Delivering Supplementary and Therapeutic Feeding in Darfur: coping with Insecurity

By Gwyneth Hogley Cotes, GOAL

Gwyneth joined GOAL in November, 2005 as the Nutrition Coordinator for Darfur, Sudan. She has a BA in International Studies and Master of Public Health (MPH) degree focusing on child health and survival. Her work experience includes researching the barriers to therapeutic feeding centre attendance in Eritrea in 2001 and training Ministry of Health staff in Ghana in improved disease control and immunisation information management techniques.

GOALs Simon Roughneen assisted in conceptualising, framing and editing this article. This article would not be possible without the professionalism and bravery of GOALs nutrition workers and the rest of the Darfur field team.

View of Fata Borno IDP camp, North Darfur, temporary home to 18,000 IDPs.

This article describes the ongoing challenges that insecurity poses to the GOAL nutrition programme in Dafur and the strategies they have responded with.

In February 2003, fighting erupted between Sudanese government forces and the Sudanese Liberation Army (SLA), a rebel movement seeking to achieve greater autonomy for the Darfur region and its people. Later the SLA was joined by the Justice and Equality Movement (JEM), a pan-Sudanese opposition group. The conflict made headlines around the world when government-armed 'Janjaweed' Arab militias conducted widespread attacks and looting in Darfur villages, resulting in an estimated 200,000 deaths and the displacement of some 2 million residents.

The fighting and displacement has slowed its pace somewhat since the start of the conflict but, in late 2005 and into 2006, areas of western and northern Darfur have seen renewed violence, resulting in new displacement. Currently, there are approximately 1.75 million Darfurians living in internally displaced persons (IDP) camps or host communities throughout Darfur, with another 200,000 refugees in Chad. The humanitarian situation has been further compromised by the spread of the conflict across the border into Chad. At the time of writing, an internationally mediated peace agreement was signed between the Sudanese government and one faction of the SLA. However, a second SLA faction and the JEM party refused to sign, causing tension throughout the Darfur region and raising concerns that the split could cause a resurgence of fighting.

As a result of the conflict, most residents of Darfur have seen a complete disruption of their lives and livelihoods, with access to land, markets, and services restricted by violence and fear. Productive assets have been depleted, either looted by warring factions, or sold as a means to get food and shelter.

Humanitarian situation

Despite the influx of aid in 2004, the humanitarian situation has remained precarious. As a result of widespread food aid and supplementary feeding, global acute malnutrition (GAM) rates have dropped from the critically high rates that were found at the height of the conflict, but are still alarming, ranging from 10-20% throughout Darfur. Even before the conflict, large portions of Darfur were characterised as 'chronically-destitute' with wasting levels of 20%, criteria that would have justified emergency intervention long before the fighting started¹. However, after three years of intense humanitarian activity, international assistance is beginning to wane. Starting in May 2006, the World Food Programme (WFP) will be forced to halve its food aid to nearly 3 million residents of Darfur, because of a shortage of donor funding.

GOAL's work in Darfur

After the conflict began, GOAL set up two emergency assistance programmes in Darfur. The first was started in February 2004, in the Kutum region of North Darfur, an arid area subject to food insecurity even before the conflict. The war in Darfur had further exacerbated the health and nutrition problems in the area, and rates of malnutrition were typically higher than in other parts of Darfur. GOAL had a history of involvement in the region, and was already monitoring the humanitarian situation before the conflict began.

Approximately 45-50,000 IDPs are currently living in host communities and in camps near the primary town of Kutum. GOAL currently provides primary health care and water/sanitation services throughout the region and in camps. GOAL's nutritional services are provided using the Community-based Therapeutic Care (CTC) approach, including supplementary feeding (SFP), outpatient therapeutic feeding (OTP), and inpatient care for complicated cases of severe malnutrition.

In March 2004, GOAL began operating in Jebel Mara, a contested area in a fertile mountain region that once provided much of the region's food. After the war began, much of the land was abandoned following attacks on villages, and the food security and health of the population declined rapidly. At that time, GOALwas the only agency working in the area. The programme distributed non-food relief items to IDPs and provided supplementary feeding, therapeutic feeding (TFP), primary health care (PHC), and water/sanitation services. Due to a significant deterioration in the security situation, this programme was closed in January 2006.

The impact of insecurity on the provision of nutritional services

Difficulty providing services

GOAL's services are spread out over a wide area of North and West Darfur. Because population movements are restricted by insecurity, GOAL must travel to field sites on a daily basis to bring services to populations in need. As a neutral agency, GOAL provides nutrition services in both government and rebel-held areas of Darfur.

GOAL nutrition worker Hawaida Tijani explains TFC rations for under-5s to mothers

This presents logistical constraints in terms of transportation and communication, as GOAL has to coordinate all activities with all the various political factions before travel can be authorised. Access to programme sites is carefully regulated, and authorities on all sides must be notified in advance of all programme staff and patients who are to be transported across military boundaries. The purpose of advance notification and communication procedures is to determine if fighting or suspicious movements are occurring in the travel areas. However it does not provide a guarantee of staff safety. Non-governmental organisations (NGOs) risk having their cars hijacked or getting stranded by an outbreak of violence each time they enter the field. Special communication equipment must be available, and all GOAL staff must adhere to very stringent security procedures at all times. Every step is taken to ensure, as much as possible, that personnel and assets are not exposed to unnecessary risk.

Rigid security protocols make it difficult to visit local communities outside of the clinic areas. Thus assessments, screening, follow-up visits, and community sensitisation cannot always take place as planned. In rural areas, nutrition services are generally provided in conjunction with clinic services, and screening is conducted among clinic attendees; active case-finding is nearly impossible given the security constraints. The coverage attained using this method is very low, and additional methods have to be developed in order to reach local communities.

Service interruptions

GOAL provides SFP and CTC services on a biweekly schedule, as weekly distributions resulted in large numbers of caretakers defaulting from the programmes. Prior to each distribution, communication with authorities and advance notification allows GOAL to identify areas that are unsafe for travel. When fighting or troop movements occur, programme activities have to be temporarily suspended, and no staff or food aid can be transported to field sites.

In most cases, there is no way to communicate to beneficiaries when services have been interrupted - no telephone service is available in rural sites. Beneficiaries sometimes travel long distances to reach the SFP/CTC site, only to find that staff and provisions have not arrived. This results in a serious lack of confidence in NGO services, particularly in rural areas. Caretakers become less willing to travel to the SFP site after a service interruption, resulting in high rates of programme default. The interruption also has a negative effect on the growth and recovery of the child, especially during periods of ongoing insecurity, when they may not receive supplementary food for six weeks or more.

Nutrition programmes are affected by interruptions of other services as well. Medical service closures can reduce the number of beneficiaries available for screening, lowering the programme's coverage. Suspensions or delays in general food distributions cause food to be shared among other family members, lowering cure rates.

Reduced programme effectiveness

Most agencies providing SFP and CTC services in Darfur report low levels of attainment of international standards for feeding programmes. In the current context, achieving the acceptable cure rates of more than 70% and default rates of less than 15% is extremely difficult.

Although much of the conflict-affected population is concentrated in IDP camps, mostly situated near major towns, hundreds of thousands of conflict-affected people are still living in rural communities. It is these populations that are most difficult to reach with nutritional services (see table 1). Even under more stable conditions, nutrition programmes often have problems with caretakers defaulting due to long distances between homes and services, poor understanding of the importance and purpose of feeding programmes, and seasonal migration. In Darfur, all those problems exist as well, but are compounded by the problem of caretakers who are often afraid to walk to SFP or CTC sites because of the threat of physical violence or harassment. In some areas of Darfur, African Union (AU) peacekeeping forces escort people twice a week from local communities to the market, or guard women as they collect firewood because the danger of rape or physical attack is so high. Caretakers may also have little confidence in the programme because the agency has previously been absent. In short, the costs of attending nutritional services often outweigh the perceived benefits.

Risk of sudden programme closure

One of the biggest problems with providing nutritional services in insecure areas is the possibility of a complete evacuation and abandonment of services in the event of a large-scale outbreak of fighting. The agency will not only lose capital assets, such as vehicles, computers, and office facilities, but less tangible resources as well, such as programme information and the training that has been invested in local staff. The community being served will suddenly be cut off from needed aid, and may be angry or resentful at the agency for pulling out, making re-entry into an area more difficult if the security situation improves sufficiently to allow for it.

Even smaller programme suspensions can present serious challenges to nutrition programmes. In December 2005, an attack on one of GOAL's key focal areas in West Darfur caused a shutdown of services in the vicinity. Numerous local field-based staff fled with their families to distant villages, including nutrition outreach workers. The food store located in the town was abandoned, all supplies and food commodities lost. Approximately 10,000 Darfurians were displaced to villages scattered throughout the area, including nearly 600 malnourished children who were enrolled in GOAL's SFP.

Arapid response was essential to ensure that a nutritional crisis did not emerge. GOAL conducted security assessments to determine the location of the majority of the new IDPs, and conducted rapid nutrition assessments within two weeks of the attack to determine where SFP services could be moved in order to reach the greatest number of displaced beneficiaries.

An additional problem was locating missing staff. In each village visited, sheikhs were asked to locate any displaced GOAL staff that had relocated to the area. The sheikhs were given the date and location of GOAL's next visit so that staff could receive pay and be returned to work in a new site if they so wished.

Although SFP supplies and staff were available in the area, the conflict was so disruptive that providing health or nutrition services was impossible. However, in another scenario, it may have been possible for SFP services to continue in this location, as all the required inputs - staff, food, and facilities - were already positioned in the field. Based on the lessons learned from this experience, GOAL is planning to test the option of self-sufficient field-based locations in its programme in North Darfur so that services can be continued for a short time, even if the location gets cut off from the programme base by fighting.

Strategies for dealing with insecurity

Decentralising services

Decentralising nutrition services allows for better access into local communities, and, if supplies and staffing are sufficient, can allow SFP and CTC services to continue even in the event of a suspension of travel to the field.

GOAL's nutrition programme in Jebel Mara operated out of one central hub, with four primary programme centres. In each, a food store was built to hold SFP supplies and food. Enough food was stored to cover at least two distributions, or one month, of food. From each of the programme hubs, two or three SFP sites were served. Every two weeks, nutrition workers travelled by car from the primary town in the region. They stayed in secure overnight locations, set up with bedding and shelters in each of the four programme hubs, which were then used as a base to provide SFP services to the surrounding sites.

Each programme hub was used as a base to serve 2-3 nearby SFP sites, and all sites were served during 3-4 day overnight visits. This strategy increased the amount of time available at each SFP distribution, allowing women enough time to walk from their homes to the project site. However, additional logistical and security planning was required to ensure that communication systems were in place and that supplies were pre-positioned and sufficient for the whole stay.

Overnight visits also increased the risk that staff could be stranded in a field location if fighting erupted between the field site and the programme base. This happened in January 2006, when the base town of Golo was attacked, and staff working in the field had to be evacuated by airlift. This underscored the importance of good communication systems, clearlydefined evacuation plans, and advance preparation - for example, one way to prepare for this scenario is to identify potential helicopter landing sites in all programme locations, and collect GPS data for each site.

Although it carries risks, the strategy of decentralising services could be taken one step further, by hiring local nutrition staff, who are then fully trained in providing SFP or CTC services. In the case of Jebel Mara, field-based nutrition staff had already been identified, and the storage capacity for food commodities and supplies was adequate. Caretakers kept their registration cards with them so record-keeping was also decentralised.With additional training, the field-based nutrition staff could have continued SFP services even if the headquarters staff were unable to reach the location.

GOAL staff meet local sheiks to discuss access and programme activities in Kutum town and IDP camps

Developing strong communication with communities, local leaders, and authorities Good communication systems are crucial for a number of reasons. First, because of the threat of insecurity and the restrictions placed on NGO movement, agencies often have very limited direct access to local communities, making screen ing and community sensitisation impossible for town-based staff. Instead, community volun teers, locally-based staff, and local leaders must be enlisted to bring messages to communities.

In GOAL's Jebel Mara programme, between 4 and 8 outreach nutrition workers operated out of each programme hub. On distribution days, the outreach workers helped provide SFP services. During the rest of the two-week cycle, they visited the homes of children who had been absent at the distribution to reduce defaulters, and conducted screening and community sensitisation. Outreach workers were selected from local communities; although they were still subject to some danger while travelling in rural areas, they had better knowledge of the local security situation, and were better able to access rural communities.

In GOAL's North Darfur programme, locally- based Community Health Promoters (CHPs) conduct house visits to follow up on children absent from SFP or CTC services, to conduct screening and education, and to raise awareness among the community. In rural areas, where distances are great, CHPs are provided with donkeys in order to travel between villages. In areas where no CHPs are present, local sheikhs are asked to inform community members about nutrition services to encourage them to bring thin children for screening.

In October 2005, GOAL carried out a household nutrition survey, covering the entire catchment population of its North Darfur programme. To enter rural villages, a number of steps had to be taken:

• Discussions were held with local authorities to gain approval to carry out the survey.
• Advance approval was sought from authorities, listing all locations selected for the survey, and the dates that villages would be visited.
• Letters were carried by clinic staff to the sheikhs in the selected villages to inform them of the purpose of the survey, and the dates on which the communities would be visited.

Without effective channels of communication, the survey would not have been possible. Regular communication enhances the acceptability of the organisation within the community and reduces the threats to staff, who can sometimes be regarded with suspicion by military and political groups. It is important to maintain visibility and transparency of programme activities, so that communities are aware of who is providing key services, and how those services are organised. This reduces the risk to staff by increasing the perceived value of the organisation - there will be less interference in programme activities if soldiers or community members perceive that the organisation is providing valuable services, and can trust that the organisation will do what it says it will.

Health and Community Education

One of the most important factors in successfully providing nutrition services in insecure areas is community awareness and education. Because agencies are limited in their direct access to communities, following up on beneficiaries is much more difficult. Instead, nutrition workers must stress at each distribution the importance of returning every two weeks for services. In order to increase the perceived benefits of the programme, mothers are encouraged to think of Corn Soy Blend (CSB) as treatment for a sick child, rather than as food. At each distribution, caretakers have to be reminded of the importance of not sharing CSB.

In both of GOAL's Darfur programmes, SFP services are provided in conjunction with clinic services, located on or near the grounds of a local health centre. This encourages the idea of SFP as a treatment, and also allows easy referral between health and nutrition services.

Planning for the future

Drug distribution during an SFP at GOAL clinic, Kassab IDP camp, north Darfur

As in most emergency situations, there was a large influx of funding and agency support after the early, critical stages of the Darfur conflict, resulting in a quick improvement in health and nutritional status among children in the region. Funding for food aid and nutritional services has slowly waned since the initial crisis passed. However, hundreds of thousands of households are still dependent on food aid as their primary food source, and still lack access to livelihoods, productive land and alternative sources of food because of ongoing insecurity.

A number of challenges have emerged in 2006. The WFP recently announced that food aid rations in Darfur will be cut in half because of a shortage of funds. This will directly reduce the effectiveness of SFPs, as food rations are shared among other family members. Donor support for SFPs and TFPs has declined as a result of lowered admissions following the early nutritional crisis. The majority of agencies providing supplementary and therapeutic feeding in Darfur have demonstrated poor performance in comparison with internationally accepted standards for cure and default rates, resulting in further questions about the effectiveness of feeding programmes given the context of insecurity and difficult access.

It is difficult to get a true sense of the nutrition context in the region because of the constraints in carrying out surveys and rapid assessments. Surveys can only be conducted among accessible populations, such as in IDP camps, towns, and more stable rural areas. The most vulnerable children are often missed by these surveys. However, several recent assessments, including one carried out by GOAL in October 2005, have found that GAM rates are still above emergency thresholds in many areas, and increasing admissions in feeding programmes indicate that the situation is worsening. Food security has been further compromised by the conflict, especially for the many vulnerable populations still living in camp settings. Faced with a reduction in international assistance, many agencies are having to adopt new strategies to sustain the gains that have been made since 2003.

Given the precarious state of donor funding, the dependence of two million Darfurians on food aid, and the inability to predict the effect the Abuja peace deal will have on the security situation on the ground, it is clear that effective provision of nutrition services in Darfur is contingent on a number of external factors. On the one hand, reduced general food rations will compromise the effectiveness of the SFPs and TFCs, where implemented. On the other, renewed fighting between opposing factions - currently divided over the recent peace agreement - will undermine the ability of agencies to provide SFPs and TFPs.

Providing nutritional services in conflict settings is particularly challenging, but can be effective with planning, flexibility, and good communication. While high rates of malnutrition persist, populations in Darfur will continue to require emergency feeding services over the coming months. However, it is clear that shortterm nutrition solutions, such as emergency feeding programmes, are at risk of being discontinued given the constraints that have developed over the last few months. In order to sustain the improvements that have been seen in nutrition over the last 3 years, greater attempts will need to be made to build the capacity of existing community and health structures to address malnutrition in the long-term.

For further information, contact: Gwyneth Hogley Cotes, Nutrition Coordinator email: ghogley@gmail.com, and Dennis Curry, Field Coordinator - Kutum, Darfur email: dcurry@goalsudan.com

¹Assessing the Impact of Humanitarian Assistance, A Review of the Methods in the Food and Nutrition Sector. Jeremy Shoham, HPG Background Paper.