Issue 28 Editorial

This issue of Field Exchange features four field articles about community based therapeutic care of the severely malnourished, a type of programming that is increasingly being rolled out by humanitarian agencies.

The article by Josephine Querubin from ACF-USA is about a home based treatment (HT) programme in Upper Nile and Bahr el Ghazal in southern Sudan, introduced following drought and a large returnee influx. HT was adopted as previous experiences of using the centre based therapeutic feeding model had been poor with high defaulter rates and low coverage. Although the HT programme appears to have been very successful, it was reliant upon a large network of home visitors for screening and referrals so that maintaining a large cadre of field staff working under arduous circumstances and difficult terrain was a significant challenge.

The article by Milton Tectonidis and his colleagues from MSF describes their experience of scaling up an outpatient therapeutic feeding programme in Naradi and Zinder provinces in Niger following drought and dramatic millet price inflation. The programme served 63,000 severely malnourished children and was the largest intervention of it's kind in MSF history. Programme outcome indicators were very good with cure rates of 91% and mortality rates as low as 3.2%. The authors suggest the experience demonstrates that in countries with high endemic rates of child wasting, the vast majority of severely malnourished children can be treated with weekly surveillance and RUTF.

A third field article by Tina Krumbein, Veronika Scherbaum, and Hans Konrad Biesalski describes the production of RUTF made from local produce for use in a rural hospital in Kumi, Uganda. Hospital staff coped well with the production process and, most importantly, costs were easily absorbed within the hospital budget so that production was sustainable.

An article by Gwyneth Hogley Cotes from GOAL describes the impact of high levels of insecurity on CTC and SFP programming in Kutum and Jebel Mara in Darfur. Programmes were frequently disrupted due to logistical and communication constraints. Consequently, programme effectiveness was significantly reduced, i.e. reduced coverage, poor weight gains and reduced cure rates. Furthermore, insecurity increased the overall cost of the programme. GOAL adopted a number of strategies to combat these problems. The programme was decentralised so that access was improved and services could continue if agency staff couldn't get to programme sites. Locally based field nutrition staff were trained and employed to continue running services, on their own if necessary. GOAL also developed strong communication channels with communities, leaders and authorities. This was facilitated by employing large numbers of nutrition outreach workers.

A fifth field article shares programme experiences following the recent Pakistan earthquake. The piece by Leah Richardson, Moazzem Hossain, and Kevin Sullivan discusses the experience of conducting a nutrition survey in very difficult terrain and various methodological adaptations that were employed to get round practical constraints.

The research section in this issue of Field Exchange covers a number of interesting areas.

There are some disturbing findings from two micronutrient studies conducted on long-term refugee populations in east, southern and northern Africa. One study found that refugees were consuming excessive amounts of iodine and that there was an urgent need for revising salt iodisation levels. The second study determined that levels of anaemia and vitamin A deficiency were unacceptably high. In three out of five camps surveyed, over 60% of individuals were anaemic while levels of Vitamin A deficiency were between 21-60% in the five camps. Over the past few decades it has generally been micronutrient problems like scurvy, beri-beri or pellagra that have been highlighted. Vitamin A and iron deficiency have rarely been assessed. These findings point to the need for more routine monitoring of iodine, iron and vitamin A status amongst displaced populations - especially the long term displaced.

Another research piece describes the Malawi government experience of utilising 'commodity options contracts' to safeguard against price volatility. These contracts involve payment of a premium in exchange for the right, but not the obligation, to either buy or sell a commodity at a predetermined price for a particular period of time into the future. The contract signed by the Malawian government with Standard Bank of South Africa in September 2005 allowed for the purchase of a maximum of 60,000 tonnes of maize at a cost of approximately $18m - enough to meet the food gap if donor and private sector commercial imports did not reach anticipated levels. In response to continued evidence of shortages in the market and concern about rising local prices, the government exercised the first tranche of the options contract on 7th of October, buying 30,000 tonnes of maize. It exercised the second tranche on 15th of November, when it bought the remaining 30,000 tonnes. Malawi's early experience with options contracts was largely positive. The majority of the purchased maize was used to meet humanitarian needs and did not reach the commercial market. The maize helped to avoid severe shortfalls in the humanitarian pipeline. Additionally, by the time of delivery in December 2005/January 2006, prices had risen by between $50-$90 a tonne above the ceiling price of the contract while transport costs had also increased.

There is also a summary in the research section of a recent HPG paper written about the current emergency affecting the Greater Horn of Africa, where an estimated 11 million are at risk due largely to drought and conflict. The authors argue that although early warning systems worked well, late, inappropriate or insufficient responses occurred due to inadequate preparedness, capacity imbalances between food aid and livelihoods programming and funding constraints. There was far too great a bias towards food aid programming, and longer-term livelihoods programming was only small-scale. These findings mirror those of an earlier study also reported in Field Exchange (Levine S and Chastre C, 2004)¹ on interventions conducted in the Gt Lakes region between 1996-2001.

This issue also carries a letter from Andy Seal and Marko Kerak concerning the new WHO growth standards. After careful comparison with the existing NCHS/WHO standards and application to a number of refugee data sets from Africa and Asia, the authors assert that in spite of the theoretical advantages of the new standards, there are potentially serious implications for emergency needs assessment and feeding programmes that have not as yet been addressed. For example, eligibility for therapeutic feeding programmes may be increased by up to 500-600%. Their conclusion is that operational agencies need to urgently work together to achieve consensus on the way ahead before these new standards find their way to the field.

Finally, the ENN has received charity status in the UK and four trustees join the Directors Board to oversee our charitable work. They are Dr Bruce Laurence, Director of Public Health in the north-east of England and former Medical Director with the NGO, Merlin; Victoria Lack, Lecturer in Public Health and Primary Care at City University, London who has previously spent years working in the field with ACF; Nigel Milway, a senior executive with British Telecom for over 14 years who now heads up his own leadership and coaching consultancy; and last but not least Arabella Duffield, currently a nutrition advisor with SC UK who has previously worked with the ENN on a number of projects. In the November issue of Field Exchange we'll include a more detailed look at the ENN and plans for its future.

Jeremy Shoham
Editor

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

¹Levine S and Chastre C et al (2004). Missing the point. An analysis of food security interventions in the Great Lakes. Humanitarian Practice Network Paper, Number 47, July 2004. See summary in Field Exchange 23, p9