Letter on Field Exchange quality control, by André Renzaho

Dear Field Exchange

A need for quality control, consistency and diligence for articles published in Field Exchange.

As an experienced practitioner and trainer in refugee public health nutrition, I have enjoyed reading the various nutritionrelated articles published in this newsletter. There is no doubt that "Field Exchange" has become a reference for both expatriate and field staff with and without a background in nutrition in terms of planning, implementing and evaluating emergency food and nutrition programs. However, over the last four years I have realized that the quality of published articles is highly variable. I therefore took a content analysis of articles and pictures published in this newsletter from issue 13 through to issue 21. The following are my findings:

Inconsistent and inaccurate definition of "global acute malnutrtion": The article by Regine Kopplow, Field Exchange 2003, Issue 20 page 22-26 is an appropriate example.

• In this article, the classification of moderate malnutrition by MUAC was "? 110 ? 124mm" and "? 185 ? 220 mm" in chil dren and women respectively. The correct cut-off points that should have been used by international definition of moderate malnutrition are: MUAC "?110 ?124 mm" for children and "?185 ?220 mm" for women.
• The BMI has been expressed as % rather than "kgm-2".
• The global acute malnutrition prevalence as defined by W/H and BMI did not include bilater al oedema (usually the cut-off point for global acute malnutri tion should read as W/H <80% and/or oedema in children or BMI <18.5 kgm-2 (vary by NGOs) and/or oedema in adults. Failure to include the prevalence of oedematous malnutrition underestimates global and severe acute malnutrition rates. This problem was also evident in articles by Grabosch, E (2002) Issues 17 p 21, Ballart, A (2002) Issues 17 p 12, and Taifour (2002) Issue 15 p23.
• Children and women referred for weight and height measure ment were those with a MUAC ?124 mm and ?220mm respectively. These were children and women with normal anthropometric measurement. Hence, the reported global acute malnutrition rates in children and women should be questioned. It has been customary to refer children with MUAC <135mm (and not ?124 mm as suggested by the article) for weight and height measurement in order to com pute W/H index.
• In the article, under the heading "targeting" paragraph 3, it is stated: "all households with at least one person fulfillingMUAC criteria (women £220mm and children £124mm) were issued with a ration card". What do £220 mm and £124mm mean? If this was a typographic mistake, why was the same error repeated through out the article under the headings " MUAC screening", "Weight for Height", and "Body Mass Index"? Similarly, under the heading "nutrition and food security", of the same article, it is reported that "36.5% of females measured had a MUAC <215 mm, indicating chronic severe malnutrition". What does chronic severe malnutrition mean?
• In the article by Grabosch, E (2002, Issue 17 p20), paragraph 2, the malnutrition prevalence in Malawi and Guinea is reported using W/H Z score <2 for acute malnutrition and H/A Z score <2 for chronic malnutrition. How do these cut-off points compare with the traditional cut-off points of W/H <-2Z or H/A <-2 Z score?

Ambiguity: In the article "community-based approach to managing severe malnutrition", published in March 2004, Issues 21: p16, figure 1 suggest a new classification of severe malnutrition. It classifies acute malnutrition into three categories: 1) complicated malnutrition, 2) severe uncomplicated malnutrition and 3) moderate uncomplicated malnutrition. Criteria for complicated malnutrition are W/H <80% or bilateral pitting oedema or MUAC<110mm and one of the following: anorexia, LRTI, high fever, severe dehydration, severe anemia and not alert. Criteria for sever uncomplicated malnutrition are W/H <70 or bilateral pitting oedema or MUAC <110mm plus appetite, clinically well and alert. The confusion is over what they have termed complicated malnutrition. It is not clear why W/H <80% was taken to be equivalent of MUAC<110mm (and not MUAC 125mm). In other words, if this new classification is to be accepted, in which malnutrition category do children with MUAC 110-125mm and who are either anorexic or have LRTI, high fever, severe dehydration, severe anemia belong to?

Lack of mutual respect, violation of intellectual property rights and egocentricity. The majority of the published articles (except those appearing in the newsletter as summary of published paper) are mainly published by western expatriate staff based either at headquarters or in the field 1) describing their representative NGOs experiences in implementing food and nutrition related programs or 2) presenting evaluation findings in terms of successes and lesson learned. In most of the cases, the authors are publishing the articles as sole authors without any mention of the contribution of the hard working local staff. It would be preferable if articles published in "Field Exchange" either acknowledges input of local staff involved in the project or invites some the staff to co-author the papers. Otherwise, the "exploitative nature" and "neo-colonial attitude" ingrained in humanitarian assistance programs will not be eradicated. The gallery of pictures accompanying the various articles and those presented at the end of each issue is testimony to "neo-colonialism". The majority of pictures imply a situation with westerners as the "master" while portraying "indigenous" as the "starved", "powerless" or "helpless". In addition, can I also point to the fact that indigenous people depicted in the various pictures/ photographs need to be consulted before their photographs are published. They need to understand from the onset how their photographs will be used. As a matter of transparency and respect, photographs/pictures that accompany the various articles published in the newsletter need to indicate whether the depicted indigenous people (including patients) granted the permission for their photographs to be published.

Recommendations: 1.The ENN editorial team needs to ensure that there is a proper process in place to scrutinize submitted articles to ensure that data presented are not misleading. There is a need to standardize malnutritionrelated concepts and ensure that, no matter how humble the project might be, presented data meet some standards of academic rigour such that the results can be internationally comprehended and compared. 2. I suggest the publication of an erratum in relation to the article by Regine Kopplow, Field Exchange 2003, Issue 20 page 22-26. 3. There is a need to reflect equality and to display non-exploitative behaviours in the gallery of pictures featuring in the newsletter as well as the articles published. Local staff may not have the infrastructure or external exposure to display their talents, but their contribution should, at least, be acknowledged.

André M.N. Renzaho

André Renzaho (B. Nutr & Diet, MPH) is currently employed at World Vision Australia as Program Quality Advisor and has just completed his PhD in Public Health Nutrition at Deakin University, Australia.

Email: renzaho@optusnet.com.au, renzah@deakin.edu.au or andre.renzaho@worldvision.com.au

The ENN would like to respond to the letter above. We appreciate the effort that Mr Renzaho has made in collating evidence for the 'variable quality of published articles'. Indeed on one level we would agree that quality is variable. However, rather than take this as a criticism we would argue that this reflects the very ethos underpinning Field Exchange. The publication (which we would like to insist is not a newsletter) was set up to facilitate the documentation of field level experiences in order that these should not be lost. Many field staff lack the time, professional support or confidence to produce articles for peer reviewed journals. Thus, many vital experiences are lost. Field Exchange therefore purposively encourages and publishes articles which may not meet the more rigorous standard of peer reviewed journals in the belief that such articles may provide invaluable lessons which would otherwise not be recorded or shared with other practitioners. While the Field Exchange editors try as hard as they can to ensure technical rigour, there is a risk that too many questions back to authors may 'scare off' potential contributors. It is therefore editorial policy to publish pieces that reflect the diverse technical capacity of a wide variety of humanitarian actors. We wonder whether Mr Renzaho has fully understood this fundamental aspect of our publication.

We were somewhat surprised at many of the specific technical criticisms posted by Mr Renzaho. Most of these are clearly typographical errors (probably occuring at the print setting stage). For example, '<185mm<220' is meaningless while defining malnutrition on the basis of wt/ht or ht/age <2 Z score is evidently an unintended mistake rather than a technical error. Similarly, using '£' signs as opposed to < or > is clearly a nonsense and could only be explained by typological error. The fact that Mr Renzaho chooses to highlight these insinuating poor technical quality is in our view unfair. Scrutiny of any publication (newspaper or journal) will throw up a large number of 'typos' and corrections in subsequent issues.

Some of Mr Renzaho's criticisms are more substantial. He identifies a number of articles where reported nutrition surveys have not included oedema with the significant risk that prevalence of malnutrition is under-estimated. While it may be that Field Exchange could have made an editorial comment in these cases highlighting the departure from best practice it just as well to be aware that a number of agency staff do not include oedema measurements in surveys - either due to lack of capacity to accurately assess oedema or because of lack of professional support in the field.

Mr Renzaho asks why weight for height <80% was taken to be equivalent to MUAC <110 mm in a new classification of malnutrition used in CTC involving 'complicated malnutrition' In this case it appears that he has misunderstood the classification. W/H <80% is not taken to be equivalent to a MUAC <110mm but an alternative criteria in conjunction with other criteria, ie.anorexia, severe anaemia, etc. While such a distinction is subtle it is not incomprehensible.

Finally, Field Exchange is squarely criticised for not obtaining more articles from local staff or at least acknowledging the contribution of local staff and for using photographic images which accentuate 'Eurocentrism'. Mr Renzaho also questions whether we obtain permission from each person whose photograph is used. In our defence we would like to say that we encourage authorship from local staff as much as possible and that our partner agency nutritionists attempt to support local staff in writing articles. There have been many notable successes. However, where this is not possible it seems prudent to still record the experience through international agency staff authorship rather than lose the experience entirely. If local staff have not been involved in writing a piece then attribution cannot take place. However, it is in our view a little unfair to jump from this to an accusation that international agency staff are perpetuating the "exploitative nature" and "neo-colonial attitude ingrained in humanitarian assistance programmes". The ENN are in fact attempting to increase the participation of southern based individuals/agencies. We have recently submitted two proposals for funding specifically to strengthen our capacity to target southern based agencies (ministries, local NGOs and church groups), with information about the ENN and Field Exchange, Finally, a criticism is levelled at Field Exchange regarding photographs. Most photographs are provided by agency libraries. Clearly, we cannot ask permission to publish these photos from the subject. Where Field Exchange staff take photos (this only happens occasionally) we of course as a matter of policy ask the subject for their permission to publish the photograph. We are well aware of issues of representation and the need to avoid representing subjects as passive victims. We are also only too aware that agencies (including World Vision) struggle with the very real conflict of representing reality while not wishing to perpetuate ingrained Eurocentrist views. We do our best to steer a middle ground.

We would like to thank Mr Renzaho for his vigilance in scrutinising our publication in order that typographical errors or misleading statements (where these exist) can be highlighed.

Editor