Issue 17 Editorial

Dear readers,

Ethical considerations figure prominently in this issue of Field Exchange. A field article written by Dr. Eva Grabosch tackles the problem of providing sustained resources for the treatment of severe malnutrition in countries with chronic nutritional situations. Working in local hospitals in Guinea and Malawi, Dr Grabosch describes how previous feeding programmes supported by international agencies relied on expensive 'therapeutic' foods which could no longer be provided by the local health service once the agency had moved on. She describes how negotiations with the hospital authorities resulted in a small budget being set aside to provide for cheap local foods, using innovative recipes (one involving peanut milk and the other a mixture of milk powder, corn flour and oil) to provide a therapeutic-type milk. Although not ideal in terms of treatment of severe malnutrition, they proved an effective nutritional compromise. Whilst not explicitly addressed, the article does raise an issue regarding the ethics of international agencies implementing a type of programme which cannot be sustained once the agency chooses to withdraw. It also highlights the dilemma of how far nutritional standards should be compromised, without truly knowing the risks we are taking on beneficiaries' behalf until they happen.

Ethical issues are raised in a more head-on fashion by a letter and two research pieces summarised in this edition. Firstly, an article in the Lancet argues that very little attention has been devoted to the relationship between external human rights contexts and the ethics of human research. The authors attempt to provide guidance on how to determine human rights conditions in a given region and whether, or under what circumstances, studies in regions with few human and political rights are appropriate. The paper describes how human rights and political considerations might affect the risks and benefits of research in a number of contexts. For example, research into the health effects of rights violations may be inherently risky, as breaches of confidentiality could lead to retaliatory measures on those who provide information. Research findings could also increase risk of violations if, for example, the existence of a health condition or health practices can be used to stigmatise the population. A major recommendation in the paper is that researchers must learn about background human rights conditions as a pre-condition to conducting the research and assess all risks to both researchers and target groups alike.

A second summarised research paper deals with the disparities in service provision between refugees in Tanzania and the host population. Ethical issues around the evident gross inequalities are hard to ignore. The large refugee population resides next to subsistence farmers who have typically very low income and relatively high malnutrition, morbidity and mortality rates. Poor farming practices are a major constraint to food production, coupled with poor road infrastructure and inadequate marketing systems. The proximity to refugee camps has influenced the prices of the local foodstuff and led to deteriorating security and destruction of the natural environment. While donors continue to provide support for the refugee operation, the Government of Tanzania bears the main responsibility for hosting the 500,000 refugees.

The health and nutrition situation in the refugeeaffected areas, unlike the refugee camps, is a significant public health problem. Malaria, pneumonia and diarrhoea are the leading causes of mortality and morbidity. Mortality and malnutrition rates amongst the host population are almost three times higher than amongst the refugees (maternal mortality is almost ten times higher). This is, in large measure, due to the camp services provided which are not available to the host population. These include micronutrient supplementation, supplementary feeding, malaria control measures, water and sanitation programmes and parasite control for children.

We also have a letter by nutritionist, Charlotte Dufour, about the ethics of using ready to use therapeutic foods (RUTFs) in current emergency feeding programmes. Charlotte is concerned about the widespread use of RUTF in Afghanistan from where she has just returned. She raises a number of ethical questions, e.g. is it ethical to distribute a (very expensive) product for which the protocol is not yet fully tested and approved, and the efficiency of which is not proven outside the TFC? How can we deal with the commercial interests lying behind the distribution of RUTFs. She ends by posing the question 'what can be done to ensure these new products are "properly" used until research yields more results'?

Ethical challenges often foment ideology. In the humanitarian aid world, ideology can be seductive especially when it provides clear solutions for programmatic problems whose complexity defeats most of us. Nutritionists and others working in the emergency food and nutrition sector are not immune. The dangers of ideologies are that that they can lead to formulaic and unthinking behaviour which is inappropriate where programme success depends to some degree on beneficiary behaviour. It could, for example, be argued that Community Managed Targeting (CMT), which has risen swiftly up the agency agenda in recent years, is in danger of becoming an 'ideology'. CMT has been envisaged as a simple way to empower communities during general food distributions and limit targeting responsibility of implementing agencies. This approach is currently being imported into the emergency response in Malawi on a large scale. Yet, in some countries and communities, CMT has simply not worked as 'the community', for a variety of reasons, do not want to exclude households from food distributions.

An example of this is described by an article in this issue of Field Exchange which, written by ACF staff, charts the implementation of CMT in Indonesia for war affected IDPs. After implementing the targeting programme over several weeks, ACF could see that the process worked fairly well on the Moslem side, whereas the results were less satisfactory on the Christian side. The focus groups (local committees responsible for targeting) identified 60% of the population as beneficiary families on the Moslem side, whereas this figure was as high as 90% in the Christians enclaves.

The teams were unable to explain the disparity in compliance with targeting aims between the two communities. Nor was it possible to attribute the difference to level of food vulnerability of the two communities (as shown later on by a Post Distribution Monitoring which also attempted to establish levels of food dependency). The authors suggest that more "sociological" explanations of differences between the two communities seem apposite. For example, "psychological" vulnerability, the different notions of solidarity / community spirit and social-economic differences due to histories of colonisation and transmigration.

This case study confirms what we should already know. CMT may work in some situations but we can't always predict whether it will work. The complexity of factors determining human behaviour in any given situation can never be fully understood - especially by 'outsiders'. Much as we would like clear-cut and easy answers to the enormous challenges faced during humanitarian work, the reality is probably that we are destined to implement programmes with a considerable degree of uncertainty about whether what we are doing is going to work - especially where social factors are concerned. Ultimately, this may not be such a bad thing if it keeps us alive to the need to react to local circumstances and to remain flexible in our thinking. In short, our methodologies should never become ideologies.

(Editor)