A collaborative approach to a nutritional crisis in an area accessible only by air

By Nicola Cadge and Lynne Russell

Nicola Cadge has a background in nursing and a Masters Degree in Public Health. Nicola has worked for Merlin for more than two years both in West DRC and presently in Sierra Leone as Medical Co-ordinator.

Lynne Russell is a nurse who has been working with GOAL since September 1999 (her first overseas medical appointment). Lynne is the Medical Coordinator for GOAL's projects in Kenema and Freetown, in Sierra Leone.

Merlin started working in Sierra Leone in 1996 in response to health and nutritional crises caused by the civil war and is currently supporting programmes in both Kenema District in the East of the country and in Freetown. Merlin is providing emergency health care services to both resident and displaced populations and reestablishing essential health care services at primary and secondary levels in both these areas. Additionally, Merlin operates a nutritional programme in Kenema District, including therapeutic and supplementary feeding and implementation of regular nutritional surveys.

GOAL commenced operations in Sierra Leone in March 1999 initially in the Freetown peninsular with emergency shelter and health care for Internally Displaced Persons and a community based approach to working with Street Children. In response to the need for increased capacity in nutrition and health care, GOAL started a Supplementary Feeding Programme in Kenema District and supported Primary Health Units.

Merlin and Goal have worked in close collaboration in the district since September 1999 when, in response to the need to increase nutritional interventions, Merlin decentralised its SFP and handed over district wide management to Goal in order to concentrate its inputs into the TFC and remaining central SFC.

Context in which the assessment was undertaken

Sierra Leone has been in the grip of a civil war for the past 10 years. Following the signing of the Lome Peace Accord in July 1999, there have been periods of relative stability and improving security and access. However the situation deteriorated dramatically in May 2000 with increased rebel activity throughout the country and hostage taking of UNAMSIL personnel. Following UNAMSIL operations in July large movements of people came into both Kenema Town (approx. 20,000) from the Northern areas of the district and into Daru Town (approx. 7,000), in Kailahun district. Whilst most of these were absorbed into the host population itself there was an increase in number of the already overcrowded internally displaced camps in Kenema District.

Due to the established nutritional programme in Kenema district, Merlin, GOAL and the other local and international agencies were able to respond quickly to the health and nutritional needs as a result of the crisis. Daru, however, was more complicated.

Daru Town, is situated in Kailahun District in the Eastern Province of Sierra Leone. It is an isolated, UNAMSIL controlled enclave surrounded by rebel forces. Road access from Kenema Town and its markets had been intermittent. Following the July operations, vehicles have been attacked by rebel forces and the road now remains closed to even local traffic. Not only has access to markets been cut off for the local population but also for the rebels. As a result there have been an increasing number of reports of harassment and looting of remaining food stores in the surrounding villages by the rebels.

Access is currently by air only, weekly through WFP, by arrangement through the INGO helicopter or through UNAMSIL. Oxfam, IMC, WFP (school feeding programme) and SCF are currently the only agencies who are operational in Daru. Their activities are greatly restricted because of the logistical constraints and lack of access routes. Only one clinic is operational and until recently did not have the necessary equipment to undertake growth monitoring and report on nutritional status.

There are no accurate population data for Daru Town. Population estimates vary from 12, 000 (7,000 resident and 5,000 IDPs) reported by UNAMSIL to 8,000 (5,000 resident and 3,000 IDPs) estimated by the agencies on the ground.

The assessment

Increasing concern amongst the international agencies over the deteriorating food security and nutritional status of the vulnerable populations in Daru Town led WFP to request that Merlin and GOAL undertake an assessment of the nutritional status of children aged 6 to 59 months. It was clear from the outset that this would not constitute a commitment to expand MERLIN or GOAL programme activities but was an attempt by all the agencies involved to utilise their relative expertise, skills, human resources and logistical support in a collaborative effort to gain an insight into the current nutritional status of the population. Appropriate interventions would be planned in collaboration with all the key agencies involved following the assessment.

Planning the assessment was complicated. The co-ordination was undertaken at three separate sites, Freetown, Kenema and Daru by radio. There were delays as a result of the WFP helicopter needing servicing. There had been close liaison with UNAMSIL to ensure cooperation and security of the assessment personnel. Two weeks after the initial request, on the 15th August the WFP Helicopter left Freetown and collected 6 Merlin, 6 GOAL and 2 IMC staff from Kenema and then flew onto Daru Town, arriving at 10:00. They were accompanied by the GOAL expatriate Medical Co-ordinator. Transport was arranged by Oxfam and sensitisation of the population performed by Oxfam volunteers.

Three locations had been identified and the staff were divided into four teams, with Oxfam volunteers undertaking crowd control. There were strict time constraints with time on the ground limited to a mere 3 hours, including travel to and from the sites. However, a total of 590 children aged 6 to 59 months were screened using weight for height indicators. Two WFP staff simultaneously conducted a quick commodity price survey and assessed food availability in the market. They also visited the outskirts of the town to assess the degree of home garden production. Following analysis of the nutritional results, calculated as a percentage of the median using NCHS/CDC/WHO sex combined reference tables the global malnutrition rate in the population screened (n = 544) was found to be 7.6%. The moderate malnutrition rate 3.9% and the severe acute rate was 3.7%.

It is not possible to extrapolate these findings to the general population as it was not a randomised assessment. It is clear that the ideal would have been to undertake a full randomised nutritional survey. However, in the absence of accurate (or even estimated) population data this was not possible. This was a key constraint in our ability to obtain meaningful data and data that could be used in the planning of appropriate interventions. Additional constraints were the limited number of places on the helicopter, time restrictions in Daru Town and limited logistical support once on the ground which resulted in time lost waiting for vehicles to transport the staff. The helipad was two miles from the centre of town and it was impossible to carry weighing and measuring equipment on foot. Despite this, there was a high level of collaboration amongst a number of agencies, which made it possible to undertake the screening exercise.

There were a number of recommendations made based on these results. First and foremost was the need to secure unrestricted and safe road access between Kenema and Daru Towns. This would increase access to markets and food, allow the teams in to undertake a mapping exercise to estimate the population in the town and verify the number of IDPs and consequently undertake a randomised nutritional survey. Such a survey would help better establish whether there was a need for TFC and SFP interventions. However, it was acknowledged that the only type of information collection that can currently take place given the existing constraints are food security monitoring (involving commodity price tracking) and initiation of nutritional surveillance at the health centre.

Post-Assessment meeting and Action Plan

An inter-agency meeting (including Merlin, GOAL, WFP, UNICEF, MoH, IMC and SCF) held following the helicopter survey concluded that due to the security and logistical constraints it would not be possible to undertake a randomised nutritional survey. Despite the limitations of the data obtained it was decided to initiate a SFP programme on the basis that malnutrition rates were above 5% in conjunction with aggravating factors, e.g. poor food security, lack of access to markets and increased population numbers due to the displacement. Furthermore, access to food was unlikely to improve in the near future. There is currently insufficient logistical support and human resources to establish a TFC in Daru Town itself or undertake a Vulnerable Group Feeding distribution. It was therefore proposed that severely malnourished children could be transported to the Kenema TFC for treatment. SCF and WFP will undertake food security monitoring while UNICEF donated equipment to the clinic to undertake growth monitoring. Merlin and GOAL do not have the capacity to operate in Daru Town at the present and introducing new agencies into the area would only increase the pressure on already stretched helicopter services. An agency currently operating on the ground has the capacity and experience to establish an SFP and is currently searching for funding. Merlin and GOAL have offered training of their staff.

The process of assessment and establishing a programme in Daru has been slow and laborious. Progress has been obstructed because of the numerous constraints. Many dilemmas still need to be resolved. Yet the collaborative approach to this situation has remained a strength. Agencies have shared resources and experience in trying to meet each challenge. Daru Town is by no means the only such enclave in Sierra Leone, there are Bunbuna and Kabala also. One of the lessons to come out of this experience was that there has to be a high degree of detailed planning for this type of assessment as time on the ground is so limited. Any delays can have a large opportunity cost. The experience gained here can be used to assess, plan and implement future programmes in a more efficient way - hopefully with the same level of collaboration between agencies on the ground.