is more than just an issue of political cor-rectness.

International agency staff who furnish FEx witharticles and accompanying photographs shouldconsider these issues of representation.Furthermore, agency staff would do well to beaware of representational issues when ‘reading’photographs or taking pictures of their pro-grammes for either public relations or academicpurposes. A final but important point is thatsimilar care should be taken over accompanyingcaptions and headlines, particularly when theseare obtained from picture libraries rather thanthe authors writing the articles.

For further information, contact; Dorrie Chettyat University of Westminster, UK. Email:Chettyd@wmin.ac.uk

The current ENN policy on using images is to sourcethem from those that have written fieldarticles/research pieces so that pictures are viewedwithin the context in which they were taken. We relyon the sensitivity of the authors and picture sourcesin doing this. Where other pictures are used notdirectly related to an article, then we seek to checkwith both the source and the article author that theimage is appropriate to use in this context. Picturesincluded on the backpage 'People in Aid' are selectedfrom what is sent into the ENN office by readers, andENN staff snapshots during work overseas or atten-dance at meetings (contributions always welcome).(eds)

Image 2. Aid in Iraq (FEx 22)

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SC UK recently conducted a review oftheir experiences of supporting FoodSecurity Information Systems (FSIS)over the past 15-20 years. The review

drew on specifically prepared case studies ofexperiences in Southern Sudan, Darfur,Somalia, Tanzania, Ethiopia, and southernAfrica and two other specially commissioneddocuments. Providing an overview of SC UKexperiences of secondment to strengthen FSISand a synthesis of donor views on FSIS, themain findings of the review are as follows;

HEA and other methodologies as a tool in FSISWhile certain criticisms of the HouseholdEconomy Approach (HEA) have a degree ofvalidity, others are often over-emphasised,reflect unrealistic expectations of the method-ology or have not taken into account recentdevelopments/advances in the approach. Theramifications of these critiques may be thatcredibility is, on occasions, undermined orthat compromise methodologies are invoked,with potentially negative consequences. Inorder to strengthen and optimise the futurerole of HEA, scenario-based guidance materi-al should be developed which highlights thestrengths and weaknesses of the approach indifferent contexts. This would require moresystematic documentation and review of theexperiences of using HEA, particularly interms of technical rigour, practicality in differ-ent contexts and proven value in advocacyand accuracy of prediction. In some contexts,compromised HEA approaches may be neces-sary in order to account for institutional, staffcapacity, security and infrastructure relatedfactors.

There is a significant gap in the literature, andwithin humanitarian agency understanding,regarding the impact and relative cost-effec-tiveness of many food and nutrition relatedemergency interventions. Given this, and thepotential of HEA to provide a practicable

approach to measuring food security impact,greater investment should be made in devel-oping and promoting the role of HEA in im-pact assessment of food security interventions.

HEA and Individual Household EconomyApproach (IHEA)) also have the methodolog-ical potential to support FSIS in longer-termvulnerability analysis and poverty monitor-ing. Its key strengths as a methodology for thisinclude the fact that HEA identifies structuralconstraints to food security and quantifieschanging components of the food economyand that it can also be used to model differentscenarios, e.g. policy changes. The approachalso focuses on process and implementation-oriented indicators at household level, an areacurrently lacking in PRSP2 monitoring (oftenreferred to as the ‘missing middle’). However,there is currently limited experience ofemploying HEA in longer term poverty moni-toring and analysis.

Factors which influence use of informationby decision-makersDesigners and implementers of FSIS need tohave an understanding of the mandates, poli-cies and politics of UN agencies and govern-ments and how these may impact on decision-making, in order to tailor their informationmanagement and alliance building strategiesaccordingly. Politicisation of information maybe critical at national government level.Consideration has to be given to whether gov-ernments are likely to be sensitive to informa-tion and therefore not react or, at worst, sup-press information. The institutional location ofthe FSIS within government may be key here.This may also have implications for the needto decentralise government FSIS capacity anddecision-making.

Credibility of the information system is alsocritical to information use. Experience hasshown that this is most enhanced when there

has been a process of multi-agency consulta-tion over methodological development, e.g.in southern Sudan and national vulnerabilityassessment committees (NVACs). Credibilityis also enhanced through involvement ofagencies/staff whom external decision-mak-ers perceive as ‘neutral’ in terms of informa-tion analysis. Thus secondment can be effec-tive in ensuring buy-in. A related issue is theneed to have a clear communication strategyfor decision-makers so that they understandhow the information is derived and analysisundertaken. Decision-makers who are notinvolved in the development of the systemmay require support/training.

FSIS information has rarely been used to pro-mote or influence non-food aid responses inemergency contexts. While this reflects a num-ber of political, institutional, and events driv-en factors, it also reflects methodologicalshort-comings in emergency needs assessmentand FSIS, as well as the limited array ofresponse capacity in the emergency humani-tarian sector. There is a clear need forincreased experience of non-food aid respons-es in emergency situations to strengthenunderstanding of the types of information andanalysis needed, to determine the appropriate-ness and feasibility of non-food aid responsesin a given context.

Sustainability Although sustainability of FSIS cannot beaccurately tested until external donor fundingis withdrawn, it is clear that where demandfor the FSIS is high, e.g. in emergencies (andgeo-politically important regions), there islikely to be consistent external donor support.However, for systems where emergencies aremore sporadic and/or which are more embed-

SC UK Experiencesof Food SecurityInformationSystemsSummary of review1

1 Food Security Information Systems Supported by Savethe Children UK: A Review2 Poverty Reduction Strategy Papers

A Dinka boy milks acow at a cattle camp inSouth Sudan

South Sudan. SC UK, A Kari/2003

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ded in, and partially funded by, national gov-ernment structures, funding is likely to be lessreliable.

Critically, there are almost no data on the costsof FSIS in the public domain. Without morestandardised data on costs, it will be impossibleto engage in debates regarding the costs ofestablishing and sustaining FSIS or differentcomponents of the system and the potential forcost-sharing amongst a variety stakeholders.Information on costs would facilitate identifica-tion of potentially sustainable funding sourcesfor different components of a system, e.g. earlywarning systems, longer term poverty monitor-ing and impact assessment, as these will havespecific values to different stakeholders. Thepaucity of data on costs of FSIS and their vari-ous components is a severe constraint on finan-cial planning in relation to sustainability.

Strategies to build and sustain capacity in FSISneed to be developed on a country-by-countrybasis and take account of existing educationallevels and capacity/skills, and movement ofstaff within government departments, andbetween government and international agen-cies. Consideration also needs to be given tocompeting demands on government staff dur-ing capacity building work and the need forrefresher courses/training of trainers, etc.Expertise can all too easily be lost, especiallywhere there is limited institutional ownershipand buy-in. A critical lesson and recommenda-tion is how important it is to undertake a capac-ity analysis prior to implementing or support-ing an FSIS and to anticipate scenarios wherecapacity can be eroded. Such an analysis, whichshould be applied at all levels of the system(central and decentralised levels), will influencechoice of methodology in terms of complexityand level of training needed.

The means to obtaining maximum institutionalownership of the approach, as well as ensuringthat the FSIS is well placed institutionally interms of maintaining support and influence, isa vital consideration. This requires substantialstakeholder analysis. For example, understand-ing the organisational structures and where thedecision-makers are, while ensuring the mostpowerful stakeholders are ‘on board’. There is amajor gap in the literature with regard tounderstanding how institutional factorsimpinge on FSIS sustainability. This could be

addressed through more systematic institution-al analysis of the many FSIS currently operatingwithin or at the margins of national govern-ments. Unfortunately, international/ expatriatetechnicians who are called upon todevelop/support/strengthen these FSIS are notequipped with the skills/background to under-take institutional or organisational analysis.

Integrating FSIS with longer-term povertymonitoring and analysisThere are many methodological, institutionaland political issues to consider in terms of inte-grating FSIS with poverty and vulnerabilitymonitoring. For example,

• What are the optimal ways of linking EW/FSIS and poverty monitoring institutionally at central, regional and district level?

• How compatible are monitoring and surveyprocedures and sampling for these distinct forms of information system?

• Is the FSIS methodology potentially too sensitive an approach for national government PRSP monitoring?

In attempting to integrate FSIS with longer-term poverty monitoring and analysis, agenciesshould consider a range of technical, institu-tional and political challenges.

Coordination Coordination of FSIS is frequently overlooked.In the case study countries, it has been less of anissue in conflict affected areas where the mainoperational FSIS has been closely linked to aUN structure. In other situations, e.g. Tanzania,Ethiopia, northern Sudan, lack of coordinationhas led to duplication/wastage, lack of stan-dardisation of information and confusion fordecision makers. Formation of multi-agencybodies, including technical institutions, hasproven to be the way forward with regard tobetter coordination. However, where the strate-gy for FSIS is to integrate these with longerterm poverty monitoring and analysis, then thelikelihood is that coordination will becomeeven more complex.

The experience in southern Africa shows thatformation of a regional (across a number ofcountries) multi-agency body, including andchaired by regional technical institutions, lendscredibility to regional leadership and buildsconsensus amongst participating institutions. Itcan also facilitate the development of appropri-

Field work as part of alivelihood developmentproject

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ate capacity at national level, while training atregional level ensures a common methodologyand understanding across the region.

Currently, within the humanitarian system it isnot clear who has the overall mandate tostrengthen coordination of FSIS at country orregional level. This needs to be addressed. Itmay be that lead international non governmen-tal organisations (INGOs) take on this rolewithin countries or that INGOs with a historyof supporting FSIS may wish to independentlydevelop this mandate and expertise.

DecentralisationThere has been limited experience of decentral-ising FSIS. Theoretically, decentralisationallows for local ownership and provides a vehi-cle through which local agencies can appraiseand plan projects. However, there is little infor-mation on the cost, feasibility, sustainabilityand real value of such initiatives. There may becritical issues around capacity of local staff andfinancial sustainability within local governmentfunding mechanisms. There may also be politi-cal issues around empowering local govern-ment and disempowering central administra-tions. In general, donors are interested in FSISthat build up from a decentralised level as longas these are effectively institutionalised in gov-ernment.

DonorsKey actors in FSIS must invest time and effortinto communicating to donors how FSIS andspecific methodologies operate in practice, aswell as how different methodologies can inter-link and complement each other, rather thanoperate in parallel. Continuous dialogue withdonors is necessary with regard to evolvinginformation systems, as well as the strengthsand weaknesses of different approaches andlessons learnt. Given the high turnover of donorstaff, these lessons need to be captured in guid-ance material. There are currently no genericguidelines (there are agency guidelines) on FSISin spite of the enormous demand for FSIS data.

Donors should be encouraged and supported instandardised monitoring of FSIS costs and theirdifferent components. Donors should also beencouraged to invest in evaluating the perform-ance of FSIS – especially from an institutionaland decision-making perspective, wheredonors will have a comparative advantage.Donors at country level should, as a matter ofcourse, be involved in FSIS design in order toensure greater understanding, trust and ‘ buy-in’ to findings. FSIS stakeholders shouldattempt to track/monitor donor policies/prior-ities and ‘internal thinking’ with regard to FSIS.These may be donor specific across a range ofcountries, donor specific for a particular coun-try, or staff/individual specific. This type ofknowledge, perhaps kept in ‘donor files’, willallow agencies with a keen interest in FSIS totarget ‘educational messages’ and fundingrequests to specific donors. It will also assist inbuilding strong partnerships in support of spe-cific FSIS approaches.

Guidance materialThere is an urgent need to develop comparativeand scenario-based guidance material on FSIS.Guidance material should allow potential usersto evaluate which type of methodology andsystem is most appropriate for a given context.Clearly, any such guidance material should be a‘working’ document. It is astonishing that thereis currently no generic guidance material onFSIS, although such systems are a prerequisitefor informing emergency and longer-term foodsecurity intervention design.

For any further information, contact MichaelO’Donnell at SC UK on email:M.O’Donnell@savethechildren.org.uk

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Current WHO guidelines for the man-agement of severe malnutrition in chil-dren recommend calculation of weightfor height z score (WHZ) or % of the

median (WHZ)2 . However, in practice, this canbe difficult to implement in resource-poor set-tings in sick children. A recently publishedstudy set out to evaluate MUAC and visiblesevere wasting3 as predictors of inpatient mor-tality at a district hospital in sub-Saharan Africaand to compare these with WHZ.

The principle aim of the study was to examinethe predictive value for inpatient death ofMUAC compared with WHZ among childrenaged 12 to 59 months. In addition, the study:

• investigated whether there were any differences in the children identified by MUAC versus WHZ

• evaluated the clinical sign of visible severe wasting as a predictor of subsequent inpatient death, and

• evaluated MUAC as an indicator of the presence of a WHZ less than or equal to –3.

MethodThe study was conducted at Kilifi DistrictHospital, located in a rural, malaria-endemicarea on the Kenyan coast. Approximately 10%of women attending the hospital antenatal clin-ic were infected with human immunodeficiencyvirus (HIV) in 2000. Antiretroviral therapy wasnot in routine use at the time of the study anddata on individual HIV status was not avail-able. Data were prospectively collected from allpaediatric admissions as part of an ongoingsurveillance study. For this study analysis, datafrom all children aged 12 to 59 months admittedbetween April 1, 1999, and July 31, 2002 wereincluded.

From April 1 1999, trained clinical assistantsmeasured MUAC, weight and height/lengthand from September 1, 1999, data on visiblesevere wasting4 was also collected. Childrenwith a clinical diagnosis of severe malnutritionwere treated according to WHO guidelines andlocal protocols.

Statistical MethodsWHZ, weight-for-age z score (WAZ), andheight-for-age z score (HAZ), using the NCHSreference standards, were calculated usingEpiInfo version 6.045 . Only children with com-plete data for all three indices were included inthe main analysis.

The predictive value for inpatient death wasdetermined as the area under the receiver oper-ating characteristic (ROC) curves with 95% con-fidence intervals (CIs) using the roctab and roc-comp (a2 test) commands in STATA version 8.0(Stata Corp, College Station, Tex).

The sensitivities6 and specificities7 of common-ly used cutoff values were investigated, as wellas the clinical data for differences between chil-

dren identified as severely malnourished by theMUAC and WHZ methods. Since the WHO rec-ommends that children be treated for severemalnutrition if they have severe wasting orkwashiorkor, the investigators evaluated thepositive and negative likelihood ratios fordeath for each of MUAC, WHZ, and visiblesevere wasting combined with (and/or) kwa-shiorkor.

To determine the independent associations ofdifferent nutritional indices with mortality,multivariable logistic regression was used thatincluded age, sex, visible severe wasting, WHZ,and MUAC.

To determine the clinical features that differedbetween children identified by MUAC andWHZ, backward stepwise multivariable logisticregression were used. All analyses were per-formed using STATA version 8.0, and P<0.05was used to determine statistical significance.

ResultsA total of 8,500 children aged 12 to 59 monthswere admitted during the study period (1999-2002). Anthropometric data were incomplete in3.6% (n=310) of children, who were mostlyadmitted in extremis and were excluded fromthe analysis. Overall, 4.4% (n=359) of childrenincluded in the study died while in the hospital.Sixteen percent (1282/8190) of admitted chil-dren had severe wasting (WHZ<–3) (n = 756),kwashiorkor (n = 778), or both.

Prediction of inpatient mortalityThe case fatality rate among children admittedwith WHZ less than or equal to –3 was 19.9%(151/756). The case fatality rate among admit-ted children with MUAC less than or equal to11.5 cm was 19.0% (166/873) and did not signif-icantly vary with age.

The areas under the receiver operating charac-teristic curves for predicting inpatient death didnot significantly differ between MUAC (0.75,95% confidence interval, 0.72-0.78) and WHZ(0.74, 95% confidence interval, 0.71-0.77) (P =0.39).

Sensitivity and specificity for subsequent inpa-tient death were similar for WHZ, MUAC andvisible severe wasting: 46% and 91%, respec-tively, for MUAC less than or equal to 11.5 cm,42% and 92% for WHZ less than or equal to –3,and 47% and 93% for visible severe wasting.However, the 3 indices identified different setsof children and were independently associatedwith mortality.

Clinical features of malnutrition were signifi-cantly more common among children withMUAC less than or equal to 11.5 cm, thanamong those with WHZ less than or equal to –3.

Visible severe wasting was present in 9.0% (608)of 6727 children assessed. The median age ofchildren with visible severe wasting was 24

months (interquartile range, 18-35 months). Ofthe 608 children with visible severe wasting,22.5% (137) died, compared with 2.5%(153/6117) without this sign (sensitivity, 47%;specificity, 93%).

The positive and negative likelihood ratios fordeath for WHZ less than or equal to –3 and/orkwashiorkor were 4.36 (95% CI, 3.95-4.84) and0.47 (95% CI, 0.41-0.53), respectively; those forMUAC less than or equal to 11.5 cm and/orkwashiorkor were 5.12 (95% CI, 4.49-5.84) and0.59 (95% CI, 0.54-0.65); and those for visiblesevere wasting and/or kwashiorkor were 5.31(95% CI, 4.71-5.97) and 0.46 (95% CI, 0.40-0.53).

A multivariable logistic regression modeladjusted for age and sex showed that MUAC,visible severe wasting, and kwashiorkor wereall independently associated with inpatientdeath.

Predicting the current WHO criterion for severewastingFor detecting the WHO standard criterion forsevere wasting (WHZ –3), the sensitivity andspecificity of MUAC less than or equal to 11.5cm were 65.1% (486/746) and 94.8%(7057/7444), respectively. The sensitivity andspecificity of visible severe wasting for WHZ-3were 52.6% (320/608) and 95.3% (5831/6119)(P<.001), respectively. Of 608 children withWHZ less than or equal to –3, 29.3% (n=178) didnot have visible severe wasting or MUAC lessthan or equal to 11.5 cm.

Differences in children identified by MUAC andWHZComparing children with a MUAC less than orequal 11.5 and those with a WHZ <-3 (univari-ate analysis), the MUAC group were more like-ly to be stunted, female, and to have a longerhistory of illness, cough, diarrhoea, subcostalindrawing, visible severe wasting, kwashior-kor, moderate anaemia, and bacteremia.

1 Assessment of Severe Malnutrition Among HospitalizedChildren in Rural Kenya. Comparison of Weight for Height andMid Upper Arm Circumference. Berkley J, Mwangi I, GriffithsK, Ahmed, I;Mithwani S, English M, Newton C, Maitland K.JAMA. 2005;294:591-597. 2 The WHO defines severe malnutrition requiring hospitaladmission as weight-for-height z scores (WHZ) of less thanor equal to –3 or as less than or equal to 70% of the refer-ence median using US National Centre for Health Statistics(NCHS)/WHO reference values (severe wasting) or symmetri-cal oedema involving at least the feet (oedematous malnutri-tion, kwashiorkor).3 Because of the recognised difficulties of measuring weightfor height, the WHO Integrated Management of ChildhoodIllness programme for primary-level care makes use of theclinical sign of visible severe wasting.4 Muscle loss manifested as a wasting of the gluteal area andas the presence of a bony prominence over the chest wall.5 Centres for Disease Control and Prevention, Atlanta6 Sensitivity was defined as the number of inpatient deathsamong children with anthropometric measures equal to orbelow a cutoff value, divided by the total number of inpatientdeaths7 Specificity was defined as the number of children dis-charged alive with anthropometric measures above a cutoffvalue, divided by the total number of children dischargedalive.

MUAC Versus Weight-for-Height in Assessing Severe MalnutritionSummary of published paper1

An infanthaving MUACmeasuredduring thestudy inKenya

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tional needs as well as those of the individ-ual to be trained. This in turn limits theaccountability on the part of both theorganisation and individuals to take for-ward and put into practice the elements ofthe training. Short courses are rarely fol-lowed up in any way.

The audiences prioritised by the reviewfor training were local NGO/governmentstaff, managers, nutrition graduates andthe trainers themselves. The primary sub-ject gaps were considered to lie in thecapacity to undertake nutrition and foodsecurity assessments and interpret theresults; to develop nutrition policy andundertake planning; to monitor and evalu-ate nutrition programmes and, amongstsenior managers, to understand wherenutrition fits into policy and program-ming.

The need for more decentralised satellitecourses was strongly emphasised duringthe workshop. These should be annual,last for up to three weeks, include fieldwork, be competency based around theparticipants’ work needs and include ele-ments for non-technical managers. Thecourses should be targeted primarilytowards national staff of the regionalcountries. The courses could either beestablished within, for example, one EastAfrican University or be a roving coursebetween countries (and universities).Trainers must be regionally based withstrong facilitation skills. There should bedual objectives of not only sharing knowl-edge and practice between the trainer andthe participants, but also in capacity devel-opment.

Areas in capacity development still requir-ing further research include determininghow organisations can work successfullyin partnership; how institutions willing tomake change can be targeted; how men-toring and support through apprenticeschemes can be set up following on fromshort courses and how academia can bebetter linked with practice and implemen-tation.

For further information, contactNutritionWorks, P.O. Box 42284, LondonE7 0YY, UK. Email:info@nutritionworks.org.uk

1 Available courses have been listed by the ‘TrainingInitiatives for Capacity Development in EmergencyNutrition’ sub-group of the ‘Nutrition in Emergencies’working group within the UN Standing Committee forNutrition and by the British Nutrition Society. A summaryof these can be found in the full report submitted toNutritionWorks.

NutritionWorks (NW) has beenrunning courses on nutrition inemergencies in the UK since1999, working in partnership

with the International Health Exchange(IHE), Merlin and the Liverpool School ofTropical Medicine. In order to assist indeveloping strategic priorities, NW com-missioned a review to identify potentialgaps in nutrition training, both for emer-gency and development contexts and part-nerships. The review also consideredpotential networks (northern and south-ern) with which NW could consider col-laboration to advance new nutrition train-ing initiatives, as well as potential fundingagencies or institutions interested in futuretraining initiatives.

The review focused primarily on the gapsin nutritional capacity building, limitingany regional focus to Sub-Saharan Africa.Approximately forty individuals wereinterviewed on their experience in nutri-tion capacity development, analysis ofgaps and recommendations for fillingthose gaps. A workshop was also heldwith academic, NGO and partner staff inwhich a prioritisation of the major gaps interms of subject and target audience wasmade. The main findings of the review aredescribed below.

Despite the large number of trainingcourses which currently exist in nutrition1,very few of these enable field workers andmanagers, particularly government staffand national staff of international ornational NGOs, to be responsible for nutri-tion policy and programming. In part thisis due to the geographical location of themajority of the most effective courses – thecourses being held outside of the areasmost in need - and in part because there isa major capacity deficiency of trainers forregional courses. Furthermore, there islimited coordination between those run-ning the courses, particularly amongst theinternational agencies. Trainers them-selves have limited shared resources inmaterials (e.g. an interagency CDRom)and many opportunities are missed, e.g.not including experienced people from thefield and/or training participants to betrainers within the existing courses.However a determination exists toimprove the sharing of materials andreduce potential wastage of resources. It isrecommended that an outside facilitator ororganisation with a coordination mandatewould be best placed to undertake this.

Findings showed that many trainingcourse lack a needs and employmentassessment, particularly of the organisa-

Review of TrainingOpportunities in Nutrition andFood Security

Although the median ages appeared similar, thedistribution of ages also significantly differedbetween the 2 groups.

Multivariable analysis showed that skin/hairchanges associated with recent kwashiorkor,bipedal oedema associated with current kwashi-orkor, stunting, subcostal indrawing, no historyof seizures, female sex, and younger age wereindependent associations of having MUAC lessthan or equal to 11.5 cm, rather than WHZ lessthan or equal to –3.

CommentThe study found that MUAC performed as wellas WHZ in predicting inpatient mortality in thiscontext. Since MUAC is inexpensive, more com-monly available, does not require a chart to calcu-late, and is easier to measure than WHZ, theauthors suggest it may be a useful screening toolfor such children. However, there were differ-ences in the groups of children identified by thesemethods, and they independently predictedinpatient death. The study observed statisticallysignificant, independent associations of age andsex and identification by MUAC alone, comparedwith WHZ alone, when adjusted for the effects ofother variables. Since the case fatality rate forMUAC less than or equal to 11.5 cm was consis-tently high (19.0%) at all ages, the authors sug-gest that an unadjusted MUAC may be clinicallyuseful in this setting.

The authors suggest that stunting is a risk factorin itself for poorer outcomes, and small physicalsize may contribute to a low MUAC measure-ment (but has no influence WHZ). In this study,the prevalence of stunting in children withMUAC less than or equal to 11.5 cm was greaterthan in those with WHZ less than or equal to –3.They also suggest that the association of a num-ber of other clinical characteristics, e.g. bipedaloedema and skin/hair changes among childrenwith MUAC less than or equal to 11.5 cm, maymean MUAC is a better indicator of severe mal-nutrition than WHZ in this setting.

Visible severe wasting was as useful as anthro-pometry in this study in detecting severe acutemalnutrition. The authors suggest subjective clin-ical assessment by trained staff in this setting isappropriate, ideally supported by an objectivemeasure such as MUAC, to allow standardiza-tion between centres and classification of thedegree of malnutrition.

Since visible severe wasting did not predict WHZless than or equal to –3 as well as MUAC, MUACmay be better in identifying less severely ill chil-dren in need of nutritional rehabilitation.

The main limitations of this study are that it wasperformed at only one site and that varyingmalaria transmission and HIV prevalence mayinfluence observations. Also, there was no sys-tematic follow-up of deaths post-discharge.

ConclusionsGiven their findings, as well as cost and practical-ities, the authors suggest that MUAC may bemore appropriate than WHZ for identifyingsevere malnutrition in children aged between 1and 5 years who are admitted to an African dis-trict hospital. However, an assessment thatincludes MUAC, WHZ, and visible severe wast-ing increases the number of at-risk children whoare identified on admission and highlights thosein overlapping groups who are at the greatestrisk of dying. They suggest further studies areneeded to evaluate MUAC and visible severewasting in other operational settings and othersituations in which anthropometric assessment isdifficult to perform.

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creating a continuing need for relief assistance and trapping people in chronic dependency on outside assistance.

iii) Dependence on external assistance is viewed as one of the features of extreme poverty, associated with a sense of shame or defeat.

iv) Dependency on relief resources on the part of governments - at local or national levels, warring parties or aid agencies.

The research report draws a number of impor-tant conclusions;

People depend less on relief than is oftenassumed. There is little evidence that reliefundermines initiative, or that its delivery is reli-able or transparent enough for people todepend on it. In practice, many concerns aboutdependency seem to stem from a preoccupationwith the disincentive effects of food aid.Framing these real concerns in terms ofdependency is unhelpful because this can pro-vide an excuse for cutting back relief for peoplewho may still be in desperate need. The moreimportant question is what forms of assistanceare most appropriate to prevent hunger, savelives and alleviate suffering. In situations wherepeople’s lives and livelihoods are under acutethreat, and local capacities to cope with crisisare overwhelmed, being able to depend onreceiving assistance should be seen as a good

Arecent study set out to evaluate theefficacy of antioxidant supplementa-tion in preventing kwashiorkor, in apopulation of Malawian children at

high risk of developing kwashiorkor. It has longbeen proposed that kwashiorkor results froman imbalance between the production of freeradicals and their safe disposal. The theory issupported by the observations that blood con-centrations of vitamin E derivatives - glu-tathione and red cell antioxidant enzymes - arelower in children with kwashiorkor than inmarasmic children. Associations betweenoxidative stress and kwashiorkor indicate thatantioxidant depletion may cause kwashiorkorand its onset may, therefore, be prevented withantioxidant supplementation.

1 Harvey P and Lind. J (2005). Dependency and humani-tarian relief. A critical analysis. HPG Research Report No19, July 2005

1 Ciliberto H et al (2005). Antioxidant supplementation forprevention of Kwashiorkor in Malawian children: randomised,double blind, placebo controlled trial. BMJ, vol 330, pp 1109-1113

thing. The focus should be not on how to avoiddependency, but how to provide sufficientlyreliable and transparent assistance so that thosewho most need it understand what they areentitled to, and can rely on it as part of theirown efforts to survive and recover from crisis.

Discourses around dependency often blame thesymptom, rather than the cause. Relief aid hasoften been the most visible, if not the only, formof international engagement in long-runningcrises. In these contexts, there is a tendency tocriticise relief for failing to improve the situa-tion, and enabling a movement towards recov-ery or development. Yet humanitarian aid maybe a wholly inappropriate instrument for thatpurpose. The problem lies not with relief and itsfailings, but with the lack of other forms ofinternational engagement with crises.

Relief should not be withheld without solid evi-dence that the needs which prompted it in thefirst place have been met. This is not to implythat agencies should ignore the potentially neg-ative effects of aid, but it does suggest a needfor caution about how the label ‘dependency’ isapplied, and how it is used to justify reductionsin relief.

The study was a prospective double blind,placebo controlled trial, randomised by house-hold and conducted in eight villages in ruralsouthern Malawi. Overall, 2,372 children aged1-4 years in 2,156 households were enrolled and2,332 children completed the trial. Childrenreceived daily supplementation with an antiox-idant powder containing riboflavin, vitamin Eselenium and N-acetylcysteine in a dose thatprovided about three times the recommendeddietary allowance of each nutrient, or a placebo,for 20 weeks. The primary outcome measure

Antioxidant Role in Preventing Kwashiorkor

was the incidence of oedema. Secondary out-come measures were the rates of change forweight and length and the number of days ofinfectious symptoms.

A total of 62 children developed kwashiorkor(defined by the presence of oedema), of whom3.3% (39/1184) were in the antioxidant groupand 1.9% (23/1188) were in the placebo group(relative risk 1.70, 95% confidence interval 0.98to 2.42). The two groups did not differ in therates of weight or height gain. Children whoreceived antioxidant supplementation did notexperience less fever, cough, or diarrhoea.

Antioxidant supplementation at the dose pro-vided did not prevent the onset of kwashiorkor.This finding does not support the hypothesisthat depletion of vitamin E, selenium, cysteineor riboflavin has a role in the development ofkwashiorkor. The study suggests that antioxi-dant depletion may be a consequence ratherthan a cause of kwashiorkor.

The authors concluded that in addition todietary and nutritional investigations, geneticmapping techniques to delineate host factorsmay prove useful to unravel the enigma of kwa-shiorkor.

Summary of published research1

A village of mothers waiting toenroll their children in Chipalonga

The antioxidant powder is mixed with water tomake an orange coloured and flavoured drink

Dependency and Humanitarian ReliefSummary of research report1

In many emergency contexts, aid agencieshesitate to provide food and other aid forextended periods because of fears that thismay create ‘dependency’. A newly pub-

lished HPG research report explores what‘dependency’ means in a humanitarian context,how the term is used and the implications thishas for how relief is provided.

The paper sets out how dependency is:

• generally seen as negative and to be avoided

• associated with the provision of relief, and contrasted with development approaches

• seen as undermining people’s initiative• contrasted with a variety of positive values

or terms, notably independence, self-suffi -ciency, self-reliance and sustainability, and

• seen as a particular problem when relief assistance has been provided over a prolonged period.

According to the report authors, there are fourmain ways in which the term is used:

i) Relief risks creating a ‘dependency mentality’ or ‘dependency syndrome’ in which people expect continued assistance. This undermines initiative, at individual or community levels.

ii) Relief undermines local economies,

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Arecently published discussion paperexamines the use of cash and vouch-ers to provide people with assistancein emergency situations. It is based

on a critical review of existing published andgrey literature, discussions with aid agencystaff and a survey of project documentationfrom recent and ongoing cash- and voucher-based responses.

The literature review threw up two principalfindings. While cash and voucher approachesremain largely under-utilised in the humanitar-ian sector, there is a growing amount of experi-ence with cash and voucher approaches, and asense that the absolute dominance of commod-ity-based approaches is beginning to erode.

The paper focuses on cash grants, cash for workand voucher programmes, where the cash orvoucher is given to individual households, notto communities or governments. The studyattempts to address the question of where cashand vouchers are suitable in the full range ofemergency contexts. The main findings of thereview are as follows;

Some of the theoretical fears about the draw-backs of cash have not been borne out in prac-tice, for example, people rarely use cash foranti-social purposes, and women are not neces-sarily particularly disadvantaged by the use ofcash rather than in-kind approaches.

Vouchers can be exchanged to purchase com-modities from traders, at distribution outlets,markets or special relief shops. Voucher pro-grammes may require more planning andpreparation than the distribution of cash (agree-ments need to be reached with local traders, forexample, and ‘seed fairs’ at which vouchers canbe exchanged take time to set up). If vouchersare not providing goods that people see as pri-orities, then a parallel market may well devel-op, with vouchers being traded for cash at a dis-counted price. Evaluations comparing vouchersand commodity approaches have been broadlypositive, emphasising that vouchers give peo-ple more choice and can have positive effects onlocal markets. Where voucher approaches havebeen compared to cash, however, questions

have been raised about whether the additionaladministrative burden that managing a vouch-er programme imposes for the implementingagency is worthwhile. Donor constraints andreservations about cash seem to play an impor-tant role in discouraging agencies from switch-ing from vouchers to cash, even where thismight be appropriate.

There may, however, be situations in whichvoucher approaches are more appropriate thancash, such as when cash raises particular secu-rity difficulties which vouchers would not,where there is a need to restrict support to aparticular type of commodity, or where marketshave been weakened and need revitalising.

It often seems that aid agencies are reluctant toconsider cash because of concerns about itsappropriateness, because agency policies orstaff skills preclude it or because funding forcash or voucher approaches is not available.Getting cash and vouchers onto the humanitar-ian agenda and into the humanitarian toolboxwould mean moving away from resource-driv-en assessments. As a first step, it would beencouraging to see agencies explicitly consider-ing a range of intervention options as part ofthe assessment process. Issues around theappropriateness of cash divide fairly neatly intotwo categories: practical questions around itsfeasibility and economic questions around theability of local markets to respond. In order tomake judgements about the economics of cashand voucher responses, agencies therefore needto improve their capacity to assess local mar-kets. The tools to do this already exist, the chal-lenge is getting these tools into manuals andstandard assessment checklists, and makingmarket analysis a routine part of the assessmentprocess.

The existing documentation of cash- andvoucher-based responses shows that they areoverwhelmingly successful in terms of theirimpact. People spend the money they are givensensibly, cash projects have not generally result-ed in sustained price rises and women havebeen able to participate and have a say in howcash is spent. Cash responses have usually beenfound to be more cost-effective than commodi-ty-based alternatives.

The body of experience that these conclusionsare drawn from is still small and there is a needfor caution. There is still only limited evidenceabout the likelihood of inflationary impacts ifcash and voucher projects were to be imple-mented on a larger scale. There is also only lim-ited evidence about their feasibility in complexemergencies. What experience there is stronglysuggests, however, a case for the further devel-

opment of cash- and voucher-based approachesand for piloting their application on a largerscale.

In many of the contexts in which humanitarianagencies work, there are clear concerns aboutputting cash into conflicts and predatory politi-cal economies. However, evidence from exist-ing projects suggests that ways can be found todeliver and distribute cash safely, even in con-flict environments. Indeed, in some situations,cash has been less prone to diversion than alter-natives. Cash is both highly portable and notnecessarily as visible as large-scale commoditydistributions. Innovative ways have been foundto minimise the risks of insecurity and corrup-tion, and evaluations have found little evidenceof insecurity or corruption relating to cash-based approaches. Since much of this evidenceis context-specific, one of the generic lessons isprobably the unsurprising point that there is aneed for a locally nuanced understanding ofparticular security risks. For example, inAfghanistan and Somalia, it has been possibleto use the local hawala (money transfer) systemto distribute cash. In Ethiopia, Save theChildren take out insurance coverage againstlosses in transporting cash to projects in areaswhere there are no banks.

Proponents of cash and voucher-based respons-es also argue that cash can be an intrinsicallymore dignified way to provide assistance.Recipients of cash tend to prefer it to alterna-tives because of the greater flexibility andchoice that it provides.

The way in which the architecture of thehumanitarian system is currently structuredseems to inhibit consideration of cash andvoucher responses. There is a wider debateabout the dominance of food aid in currenthumanitarian responses and the extent towhich this is due to the continued tying of aidto food surpluses in donor countries. Outside ofthe UN system, there seem to be fewer barriersto considering cash and voucher responses, andNGOs and the Red Cross have led the way intheir increasing use.

ConclusionsThere is a strong case for investing further inthe rigorous evaluation and documentation ofcash and voucher based responses, in order tobe able to make better informed judgementsabout their impact. There is also a need forhumanitarian practitioners to develop the skillsand capacities they need to implement cash andvoucher interventions, and for the develop-ment of a body of practice and guidelines.

1 Harvey P (2005). Cash and vouchers in emergencies. HPGDiscussion paper, February 2005

Cash andVouchers inEmergenciesSummary of published paper1

Women have not been foundto be disadvantaged by cashfor work programmes

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Compact Norway has developed a newproduct called AFYA to be used as anutrition supplement for householdsaffected by HIV/AIDS and TB in

resource poor settings, within the context ofHome Based Care (HBC) programmes. Table 1outlines the nutritional profile of AFYA. Theacceptability of AFYA included in two types ofHBC kits was tested in a study carried out inLilongwe, Malawi. The HBC kits used in thisstudy were the Community Volunteer (CV) kitfor use by a trained health worker and theHome Based Care and Nutrition (HBCN) kit foruse by care takers at home (see table 2).

The main objectives of the study were:

a) to determine whether AYFA can be used over a long period as a supplement to otherfoods without creating adverse effects

b) to investigate acceptability in terms of taste/smell, packaging and practicality of use

c) to gain feedback on the value of the kit itself and the items in it.

Study designThe study was conducted at two sites inLilongwe, Likuni and Alinafe, where HBC issupported by CHAM (Christian HospitalAssociation of Malawi). A total of 75 homebased care patients were enrolled into thestudy. These 75 study subjects were dividedinto two groups based on the type of theMedeco HBC kit they received. A total of 11subjects used the Community Volunteer (CV)kit while the remainder (64 patients) used theHome Based Care Nutrition (HBCN) kit. Threepackets of AFYA (180 g), containing 840 kcaland approximately one recommended dailyallowance (RDA) of vitamins and micro-miner-als, were provided to each patient per day.

The acceptability of AFYA was assessedthrough the use of a patient diary which wascompleted daily and an AFYA qualitative ques-tionnaire completed every 10 days. Mid-Upper-Arm-Circumference (MUAC) was meas-ured in order to monitor any increase or

decrease in weight during the study period.Trained supervisors at Alinafe and Likuni hos-pitals supported the HBC volunteers throughregular quality control visits.

Study findings Table 3 indicates the age and illness profile ofthe patients who took part in this study2. A totalof 93.2% of the patients managed to consumethe recommended daily ration of three packetsof AFYA, providing a total of 840 kcal per day.Sixty-two of the patients (86.1%) reported anoverall improvement in their health, while79.7% of the patients said AFYA tasted goodand was appetizing. Overall, 70.8% of thepatients said that what they liked most aboutAFYA was its flavour.

At the beginning of the study, only three of theadults were found to be severely malnourished(MUAC <16 cm), 9.3% were moderately mal-nourished (MUAC >16 and <18.5 cm) while therest had a normal arm circumference measure-ment (MUAC >18.5 cm)3 . Of the three severelymalnourished adults, two died just before theend of the study, while the third patient showedimprovements in MUAC by the end of thestudy. Overall, 82% of the patients registered anincrease in weight based on MUAC readings.

DiscussionThese findings suggest that AFYA could beused to restore nutritional status amongHIV/AIDS and TB patients within the contextof Home Based Care. However, it should benoted that this study did not verify whether theobserved weight gain was due to both lean andadipose tissue. Lean tissue is the functional tis-sue that includes major components of theimmune system. Sharing of AFYA among fami-ly members was limited, suggesting that AFYAmay be perceived as a specialised supplementfor targeting HBC patients.

The contribution of Medeco CV and HBCNkits to the health and hygiene of the study sub-jects is very important. As health directlyimpacts nutrition, the kits will have contributedto the nutritional effect separately from theAFYA. Due to its compact nature, AFYA caneasily be incorporated into a Home Based Caremedical kit for HIV programmes in resourcepoor settings. However, most of the respon-dents raised concerns about their inability toreplenish the Medeco CV and HBCN kits due tolack of money. It is unlikely that families couldsustain provision of HBC kits and nutritionsupplements without external support.

The composition of AFYA should be flexibleand based on latest research findings. The mostrecent study carried out in Tanzania has shownthat some selected vitamins taken in stipulateddoses are important determinants for slowingdown HIV disease progression and mortality4 .These types of study should inform futureproduct development.

For further information, contact StanleyChitekwe, Nutritionist, UNICEF, email: schitek-we@unicef.org (Stanley Chitekwe was notworking with UNICEF at the time of the AFYAproject), or Reidar Retzius, Compact AS,Smoget 29, N-5212 Soefteland/Bergen-Norway.Tel: +47 56 30 35 00, fax: +47 56 30 35 40, e-mail:rr@compact.no, website: http://www.com-pact.no or

1 Possibility of using AFYA, as a nutrition supplement con-tained in a Home Based Care kit for HIV/AIDS and TBpatients – an acceptability study carried out in Lilongwe,Malawi. COMPACT. Available online athttp://www.compact.no/nyhet.cfm?id=51968 2 Serial MUAC measurement is not a standard method forassessing change in weight (eds).3 Mid-Upper Arm Circumference (MUAC) theoretical andpractical problems,http://www.unsystem.org/scn/archives/adults/ch06.htm 4 Fawzi WW, Msamanga GI, Spiegelman D, et al. A random-ized trial of multivitamin supplements and HIV disease pro-gression and mortality. N Engl J Med 2004; 351: 23-32.

Table 1 Nutritional profile of AFYA

Table 2 Contents of CV and HBCN kits

Table 3 Profile of AFYA study subjects

Energy: 1950 kJ/468kcal/100gProtein: 15.6%Fat: 37.7%Carbohydrates: 46.7%

Paracetamol tabletsReSomalLatex GlovesHand towelBed sheetCotton woolApron, plastic disposableThermometerScissors, surgical straightForcepsSwabGauze padAdhesive tapeGauze bandageSoap barSphygmomanometerStethoscopeBedpanAFYA

Carbohydrate: 54g Protein: 18g Total fat: 20g

saturated: 8.1gmonounsaturated: 8.1gpolyunsaturated: 3.8gΩ-3/ Ω-6 ratio: 0.14

Ash: < 4gHumidity: < 4g

Oral rehydration saltMiconazoleCondomsGentian Violet crystalsBed sheetHand towelCotton woolGauze padsAdhesive tapeWound plasterGauze bandageSoap barWashing detergentCalamine lotionAFYA

Shelf life18 months at moderate temperature and humidity,with a minor decrease in some vitamins.

Gender

AlinafeHospital attended

Type of illness

Variable

male

female

total

Likuni

Bottom

total

HIV-related

TB/PTB

Other, e.g. malaria,diabetes

34

41

%

45.3

54.7

100

46.7

49.3

4.0

100

37.0

52.1

10.9

100

75

35

37

3

75

27

38

8

73total

n

Pack size 60g (2x30g tablets)Kits produced by Medeco

NutritionSupplement for PeopleWith HIV Summary of unpublishedresearch1

The BHC supervisor talks with a mother,who receives a HBCN kit

One of the HBCN kits containing Afya

Mal

awi, R

Ret

zius,

Com

pac

t/2004

Mal

awi, R

Ret

zius,

Com

pac

t/2004

Research

Energy profile Nutrient content/100g

Community Volunteer Kit(CV Kit)

Home Based Care andNutrition Kit (HBCN Kit)

16

Acción Contra el Hambre (ACH) hasbeen working in Argentina for thepast three years, implementingrelief and development pro-

grammes in the nutrition and food securitysectors. In April 2003, the City of Santa Fe(390,000 inhabitants) was affected by signifi-cant flooding. The impact of the disaster onthe population affected more than 130,000people who were evacuated into public andprivate buildings (schools, stadiums, parishes,clubs, tents, etc.) and 23 deaths were reported.

In this context of emergency, a nutritional sur-vey was carried out by ACF. The study includ-ed assessment of anthropometric status andhaemoglobin (Hb) levels in children and alsoexamined a number of socio-economic vari-ables, as well as neurodevelopment in youngstudents. This article focuses on the identifica-tion of anaemia and its link with intellectualdevelopment, learning capacity and earlychildhood development in young school agechildren. Analyses of the anthropometric find-ings are not included.

Study methodThe study sampled from three different typesof sites covering the most vulnerable popula-tion areas: Homes, Centres for Evacuees, andSchools. Selection criteria varied for each typeof site (see table 1). Variables assessed in thehome and evacuee sites were socio-economic(home structure, conditions of the house priorto floods), prior health (weight at birth,amount and quality of health checks in thepast two months), anthropometry (weight andheight), and biochemistry (red blood cell Hb).The school survey assessed anthropometricstatus (weight and height) and red blood cellHb levels. Students were also evaluatedthrough an academic survey questionnairecompleted by the teachers at the end of theschooling cycle.

Prevalence of anaemia Anaemia was defined as a Hb value lowerthan the 5th percentile of the normal distribu-tion, as proposed by the WHO1. Hb levelswere measured using a portable photometer(Hemocue‚). Five areas of intellectual develop-ment were explored in the academic survey:attention, concentration, memory, conceptual-isation and anticipation. A guiding questionwas formulated for each of the studied areas(see table 2). Each question required one ofthree responses, ‘Very Frequently’,‘Frequently’, and ’Rarely’, which were givenscores of 3, 2 and 1 points, respectively. Thesum of these points gave the Global SchoolPerformance.

ResultsA total of 1089 children were included in theHomes group, 218 children in the Centres forEvacuees, and 626 children in the Schoolgroup. With regards to the biochemical vari-able, anaemia was a highly relevant problemin all of the studied groups, significantly moreso in Homes and Centres for Evacuees (chil-dren aged 6 to 71 months) when comparedwith the school group (see graph 1). However,it stands out that anaemia in the infantile pop-ulation prevailed in the Centres of Evacueescompared to the one found in Homes, despitecorresponding age groups (p=0.007). The mostaffected group were children less than 2 yearsold, where the proportion of anaemia reached48% in homes and 61.5% in evacuee centres.There was also a statistically significant associ-ation in the home sample between anaemiaand overcrowding (p=0.02) and anaemia andconditions of the house (p<0.000).

In the School survey, the group of childrenwho were older than the normal age for theircourse had a higher prevalence of anaemiathan the group of normal age for their course(p< 0.009) (see graph 2). Sixty percent of chil-dren were classified as having low school per-formance. The percentage of children with lowschool performance was significantly greateramongst those with anaemia compared to thenon-anaemic ones (p=0.024) (see graph 3). Thefunctions most affected in relation to anaemiawere those of conceptualisation (p=0.0009),anticipation (p=0.023) and memory (p=0.032).

Prevalenceof AnaemiaAmongstYoungChildren inArgentina

This field article outlines the results of a nutri-tional study carried out by ACH in Argentina,which highlights how anaemia remains a pub-lic health issue, impacting on intellectual devel-opment in school age children.

By Adrian Díaz, Amador Gómez,Nuria Salse and Gabriela Cormick

Our most sincere gratitude to Reyes Varella,ACH-Argentina Head of Mission, for herhelp and support during this project.

Adrian Díaz is a physicianand Technical Coordinatorfor ACH in Argentina. He hasworked with MSF inHonduras on a nutrition andmedical programme with thede Misquitos population andon nutritional projects withMedecins Du Monde inGreater Buenos Aires.

Amador Gomez is TechnicalDirector of Accion Contra elHambre (ACH). Previouslyhe spent several years work-ing on nutrition and medical programmes in Angola,Somalia, Guinea, Nicaraguaand Colombia.

Nuria Salse is a nurse/nutritionist who has workedwith ACH in Angola, Guineaand Argentina.

Gabriela Cormick is a nutritionist who has workedwith the ACH team in SantaFe during this project.

Taking blood sample at school for Hb test

Sante Fe, ACH Argentine/2003

Field Article

Table 1 Sample selection

Scope

Homes Provincial institute ofStatistics and Censuses

Centres forEvacuees

First-grade students(aged between 6-7years old)

Population Design

Children aged between6 and 71 months

Children aged between6 and 71 months

Secretariat ofCommunitarian Promotion -Santa Fe Municipality

Exhaustive study, including all floodedschools (14)

Source

Representative sample, auto-weight-ed stratified by conglomerates (40 sample Primary Units)

Exhaustive study, including all centresfor evacuees (23)

Schools Ministry of Education – Santa Fe Municipality

Table 2 Academic Survey Questionnaires

Areas

Concentration

Attention

Memory

Conceptualisation

Question

The Pupil DOES NOT finish a task that he/she has started and goes from one incomplete activity to another one?

The Pupil easily forgets school contents and/or what he/she remembers is deficient,nothing or inexact?

The Pupil has difficulties in solving problems and comprehending tasks?

Anticipation The Pupil shows difficulties following the required steps to develop a task?

The Pupil has difficulties in holding the attention during classroom work?

17

DiscussionThis study demonstrates the significanceof anaemia as a public health problem intraditionally affected groups, such as chil-dren less than 2 years old and pre-school-ers, as well as school-age children.Furthermore, there appears to be a stronglinkage between anaemia, learning capaci-ty and school performance.

The findings of this survey support anoth-er recent study by ACH in a population ofchildren less than 6 years of age in theprovince of Tucumán2 . Here, nutritionaldeficiencies, in conjunction with otherpoverty related factors, are showing tohave a significantly adverse impact onneurodevelopment. These preliminaryfindings in turn, concur with other popu-lation studies in Argentina and elsewherein the Latin America region and argue fortypes of nutritional interventions whichare more oriented towards establishingbalanced diets, than many of the currentactivities which focus largely on satisfyingcalorific needs.

Finally, the use of a rapid method for thedetermination of haemoglobin levels(Hemocue‚) constitutes a highly effectivemethod for detection and treatment of anotherwise hidden form of under-nourish-ment, i.e. iron deficiency anaemia. Themethod and study findings should helpconvince programme designers of theneed and feasibility of systematicallyassessing nutritional anaemia in at riskgroups, specifically in relation to growthand neurodevelopment.

With the knowledge of these results, ACH,in coordination with local health andschool authorities in Santa Fe, initiated aprogramme of weekly supplementationwith ferrous sulphate for children lessthan 6 years of age and first-graders. Theresults of this intervention will be writtenup and disseminated in the near future.

For further information, contact AdriánDíaz, email: adiaz@ach-argentina.org.ar orGabriela Cormick, email:gcormick@ach-argentina.org.ar

The constitution of a sub-group on‘mental health and care in emergen-cies’, of the thematic groupNutrition in Emergencies, was vali-dated at the 2004 UN StandingCommittee for Nutrition (SCN)meeting in Brasilia. In preparationfor SCN 2006, the sub-group aregathering information about thespectrum of programmes thatinclude or target the care practiceslinked to malnutrition in emergen-cies. Specifically, the group wishesto:

• Compile details of mental/social support given by agencies in nutritional programmes, to directfuture activities in the area

• Investigate these interventions inorder to recommend the most effective, efficient and locally adapted ways to address care practices in emergencies.

A brief questionnaire has been pre-pared and is available from CécileBizouerne, Psychologist in charge ofthe mental health and care practicesprojects, Action Contre la Faim, 4,rue Niepce, 75 014 Paris, FranceTel: 01 43 35 88 82, email: cbizouerne@actioncontre-lafaim.org

1 WHO: Iron Deficiency Anaemia. Assessment, Prevention andControl. A guide for programme managers. WHO/NHD/01.3. 20012 At time of writing, the results were not completed but will beavailable from ACH towards the end of 2005.

Graph 1 Prevalence of Anaemia according toPlacement

Graph 2 Percentage of Anaemic First-gradersAccording to Age During the School Year

45

40

35

30

25

20

15

10

5Homes Centres for

EvacueesSchools

%

45

40

35

30

25

20

15

10

5

%

p< 0.009

p 0.009

Correct age for school grade

Over-age for school grade

21

39.4

Graph 3 Prevalence of Anaemia according toglobal academic performance

45

40

35

30

25

20

15

10

5

%

p=0.024

Adequate school performance

Low school performance

18

25.9

Note: In Homes and Centres study, children aged from 6 to 71 months

Care Practicesin Emergencies

A recovering child from the TFCenjoying football

Infants in the TFC playroom inAfghanistan

Flood affected people in one of the camps in Santa Fe

San

te F

e, A

CH

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entine/

2003

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n,

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izouer

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2005

Afg

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C B

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2005

Field Article

18

In a food crisis, distributing cash in a targetedmanner can often meet people’s immediateneeds more quickly and appropriately thanproviding food aid or other commodities.Cash gives people choice and preserves theirdignity. Commodity distribution poses logis-tical problems, and food aid may disrupt localmarkets if food is available locally. There isgrowing consensus amongst humanitarianactors that cash is an appropriate interventionwhen food or other essential commodities areavailable locally, and markets are functioning.But fears remain among many humanitarianagencies that cash transfers will pose securityrisks and not be used to meet basic needs. Anew guide by Oxfam on Cash Programmingin Emergencies addresses many of theseissues. In this guide, the first of its kind,Oxfam staff present the rationale behindcash-transfer programmes, compare cashgrants, vouchers, and cash-for-work, anddescribe the practical steps in the implemen-tation of each. They draw on Oxfam’s wideexperience of operating such programmes inAfrica, Asia and Latin America, including therecent responses to the devastation caused bythe Indian Ocean tsunami in December 2004.

The aim of the guide is to support the imple-mentation of cash programmes. It is dividedinto two parts. The first part covers the plan-ning of cash interventions. This includes thereasons why and when cash is an appropriateresponse to meet basic food and non-foodneeds, as well as livelihood needs, in manyemergency contexts. It gives basic checklistsfor assessments, in particular for assessingmarkets. Part one also covers criteria fordetermining whether cash grants, cash forwork, or vouchers are the most appropriate

nutrition is a new publication catering specifi-cally for national nutrition practitioners work-ing towards longer term nutrition goals. It pro-vides an opportunity for those working in thefield to share their valuable practical experi-ences (both successful and less successful) andupdates nutrition practitioners on related poli-cy, research and technical issues.

Presented in a clear and easy to read format,nutrition contains practical information, arti-cles, summaries of research, pullouts, interestpieces and updates on courses, conferences andnew books. Nutrition practitioners are encour-aged to write up their experiences and can begiven help by the editors to ensure that theircontributions are clearly written.

nutrition is edited and published by NutritionInternational based in the UK, in collaborationwith a number of southern-based nutritioninstitutions.

Three thematic pilot issues of nutrition will bepublished over the first year:

1 Nutrition and HIV/AIDS, September 20052 Breastfeeding and infant/child feeding,

January 2006 3 Iron deficiency anaemia, May 2006

If you wish to receive your free copy of nutrition, or if you wish to submit a contribu-tion please go towww.nutritioninternational.org.uk or contactthe editors@nutritioninternational.org.uk

Cash-Transfer Programming in Emergencies, Edited byPantaleo Creti and Susanne Jaspars. Trial edition forOxfam Skills and Practice, June 2005

nutrition-New Publication for Nutrition in Development

In 2001, an Operational Guidance on Infantand Young Child Feeding in Emergencieswas developed by an Interagency WorkingGroup, supported by 30 INGOs/ NGOs/UNagencies. It aims to provide concise guide-lines to emergency relief staff, policy makersand donors on appropriate infant and youngchild feeding in emergencies.

The Operational Guidance is currently underrevision by the IFE Core Group who inviteanyone with experiences of using theOperational Guidance or who has commentson its content to contact the group via theENN. Notification of a revised version willbe posted on the ENN website and other rel-evant sites.

The current document, OperationalGuidance for Emergency Relief Staff andProgramme Managers on Infant and YoungChild Feeding in Emergencies, is availablein print from the ENN, or at the ENN web-site, http://www.ennonline.net

If your agency would like to be included inthe list of supporting agencies, you can postyour support on the ENN website or regis-ter your interest by emailing MarieMcGrath, email:ife@ennonline.net.

Review ofOperationalGuidance on IFE

New Guide on Cash-TransferProgramming in Emergencies

type of cash intervention. Part two givesguidance on the implementation of differenttypes of cash programmes. Grants, cash forwork and vouchers are covered in one chap-ter each. Each chapter follows a similar for-mat, and includes practical information onplanning the intervention, selecting benefici-aries, setting pay rates (or size of grant, valueof voucher), transferring cash, staff and man-agement requirements, monitoring and eval-uation.

The guidelines are primarily intended forNGO personnel, such as humanitarian pro-gramme managers, food-security specialists,public-health engineers, finance staff, andlogisticians. Policy makers in donor organisa-tions and international agencies will also findthem relevant.

A trial edition has been produced before finalpublication to get feedback from field work-ers and academics. The review process will becompleted by the 19th of August 2005, afterwhich the final version of the guide will bepublished as a book in Oxfam’s Skills andPractice Series in January 2006.

If you would like to pre-order copies of theguide, please contact the Oxfam publishingteam on email: publish@oxfam.org.uk, orthrough their website:www.oxfam.org.uk/publications.Alternatively, contact Oxfam Publishing,Oxfam GB, Oxfam House, John Smith Drive,Cowley, Oxford, OX4 2JY, UK. Tel: + 44(0)1865 473727

Over the past four months, the ENN hasundertaken a funding review, to exploreoptions around longterm sustainability. TheENN originally arose out of a collaborativeinter-agency initiative and has continued as ajointly owned multi-agency partnership. Ithas been supported over the years by a widevariety of bilateral donors, and an increasingnumber of UN agencies and NGOs.

In this review, the ENN has consulted withsupporting agencies, to explore otheravenues of funding to try and place FieldExchange and other ENN activities under amore secure funding arrangement. So far, thefeedback and support from agencies has beenpositive and constructive and a number ofavenues are being explored. As part of thisongoing process, a key decision has now beentaken by the ENN directors for the ENN toapply to register as a charity in the UK. Thiswill open up funding opportunities, has tax

advantages, and, in subjecting the ENN to thescrutiny of the Charities Commission, furtherstrengthen our accountability to FieldExchange stakeholders and readership.

We therefore invite nominations for the posi-tions of ENN trustees to comprise the ENNtrustee board. This is an unpaid role andrequires considerable investment of time, aswell as a strong sense of belief in the ethosand role of the ENN. The specific role oftrustees, as laid down by the CharitiesCommission, can be accessed athttp://www.charitycommission.gov.uk/recent_changes/CC3_the_essential_trustee.asp

Anyone who would like volunteer, make anomination or discuss this further can con-tact Marie McGrath, email: marie@ennon-line.net, tel: +44 (0)1865 249745, or JeremyShoham, email:jshoham@easynet.co.uk,tel:+44 (0)208 4469286

Call for Trustee Nominations for ENN

Men at work on gulley control inCFW programme in Somalia

Somalia, Oxfam GB/2005

News & Views

19

News

A CD-Rom of training materials on Infant Feedingin Emergencies is now available from ENN. BothModule 1 for emergency relief staff and Module 2for health and nutrition workers in emergency situ-ations are included, along with key documentssuch as the Operational Guidance for EmergencyRelief Staff and Programme Managers, and theWHO/UNICEF Global Strategy for Infant andYoung Child Feeding.

Feedback on use of the CD, suggestions on othermaterials to include, and requests for copies shouldbe sent to Marie McGrath, Emergency NutritionNetwork, Unit 13, Standingford House, Oxford,Ox4 1BA, UK. Tel: +44 (0)1865 722886/249745, email:ife@ennonline.net

Alternatively, you can make your own CD directlyfrom the following link on the ENN website:http://www.ennonline.net/ife/cddownload/index.html

New CD of IFE Training Materials

Concord is the Confederation of EuropeanRelief and Development non-governmentalorganisations (NGOs). Its 18 internationalnetworks and 20 national associations fromthe European member states represent morethan 1500 European NGOs vis-à-vis theEuropean institutions. It attempts toenhance the impact of development NGOsat European level, by combining expertiseand accountability and through presentingclear messages on trade and agriculturalpolicy to influence the institutions andmember state governments. Concord co-ordinates co-operation among NGOs inorder to influence political debate and poli-cy formulation on development andhumanitarian issues at EU level and pro-motes the political interests of EuropeanNGOs as strategic partners of the EU andthe Member States. It also strengthens thequality of NGO work, particularly regard-ing the relationship with civil society in theSouth; and contributes to capacity buildingat NGO level by stimulating new synergiesbased on sharing, co-operation and consul-tation.

The work of the Confederation is carriedout by its members, who are split into spe-cific working groups depending on theirexperience. These include groups on trade,aid, and the European Food Security Group(EFSG). The EFSG was convened by theEuropean network, EuronAid, and ischaired by Tom Arnold, Chief ExecutiveOfficer of Concern and member of theHunger Task Force of the UN.

The establishment of the EEFSGAt the beginning of 2005, the EFSG ‘ear-marked’ the year as heralding in a criticalperiod for the future of food security policy,given the World Trade Organisation (WTO)negotiations in Hong Kong, the reorganisa-tion of EU budget lines, and developmentswithin the World Food Programme (WFP).With these in mind, it acted decisively andswiftly in establishing a specialised taskforce on emergency food security issues, theEuropean Emergency Food Security Group(EEFSG). The EEFSG is a small and focusedgroup of food security and nutritionalexperts, drawn from NGOs with directoperational experience of emergency foodsecurity – Save the Children UK, ActionContre la Faim, Concern, Oxfam andGerman Agro-Action.

The ultimate objectives of the group are toinfluence policy debate and formulation atthe highest levels, and to promote betterpractice and analysis of emergency foodsecurity situations - by both NGOs andinternational agencies. Though still in itsinfancy, the group has already played animportant role this year in feeding into theWFPs new strategic plan, and has alsoestablished links with other key stakehold-ers in the field.

Dublin meetingThe EEFSG meets on average four times a

year, with the latest meeting taking place inConcern’s headquarters in Dublin onWednesday September 7th 2005. This meet-ing was convened by the members in orderto focus on a number of current key foodsecurity issues. In particular, the groupaddressed the increased promotion ofSchool Feeding Programmes (School FPs)by international donors. In the discussionon School FPs whilst the members did notrule out the use of them completely, theydid highlight a number of concerns theyhave:

• If School FPs ‘attract’ children to come to school in the short term, does the effect wear off in the medium to long terms.

• Some members felt that School FPs suffer from mixing nutritional and edu-cational objectives, and in the process fail to address either as well as spe-cialised programmes might do.

• It was suggested that real nutritional improvement could only arise as a result of an integrated package of sup-port in terms of water, sanitation and health.

• Whilst School FPs might increase both enrolment and attendance rates, they fail to address the underlying question of education quality.

A previous DFID study made the point thatthe potential for catch-up growth amongstunted school children is thought to be lim-ited after two years of age, which supportsthe argument for early community inter-vention (ECCD) prior to enrolment in for-mal education. Furthermore, it was ques-tioned whether the objectives of School FPswould not be better served by groundingthem within programmes which addressednutritional and educational issues withinthe community as a whole.

As there is a dearth of critical analysis ofSchool FPs - making informed debate on theissue difficult, the group agreed to conductfurther research and analysis of School FPsbased on their respective organisationalexperiences, before coming to any definitiveconclusions.

In the same meeting, the EEFSG alsoaddressed the donation of food aid in theform of cash, given that it is being used byincreasing numbers of NGOs. In particular,the impact of cash transfers on local marketsand regional economies was discussed. Atthe moment, the group is monitoring anumber of on-going cash transferring stud-ies.

The group also went on to address the issueof food aid disciplines within the WTO andthe Food Aid Convention, and the future offood aid from the EU. They discussed thepossibility of developing a common posi-tion on food aid, and finding greater com-mon ground with American NGOs.

The next meeting of the EEFSG is scheduledto take place in London on December 9th2005.

For further information, contact Concord atemail:secretariat@concordeurope.org

European Emergency FoodSecurity Group (EEFSG)

Complementary feeding of older infants and youngchildren continues to present a real challenge tofield workers. Practical questions typically faced inthe field by nutritionists working in developingcountries include:

• Is it possible with locally available food to provide all nutrients needed by a young child?

• What quantity of nutrient rich foods are neededto provide all micronutrients?

• If this is possible, how much will it cost? • What food combination is best adapted to

provide all needed nutrients at the lowest cost? • Are micronutrient supplements or fortified

foods useful to feed a child a balanced diet at low cost?

Now, adapting local foods to meet nutrient needscan be aided by a mathematical tool, linear pro-gramming. The user-friendly programme (LinearProgramming Module of Nutrisurvey) can bedownload athttp://www.nutrisurvey.de/lp/lp.htm and allowsyou to design diets compatible with local foodhabits and fulfilling different sets of nutritionalrecommendations, at the lowest possible cost.Nutritional recommendations incorporated aredefined for the following age groups: 6-8 months,9-11 months, and 12-23 months.

For further information, contact André Briend,Medical Officer, Department of Child &Adolescence Health and Development, WorldHealth Organization, Genèva, Switzerland,email:brienda@who.int or Juergen Erhardt, SEAMEO-TROPMED, University of Indonesia,Jakarta, Indonesiaemail: mail@nutrisurvey.de

User Friendly Softwareto Design Low CostComplementaryFeeding

This overview of the EEFSG and report on therecent Dublin meeting was prepared by NiallCassidy, Concern Worldwide, in consultationwith the meeting participants.

20

With a view to providing the internationalcommunity with more analysis on theworldwide occurrence and impact of disas-ters, the Centre for Research on theEpidemiology of Disasters (CRED) haslaunched its first newsletter. Titled CREDCRUNCH, the first issue presents analyseson the occurrence and impact of natural dis-asters in 2004, focusing in particular on theTsunami disaster. It also introduces the EM-DAT database – a compilation of naturaland man-made disasters since 1900, withinformation on each disaster’s characteris-tics, human and economic impact.

The database is validated and updated reg-ularly and can be fully accessed, alongwith the newsletter, at http://www.em-dat.net

All comments and suggestions on thenewsletter, including the types of analysesthat readers would like to see, are wel-come. For any feedback or enquiries, email: cred-crunch@em-dat.net

New CREDNewsletter onDisasters

Many private voluntary organisations (PVOs)are engaged in projects aimed at improving foodsecurity and household nutrition worldwide.Increasingly they are being asked to monitor andevaluate the impact of their interventions.FANTA has completed the 2005 revised editionof Measuring Household Food Consumption: ATechnical Guide. The guide describes the processand procedures for collecting information toassess the food-intake requirements of a house-hold and a step-by-step analysis of the food con-sumed. The newly revised Appendices also pro-

New FANTA Technical Guide on MeasuringHousehold Food Consumption

News

As part of its project on 'Southern Voices forChange in the International Aid System', theOverseas Development Institute (ODI) in the UKhas launched a virtual Forum on the Future ofAid (FFA), dedicated to research and opinionsabout how the international aid system currentlyworks and where it should go next.

The Forum is a discussion network, with expertresearch, briefing and consulting support, dedi-cated to the international aid system and how itevolves over time.

Forum on the Future of Aid

Southern perspectives and proposals for reformare particularly welcome.To learn more and get involved, visit the FFAsite at http://www.odi.org.uk/ffa/or contact: Andre Rogerson and Alina RochaMenocal, Centre for Aid and Public Expenditure(CAPE), Overseas Development Institute, 111Westminster Bridge Road, London SE1 7JD,UK,email: ffa@odi.org.uk

The Child and Adolescent Health Departmentand the Department of Nutrition for Health andDevelopment of WHO, in collaboration with theStanding Committee for Nutrition of the UnitedNations, have begun the process to formulaterecommendations on the community based man-agement of severe malnutrition. This has largelycome about with the increased attention on com-munity based treatment over the last five yearswith the development of Ready to UseTherapeutic Foods (RUTF).

As part of this process, an evidence database isbeing systematically compiled, building on thefindings of a previous literature review made in2001 for WHO1 and a recent initial literaturesearch. The team is calling for relevant studies toadd to these. Priority is given to studies pub-lished in peer reviewed journals, however, WHOcan assist in the preparing for publication the

Collecting Evidence for Community BasedTreatment of Severe Malnutrition

1 Community based rehabilitation of severely malnourishedchildren: a review of successful programmes. Ann Ashworth,London School of Hygiene and Tropical Medicine, July 2001.Available from email: prudhon@who.int

results of relevant but still unpublished studies.

This evidence gathering is not limited to agencieswith community based programmes using RUTF- contributions from other agencies using differ-ent community based programmes to treatsevere malnutrition are welcome.

To find out more and take part in this process,contact Claudine Prudhon, United NationsSystem Standing Committee on Nutrition, c/oWorld Health Organisation, 20 Avenue Appia,CH 1211 Geneva 27, SwitzerlandTel: +41-22-791-34-81, Fax : +41-22-798-88-91,Email: prudhonc@who.int, scn@who.int

WHO GuidingPrinciples onFeeding Non-BreastfedInfants

WHO has just issued a booklet, Guidingprinciples for feeding non-breastfedinfants, 6-24 months of age, which pro-vides health workers with a grounding inthe principles involved in designing andsafely feeding diets to young non-breastfedinfants. The content includes sections on:

• food consistency, meal frequency, and energy density

• nutrient content of foods• use of vitamin-mineral supplements

and fortified foods• safe preparation and storage• responsive feeding, and• feeding during and after illness.

The annexes contain practical advice ondeveloping locally appropriate feeding rec-ommendations based on these GuidingPrinciples, and addresses key issuesaround early breastfeeding cessation, andfeeding young children of HIV-positivemothers.

The publication is available online athttp://www.who.int/child-adolescent-health/New_Publications/NUTRITION/ISBN_92_4_159343_1.pdf For further information, contact:Department of Child and AdolescentHealth and Development (CAH), WorldHealth Organization, 20 Avenue Appia,1211 Geneva 27, Switzerlandtel + 41 22 791 32 81, fax + 41 22 791 48 53, email: cah@who.inthttp://www.who.int/child-adolescent-health

At the IFPRI conference on HIV/AIDS and Foodand Nutrition security in Durban in April 2005,preliminary work was presented on capturingand documenting community driven initiatives(CDI), and was well received by those attending.Building on an initial call for a web-based livinginventory, the Food and AgricultureOrganisation (FAO) have renewed an invitationto stakeholders to become involved and sharetheir knowledge on community driven initia-tives. Based on the response, FAO will decide ifthere is sufficient interest to continue this effort.

In responding, the type of information toinclude is:• Where is the Community Driven Initiative

(CDI) taking place?• Describe the CDI

Renewed Call to Share Knowledgeon Community Driven Initiatives

• What was the trigger for the CDI?• Who is participating or driving the response

(specific groups, NGOs, CBOs, churches etc) • Are there specific target groups or people

involved? • If possible, indicate how may people or

households are covered under the initiative.• When did the CDI start?• What are the enabling factors that have

helped the CDI succeed? • What are the constraining factors that have

hindered the CDI?

Feedback should be sent to Josee Koch, FAORIACSO Johannesburg, HIV/AIDS and FoodSecurity programme officer. Tel: +27-11-5171670, Cell: +27-83-2910720,Email:Josee.Koch@fao.org

vide detailed information about analysing thedata.

Copies of the publication can be downloadedfrom the website athttp://www.fantaproject.org, or can beobtained from: Food and Nutrition TechnicalAssistance Project (FANTA), Academy forEducational Development, 1825 ConnecticutAvenue, NW, Washington, D.C. 20009-5721Tel: 202-884-8000, Fax: 202-884-8432, email: fanta@aed.org

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This article details current negotiations in theWorld Trade Organisation (WTO) on improvingthe effectiveness and efficiency of food aid, based onresearch undertaken by Oxfam GB.

The last months of 2005, and 2006, pro-vide unprecedented opportunities toshape the future of food aid.Negotiations at the World Trade

Organisation (WTO) on agriculture in 2005include a review of food aid disciplines, whichwill influence the review of the Food AidConvention (FAC), postponed pending theWTO outcome. WTO rounds are only launchedonce every 15 years or so, and the Food AidConvention was last revised in 1999. The finalWTO ministerial meeting is in December 2005,but negotiations are on-going until then. Thisarticle presents some of the issues, and Oxfam’sposition, on the disciplining of food aid underthe WTO. Others who have put forward sug-gestions or concerns on the WTO food aid dis-ciplines include the Coalition for Food Aid(CFA) in the US, WFP, World VisionInternational (WVI) and the EuropeanCommission (EC). This article is intended tostimulate discussion, and to provide the start-ing point for developing a common NGO posi-tion on the WTO food aid disciplines.

The WTO negotiations on food aid are of rele-vance to NGOs operating on the ground,because these negotiations could change theway in which food aid is provided. Heated dis-cussion is taking place around the role of tiedfood aid, monetisation, and the role of localpurchase (see box for key terms used and keyactors involved). Any change in these aspectswill affect ration size and composition, thespeed of delivery of emergency food assistance,as well as potential impact on production, mar-kets and trade. The emergency nutrition com-munity should have an input in this debate.

Current practice on the tying of food aid Tied food aid is defined as “….aid which is, ineffect, tied to the procurement of goods and/orservices from the donor country and/or arestricted number of countries”. In 2004, 74% offood aid was tied aid, 12% were triangulartransactions (purchase in neighbouring coun-tries) and 14% were local purchases. Australia,Canada, China, and South Korea provided over80% tied aid. The US provided 56% of food aidcommodities by volume, of which 99% weretied or sourced in the US. Other donors collec-tively sourced 42% in the donor market1.

For the first time in half a century, there are seri-ous, high level discussions in the US andCanada for, at least, the partial untying of foodaid2. Earlier this year, the US government pro-posed to reduce PL480 Title II food aid by £300million (a quarter of the budget) and establish

an International Disaster and FamineAssistance account of equivalent value, “to per-mit USAID to provide food assistance in themost timely and efficient manner to the mostcritical emergency situations”. This proposalappears to be headed for defeat in Congress, asit ran into fierce opposition from agriculturaland shipping interests. The CFA, a coalition ofUS NGOs, proposed a pilot programme thatwould only go forward if Congress appropriat-ed extra money for food aid3.

What are the consequences of tied aid?It makes it difficult to meet the minimumstandards on food aidThe Sphere minimum standards on food aidstate that to meet nutritional needs, generalrations must provide access to a range of foods,access to micro-nutrients, and eliminate theneed for affected people to adopt negative cop-ing strategies. Food items must be appropriateand acceptable to recipients, and can be usedefficiently at household level. Furthermore, theintroductory section to the food aid chapterstates that, “food commodities are importedonly when there is an in-country deficit or nopractical possibility of moving available sur-pluses into the disaster affected area4.”

Whilst tied aid is not the only problem in ensur-ing that minimum standards are met, it makesit more difficult for the following reasons:

• It takes up to 4-5 months for food pur-chased in the US to arrive in the recipient country. If people are totally dependent on food aid in the early stages of an emer-gency, this can lead to high rates of malnu-trition, mortality, and the adoption of damaging coping strategies.

• Commodities are not always culturally appropriate, so disaster affected populationsmay not know how to prepare the foods.

• Rations may be nutritionally inadequate, as they are often dominated by cereals. Pulses,oil, and blended foods are notoriously difficult to resource.

• Foods are often unprocessed or unfortified, which means that disaster affected popula-tions have to make their own arrangements for milling of cereals.

• Food aid recipients are more likely to sell unfamiliar food commodities to buy other foods (as well as to buy other basic items, and to pay for milling), making tied food aid an inefficient way of meeting food needs.

It is an inefficient method of providing food aidTied aid is a very inefficient way of providingdevelopment assistance. The cost of tied directfood aid transfers is, on average, 50% more thanlocal purchase, and 33% more costly than pro-curement of food in third countries5. Untyingfood aid would lead to a saving of approximate-ly $750 million6.

Tied food aid can have negative impacts onmarkets and trade There is strong evidence that food aid displacescommercial imports in recipient countries. Inmarkets that are relatively open, food aidimports result in the displacement of othercommercial imports. Demand is thereforereduced for commercial imports. Food aid hasbeen found to be associated with long termincreases in imports by beneficiary countries of

WTO Negotiations on Improving Food AidBy Susanne Jaspars and Chris Leather, Oxfam GB

Susanne Jaspars was the team leader for Oxfam'semergency food security and livelihoods teamfrom October 2002 to June 2005. She has workedin emergency nutrition, food security and liveli-hoods since 1987 for a number of agencies andhas published widely on the subject. Susanne con-tinues to support Oxfam's food aid advocacy workon a consultancy basis.

Chris Leather is the current team leader for OxfamGB's emergency food security and livelihoods team. He has worked in emergencyfood security and livelihoods since 1987 for ActionAgainst Hunger and now Oxfam.

1 OECD (2005). The development effectiveness of food aid.Does tying matter? 2 Barrett, C. (2005,April). Food Aid At A Crossroads; theShared Challenge that NGOs face.3 Burley, N. (2005, September 22). In places where the hungry are fed, farmers may starve. New York Times.4 The Sphere Project, 20045 See footnote 16 Overseas Development Institute (2005, September 26).Statement made for the record at a meeting on Food Aid andthe Doha Round Process, by Simon Maxwell, Director.7 Barrett, C. and Maxwell, D (2005). Food aid after fiftyyears: recasting its role. Routledge, UK, and footnote 18 See footnote 7

commodities supplied as US food aid7. Late arrival of food aid in country may mean itarrives during harvest time, and therefore low-ers market prices and the income of farmers.This may increase vulnerability and the needfor on-going assistance.

The form of food aid which has the most directtrade implications is programme food, which isaid provided as budget support, for example inthe form of concessional sales. It is direct bilat-eral (government to government) aid.Programme food aid provided by the US hasthe explicit objective of creating overseas mar-kets.

Is tied food aid needed for development projects?There are two types of project food aid. First,projects which use food aid for direct distribu-tion to beneficiary groups, such as food forwork, maternal and child health, school feedingand the establishment of strategic grainreserves. Second, commodities are sold (mone-tised), and the local currency is used to promotepoverty reduction and food security initiatives.In 2002, about half of all project food aid, chan-nelled through NGOs, was monetised. There isa lack of monitoring and evaluation of projectfood aid, but findings on the impact of projectfood aid range from moderately positive toextremely negative.

Food aid that is monetised is not targeted atthose most in need and is, therefore, more like-ly to have negative impacts on markets.Furthermore, NGOs monetise food aid to beable to fund development projects, which is anextremely cumbersome and inefficient way offunding development programmes.

The role of local purchaseWhen food aid is available in other parts of thedisaster affected country, or in neighbouringcountries, local purchase could potentially pro-vide a quicker and cheaper response, as well asproviding commodities which are more cultur-ally acceptable to the affected population. Inaddition, it would support the local economy. Acomputation of the statistical correlationbetween nations’ annual per capita productionof cereals with that of their neighbours foundthat there was the potential for expanding trian-gular transactions8.

Local purchase must be preceded by carefulassessment of local markets, to make sure thatthis does not lead to price increases for con-sumers in the areas where the food purchased.In some situations, local purchase may be diffi-cult because of limited suppliers, quality of thelocal products, trader reliability, or weak trans-port and infra-structure.

The role of WTO in reforming food aid Currently, food aid is not subject to tight disci-

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Emergency food aid: the distribution of gen-eral food rations, supplementary and thera-peutic feeding, to meet the food needs ofemergency affected populations.

Project food aid: development projectswhich use food aid to food security and whichhave a number of other non-food relatedobjectives. Projects include food for work,school feeding and vulnerable group feedingthrough MCH clinics.

Programme food aid: aid provided as budg-et support, for example in the form of conces-sional sales. It is direct bilateral (governmentto government) aid.

Monetisation of Food Aid: the sale of foodaid commodities on the market. The local cur-rency is then used to fund development proj-ects.

Tied food aid: Aid which is tied to the pro-curement of goods and/or services from thedonor country and/or a restricted number ofcountries.

Key terms, regulations, and players in international food aid

In kind food aid: Imported food aid, whichcan be tendered on international markets.

Food Aid Convention (FAC). Conventionaimed at guaranteeing a predictable flow offood aid every year. The signatories made min-imum annual commitments. The FAC wasdeveloped in 1967, and is periodically updatedwith the latest version agreed in 1999. TheFAC was scheduled to be re-negotiated in2002, but has been put on hold pending actionon food aid disciplines at the WTO. The 1999FAC sets minimum aggregate commitments at5.5 MT, whereas originally minimum commit-ments were set at 10 MT.

Coalition for Food Aid (CFA). Established in1985, a Washington based lobby group thatrepresents 14 US NGOs.

US Public Law 480 (PL 480). Originatesfrom 1954 with three ’titles’, each facilitatingdifferent kinds of food aid; title I and II areexplained below. Title III has not been usedrecently.

9 Oxfam International (2005, March). Food aid or hiddendumping? Separating wheat from chaff. An Oxfam briefingpaper. Oxfam.10 Levinson, E. Executive Director for the Coalition for Food Aid(2005, June 13). Letter to Portman, United States TradeRepresentative, Office of the President. Put on congressionalrecord on 16 June 2005.11 European Commission (2005, June 18). Proposal on ExportCompetition: key “building blocks” for parallel export subsidyelimination commitments.

What is the way forward? Recommendations on food aid disciplines wouldbe much more powerful if they were the result ofa shared NGO vision on the role of food aid.

Oxfam acknowledges some of the concernsexpressed by other agencies on the discipliningof food aid. Oxfam are aware that the US CFA hasrecommended that none of the forms of food aidshould be excluded or limited in WTO DohaRound Negotiations (i.e. the current negotia-tions), but that the WTO should focus on the oneaspect of food aid related to trade interests. . Incontrast, the EC recommends the elimination ofall tied food aid, to be replaced by more flexibleresponse mechanisms, in other words to promotethe local purchase of food aid . Oxfam recognisethat the majority of food aid is currently provid-ed in tied form, and that the food aid provided inmany emergencies is currently insufficient tomeet the estimated needs. Tied food aid cannotbe reduced substantially overnight.

Any reduction in tied aid would need to beaccompanied by cash resources to purchase atleast an equivalent amount of food aid. Thelower cost of local purchase would, however,mean that the funds required to purchase anequivalent amount of food aid locally would bemuch lower. Furthermore, the emergency sectorcurrently do not have the market assessmenttools, nor the capacity, to carry out local purchas-es on the scale that would be required, if the newdisciplines are adopted. The recommendationsfor new disciplines would need to be phased ingradually. We hope that this short article can bethe starting point for developing a commonNGO vision.

For further information, contact Chris Leather,email: CLeather@oxfam.org.uk or SuzanneJaspers, email SJaspars@oxfam.org.uk

To contribute to this debate, contact the authors,or ENN at email: office@ennonline.net

Oxfam believes that food aid is most needed inhumanitarian crises, and that the objective ofgiving food aid in a crisis situation should be toalleviate malnutrition, to meet immediate foodneeds and to protect livelihoods. Oxfam alsobelieves that the value of project food aid (foodfor work, school feeding, vulnerable groupfeeding) to support specific poverty alleviationand disaster prevention activities is limited,and that this should be discouraged as part oflonger term development projects. Food aidcan be useful in development contexts as partof social safety nets and livelihood protectionand recovery in slow onset disasters. In mostcases, cash based programmes or funding fordevelopment programmes is a more effectiveway to address food insecurity. Food aid can-not be a substitute for sustainable develop-ment, policy and belief change, which togethercan reduce hunger in the world in the long-term.

In many humanitarian disasters, cash is a moreappropriate response to meet people’s foodneeds than food aid. Cash transfers (cashgrants, cash for work, or vouchers) should beprovided to meet food needs in situationswhere food crisis is a problem of people’s abil-ity to purchase food, and not of food availabil-ity. Providing cash to meet food needs is onlypossible where food markets are functioningand accessible.

Sourcing of food aid, in order of preference,can therefore be summarised as follows:

Order ofpreference

Option Criteria of appropriateness

1

2

3

4 In-kinddonations bydonor coun-tries

• Cheaper and quicker than alternatives

• Meet requirements of recipient countries in terms of type of food, GM content, etc.

• Food available regionally • Cheaper and quicker

than alternatives

Provide cashdirectly tobeneficiaries

• Food available locally• Markets are functioning

Procurementin recipientcountry

• Food available nationally • Cheaper and quicker

than alternatives

Procurementin region

plines under the WTO Agreement onAgriculture, and rules governing food aid arenot subject to dispute settlement. The Food AidConvention has not been effective in regulatingthe provision of food aid, as it lacks a bindingenforcement mechanism and dispute settle-ment body. New disciplines on food aidthrough the WTO, a widely accepted interna-tional legal instrument, could have the advan-tage of providing a well established adjudica-tion process and will facilitate legitimate foodaid, while restricting the abuses of food aid.The current negotiations about the revision ofthe WTO food aid disciplines, therefore, pro-vide a unique opportunity to improve the wayin which emergency food aid is provided. Apotential drawback, however, is that the WTOdoes not have institutional expertise in foodaid.

Oxfam’s position on these issuesOxfam International has recommendedstronger food aid disciplines as part of theWTO agriculture agreements. The recommen-dations are as follows:

• Food aid is provided exclusively in grant form (i.e. no food aid sales on a concession-al basis).

• Food aid should not be linked, either explicitly or implicitly, to commercial trans-actions or services of the donor country.

• The use of in-kind food aid (some of whichcan be sourced in donor countries) should be limited to situations of acute local food shortage and/or non-functioning local food markets, where regional purchase is not possible. In other situations, food aid should be provided in cash form, to purchase food locally or regionally.

• Monetisation of food aid should be limited and replaced with cash donations, to avoid displacement of local production or commercial imports.

• Food aid should only be provided in response to calls from national govern-ments, specialised United Nations agencies,other relevant regional or inter-governmen-tal agencies, non-governmental human-itarian organisations, and private charitablebodies.

• All food aid transactions must be notified in a timely manner to the Food and Agriculture Organization of the United Nations (FAO) and WTO.

• Title I provides ’programme’ food aid to recipient governments. Most Title I food aid is provided in the form of concessional sales, rather than in grant form. Title I is administered by USDA and has a strong emphasis on expanding US export markets.All Title I food aid is monetized. This is thetype of food aid most likely to be eliminat-ed under WTO, but only forms a minority of overall food aid.

• Title II is administered by USAID, and provides for the donation of US agricul-tural commodities to meet emergency andnon-emergency food aid needs. NGOs, theWFP, and governments are eligible for TitleII food aid. As much as 70 per cent ofnon-emergency project food aid is mone-tised by NGOs or recipient governments tofund development projects.

Note that there are four other US food aid programmes,three of which are administered by USDA, including foodfor progress and the McGovern-Dole International Foodfor Education and Child Nutrition Programme.

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A word from ENN

In Issue 23 of Field Exchange, a letter by Mary Lunga'ho, Lida Lhotska and Rebecca Norton was published highlighting concernsthey had regarding potential ENN conflict of interest, with particular reference to the company Nutriset. Nutriset responded with aletter that was published in Issue 24. Linked with this, a letter was submitted to ENN from Noreen Prendiville, published here, rais-ing her concerns. Further communications around this have established that all agree the key issues raised would benefit from awider, open airing and debate. To this end, a selection of people whom we thought would have an interest and an opinion on thesubjects raised, were invited to submit an opinion to ENN. Three responded and their perspectives are published here. We hope thatthese mark the beginning of an ongoing discussion in which the Field Exchange readership will actively participate. Anyone whowould like to feedback, offer an opinion or comment, should email the ENN at marie@ennonline.net.

Dear Editors,

As a follow up to the letter from R. Norton, M.Lung’aho and L. Lhotska in Issue 23 of FieldExchange (FEx), I would like to also express myconcern about the ever increasing prominencegiven to commercial products in the articlespresented in FEx on management of severemalnutrition, and the relative absence of ideasand research on alternative approaches.

Few will argue with the fact that managementof severe malnutrition has benefited from sub-stantial research and private sector involvementin recent years; with guidelines for improvedregimes and increasing availability of commer-cially produced foods. These have no doubthelped to decrease mortality and morbidity inacute emergency settings where externalresources are available, and have allowed inter-national non-governmental organisations(INGOs) to reach a Gold Standard in the man-agement of severe malnutrition during the peri-od of their intervention.

However, typically in the Greater Horn ofAfrica, only the very peak period of an ‘emer-gency’ attracts external attention and interven-tions. High levels of severe malnutrition arepresent before INGOs arrive and continue longafter the INGOs have left. For the periods whenlocal health services have to manage with mini-mal support, little is available in terms ofguidelines, support or training, to ensure ade-quate management of severe malnutrition. It isnot a coincidence that areas experiencing con-tinued high levels of severe malnutrition todayare also those with the lowest levels of humani-tarian access. Much as we might hope that thissituation will change, it is unlikely to do so ade-quately in the near future. In the meantime,concerted efforts are needed to support thepreparation of appropriate foods at householdor health facility level. We should ensure thathealth workers are well convinced that ‘new’,imported, packaged foods while wonderful, arecertainly not essential.

Technical recommendations of INGOs, publica-tions etc. will have far greater credibility in theHorn of Africa and will certainly have thepotential for wider application if de-linkedfrom branded products. Nutrition profession-als, publications and INGOs need to ensure thattheir efforts to provide a Gold Standard do not,in any way, undermine the existing Silver andBronze Standards.

Finally, I believe that we ‘do harm’ when weconvince local health workers that externallysourced food products are essential in the man-agement of severe malnutrition in situationswhere long term uninterrupted access to theseitems cannot be guaranteed. While I fullyappreciate the driving force behind the recentdevelopment in management of severe malnu-trition, I urge INGOs to support existing capaci-ty to manage severe and moderate malnutritionin a sincerely sustainable way and to exerciseextreme caution in the marketing of foods notreadily and consistently accessible in resource

poor communities. Field Exchange can con-tribute very positively by ensuring thatresearch and articles on severe malnutritionrepresent the majority of those involved in thisfield, who are located in resource poor coun-tries. This is not at all an argument againstthese new special foods, but a call for a morebalanced approach.

Your interest in broadening this discussion hasbeen greatly appreciated.

Noreen PrendivilleFood Security Analysis Unit, FAO Somalia

This letter represents the views of the author anddo not necessarily represent the views of FAO.

Dear Editors,

In issue 23 of Field Exchange, a letter byLunga'ho, Lhotska, and Norton was publishedhighlighting their concerns regarding a poten-tial conflict of interest, with particular referenceto the private sector company Nutriset that pro-duces and markets a ready-to-use therapeuticfood (RUTF) under the brand name ofPlumpy'nut.

Lunga'ho, Lhotska, and Norton do not take astrong ideological position with regard to theinvolvement of the private sector in humanitar-ian interventions. This is both sensible andpragmatic. Without the private sector, wewould be severely restricted in our work. Manyinternational NGOs receive preferential termswhen purchasing essential services and itemssuch air travel, vehicles, and communicationequipment from large multinational corpora-tions. Even without such preferential terms,many such items would still be sourced fromthese, or similar, corporations. In addition,numerous private sector companies have beenestablished that receive the bulk of their profitsfrom trade with the humanitarian community.Many NGOs purchase items such as airlinetickets and insurance from such companies.

The difference between these companies andNutriset is that none of these companies has amonopoly position in the marketplace. NGOscan source products and services from a varietyof competing suppliers but, at present, mustsource RUTF through Nutriset or one of theirpartners. Nutriset hold a patent not just on thespecific formula for their Plumpy'nut product,but on spreads and pastes used as RUTFs. Thecompany's website clearly states:

‘Plumpy’ type products are covered by an IRD/Nutriset patent.

Nutriset have shown themselves to be bothwilling and able to enforce this patent. Thissuggests that Nutriset is seeking to maintain amonopoly position with regard to any and allsimilar products. It is generally accepted thatwhat is good for a monopolist is bad for con-sumers and the consumers in this case are chil-dren in extreme need.

The economic rationale for seeking and main-taining a monopoly position is to maximiseprofits through the maintenance of high pricesenabled by the suppression of competing prod-ucts. It is fair, however, to consider whetheranother rationale may be informing Nutriset'sactions with regard to patent enforcement. Theobvious consideration is the desire to ensurethe quality of RUTF. This is clearly an impor-tant issue but it should be considered whethermonopoly is the only way of ensuring this.Certification of quality of generic RUTF prod-ucts by an independent standards body is analternative that merits consideration.

Quantity, as opposed, to quality is also animportant issue. Monopoly of large-scale pro-duction of RUTF entails risk with regard to con-tinuation of supply. It is not clear that Nutriset'smodel of maintaining a monopoly of large-scaleproduction at one location, principally for usein emergency contexts, whilst allowing small-scale local production in developmental con-texts is one that can provide continuation ofsupply or supply sufficient quantities to meetneed in large-scale emergencies.

These concerns are not new. They have beenraised in international meetings at which ENN/ Field Exchange workers have either beenpresent or have been responsible for recordingand publishing proceedings. It has to be a mat-ter of concern to readers that ENN / FieldExchange did not take the opportunity to reportthese concerns when they were raised and didnot specifically address these issues when visit-ing and interviewing Nutriset's management.Instead we were treated to a “puff piece” on acompany that, as far as RUTF is concerned, haslittle claim to being “an ideal model for poten-tial public and private sector partnerships”.

It is a matter of record that ENN / FieldExchange has accepted funding from Nutriset. Ithink we can assume that ENN / FieldExchange staff have also received hospitalitypaid for from Nutriset's marketing budget.Lunga'ho, Lhotska, and Norton suggest thatthis may have influenced the way Nutriset andtheir products are depicted in Field Exchange.To purchase such influence is the usual purposeof corporate funding and hospitality. WhetherNutriset sought and whether they succeeded topurchasing influence is something that we, asreaders, will probably never know. What isclear, however, is that accepting money from aprivate sector company and then failing toreport on a major issue regarding the conductof that company creates the perception of a con-flict of interest.

This is not an easy matter for ENN / FieldExchange to address. There is a potential forsimilar, perceived or otherwise, conflicts ofinterests to arise regarding any of ENN / FieldExchange's sources of funding. This could, per-haps, be solved by moving to a subscriptionmodel or by relying on advertising-revenue. Idoubt that a subscription model would be sus-tainable or cheap for individual readers andENN would probably have to rely on bulk sub-

Letters

24

Dear Editors,

I have read with interest the lively debateover the role of commercial products and thesustainability of interventions to addresssevere acute malnutrition. The central ques-tion underlying much of this debate is howcan effective interventions to treat severeacute malnutrition (SAM) be made sustain-able? The reason that these debates areincreasingly common is that the advent ofCTC using RUTF now provides a model thatoffers the potential to convert our theoreticalknowledge of how to treat SAM into effectiveand sustainable long-term strategies, even inthe poorest countries of the world. This repre-sents a major advance as hitherto, despiteinpatient clinical management protocols capa-ble of reducing case fatality rates to 1-5%being available for at least thirty years1 , casefatality rates in developing country hospitalstreating SAM continue to be at 20-30% andhave remained largely unchanged since the1950s2 .

To clarify some of the issues in this debate, Iwould first like to correct some misconcep-tions that appear in these letters. The CTCmodel stipulates that wherever possible,intervention should work with or throughlocal capacity, strengthening communities’abilities to treat and prevent acute malnutri-tion. Although first trialled as humanitarianinterventions implemented by INGOs, CTC isincreasingly being implemented by localactors often through local clinics. CTC is only5 years old, but already its model of earlycase finding, simple outpatient treatment,peer support and the local production ofRUTF is looking to be sustainable over thelonger term. All longer term CTC pro-grammes that Valid supports are trying toevolve towards using locally manufacturedRUTF made either at the capital or better, atthe district level. As Noreen points out, inter-nationally procured Plumpy’nut is not onlytoo expensive but it also gives out the wrongmessages. I had to smile that the CTC SpecialSupplement edited by Tanya Khara andmyself, apparently gave the impression ofadvertising Plumpy’nut3. In reality, I am adirector of Valid Nutrition, a not for profitcompany producing and developing RUTFproduction in several developing countries indirect competition with Nutriset andPlumpy’nut. We obviously have a lot to learnabout advertising and branding!

We set up Valid Nutrition because we alsoshare Noreen’s view that uninterruptedaccess to quality therapeutic products is vitalif programmes to treat acute malnutrition areto have long-term impact. The success of theCTC approach is dependant upon the avail-

ability of cheap, effective, locally producedtherapeutic products and whilst Noreen iscorrect is stating that these can be made inpeople’s houses from local ingredients, theevidence from the past 30 years indicates thatthis is seldom achieved in practice. Therefore,in addition to the more traditional strategy ofpromoting the use of nutritious local foodwithin people’s homes, I believe that we mustengage and support local businesses andfarmers to develop economically viable localproduction of RUTFs. I do not see a conflictbetween the two strategies and believe thatadding value to local crops by convertingthem into RUTF in local clinics (as happens inMalawi, for example) and delivering themthrough the local health infrastructure is com-pletely compatible with Noreen’s vision ofsustainable and effective treatment thatempowers people and communities.

However, for local RUTF to be both as cheapas possible and economically viable andtherefore sustainable, there must be free com-petition to drive the price of RUTF down andlocal RUTF manufacturers must have freeaccess to markets.

Nutriset’s plans for a franchised group of pro-ducers as outlined in their recent letter4 to theENN, will help to increase the number oflocal producers and should help increaseaccess to quality RUTF. However, a singlefranchise is still a monopoly and still runs therisk that prices can be maintained artificiallyhigh. Other independent producers or net-works of producers are necessary in order tointroduce the cost benefits of real competi-tion. To that end, Nutriset’s public undertak-ing in Washington5 not to contest the rights ofcompetitors to produced RUTF for humani-tarian use, is in reality more important.Nutriset should be commended for takingthis step. I feel that this very positive devel-opment is the direct result of the engagementbetween private business and the not forprofit sector of which the ENN has been animportant part. I see great potential for thiscooperation to produce further lasting bene-fits to the lives of the poorest people of theworld and although we of course, must bewary of conflicts of interest, I think that weshould see things in perspective. By itsnature, the ENN tends to attract contributionsthat serve both to inform and to advertise.Agencies, whether they be NGOs, UN or pri-vate companies, like to write about their suc-cesses and their innovations. These articlesserve both to inform but also to advertise theagency to their customers, whether these cus-tomers be donors, the public, governments orthe NGOs. It is a great shame that few havethe confidence to write about their failuresand this I believe is a more important factorundermining progress in international nutri-tion and humanitarianism. Indeed, if youonly read the ENN without going to emer-gencies, you’d happily believe that allhumanitarian interventions were innovativeand of the highest quality. Would that thiswere the case.

Steve CollinsCo-director

Valid International and Valid Nutrition

1 Golden M. The effects of malnutrition in the metabolismof children. Trans.R.Soc.Trop.Med.Hyg. 1988;82(1):3-6.2 Schofield C, Ashworth A. Why have mortality rates forsevere malnutrition remained so high? Bull.World HealthOrgan 1996;74(2):223-9.3 Steve’s comment refers to a point made in a circulateddraft letter by Noreen Prendiville, which flagged theprominence of the product Plumpy’nut in the ENN SpecialSupplement on Community Therapeutic Care4 See Field Exchange 24.5 CTC meeting, Washington, March 2005. Report availablefrom ENN online or email:office@ennonline.net

Dear Editors,

I am joining this discussion concerning the ENN,Nutriset, conflict of interest and the variety offoods used in response to nutritional emergenciesas someone who has taken care of thousands ofmalnourished children as patients in Malawi, andworked with, at central and regional levels, toimprove the outcomes and care of these unfortu-nate children. The discussion was prompted by anarticle in issue 22 of Field Exchange about Nutriset,and I also have personal experience of workingwith Nutriset.

The article itself profiles Nutriset as a company in avery favorable light and does not feature orendorse any product that they sell. The article isconsonant with my experiences and interactionswith Nutriset. I was not suspicious in reading thearticle that Nutriset was being unduly ‘promoted’.Conflict of interest refers to mutually beneficialrelationships between two parties that provide somany benefits that objectivity with regard to eachother is impossible. Often this involves the transferof monies and income between the two parties. Onan absolute level, conflicts of interest colour almostevery relationship we have in this world.Practically, it is those significant conflicts of interestwhere the truth is distorted that we need to guardagainst. ENN portrays itself as foremost an advo-cate for malnourished people, not a champion ofeither NGO or business interests. Thus, it is fair forreaders to ask the question, what is the relationshipbetween ENN and Nutriset, and it is completelyunderstandable that this question was raised giventhe cheery tone of the article in question. The co-directors of ENN have answered that the ENN hasaccepted a very modest amount of support fromNutriset, no more than from many NGOs. Theirannual report verifies this. The track record of ENNremains one of uncompromised support for vulner-able populations, and their reputation is not tar-nished by this questioning. Questions about con-flict of interest only damage the parties involvedwhen they are not forthcoming, and this is not thecase with ENN.

The problem of finding effective, lower cost, localfoods to therapeutically feed malnourished peopleis very important. 80% of the malnutrition world-wide is not associated with disasters, such as waror drought, but it is simply the result of grindingpoverty. Disasters attract the INGOs, and theymay appropriately bring imported, specialisedfoods with them. Malawi, the nation I haveworked in for 11 years, is not one wracked byarmed conflict or masses of people moving insearch of food and security, yet we estimate that13% of all Malawian children die before their fifthbirthday from lack of adequate nutrition. We obtainour therapeutic foodstuffs locally. Field Exchangecould be a forum where experience with localfoods is reported, even though Field Exchange isnot a scientific nutrition journal with institutional-ized peer review. Ways for ENN to highlight thisimportant element might be to have a dedicatedcolumn each issue where projects using indigenousfoods are described, or to collect several articlesand place them in a special section or issue.

To develop feeding regimens with local foods, Iwould encourage practitioners to use the WHOsupported linear programming tool available freeon the web athttp://www.nutrisurvey.de/lp/lp.htm. The tool isan excel spreadsheet. If one lists the locally avail-able foodstuffs on the sheet, the tool can determinethe amounts of these foodstuffs necessary to pro-vide a complete compliment of nutrients. This willgive an idea of what foods should be used togetherin the therapeutic diet. Of course edible prepara-tions of these foods must be made in local kitchens.

Mark Manary MDCollege of Medicine, University of Malawi

scriptions by its current donors. Advertisingis also problematic. If, for example, Nutrisetwere to regularly place a double page spreadto advertise their products, then the chargecould be made that ENN / Field Exchangewill not criticise Nutriset for fear of losingadvertising revenue.

Perhaps the best way is to keep things as theyare and rely on an active and informed read-ership to raise issues of conflicts of interest asthey arise. The fact that ENN / FieldExchange published Lunga'ho, Lhotska, andNorton's letter and have encouraged and arecommitted to further discussion can onlyreflect well upon their integrity.

Mark MyattInstitute of Ophthalmology

Letters

25

Field Article

A key component of the WFP programme inMyanmar has been community based targeting(CBT) as part of the vulnerable group feeding(VGF). As a member of the evaluation team,Jeremy was involved in discussions and interviewswith WFP staff and the UN ResidentRepresentative in Yangon, undertook field site vis-its in Maungdaw and Buthidaung Townships,northern Rakhine State, and Yenanchuang andPakokku, Townships, and Magway Division meet-ing with UNHCR and co-operating partner staff,Food Management Committee members, benefici-aries, and non-beneficiary community members.This article focuses on the CBT element of the pro-gramme and lessons learnt.

Community based targeting (CBT) offood aid in emergencies was initiallypiloted in the mid-1990s in eastAfrica. It grew out of early experi-

ences of community-based distributionswhich had been piloted in Uganda and Kenya.In CBT, the community is used to identify ben-eficiaries so that those who have the greatestknowledge about socio-economic factors inthe targeted communities identify the mostneedy. This approach is usually distinguishedfrom ‘administrative’ systems by the moreactive participation of the recipient popula-tion, rather than only its representatives, withthe aim of reaching mutually agreed andacceptable eligibility criteria. Thus eligibilitycriteria tend to be more subjective, complexand locally specific.

BackgroundThe Union of Myanmar comprises states anddivisions that include 135 ethnic groups in itspopulation of 50 million people. It is a ‘least-developed’ country and in 2003, ranked131/175 in the UN Human DevelopmentIndex. Myanmar is governed by a central gov-ernment and through military commandareas. The country is under sanctions, creating

difficulties in sourcing international aid. UNagencies are expected to provide assistancedirectly to communities and not through gov-ernment channels. National planning andbaseline information on population numbers,vulnerability, food insecurity, socio-economicstatus, adult literacy, school enrolment, healthand nutrition that is available is at a high levelof aggregation, and there are areas of the coun-try for which no data are available.

WFPs Protracted Relief and RecoveryOperation (PRRO 10066.2) in Myanmar hasproject sites in the northern part of RakhineState and Magway Division. Northern RakineState (NRS) is largely populated by peoplewho are ethnically Rohingya (82%) andMuslim, rather than Bamar and Buddhist thatmake up the central government and military.Approximately one quarter of the Rohingyapopulation of NRS (250,000 people) moved toBangladesh as refugees in 1991-2. Under anagreement between Bangladesh andMyanmar, all but 18,000 of these people havereturned to resettle in Myanmar in subsequentyears. Of the 18,000 who have not returned,around 6,000 have been recognised for returnby the Government of Myanmar (GoM) buthave not yet chosen to do so, mostly for eco-nomic reasons.

The central government creates and applieslaws differently to Rohingya and other ethnicgroups living in NRS. The movement, citizen-ship, taxation, trade and other aspects of lifefor the Rohingyas are made extremely difficultby the laws and informal and formal taxationto which they are subject. Returning Rohingyarefugees are granted Myanmar resident status.However, most other Rohingya people arestateless and without the protection of citizen-ship of Myanmar.

Magway Division is part of the dry zone ofMyanmar. Historically it receives only 500mmof rain per year, which is possibly decreasingbut insufficient data are available to confirmthis. The aridity severely limits crop and live-stock production and it may be that increasingnumbers of the population are seasonallymigrating from the Division to other parts ofMyanmar for employment.

The majority of the populations of NRS andMagway are chronically poor and have weak-ly developed social and economic infrastruc-ture. Like the rest of Myanmar, they areadversely affected by what most stakeholdersregard as inappropriate agricultural and eco-nomic policies of the central government. NRSand Magway Division are regarded by the UNCountry Team as amongst the parts of thecountry most vulnerable to poverty, unem-ployment and food insecurity. In January 2003,Action Contre la Faim (ACF) undertook ananthropometric nutritional survey in NRS andfound a prevalence of 16.4% global acute mal-nutrition (GAM) and 3% severe acute malnu-trition (SAM) in children under five in threezones. Rates of chronic malnutrition were63.6%. Furthermore, over half of mothers(52.1%, n=701) had a Body Mass Index of <18.5.

In NRS, government measures make themovement of food across military commandareas difficult as the authorisation procedureis slow and often does not work. This hascaused a number of pipeline breaks in WFPoperations and continues to seriously disruptthe PRRO.

CommunityBasedTargeting inMyanmar By Jeremy Shoham

In May/June 2005, Jeremy Shohamwas part of a WFP Office of Evaluation(OEDE) team which fielded a missionto Myanmar as part of a five countrycase study thematic evaluation of tar-geting in relief operations.

Beneficiaries inMagway divisionbuilding a village

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Recovering childwith mother inACF TFP in NRS

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Targeting structuresThe PRRO has the following components:• Protracted Relief for Vulnerable Groups

(6 months): refugee returnees (3,000planned), households headed by women, widows without support, orphans, elderly, chronically sick or disabled people (65,000 planned), and TB patients (2000 planned).

• Food for Education (FFE): take homerations for boys and girls enrolled in Grades 1 to 5 in 95% of the NRS primary schools

• Food for Training (FFT): a daily ration to off-set wage loss paid to people attending vocational skills training

• Food for Work (FFW): community activi-ties that enhance agricultural productivity, access to services or improved WATSAN, and woodlot construction.

Targeting in Northern Rakhine State (NRS)Geographic TargetingIn NRS, all three townships were selected forthe PRRO. The village tract selection wasbased upon an ACF food security survey cir-culated in November 2002.

Community Based TargetingCBT is the system employed for identifyingrecipients for the Vulnerable Group Feeding(VGF). The FFW programme beneficiaries arealso identified through the system, althoughthis does not involve the same degree of com-munity involvement. Up until 2004, themethod of targeting at community level,which had been employed for a number ofyears in NRS, involved a village meeting,organised by village elders, where WFP fieldmonitors outlined eligibility criteria. Villagerswere then asked to nominate beneficiaryhouseholds.

There were a number of problems with thisapproach. Many people were left out, the vil-lagers argued for an increased range of criteriain order to include more beneficiaries and cri-teria were not always adequately linked tofood security. Also, many villagers ‘felt’ thatthe community was not adequately involvedin the process and that there was too great aninfluence of village leaders in the process. As aresult, a new system was established in 2004.

This system involves WFP field monitors list-ing all the households in the hamlets and con-vening a village meeting (minimum of 50-60%must be present). WFP then suggest criteriafor inclusion of individuals in VGF. These cri-teria may be modified at the village meeting.Village participants are placed in one of threegroups that, in turn, allocate each householdin the village to one of four wealth categories(rich, middle, ordinary poor, and extremelypoor). These lists are then compared (triangu-lated) and, in order to qualify for inclusion inthe VGF, households/individuals have tohave been nominated as extremely poor in allthree lists. At this point WFP field monitorsvisit the households to ensure that nominatedhouseholds are extremely poor. This screeninginvolves assessing standard of dwelling, landsuse, livestock assets, furnishings and storedfoods. An assessment is also made of house-hold income and expenditure with a view tocalculating surplus/savings and debt.

In NRS, an estimated 12% of villagers areenrolled as extremely poor (data from only1800 households have been analysed at thetime of writing this article). A key difference inoutcome between the old and new system isthat the old system usually resulted in a 95%female headed beneficiary case load, whereasthe new system also includes many othergroups, e.g. landless, elderly with no support,physically and mentally handicapped, etc. sothat the female headed household case loadwill now be an estimated 80% of beneficiaries.In order to undertake this new form of CBT, anadditional 20 temporary field staff wererecruited and trained at a cost of less than$5,000. This represents a very small propor-tion of the total project costs that were origi-nally planned to be $12 million. The wholeexercise took approximately two months andinvolved approximately 400 hamlets.

Food for Work (FFW)FFW activities have also been targeted withinthe accessible, high vulnerability areas asidentified in the ACF food security survey.The household targeting element of the FFWprogramming employs an elected FoodManagement Committee (FMC). Each FMChas equal male and female representation. The

FMC are meant to first select the extremelypoor and then, resources and work permitting,the ordinary poor as workers. There is areported excess of demand for work while thetasks, which are mainly road building andpond renovation and therefore involve fairlyheavy work, predispose towards greaterinvolvement of men.

Monitoring To date, the monitoring of targeting has been aweak area of the programme with limited sta-tistical analysis. The main monitoring activityhas been to report on the number of benefici-aries and tonnages of food delivered for eachprogramme type. Targeting for the VGF hasbeen assessed by WFP to be 88% successful inidentifying the most vulnerable people in thecommunities. This is based upon the screeningprocess undertaken by field monitors to verifythat the communities’ beneficiary lists doinclude only those meeting the agreed criteriafor selection.

Targeting in Magway Division Geographic TargetingThe selection of townships was based on aranking exercise involving governmentdepartments (agriculture, livestock, educa-tion, development affairs, nutrition training),the private sector, and community basedorganisations (CBOs).Village tracts wereselected based on the findings of an assess-ment conducted in the six selected townshipsbetween 15th Nov 2004 and 7th Dec 2004. Thisassessment primarily utilised secondary datafrom government township departments andqualitative ranking by two key informantsfrom each village tract.

CBT methodologyAs this is the first year of a PRRO in MagwayDivision, WFP has benefited from the NRSexperience and is using the revised CBT sys-tem for VGF introduced this year in NRS. Fivenon-governmental organisations (NGOs) areimplementing the FFW through the creation ofa CBO or FMC of villagers. There appears tobe less adherence to targeting the poor andvery poor (compared with NRS) in FFW activ-ities, with a more relaxed policy of allowing allable-bodied person to work. The time spent by

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Field Article

Members of relief committee in NRS

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The European Commission’sHumanitarian Office (ECHO)recently conducted an evaluationto assess the appropriateness of

their interventions in the DemocraticPeople’s Republic of Korea (DPRK) since2001. The methodology involved examin-ing documentary research and interviewswith primary stakeholders. The evaluationteam spent three weeks in DPRK, withapproximately half the time on field visitsto ECHO-supported projects. AlthoughECHO have supported health, water, sani-tation, nutrition and food sectors duringsince 2001, this summary of the evaluationonly focuses on the findings in relation tothe food and nutrition sectors.

Since the beginning of the emergency in1995, international agencies have workedunder severe restrictions in DPRK withlimitations on access and very limitedaccountability. Agencies have generallybeen unable to work with technically qual-ified Korean counterparts, limiting oppor-tunities for training and capacity building.Analysis of overall food aid to DPRK inrecent years shows that political, ratherthan humanitarian, factors are the primaryreason for variations in donor contribu-tions. In DPRK, the food gap has officiallybeen determined by the annual cropassessment and the national nutrition sur-veys (1998, 2002 and 2004). Uncertaintiesabout the extent of the food gap are com-pounded by uncertainties about the extentof food aid, since food aid from China isnot made public and is invariably the sub-ject of considerable speculation. Themethodological limitations of crop assess-ments are widely recognised. As in manyother countries, the crop assessment inDPRK is largely based on figures providedby the government. In DPRK there is lim-ited information available and what isavailable should be treated with caution.Vulnerability analysis crucially dependson data obtained at a local level. A gooddeal of this has been collected informallyand/or unofficially by WFP in the courseof its extensive monitoring programme,though much of it remains unanalysed.

There are particularly positive aspects ofthe food aid programme. These includeimplementation of the targeting systemthrough institutions such as nurseries andkindergartens and the local production offortified food. The targeting system, whichis based on data made available by thegovernment, provides WFP with a pictureof the groups that require food aid, thoughnot complete beneficiary lists. The divisionof beneficiaries into groups also allows forthe adjustment of coverage, depending onfunding availability, and the centralisedsystem makes it possible to assume thatmost children will attend nurseries andkindergartens.

If economic reform and progress takes off,WFP may find it more difficult to justifythe need for food aid in the near future,whether or not the position of vulnerablegroups actually improves. Providing dataon the access to food of vulnerable groupsis more important than calculating thenational food gap, and the continuation ofWFPs programme will, in part, depend ontheir ability to persuade donors of theneed to continue feeding vulnerablegroups.

ECHO support to UNICEF in nutritionincludes a wide range of inputs, includingmicronutrient premix for the local produc-tion of fortified food, F-100 therapeuticmilk, micronutrient supplements and IEC(information, education and communica-tion) support. The main findings of theevaluation in relation to nutrition includ-ed;

• ECHO could have benefited from someexpert input on nutrition programmingdesign and implementation and in future, technical assistance on nutritionshould be sought, particularly at the time proposals are being reviewed.

• There is only limited implementation of nutrition programmes at a local level in DPRK. Local level implementa-tion should be promoted along with anexpansion of appropriate INGO part-ners.

• Protocols for the treatment of severe malnutrition are not being adequately implemented, leading to decreased impact on reducing severe malnutri-tion and lower chances of recovery andsurvival for severely malnourished children. The comparative ability of hospitals, baby homes and orphanages to manage malnourished babies and children should be assessed.

• F100 is being extensively used to feed non-malnourished children, which is inappropriate and is not cost-effective. In future, proper milk sources (not F100) should be provided to children aged 6-24 months who are not mal-nourished.

• Use of F100 for infants (under 6 months)is dangerous and measures should be in place to prevent this.

• Support to micronutrient premix is a strong component of the programme with potential to reach many vulnera-ble children.

• Lack of transport prevents some insti-tutions from receiving food from WFPparticularly as the quantities are usual-ly small.

1 Dammers C, Fox. C and Jiminez M, (2005). Report forthe evaluation of ECHO’s actions in DPRK 2001-4. January2005, http://europa.eu.int/comm/echo/pdf_files/evalua-tion/2005/DPRKreport.pdf

Evaluation of ECHOActions in DPRKSummary of evaluation1

the FMCs in managing the FFW and allo-cating food may be considerable. Evenwith rotation of committee members, afew hours per day appears to be thenorm. However, the FFW does coincidewith a period of least activity at villagelevel.

MonitoringA monitoring system has yet to be put inplace for the PRRO activities in Magway.This is largely due to the fact that staffhave been engaged with getting the pro-gramme up and running.

Observations on CBT in the MyanmarPRRO The CBT component of the programmehas been very successful. Recent refine-ments have considerably strengthenedthe system in terms of ensuring a lowerexclusion error. Household screening byWFP/NGOs and the mission field workshows that the poorest of the poor areinvariably targeted (inclusion estimatedat 88%). This exemplifies the learningthat has taken place in the programme.

CBT appears to bypass political struc-tures at village level and may also con-tribute to strengthening of civil society,as well as establishing an instrument forother development activities.

CBT may work particularly well in theMyanmar context as other ‘poor’ areincluded in FFW/FFT and school feed-ing, so that the community do not feelunder so much pressure to includeeveryone in the VGF. However, theseoptions may not be available on thisscale in other societies where there is lesseducational and management capacity atvillage level to implement large scaleFFW and FFT activities.

The CBT approach employed inMyanmar necessitated the recruitment ofextra, temporary staff (20 in NRS) toestablish the system and also took con-siderable time and investment ofresources. There are, however, no dataavailable on comparative costs withother forms of targeting.

For further information, contact JeremyShoham, email:jshoham@easynet.co.uk

Workers in Magway divisionpreparing food for distribution

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Field Article Evaluation

28

Field Exchange recently interviewedRoger Yates from ActionAid UK in theiroffices near Archway station in northLondon. Roger, whose professional

background is engineering, began workingoverseas in 1984, alternating between develop-ment and emergency work. Prior to joiningActionAid in 1999, he worked for a variety oforganisations, including Oxfam and DFID, andtook up the post of head of emergencies inActionAid UK in 2000.

Through consultation with country pro-grammes, ActionAid has recently gone througha long process of re-defining strategic priorities.There are now six strategic priorities, which areall based around human rights. Roger isresponsible for one of the newer priorities in theorganisation – “the right to human security inconflict and emergencies”. The other strategicpriorities relate to right to food, women’srights, HIV, education and governance.

Historically, ActionAid has mainly worked indevelopment programming. In fact, the firstemergency unit was only established in 1995.At the time, there was resistance within theorganisation from ‘purists’ who viewedActionAid as a predominantly developmentalorganisation. For the next few years, the emer-gency section had an uncertain existence.However, within months of arriving, Rogerundertook a review of Action Aid’s emergencywork. A main conclusion was that the organisa-tion really had “no option but to continueworking in emergencies”. Also, rather than just“flying in and flying out of emergencies”, thereview argued for an approach which strength-ened the interface between development andemergency programming. Given that it is thepoorest who suffer most in emergencies, thereview highlighted two ways to strengthen theemergency/development interface. First,development can reduce vulnerability of thepoorest to emergencies and secondly, emergen-cies provide a chance to reduce vulnerability ifthese are largely determined by power rela-tions, i.e. in emergencies power relations can bechanged. This conceptual approach to emergen-cies was accepted within ActionAid and stilllargely underpins the organisation’s emergencywork.

Although ActionAid do engage in traditionalforms of humanitarian intervention like fooddistributions - particularly when they have alead presence in an emergency affected area -their emergency interventions are mainlylonger-term, with a livelihoods and povertyfocus. Interventions strive to empower thepoorest following emergencies, a good examplebeing the recent communal riots in Gujaratwhere ActionAid helped the poorest submitcompensation claims. Another typical form ofActionAid emergency activity is in the area ofpsycho-social support following natural disas-ter. For example, in post-cyclone Orissa or fol-lowing the Indian Ocean Tsunami, cadres ofpeople in the community were trained to recog-nise and deal with distress and trauma.ActionAid usually work through communityvolunteers who are trained and then take on thework.

Another unique element of ActionAid’s workhas been the development of a participatoryvulnerability analysis tool with a high degree offocus on policy issues. This approach is now

being taken up by country programmes as wellas other agencies.

Up until recently, ActionAid have tended toembark only on emergency programmes inthose countries where they already have a long-term presence. However, this started to changearound 2002 with the realisation that ActionAidhad a valuable contribution to make in emer-gencies, especially in terms of addressing exclu-sion of the poorest. Consequently, ActionAidare now committed to scaling up their emer-gency work and working in countries wherethere have been no prior programmes, forexample, Niger, Sri Lanka, Maldives, and Iran,through operational partners. ActionAid will,however, only work in emergency contextswhere poverty is an issue. Thus, after an initialappraisal before the invasion, ActionAid decid-ed not to work in Iraq because poverty was nota major issue. In other emergency situations,there may be different constraints. In Darfur,ActionAid lacked the capacity to get involvedwhile in Indonesia, a combination of limitedcapacity and lack of available partners prevent-ed engagement.

In essence, ActionAid does not consider itself tobe a relief agency, although they “do somerelief”. ActionAid don’t arrive in an emergency“with a solution looking for a problem”, but area people-centred and rights based agency –“which means listening and then acting”.Furthermore, their focus is on recovery, whichis planned from day one of their arrival.

ActionAid is mainly funded by the Europeanpublic (largely British). The predominant mech-anism is through the child sponsorship schemewhereby the funding public are matched withchildren/families and are kept in touch withhow their support is being used and how theirchildren/families are doing. ActionAid doesnot submit many emergency programmes pro-posals to traditional donors like DFID or theEU, although it is increasingly recognised that ifActionAid want to scale up more in emergen-cies, they will have to strengthen their capacityto submit proposals to the bilaterals. ActionAidis a member of the Disaster EmergenciesCommittee (DEC) so that when a major disasteroccurs, ActionAid takes part in national appealsand is entitled to a percentage of the fundsraised to respond to the crisis. ActionAid,where necessary and appropriate, can and doeslaunch emergency appeals to its supporters. Inthe event of a disaster, a country programmemay also reallocate its funds to support theresponse.

ActionAid do not have permanent staffemployed as nutritionists so they hire in nutri-

tional expertise when needed. The organisationis structured so that there are internationalemergencies advisors in the region (three inAfrica, one and a half in Asia and one in theAmericas). These advisors have three mainroles;

i) Emergency response with a global remit, i.e. they can be asked to work in any region

ii) Getting country programmes in the regionto incorporate ‘emergency thinking’ into their development programmes, e.g. Disaster Preparedness and understanding of vulnerability

iii) Engagement with policy development.

Roger reckons that one of the biggest challengesfor ActionAid in the emergency sector isstrengthening their engagement in conflict situ-ations. This is not to say that ActionAid do notalready work in conflict situations, e.g. Burundisince 1993, Sierra Leone, Nepal, etc, but ratherthat ActionAid need to develop their conceptu-al approach to working in conflict across theorganisation. Up to now, each country in crisishas had to develop its conceptual approachfrom scratch. As Roger put it, they need to work“on” rather than “in” conflict. There are manyissues to consider, not least how to engage withdifferent factions like peace movements/peacekeepers and what are the implications of thesenew relationships. There is hope of setting upnew ActionAid offices in New York with a viewto developing a closer relationship with the UNSecurity Council.

According to Roger, one of the unique featuresof ActionAid is its degree of decentralisation.Their headquarters are in Johannesburg andeach country programme has a large degree offinancial and policy autonomy. There is a cul-ture in ActionAid of challenging views and pre-vailing wisdom. Furthermore, policies andstrategies are largely shaped by country pro-grammes and their staff. A good example is theemergence of ActionAid policies and strategiesaround engagement in conflict, which havebeen largely informed by consultation withstaff from country programmes experiencingconflict.

One of the biggest challenges for ActionAid,according to Roger, is that their “eyes are biggerthan their stomachs”. In other words, they wantto get involved in everything, i.e. conflict, cli-mate change, HIV, etc. “ActionAid are good atstarting initiatives but not so good at consoli-dating and deepening focus. Furthermore,Action Aid need to improve the flow of infor-mation from the field to inform policy develop-ment. Country programme staff are alwayspressed for time and their priorities tend to liein the communities where they work. It is hardfor those in the field to judge what informationis going to be useful internationally and how topresent it”.

Roger was unnervingly open about ActionAid’sweaknesses and challenges. This seems to be apart of the ActionAid ethos, i.e. challenging,questioning and internal critiquing. Getting thepolicies and strategies right also seems verymuch a priority. While ActionAid may not havethe profile of some of the larger UK agencies(this may in part relate to the way in which theyare funded), there is no question that they haveequally interesting things to say.

Agency....................ActionAid InternationalChief Executive.........Ramesh SinghActionAid UK Director...................Richard MillerPhone.....................+27 (0) 11 880 0008 Fax.........................+27 (0) 11 880 8082Website...................http://www.actionaid.orgStaff.......................international - 26

regional offices - 25 field staff - 1,942

Financial turnover 2004.......................£92 million

Agency Profile

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Applying GIS toNutrition SurveysBy Filippo Dibari, Andrew Seal and Paolo Paron

Filippo Dibari is a Food Technologist with long termcommunity based experience in developing coun-tries and consultancies with NGOs and UN agenciesin Africa, Latin America and South East Asia.Having recently completed an MSc in Public HealthNutrition at the London School of Hygiene andTropical Medicine. He is currently working for ValidInternational.

Andrew Seal is a Lecturer in International Nutritionat the Centre for International Child Health, ICH,London. He has worked as a researcher/nutritioniston refugee and emergency nutrition projects inAfrica, Asia and Eastern Europe. His main researchinterests are in micronutrient deficiencies andemergency nutrition programmes.

Paolo Paron is a Geomorphologist and GISSpecialist with research and teaching experience inthe fields of GIS and remote sensing analysis andin environmental geology. Currently a visitor at theOxford University Centre for the Environment, he issoon joining an FAO Project based in Nairobi as along term consultant.

We would like to thank the Ministry of Health, Angola and WFP fortheir support, and are grateful to the Canadian InternationalDevelopment Agency for funding the survey via WFP. Thanks also toMSF-B for providing the Kuito town plan used in the case studyexample, and for their collaboration during the survey.

ACRONYMS AND TERMINOLOGY

GIS: Geographical Information Systems. A system composed of hardware,software, data and people whcih helps in the elaboration and analysis ofdata that have a geographical location.

GPS: Global Positioning System. This system is composed of a constella-tion of satellites and a device that can be handled in one’s hand and thatcan mark and store points (waypoints) and paths (tracks). These can beuploaded into a software programme and visualised.

DIGITIALISED MAP: A map that has been transformed from a paper-based medium to a digital one in order to be edited in a computer (alsocalled a Raster).

GEOREFERENCED MAP: A digitalised map that has been uploaded into asoftware programme and assigned its proper geographical coordinates.

ESRI: Environmental System Research Institute - a commercial supplier ofGIS software.

ArcGIS: An ESRI GIS programme that incorporates virtually all known GISfeatures and functions, i.e. mapping, analysis, database management,editing, and integrates with other software and devices.

ARCMAP: The main ESRI Mapping and Analysis module of the ArcGIS pro-gramme. Functions include uploading and georeferencing maps, importingdata from other sources, and analysis.

ARCCATALOG: The main ESRI database management module of theArcGIS programme. It allows you to load data onto a computer, and man-age the data, files and a directory within a particular GIS project.

WAYPOINT: A fixed location with specific coordinates (longitude and lati-tude) which is determined and stored in a GPS. In most cases, altitude canalso be stored..

TRACKS: A series of waypoints that represent a path.

AGeographical Information System (GIS) comprises a set ofhardware and software tools that help to visualise and tolocate, rather than analyse, the patterns of a phenomenon.Nutrition is one of the many areas of possible application of

GIS methodologies and Public Health Nutrition in emergencies has onlyrecently discovered the potential. Almost any nutrition survey aiming todefine the nutritional status in a certain area (at district, town, province,region, state, nation or continent level) can be enhanced by a GIS presen-tation. No major changes are needed in conducting the nutrition surveyor in identifying its best epidemiological design.

UN Agencies and NGOs are already including greater use of GIS in theirwork. Early Warning Systems Mapping, Poverty Mapping andVulnerability forecasts are three of the largest applications among suchinstitutions. The skills required in data management and digital mappingare still limiting the use of such powerful tools among smaller organisa-tions. The demand has stimulated the creation of not-for-profit compa-nies dedicated specifically to GIS applications in humanitarian relief1.

Even EP-INFO, probably the most popular software among public healthnutritionists, has evolved in the last few years to include a GIS analysiscomponent (Epi Map) plus a large free source variety of maps of admin-istrative boundaries, online atlas, health risk exposure data, and others2.

This article highlights the potential benefit, resource needs and con-straints of applying Geographical Information Systems (GIS) analysisto a conventional nutritional survey dataset in a developing country oran emergency context.

The article is organised on two levels. Those completely new to GISapplications should find the body of the article useful in decision mak-ing and in designing the terms of reference for initiatives in this area.For nutritionists who are already familiar with datasets managementand with the basics of GIS and who have already tried to apply GIS tonutrition surveys, the step-by-step approach outlined here is supportedby substantial technical detail online athttp://www.ennonline.net/articles/gis/index.html

Figure 1 Relationship between a GIS map and its original dataset

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Taking a blood sample for analysis

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1 See section later for references to GIS application sources.

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Why field programmes should consider using GISMost humanitarian workers will find the following questions familiar:

“Where is the best site to set up the next Therapeutic Feeding Centres in accordance with the prevalence of registered acute malnutrition and the distance from the available health posts?”

“We have nutrition data of this area, plus an old non digitalized (papercopy)map of the region, and a very basic GPS. How is it possible to create a map onmy computer with all the information in order to show it to both the donorsand the local community authorities and then use it to help make importantdecisions about future initiatives?”

“In order to better target the beneficiaries, how do we set up a quick decision-making set of criteria based on the available data coming from nutri- tional sta-tus but also administrative boundaries, traditional family clan areas, wateravailability, transport routes and security considerations?”

“I have driven for hours up this increasingly narrow track in search of a non -existent village in the middle of nowhere. Where exactly am I right now”

While GIS is not the “magic bullet” for such questions, the use of GIS cer-tainly contributes tools to provide better answers. Under the mantra‘keep it simple’ and equipped with basic data management skills, thereare simple GIS steps which can add significant value to a nutritionalanalysis report. More specifically, GIS helps in decision making becauseit provides maps of the phenomenon of interest. The map is like the ‘tipof an iceberg’, visually representing the bulk of the information anddatasets ‘underneath’. This key concept is reflected in figure 1, where theyellow area in the map graphically represents the record and all its data,also highlighted in yellow in the table.

How data are presented can have a number of practical implications. Forexample, there might be the need to share a decision regarding the out-comes of a recent nutrition survey with the leaderships of a few villagesin a rural area. How these data are represented will affect how well theycan be shared and how much the programme can benefit from the stake-holders’ contributions, independent of their education level. With thisscenario in mind, figure 2 presents three different ways of representingthe same dataset: a table, a histogram and a map. In this situation, theGIS map may well be the best way to communicate the available data.

Applied to nutrition, GIS analysis is potentially an extremely powerfultool for monitoring, evaluation and targeting. For example, it can reflectsituations where the overall nutritional status does not change in quanti-tative terms, but marked changes in the spatial distribution of malnutri-tion occur (see figure 3). This is reflected in the theoretical scenarioreflected in figure 4, which compares the distribution of child globalacute malnutrition (GAM) at time 0 and 1. The prevalence of GAM isroughly the same at the two moments in time, however the spatial distri-bution has completely changed and therefore the appropriate areas totarget have/should also. In figure 4, the areas in which the socio-econom-ic indicators have reported a high prevalence of “very poor” people havebeen coloured blue. Compared with figure 3, it can be clearly seen thatthese blue sections do not overlap with the sections in which the highestlevel of acute severe malnutrition is actually located. This suggests thatusing socio-economic status to target geographic areas would not be arobust means to target severe acute malnutrition.

Resource implications of applying GISTo apply GIS to a nutrition survey, extra time is demanded in two phas-es of the survey. A few minutes will be enough to collect geographicaldata using a Global Positioning System (GPS) during the field phase ofthe survey. However, extra time is required for cleaning and analysis ofthe dataset to prepare for presentation in a GIS-map. As a whole, theprocess does not require a high level of ‘personnel time’, as long as theperson working with GIS is already experienced or has received hands-on training. The steps for conducting a nutrition survey, together withGIS-related actions, are listed in table 1.

What equipment is needed?When applying GIS analysis in a nutritional survey, a GPS device andGIS software are needed. The GPS allows users to collect data on bothlocations and tracks, while the GIS software allows the display andanalysis of these data combined with data derived from a nutrition survey.

GPS deviceThere are different kinds of GPS that can be categorised in order of com-plexity and cost as basic GPS, mapping/cartographic GPS, car GPS anddifferential GPS. The first two are quite enough for survey purposes. Three brands of GPS handsets are the most common on the market, andare considered the most reliable by the authors3. For the purposesdescribed in this article, the models Garmin GPS or Garmin e-trex fami-ly (or similar other brand) are recommended. The choice of the model isrelated to the storage capacity of the waypoints and how data are down-loaded into the computer.

Figure 2 Data representation using a map, table and histogram

Figure 3 Comparison of the distribution of child global acute malnutrition

CLUSTER Global AcuteMalnutrition %

0.0

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GIS

Figure 4 Analysis of the prevalence (%) of a low socio-economic status(SES) indicator

Figure 5 Flowchart of data processing

A commercial GPS has a standard error of about 10 metres in position-ing, which normally is well below the precision that a nutritional surveyrequires. Some GPS can measure also the altitude, which can be useful inadjusting haemoglobin cut-offs to calculate the prevalence of anaemia ina survey.

GPS/GIS softwareOnce the data have been collected by a GPS, there are several possiblemethods, solutions and software options for proceeding with the analy-sis. Here only one of them is considered.

In order to run the GIS analysis, at least three pieces of software arerequired. The first is necessary to download the data from GPS into thePC with the correct geographical coordinates (e.g. Mapsource4 ). The sec-ond facilitates combining the GPS data with the nutrition dataset andavailable maps (e.g. Microsoft Excel or Access). The third is the GIS soft-ware, which is used for spatial analysis (e.g. ArcView, EpiMap, ArcGIS).In this article, ArcGIS (ESRI) is chosen to illustrate a case study.

Guide to applying GIS to a nutrition surveyThree kinds of data are necessary for GIS analysis in the context of anutrition survey (see figure 5):

1. Data coming from anthropometry, questionnaires, biochemical analysis, etc.

2. Waypoints collected with a GPS

3. Maps of the area obtained from different sources5.

The sets of data are combined within the GIS software which allows fortheir integration and analysis. The way to introduce waypoints andmaps into the GIS can appear complex and therefore a step-by-stepapproach is summarised here. Reference is made to a series of boxes (1-10), which go into a high level of technical detail and are available onlineat http://www.ennonline.net/articles/gis/index.html In order to high-light critical points in the procedure described in the boxes, a case studyhas been taken into consideration. It consists of a nutrition survey under-taken by the Institute of Child Health, London in collaboration with WFPand MSF-Belgium in Bie Province, Angola, in November 2004.

Step 1: How to introduce the waypoints into the GIS software

The GIS analysis of nutritional data consists of four phases:

Phase 1 Geographical collection of the waypoints using a GPS in the field (see box 1 online)

Phase 2 Downloading the waypoints from the GPS into the computer (see box 2 online)

Phase 3 Adjustment of the waypoints/tracks dataset (see box 3 online)Phase 4 Combining the geographical data with the nutritional

survey data to answer specific queries (see box 4 online)

An example of the final result can be seen in figure 6.

Step 2: How to introduce a map into the GIS software

Once a map has been obtained, it must be made compatible with the GISsoftware. The steps to follow are:

1. Preparation of a digitalised map of your area of interest (see box 5 online)

2. Digitalisation and cleaning of the map (see box 6 online)

3. Importing the map and the GPS waypoints and tracks into the GIS (see box 7 online)

4. Georeferencing the map (see box 8 online)

5. Joining the nutritional survey data and cluster points (see box 9 online)

6. Visualising the nutritional survey data on top of a map (see box 10 online).

Key considerations when employing GIS analysis for the first timeSkills in GIS software are required as GIS software are not always userfriendly and training in their use can be expensive, according to the levelof knowledge. Supervision of data management by an experienced useris recommended for the first time.

Skills in managing data using different software are required. For exam-ple, it is necessary to know how to export data from EPINFO intoArcMap, passing through Microsoft Excel or Word, in order to achieve

Steps for conducting aNutrition Survey* Action Specific

equipment

1. Define survey objectives

13. Analyse and report thesurvey results

2. Budget for the survey

3. Choose the survey design Decide where to collect the way-points or the tracks: i.e. centrepoints of the clusters, wells, roads,administrative boundaries, etc.

4. Plan for personnel, facili-ties and equipment

5. Select the sample

Include a GPS, ensure software isavailable

Include an area in the question-naire for the collected GPS data

Train the personnel in collectingthe GPS data and filling in thequestionnaire correctly

GPS

GPS

Data entry of the GPS data onrelation with the answers and/oranthropometric data

GPS, PC,software

The prepared tables include alsothe GPS data

PC

Queries regarding geographicalaspects are answered, and theninterpreted

PC

6. Develop the questionnaire

7. Pre-test the questionnaire

8. Train the personnel

9. Standardize the anthropo-metric technique

10. Interview/data collection

11. Edit and code theanswers

12. Tabulate the data

waypoint(GPS)

Nut Dataset(Epinfo, Stata,

SPSS, etc.)

Mapsource

Digital map ofthe

survey areaExcel

GIS software(i.e. ArcMap)

Individual data(anthropometry,

etc.)

Household data (Health,

socio-economic,etc.

internetScannedexistingmaps

MapsourceSoftware

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3 Garmin (http://www.garmin.com/) – manuals of recommended models can be downloadedfrom this site, Magellan (http://www.magellangps.com/en/) and Trimble (http://www.trim-ble.com)4 Mapsource is the software used with the Garmin model GPS, typically sourced from wherethe GPS has been purchased.5 See online link http://www.ennonline.net/articles/gis/index.html for map sources.

* Adapted from FANTA (2003)

Table 1 Actions needed when including GIS in a nutrition survey

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the correct format of the files or of the tables to insert into the GIS soft-ware. These operations are not complicated or time demanding per-sewhenever the procedure is known. They can be so, however, if the oper-ator has to find the way to do it on his /her own.

Choosing which GPS to use is important. Certain GPS do not allow theuser to download their coordinates into the computer, or require addi-tional equipment/manual data copying which has resource implicationsand introduces greater room for error.

Which GIS software to use is also a key consideration. There is a largechoice of GIS data software, recently even open-source ones, th have min-imum computer operating requirements6. The three leading softwarehouses are ESRI, MAPINFO and PCI. ESRI is the most common source ofthe relatively old, but still reliable and useful, ArcView software (recent-ly updated) and their new GIS platform, ArcGIS. The latest version ofEPINFO (2005) includes a component to apply epidemiological data onto digitalized maps and an instruction manual accompanies the software(MAPINFO). The authors are not familiar with this system so cannot pro-vide further comment. However, EPINFO 2005 is downloadable for freefrom the Centres for Disease Control, Atlanta7.

From the point of view of inferential statistical analysis, GIS is of littlevalue for comparisons within single cluster-sampled surveys, since suchsurvey can only provide a reliable estimate for the entire survey area. Itis not valid to analyse such surveys by cluster to try and prove a relation-ship between a risk factor and an outcome. If comparisons between sec-tions are required, then an independent representative sampling methodis needed for each geographical section that you wish to compare.

There are plenty of good GIS manuals that can help the reader gain morein-depth knowledge, and two recommended reads are included at theend of this article. More specific public health oriented resources areavailable on the web, although they tend to consider ‘western contexts’rather than developing countries ones. Good online resources includeWHO (which includes a Global Atlas)8 and the National Centre forHealth Statistics of USA9.

Final conclusions and considerationsStatistical analysis of GIS nutrition datasets is an area still in its infancyand requires further research and development. Where stratified clustersurveys are used or several different discrete surveys are available, thenGIS provides a clear and powerful means to compare differencesbetween areas. As mentioned earlier, cluster survey data is, as a result ofthe sampling design, only statistically representative of the whole surveyarea so care must be taken in ascribing significance to geographical vari-ations between clusters within the same survey. When comparing areaswithin the same cluster survey, then differences that are observedbetween clusters may be suggestive of real geographical differences, butsuch differences should not be accepted as statistical fact. This is animportant issue to remember if GIS is used for targeting. When system-atic (interval) sampling is used, then true geographical differences areeasier to identify using spatial statistic tools that are becoming morewidely available within GIS software packages.

An investment in GIS in a nutritional survey today, may allow users tobenefit from the opportunity to link their data with other databasessources at a relatively low cost in the future. For instance, data on climate,rainfalls, soil erosion, but also food items prices and most of the typicalfood security parameters, could be subsequently linked. Those data arebecoming more and more readily available on the internet thanks to gov-ernmental and non governmental agencies, institutions and academicbodies. All this should greatly expand the range of potential cross-refer-encing of this tool.

It should mot be forgotten that, in some situations, GPS handsets may beconsidered as military equipment and not appropriate for humanitarianorganisations. The potential risks involved in using GPS should beassessed in each operational context.

For further information, contact: Paolo Paron, email:paoloparon@yahoo.it or Andy Seal, email: a.seal@ich.ucl.ac.uk

Recommended manualsP.A. Longley, M.F. Goodchild, D.J. Maguire and D.W. Rhind (2001)Geographic Information Systems and Science, Wiley.(http://www.wiley.com/legacy/wileychi/gis/volumes.html)Ellen K. Cromley & Sara L. McLafferty (2002) GIS and Public Health, TheGuilford Press. This explores in depth the nature of spatial data, themapping of health information and it presents also the use of GIS in dif-ferent contexts of public health (e.g. vector-borne diseases and access tohealth services).

Figure 6 Comparison of the distribution of child global acute malnutrition

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Cluster searching by thesurvey team

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Measuring height duringthe field survey

6 They normally require a PC with a minimum of : Windows operating system, Pentiumprocessor or AMD equivalent, 256 or higher RAM, and a good graphic memory (at least 64 MB).7 http://www.cdc.gov8 http://www.who.int/csr/mapping/en/9 http://www.cdc.gov/nchs/about/otheract/gis/gis_publichealthinfo.htm

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People in Aid

Participants talk with mother during a clinical session: AhmedSheik Abdi, Anne Njuguna, Mohamed Shukri Elmi

Small group work: Mohammed Ahmed Yassin, Fatuma Kuno Muhumed,Malima Dahir Ali, Mohamed Shukri Elmi

Translation team: Ahmed Sheik Abdi, Abdi Ahmed Mohammed,Mohammed Ahmed Yassin, Mohamed Shukri Elmi

Participants at the interagency Infant and Young Child FeedingWorkshop sponsored by CARE Indonesia, Sanur Beach Hotel:19-20 September, 2005.Standing: Frank Page, CARE Indonesia.

ACF team pic, fromleft to right: AliciaMasautis, Nuria Salse,GabrielaCormick,EstelaRúgolo, Adrián Díaz

Participants atCARE Indonesia’sInfant and YoungChild Feedingtraining session,Kefamenanu,West Timor

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WHO-UNICEF Breastfeeding Counselling coursefor CARE, GTZ and UNHCR staff and workers:July 25-August 5: Dadaab Camps, Kenya

Food relief committee in Magway Division, Myanmar

Mrs. Margaret Moyo, Mrs. Elizabeth Johnson,

and Modesta Simango(Norwegian Church Aid)

of the HBC team in Malawi

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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, stim-ulate learning and provide vital support and encouragementto food and nutrition workers involved in emergencies. TheENN officially began operations in November 1996 and haswidespread support from UN agencies, NGOs, and donorgovernments. The network aims to improve emergency foodand nutrition programme effectiveness by:

• providing a forum for the exchange of field level experiences

• strengthening humanitarian agency institutional memory

• keeping field staff up to date with current research andevaluation findings

• helping to identify subjects in the emergency food andnutrition sector which need more research.

The main output of the ENN is a tri-annual publication,Field Exchange, which is devoted primarily to publishing fieldlevel articles and current research and evaluation findingsrelevant to the emergency food and nutrition sector.

The main target audience of the publication are food andnutrition workers involved in emergencies and thoseresearching this area. The reporting and ex-change of fieldlevel experiences is central to ENN activities.

The Team

Editorial teamDeirdre HandyMarie McGrathJeremy Shoham

Office SupportRupert GillDan George

DesignOrna O’Reilly/Big Cheese Design.com

WebsiteJon Berkeley

Contributors for this issueHolly Welcome RadiceMary MyattFrances MasonDominique BrunetDorrie ChettyMichael O’DonnellFiona WatsonMark ManaryReidar RetziusStanley ChitekweAdrian DiazAmador GomezNuria SalseGabriela CormickSuzanne JaspersChris LeatherNiall CassidyNoreen PrendervilleSteve CollinsJeremy ShohamRoger YatesFilippo DibariAndrew SealPaolo Paron

Pictures acknowledgementHolly Welcome RadiceDevrig VellyJoyce KellySteve TownsendJohn WeaverS FreedmanA KariJay BerkeleyMicah ManaryPaul HarveyPantaleo CretiReidar RetziusAmador GomezCecile BizouerneAndrew SealFilippo DibariMary Lung’ahoJeremy Shoham

On the coverMothers working on a garden plot in UgandaUganda, ©ACF/2004

The Emergency Nutrition Network is a company limited by guaranteeand not having a share capital.Registered in England and Wales number: 4889844Registered address: Unit 13, Standingford House, Cave Street,Oxford, OX4 1BA, UKENN Directors: Jeremy Shoham, Marie McGrath.

Field Exchangesupported by:

Dan George is the ENNfinance assistant, workingpart-time in Oxford.

Rupert Gill is ENN administrator and projectcoordinator, based in Oxford.

Jeremy Shoham (Field Exchange technical editor) andMarie McGrath (Field Exchange production/assistant editor)are both ENN directors.

Orna O’ Reilly designsand produces all ofENN’s publications.

Jon Berkeley managesENN’s website and supportsthe production of ENN publications.

34

Matt Todd is the ENN financial manager, overseeing the ENN accounting systems, budgeting and financial reporting.

Emergency Nutrition NetworkUnit 13, Standingford HouseCave Street, Oxford, OX4 1BA, UK

Tel/fax: +44 (0)1865 722886Email: office@ennonline.netwww.ennonline.net