Feeding without fear

Anonymous

This is a story to illustrate that however experienced you are, there is always the chance that you will find yourself in a situation that you are not prepared for, and that you do not feel qualified to deal with. Unfortunately, this is the nature of disasters, and the humanitarian system in which we work. It is also a story which shows that with the right support, determination, energy and common sense, you can probably do it. Moreover, you may have to, because there will be no one else. In my case, I ended up re-organising a therapeutic feeding programme for adults, when I thought I was going to do a food security assessment. I had no recent experience of therapeutic feeding, certainly not of adults, and have no medical background. Whilst obviously it would have been better to have someone qualified and experienced in therapeutic feeding, I think that in the end, we did a fairly good job.

Last year, I went to Central Africa to do a food security assessment of people recently displaced by fighting in a nearby region. At least that is what I thought I was going to do. I had also been asked to take a quick look at the therapeutic feeding programme. The nutritionists at the agency's headquarters wanted to be re-assured that the correct procedures were being followed. Before my departure, however, there were no major concerns.

In my 15 years experience of working as an emergency nutritionist, I have often advised on and co-ordinated feeding programmes. On occasion, I also had to teach the basics of therapeutic feeding, so I was aware of the recent developments and new guidelines for the treatment of severe malnutrition. I therefore felt I could review the programme, but not manage the feeding of severely malnourished individuals. The last time I had any direct involvement in therapeutic feeding was in 1987, when we used to give mothers of severely malnourished children a take home ration of DSM, oil, and sugar to feed their children in the afternoons.

When I visited the feeding programme, I knew just about enough to realise that there were several problems with the procedures used in the programme. Problems ranged from the actual treatment of severe malnutrition, to ones related to the organisation and management of the programme. The programme was implemented by highly motivated national staff, who had received some training in feeding programmes during earlier conflict related displacement in 1997. The situation in 1999 was very different however. The majority of the severely malnourished had oedematous malnutrition, something that was not seen before in the area concerned. Also, the prevalence of severe acute malnutrition was much higher in 1999 than in 1997.

So we were in a serious situation, with very high levels of severe, oedematous, malnutrition in adults, and no agency field staff who knew how to deal with it. After one week of frantic phone calls to headquarters, I was finally told there was no one with experience of therapeutic feeding who could come to assist, and "if you have to save lives, you save lives."

This is what saved us (and them):

• The presence of other agencies who were running therapeutic feeding programmes.
• Very supportive headquarters staff.
• Availability of the new WHO guidelines on the treatment of severe malnutrition
• Knowledge of related public health issues, e.g. the need for immunisation, adequate water supply, sanitation, etc., as well as the necessity of adequate general rations for the family.
• Dedicated international and national nurses within the organisation.
• My previous experience in the management and organisation of feeding programmes, e.g. issues of crowd control, number of beneficiaries per centre, record keeping, weight monitoring, follow-up, etc.
• The realisation that as long as your centre is well organised enough to monitor people individually, you can try things out, and adjust feeding regimes accordingly.
• The realisation that no one will die from one bowl of porridge.
• The realisation that you can talk to malnourished adults. They can tell you how they feel and if their condition is getting better or worse.

Without doubt, the other agencies and the WHO guidelines were the most crucial in helping us re-organise the programme. However, some innovation was necessary. We did not have the modified ORS for malnourished people (ReSoMal), nor did we have the F-75 therapeutic milk for phase 1 of therapeutic feeding. We modified normal ORS immediately for oedematous cases, by adding 2 litres of water instead of 1 litre, and adding 50 g of sugar. The headquarters nutritionist suggested a modification of F- 100 therapeutic milk. By adding more water, as well as oil and sugar, we lowered the protein content whilst keeping the energy content at 100 kcals/100 ml. This became known by everyone as "special milk." Immunisation of children was another immediate priority, as was the recruitment of health staff specifically for the feeding programme.

All feeding beneficiaries were screened, to determine whether they should be in therapeutic or supplementary feeding. These were then separated in different shelters for feeding, and given different coloured bracelets. On the first day of the new therapeutic feeding, every adult was asked on entry, whether their oedema had got better or worse in the last few days. People with very severe oedema, or whose oedema got worse, were put in phase 1, and received "special milk" for at least three days according to their body weight. Arrangements were made to weigh people on "special milk" on a daily basis. If their oedema was going down over these days, they were allowed to eat solid meals as well the following day, but were closely monitored. We knew this was not strictly according to protocols, but it was difficult to keep adults on a milk only diet for more than 3 days. Not only did they find this very boring, but also, they had really looked forward to eating their traditional food upon coming home.

Amazingly, our re-organisation and new feeding regime worked. It was one of the most satisfying experiences in my professional life to have people tell me their oedema was going down after a couple of days on "special milk." It seems strange now, but when we started, I honestly thought we would kill someone with a bowl of porridge that was too high in protein for a severely malnourished person. I later realised, that even if someone should not have received porridge yet, and their condition deteriorated, we would soon know about it, and could adjust their feeding regime.

This brief description cannot possibly reflect the often chaotic and hectic first week of re-organisation. Of course there were many more things to do than written here; new registers, attendance sheets, organising regular weighing, follow-up people who did not lose their oedema or did not gain weight later, follow-up of defaulters, medical examination and treatment of sick people, screening of new arrivals, registration of new arrivals for general rations, etc., etc. It wasn't perfect, but I think I can honestly say we improved some people's lives, and perhaps even their chances of living, at least for a little while.