Scoop situation - Field Exchange - Emergency Nutrition Network

January 2008 Issue 32ISSN 1743-5080 (print)• ‘Scoop situation’ in Tanzania• Wet-nursing and HIV in Bangladesh• Food sharing in South Sudan• Nutrition coordination in Zimbabwe• Acute malnutrition in young infantsin Afghanistan

ContentsField Articles2 Nutrition coordination in Zimbabwe:Achievements and Challenges12 Treatment of severe malnutrition inTanzania – a problem with ‘scoops’• PostscriptResponse on F-75 and use of measuringscoops21 Socio-Cultural Determinants of FoodSharing in Southern Sudan26 Wet nursing for refugee orphans inBangladesh• PostscriptUNHCR Comment29 Evaluation of Relactation by theSupplemental Suckling TechniqueResearch4 Review of targeting methods in HIVprogrammes5 An investigation of anthropometric trainingby NGOs6 Mortality and nutrition surveys by NGOs7 Famine in North Korea: Markets, Aid andReform8 Market analysis and humanitarian action inNiger8 Livestock Feeding Support as DroughtResponse9 Assessing micronutrient deficiencies inemergencies10 Triggers, Early Warning and Response inFFP Assistance11 WHO growth reference for children andadolescentsNews14 Regional workshop on IFE in Bali 200814 The Humanitarian Response Index15 New Red Cross Guidelines for CashTransfer Programming15 IASC Guidance on Mental Health andPsychosocial Support in emergencies15 Health and Nutrition evaluation guidelines15 FAO Livelihoods Assessment and Analysise-learning course16 WHO Technical Consultation and Updateon HIV and Infant Feeding16 Launch of The Lancet’s Series on Maternaland Child Undernutrition16 Sphere Project celebrates 10th anniversary17 Nutriset and Valid Nutrition sign licenceagreement17 WHO/UNICEF Joint Statement on OptimalIodine Nutrition17 Revival of ‘New & Noteworthy in Nutrition’18 Joint Statement on micronutrientdeficiencies in emergencies18 Reporting Skills and Professional WritingHandbook19 Report on WFP Training Workshop in Sudan19 Changes in eligibility for specialised food forHIV positive adults20 Workshop on the Integration ofCommunity-based Management of AcuteMalnutrition (CMAM)25 ENN led Management of Acute Malnutritionin Infants (MAMI) ProjectEvaluation23 WFP Targeted Supplementary Feeding inEthiopia25 Real time evaluation of Pakistan FloodResponseAgency Profile27 Department of Nutrition for Health andDevelopment (NHD), World HealthOrganisation33 People in AidFrom the EditorThe devil is in the detailIn this edition of Field Exchange we have anumber of field articles that address verydetailed programming issues.A field article by ACF deals with theexperience of implementing thesupplementary sucking technique (SST) forthe many infants under six monthspresenting at therapeutic feeding units inKabul, Afghanistan. Although the techniqueappears to lead to good outcomes whencorrectly applied, there were many instanceswhere the SST was not well implemented.For example, many infants were consideredcured when still mixed feeding and evenwhere infants were discharged on breastmilkalone, mothers often reverted to mixedfeeding at home. Unit staff found the admissioncriteria vague and difficult to apply, andwere also confused by the treatment protocolsand discharge criteria. Many of theinfants presented with breastfeeding difficultiesbut were not severely malnourished. Theauthor’s frank evaluation of their programminghas led them to question whether theadmission criteria used in the Kabul contextwere the best ones and whether the risks ofmanaging young infants, who need skilledsupport but may not specifically need to bein these intensive care centres, outweighsthe benefits.Another field article by Yara Sfeir of UNHCR,describes the challenges of feeding a smallnumber of infant orphans amongst Rohingarefugees in a camp in Bangladesh. Befittingthe local context, it was decided to locatewet nurses for these infants. However,locating wet nurses was not straightforward,even though there were only five orphans.Eventually, wet nurses were found in thewider community, i.e. not just amongstrelatives. Even then, a number of practicalproblems emerged, for example onehusband didn’t want his wife to breastfeedanother person’s child while one wet-nursefound it difficult to come to the centre tofeed eight times a day as she lived somedistance from there. There were alsosecurity issues about attending the centre atcertain times. All these challenges wereeventually met through ‘creative’ adaptationand according to the author, were well worththe effort.An article by Chloe Angood fromSouthampton University describes theproblems of using scoops provided withNutriset F75/F100 therapeutic milk formula.Through her work in a paediatric ward inTanzania where mortality rates amongstseverely malnourished children were veryhigh, she observed a number of difficulties inusing the Nutriset scoops. These includedover-feeding children, nurses finding it difficultto calculate the correct recipe for differentfeed volumes, miscounting of scoops andthe difficulty of making up individual feedsfor each child. A number of practicalrecommendations are made by the author toaddress these problems. Nutriset havewritten a post-script addressing some ofthese issues.These articles remind us that although wemay think our programme approaches andimplementation tools are the right ones,reality on the ground may, at times, causeus to re-assess how we do things.Approaches cannot just be devised andimplemented from ‘on-high’. We need to holdthe old mantra about ‘bottoms-up’programming at the forefront of ourthinking. In other words, not only is thedevil in the detail, but so is the answer.We also have our usual ‘bigger picture’material in this issue of Field Exchange.There is a particularly interesting field articleabout nutrition sector coordination in thecurrent Zimbabwe crisis, written by DianneStevens from UNICEF Zimbabwe. The articledescribes how UNICEF and partners havegradually plugged the coordination vacuumin Zimbabwe through establishing a NutritionTechnical Consultative Group (NTCG) thatnominally focuses on consultation and bestpractice, but in effect has become acoordination mechanism that is accepted bygovernment. Achievements of the NTCG todate, especially given the challengingprogramming environment, are considerable.These include greatly expanding reliable datato inform programming and mappingactivities in the nutrition, water and healthsector thereby strengthening inter-sectoralcoordination.We know from recent history how importantit is to get humanitarian co-ordination rightand what happens when we don’t.Coordination is essential for strategicplanning, gathering data and managinginformation, mobilising resources, ensuringaccountability, having a clear division oflabour and providing leadership. The work ofthe IASC global cluster (see Field Exchangeissue 31 news section) is making strikingheadway in strengthening country levelcoordination across a range of sectorsincluding nutrition. As highlighted by DianneStevens, while the cluster approach has notyet been officially activated in Zimbabwe,the approach has been collectively endorsedat a Workshop on Humanitarian Reform inJune 2007, and endorsed by the IASCCountry Team.This issue of Field Exchange also contains awide range of research, evaluation and newspieces. Research topics include summaries ofpapers on the development of the WHOgrowth reference for school-aged childrenand adolescents, and on livelihoods-baseddrought responses in pastoralist areas ofEthiopia. There are also summaries of areal-time evaluation of the response to thePakistan floods in 2007 and of a retrospectiveevaluation of the targeted supplementaryfeeding component of WFPs protracted reliefand rehabilitation programme (PRRO) inEthiopia from 2005 onwards.We hope you enjoy this issue of FieldExchange and, as always, please feel free towrite in with contributions and opinions.Jeremy ShohamEditorAny contributions, ideas or topics for futureissues of Field Exchange? Contact theeditorial team on email: office@ennonline.net1

Field ArticleA health centrein ZimbabweD Stevens/UNICEF, Zimbabwe, 2005Nutrition coordination in Zimbabwe:Achievements and ChallengesBy Dianne Stevens,UNICEF ZimbabweDianne Stevens is the NutritionManager with UNICEF in Zimbabwe.She chairs the Nutrition TechnicalConsultative Group responsible for nutrition coordinationin Zimbabwe. Dianne has 10 years experiencein working in emergencies both with NGOsand the UN and has been with UNICEF inZimbabwe since 2004.Over the past several years,Zimbabwe has experienced politicaland economic upheaval resulting inrampant inflation, drought, unemployment,food shortages and general deteriorationacross multiple sectors. Combined theyhave the potential to create a nutritional crisis.In 2004 there was a vacuum in the coordinationof nutrition activities in Zimbabwe.However, through a process of negotiation,UNICEF was given permission to establish theNutrition Technical Consultative Group(NTCG) with a focus on consultation and sharingof best practice rather than coordination.Since August 2004 the NTCG, chaired byUNICEF, has been meeting monthly and isincreasingly accepted by Government as theUnited Nations (UN) nutrition coordinationmechanism. Over the past year there has beenwide consultation in Zimbabwe on movingtowards cluster coordination. The clusterapproach has not yet been officially activated inZimbabwe. However, the approach has beencollectively endorsed at a Workshop onHumanitarian Reform in June 2007 and by theIASC Country Team. The next steps are for theIASC Country Team to make a formal submissionto the Emergency Relief Coordinator.This article highlights some of the challengesand successes to date of the UN-led nutritioncoordination mechanism in Zimbabwe.ChallengesCoordination and LeadershipThere are differing perspectives on the humanitariansituation, particularly betweenGovernment and the international community,leading to debates about whether Zimbabwe’ssituation is an emergency. As a result, the UNhas had to be flexible in its humanitarianprogramming in order to address needs.Furthermore, although Government has nominallybeen in charge of coordinating emergencynutrition interventions, it has not played anactive role in this. The NTCG was formedinitially with an information-sharing mandatebut also took on a ‘low profile’ coordinationrole. Through advocacy, negotiation and diplomacy,the benefits of having a coordinationmechanism are now recognised by Government(although it is technically not a member, it doesnow send a representative to some meetings.)Since 2004, UNICEF in its role of chair of theNTCG has effectively acted as a broker betweenthe Government and the non-governmentalorganisation (NGO) nutrition community.NGOs had not been permitted to conduct nutritionsurveys or establish therapeutic feedingprogrammes in isolation of government.Through this role, more NGOs are becominginvolved in support to both nutrition surveillanceand Community Therapeutic Care (CTC).Thresholds and Supplementary FeedingGovernment has its own established protocolsfor the treatment of acute malnutrition that arenot entirely in accordance with internationalprotocols. For example, the Government has athreshold of responding when acute malnutritionis above 7% - the national policy on supplementaryfeeding dictates that all supplementaryfeeding is blanket wet feeding of all childrenunder five years, in geographical areasidentified with high acute malnutrition. Withglobal thinking on emergency thresholds shifting,and with trend analysis indicating a deterioratingsituation with regard to acute malnutrition,partners are willing to intervene using thenational threshold of 7%. However, internationalagencies are generally not supportive ofthe delivery mechanisms in the nationalD Stevens/UNICEF, Zimbabwe, 2005supplementary feeding policy. Evaluation ofthe large-scale, blanket wet supplementaryfeeding programme (SFP) in 2003 was not positivein terms of resources and opportunity cost.Zimbabwe has therefore been facing a dilemmain 2007as acute malnutrition levels areapproaching 7% and in some districts are abovenational thresholds and may deterioratefurther. The NTCG is coming together on developinga common position on supplementaryfeeding and working towards solutions that canbe negotiated with Government.Capacity and dataDue to the limited capacity of the Governmenthealth system, their ability to monitor theimpact of emergency nutrition programmes ischallenging, especially as there are more than60 Ministry of Health and Child Welfare(MoHCW) hospital based therapeutic feedingsites across the country. It is therefore difficultto establish the actual numbers of admissions,performance of therapeutic feeding sites, typesof support required, commodity needs and sitesthat require external support. Much of thecontingency planning is therefore based onweak data.Mothers and children at a health centre inZimbabwe2

Field ArticleThe economyHyperinflation of more than 15,000% makes thelogistics of programming very difficult. Theunavailability of cash and fuel is particularlyproblematic. Local NGOs often find it difficultto get into the field and staff salaries are erodedaffecting morale and turnover. Through thecoordination mechanisms, the UN is supportingNGOs through payment in USD (UnitedStates dollar) or USD equivalent, providing fuelto implementing partners and disbursing fundsin ZWD (Zimbabwe dollar) based on timing ofthe activity rather than in large lump sums.DonorsThere is a difficult donor and funding environmentin Zimbabwe involving restrictive conditionson funding. Support is provided mainly tohumanitarian interventions and there is restrictionon support to government interventions.This poses challenges when emergency nutritioninterventions are primarily the domain ofthe government. It has therefore been very difficultto attract support to treat malnutrition in thecontext of HIV/AIDS although donor advocacyand linking malnutrition to HIV proposals hasresulted in some success in attracting funding.Brain drainZimbabwe has a strong nutrition infrastructurewith tertiary training in nutrition and alsoprovincial and district level nutritionist positionswithin the MoHCW. However, the ‘braindrain’ over the past several years has meantthat many of these positions are now vacant orare filled by new graduates with limited experience.Because of this there is a diminishingcapacity to implement quality nutritionprogrammes, including the treatment of severemalnutrition. UNICEF has been providingsupport to the National Nutrition Unit in theestablishment of community based nutritionprogramming, including CTC, to alleviate thestrain on the health services. Some NGOsprovide nutrition support to health clinics.However, since historically the MoHCW hashad good capacity, few NGOs have beeninvolved. UNICEF through the NTCG has beenworking to improve government and NGOcollaboration.Addressing chronic nutritional problemsNutrition trend analysis in Zimbabwe hasshown increasing levels of chronic malnutritionand the Demographic and Health Survey(DHS) of 2005/6 found national levels of stuntingof 29%. Addressing chronic malnutritionrequires an integrated response including foodsecurity, care practices, health aspects of malnutritionand water and sanitation. However,Zimbabwe does not have a National NutritionPolicy in which to frame these interventions. A2005/6 nutrition intervention mapping exercisefound that the focus of NGO nutritional activitiesis on food security with few working on thehealth and care components of malnutrition. In2007 the NTCG emphasised capacity developmentof its members and a number of trainingswere conducted to broaden nutrition skills.Plans are in place to develop a NationalNutrition Policy and the NTCG will beincluded in the consultation process.Key AchievementsGreatly expanded reliable dataGiven the reluctance of the MoHCW to allownutrition surveys, few have been conductedsince 2003 to inform programming. In 2004,UNICEF started supporting the Food andNutrition Council to establish a National Foodand Nutrition Sentinel Site Surveillance System(FNSSS). The system now collects data biannuallyin 23 sites but is flexible and can beexpanded to respond to worrying trends. Thisoccurred following the June 2007 assessmentand has resulted in the October assessmentcovering 60 rural districts and selected urbansites. Through the FNSSS the country now hasaccess to timely nutrition data to informprogramming. The NTCG has facilitated NGOinvolvement in the FNSSS in their areas of operationand NGOs are encouraged to participatein the FNSSS rather than conduct their ownsurveys.The NTCG has undertaken an interventionmapping exercise for the Nutrition Sector. The2005/6 Who-What-Where Atlas has been developedto serve as a planning tool for improvedcoordination in nutrition. Continued mappingis planned on an annual basis to determine theresponse capacity of the sector and identify keyplayers for specific activities. In June 2007 thesecond Nutrition Atlas was published which ispart of a broader initiative that includes interventionmapping for child protection (Orphansand Vulnerable Children (OVC)) and water andsanitation. Mapping exercises include alreadyimplemented activities as well as planned activities,in order to further strengthen coordination.Data collection tools are standardised topromote recognition and participation amongpartners.Creation of the NTCGThe NTCG has acted as a forum for presenting,sharing and discussing best practice in nutritionand HIV – an emerging area where newfindings and guidelines regularly enter thepublic domain. The NTCG has opened itsmembership to include agencies working inHIV.The NTCG has maintained a degree of emergencypreparedness for Zimbabwe with coordinationmechanisms in place for a scaled upresponse if needed. The Group meets monthlyand is active in emergency preparedness activitiesincluding contingency planning and capacitydevelopment.Currently, many non-specialists are workingin the nutrition sector as well as members of theNTCG. Based on findings from the NutritionAtlas and from a training needs assessmentdone with members of the NTCG, a trainingprogramme was conducted in 2007 with anemphasis on nutrition education for peopleliving with HIV/AIDS (PLWHA).Cluster approachThere has been considerable consultationaround Zimbabwe becoming a global cluster.Several workshops on UN humanitarianreform, and specifically on cluster coordinationand what it means for Zimbabwe, have beenconducted. Deliberations from these meetingsand workshops are always fed back to theNTCG. The Group is in the process ofdiscussing possible implications for nutritioncoordination so that all members are fullyaware and have participated in the process.CoordinationThe ‘Atlas’ intervention mapping exercise,which describes who is doing what and wherein the nutrition, water and sanitation and OVCsectors, has been a successful initiative to linkcoordination between the sectors. There isstrong representation of different sectors ineach of the coordination meetings along withstrong informal linkages.ConclusionsZimbabwe’s complex and colliding problemspresent enormous challenges to the nutritionsector. However, greatly improved coordinationand reliable and current data have createdthe foundation for effective interventions. Asthe need in Zimbabwe grows, it is vital thiscoordination is maintained and donor supportis broadened.For further information, contact: DianneStevens, email:dstevens@unicef.orgD Stevens/UNICEF, Zimbabwe, 2005A focus group discussion in Zimbabwe3

ResearchMUAC measurement in MalawiAn investigationof anthropometrictraining by NGOsBy Naomi TilleyNaomi has just completedher MSc in Public HealthNutrition at the LSHTM. Aqualified nurse, she haspreviously worked withMSF in Ethiopia and Sudan.A recent cross-sectional study reported in FieldExchange 1 investigated weighing scales used inemergency nutrition programmes specifically forinfants less than six months old. The purpose ofthe study was to see which type of scale wasused in emergency nutrition programmes andthe type of scale that would be most appropriate.In response to the deficiencies identified, theUniversity of Southampton is developing weighingscales for field conditions suitable for children0-5 years. While this will improve capacityto assess young infants accurately and precisely,this outcome will also depend on the competencyof the measurer. If the staff that are undertakingthe anthropometric measurements havelimited training and standardization, the measurementerror could continue to be significant.The aim of this project 2 was to investigate anthropometricmeasurement training in nutritionprogrammes. The main objectives were:• To investigate the level, depth and frequencyof training provided by a sample of nongovernmentalorganizations (NGOs) inweight, height and mid upper armcircumference (MUAC) measurement forstaff in emergency nutrition programmes.• To analyse and evaluate the anthropometricmeasurement training guides and methodsused by a sample of NGOs.• To explore methods of standardising trainingfor field staff in emergency nutritionprogrammes.MethodologyA literature review was undertaken to look atanthropometric measurement error, training andstandardisation methods that have beenemployed in emergency nutrition programmes.Staff and students at LSHTM who had previouslyworked for a NGO in a nutritional interventioncapacity were solicited to be involved inthe study and recruitment emails were targetedat international NGOs and to contacts suppliedby the Emergency Nutrition Network (ENN).Both self-administered and interview-administeredquestionnaires were used.ACF, MalawiParticipants were split into three categories:• National nursing or nutritional staff workingwithin a nutrition programme.• Nursing or nutritional supervisors (nationalor expatriate) working within a nutritionalprogramme.• Nutritional or medical coordinators oradvisors to the nutrition programmesOne questionnaire was devised for each of thethree categories of interviewee. The questionnairewas pilot tested by five individuals withexperience in nutritional interventions.Fourteen nutrition and anthropometric measurementmanuals were tested for:• Readability• Clarity of instructions/explanation• Clarity and depth of diagramsThe Flesch/Flesch–Kincaid Readability Testswere used to measure how difficult a pasage oftext was to read and what level of educationwould be needed to comprehend the text(American grading converted to age in years)Clarity of instruction was assessed according todefined criteria and scored (1-3). Diagrams werealso scored 1 (clear diagram present), 2 (diagrampresent) and 3 (no diagram).ParticipantsThirty-two individuals participated in the study(91% response rate). Countries representedincluded Somalia, Ethiopia, Niger, Malawi,Zimbabwe, and Uganda. The participants workedfor a variety of NGOs including Samaritans’Purses, Medecins sans Frontieres (MSF) Holland,MSF UK, MSF France and MSF Spain, ConcernWorldwide, Valid International, Action Contre laFaim (Spain, UK and USA offices), Save theChildren UK and Medecins du Monde.The limitations of the study included:• Small sample size• High proportion of the nursing and nutritionalstaff having a good level of English andcomputer skills• Some of the participants required translationof the questionnaire. This process introducesan element of error.• There were discrepancies between the tworeadability scores used to measure themanuals.ResultsQuestionnairesOf the 32 study participants, 94% had receivedanthropometric training. Five respondents (16%)had received only theoretical training from readinga book or listening to a lecture. One fifth (20%)of the supervisors have not received anthropometricmeasurement training in the last 5 years.In general, national staff received longeranthropometric training - 87% reported trainingof 2 or more days, compared to 7% and 10% ofcoordinator/advisors and supervisors respectively.Over half (55%) of the national staff weretrained by the nursing or nutritional supervisor.Twenty two percent of the trainings receiveddid not include infants less than 6 months andadult assessment.Ten of the 13 medical / nutritional coordinator oradvisors had been actively involved in trainingnursing or nutritional staff within a nutritionalprogramme. One third (33%) of the coordinator/advisorparticipants described the training atthe project sites as “very good”.Of the nursing and nutritional supervisors, 64%were content with the anthropometric measurementtraining they received. Half of the 36% ofparticipants who were unhappy with the trainingreceived attributed this to a lack of practicaltraining and experience. Recurring issues regardinganthropometric measurements/trainingreported by nursing and nutritional supervisorsincluded:• Undertaking MUAC on infants under 6 months• Staff becoming tired and bored causingsloppy measurements• Inconsistent clothing removal and positioningof individual• Calculation and number problems• Problems distinguishing between calibrationand zeroing of scales• Concept of eye level for Salter scales• Time of day the measurement is undertaken• When to measure length or height• Scales not accurate enough to measure infants• Too many different MUAC tapes that can beconfusing to read.CalibrationHalf (50%) of the supervisors said calibration ofthe weighing scales occurred every time thescales were used, 25% said calibration occurredmonthly and 12.5% said calibration neveroccurred. A quarter of nursing / nutritional staffhad never calibrated, whilst three-quartersreported calibration with each use 3 . Howeverover half (63%) of the supervisors highlightedcalibration as an area of concern with little consistencyof calibration or zeroing in the project sites.Perceived competencyWhile 88% of national nursing and nutritionalstaff said they felt very competent at undertakingweight measurement for children aged between6 months and 5 years, this fell to 29% for infantsless than 6 months. The majority (86%) of participantssaid they were ‘very competent’ at measuringheight, while a lower proportion (71%) felt‘very competent’ at measuring length.The study identified some confusion amongstparticipants on when to measure height andlength (75cm v 85cm cut off).Policy on trainingTwo-thirds (67%) of participants said there wasno agency recommendation for the frequency oftraining, while 17% of participants said thattraining depended on a number of variables,namely:• Undertaken before every nutrition survey• Depending on the motivation of the trainer• Depending on the need of the project andcontext• On induction for new staff members.When asked about refresher training, 11% of theparticipants said it occurred prior to the surveysor randomly rather than routinely.Evaluation of training manualsMost of the manuals scored ‘1’ in clarity, i.e. theanthropometric measurement instructions wereclear and broken down into a step-by-stepprocess. Overall, nearly half (46%) of the participantssaid the manuals were “very good”,because the manuals were clear, comprehensive,user friendly and complete. One third (33%) ofrespondents considered the manuals were “OK”,describing them as not stimulating or interactiveand too focused on the 6 – 59 months age bracket.This report varied between the three groups -three quarters (75%) of the nursing and nutritionstaff said the manuals provided by the NGOSwere very good, compared with only one third(33%) of supervisors. One fifth (19%) of thesupervisors and advisors/coordinators said themanuals were not good. For the manuals to bemore engaging participants suggested the5

ResearchFamine in NorthKorea:Markets, Aidand ReformAnti-floodingoperation inCongjin that wassupported byWFP in Food forWork programmein 2004.Summary of book review 1‘Famine in North Korea: Markets, Aid, andReform’ is a newly published book 2 with a forewordby Nobel prize winning economist,Amartya Sen. It provides a pithy analysis of themass starvation that began in North Korea inthe early 1990s leading to an estimated 600,000– 1 million deaths out of a population of 22million people. This is a summary of a bookreview appearing in a recent edition of theLancet.Although North Korea had suffered frombad weather, external shocks and low foodproduction, the authors suggest that the causeof famine was primarily the collapse of entitlements,notably the ability of people tocommand food from the public food distributionsystem in an authoritarian state. Accordingto the authors, locked into a landmass of whichonly about 20% can be cultivated, North Koreaadopted a misguided strategy of food selfreliance.Chronic difficulties in agriculture andfood spiralled into a full-blown crisis in 1995with a series of set backs: withdrawal of aidfrom the then Union of Soviet SocialistRepublics) (USSR), flooding and a succession ofnatural disasters, and geopolitical isolationresulting from the country’s attempt to developa nuclear arsenal.However, it was neither the weather orshocks which caused the famine but rather statefailure of denying people their food entitlementfrom a collapsed public food distributionsystem. Not all Koreans suffered equally.Hardest hit were the young and elderly, peoplein the north-eastern provinces and those fromlower status occupational groups, such as farmershousekeepers and the jobless.North Korean workers packing fortified biscuitsat factory in Sinuiju city, North Pyonganprovince supported by WFP and UNICEF in 2003.WFP/Gerald Bourke, DPR Korea, 2003The authors place responsibility for thefamine squarely with the North Korean government.They argue that the crisis was systemic,intimately related to the authoritarian structureof government, the absence of accountability tothe citizenry, and the denial of political andcivil liberties and property rights. “The governmentrequested international food aid only in1995, although food difficulties were evident asearly as 1991”. How much of the government’sprocrastination and ineptitude were due tomalfeasance or lack of information is unclear,which the authors generously accept by consideringa range of explanations for failure of thestate. Such entitlement failures of socialist politicalsystems are the source of some of the greatest20th century famines: the USSR in 1921-22and 1946-47; Ukraine in 1932-34; China in 1958-62; Cambodia in 1976; and Ethiopia in 1984-85.The international humanitarian aid communityis not let off the hook either. Between 1995-2005, North Korea received about $2.3 billion inforeign aid, two-thirds as food aid.Government insisted upon controlling food aidby restricting the number and movement offoreign staff, blocking agencies from developingindependent channels for food delivery,and forcing them to accept assigned Koreantranslators. Data show that as donated foodvolumes increased, the government reduced itspurchase of imported food. Aidgivers wereforced to accept North Korean “exceptionalism”,tight restrictions on their oversight, andsupervision of donated food. Consequently,aid-givers worried over access to people inneed, monitoring and tracking, and outrightleakages. The authors estimate that about 30%of food aid was diverted, mostly to the county’selite, including the military.The routing of food aid reflected, respectively,harder line versus softer line in pushingfor North Korean cooperation in security negotiations.Aid-givers thus had mixed humanitarianand political motives, with the latter heightenedduring political negotiations over NorthKorea’s ambition to develop nuclear armaments.The authors are quick to point out that thesedifficulties do not mean that aid was withoutpositive benefits. The ruthless behaviour of aself-preserving regime unresponsive to theneeds of its citizens was balanced by the mixedmotives and poor coordination of foreign aidgivers.The collapse of the public distributionresulted in a bottoms-up marketisation of food,changing the basic economic pattern of fooddistribution in North Korea and opening upspace to secure food beyond the public distributionsystem. An expanding food market inNorth Korea was an unintended consequencethat the regime now treats with mixed signalsof tolerance. Markets in food, if sustained andexpanded, could become the seeds of majorreforms of North Korea’s economy that areessential for sustainable food security andfamine prevention.The final conclusion of the authors is that“we see no substitute for a policy of seeking toaid the North Korean people while engagingthe government and encouraging its political,as well as economic, evolution.”1Chen. L and Lam. D (2007). A penetrating analysis offamine in North Korea. www.thelancet.com. Vol 370, Dec8th, 2007, pp 1897-18982Haggard. S and Noland. M (2007): Famine in North Korea:Markets, Aid and Reform. Columbia University Press, 2007.Pp 368, US$35.00. ISBN o-231-14000-2Market analysisand humanitarianaction in NigerSummary of published research 1In April 2005, a typical household in Nigerdepended on market purchases for 90% of itsfood. The large majority of Sahelian householdsare not self-sufficient in staple foods. Thismarket dependence increases in years of pooragricultural production. Food security analysisin the Sahel has for some time focused on theassessment of agricultural production. A recentarticle in Humanitarian Exchange argues that itis now time to devote more resources toanalysing how markets contribute to the distributionand pricing of food and that marketanalysis is important for food security assessment.There are three main reasons for this.First, markets have the capacity to amelioratethe negative impacts of shocks. Second, marketanalysis contributes to food security monitoringand third, market analysis informs the debateover cash versus food assistance.The hike in food prices in Niger followedsteep price rises in Nigeria, caused by loweragricultural production and buoyant demand.This stemmed from high consumer purchasingpower and demand from the poultry and foodprocessing sectors. Higher prices in Nigeriacaused a drastic drop in exports to Niger.Meanwhile cereal flows reversed with Nigernow supplying Nigeria. This trade-drivensupply squeeze was compounded by lowerdomestic crop production because of locustattacks and some dry spells.During 2004-5, SIMA (the national systemfor agricultural market information in Niger)and FEWS NET 2 reported relatively high pricelevels, although this alert was not well receivedby humanitarian actors and donors. Thereasons advanced to explain the price increaseswere neither complete nor convincing. This wasmainly because of a lack of shared knowledgeof cereal markets and trade and the absence ofreliable statistics on imports and agriculturalproduction in Nigeria. In addition, humanitarianactors did not understand just how dependenthouseholds in Niger were on food marketpurchases, how households were linked tomarkets and how these relations had evolved.Lastly, there was no agreed alert threshold forprice increases amongst humanitarian actors.The widespread publicity given to foodprices and markets during the Niger crisisencouraged greater analysis of cross-bordertrade and markets. FEWS NET, SIMA and thePermanent Interstate Committee for DroughtControl in the Sahel (CILSS) began conductingmissions to markets in northern Nigeria thathelped provide an explanation of the 2005 pricehike. The following lessons were learnt.• A sub-regional or regional approach,covering all the key trade linked zones inWest Africa, is preferable to a purelynational approach.• Assessments should devote more attention

Women and children,in the village ofBarmou, gather andwait to receive WFPdistributed foodto demand factors at the micro level, inaddition to analysing the various sourcesof food supply, prices, markets and tradestructures. Market monitoring should beconducted on the basis of an agreedunderstanding of the market’s structure,conduct and performance. The analysisshould cover flow information, as well asprices. Partnerships for market assesmentsshould be broadened to capture themultidimensional character of marketsand to agree on conclusions and recommendations.At the end of 2005, FEWS NET and the WorldFood Programme (WFP) launched a study toidentify knowledge gaps regarding linksbetween markets and food security in WestAfrica. The study also formulated recommendationsto reinforce market analysis of foodsecurity assessments. These included establishinga regional monitoring system forcross-border flows, strengthening capacitiesto conduct market analysis, and developingtools to analyse the links between householdsand markets.In the context of making CILSS theregional centre of excellence for marketanalysis in West Africa, two high-prioritychallenges have been identified. First, CILSSand its sister organisation, the ‘Reseau desSystèmes d’Information sur les Marchés enAfrique de l’Ouest (RESIMO), must besupported to establish a strong regionalmarket monitoring system and to become atechnical assistance provider to nationalmarket information systems.The second challenge concerns the interactionbetween households and markets.Characterising these relationships wouldassist in identifying when price changes couldjeopardise food access. Pilot testing of qualitativeand quantitative methods to analysethese interactions has been conducted inMauritania, but further work is necessary. Asthe influence of markets on household foodsecurity varies for each livelihood group, alivelihood approach is essential. In addition,due to intra- and inter-annual variations,longitudinal data is necessary to enable ameaningful characterisation of households’interaction with markets. FEWS NET andWFP are ready to support CILSS in tacklingthis priority challenge – an initial stock-takingof experiences in other regions of the world,which might be adapted to the West Africancontext, has been initiated by FEWS NET, incollaboration with its partners.1Beekhuis. G and Laouali. I (2007). Cross-border tradeand food markets in Niger: why market analysis isimportant for humanitarian action. HumanitarianExchange, No 38, pp 25-27, 20072Famine Early Warning System. Seehttp://www.fews.net/WFP/Martin Specht, Niger 2005Livestock Feeding Support asDrought Response Summary of research 1A livelihoods-based drought response in pastoralistareas could aim to protect key livestock assetsand support rapid rebuilding of herds afterdrought. One aspect of developing such aresponse requires decision makers to understandthe relative importance of different causes of livestockmortality during drought.Research conducted by the Pastoralist LivelihoodsInitiative in Afar, Borana and Somali areas ofEthiopia aimed to quantify different causes of livestockmortality during ‘normal’ and ‘drought’years (see Table 1). These figures show that:• Most of the excess livestock mortality recordedin drought years is caused by starvation.• Disease is an important cause of mortality inboth normal years and drought years, indicatingweaknesses in veterinary services inboth situations (disease-related mortality doesnot always increase during drought).Evidence from Pastoralist Livelihood Initiative(PLI) impact assessments in southern Ethiopiashowed that when some livestock were destocked,pastoralists chose to use part of theresulting income on both animal feed support (upto 31% of income) and veterinary care (6% ofincome). This pattern of investment contrastedwith a typical aid response for livestock duringdrought, which focuses heavily on veterinarytreatments or vaccinations.An analysis of supplementary livestock feedingprogrammes in northern Kenya in 2001 assumedthat feed was provided for 8000 sheep and goatsfor three months during drought. Each animal wasfed 250g concentrate/day. The cost was comparedwith the cost of replacing these animals by restockingafter the drought. Whereas the feedTable 1Reason for off-take orloss from herdA sick cow and a shepherdboy in Ab'Ala Afar RegionLivestock leaving pastoralist herds in normal and drought yearsAfar herds Borana herds Somali herdsNormalyearDroughtyearNormalyearDroughtyearNormalyearResearchprogramme cost US$82,353, the restocking wouldhave cost US$258,065 – it was around three timesmore expensive to restock than to keep sheep andgoats alive during the drought through feedsupplementation.A theoretical analysis of feed, transport, operationaland administration costs for delivering feedin Afar region found that restocking sheep andgoats cost around 6.5 times more than supplementaryfeeding. Restocking cattle costs 14 times morethan supplementary feeding.The PLI research highlighted a number of keypolicy and programming issues:• The livelihoods objective of supplementaryfeeding is to protect a core herd of breedinganimals, and encourage post-drought recovery.This requires participatory assessment withpastoralists to agree on the composition andsize of core breeding herds before droughtoccurs.• Supplementary feeding is not a stand-aloneintervention – it should be part of an overalldrought cycle management approach thatcombines early de-stocking and preventiveveterinary care. However, in terms of proportionalinvestments in different types of livestockintervention, far more investmentshould be made in supplementary feedingand this investment should probably exceedexpenditure on veterinary care.• Feeding can start during the alarm phase of adrought with high energy, high fat and highprotein concentrates – this is very cost-effectivecompared to restocking after drought. Someroughage, such as hay, may also be needed.• Maintaining drought-stricken herds onroughage alone may not be very effective asweakened animals cannot regain body weightand strength in a short time to cope with thesituation. Hay is also relatively expensive totransport due to its physical bulk.• Optimal feed provision in pastoral areasshould be planned for a maximum of threemonths at a time, as most droughts (or theneed for additional feed from outside) do notlast longer than that.• In normal periods, agencies need to assumethat livestock feed purchase and distributionwill be required in the next drought.Procurement and transport costs need to beanticipated, and reliable sources of feed identified.This type of planning will assist rapidbuying and distribution of feed.1Pastoralist Livelihoods Initiative (2007). Food for Thought:Livestock Feeding Support during Drought. Policy Brief,Number 2, November 2007DroughtyearStarvation 0% 19.5% 0.7% 13.1% 0% 15.5%Disease 10.1% 16.7% 12.5% 11.9% 12.6% 7.3%Sale 6.0% 6.5% 8.4% 8.5% 7.0% 5.1%Slaughter 0.6% 0.4% 1.7% 1.8% 4.1% 3.1%Predation 4.7% 5.1% 6.8% 6.1% 6.1% 4.6%Other 6.1% 5.3% 7.0% 6.2% 2.9% 1.2%Total 27.5% 53.5% 37.1% 47.6% 32.7% 39.8%WFP/Wagdi Othman, Ethiopia, 2002Group at a Khasdhalai floodshelter in Bangladesh 8

ResearchAssessing micronutrient deficiencies inemergencies Summary of review 1Micronutrient deficiencies have been reportedfor years in emergency settings, especially inrefugee camps where they were most frequentlyassessed. However, assessments have remainedscarce, with less than 10% of anthropometricnutrition surveys reported in the NutritionInformation in Crisis Situations (NICS) 2 bulletinin 2005-6 having a micronutrient assessmentcomponent. Anaemia, measured by bloodhaemoglobin concentration, and clinical vitaminA deficiency were the main deficiencies investigated.A recent review published by the StandingCommittee on Nutrition (SCN) explores optionsavailable for investigating micronutrient deficiencies.It draws attention to best practices andincludes references to practical tools and guidelines.It begins with the premise that when investigatingmicronutrient deficiency disease(MNDD), it should be remembered that clinicalsigns will usually only be the tip of the iceberg.Beneath this a much greater burden of sub-clinicaldeficiency will almost always be found. Twomain approaches to investigate micronutrientdeficiency disease are used:i) Indirect assessment that involves estimationof nutrient intakes at population level andextrapolating risk of deficiency and likelyprevalence and public health seriousness ofMNDD.ii) Direct assessment involving measurement ofclinical or sub-clinical deficiency in individualsand using information to estimate populationprevalence of MNDD.The review highlights a number of recent initiativesand resources to improve field practice, e.g.World Health Organisation (WHO) reviews,field manuals by the Centre for DiseaseClassification (CDC) and the MicronutrientInitiative (MI) and SPHERE project manuals.However the reviewers argue that many gapsexist in our knowledge of how to assess micronutrientdeficiencies and how to react to the informationcollected.Field haemoglobin testingusing a hemacue machineFilippo Dibari/Andy Seal, Ethiopia, 2004The main conclusions of the SCN review are asfollows;Further improvements in field friendly techniquesfor assessment are needed. Using directcollection and storage of liquid serum and urineremain a more reliable method of sample collectionthan blood spots, but more work on samplecollection and storage is needed to make fieldsurveys easier to conduct in remote locations.The increasing introduction of micronutrientfortifiedfoods in food rations (especially blendedfood) since the mid-nineties, has probably helpedto prevent a number of major micronutrientoutbreaks. However, outbreaks have continued toarise. The review suggests that a combination ofresponses may be appropriate, namely increasingaccess to fresh food, improving livelihoods andaccess to markets, enhanced fortification of fooditems of the general food distribution, distributionof pills, and home-based fortification withmicronutrient powders or fortified condimentsare some of the alternatives 3 .For the rapid design of nutritionally adequaterations at minimum cost, linear programmingand other mathematical optimisation techniquescan be important tools. They can take intoaccount constraints like dietary practices andfood costs in developing diets that meet nutrientrecommendations and can be used to model theworst and best case scenarios to more reliablydetermine risk of deficiency. They can also beused to assess the economic value of fortifiedfood supplements. Implementation of theseapproaches in easy-to-use software tools couldlead to dramatic improvements in the nutritionalquality of rations and a reduction in costs.However, they have seldom been used in emergencycontexts to date.In the absence of fortification or supplementation,diets need to be diversified and balanced.However, it has proven difficult to distributefresh, perishable foods on a large scale due tologistic constraints. Some small-scale successfulPremxing fortified food in ZambiaFilippo Dibari/Andy Seal, Zambia, 2004home gardening programmes have beenreported, but their impact on nutrient intake wasnot investigated.Fortification of food aid commodities may beachieved at different stages of the logistic pathway.Guidelines on food fortification have beenrecently released by WHO and initiatives toincrease the fortification of foods within developingcountries continue to expand.While pill distribution has been useful inpreventing/treating MNDD in the short-term,longterm supplementation might be less sustainable.Maintaining a distribution network to servethe whole population and ensuring adherenceand safe use by different population sub-groupswould also be a major challenge for health andnutrition agencies.Home based fortification using a micronutrientpowder, highly fortified paste or sauce hasbeen increasingly used in programmes.However, published evidence on its use in emergenciesis still scarce. A large-scale distribution ofa micronutrient powder to children aged 6months to 12 years in families displaced by theTsunami was successfully implemented in Acehand Nias provinces of Indonesia in 2005-6, but nodata on nutritional impact has been reported.A number of issues related to supplementationpersist, e.g. the potential toxicity of supplementingchildren with iron in malarious areas ifsupplementation is targeted at the whole populationrather than those known to be iron deficient.There is also uncertainty, and therefore theneed for caution regarding the use of micronutrientpowders in home fortification.The authors conclude that efforts to improvethe micronutrient status of populations in emergencysituations should continue and be givenpriority as a major public health issue.1SCN (2007). Assessing micronutrient deficiencies in emergencies:Current practice and future directions. Supplementby Andrew Seal and Claudine Prudhon October 2007.Standing Committee on Nutrition (SCN), Geneva,Switzerland.2See online athttp://www.unsystem.org/SCN/Publications/html/rnis.html3Exclusive breastfeeding for infants under six months andcontinued breastfeeding is another significant and recognisedmeans to protect micronutrient status of infants and youngchildren. See news piece this issue of Field Exchange onWHO/UNICEF Joint Statement on micronutrient deficienciesin emergencies (p18). (eds)A case of Casals necklace(pellagra) in AngolaFilippo Dibari/Andy Seal, Ethiopia, 20049

ResearchWHO growth reference forchildren and adolescentsSummary of published research 1The need for a widely applicable growth referencefor older children and adolescents hasincreasingly been recognised by countriesattempting to assess the magnitude of thegrowing public health problem of childhoodobesity. This need has been reaffirmed by therecent release of the new under-five growthstandards by the World Health Organisation(WHO) (see Field Exchange issues 28 and 30).A paper has just been published whichreports on a reconstruction of the 1977 NationalCentre for Health Statistics (NCHS)/WHOgrowth reference for older children. It comparesthe resulting new curves (the 2007 WHO reference)with the 1977 NCHS/WHO charts, anddescribes the transition at 5 years of age fromthe WHO references for under-fives to thesenew curves for school-aged children andadolescents.The approach used in constructing the 2007WHO reference addressed the limitations of the1977 NCHS curves, recognised by the 1993expert committee that recommended their provisionaluse for older children. The height-for-agemedian curves of the 1977 and 2007 referencesoverlap almost completely with only a slightdifference in shape. This is probably due to thedifferent modelling techniques used. Whencompared to the 1977 NCHS/WHO curves, thedifferences in the newly reconstructed weightfor-agecurves are significant in all centiles apartfrom the median and the –1 standard deviation(SD) curves. This reflects the important differencein curve construction methodology. The factthat the median curves of the two referencesoverlap almost completely is reassuring in thatthe two samples used for fitting the models arethe same within the healthy range (i.e. middlerange of the distribution).The reference data for Body Mass Index(BMI)-for-age recommended by WHO arelimited in that they begin only at 9 years of ageand cover a restricted distribution range(5th–95th percentiles). The 2007 reconstructionpermits the extension of the BMI reference to 5years, where the curves match WHO under-fivecurves almost perfectly (see table 1 for referencevalues). Furthermore, at 19 years of age, the2007 BMI values for both sexes at +1 SD (25.4kg/m 2 for boys and 25.0 kg/m 2 for girls) areequivalent to the overweight cut-off used foradults (25.0 kg/m 2 ). The +2 SD value (29.7kg/m 2 for both sexes) compares closely with thecut-off for obesity (30.0 kg/m 2 ).The 2007 height-for-age and BMI-for-agecharts extend to 19 years, which is the upper agelimit of adolescence as defined by WHO. Theweight-for-age charts extend to 10 years for thebenefit of countries that routinely measure onlyweight and would like to monitor growththroughout childhood. Weight-for-age is inadequatefor monitoring growth beyond childhooddue to its inability to distinguish between relativeheight and body mass. Hence, the provisionof BMI-for-age complements height-for-age inthe assessment of thinness (low BMI-for-age),overweight and obesity (high BMI-for-age) andstunting (low height-for-age) in school-agedchildren and adolescents.Growth reference data for children and adolescentsaged 5-19 years (or 61-228 months) isavailable on the WHO website,http://www.who.int/growthref/en/1Onis de M et al (2007). Development of a WHO growthreference for school-aged children and adolescents. Bulletinof the World Health Organisation, volume 85, No 9, pp 649-732, September 2007. Available athttp://www.who.int/bulletin/volumes/85/9/07-043497/en/print.html#R18#R18Table 1 Reference values for height-for-age, weight-for-age and body mass index-for-age at 5 years by sex for the 1977 and 2007references, and the WHO Child Growth Standards1977 reference 2007 reference WHO standards* 1977 reference 2007 reference WHO standards*Z-scores Boys GirlsHeight-for-age (cm)–3 SD 96.1 96.0 96.1 95.1 94.9 95.2–2 SD 100.7 100.6 100.7 99.5 99.6 99.9–1 SD 105.3 105.2 105.3 104.0 104.3 104.7Median 109.9 109.7 110.0 108.4 109.1 109.4+1 SD 114.5 114.3 114.6 112.8 113.8 114.2+2 SD 119.1 118.8 119.2 117.2 118.6 118.9+3 SD 123.7 123.4 123.9 121.6 123.3 123.7Weight-for-age (kg)–3 SD 12.3 12.6 12.4 11.9 12.2 12.1–2 SD 14.4 14.2 14.1 13.8 13.8 13.7–1 SD 16.6 16.1 16.0 15.7 15.8 15.8Median 18.7 18.3 18.3 17.7 18.1 18.2+1 SD 21.1 20.9 21.0 20.4 21.0 21.2+2 SD 23.5 23.9 24.2 23.2 24.5 24.9+3 SD 25.9 27.5 27.9 26.0 29.1 29.5Body mass index-for-age (kg/m 2 )**–3 SD – 12.1 12.0 – 11.8 11.6–2 SD – 13.0 12.9 – 12.8 12.7–1 SD – 14.1 14.0 – 13.9 13.9Median – 15.3 15.2 – 15.2 15.3+1 SD – 16.6 16.6 – 16.9 16.9+2 SD – 18.2 18.3 – 18.8 18.8+3 SD – 20.1 20.3 – 21.3 21.1*WHO Child Growth Standards for 0–5 years of age.**For BMI, the 1991 reference data start at 9 years of age.11

Field ArticleA group of nurseslearning how to makeF75 and F100Treatmentof severemalnutritionin Tanzania– a problemwith ‘scoops’By Chloe AngoodC Angood, Tanzania, 2007This article describes practical problems in preparingtherapeutic milk in a hospital-based setting andmakes some suggestions to resolve them.It is estimated that 3% of children under 5years are severely wasted in Tanzania 1 .Severe malnutrition with complicationsrequires inpatient management 2 . As adequatestructures do not yet exist in Tanzania toprovide community-based care, uncomplicatedcases are also currently treated as inpatients.Significant efforts have been made in recentyears by UNICEF, the World HealthOrganisation (WHO), the Tanzania Food andNutrition Centre (TFNC) and the PaediatricAssociation of Tanzania (PAT) to build thecapacity of inpatient facilities in Tanzania tomanage severe malnutrition. These efforts haveincluded training of selected health staff byWHO and UNICEF and the supply of F75,F100, Plumpy’nut®, weighing scales andlength boards to 11 inpatient facilities byUNICEF since October 2006.In April 2007, a follow-up visit was madeon behalf of the International MalnutritionTask Force (IMTF), in association withWHO/UNICEF and the Royal College ofPaediatrics and Child Health, to assessprogress, particularly at Muhimbili NationalHospital (MNH). It was found that althoughthe WHO and UNICEF training had improveddoctors’ knowledge and prescribing practicesat MNH, training had not been adequatelytransferred to nurses delivering care and thequality of care remained unsatisfactory. Thecase fatality rate at MNH for October 2006 toApril 2007 was 33%.Programme to improve the inpatienttreatment of severe malnutrition inTanzaniaThe author, working with University ofSouthampton and IMTF, was subsequentlyinvited to Tanzania for 6 months to helpimprove the treatment of severe malnutritionand to support MNH staff through aprogramme of task-oriented training andsupervised practice. This activity wasconducted in collaboration with the ChildHealth Team of WHO Tanzania. Workingclosely with a paediatrician from MNH, a fourphaseprogramme was developed, described inFigure 1. Input and advice was also received byother staff members of MNH, PAT, WHO, theIMTF and University of Southampton. Parts ofthe programme were subsequently tested at theregional level, at Morogoro Regional Hospital,where the case fatality rate for February toMarch 2007 was 50%, and at the district level atAmana District Hospital, with an estimatedcase-fatality rate of 36%. The knowledge andskills of nurses greatly improved following thetraining and there were many positive changesin practice at each of the three hospitals.Preparation of F75 and F100 on thewardsIn all three hospitals, UNICEF Tanzaniaprovides boxes of Nutriset-produced F75 andF100 sachets. The sachets are a considerableadvantage to staff, as they make feeds easy toprepare and provide children with micronutrientsthat are otherwise difficult to obtain inTanzania. To make up one sachet of either F75or F100, 2 litres of water should be added, tomake 2.4 litres of feed. However, in most wardsvisited, only a few cases of severe malnutritionare treated at any one time, usually two to fourchildren. Furthermore, there is usually norefrigerator, so fresh feeds must be made upevery 3 to 4 hours. Therefore making up onewhole sachet of F75/F100 (2.4 litres) each time1United Republic of Tanzania, Ministry of Health and SocialWelfare (2006). National Nutrition Strategic Plan 2006/7 –2009/10. Dar es Salaam: MoH.2WHO (2003). Guidelines for the inpatient treatment ofseverely malnourished children. Geneva: World HealthOrganisation.Chloe Angood has an MSc in Public HealthNutrition and a BA and MA in InternationalDevelopment Studies. She works for theInternational Malnutrition Task Force, at theInstitute of Human Nutrition at the Universityof Southampton. In the past she has workedfor various NGOs, including Viva Network,with whom she spent several years workingin Sub-Saharan Africa. Chloe has also workedfor ENN on the Infant Feeding in Emergenciesprogramme.The author would like to acknowledge thehard work of local staff at Muhimbili NationalHospital, Morogoro Regional Hospital andAmana District Hospital reflected here. Inparticular, the author would like to mentionDr Mary Azayo, Dr Jesse Kitundu and thenurses at Makuti B, Makuti A and the generalpaediatric complex at Muhmbili NationalHospital. The author would like to acknowledgethe Tanzania Food and Nutrition Centreand WHO Tanzania Child Health Team whoare spearheading the work in Tanzania. Theauthor would also like to acknowledge thesupervision and support of Professor AnnAshworth, of the London School of Hygieneand Tropical Medicine and Professor AlanJackson and Dr Penny Nestel, of the Instituteof Human Nutrition at the University ofSouthampton.Figure 1Four-phase programme to improve the inpatient treatment of severemalnutrition in TanzaniaPhase one: Assessment (of each ward where severely malnourished children are treated)• Detailed assessment of 10 child records.• Observations of staff actions and procedures over several days.• Findings discussed with ward staff and hospital managers and action plan and timelinesput together.Phase two: TrainingA 10-hour hour training course was developed for all ward nurses and nursing assistants, basedon the WHO guidelines (WHO, 2003*). The course is highly participatory and practical andfocuses on nursing tasks. This course was run for 22 nurses at Muhimbili (the course wassubsequently run for 12 nurses at Morogoro and 12 nurses at Amana).Phase Three: Implementation of new procedures• Practical training sessions on each ward to teach correct feeding procedures to nursesand doctors; problems were identified and solutions discussed with staff.• Provision of missing necessary equipment e.g. measuring jugs, feeding cups.• Provision of wall charts detailing important information (e.g. feed recipes, dischargeprocedures); nurses were taught how to use the wall charts as job aids.• Provision of charts to help nurses and doctors record 24-hour food intake for eachchild, and to calculate how much feed to prepare daily for the ward.Phase Four: Supportive supervision (implementation of systems to ensure ongoingsupportive supervision and quality improvement on each ward)• Institution of a weekly meeting to review deaths occurring (using a special form) andto create weekly action plans.• Set up of data collection systems to help staff to record important patient data andcalculate monthly case fatality rates.• Institution of ‘nurse-of-the-month’ to reward good work amongst nurses and providemotivation.• Provision of a checklist to help train new staff coming onto the ward in good practice.* Guidelines for the inpatient treatment of severely malnourished children. Geneva. WHO 2003.12

Training in ActionC Angood, Tanzania, 2007leads to considerable wastage. With a limitedcountry supply of F75 and F100 sachets available,this system is unsustainable.To avoid wastage, nurses prefer to make uponly the volume of feed required on the wardevery 3 hours. In the absence of dietary weighingscales, scoops are a practical way of measuringthe right amount of F75/ F100 powder tomake up feeds. Nutriset provides a packet ofsmall red scoops inside each box of F75 andF100 to help with exactly this problem. Thesescoops measure approximately 4g of F100/ F75powder. The instructions that come with thescoops instruct users to add 20ml water to onescoop of F75 and 18ml water to one scoop ofF100. This is potentially a very helpful solutionfor nurses. However, in practice, the use ofthese scoops throws up problems.Problems with the Nutriset ‘red scoop’The following problems were observed in theapplication of these instructions in Tanzania:1. Children are commonly overfed F75. Thefinal volume of ‘made up’ F75 or F100 isnot stated. Nurses commonly assume thatthe final volume is the same as the volumeof water added (e.g. 20ml when makingF75, when, in fact, the final volume is 20%higher, i.e. 24ml). If a child is prescribed100ml F75, nurses using this system willcommonly feed the child 120ml. This putsthe child at risk of fluid overload.2. Nurses find it difficult to calculate thenumber of scoops to use for different feedvolumes. For example, if a child requires80ml of F75, the nurse must divide 80ml by24ml to find the number of scoops ofpowder to use. The answer is 3.3, whichmust be rounded to 4 scoops. The nursemust then calculate how much water toadd by multiplying 4 by 20ml (which is80ml water). The maths skills of the nursesencountered were generally quite low andall found this calculation to be verycomplex. Calculations were frequentlywrong, leading to risk of either fluid overload (if too much F75 is given) or hypoglycaemia (if too little F75 is given). To avoidthis calculation, a table is needed showingthe volume of water to add to 1, 2 3 scoopsetc., and the final volume of reconstitutedF75 or F100. But Nutriset does not indicatethis final volume per scoop, and so thetable is difficult to create.3. Miscounting of scoops: When making upfeeds, it is very easy to miscount thenumber of scoops when the numberrequired is above 5. This happens whenfeed volumes are in excess of 100ml, whichis very common. This means that it is alltoo easy to reconstitute feeds incorrectly.4. Difficulties of making up feed for severalchildren: The red scoop is too small whenthere are more than 10 severely malnourishedchildren, all feeding 2 or 3 hourly.Larger quantities need to be prepared whichrequires a larger scoop. The big challengewith this method is finding an accuratemeasure of one quarter/one half of a sachet.Possible solution to the problem of‘scoops’A meeting of the partners was held in October2007, including representatives from MuhimbiliNational Hospital, Morogoro RegionalHospital, Amana District Hospital, TFNC,WHO Tanzania, Muhimbili National Hospital,the IMTF and University of Southampton. Theabove issue of scoops was discussed. It is verydifficult to source ready-made, calibratedscoops in Tanzania. Much research was doneduring the 6 months and no satisfactory solutionwas found. The possibility of sourcing ormaking better scoops in Tanzania was consideredby the partners, but quickly dismissed dueto technical and resource constraints. Instead itwas felt by the group that Nutriset shouldconsider adapting the existing red scoop tosomething more useful that could have internationalapplicability. Specifically, the groupwould like to request the following fromNutriset:PostscriptResponse on F-75 and use ofmeasuring scoops By Mamane Zeilani, NutrisetMamane Zeilani is Director for International Development and Nutritional Strategies at Nutriset, includingproduct Research and Development Before joining the team in August 2006, he implemented and oversawemergency nutrition and food security programmes in west and southern Africa (Malawi, Burundi,Eritrea, Zimbabwe, Niger), and Asia (DPRK, Afghanistan and Tajikistan) for several international NGOs.Since 1986, Nutriset has been very involved inseeking practical solutions for the developmentof quality nutritional products. These productsare today widely used by humanitarian actorsin the developing countries. Among them aretwo formulae utilised in the dietetic treatmentof severe malnutrition, mostly in children agedunder 5 years of age. These therapeutic milks,named F-75 and F-100, are used for the initialtreatment (or stabilisation phase) and for nutritionalrehabilitation of severely acutelymalnourished children, under medical supervisionand according to internationally recognisedguidelines and protocols .From large scale to individual solutions(using scoops)The F-100 formula was designed in 1993 and F-75 in 1994. They were first used in large emergencies.As is the case for the majority of productsdeveloped by Nutriset, packaging andinstructions were initially created to reflect thesituation on the ground. The need of the internationalcommunity was to rapidly treathundreds of children in any given therapeuticfeeding centre (TFC). Thus, at the request ofnon-governmental organisations (NGOs), eachsachet contained the quantity of milk powderrequired to make up 2.4 litres of formula. Thiswas considered to be the most pragmatic solution.The sachet had to be manufactured in sucha way so as to withstand tough transport andstorage conditions. The quantity of F-75 and F-100 added to 2 litres of boiled water is 410g and456g, respectively. NGOs did not request anymeasuring instrument for smaller quantities.With the progressive and extensive implementationof the WHO manual for the managementof severe malnutrition , Nutriset adaptedits supply in terms of products and packaging.Smaller size TFCs were set up in countriesfacing nutrition emergencies. However, the lackof refrigeration facility and the resultingwastage of therapeutic milk then became a seriousissue. To satisfy a special request from oneof its partner working in such a context (treatingsmall number of children at any one time ina TFC), Nutriset developed red measuringscoops. This enabled field workers, and particularlylocal staff, to easily measure the exactquantity of milk powder needed to preparesmall quantities of F-75, as well as F-100. Thesered scoops are also used to make up ReSoMal(Rehydration Solution for the SeverelyMalnourished).Ongoing research and developmentThese red scoops are currently packed in everybox of F-75 therapeutic milk manufactured byNutriset in Malaunay, France. Further technicalsolutions, including the development of smallersachets, have been sought and are reachingfinal technical validation stages. Moreover,sachets that contain the equivalent of either aquarter or a half of the original F-75 sachet havesuccessfully passed the final validation processin 2006.As can be seen, Nutriset is constantly seeking todevelop products and related packaging solu-13

Field Articlea) Much clearer instructions that avoid confusionand miscalculations and that explainhow much water to add to each red scoopand the resulting volume of feed.Instructions could include a chart of precalculationsfor 1, 2, 3 scoops, etc.b) A scoop that accurately measures onequarter of a sachet (perhaps a blue scoopfor F100 sachets and an orange scoop forF75 sachets to co-ordinate with respectivebox and sachet colours) with clear instructionsthat explain how many scoops to use,how much water to add and the resultingvolume of feed (instructions should detailhow to make one quarter and one half of asachet).For more information, contact:Chloe Angood, Institute of Human Nutrition,University of Southampton,email:c.angood@soton.ac.ukFeed preparation instructions on thewall in one hospital before the training– these are copied from the NutrisetinstructionsThe reorganised feeding stationwith new, clear instructions,after the trainingC Angood, Tanzania, 2007Regionalworkshop onIFE in Bali 2008A three day strategy workshop/one day trainingon Infant and Young Child Feeding inEmergencies (IFE) is scheduled to be held inBali, Indonesia on 10-13th March, 2008. Thisworkshop is being organised under theauspices of the Inter Agency StandingCommittee (IASC) Global Nutrition Cluster 1that is led by UNICEF. Within the cluster, themain organiser is the IFE Core Group 2 , incooperation with UNICEF East Asia andPacific Regional Office, UNICEF South AsiaRegional Office and the Ministry of Health,Indonesia. The Emergency Nutrition Network(ENN) as co-ordinator and representative 3 ofthe IFE Core Group is co-facilitating this workshop.The workshop is funded by the GlobalNutrition Cluster and by contributions and inkindsupport of IFE Core Group members.This strategy workshop on IFE has been identifiedas a key step to help improve coordination,policy guidance, implementation andresponse capacity in the region. The focus ofthe workshop is on emergency preparednessand improving the early response to protectand support IFE. Indonesia was chosen as thehosting country in order to learn from theirIFE experiences in the recent tsunami andearthquake responses.The workshop will bring together participantsfrom a mixture of key government, UN,donor, international and local NGO representativesfrom 16 countries – Afghanistan,Bangladesh, Cambodia, China, India,Indonesia, Maldives, Myanmar, Nepal,Pakistan, Papua New Guinea, Philippines, SriNewsLanka, Thailand, Timor-Leste and Viet Nam.The objectives of the meeting are to:• Increase awareness of the importance of IFEin the region, including orientation on relevantpolicy, guidance and key issues in IFE• Identify key constraints to providing earlysupport and protection for appropriateinfant feeding practices in emergencies, and• Identify strategic directions and practicalsteps to address these at country andregional levels.Further information and an agenda are availableon the ENN website and from the keymeeting contact (below). A summary of themeeting report and of experiences shared atthe workshop will feature in future issues ofField Exchange.For further information, contact:Ali Maclaine, tel (UK): +44 (0)20 8989 5735fax: +44(0) 1865 324997email: alimaclaine@btinternet.comor Marie McGrath, ENN,email: marie@ennonline.netThe Operational Guidance on Infant and YoungChild Feeding in Emergencies (v2.1, Feb 2007) isnow available in Bahasa (Indonesia), Japanese andChinese, online at http://www.ennonline.net/ife1http://www.humanitarianreform.org/2The IFE Core Group is an inter-agency collaboration thatcomprises UNICEF, UNHCR, WFP, WHO, EmergencyNutrition Network (ENN), Action Contre la Faim and CAREUSA. It is co-ordinated by the ENN.3The ENN/IFE Core Group is a member of the UNICEF-ledIASC Global Nutrition Cluster on behalf of the IFE CoreGroup and highlights IFE issues in global cluster activities.tions best adapted to the context of humanitariannutrition interventions. Having readChloe Angood’s article in this issue of FieldExchange it is clear that further work needsto be done in order to facilitate the use of F-75 and F-100 therapeutic milk by nutritionistsin the field. Nutriset would like toacknowledge the great value of the workdone by this research group.Nutriset would like to invite organisationsand individuals that train and/ormanage therapeutic feeding programmeswithin health structures in the developingworld to contact us, as we would be verypleased to explore new means of improvement.Nutriset will welcome solutions toimprove packaging of F-75 and F-100, aswell as its other products for the treatment/preventionof malnutrition. Our teamwill work to clarify instructions accompanyingred scoops to enable everyone tocomprehend the quantities of scoopsneeded per quantity of water to make upthe different volumes of feed.For more information, contact:Mamane Zeilani, Nutriset,email:mzeilani@nutriset.fr ornutriset@nutriset.frThe Humanitarian Response IndexSummary of published news 1A recent news piece in the Lancet covered thelaunch by Kofi Annan, former UN SecretaryGeneral, of an index that ranks 23 countries inthe Organisation for Economic Co-operation(OECD) according to their effectiveness inhumanitarian donorship. The HumanitarianResponse Index aims to make donors moreaccountable by ranking them according to 57indicators that reflect the principles and goodpractices that govern humanitarian action.The Indicators are focused around fivethemes – responding to humanitarian needs,integrating relief and development, workingwith humanitarian partners, implementinginternational guiding principles, and promotinglearning and accountability. The outcomesare based on hard data and the views of varioushumanitarian agencies working on theground in eight countries.According to the index, Sweden is the mosteffective donor and Greece is the least effective.The wide-ranging indicators also high-light where donors could ‘do a lot better’. Forexample, the UK is ranked ninth andalthough it scores well in the amount ofmoney given and its speedy response tohumanitarian crises, it is let down by having apoor human rights record.The authors conclude that this new index is auseful “report card on donor activity” but itwill only be truly effective if it inspires donorsto improve their humanitarian donorshiprecord. Individual citizens, civil society, nongovernmentalorganisations, and politiciansshould use this new tool to hold their governmentsto account.For more on the Humanitarian ResponseIndex, visit the website of DevelopmentAssistance Research Associates (DARA) whohave devised the index,http://www.daraint.org/1The Humanitarian Response Index. The Lancet - Vol.370, Issue 9603, 8 December 2007, Page 1880. Registerfor access to full text at http://www.thelancet.com14

NewsNew Red CrossGuidelines forCash TransferProgrammingThe International Red Cross and Red CrescentMovement have just published Guidelines forCash Transfer Programming. The guidelinesare designed for field practitioners with experienceof humanitarian programmes, includinggeneralists such as programme managers orrelief coordinators, as well as specialists onfood security, economic security, livelihoods orshelter. They are designed for use at national orinternational level, for headquarters, branch orfield offices.There is a growing body of evidence that cashbasedprogramming can be a very appropriateand effective form of response, alone or incombination with other in-kind programmes.Building on the broad range of cash experienceswithin the Movement and in the humanitariansector, these guidelines helpprogramme managers identify those situationswhere cash is appropriate, and provide practical,step-by-step support to the design andimplementation of cash programmes. They canbe used following a rapid assessment and alsoto support programmes at any point of thedisaster cycle – disaster risk reduction,preparedness, response or recovery – or in asituation of conflict or political instability.The first section of the guidelines follows theprogramme cycle with detailed information onwhether, when and how to design and implementcash-transfer programmes. The secondsection gives step-by-step guidance on particularforms of cash transfers. The last sectionprovides some practical tools that can be usedin any cash transfer programme, such asmarket assessment, community-based targeting,or how to assess financial institutions.A revised edition of the guidelines is plannedfor 2009 and a feedback form is included at theend of the document in order to allow fieldpractitioners to contribute to the improvementof the document.For further information, contact:Charles-Antoine Hofmann, HumanitarianPolicy Adviser at the British Red Cross,email: cahofmann@redcross.org.uk,Mija-tesse Ververs, Senior Advisor FoodSecurity, Nutrition, Livelihoods, InternationalFederation of Red Cross and Red CrescentSocieties, email: mija.ververs@ifrc.org,tel: +41 22 730 4449IASC Guidance onMental Health andPsychosocial Supportin emergenciesThe Inter Agency Standing Committee (IASC)has issued Guidelines on Mental Health andPsychosocial Support in Emergency Settings:Minimum Responses in the Midst ofEmergencies. The guidelines have been developedby 27 agencies, with input of hundredsof experts worldwide.The aim of these guidelines is to enablehumanitarian actors to plan, establish and coordinatea set of minimum multi-sectoralresponses. These guidelines are responding tothe absence, until now, of a multi-sectoral,interagency framework to enable effectivecoordination, identify useful practices, highlightpotential harmful practices and clarifyhow different approaches to support mentalhealth and psychosocial support in emergenciescomplement each other.The guidelines specify 25 minimum responsesin emergencies in three areas:Area A. Common functions – coordination,assessment, monitoring and evaluation,protection and human rights standards, andhuman resources.Area B. Core mental health and psychosocialsupports – community mobilisation andsupport, health services, education anddissemination of information.Area C. Social considerations in sectors – foodsecurity and nutrition, shelter and site planning,water and sanitation.The guidelines include 25 Action Sheets thatexplain how to implement each of the minimumresponses.For further information, visithttp://www.humanitarianinfo.org/iasc/content/products/default.asp or email:IASCmhpss@who.int orIASCmhpss@interaction.orgHealth and Nutrition evaluationguidelinesThe Inter-agency Health and Nutrition(IHE) Initiative, comprised of a broad rangeof NGOs, UN agencies, CDC, donors andacademic institutions, has produced theirfirst version of IHE Evaluation Guidelines.The guidelines outline a process forcommissioning and managing inter-agencyhealth and nutrition evaluations, as well asprovide an evaluative framework for thesetypes of evaluations. The aim of these evaluationsis to analyse the overall performanceof the health and nutrition sector, andthe impact of interventions on the health ofcrisis affected populations.FAO LivelihoodsAssessment andAnalysis e-learningcourseThe EC-FAO Food Security Programme hasproduced an e-learning course on‘Livelihoods Assessment and Analysis’.The Livelihoods course introduces theconcept of livelihoods and the components ofthe livelihoods framework. It also providesguidance on assessing livelihoods in differentfood security contexts and on selecting andinterpreting livelihoods indicators.Previous e-learning courses include FoodSecurity Information Systems and Networks,Reporting Food Security Information, andThis is the first version of these guidelines,based on experience gained during the six IHEevaluations done so far and feedback receivedon earlier draft versions. It is hoped that theseguidelines will stimulate more inter-agencyevaluations in the health sector. Ongoingdiscussions are planned within the health cluster,to see how such evaluations can complementassessment and monitoring processes.For more information, please contact OlgaBornemisza at olga.bornemisza@lshtm.ac.ukTo see copies of the evaluations done so far, seehttp://www.unhcr.org/doclist/research/3b8a2e3de.html and search for IHE.Nutritional Status Assessment and Analysis.All of these are available in English andFrench.The new course is available for free online at;http://www.foodsec.org/dl/dlcourselist_en.asp or on CD-Rom,email: information-for-action@fao.org,tel: +39 06 570 54003. Related resources fortrainers, which can be customized for faceto-facetraining, are also available.EC-FAO Programme website:www.foodsec.org FAO website: www.fao.org15

NewsWHO TechnicalConsultation andUpdate on HIV andInfant FeedingThe Report of a Technical Consultation onPrevention of HIV Infections in PregnantWomen, Mothers and their Infants and InfantFeeding and an Update of recommendations 1 isnow available.At a Consultation (held in Geneva on 25–27October 2006), researchers, programme implementers,infant feeding experts and a broadcross-section of agencies reviewed the substantialbody of new evidence and experienceregarding HIV and infant feeding. The aim wasto further clarify and refine the existing UnitedNations (UN) guidance, which was based onthe recommendations from a previous consultationin 2000.The group endorsed the general principlesunderpinning most of the October 2000 recommendationsand reached consensus on a rangeof new issues and their implications. New datathat were not available in 2000 were reviewed.These included recent trial data on 18-monthand 24-month HIV-free survival based ondifferent infant feeding practices, and morbidityand mortality reported among HIV-exposedbut uninfected infants enrolled in several ongoingtrials where mothers ceased breastfeedingby six months.The Technical Consultation Report presents asummary of the new findings, conclusions andrecommendations and Annex 1 provides detailsof the discussions that took place.Based on the Technical Consultation, ‘HIV andinfant feeding: Update’ has just been producedby WHO to provide the full list of updateLaunch of The Lancet’sSeries on Maternal andChild UndernutritionThe Lancet’s Series on Maternal and ChildUndernutrition has just been launched.(January 16, 2008). The Series aims to increaseawareness around maternal and child undernutritionand serve as a catalyst for national-levelgovernments, non-governmental organisationsand the international nutrition community tospur action and stimulate national interest,leadership, and commitment.Series launches have been held in Washington,D.C. and London, and will continue inEthiopia, India, Peru, Vietnam, and West Africato help raise awareness of and deepen supportfor maternal and child nutrition at the donor,policy and programmatic levels in countriesthat face the most serious nutrition challenges.Many health and development agencies includingJohns Hopkins Bloomberg School of PublicHealth, UNICEF, USAID, the World Bank, therecommendations and an explanation of keypoints 2 . It is aimed at programme managersand decision makers, and those who will be incharge of revising national guidelines onprevention of mother-to-child transmission andinfant and young child feeding. Guidance willcontinue to be refined and clarified as newevidence becomes available.For further information, contact:World Health Organisation, 20 Avenue Appia,1211 Geneva 27, Switzerlandemail: cah@who.int or hiv-aids@who.int ornutrition@who.inthttp://www.who.intThe updated guidance is available athttp://www.who.int/child-adolescenthealth/documents/en/The Consultation Report and other WHOdocuments on HIV and infant feeding can befound at:http://www.who.int/child-adolescenthealth/NUTRITION/HIV_infant.htm1HIV and Infant Feeding. New evidence and programmaticexperience. Report of a Technical Consultation. Geneva,Switzerland, 25–27 October 2006, held on behalf of theInter-agency Task Team (IATT) on Prevention of HIVInfections in Pregnant Women,Mothers and their Infants. WHO, UNICEF, UNAIDS, UNFPA.WHO 2007.2WHO, UNICEF, UNAIDS, UNFPA. HIV and Infant Feeding:Update. Geneva, WHO, 2007.World Health Organisation, and the Bill &Melinda Gates Foundation contributed to theproduction of the series. It includes contributionsfrom leading academics and nutritionexperts from the UK, USA, Asia, Africa, andLatin America.There are five papers in the series with onebeing published in the print edition of TheLancet each week. All five papers, the webappendices, and a 12-page Executive Summaryof The Lancet's Series, are available online (free)at: http://www.globalnutritionseries.org/The website also includes details of globalevents, a media centre and resources centre.Sphere Projectcelebrates 10thanniversaryThe Sphere Project celebrated its 10thanniversary in 2007. To mark the occasion,a special report has been published, ‘10years of Sphere in Action, enhancing thequality and accountability of humanitarianaction’. This report aims to provide adegree of insight into the first ten years ofthe Sphere Project. It includes examplesboth from those who 'govern' the Projectand those who 'use' the HumanitarianCharter and the Minimum Standards,citing first-hand experiences and casestudies from diverse contexts.The report is available for download inPDF format and as a Flash presentation at:http://www.sphereproject.org/content/view/301/32/lang,English/A Memorandum of Agreement has beensigned with 'Books for Change' in India toprint a low cost, English language editionof ‘The Sphere Project: HumanitarianCharter and Minimum Standards inDisaster Response’ handbook, 2004edition. The handbook is available for 210Indian Rupees (discounts for bulk orders)in the following countries only: India,Bangladesh, Pakistan, Afghanistan,Bhutan, Nepal, Sri Lanka and theMaldives (Sales Territories).Requests should be addressed directly to:Shoba Ramachandran, Publisher andChief Editor at Books for Change, 139Richmond Road, Bangalore 560 025,Karnataka, India Ph: +91-80-25580346Fax: +91-80-25586284Email: shoba.ram@actionaid.orgThe Sphere Project team also invite registeredSphere Project members to updatetheir contact details online, to send newsarticles on the Sphere related activitiesand to include any ‘Sphere event’ in theevents calendar on the Sphere Projectwebsite.For further information, contact: LauraLopez-Bech, The Sphere Project,http://www.sphereproject.orgTel.: +41 (0) 22 730 4482Fax: +41 (0) 22 730 4905email: laura.lopez@ifrc.org16

NewsNutriset and ValidNutrition signlicence agreementIn 1996, Nutriset patented an innovativeconcept of ready to use therapeutic food(RUTF) products sold under the brand namePlumpy’nut® and used in the treatment ofsevere acute malnutrition. In 2000, ValidInternational developed the CommunityBased Therapeutic Care (CTC) model todeliver care to people with severe acutemalnutrition.Nutriset and Valid Nutrition (VN) have justannounced (December 2007) that they haveformally signed a Licence Agreement. Thisagreement enables Valid Nutrition to independentlymanufacture peanut based Readyto Use Foods covered by the Nutriset patent indeveloping countries and to market theseproducts under the VN brand name.This significant development should increasecompetition and improve availability ofRUTFs for the treatment of malnutrition, aswell as encourage innovation and stimulatenew product development of cheap and costeffective formulations.Valid Nutrition (VN) is a not-for-profit companyestablished in 2005 to make and market highlyfortifiednutritional pastes to treat and preventmalnutrition in a number of developing countries.The aim of Valid Nutrition is to set the benchmarkfor the quality, effectiveness and cost of Ready-to-Use Foods (RUFs). All profits are channelled backinto expanding local production and funding theprovision of Community-based Therapeutic Care(CTC). For more information, visithttp://www.validinternational.orgLocal production of RUTF in VN Kanengofactory in Lilongwe, MalawiValid Nutrition, 2008 Valid Nutrition, 2008WHO/UNICEF JointStatement on OptimalIodine NutritionWHO/UNICEF have released a joint statementon Reaching Optimal Iodine Nutrition inPregnant and Lactating Women and YoungChildren. This statement presents the conclusionsof a technical consultation and subsequentfollow up meeting in 2005, on theprevention and control of iodine deficiency inpregnant and lactating women and in childrenless than two years of age.The primary strategy for sustainable eliminationof iodine deficiency remains UniversalSalt Iodisation (USI). However new evidenceand lessons learned in the last decade showthat implementation of salt iodisationprogrammes may not be feasible in all areas ofall countries, thus resulting in insufficientaccess to iodised salt for some groups withinthe population. In these cases, as well asstrengthening USI programmes, additionalcomplementary strategies are suggested.As a first step, countries need to assess andcategorise the level of implementation of saltiodisation programmes and based on thisanalysis, revisit the strategy for the control ofIodine Deficiency Disorders (IDD), as necessary.The statement includes guidance on categorisationand the subsequent planningprocess for additional iodine intake in pregnantand lactating women and young children.Guidelines for decision-making are alsogiven for these population groups in specificsituations such as emergencies, amongstdisplaced people, and in geographicallyremote areas, where additional iodine intakeshould be considered. If iodised salt is notaccessible in these specific situations, increasingiodine intake is required in the form ofiodine supplements for pregnant and lactatingwomen, and a supplement or a complementaryfood fortified with iodine for children 7-24 months of age. In cases where it is difficultto reach pregnant women, supplementation toall women of reproductive age is advised.The new publication New & Noteworthy inNutrition (as a reincarnation of the earlierWorld Bank publication) is now available(Issue 1, December 2007). Originally a WorldBank Publication, it was taken over by theInternational Food Policy Research Institute(IFPRI) in 2000 where it continued until 2003.The Population Reference Bureau (PRB) hasnow relaunched it.The aim of reviving the publication is toenhance learning opportunities in nutritionand to complement the SCN News 1 and otherrelevant materials. For the moment it will bepublished every four months. Content will bebased on a review of recent literature, newsarticles, and outcomes of important eventsand conferences related to nutrition. Eachissue will close with a section entitledRecommendeddosages are includedfor daily or annual supplementation for pregnantwomen, lactating women, women ofreproductive age (15-49y), and for childrenunder 2 years (7 – 24 months). For infants 0-6months of age, iodine supplementation shouldbe received by the infant through breastmilk,assuming that the infant is exclusively breastfedand that the lactating mother receivediodine supplementation.Monitoring of IDD prevention and controlprogrammes is crucial – whether they arebased on fortification or supplementation – toensure that additional iodine intake is effectivein reducing the deficiency, while preventingexcessive intake that may lead to adversehealth consequences. The monitoring processshould include the assessment of coverageand iodine nutrition status.The joint statement is available at: https://www.who.int/entity/nutrition/publications/WHOStatement _IDD_pregnancy.pdfFor further information, contact: Dept. ofNutrition for Health and Development,WHO, 20, Avenue Appia, 1211 Geneva,Switzerland, email: micronutrients@who.intOr Nutrition Section, Programme Division,UNICEF, 3 United Nations Plaza, New York,NY 10017, USA, email: nutrition@unicef.orgA woman witha goitre inEthiopiaRevival of‘New & Noteworthy in Nutrition’‘Whatever Happened to . . .?’ that takes a lookback at the ideas that were supposed to helpsave the world nutritionally but didn’t, basedon readers suggestions.The publication is available at:http://www.prb.org/NewandNoteworthy.aspxSubscribe to NNN by visitinghttp://www.prb.org/NewandNoteworthy.aspxTo give feedback or make suggestions,contact: Population Reference Bureau, 1875Connecticut Ave., NW, Suite 520, Washington,DC 20009 USA.tel: 202-483-1100 fax: 202-328-3937email: email: nnn@prb.orghttp://www.prb.org1http://www.unsystem.org/scn/publications/html/scnnews.htmlFilippo Dibari/Andy Seal, Ethiopia, 200417

Joint Statement on micronutrientdeficiencies in emergenciesA Joint Statement has been issued by WHO,WFP and UNICEF on preventing and controllingmicronutrient deficiencies in populationsaffected by an emergency. It focuses on pregnantand lactating women and children aged6 to 59 months, as the groups most vulnerableto micronutrient deficiencies and their consequences.For a pregnant woman these includea greater risk of dying during childbirth, or ofgiving birth to an underweight or mentallyimpaired baby. For a lactating mother, hermicronutrient status determines the healthand development of her breastfed infant,especially during the first 6 months of life. Fora young child, micronutrient deficienciesincrease the risk of dying due to infectiousdisease and contribute to impaired physicaland mental development.Micronutrient deficiencies can easily developduring an emergency or be made worse ifthey are already present. So the micronutrientneeds of people affected by a disaster must beadequately met. One way of achieving this isthe regular provision of adequate amounts offoods fortified with micronutrients as part offood rations during emergencies.Fortified foods include corn soya blend,biscuits, vegetable oil enriched with vitaminA, and iodised salt.However, foods fortified with micronutrientsmay not fully meet the needs of certain nutritionallyvulnerable sub-groups. Two dailymultiple micronutrient formula have beendeveloped by UNICEF and WHO to meet therecommended nutrient intake (RNI) of pregnantand lactating women and children aged6-59 months in emergencies (see table 1).Pregnant and lactating women should begiven their supplement (1 RNI/day) whetherthey receive fortified rations or not. Dosagesand schedule for administration of the children’ssupplement are included for situationswhere there is or there is not provision of fortifiedrations. Recommendations are madeTable 1regarding continuation of iron and folic acidsupplementation in pregnant and lactatingwomen, and vitamin A supplementation toyoung children and mothers post-partum.Breastfeeding and appropriate complementaryfeeding should be promoted actively.The Joint Statement recommends that multiplemicronutrient supplements should begiven until the emergency is over and accessto nutrient rich foods is restored. At this timethe micronutrient status of the populationshould be assessed to decide whether furtherinterventions to prevent and control micronutrientdeficiencies are needed.The delivery of supplements should be monitoredto assess coverage, existing micronutrientprogrammes should continue as before theemergency, and the health of target groupsmonitored for deficiencies as well as excessiveconsumption. The continued need for supplementsand fortified foods should be assessedperiodically during and after the emergency.As the crisis wanes, the general distribution ofsupplement is likely to be reduced and thenincreasingly targeted to specific groups.The Joint Statement is available at:www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdfComposition of multiple micronutrient supplements for pregnant women,lactating women, and children from 6 to 59 months of agePregnant/lactating womenVitamin A µg 800.0 400.0Vitamin D µg 5.0 5.0Vitamin E mg 15.0 5.0Vitamin C mg 55.0 30.0Thiamine (vitamin B1) mg 1.4 0.5Riboflavin (vitamin B2) mg 1.4 0.5Niacin (vitamin B3) mg 18.0 6.0Vitamin B6 mg 1.9 0.5Vitamin B12 µg 2.6 0.9Folic acid µg 600.0 150.0Iron mg 27.0 10.0Zinc mg 10.0 4.1Copper mg 1.15 0.56Selenium µg 30.0 17.01WHO, WFP, UNICEF Joint Statement. Preventing andcontrolling micronutrient deficiencies in populations affectedby an emergency. Multiple vitamin and mineral supplementsfor pregnant and lactating women, and for children aged 6to 59 months. WHO, 20072Both supplements contain iron (27mg/day for pregnant/lactatingwomen and 10mg/day for children 6-59months). Risks and consequent recommendations regardingiron and folic acid supplementation in highly malariousregions are given in a WHO statement, Iron supplementationof young children in regions where malaria transmission isintense and infectious disease highly prevalent. (undated).Available at http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/WHO_statement_iron.pdfThis WHO Statement is reflected in the recommendation ofthe Operational Guidance on Infant and Young Child Feedingin Emergencies, v2.1, February 2007, Section 5.1.2, a positionreached by consensus at the UNSCN meeting in Rome,2007. Available at http://www.ennonline.net/ife (Eds)Children (6–59 months)ReportingSkills andProfessionalWritingHandbookNewsTo help develop writing and reporting skills,a self-study programme has been developed,designed for development professionals butalso relevant to those working in the emergencysector.The Handbook covers the entire reportingprocess from setting objectives, through datagathering and analysis tools, to planning,drafting, editing and designing a report. Itcontains examples, practical exercises, and anextended case study to fully apply all thetools presented.Two example modules (Data GatheringMethods and Writing Clarity) are available todownload fromhttp://www.reportingskills.org/resources.htmThe whole Handbook comprises eight stepsto ‘effective reports’:1: Professional Writing and the WritingProcess2: Setting Objectives & Data GatheringMethods (entire module available fordownload)3: Analysing & Interpreting Information4: Planning the Report5: Writing Skills – Clarity (entire moduleavailable for download)6: Writing Skills – Organisation7: Putting it all Together8: Finishing Off the ReportA moderated web forum, where users canpost ideas and reach the author withcomments, questions and feedback, supportsthe Handbook.The Handbook is only available as an electronicdownload and can be bought anddownloaded fromhttp://www.reportingskills.org(single user edition costs £30GBP).There are special licenses for organisations(10 users) and the Project Office Edition (50-user licence) also includes a Training Pack –Trainer Guide, Participant Notes,Supplementary Materials and over 250 slides.The Reporting Skills and Professional WritingHandbook: a self-study programme fordevelopment professionals, © Neil Kendrick2007. Published by Education, Language andDevelopment Training Programmes (UKCharity no. 1083385)Iodine µg 250.0 90.018

NewsWFP/T Loro, Sudan, 2007 WFP/T Loro, Sudan, 2007Report on WFP TrainingWorkshop in SudanBy Theresa Loro, WFP SudanTheresa Loro is a Senior Nutritionist working withWFP Sudan and has been based in Khartoum since2004 as a National Officer for Nutrition andHIV/AIDS focal person. Previously Theresaworked with UNICEF Sierra Leone as UNVNutritionist for 18 months, and has worked withthe Combined Agencies Relief Team (CART),UNICEF Sudan, and the Ministry of Agriculture inSouthern Sudan since 1990.From 6-8 May 2007, WFP Kadugli sub-office, incollaboration with the State Ministry of Health(SMOH) and UNICEF, conducted a three-dayHealth, Nutrition and HIV/AIDS MessagesPromotion Training Workshop in Kadugli locality,Sudan.The aim of the workshop was to promoteappropriate diets, healthy lifestyle measuresand protection against HIV that would help inreducing malnutrition and inappropriate feedingpractices in children, promote good hygieneand sanitation, and contribute towards theeradication of HIV/AIDS disease. This wouldcomplement the work of health workers fromMOH, UNICEF and collaborative partners inKadugli area.Workshop objectives• To build up capacities of WFP staff andcooperating partners (CPs) to impart keyhealth, nutrition and HIV awarenessmessages to beneficiaries at general fooddistribution (GFD) sites, using a communityapproach.• To develop and establish a joint healthpromotion educational strategy betweenWFP, MOH, UNICEF and CPs to raisecommunities’ awareness of key issuesthrough community women training. Thiscommunity based training would takeplacein pilot project selected locations of GFDareas.Thirty-two participants (18 men and 14 women)attended the workshop, representing eighteenGroup work presentationorganisations, the Government of Sudan (GOS),United Nations (UN) and non-governmentalorganisations (NGOs), including WFP staffselected from Kadugli, Kauda and Abyei.Additional representatives from the FederalMinistry of Health (FMOH) and SMOHattended the workshop.Professionals from the FMOH, SMOH, UNICEFand WFP nutrition unit were the main facilitatorsof fourteen training sessions. Field sessionsin selected community villages were used topractice application of the Training of Trainers(TOT). Participants also practiced formulatingtraining plans to train community-basedwomen in the delivery of health promotionmessages.OpportunitiesMost of the partners’ organisations’ participantshad an adequate background in health,nutrition, HIV/AIDS and health promotioneducational messages. This will strengthen thecommunity women training in the pilotproject’s locations.Collaborative partners involved in the pilotproject (SMOH and UNICEF) have mandatedstrategies and policies that encourage involvementof communities in health, nutrition, andHIV/AIDS and health promotion messagesdelivery.ChallengesAn evaluation of the training workshop wasundertaken. The short time allotted to trainingsessions limited discussion and interactionbetween trainers and facilitators, which led tosome dissatisfaction amongst participants(19.6%).The administration of the training budget tocover expenses needed good planning. A perdiem/transportation allowance has not beenconsidered/allowed in the training budgetplanning. This negatively influenced GOSPractical work in the community sessiontraining participants’ motivation as they areused to receiving payment in similar organisations’training exercises.The provision of one meal during the day wasinsufficient where participants were expectedto work for long hours.Follow upWFP field monitors and representatives fromCPs who participated in health promotion trainingare now engaged in a pilot project, responsiblefor the training of community women,selected from 5-6 locations in the GFD targetedareas. Awareness programmes shall be advocatedin these communities to disseminate keyhealth messages within the programme plannedactivities, including nutritional values andpreparation of food aid, HIV awareness, hygienepromotion, and diarrhoea management.Recommendations• SMOH, UNICEF and WFP should developclear strategies for community womentraining programmes.• SMOH, UNICEF and WFP should set outplans for community women training in thedesignated pilot project’s locations.• WFP-Khartoum should make sure thattraining equipments and materials areready before a community training plancommences.• Collaborative partners should ensure thatmore guidance in planning and communicationskills and on follow-up of communitywomen training are developed before pilotproject community training commences.• Literacy education partnering projectsshould be encouraged at project locations,as high illiteracy among the women is amajor contributing factor to poor nutritionalstatus.For more information, contact: Theresa Loro,WFP Sudan, email:Theresa.Loro@wfp.orgChanges in eligibility for specialisedfood for HIV positive adultsThe US government HIV/AIDS office on theuse of food in programming with PEPFAR(President's Emergency Plan for AIDS Relief)has changed policy with regard to food andnutrition programming.This policy change relates to adult patients whoare enrolled in Anti-Retroviral Therapy (ART)and care programmes. Effective immediately,U.S. Government Emergency Plan countryteams may provide food support to patients inART and care programmes with a Body MassIndex (BMI) less than 18.5 (previously the criteriawas

NewsWorkshop on the Integration of Community-basedManagement of Acute Malnutrition (CMAM)Date: April 28-April 30, 2008The Food and Nutrition TechnicalAssistance (FANTA) Project is hosting aCommunity-based Management of AcuteMalnutrition (CMAM) international workshopin Washington DC, sponsored byUSAID’s Office of Foreign DisasterAssistance and Office of Health, InfectiousDiseases and Nutrition. The workshop willbe organised jointly with United Nations(UN) and non-governmental organisation(NGO) partners.In recent years, CMAM has moved intomainstream programmes. Practices onceconfined to humanitarian emergencyprogramming are now being implementedin standard clinic settings. NationalMinistries of Health, not only NGOs, nowimplement CMAM. With the recent UNJoint Statement on Community-basedManagement of Severe Acute Malnutrition 1 ,this trend is expected to accelerate rapidly,putting extra strain on existing capacity fortraining and dissemination. Within thehumanitarian sphere there has been adiscernable evolution of CMAM programmingto address sustainability concerns,and to enable more effective integration intoexisting national health services. However,there remain a number of challenges.The April 2008 workshop is expected toprovide an opportunity to share currentpractices in the integration and scale-up ofCMAM. Organisers hope to attract presentersfrom Ministries of Health in countriesimplementing CMAM, as well as NGOs andother partners.Interested agencies and individuals shouldvisit the FANTA website (see below) for alist of workshop themes and sessions, andinstructions for registering and for submittingpresentations for consideration.Food and Nutrition Technical Assistance(FANTA) Project Academy for EducationalDevelopment, 1825 Connecticut Avenue.,NW, Washington, DC 20009-5721Tel: +1 202 884-8000 fax: +1 202 884-8432e-mail: fanta@aed.orghttp://www.fantaproject.org1See news piece, Field Exchange 31. p15. The JointStatement is available at:http://www.who.int/entity/nutrition/topics/statement_commbased_malnutrition/en/ENN led Management of Acute Malnutritionin Infants (MAMI) ProjectFunded by the UNICEF led InteragencyStanding Committee (IASC) Nutrition Cluster,the ENN is planning a review in 2008 of the fieldmanagement of acutely malnourished infantsunder six months of age.The management of malnutrition in infantsunder six months of age has been severelyhampered by a poor evidence base upon whichto base guidance materials 1 , and consequentlyhow best to support these infants in practice.Efforts have been made to ‘stop-gap’ the lack ofguidance to support field practitioners 2 andagencies have evolved guidance to meet theneeds of infants as they present. A body ofexperience in the management of this agegrouphas been accumulating over the past 5years amongst agencies. However in manyinstances, programme data are collected butnot analysed, or internal reports written butnot routinely shared with outside agencies.The ENN believe that reviewing and possiblyre-analysing ‘hidden field evidence’ is a criticalfirst step to gain some understanding of keyissues around management of malnutrition inthis age-group, e.g. overall admissionnumbers, programme coverage, agency guidancematerial, management practices and treatmentoutcomes.The Management of Acute Malnutrition inInfants (MAMI) Project will endeavour toestablish what is currently advised or recommendedregarding the management of acutemalnutrition in infants under six months in theform of guidelines, policies and strategies, bydifferent organisations and then determinewhat is carried out in practice.The review will involve an inter-agencycollaboration, with the formation of a steeringcommittee involving those agencies wishing tocontribute information and data. There willalso be a research advisory committee of‘experts’. The Centre for International Healthand Development, University College London(CIHD), will provide academic leadership andsupport while Action Contre la Faim (ACF)will be the lead for operational agencies.This review will engage with the currentreview process of severe malnutrition managementundertaken by WHO and theInternational Malnutrition Taskforce.Findings of the MAMI study will be sharedthrough the ENN regular publication, FieldExchange. Updates and the findings will beshared at the Global Nutrition Cluster meetingsand at international fora, such as the UNStanding Committee on Nutrition meeting in2009.A framework and detailed scope of thereview will be developed in consultation withthe steering committee and research advisorygroup. Any individuals or agencies, includinggovernment bodies, local and internationalNGOs and UN agencies, who would like toparticipate in this project should contact MarkoKerac, email: m.kerac@ich.ucl.ac.uk orMarie McGrath, ENN, email:marie@ennonline.net, tel: +44 (0)1865 249745For more information, including a questionnaireto gauge interest and data potential,visit: http://www.ucl.ac.uk/cihd/research/nutrition/mamiOr http://www.ennonline.net/research1Severe Malnutrition: Report of a Consultation to ReviewCurrent Literature (WHO, 2005)2A chapter on managing severe malnutrition in infantsunder six months was included in the Module 2 trainingresource (available at http://www.ennonline.net/ife) developedby the IFE Core Group, with input from externalexperts and guided by expert technical opinion and review.A mother with her infants enrolled inTahoua feeding centre in Niger, run byCONCERN and supported by WFPWFP/T Loro, Sudan, 200720

Field ArticleSocio-CulturalDeterminants of FoodSharing in Southern SudanBy Emmanuel Mandalazi and Saul Guerrero, Valid International LtdEmmanuel Mandalazi is aSocial & CommunityDevelopment Advisor workingfor Valid International. Overthe last three years, he hasworked on community-relatedissues in a number of CTCprogrammes in Ethiopia,Malawi, Southern Sudan, Zambia, and Uganda.The authors would like to thank ConcernWorldwide for funding the research and publicationof this paper.This field article explores the socio-cultural determinantsof food sharing amongst the Dinka ofSouthern Sudan and explores the implications forhumanitarian programming.In 2004 the Concern Worldwide SouthernSudan Supplementary FeedingProgramme (SFP) faced sub-standardrecovery rates (vis-à-vis Sphere standards),long lengths of stay, and children becomingseverely malnourished in spite of the supplementaryrations provided. Anecdotal reportspointed to food sharing as the primary underliningcause. A field study was commissionedby Concern Worldwide to explore food sharingas a cultural phenomenon, to determine itsroots and its implications for the CommunityTherapeutic Care (CTC) programme, as well aspossible responses. Much of this article isbased on the findings of this study.Local Dinka volunteersSaul Guerrero is also a Social &Community DevelopmentAdvisor working for ValidInternational. Over the lastfour and a half years, he hasassisted in the design, implementationand evaluation ofcommunity mobilisation strategiesfor CTC programmes. He has also beeninvolved in a wide range of operational researchprojects. He has worked in Ethiopia, Malawi,South and North Sudan, the DemocraticRepublic of the Congo (DRC), Zambia, Niger,Chad, Sierra Leone and Indonesia.Given the proximity to the border betweenNorth-South Sudan, Dinka communities experiencedsome of the heaviest attacks and raidingby murahaleen (northern militia groups)coming from the Kordofan and South Darfurregions in the north. The socio-economic costsof these attacks were immense. For example, inareas such as Paliau, the decline in cattlenumber was so significant that it led to agricultureentirely replacing pastoralism as theprimary source of livelihoods 5 . From aneconomic perspective, raiding and lootingprecipitated a decrease in the socio-economicstatus of most Dinka families in the affectedareas (particularly in Bahr-el-Ghazal and UpperNile regions). This impacted not only on theoverall vulnerability of households, but alsohas led to the loss (almost overnight) of significantwealth amongst the richest families andclans. Polygamous men (often married to tensof women) became unable to sustain andsupport the individual female-headed householdslinked to them through marriage.Individual Dinka family units, and in particularfemale-headed households, have had tobecome increasingly self-sufficient. In thiscontext, food aid has proved useful in supporting,as a primary pillar of Dinka identity, cannotbe ignored because it ultimately determines thedegree of success of humanitarian interventions.MethodologyThe writing of this article was prompted bywhat was perceived as a deficit of informationon food sharing practices amongst the Dinka ofSouthern Sudan, and the impact that such practicesand obligations had on humanitarianprogramming. The main bulk of the data werecollected in 2004 as part of a month-longresearch study, funded and supported byConcern Worldwide in Aweil West and North,Bahr-el-Ghazal (Southern Sudan). Further fieldvisits to Aweil West and North in 2005 and toTonj County in 2007 provided additionalresearch opportunities. During these visits,information was gathered using qualitativeresearch methods including Focus GroupDiscussions (FGDs), in-depth interviews andinformal discussions with key stakeholders.BackgroundThe Dinkas, or Moinjaang, are the largest ethnictribe in Southern Sudan, inhabiting the swamplandsof the Bahr el Ghazal region of the Nilebasin, Jonglei and parts of southern Kordofanand Upper Nile regions. The group has an estimatedpopulation of around 2 million, constitutingabout 5% of the population of the entirecountry 1 . The numerical strength of the Dinka’shas historically made them a force to be reckonedwith in the political and economic direc-N Dent, S SudanFood sharing has been, and continues to be,an important feature of the identity of theDinka of Southern Sudan. Kinship structuresplay an important role in how food is utilised inthe Dinka society. The Civil War that engulfedNorth and South Sudan for over two decadeshas led to an increased reliance by Dinka (andother) communities on these kinship structuresfor their survival. These important featureshave gone largely unacknowledged by humanitarianpractitioners working with communities,such as the Dinka, in which sharing playsa prominent role. This article argues that shartionof Southern Sudan 2 . Their involvement inthe Civil War was particularly prominent, withDinkas filling the ranks and providing much ofthe strategic direction of the Sudan People’sLiberation Army/Movement (SPLA/M). Theinteraction between Dinka socio-political identitiesand the Civil War has been multifacetedand has been extensively explored elsewhere 3 .For the purpose of this discussion, however,two elements are worth exploring. First, theimpact of the conflict on the Dinka’s traditionalsource of livelihood (pastoralism), and second,the war-induced changes in traditionalmarriage practices and polygamous householdsin particular.The Dinkas have traditionally consideredthemselves pastoralists. Recently, however,environmental factors such as flooding anderratic rains have led to the emergence of agropastoralismas the primary livelihood in muchof the Upper Nile region 4 . Livelihood changesaside, cattle continue to play a central social,political, cultural and economic role in theDinka traditional identity. Cattle have been thehistorical measure of a family’s wealth, and themeans by which further wealth is sought. Cattleare the primary means by which householdsand clans are expanded, as it represents themain form of dowry (known locally as arueth)used in marriages. The Dinka are polygamous,and the number of wives taken by a man hasbeen closely linked to the number of cattle thateach man (and his clan) posses. The cattle givenby a man to his wife’s family, is then redistributedbetween the man and his close relatives,thus expanding their communal wealth.1FAO/WFP (2006). FAO/WFP Crop and food supply assessmentmission to Sudan (Special report).2Jok, Jok Madut and Hutchinson, S. E, (1999). Sudan’sProlonged Second Civil War and the Militarisation of Nuer andDinka Ethnic Identities.3See reference 1. p1264Johnson, D. H. (1989). Political Ecology in the Upper Nile:The Twentieth Century Expansion of the Pastoral 'CommonEconomy'. The Journal of African History, Vol. 30, No. 3.p4635Harrigan, S and Changath, C. (1998). The SudanVulnerability Study, (Save the Children Fund- UK, Nairobi)6Ntata, P. R.T (1999). Participation by the AffectedPopulation in Relief Operations: A Review of the Experienceof DEC Agencies during the Response to the 1998 Famine inSouth Sudan. (Chancellor College, University of Malawi,unpublished report). p2121

Field Articleing households – but it has been kinshipsupport networks and obligations that haveproved essential in safeguarding the mostvulnerable 6 .Dinka Kinship Structures: a briefoverviewFor the Dinkas of Southern Sudan, kinshipstructures have been and still remain an importantmechanism that dictates their lives. Thereare three kinship structures in the Dinka societythat regularly influence people’s lives - frommarriage, to allegiance in local conflicts to foodsharing. First, there is dieth or ‘clan’ - the largestkinship structure that an individual belongs towhich an individual belongs, membershipbeing inherited patrilineally (from one’s father).Clans tend to comprise a large number of familiesin a given area. For example, there are fivedieth (panchol, panayuel, panrec, panayik andpanakuol) amongst the Bor Dinkas of Paliau 7 .The second significant group is the paruaidie or‘in-law’, which generally includes the clan andclose relatives of one’s spouse. Thirdly, is themac thok - the smallest and closest group in thelineage with which a person identifies. It generallycomprises members of the nuclear family,parents, siblings and their nuclear families. Theboundaries of the mac thok are individuallydetermined, and do not seem to follow rigidkinship or social lines. It is from the mac thokthat the dowry (or bride wealth) generallyderives – and to which the dowry for a marriedwoman is in turn distributed.Food sharing mechanismsFood and asset sharing is a multilayeredprocess; essential to everyday life amongst theDinkas, and equally central as a coping mechanismin times of food insecurity. Not only isfood sharing widely recognised as a socialnorm but it has also been firmly imprinted onthe traditional legal system of the Dinka.Broadly speaking, food sharing relies on tworegular mechanisms; informal but regular‘meal’ sharing, and the more formalised sharingof foodstuff and assets.Informal Meal SharingInformal meal sharing is a regular practice thattakes place between different households butmostly (though not exclusively) amongstmembers of a mac thok. This communal sharingof meals is widely referred to as buro andhas traditionally been used as an informalforum to discuss community issues, retellstories and share advice from one generation(older) to another (younger). Our own fieldobservations showed that buro is conductedalong very strict gender lines. Men over the ageof eight come together in one central place(usually in one of the participants’ households)while women and children have a separate andusually distant location 8 . Another subdivision ismade where women have their own burowhereby young children are given their owndish to eat from. The Dinka often explain thisarrangement by pointing to the difficulties forchildren to eat their fill if they had to ‘compete’for food with older siblings or adults. The civilwar, and the resulting loss of resources anddisplacement of entire communities, has weakenedthis practice – but it remains an active andrelevant institution for the Dinka. From a foodsharing point of view, buro relies on individualcontributions of food according to individualcapacity – it is not imperative to contribute,thus allowing for food insecure individuals torely on the more food secure. Although theShamingAs Harrigan (1998) 12 reports, the Dinkas useshaming as a mechanism to advocate for a fairdistribution of resources amongst a largermajority of people – especially one’s mac thok.People who do not share food with members oftheir mac thok (i.e. who do not engage in pracpracticeof buro is reportedly decreasing, thereis evidence to suggest that it is still part andparcel of the Dinka culture and everydaycommunity interaction.The introduction of humanitarian foodrations into Dinka society has had mixed effectson buro. The use of Corn Soya Blend (CSB) inSFPs has introduced quantities of flour, whicheven though may not be considered sufficiently‘large’ to be shared as an asset (see below), havecertainly entered into the communal meals incooked form (e.g. porridge). Our research indicatesthat the porridge prepared by mothers oftargeted households, is openly and systematicallyshared amongst the children of all householdsparticipating in buro 9 . Whilst CSB may beshared during buro, our research found littleevidence to suggest that Ready-to-UseTherapeutic Foods (RUTFs) such asPlumpynut® undergo a similar sharingprocess. The exclusion of RUTFs from thesystematic means of food sharing such as buroare, arguably, the result of two factors; first, theindividually packaged RUTF rations are moredifficult to add to a communal meal on a regularbasis. Secondly, nutrition programmes haveconsistently presented RUTF as a ‘medicinalfood’ – a hybrid between medicine for thechild’s condition, and food to fulfil its dailynutritional requirements. As such, mothers maybe less willing (at least during the initial stagesof treatment) to allow other seemingly healthychildren to consume the product.Formal SharingThe more formalised type of sharing takes placein times of need or shortage and mainlyinvolves borrowing foodstuff and livestockduring food insecure periods or when individualsare entitled to request assistance frommembers of their mac thok. During these periods,individuals may request items such asgrains, pulses and livestock from close relativessuch as nephews, uncles, in-laws and siblings inorder to meet their food needs. Duringmarriage, an individual is also entitled to askthe members of their mac thok for assistance toraise the required dowry (mostly in the form ofcattle). In turn, the bride wealth that the bride’sfamily receives from her husband is sharedamongst members of her mac thok so that it isA group of Dinka eldersalso used as dowry contribution duringmarriages of their male children. When thedowry is to be collected, a bull is slaughteredand a meal prepared for all people from bothsides except for the groom who waits for lokthok 10 to be performed. Repayment mainlydepends on the quantities shared; no immediateor future repayment is generally expectedwhen very small quantities – such as 1 tin ofsorghum – are exchanged. Only when the quantitiesare large (over 3 tins of sorghum for example)– is repayment generally expected. There isevidence that food aid sharing is also part andparcel of the formal sharing. For example asNtata reports, “during the 1998 emergency,food, after being distributed to women, wassubsequently taken to a secondary distributionpoint where it was redistributed by the leadershipstructure based on its own definitions ofvulnerability” 11 . Our own evidence supportsNtata’s findings of ‘secondary sharing’ athousehold (or mac thok) level.Enforcing and formalising food sharingoptionsAmongst the Dinka there are a few generalrules, such as legal action, social exclusion andshaming, that govern the way sharing isconducted.7See footnote 3, p33.8See footnote 3, p21.9Guerrero, S. (2004). Socio-Cultural Assessment of FoodSourcing and Sharing in the Communities of Aweil West &Aweil North, Bar-El- Ghazal, South Sudan (Valid International& Concern Worldwide, unpublished report)10The lok thok is a traditional Dinka ritual amongst theDinkas that is performed when dowry is paid for and iscollected by the bride’s family. It literally means ‘cleansingone’s face with water’ a necessary step to allow the groom toeat together with his in-laws. Prior to the performance of lokthok, the groom is traditionally considered ‘dirty’, ‘impure’and too immature to eat together with his in-laws. For theceremony, a bull is slaughtered for the groom and he eats itwith his peers as a way of bidding farewell to them and graduatinginto adult life.11See footnote 4. p14.12See footnote 313See footnote 3N Dent, S Sudan22

Field Articletices such as buro) are often branded as kor (lit.‘lion’). This has elsewhere been attributed to thenotion that like lions, people who eat alone givenothing to others, and should expect nothingfrom other members of the group 13 . Sometimesif one refuses to share food with those in need itcould lead to death - through spear masterswho may invoke the wrath of the ancestral spirits.Whilst selfishness is socially shunned, sharingis socially rewarded. A wife who is generousto the children of her in-laws, for example,will be highly esteemed by the members of herhusband’s family. Shaming, traditional beliefsand appreciation are the socially constructedand powerful enforcement mechanisms thatpromote food sharing.Legal action in traditional courtsThe ability of households to rely on members oftheir mac thok in times of food insecurity is alsofirmly protected by traditional Dinka law.Traditional law allows individuals to bring tocourt members of one’s mac thok who areunwilling to assist in times of need. In exceptionalcases, in-laws can also be brought tocourt if they fail to complete dowry payment.These courts, known locally as luke, are run byvillage elders and socio-political leaders (e.g.Executive Chiefs). The courts are responsiblefor cases ranging from adultery (luke ting cikor) to stealing (luke cur) and murder (luketier). During the pre-harvest months, the courtsalso witness a significant increase infood/hunger related cases (luke ecok). Thesecases are mostly founded on refusals to sharefood, or failure to pay for cattle given or promisedduring marriage. The system allowspeople to ‘file’ cases against any member of themac thok for failure to honour a debt or promise.The system also ensures that sharing offood and assets such as livestock eventuallytakes place, especially in situations where theaccused does not sympathise with his/her relative’splight and/or needs. This makes sharingfood with one’s disadvantaged relatives notonly an issue of social or moral responsibility,but also a legally founded obligation.Implications of food sharing practicesfor humanitarian programmingMuch of this article has focused on the social,economic and cultural roots of food sharing – asan integral feature of local livelihoods, andsocial norms, as well as a legal obligation inDinka society. In doing so, it has highlighted theimportance of the system for the Dinkas themselves.Food sharing is not merely a characteristicor feature of Dinka society and humanitarianprogrammes should recognise it as an operationalvariable and a factor to be acknowledgedand accounted for in order to maximise humanitarianprogramme performance. Doing sowould ensure two of the most fundamentalprinciples of humanitarian programming –A homestead in South Sudanminimising the negative impact on localsupport networks, and maximising the impactof proposed interventions.A clear understanding and recognition of theDinkas as a social group with a social andcultural structure that leans towards a collectiveway of life would help minimise any potentialnegative impact on local support networks ofhumanitarian programming. Members of thecommunity and, in particular, from the macthok, may try to help those in need and overlooktheir own individual requirements inorder to conform to societal obligations. Foodsharing may play an essential role in humanitarianprogramming in that food sharing mechanismsand obligations will ensure that all familiesbenefit from the food that is available, especiallywhen some families have surplus foodreserves. However, it must be recognised that insituations where the majority of families havelimited food, food aid will still be shared out inthe wider community. For example, the humanitarianfood rations such as CSB in SFPs havebeen part and parcel of communal meals (buro).The rations effectively become diluted so that thenutritional requirements of the most vulnerable,e.g. the malnourished, are least likely to be met.In order to maximise humanitarianprogramme performance, food aid meant tobenefit the vulnerable directly may need to bemarked as medicinal food as it will be lessexposed to sharing. However, even where foodis ‘medicinalised’ this may not be enough sincein Dinka culture, a person is regarded asvulnerable mainly on the grounds of thekinship structures that an individual hasaround them to support them. Local peopleoften say that rather than targeting, it is betterto get a handful for everyone as it makes themall equal. In these and in other instances whenfood aid might not be easily medicinalised,programmes may be more effective if they areaccompanied by ‘civic education’ throughcommunity sensitisation, to highlight theimportance of only making the food availableto the most vulnerable. Key people, includingleaders of clans, community and traditionalcourts, directly involved in the decision makingaround food and asset sharing, should betargeted.All in all, food and asset sharing is deeplyrooted in the Dinka culture. It is thereforeimperative for the humanitarian practitionersoperating in Southern Sudan to invest adequateresources in exploring and recognising culturaltraits that will ultimately enable programmes tobecome more culturally amenable.For further information contact EmmanuelMandalazi, email:emmanuel@validinternational.org or SaulGuerrero, email: saul@validinternational.orgN Dent, S SudanEvaluationWFP TargetedSupplementaryFeeding inEthiopiaSummary of evaluation 1In October 2004, the Executive Board ofthe United Nations (UN) World FoodProgramme (WFP) approvedProtracted Relief and RecoveryOperation (PRRO) 10362.0 for Ethiopia.This intervention aimed to address the foodneeds of 3.8 million beneficiaries (relief 1.7million, recovery 2.1 million) over theperiod 1 Jan 2005 to 31 December 2007.PRRO 10362.0 comprises four mainprogramme components including targetedsupplementary feeding (TSF) for vulnerablechildren and women, working withinthe Government of Ethiopia’s framework ofEnhanced Outreach Strategy (EOS).The EOS/TSF programme delivers acombination of key child and maternalhealth interventions including Vitamin Asupplementation, measles vaccination,provision of insecticide treated bed netsand de-worming on a six-monthly basis.Screening of pregnant women, women withinfants under six months of age and childrenunder five years of age 2 using midupperarm circumference (MUAC) 3 alsotakes place, in conjunction with delivery ofthe health inputs. Those women and childrenwho are found to have a MUAC belowthe cut-off point of 21.0cm and 12.0cmrespectively are given a ration card andreferred to the TSF programme. Those witha MUAC below 11.0cm and/or withoedema are referred for treatment of severemalnutrition where available. The TSFbeneficiaries receive two 3 monthly foodsupplements that comprises 25 kg ofmicronutrient fortified Corn or Wheat SoyaBlend (CSB/WSB) and 3 litres of fortifiedvegetable oil. This provides 1,690 kilocalories,55g of protein and 15g of fat per day.At the end of 6 months, beneficiaries automaticallyleave the programme.The MUAC screening and TSF referraltakes place every six months at designatedEOS sites. The TSF distribution takes placeevery three months at TSF designated sites.The FMOH/UNICEF are responsible forthe EOS component while the DisasterPreparedness and Prevention Bureau(DPPB)/WFP are responsible for the TSFcomponent.The overall aim of the combined componentsof the EOS/TSF is to “reduce morbidityand mortality in children under five”.The TSF objectives are nutritional and areas follows:23

Breastfeeding class in progress at 2006 Child Survival SFP siteWFP/Paul Turnbull, Ethiopia, 2006• To prevent the nutritional deterioration ofchildren under five and pregnant andlactating women.• To prevent those moderately malnourishedbecoming severely malnourished.• To rehabilitate moderately malnourishedchildren and pregnant and lactating womenthrough the provision of fortified supplementaryfood.• To promote key nutrition messages.It should be noted that while the objectives of theTSF are typical of traditional supplementary feeding(SFP) programmes, the TSF is not a standard SFP.The TSF operates on the basis of a three-monthlyfood distribution without a general ration, absence offacilities for treatment of severe acute malnutrition(SAM)) and no follow up of a child or women’sweight gain during their enrolment in theprogramme. (Ed).In December 2006, WFP conducted an evaluation4 of the TSF/EOS component of the PRROas part of a larger evaluation of the wholeprogramme. Interviews were conducted withkey stakeholders in Addis Ababa and the evaluationteam visited five regions of Ethiopiawhere the TSF was being implemented.Interviews were conducted in regional capitalsand at field level. The following were the mainfindings of the evaluation team.• The achievements of the TSF in a relativelyshort space of time have been impressive.• Over a one and a half year period, the TSFhas expanded from just one region and 10woredas in April 2005 to 264 woredas in 10regions by the end of 2006.• In 2005, only 62.2% of planned TSF beneficiarieswere reached. This was due to start upproblems related to capacity constraints ingovernment, including a lack of training andcoordination, under-achievement in terms ofnutritional screening targets and delays insecondary transport of food delivery. ByNovember 2006, approximately 400,000 childrenand 190,000 pregnant and lactatingwomen received two distributions of thefood supplement i.e. a total of six months ofsupplementary food. Furthermore, 4,000food distribution agents had been trained.• Considerable resources have been investedin TSF staff training at all levels. In addition,the programme provided a ‘minimum package’for the regions that included cars,motorbikes and computers. In 2006, an estimated54% of all TSF woredas received theminimum package.• Another significant achievement has beenthe substantial network of highly capabletrained local women (Food DistributionAgents (FDAs)) created for overseeing allaspects of the food distribution and forproviding nutrition education. In addition,WFP has made considerable efforts tostrengthen programme implementation –largely through operational research/pilotstudies. WFP have also developed a monitoringsystem especially for the TSF.ChallengesCurrently, there is insufficient evidence that theTSF is having a positive impact on nutritionalstatus of children enrolled in the programme.This is a critical gap given the unusual design ofthis programme and lack of precedent forimplementing this type of programme. Thereare also no population level data (baseline andpost-intervention) on prevalence of acutemalnutrition in children under five and womenor infants and under five mortality rates thatcould be used to demonstrate an impact of theprogramme at population level. However, thescale of the food transfer, the coverage and theintegration with EOS health inputs wouldsuggest that the programme must have somenutritional and health benefit even though themagnitude of this has as yet to be measured.There is also a lack of clarity and policy guidancewith regard to how the TSF should beadapted where acute nutritional crises occur.This has reportedly led to situations where theEOS/TSF has been viewed as a replacement fortraditional SFPs in situations where child wastinglevels have substantially increased.Another challenge is that there are no formallinkages between the TSF and relief/ProductiveSafety Net Programme (PSNP) components ofthe PRRO. Although, according to the PRROdocument, the TSF programme was meant toserve a subset of the relief/PSNP beneficiarypopulation, no operational linkages have beenestablished. A high proportion of TSF beneficiariesmay therefore not be in receipt of an adequategeneral ration. This will lead to sharing (smallscale studies conducted by WFP suggest thatover 50% of TSF beneficiaries may be sharingrations with other family members) and consequentdilution of impact of the TSF ration.However, as a significant proportion of thoseidentified as mild and moderately malnourishedmay not be food insecure but affected by poorhealth and/or caring practices, it may not beappropriate to formalise a linkage between theTSF and relief/PSNP components of the PRRO.This issue requires follow up study to determinewhether a formal linkage between theprogrammes should be established.Another issue is that there is no clearly articulatedexit strategy for the TSF component,although the overall EOS/TSF programme isexpected to phase out as the national HealthExtension Programme (HEP) expands. It isunclear how long the planned HEP expansionwill take although considerable progress isbeing made in training Health ExtensionWorkers (HEW) and in constructing healthposts. In addition, there is currently no statedrole for supplementary food in the HEP documentation.It is therefore unclear how theprogramme will continue if WFP withdrawsfrom programming in the future.The evaluation made a number of recommendationsthat include the following.In order to demonstrate impact of this noveltype of programming, WFP should:• Conduct a robust nutritional impact andefficacy assessment of the TSF as a priority,with all parties and donors involved in thestudy design to ensure shared objectivesand ownership of the results.• Ensure the study involves representativesamples of cohorts of children to assessnutritional outcome and also includeprogramme coverage indicators to understandwhat levels of exclusion and inclusionerror are occurring.• Ensure that if impact and efficacy aredemonstrated, there are discussions withkey stakeholders to determine clearprogramme targets for the future, includingexit criteria.To strengthen linkages between EOS and createopportunities for FDAs to become a bridge tothe HEP, WFP should formalise the role ofFDAs in EOS screening.To ensure that the TSF does not inhibit anappropriate response to acute nutritional crises,WFP should develop clear guidance materialon the role of the TSF in acute crisis, especiallywith regard to emergency targeted SFPs implementedby international non-governmentalorganisations.1Summary Evaluation Report Ethiopia PRRP 0362.0. 10October 2007. Available athttp://www.wfp.org/eb/docs/2007/wfp137560~2.pdf2The screening actually includes older children who arestunted as the entry to the EOS programme is based on aheight less than 110.0cm3Up until March 2006, MUAC screening was followed byweight for height measurements but this was stopped afteragreement among all stakeholders to simplify the system anduse only MUAC as a good predictor of mortality risk.4WFP (2007): Summary Evaluation Report Ethiopia10362.0: Enabling livelihoods protection and promotion.Executive Board 2nd Regular Session, Rome 22nd-26th ofOctober. Agenda Item 624

EvaluationReal timeevaluation ofPakistan FloodResponseSummary of evaluation 1The Pakistan floods of 2007 devastated largeswathes of rural Sindh and BalochistanProvinces in southern Pakistan, destroyinghomes, crops and roads, and caused thetemporary displacement of over 2.5 million people.The Government of Pakistan (GoP), through itsnewly created National Disaster ManagementAuthority (NDMA) and with the help of the Army,launched a major relief operation. The UnitedNations (UN), with other members of the internationalhumanitarian community and local nongovernmentalorganisations (NGOs), mobilisedresources to help. The decision was taken by theInter Agency Standing Committee Country Team(IASC CT) 2 to launch a full-scale humanitarianresponse. An application was made to the CentralEmergency Response Fund (CERF). Clusters wereset up and started work, a joint rapid assessmentwas carried out with NDMA, and a Flash Appealwas announced and promoted.For a variety of reasons, the GoP did not fullysupport the IASC CTs decision and approach. Inaddition, the assessment was delayed, the FlashAppeal was issued three weeks after the onset of theemergency and raised only 26% 3 of its target, andthe Clusters failed to achieve their full potential ascoordinating mechanisms. As a result and despitesubstantial efforts, the humanitarian communitydid not succeed – to the extent it considered appropriate– in delivering humanitarian relief to thealready-impoverished people of Sindh andBalochistan. A Real Time Evaluation (RTE) was setup over a two week period, staffed and operatingindependently of the UN, to help understand thereasons and suggest improvements for the future.The main findings of the evaluation go some way toexplaining the disappointing overall response andinclude:• When the floods struck, the UN reforms (beingpiloted in Pakistan), the Humanitarian Responsereforms, and the NDMA set up were all still intheir transition phases. They needed more timeto take root and for all parties to understandnew mandates, roles and modes of operating.• There were huge expectations within the UNthat the success of its own Pakistan earthquakeoperation, mounted jointly with the GoP andfully supported by the international humanitariancommunity, could be repeated. However thecontexts were very different and expectationswere disappointed.• Balochistan, in particular, is a highly politicallysensitive part of Pakistan, and there have beenrestrictions on access for non-Pakistan nationalsfor some time on safety grounds.• The GoP, and specifically the NDMA, was uneasyabout launching a full scale international humanitarianresponse, including the Flash Appeal.• The UN did not really grasp the implications ofthis GoP unease. Decisions were made by theIASC CT (to establish 12 Clusters, for example)with the best of intentions that, with hindsight,were over-ambitious and over-complex in allthe circumstances.• Lessons from the 2005 Pakistan earthquake,particularly in relation to the operation of theClusters, had not been learned or implemented,and many of the issues that were identified inthe earthquake RTE re-emerged this time.Main recommendations of the RTE may besummarised as follows:• The UN, the GoP and indeed the internationalhumanitarian community as a whole, mustcontinue to invest in the new structures so thatthey achieve their objectives. Greater effortsmust be made to understand each others’mandates, roles and operating procedures anddevelop a real sense of partnership in workingtowards common humanitarian goals.• Common assessment tools, an effective managementinformation strategy and systems, andshared operating procedures, contingency plans,standards and principles are needed.• The Resident Coordinator/HumanitarianCoordinator (RC/HC) needs, in some circumstances,a special budget for immediate emergencyresponse, or fast-track access to the CERF.Also, the capacity for a ‘quick Flash Appeal’,followed by a later full assessment-based appealupdate, could achieve greater response fromdonors while media attention is still focused onthe emergency.• The RC/HC role is extremely testing, and themanagement and decision-making structures atcountry level are labyrinthine, particularlyduring a humanitarian response. A constructivedevelopment would be the separation of bothroles by appointing a HC, as deputy to the RC,with Disaster Management (DM) and leadershipskills and experience. The RC should beempowered during the period of the responseto exercise overriding authority over the countryheads in exceptional circumstances, and ifnecessary for the purposes of the response.• The decision-making structures should besimplified by creating a senior level DisasterManagement Team (DMT) jointly with theGoP/NDMA and representative(s) of otheragencies as appropriate. The DMT should beempowered to make all the key strategicresponse decisions quickly and effectively.• The Office for Coordination of HumanitarianAssistance (OCHA) needs to be adequately andquickly resourced for a humanitarian response incountry, if it is to do its job effectively. The generalview is that this was not the case in Pakistan.• The lessons of the 2006 earthquake RTE particularlyrelating to clusters, and reinforced by thefloods RTE, should be learnt and implemented.The issue at the heart of the findings from the RTErelates to the role of the UN in a sovereign state witha strong government, and a humanitarian crisis towhich the humanitarian community feels impelledto respond, but where the government does notwish to seek or receive international assistance atthe level which the humanitarian communitybelieves is appropriate.This fundamental issue is a delicate and sensitiveone and raises essential issues of international lawin a situation where passions run deep on both sidesof the argument. One person’s imperative can easilybecome another’s imperialism. Careful negotiationand discussion are required as well as patient advocacybased on good quality information.1IASC Inter-agency real time evaluation of the Pakistanfloods/cyclone – October 2007. FINAL Version: 31st October 20072Inter Agency Standing Committee. Seehttp://www.humanitarianreform.org3Correct on 30th September 2007Field ArticleWet nursingfor refugeeorphans inBangladeshBy Yara Sfeir, UNHCRBangladeshYara Sfeir is an International UnitedNations Volunteer posted as aNutrition Coordinator for the twoRohingya refugee camps ofNayapara and Kutupalong on theborder of Myanmar in Bangladesh.The opinions expressed are those ofthe author and cannot be attributedto UNHCR.In Nayapara TFC, the first wetnurse was the baby's aunt25

This article shares the practical realities ofidentifying wet nurses for young orphanswhere artificial feeding was not considered anacceptable, feasible, affordable, sustainableand safe option.UNHCR started working inBangladesh in 1992 upon the invitationof the Government ofBangladesh to assist in the repatriationof more than 250,000 Rohingya refugees.These people had fled from Myanmar duringthe same year due to socio-economic and politicalreasons. UNHCR has since assisted in therepatriation of around 230,000 refugees, equivalentto 95% of the original registered refugeecaseload.As of end December 2007, there were some27,400 refugees residing in the two camps ofKutupalong and Nayapara situated along theBangladesh-Myanmar border. UNHCR providescare and maintenance while activelypursuing durable solutions for the remainingrefugees 1 . The Ministry of Health along withone local non-governmental organisation(NGO), Technical Assistant Inc (TAI), were theonly two UNHCR implementing partners untilrecently. In November 2007, Research TrainingManagement International and HandicapInternational began working in the two camps.In both camps 2 , Medecins Sans Frontieres-Holland has been present and is planning toclose down its operation in 2008.In the Rohingya refugee camps of Nayaparaand Kutupalong in Bangladesh, three types ofnutrition programmes are operating, in additionto the World Food Programme (WFP)general food distribution.• A Blanket Feeding Programme (BFP) for allchildren between 6 and 24 months residingin the camps• A Supplementary Feeding Programme(SFP) for pregnant or lactating mothers andmoderately malnourished children between6 to 59 months. A total of three SFPs areoperating between the two camps.• A Therapeutic Feeding Centre (TFC) forseverely malnourished children from 6 to59 months. One TFC is present in eachcamp, run by the MOH.The challengeIn October 2007, Ministry of Health staff workingin the TFC alerted the UNHCR teammanaging the camps that five orphans belowsix months of age had been brought by caretakersto the TFC but were sent home again sinceno guidelines were set for their care. No infantformula is provided in the camps and the caretakerswere feeding the infants with cereals. Atfirst the UNHCR team thought about providinginfant formula for the orphans. However,after consulting the ‘UNHCR Policy Related tothe Acceptance, Distribution and Use of Milkproducts in Refugee settings (2006) 3 , anddiscussions with the UNHCR HeadquartersNutrition Unit, the challenges of introducinginfant formula to such an unhygienic settingwere recognised. Furthermore, the caretakerswere illiterate and unable to read writtenguidelines. Another fear was that all motherswould start requesting infant formula for theirinfants, as it was common practice for distributedfood to be sold in the camps.The optionsWe therefore opted to find a ‘wet nurse’ – awoman who is not the mother who wouldbreastfeed the infant. This strategy is includedin the options outlined in the OperationalGuidance on Infant and Young Child Feedingin Emergencies (2007) 4 produced by the IFECore Group, of which UNHCR is a member.We realised that the HIV status of the wetnurse should be considered. However, in theNayapara and Kutupalong camps the risk ofHIV was considered to be low 5 , therefore thewet nurses were not offered Voluntary andConfidential Counselling and Testing forHIV 6 .In the Nayapara camp there was a motherwho was already breastfeeding one orphanwho was not a relative. She was also breastfeedingher one year old child at the sametime. Since this seemed to be an accepted practicein the community, we asked theCommunity Health Worker (CHW) and theTFC and SFP staff, as well as the caretaker, toactively look for wet nurses amongst the relativesof orphans. In the event that no relativewas lactating, we urged them to extend theirsearch to the wider community. As an incentive,we agreed to offer the wet nurses foodfrom the SFP. After a few days, one wet nursewas found for one orphan: she was theorphan’s aunt. It had not occurred to her thatshe could also breastfeed her orphan nephew.“It is an honour to breastfeed my nephew”said the aunt smiling, hugging the baby andcuddling him. This positive experienceencouraged us further.The CHW and selective feedingprogramme staff informed us that no otherwet nurse could be found so we decided toreach out to the community. One of the waysin which we did this was to talk with groupsof pregnant and lactating women when theycame to the SFP for food. We told them, “Weare the team responsible for nutrition in thecamps. We are facing a problem. We need yourhelp. We have orphans in our camps that aretoo small to be given food. They should onlybe breastfed. We don’t want to give thempowdered formula because if the water in theformula is not clean, they will be sick and havediarrhoea. Would you or someone you knowbe able to breastfeed the orphan?” Weexplained that the baby already has a caretakerand that their role would only be tobreastfeed the baby several times a day. Wealso explained that the wet nurse wouldreceive an extra food ration from the SFP (anegg, a banana and some porridge) every day.Two lactating mothers agreed on the spot. Oneof them was hesitant but when we took her tosee the orphan her doubts disappeared. Weasked the wet nurses to come to the centreevery day. The TFC staff and the caretakerwould make sure the wet nurse was breastfeedingthe infant 8 times a day and that shealso received her extra ration. In theKutupalong camp, a wet nurse was easilylocated for one orphan and she breastfed himmore than 6 times a day, in the morning andthe afternoon. This was also a very encouragingoutcome.However, a number of difficulties did arise.One wet nurse was not allowed by herhusband to breastfeed an unknown child, sowe had to actively locate and recruit anotherField Articlewoman for this child. Luckily, we were able tofind another willing wet nurse, although shefound it difficult to breastfeed 8 times a daysince she lived far from the centre. Since theTFC closes at 2pm, we asked the caretaker totake the infant to the wet nurse every afternoon.This seemed to work well for all theorphans. However, another problem soonarose. As refugee women do not feel safe travellingat night, the caretakers were asking forinfant formula for night-feeds. During a trainingon breastfeeding organised by UNHCR, asolution was found through discussion andbrainstorming led by a trainer from theBangladesh Breastfeeding Foundation. Thewet nurse would hand over expressed breastmilkto the caretaker who would keep it in acontainer. If the milk needed to be kept formore than 6 to 8 hours, then a box of ice wouldbe given to the caretaker for storing theexpressed milk. The milk could then be heatedand given to the infant by cup. This practice isnow adopted in the camps.Of course, a number of challenges remain.For example, there was an occasion when acaretaker decided that when her orphan had about of diarrhoea that this was due to the wetnurse’s breastmilk. She therefore boughtpowdered milk. On showing it to us it wasclear that she was unable to read the warningthat clearly stated “not suitable for infantsbelow 1 year”! We discussed the issues aroundthis with her and offered advice. However, sheseemed uninterested and never came back tothe TFC. Challenges like these are, of course,to be expected but in my opinion, the advantagesof wet nursing outweigh the problemsfaced. The best results for malnourishedorphans have so far consistently been whenthe caretaker is also the wet nurse.For more information, contact: Yara, Sfeir,email: SFEIR@unhcr.orgAn UNHCR Guidance on Infant feeding and HIVin Emergencies for Refugees and Displaced populationsis being finalised. The purpose of the guidanceis to assist UNHCR, its implementing andoperational partners and governments on policiesand decision-making strategies on infant feedingand HIV in emergency situations. For furtherinformation, contact: Fathia Abdallah, UNHCR,email: Abdallah@unhcr.org1As per the memorandum of understanding between theGovernment of Bangladesh and UNHCR, a third camp (Tal),present on the banks of the Naf river, is not supported byUNHCR.2MSF-H is also operating in Tal camp where UNHCR is notpresent.3Policy on the acceptance, distribution and use of milkproducts in refugee settings (2006). Available in English andFrench. Download from http:///www.unhcr.org orhttp://www.ennonline.net Contact: ABDALLAF@unhcr.org orHQTS01@unhcr.org4Operational Guidance for Emergency Relief Staff andProgramme Managers on Infant and Young Child Feeding inEmergencies. Version 2.1. February 2007. Available athttp://www.ennonline.net5Bangladesh is deemed a low HIV/AIDS prevalent country -it is estimated that the HIV prevalence in the adult populationis less than 0.01%. However vulnerability is consideredhigh for reasons that include low awareness of HIV/AIDS andlow condom use. (http://www.whoban.org/hiv_aids.htmlUpdated 7 Jan 2008. Accessed 7 Jan 2008). When dealingwith refugee populations, the HIV prevalence of the countryof origin and associated knowledge and practices, shouldalso be considered for more recent arrivals (eds).6In the context of wet nursing where the risk of HIV transmissionis considered very low because of an overall lowprevalence and incidence, and voluntary and confidential HIVcounselling and testing is thus deemed unnecessary, apotential wet nurse should still be counselled about how toavoid HIV exposure during breastfeeding. The refugeewomen in the TFCs are counselled regularly on HIV as agroup and individually on a number of health related topics.A major campaign on HIV was ongoing in the camps inNovember and December 2007.26

PostscriptUNHCR CommentAnn Burton, Senior HIV AsianRegional Officer, Bangkok, UNHCR.Marian Schilperoord, Senior HIVTechnical Officer, Geneva, UNHCR.Paul Spiegel, Chief of Public Healthand HIV Section, Geneva, UNHCR.Bangladesh is experiencing alow level HIV epidemic. Inparticular, the level of HIVinfection in southernBangladesh where the refugees arelocated is extremely low. Notably , the7th and latest round of sentinelsurveillance in the first half of 2006 didnot detect any HIV infection in sexworkers (an most-at-risk population)in southern Bangladesh borderingMyanmar where the camps arelocated 1 . Though Myanmar is experiencinga generalised epidemic, thegeographical pattern is heterogeneousand available evidence indicates thatnorthern Rakhine State (the area oforigin of the refugees) is experiencinga low level epidemic. Moreover, this isa long-term refugee situation and HIVprevalence in the refugees is morelikely to approximate that of the hostcommunity. Thus, in the Nayaparaand Kutupalong camps, the risk ofHIV is considered to be very, very low.UNHCR’s policy, following internationalguidelines, is that the firstoption should be replacement feedingwhere this is acceptable, feasible,affordable, sustainable and safe(AFASS), Where this is not available,wet nursing should only be consideredin women known to be HIV negativeand include HIV awareness andcounselling support to the breastfeedingwomen (and her partner) to stayHIV negative. Thus, voluntary andconfidential counseling and testing(VCCT) is required before wet nursingbegins and thereafter on a periodicbasis to ensure that the wet nurseremains negative.HIV services in the surroundinghost community are in the early stagesof implementation; the nearest HIVVCCT centre is in Chittagong, a 4-5hour journey one way. Though farfrom ideal, due to the extremely lowrisk and the considerable operationalconstraints, it was determined at thecountry level that the risks of notbreastfeeding in this context were fargreater than those posed by the risksof not offering HIV testing. However,after consultation within and outsideof UNHCR, UNHCR will work withits implementing and operationalpartners to ensure that before potentialwet nurses begin to breastfeedinfants, they are HIV negative. Thiswill require the provision of VCCT.1http://www.icddrb.org/activity.htm Accessed20th January 2008Zita on a WHO field tripBy Jeremy Shoham, ENNThe ENN interviewed Zita WeisePrinzo, who works in the Nutritionin Emergencies (NIE) programme ofthe WHO’s Nutrition for Health andDevelopment Department (NHD), for thisissue’s agency profile slot. Zita has been afocal point for WHO’s emergency nutritionwork for many years now. Her first work forWHO was in Nepal between 1992-5, whereshe worked as an APO, effectively secondedto the Ministry of Health (MoH) nutritionunit. In 1995 she took on the first of a seriesof short term assignments in the nutritiondepartment of WHO in Geneva and hasremained at head office since then. Zita’sprofessional background includes a Mastersin Science and Food Technology and afurther Masters in Nutrition at LSHTM(1990-1).WHOs interest and involvement in nutritionemerged at the First Health Assembly in1948, where nutrition was included as one ofsix WHO priorities. In the early years, WHOnutrition work was mainly focussed onnutrition in development contexts. Earlyemergency related work included provisionof technical support to WFP through the foodaid programme (FAP) situated in WHO. FAPprovided technical appraisals of WFPprogrammes and participated in joint interagencyevaluation missions. However, theprogramme was mostly involved in ‘developmental’programming, like school feedingand food aid for Maternal and Child Health(MCH) programmes, and had a limitedemergency role. During the 1990s, WHOalways had at least one nutritionist workingat headquarters on NIE issues. However, itwas not until 2005 that the WHO nutritiondepartment formally instituted a nutrition inemergencies programme. The NIEprogramme was one of seven programmesbeing implemented within the Nutrition forHealth and Development Department inWHO. The other programmes were growthassessment and surveillance, micronutrients,nutrition policies and programmes, infantand young child nutrition, obesity, and HIVand nutrition.Z Weise Prinzo, WHO.During the 1970s and 80s, WHO’s nutritiondepartment produced a number of keyguidelines and management tools, some ofwhich were specifically for the NIE sector,e.g. Seaman and Goyet’s Nutrition inEmergencies handbook. However, morerecently, the scope of WHO involvement inNIE has increased substantially. In additionto development of guidelines and tools formanaging nutrition programmes, capacitydevelopment at national level, as a componentof preparedness and recovery andoperational support during emergencies, isnow a key element of the NIE programme.The capacity development work hasmainly focussed upon regional and in-countrytraining for the management of severemalnutrition. WHO have worked, andcontinue to work closely with, UNICEF inthis area. In the 1990s, WHO undertook aseries of regional trainings in the managementof severe malnutrition. Capacity developmentinvolving the training of nationalstaff has included curricula on infant andyoung child feeding and Nutrition and HIV.The NIE programme works closely with theHAC department in WHO by, for example,feeding into the HAC pre-deployment trainingof staff.Provision of operational support in acuteemergencies is perhaps the newest elementof NIE work. Zita feels that, in some ways,WHO are not currently well set up to undertakethis kind of work in nutrition. In thepast, WHO sent out HQ staff to assistgovernment or WHO country offices whenrequested to do so following the onset of anemergency. However, this did not have asustainable impact at the country level. Zitaexplained “there was not a great deal ofsense in suddenly getting involved in nutritionwhen there had been no previousinvolvement or presence on the ground”. Itwas recognised that WHO needed to buildup a network of nutritionists at country andregional level in advance of an emergency,in order to be able to provide operationalsupport adequately. This would allow moreappropriate responses as in situ staff “wouldbe building upon ongoing partnershipswhen an emergency struck”. The NIEprogramme has now put together a proposalthat would fund nutritionists at countrylevel. This was completed at the end of 2007but there has, so far, been little interest fromdonors. Zita fears that this may partly bedue to competing demands of the UNICEFledInteragency Standing Committee (IASC)27

Agency ProfileZita on a WHO drought surveyZ Weise Prinzo, WHO.Zita on a WHO field tripZ Weise Prinzo, WHO.Name of organisation:Department of Nutrition forHealth and Development (NHD),World Health OrganisationYear formed:2005 (with Nutrition in Emergencies as aprogramme area)Address of head office:20, Avenue Appia, CH-1211Geneva 27, SwitzerlandDirector:Dr Jørgen Schlundt, Acting Director, Department ofNutrition for Health and DevelopmentTel:+41 22 7914440 (direct)+41 22 7914156 (operator)No of Nutrition Staff(HQ):50 (48 nutrition and support staff plus 2 nutritionstaff that fall under the Health Action in Crisis(HAC) umbrella). Additional small number ofnational programme officers at country level withnutrition terms of reference.Website: http://www.who.int/nutrition/en Approx annualbudget for 2007:USD 500,000 (HQ Nutrition in Emergenciesprogramme only).Nutrition Cluster and the perceptionamongst donors that this should be aNutrition Cluster rather than a WHO role –thus failing to see the complementary role ofthe agencies.Zita reflected that, in the past, WHO haveput out guidelines and management tools asWHO documents but have learnt that theyneed to work more inclusively with otheragencies in order to get comprehensive buyin. The current development of tools on theintegrated management of severe malnutrition(community-based and hospital basedapproaches) follows this model, with othernon-governmental organisations beinginvolved in developing the guidelines. Zitaand her colleagues are also aware that in thepast some guidelines and tools have simplygathered dust as dissemination and roll outhas been poorly planned. “To be effectivelyused, these finely honed documents need tobe disseminated through mechanisms basedon long-term relationships between WHOand governments and other local agencies”.Zita sounded a little downbeat in responseto my question about NIE funding. In shortshe said that it was a continual struggle.Certainly, the advent of the Nutrition Clusterwith UNICEF as the lead has not helped theNIE programme cause. There are also battlesto be won in house, as some NIE fundingtraditionally comes through HAC, and thereare staff at the country-level that in turn havequestioned whether certain NIE activities fallmore within the domain of UNICEF. At themoment there are 25 staff in the WHO nutritiondepartment, three of who work in theNIE programme (Zita and Chantal Gegout onthe technical side and one support staff).Zita was far more upbeat about NIE plansfor the future. Work in a number of key areasis planned including;• Updating the WHO training for hospitalbased management of malnutrition• Reviewing the implications of newgrowth standards for operational practice• Producing policy guidance on integratedmanagement of malnutrition• Reviewing and providing guidance onmanagement of moderate malnutritionthrough supplementary feedingprogrammes and dietary counselling• Reaching greater clarity on preventingand controlling micronutrient deficienciesin emergencies, e.g. use of iron in malariaendemic countries• Infant and Young Child Feeding inEmergencies (IFE)• Improving maternal nutrition in emergencies.Z Weise Prinzo, WHO.I left the most controversial questions untilthe end. I couldn’t finish the interview withoutasking about WHO and UNICEF’s relationshipand any problems therein. Zita wassurprisingly frank in stating that things canget a “little competitive,” especially at countrylevel, and that the outcome (good or bad)depends very much on personalitiesinvolved and level of resources available. Ialso asked her about the view that WHO take‘forever and a day’ to produce guidelines andmanuals and that by the time these eventuallycome out, knowledge and practice havemoved on. Again Zita held her hand up onbehalf of WHO, saying that the length of timeit can take is unacceptable but that delaysalso included late inputs from stakeholdersand Member States on certain standardsettingwork. She did, however, say thatWHO are now producing fact sheets as a wayof getting information out more quickly. Sheobserved that delays are not just due to thetechnical discussions but also that fact thatdocuments have to be cleared by so manystakeholders and parties within the organisation.Apparently WHO now have guidelineson how to develop guidelines.A final question for Zita was how she sawWHO’s NIE programme fitting into thesector. She quickly identified the fact that it’slocation, i.e. within a health organisation,allows for integration of nutrition with healthand vice versa in all activities. She alsobelieves that the NIE programme has thepotential of doing excellent work in providingan evidence base for the management ofnutrition in emergencies, as well as supportingand developing the capacity of membercountries to undertake this management.An overriding and familiar impressionfrom the interview was that, as seems tooccur in so many agencies, nutrition andtherefore NIE, has to continually fight itscorner to survive. In Zita it is clear that WHOand the nutrition community have an individualwho is more than able to go the 10rounds.Zita on well-earned R and R!28

Field ArticleEvaluation ofRelactationby theSupplementalSucklingTechniqueBy Odile Oberlin and Caroline Wilkinson,Action Contre la Faim (ACF)Odile Oberlin is a paediatrician working in a Paris hospitaland research institute. She works as a volunteerconsultant with Action Contre la Faim on a regular basisin Afghanistan.The authors would like to acknowledge the contributionsof the Ministry of Public Health, Afghanistan, the ACFteam in Afghanistan and Cecile Bizouerne, ACFPsychologist, to this article. Acknowledgements also tothe Afghan Ministry of Public Health, the French Ministryof Foreign Affairs and UNICEF for proving the financialsupport for the nutrition programmes in Kabul.A mother feedingher baby usingthe SSTACF, Afghanistan, 2004This article describes ACFs experiences of managing malnourished infantsunder six months in an inpatient setting in a challenging environment,which leads them to raise key questions about managing this age-group.Action Contre la Faim (ACF) supports the only structures treatingsevere malnutrition within three paediatric hospitals or wards inKabul. The children treated in the nutrition centres are mainlyless than 5 years old with infants less than six months comprisingover one-third of the admissions (37.4% from January to May 2006). Theproblem of infant malnutrition in Kabul is not new. Field Exchange Issue 9,p16-17, highlighted the high mortality rates (17%) observed amongst infantsless than 6 months old who had been admitted in the Therapeutic feedingUnits (TFUs) in Kabul in 1999.The 1999 WHO guidelines on the management of severe malnutrition 1 donot address the specific needs of infants under six months 2 and do notinclude breastfeeding support. Supportive care to reestablish breastfeedingis described in Integrated Management of Childhood Illness (IMCI) guidelines3 . A chapter on the management of malnourished infants less than sixmonths is included in resource materials 4 collaboratively developed by theIFE Core Group 5 . ACF has developed their own protocols based on advicefrom experts, observation and evaluation of the responses of infants treatedwithin therapeutic feeding programmes, the integration of recently developedmaterials regarding breastfeeding, and the experience gained throughthe psychosocial approach to treatment developed by ACF in recent years.1Management of severe malnutrition: a manual for physicians and other senior health workers.Geneva, World Health Organisation,1999.2Severe malnutrition: report of a consultation to review current literature. Geneva, World HealthOrganization, 6-7 September 2004. http://www.who.int/nutrition/publications/malnutrition/en/3Supportive care to reestablish breastfeeding is described in IMCI Management of the child with aserious infection or severe malnutrition: guidelines for care at the first-referral level in developingcountries (p99–104).4Module 2 for health and nutrition workers in emergency situations. UNICEF, UNHCR, WHO, WFP,ENN, IBFAN, TdH and collaborators. Version 1.0. November 2004. Available athttp://www.ennonline.net/ife/5The IFE Core Group is an interagency collaboration concerned with policy guidance and capacitybuilding on infant and young child feeding in emergencies. Current members are WHO, UNHCR,UNICEF, WFP, IBFAN-GIFA, CARE USA, ACF and ENN. See http://www.ennonline.net/ifeTable 1Admission criteriaType of beneficiariesInfant below 6 monthsorInfant above 6 months &< 4 kgAdmission• Difficulties breastfeeding (Mother MilkInsufficiency (MMI), baby too weak to suckle,cracked nipples…)and/or• Bilateral oedemaand/or• Weight less than 2.5 kg for length less than49 cmand/or• Infant is more than 6 months but less than4 kgand/or• Infant has a W/H < 80% and infant notgaining or is losing weightTwins admitted to one of the TFUsACF, Afghanistan, 2004This picture was adapted with permission of the authors to respect cultural sensitivity29

Field ArticleAdmission criteriaIn Kabul, many mothers complain of a lack of breastmilk and believethat this is due to stress and not eating enough good food. Motherspresenting with breastmilk insufficiency raise a number of challengesfor treatment of infants in feeding centres. The admission criteria andtreatment of these young infants in the TFUs in Kabul has evolved overtime. In 2003, the criterion of ‘mothers milk insufficiency (MMI) 6 , wasadded to the existing admission criteria. In June 2005, the criteria wereamended further to admit infants with a weight-for-length less than orequal to 80% if the mother reported she was suffering from a ‘lack’ ofbreastmilk and the infant was not gaining or was losing weight at home.Admission criteria at the time of the study in 2006 for this age-groupthus comprised a combination of anthropometric criteria, weight criteriaand difficulties in breastfeeding (see Table 1).The protocols that have been developed to manage this age-groupinvolve increasing the production of breastmilk through the supplementarysuckling technique (SST) (see Box 1). The aim is that infantsunder six months should be discharged when gaining weight andexclusively breastfed, independent of their anthropometric status. TheSST for relactation has been implemented systematically in the KabulTherapeutic Feeding Units (TFUs) since August 2004. This articledescribes one of a series of studies aimed at improving the managementof these young infants and their mothers.Study ObjectivesThe aim of the study was to evaluate the impact of the SST during theperiod of management in the TFU (including the support, advice andactivities proposed by the psychosocial workers). Analysis was basedon data found in registration books, therapeutic cards, psychosocialforms (included family history, medical, treatment, feeding history ofthe infant, caregiver-infant observations), MMI forms (which focus onobserved and reported infant feeding practices and health status ofmother) and interviews with mothers. The indicators assessed wereweight gain (g/kg/d), increase in estimated breastmilk quantity duringthe period in the TFU 7 and evaluation of SST application.The study also planned to assess progress of the infants on dischargefrom the TFU, including weight gain, breastfeeding status, and feedingpractice. Follow-up of the patients was based on analysis of the ‘dryration books’ in which infants are registered at discharge and wheretheir weights and heights are registered during follow-up.The target group comprised infants under 6 months of age andinfants aged 6 months or over with a weight of less than 4 kg.Data for each of the infants were entered into a spreadsheet andanalysed using excel. Anthropometric indexes were calculated usingEpinut version 5 and were exported into the excel spreadsheet.Limitations of the studyThese included;• The size of the study was limited to infants discharged between02/01/06 and 23/04/06.• Some therapeutic cards (14 %) were unavailable due to poor storageand/or retrieval systems.• The data on the therapeutic forms were often incomplete, e.g. onbreastfeeding or use of the SST.• Weight and mid upper arm circumference (MUAC) measurementswere typically reported as rounded up figures. This was despiteweighing scales accurate to the nearest 10g being available in all ofthe TFUs.Figure 1FrequencyAge distribution of infants under six months and/orweighing less than 4kg• The proportion of infants that were lost to follow-up after dischargehindered outcome evaluation.Age profileData were analysed on the management of 94 infants aged less than 6months old and/or less than 4kg discharged between 2/01/06 to23/04/06 from three TFUs – Ataturk TFU (n=25), Indira Gandhi TFU(n=36), and Maiwand TFU (n=33).The mean age of the sample was 4 months (see Figure 1). There weremore boys (63%) than girls (37%). Twin births accounted for 17 % (n=16)of these admissions. According to the recorded TFU data, 18 infants hadsome form of disability and/or developmental problem that couldaffect feeding (including cleft palates, and suspected Down’sSyndromes).Admission criteriaGiven the lack of consensus on admission criteria for infants under 6months, severe and moderate acute malnutrition are referred to accordingto the criteria commonly applied to infants and children from 6 – 59months of age.Thirty-five infants met the classic criteria for severe acute malnutritionin this age-group of whom:• 8 had oedema• 21 had W/H < 70 % with no oedema• 6 infants were over 6 months and weighed less than 4 kg.Nearly one-third (31%, n=29) of infants under six months were admitteddue to MMI but were not severely malnourished. Of these, 26 hadmoderate acute malnutrition (70 % < W/H 80 %) and three infants werenot malnourished according to anthropometric criteria 8 . Reasons foradmission did not vary significantly according to gender or from oneTFU to another.6Maternal Milk Insufficiency (MMI) is where a mother reports a lack of breastmilk, howeverthere is no quantifiable measure of this on admission.7This data is not presented in this field article but is available in the full study report fromthe authors (see contacts at the end).8An additional 3 infants had missing length data (therefore no W/H calculated).9Length data on 91/94 was available.10The lengths of 3 children were not measured. These children weighed 1.5, 1.5 and 1.7 kgrespectively (they were aged 1 day, 2 months and 1.5 months respectively).11One infant was classed in the category ≥ 6 months and

Field ArticleAdmission weights ranged from 1.2 to 4.4kg, mean weight 2.6 kg (SD 0.6 kg). For infants=49cm. Instead, weight-for-age z score(WAZ) and length-for-age z score (WHZ) werecalculated for infants

Field ArticleMothers therefore would want to go home.However this was not the experience of theTFUs where the SST was more successful.Also, of the seven infants who defaulted, thedefault does not appear to correspond to adecrease in the quantity of therapeutic milkgiven to the infants.Where infants were not receiving therapeuticmilk using the SST, the diluted F100 wasgiven with a large cup and a spoon. This is avery ‘passive’ feeding technique for the infantand may cause aerophagia and feeling of satiety,thereby reducing appetite while increasingthe risk of aspiration of the milk into the lungs.The use of a small cup allows the infant todrink actively, which is more appropriatewhere use of the SST is really not possible.Staff in the TFUs did not show mothers howto bottle-feed or how to prepare artificial milksout of fear that this could encourage mother toadopt artificial feeding. Consequently, twothirdsof mothers were discharged usingsupplemental milk with no instruction on howto safely prepare feeds at home.Follow-up of infants on dischargeA total of 64 of the discharged infants met thecriteria for follow-up 15 . Transfers, defaulters,and admission errors were not followed up. Of64 infants, only 26 were available for follow up– 67% (10/15) of discharges were from AtaturkTFU, 58% (14/24) from Maiwand TFU andonly 8% (2/25) from Indira Gandhi TFU. AsIndira Ghandi is the largest paediatric hospitaland of national repute, it is often the first portof call for the mothers from distant provinces.The follow-up of infants discharged fromIndira Gandhi Hospital was also limited by theissuance of a ‘dry ration identificationnumber’ at discharge that was not linked totheir TFU admission number. The follow-up ofchildren discharged from Ataturk andMaiwand was easier, due to the notes taken inthe dry ration book and the possibility ofattending the dry ration days at the TFU.Of the 26 infants:• Fourteen of 20 infants who weredischarged on breastmilk alone werefollowed up. These infants had an averageweight gain of 113g/week during theperiod of follow up (range -50g to + 300g).• Twelve of 44 infants who had beendischarged whilst still receiving a milksupplement were followed up. Averageweight gain in this group was 120g/week(range minus 50g to +290g).In both groups, one infant lost weight at a rateof 50g/week during the period of follow upand all of the others gained weight.Interpretation of these figures should be donewith caution, given that two-thirds of infantswho were receiving milk supplements ondischarge were not followed up. There wasalso a large variation in both the number ofweeks for which infants were recorded forfollow up and the average weight gains perweek between the infants in both groups.Ten in-depth interviews were carried outwith mothers who returned after dischargefrom the TFUs. Two reported a medical problemsince discharge. Although all the motherswere still breastfeeding their infants, ninemothers were also giving their infantspowdered milk and two were adding biscuitsto the milk (infants aged 5.5 and 7 months).Powdered milk was either infant formula orpowdered milk bought from the market takenfrom large bags (shir e kilogaki). The latter wasmuch less expensive than the infant formula,but both the composition and the poor storageconditions of this powdered milk meant it wasinappropriate for the needs of these younginfants. On the basis of interviews with mothers,it was apparent that the way they reconstitutedthe powdered milk meant over-dilution(1 or 2 spoons for half a glass of water).Powdered milk was usually given after breastfeeding,but sometimes before breastfeeding.All the mothers reported using a cup andspoon to give the powdered milk.ConclusionsThe TFUs in Kabul show a much higherproportion of admissions of infants under 6months than in TFUs in other countries. Thetreatment of these infants is more complexthan that for older children. The high presentationof infants

Sphere Project, 2006Sphere Project, 2006Sphere training of trainers in Singapore in October 2006Sphere Audit/Review workshop with CARE Somalia, May 2006People in aidMs Shafia Khatun, Ms Jolly Khanum, MsAklima Parvin, Bangladesh BreastfeedingFoundation (BBF)Dr Shahed Rahman and Dr Younus, SC USBangladeshAli Maclaine, Consultant, SC USFrom left, Dr Isabella, Chloe Angood and DrMary Azayo, Muhimbili National Hospital, Dares SalaamDr Jesse Kitundu (Head of Pediatrics atMuhimbili National Hospital, Dar es Salaam)presenting the 'nurse of the month' award toSister Gabriella from the Malnutrition WardSister Sangali (centre) with two nurses fromthe Malnutrition Ward, Muhimbili NationalHospital, Dar es Salaam33

Invite to submit material to Field ExchangeMany people underestimate the value oftheir individual field experiences and howsharing them can benefit others working inthe field. At ENN, we are keen to broaden thescope of individuals and agencies thatcontribute material for publication and tocontinue to reflect current field activities andexperiences in emergency nutrition.Many of the articles you see in Field Exchangebegin as a few lines in an email or an ideashared with us. Sometimes they exist as aninternal report that hasn’t been sharedoutside an agency. The editorial team at FieldExchange can support you in write-up andhelp shape your article for publication.To get started, just drop us a line. Ideally,send us (in less than 500 words) your ideasfor an article for Field Exchange, and anysupporting material, e.g. an agency report.Tell us why you think your field articlewould be of particular interest to FieldExchange readers. If you know of others whoyou think should contribute, pass this on –especially to government staff and localNGOs who are underrepresented in ourcoverage.Send this and your contact details to:Marie McGrath, Sub-editor/Field Exchange,email: marie@ennonline.netMail to: ENN, 32 Leopold Street, Oxford,OX4 1PX, UK. Tel: +44 (0)1865 324996Fax: +44 (0)1865 324997Editorial teamDeirdre HandyMarie McGrathJeremy ShohamOffice SupportRupert GillDan GeorgeSarah FosterMatt ToddDesignOrna O’Reilly/Big Cheese Design.comWebsitePhil WilksContributors forthis issueCaroline WilkinsonChloe AngoodNicky DentOdile OberlinYara SfeirFathia AbdallahPaul SpiegelAnn BurtonMarian SchilperoordEmmanuel MandalaziNaomi TilleySaul GuerreroMamane ZeilaniZita Weise PrinzoPicturesacknowledgementDianne StevensCaroline WilkinsonSir YoungLucia ElmiFilippo DibariAndy SealWFP Photo LibraryChloe AngoodNicky DentCecile BizouerneO AboubacrineLaura LopezClaire MartinOliver DegommeOn the coverWomen with their undernourishedchildren, in the village ofBarmou, gather and wait toreceive food distributed by WFPat the distribution centersthroughout Niger’s hardest hitareas.WFP/Martin Specht, Niger, 2005.The opinions reflected in FieldExchange articles are those ofthe authors and do not necessarilyreflect those of their agency(where applicable).Field Exchangesupported by: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, stimulatelearning 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 levelexperiences• 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,FieldExchange, 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 exchange of fieldlevel experiences is central to ENN activities.The TeamJeremy Shoham (Field Exchange technical editor) andMarie McGrath (Field Exchange production/assistant editor)are both ENN directors.Rupert Gill is ENN officemanager and fundraiser,based in Oxford.Matt Todd is the ENNfinancial manager,overseeing the ENNaccounting systems,budgeting and financialreporting.Dan George is the ENNfinance assistant, workingpart-time in Oxford.Orna O’ Reilly designsand produces all ofENN’s publications.Phil Wilks managesENN’s websiteThe Emergency Nutrition Network (ENN) is a registered charity in theUK (charity registration no: 1115156) and a company limited byguarantee and not having a share capital in the UK (company registrationno: 4889844)Registered address: 32, Leopold Street, Oxford, OX4 1TW, UKENN Directors/Trustees: Marie McGrath, Jeremy Shoham, BruceLaurence, Nigel Milway, Victoria Lack, Arabella Duffield34

Emergency Nutrition Network (ENN)32, Leopold Street, Oxford, OX4 1TW, UKTel: +44 (0)1865 324996Fax: +44 (0)1865 324997Email: office@ennonline.netwww.ennonline.net