Issue 10 Editorial

Dear Readers,

Over the past ten years large-scale outbreaks of pellagra have only occurred amongst populations dependent on emergency food aid. The most recent outbreak in Kuito, Angola highlighted in this edition of Field Exchange is the largest since the outbreak in Malawi among Mozambican refugees in the early nineties. Unfortunately Pellagra is not the only micronutrient deficiency disease to have been reported amongst food aid dependent populations in recent years. There have also been epidemics of scurvy, beri-beri, angular stomatitis and severe anaemia. The question is, why are these eminently preventable diseases allowed to develop amongst populations under international care and protection?

It is not as if we lack policies and strategies to prevent outbreaks or deal with them when they occur. Current humanitarian aid policy dictates that if an emergency affected population is entirely dependent on the emergency ration, fortified blended foods like Corn Soya Blend (CSB) should be added to the ration to remedy micronutrient shortfalls. In the longer term efforts are to be made to fortify one of the main ration commodities with micronutrients. So where do things go wrong?

In the Kuito case, it took several months to agree that fortified CSB should be added to the general ration after the outbreak of pellagra begun. It then took a further six months for the CSB to arrive. The fact that the outbreak in Kuito was not predicted - suggests that the assessment of the level of dependency on the general ration was flawed. The subsequent late provision of CSB may have been due to a variety of factors - cost, logistics or limited availability. Clearly we have not learnt sufficiently from past 'outbreak' experiences. The tragedy in Kuito now provides an opportunity to put that right.

The experience of Kuito in conjunction with past outbreaks highlight where efforts need to be focused to prevent future epidemics of micronutrient deficiency disease. First, the process and method of assessment of dependency on the general ration is often weak and insufficiently focussed upon micronutrient intake. Review and revision of both the process and method is therefore a matter of urgency. Second, there is a need for greater transparency about the difficulties of obtaining fortified blended foods for populations dependent on food aid. This is not the first time there have been problems in providing CSB. Potential impediments could be explored and identified at the start of any given emergency, and alternative strategies, e.g. fortification of cereals or oil, put in place and ready to implement should CSB provision prove problematic.

It is difficult to think of excuses for pellagra outbreaks amongst populations receiving food aid. The fact that the diversity and adequacy of emergency general rations supplied around the world seems to depend at least in part, on geopolitical factors and cultural affinity between donor and beneficiary populations raises the issue of political commitment. Susanne Jaspar's article on food rations in Kosovo in this issue, 'Let them eat cake', demonstrates yet again the glaring inequities in global food aid. While no-one is seriously advocating the provision of chocolate bars and cake as part of the general ration, as occurred in Kosovo, it is obvious that with enough political commitment the Kuito outbreak could prove to be an 'end-chapter' in a long history of preventable disasters.

This edition of Field Exchange also carries an evaluation by Oxfam of their emergency intervention in response to drought and flood between 1996-8 in Wajir district, Kenya. A key finding of the evaluation was that the most costeffective component of the intervention, which included provision of general rations, livestock restocking and food for work, was the cash for work project. This finding is potentially very significant.

There has been a long, albeit largely theoretical, debate about whether the provision of cash rather than food in emergencies would be a more costeffective form of intervention. Food aid still dominates in emergencies (80% in the current horn of Africa appeal). Cash could be provided as payment for work (cash for work) or simply in place of the general ration. Advantages of cash provision would be that large quantities of food do not have to be procured and moved long distances while the cash would allow recipients freedom to purchase other essential commodities apart from food e.g. fuel, shelter, water, livestock fodder and service crippling debt repayments. Shipping and other transactional costs amount to roughly 60% of food aid costs, while an estimated 50% of food aid is sold soon after delivery. Another potential advantage is that cash provision would inject effective demand into collapsing local markets. There are however certain unknowns with this type of intervention: the effect on security in conflict situations, the effect on gender resource control i.e. it may be easier for women to control donated food resources than cash. It is also unclear whether the injection of large quantities of cash into a food scarcity situation would lead to inflation. Equally, unclear is the extent to which donor governments would be happy to furnish humanitarian agencies with cash for distribution to individuals rather than cash which is tied to the purchase of food aid sometimes within the donor country. What is clear is that further studies are necessary and long overdue.

Finally, it is with a certain amount of regret that we publish Field Exchange's first anonymous article. To date agencies have been particularly open and transparent and have shown their commitment to learning through endorsing the publication in Field Exchange of articles written by their staff about field level experiences. These accounts have highlighted both positive and negative aspects of agency intervention. In this instance however the agency did not want to be recognised through this article in view of the sensitivity of the programme. The author has therefore edited the article in such a way so as the agency and country programme cannot be identified. The article contains valuable lessons, which should be documented and available to anyone establishing a Therapeutic Feeding Programme.

Editors,
Fiona O'Reilly
Jeremy Shoham