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MITIGATING THE RAVAGES OF A CYCLONE:SECURING CHILD NUTRITION AFTERAILA
Process Documentation Report
Department of Child Health and Development,Child In Need Institute (CINI),
Daulatpur, via: Joka ,South 24 ParganasWest Bengal, India
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2010
Contents
Page no.
Background 4
Responding to the Disaster 5
Processes for Stakeholder Engagement and Promotion of Community Action 7
Mitigating the Ravages of a Cyclone: Results Achieved 11
Challenges and Lessons Learned 15
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Abbreviations
ANM Auxiliary Nurse cum Midwife
ASHA Accredited Social Health Activist
BMOH Block Medical Officer of Health
BPHN Block Public Health Nurse
CDPO Child Development Project Officer
CINI Child In Need Institute
ICDS Integrated Child Development Services Scheme
MLC Mandra Lions Club
MAM Moderate Acute Malnutrition
MIS Management Information System
MUAC Mid Upper Arm Circumference
NGO Non Governmental Organisation
NRC Nutrition Rehabilitation Centre
PRI Panchayati Raj Institution
SAM Severe Acute Malnutrition
SHG Self Help Group
UNICEF United Nations Childrens Fund
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Background
The afternoon of 25th May 2009 invokes painful memories in the minds of people in
southern West Bengal, India. A severe cyclone by the name ofAila hit the coastal areas
of the state that day, destroying lives and property. Embankments gave way and
seawater gushed in. Farmlands were destroyed overnight. Relief poured in from various
quarters, providing food and temporary shelter to people. However, it dried up after a
few months. The cyclone had upset the lives and livelihood of millions of people in the
area.
Fig 1:Aila affected areas
Months after the cyclone had wrecked havoc in the area, vast parts of land where
houses once stood, lay under water. Access to these areas is still a challenge. Makeshift
bamboo bridges called sanko in Bengali (the local language) connect these areas to the
outside world. In such areas, people measure the distance to destinations by the number
of sankothat are to be crossed. Traversing the sanko is a precarious exercise putting
the lives of people in danger.
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Submerged Land
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This report is a process documentation of the civil society response to mitigate the
effects of the devastating cyclone on the nutritional status of under five children in the
area. It captures the processes undertaken and the results achieved, distilling the
challenges and the lessons learned. Project reports, meetings with a variety of
stakeholders in the project implementation sites, field observations and discussions with
the members of the project team have informed this report. Qualitative fieldwork was
undertaken to explore issues in an iterative manner that helped establish internal validity
of the data.
Responding to the Disaster
Nutritional security was one of the foremost casualties of the cyclone. Many farmlands
could not be cultivated owing to water logging and/ or salination. Livelihoods were
severely affected and people displaced. Many of the local anganwadicentres had been
destroyed by the strong winds and lashing rains1. Food supply was scarce and irregular.
It was under these circumstances that UNICEF, in collaboration with CINI and Mandra
Lions Club, undertook an emergency response initiative to prevent and manage
malnutrition among under five children in three affected blocks and promote community
action on it. The project Emergency Response for Nutrition Action in Aila Affected
Areas to Prevent and Manage Malnutrition including Severe Acute Malnutrition
(SAM) And Promoting Community Based Actionwas popularly known as the Aila
emergency response project. UNICEF, the worlds leading agency for the promotion of
child rights, mobilized funds and provided the technical support in the project. CINI, a
leading NGO of India and a pioneer in the field of child nutrition and community based
programming in the country, was responsible for overall programme implementation.
The third partner, MLC, was responsible for field based activities.
1 An assessment in August 2009 revealed that 464 anganwadicentres had been damaged due to Aila out
of a total of 865 in the three blocks of the project intervention area. Sandeshkhali I was the hardest hit with219 of its 279 anganwadicentres damaged due to the cyclone.
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The project was for a period of six months commencing 1 st July, 2009. The blocks of
Gosaba, Sandeshkhali I and Sandeshkhali II formed the project implementation areas. In
all, the project covered 101 villages spread across 30 Gram Panchayat areas and
covering a population of approximately 4,00, 000.
Table 1: Project Implementation Area
Sl. no District Block GramPanchayats
Villages
1 South 24Parganas
Gosaba 14 49
2 North 24Parganas
Sandeshkhali I 8 30
3 North 24Parganas
Sandeshkhali II 8 22
Total 3 30 101
The Aila emergency response project had the following objectives:
To monitor nutritional status of children (6- 59 months) using MUAC tape
To identify and screen SAM children and provide facility based care and
services to complicated ones.
To prevent and manage malnutrition amongst children 6-59 months in Aila
affected areas
To improve knowledge about child care and feeding practices in the community
To promote effective linkages with community groups, Panchayats and service
provides to promote early and exclusive breast feeding, appropriate
complementary feeding and care of children
To promote appropriate care and feeding for pregnant and lactating women
To facilitate quality improvement of food supported under public funded
programme through monitoring and technical support with special focus on
children
To promote effective functional convergence with various service providers
To facilitate community engagement on the issue of child nutrition
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Major project activities included:
Assessment of nutritional status of under five children through the MUAC tape. A
cadre of community based animators was trained for the purpose
Community based events like nutrition camps, video shows, quiz competitions,
mothers meetings and health checkups to promote awareness of appropriate
cooking and feeding practices for children and promote healthy behaviour
Training of service providers including ICDS personnel, Medical Officers and
nurses on identification and management of childhood malnutrition
Referrals of SAM cases (with complications) to the Nutrition Rehabilitation
Centre at CINI for timely medical intervention
Distribution of supplementary nutrition packets (Nutrimix) for identified SAM
cases in the project implementation areas
Processes for Stakeholder Engagement and Promotion of Community Action
TheAila emergency response had a strong community based team to roll out the project
on ground. There was a cadre of 30 animators, each in charge of a Gram Panchayat.
Block Coordinators supervised the cadre. The programme management unit was
headed by a Project Director (a physician by training) and comprised of a Nutritionist,
MIS Coordinator, Documentation Officer and District Coordinator. Personnel at MLC
included Project Coordinator and two Block Coordinators. The animators were also
recruited by MLC.
Community gatekeepers like Panchayat representatives and local leaders were taken
into confidence at the start of the project and throughout. Rapport was developed with
senior ICDS and medical personnel in the three blocks and their support garnered.
The baseline study, initiated at the start of the project offered an opportunity to talk
about child malnutrition with various stakeholders. The animators went from house to
house in their area to assess the nutritional status of children aged 6-59 months. The
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MUAC tape used for the purpose was a simple and effective tool. It visually displayed
the nutritional status of the child to the parents and other stakeholders. It is interesting to
note that long after the baseline study had ended, animators still toured the area with the
MUAC tapes in their pockets, taking it out to measure a child they came across. On one
such occasion, an animator expressed satisfaction stating that the nutritional status of
the child had improved, red chhilo, ekhon yellow hoyegeche (the child was a case of
SAM and had subsequently improved).
Assessing a childs nutritional status with MUAC tape
A total of 35,360 children were measured during the baseline study. Of these, 92.7%
had normal nutritional status, 6.5% were MAM cases and 0.8% was SAM cases (Table
2)
Table 2: Key Baseline Findings
Block
Children
(6-59months)
Normal Children MAM SAM
Number%
Number%
Number%
Gosaba 16172 14937 92.36 1125 6.96 110 0.68
Sandeshkhali I 10393 9694 93.27 627 6.03 72 0.69
Sandeshkhali II 8795 8170 92.89 532 6.05 93 1.06
Total 35360 32801 92.76 2284 6.46 275 0.78
During and after the baseline study, animators referred under five children identified as
SAM cases with complications to the NRC at CINI. Set up in the 1970s, the NRC at CINI
is a pioneer in India. Here, malnourished children and their primary caregivers spend a
few days and the emphasis is on correct child feeding and cooking practices. Other
features of the NRC include the following:
Providing food to admitted children seven times a day by following a cyclic menu
prepared with locally available low cost nutritious food which can be easily
followed at the household level to ensure sustainable improvement of the
nutritional status of the child
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Daily weight monitoring of the child
Treatment of malnutrition associated complications and common childhood
ailments
Nutrition/health education and feeding counselling for the primary caregivers on a
regular basis
Community based management ofSAM cases (without complications) and MAM
cases was undertaken in the following manner:
Regular home visits for growth monitoring and to ensure correct feeding
practices
Counselling on feeding for primary caregivers as well as for other members of
the household
Distribution ofNutrimixas a supplementary food and demonstration of its cooking
procedure. About 617 packets of Nutrimix (each weighing 500 grams) were
distributed in the three blocks till October 2009.
Seeking support of PRI members and other stakeholders to motivate households
to adopt health promoting childcare practices
Organizing health/ nutrition camps led by a medical doctor and nutritionist in
weak pockets of the project implementation areas.
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Caregivers learning correct
cooking practices at NRC
Distribution ofNutrimix
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The various community based events actively engaged systems functionaries,
especially the anganwadiworkers. The anganwadiworkers mobilized local communities
for events like nutrition camps, quiz shows and mothers meetings. Such events were
usually held at anganwadicentres in the project implementation areas. The local Gram
Panchayats also provided the venue for such community based events. Often, a group
of anganwadi workers would come together for such events, sharing notes on the
nutritional status of children in their respective areas. The MUAC tape had high utility in
such forums, being simple to use and interpret.Anganwadiworkers were instrumental in
referring SAM cases to the NRC for institutional care, as well.
In the months of November and December 2009, various stakeholders were oriented
to the issue of childhood malnutrition. In addition, a wide array ofservice providers was
trained on management of malnutrition in the three intervention blocks. The various
capacity building programmes were usually held in the premises of the Block
Development Office, the Block Primary Health Centre and the ICDS offices. Sometimes,
Panchayats also provided the venue for the trainings. Orientation sessions were held for
representatives of the PRI and SHG members. The following categories of service
providers received training on management of malnutrition:
Block Medical Officers of Health
Medical Officers
Nurses
Auxiliary Nurse cum Midwives
Child Development Project Officers
ICDS Supervisors
AnganwadiWorkers
ASHA
SHGs
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Training ofanganwadiworkers in progress
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Mitigating the Ravages of a Cyclone: Results Achieved
Despite the adverse conditions, results began to show soon after the initiation of the
project. Stakeholders like Panchayat members and SHG members would often stop by
and enquire how the project was doing. Senior officials like the BMOH and the CDPO
were very forthcoming with their support, often facilitating meetings with systems
functionaries. Officials wanted a longer presence for the project in the area- an
intervention that could help sustain the benefits longer.
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Case Study
We are not only economically empowered to support our family toovercome the struggles due to Aila but are also capable to help themalnourished children of our villages
Saraswati Garu, President of Sundarban Swanirbhar Gosti
Provision of Nutrimix to the project implementation areas was initially supplied byCINI. However, the demand for the product increased tremendously and meetingit posed a major challenge. Sundarban Swanirbhar Gosti of Sandeshkhali I blockis a homogeneous Self Help Group consisting of seven members fromhouseholds affected by Aila. Most of the members did not have any livelihood
opportunity to fall back upon.
The women were trained under the project to produce Nutrimix. Thereafter, CINIplaced orders with the group to produce specified quantities of Nutrimix,depending on the requirements of the project. This helped the group to tide overits economic hardships and respond to the demand forNutrimix.
Members of the SHG soon became involved in various project activities likeawareness generation on community based management of malnutrition,immunization, etc. They are working as change agents in the community. Theyare also ensuring sustainability of the project through community basedmonitoring.
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A total of 41 referrals took place from the project implementation areas to the NRC at
CINI during the period (Table 3). Most referrals were from Sandeshkhali I and II, the two
blocks that were proximally located to Kolkata. In contrast, Gosaba, despite having the
highest number of SAM cases as identified in the baseline study, recorded few referrals.
The long distance of Gosaba from Kolkata, the deltaic terrain and problems in
transportation were often cited as the major reasons for such low referrals. As a senior
government official said, it is unimaginable that a daughter in law in Gosaba, who has
never ventured out of her island, would go away to distant Kolkata for some weeks.
Efforts were made to partner with an NGO in the area to provide for facility based
nutrition rehabilitation in Gosaba. However, this did not ultimately materialize.
Apart from distance, other reasons cited across the three intervention blocks for not
seeking care at the NRC at CINI included the need to stay at NRC by caregivers for
some days at the expense of household and childcare responsibilities at home, and
displeasure at being made to participate in cooking and feeding practices. The NRC
was not like a hospital a mother had once articulated. The setup was alien to many.
Sometimes, husbands and other senior members of the household objected to the
mother being away at the NRC for a period ranging from a few days to some weeks.
Table 3: Total referrals to NRC at CINI
All the SAM cases admitted to NRC at CINI registered weight gain and
improvement in nutritional status.
Block Referrals Females Males
Gosaba7 5 2
Sandeshkhali I13 9 4
Sandeshkhali II
21 13 8
Total 41 27 14
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Case Study: Successful Rehabilitation in the NRC
The devastating cyclone, Aila had completely destroyed the paddy fieldsleaving eighteen month old Srijoni's father with no work and no money. All theirbelongings had been washed away by the tidal waves rendering them
homeless and vulnerable. At the time of identification, Srijoni was severelymalnourished. She had also contracted skin infections.Srijoni was referred to the NRC at CINI. Her father brought her to the NRC
under the instructions of the project team in Gosaba. Srijoni weighed 6.8kilograms at admission. During her stay at the NRC, Srijoni's appetite graduallyimproved with proper medication and improved feeding pattern. Her weightincreased by 600 grams during the three week stay at NRC. Her incomplete
immunization schedule was soon upgraded. Srijonis improvement made her
mother, Pratima, very happy and she started taking keen interest in variouschildren and nutrition issues subsequently.
Upon return to Gosaba, Pratima shared her learnings with other women in hercommunity, demonstrating the cooking ofNutrimix and explaining the nutritionflag to them. She is active in various community based events promotingnutrition education. When the animator visited her home after a month, Srijoni
weighed 8.2 kilograms, a further improvement of 800 kilograms.
The nutritional status of most SAM and MAM cases improved by the end of the
project period (Table 4).Parents and household members can see the visible changes
in their children. This is often attributed to the consumption of Nutrimix. The local
animator is seen as a vital resource for guiding caregivers on good childcare practices.
Many caregivers voluntarily seek Nutrimixpackets from the animators.
There is enthusiastic participation of members of the household in various communitybased events and activities. Often, service providers and stakeholders actively support
such events. In many Gram Panchayats across the three blocks, ANMs and the BPHNs
attend the community based events and encourage mothers to adopt better childcare
practices.
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However, many households are still resistant to the adoption of improved childcare
practices. Unfortunately, pockets in the project implementation area have also been
missed out.
Table 4: Nutritional status of SAM and MAM cases by the end of project period
Nutritional Status Block Total
Sandeshkhali I Sandeshkhali II Gosaba
Status ofSAMcases
Total SAM casesidentified during baselinestudy
72 93 110 275
Cases remained SAM12 17 5
34
Cases turned to MAM34 29 45
108
Cases turned to normal22 31 55
108
Total cases of migration(lost to follow up) 3 16 5
24
Deaths1 0 0 1
Number ofnew SAMcases identified afterbaseline study
1 0 6 7
Status ofMAMcases
Total MAM casesidentified during baselinestudy
627 532 1125 2284
Cases remained MAM176 83 172
431
Cases turned to normal 439 396 926 1761
Total cases of migration(lost to follow up) 12 53 25
90
Deaths0 0 2
2
Number ofnew MAMcases identified afterbaseline study
24 0 21 45
It was widely reported by anganwadiworkers from the three blocks that they proactively
seek out cases of SAM and MAM and counsel the caregivers. Some workers also
recounted that they make it a point to see that such cases receive the supplementary
nutrition provided at ICDS centres. If the children are unable to come to the anganwadi
centres for the purpose, then, the food is delivered to them.
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Challenges and Lessons Learned
The Aila emergency response project was aimed at arresting the deterioration of the
nutritional status of under five children in the face of the devastating cyclone.Interventions of such nature, struggling as they do to protect citizens entitlements on the
face of disasters, are necessarily challenging. The sudden disruption of normalcy and
the ensuing chaos offer a disturbing backdrop. Challenges faced in the effective
implementation ofAila emergency response project were:
Putting the team in place for the intervention posed a major challenge in the
beginning. Human resources had to be mobilized overnight and project
personnel had to be oriented to the project on a war footing. Human resourcescontinued to be a challenge throughout the six month project implementation
period. Constant staff attrition, especially at the animator level, often hampered
field activities. The sudden and untimely demise of Bappaditya Samanta, Block
Coordinator Gosaba of CINI, was shocking and temporarily halted the operations
in the block.
The cyclone was followed by the monsoons, further hampering operations.
Continual rains worsened the situation further, the water claiming vast tracts ofland and rendering thousands homeless. The conduct of the baseline census
was hindered in such conditions.
Numerous anganwadi centres had been destroyed in the cyclone bringing
activities like provision of supplementary nutrition and community based nutrition
promotion activities to a halt. In the initial stages of the project, it was especially
challenging to mobilize anganwadiworkers on the issue.
Striking a common understanding of the project objectives and activities
among the partner NGOs remained a persistent challenge. Partners brought in
differing levels of expertise and experience into the project. The short period in
which the project was unfolded on ground often provided little time to forge and
sustain effective sharing mechanisms.
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Gosaba block was particularly challenging. The block comprises of several
islands in the deltaic region and the block headquarters is located about 100
kilometres from Kolkata. Boats are the means of transportation from one island to
another of the block. Some islands are located well into the Bay of Bengal and
take several hours to reach by boat from the block headquarters. Gosaba poses
many challenges in normal times, which were exacerbated afterAila.
The Aila emergency response project offered many lessons. The following are the
majorlessons learned from the project:
Community based cadre of animators is a valuable and sustainable
resource. The animators are the face of the project in the local communities and
the repository of the knowledge. Local communities trust them and access them
for queries and stocks of Nutrimix. Increasing the knowledge and skills of
animators greatly enhances their functioning and leaves behind a sustainable
resource in the communities.
The trainings of service providers were scheduled towards the end of the
project implementation period. This left little time to follow up on the trainings to
understand participants increase in knowledge and subsequent application to
their work. Further, the scheduling of trainings towards the end resulted in losing
out on a valuable resource that could have been tapped into earlier to garner
support and maximize on project activities.
The role of the civil society is to strengthen the state and ensure citizens
entitlements. Working with the system, even during such trying times like in the
aftermath of the cyclone, is necessary and fruitful. As the Aila emergency
response project demonstrated, it is essential to come together on common
platforms like the nutrition demonstration camps or the maternal health checkup
camps and speak in a common voice, thereby complementing one another.
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