Issue 21 Editorial

Welcome to the launch issue of Field Exchange (no 21) for the fourth phase of the ENN. The ENN office has now moved from Dublin to Oxford in the UK and operates under the company name Emergency Nutrition Network. Marie McGrath has taken over company secretary role as well as programme manager responsibilities. The editorial team remains unchanged and is ready to bring to you new and valuable experiences from the field, as well as latest research and evaluation findings, over the next three years.

Treatment of severely malnourished children emerges as a central theme in this issue of Field Exchange, with all four field articles based on the subject. Claire de Menezes describes the process of strengthening the national nutritional rehabilitation unit (NRU) system in Malawi against the backdrop of a droughtinduced emergency. Attempts to improve protocols and train national staff across the country faced many challenges, not least of all a lack of human resources and incentives. However, on balance the results were positive and throw up constructive lessons for other national programmes attempting to overhaul their system of treating the severely malnourished.

Two other field articles deal with experiences of home based treatment (HBT) of the severely malnourished using RUTF. In Sierra Leone, Adrienne Daudet and Carlos Navarro-Colorado describe a study to examine beneficiary and community perceptions of this relatively new treatment strategy. The study compares findings with those of a control group where children attended a traditional centre-based therapeutic feeding programme. The HBT group appeared to fully embrace RUTF and the home based protocols. Interestingly, the wider community supported the caretaker mothers by taking on many of her domestic and work responsibilities so that she had time to care for the child at home. Mark Manary and Heidi Sandige describe another programme in Malawi where home based treatment worked well. In the 2002-2003 hungry season, seven sites - including mission, rural, and district NRUs - participated in the programme, transferring inpatients directly to the RUTF programme for phase 2 home treatment. In addition, children were accepted directly from the community without an inpatient therapy, provided that their condition was stable and they were not anorexic. Overall, 80% of these children reached a weight-for-height greater than 85%, with a mean time in the programme of 6 weeks.

A fourth field article by Amador Gomez and Elisa Dominguez of ACH, describes their experiences of managing malaria in a therapeutic feeding programme in Angola. The study examined the efficacy of their standard protocols based on national standards and has led them to change first line treatment, which they hope will improve outcomes in their TFCs. Their move towards artenisinin-based combination treatment, and away from chloroquine and sulfadoxine- pyrimethamine, is in keeping with recent international debate on effective malaria treatment¹ and shows how field practitioners are keeping abreast of, and responding to, technical advances.

This issue also contains a summary of the proceedings of the CTC meeting held in Dublin earlier this year (see news section). The main objectives of the meeting were to compare lessons learnt after 3 years of experience of CTC and other HBTs of severe malnutrition, describe substantive differences between agencies in protocols for non-centre based treatment of severe malnutrition, and focus on gaps in our knowledge of non-centre based treatment.

Impact assessment is another theme running throughout Field Exchange 21. There is currently a great deal of interest, particularly at donor level, in how to determine the impact of humanitarian interventions. This partly reflects the increasing application of Results Based Management in the public sector. At the moment, there are a number of ongoing studies funded by donor organisations looking into methods for assessing intervention impact.

In this issue of Field Exchange, the research section carries a summary of a retrospective mortality survey on demobilised soldiers and their families in Angola. The data appear to show failure of the food and nutrition humanitarian intervention, as mortality reached six times normal levels. Another recent study in the greater horn of Africa demonstrated the failure of humanitarian information systems, using programme examples from Kenya, Ethiopia and Burundi. One component of these failures was the lack of impact evaluation data. There is also a summary of a background paper on market analysis prepared for the WFP technical expert consultation on Emergency Needs Assessment held in Rome in 2003. The author argues that market information analysis for demonstrating the positive (or negative) impacts of food-based interventions in emergencies is critical, yet methods for analysing such information are poorly developed.

In spite of the apparent growing interest in, and demand for, impact related information, the bottom line is that impact assessment of humanitarian interventions will, in most situations, remain equivocal. Without control groups (and control groups cannot, in most situations, be established for ethical reasons) impact assessment can rarely rise above the intuitive. Cause and effect cannot be proven with scientific rigour. There are simply too many confounding variables, e.g. seasonal availability of foods, expanded remittances, social adaptations, etc. The best that may be hoped for is to combine information on process indicators/service delivery and outcome variables, such as mortality and malnutrition, with information on speed of change in outcome variables in relation to onset of intervention. At the same time, there would need to be careful analysis of other non-intervention factors that may have an impact on outcome measures.

Finally, interest in impact assessment does not just extend to humanitarian interventions. In this issue we carry a report of a meeting on HIV/AIDS and food security hosted by ACF and Oxfam at the end of 2003. The report shows that the growing interest and concern over the impact of HIV/AIDS on food security is mostly based on intuitive reasoning rather than expansive empirical evidence. Yet, predictions of 'new variant famine' are highly emotive and potentially have enormous influence in terms of resource allocation. Further evidence for the impact on food security, at a time when HIV prevalence in many parts of the world is already high and rising, is therefore critically needed. Such studies, particularly at the macro-level, have yet to be carried out.

We hope that you enjoy this issue of Field Exchange and look forward to your future contributions whether in the form of field based articles, evaluations, news, or letters.

Jeremy Shoham

Any contributions, ideas or topics for future issues of Field Exchange? Contact the editorial team on email: marie@ennonline.net

¹Attaran A et al (2004). WHO, the Global Fund and medical malpractice in malaria treatment. Lancet 2004;363:237-240. Full text online at http://www.thelancet.com