Caring for Unaccompanied Children under Difficult Circumstances

by Jean Long, Ros O'Loughlin, Annalies Borrel

Jean Long and Ros O'Loughlin worked for Concern in Kisingani (DRC) in the fall of 1997, establishing the programme described below. Annalies Borrel is the agency's HQ Nutritionist.

Generally, emergency interventions are conceptualised as having an impact on nutritional status through a combination of strengthening food security, health service provision and providing or supporting caring practices. However, there is currently a debate about what constitutes caring practices in emergency programme interventions. The authors of this article would propose that caring acts as a catalyst or effect modifier, which increases the effectiveness of the intervention and/or allows an intervention to be delivered in a more sensitive manner. The following case history intends to demonstrate the caring process and practices utilised to make the treatment of severe malnutrition among unaccompanied children more effective in Kisangani, Democratic Republic of the Congo (DRC).

Background

From May to July 1997, Concern Worldwide was responsible for the general welfare of unaccompanied Rwandan children while in transit from the DRC to Rwanda. The background to this situation is described in detail in the article on Responding to the Crisis in Congo Zaire: Emergency Feeding of Rwandan Refugees in Issue 3 (January 1998) of Field Exchange. The registration of these children and preliminary preparations for tracing was the responsibility of Save the Children, UK and UNICEF. At the time, the internal situation within the DRC was complex and often dangerous for the refugees. Concern Worldwide (Concern), an international NGO, with experience in child care was requested to prepare all unaccompanied children for return to Rwanda. All children were to be repatriated to Rwanda within 60 days, and initially within 48 hours of arrival in the Kisangani transit centre. However, it was assumed that the children's health and nutritional status was sufficiently adequate to allow them to make the onward journey. There was no reliable information to indicate otherwise.

In early May 1997, following Concern and other NGOs arrival in the transit camp, it was realised that at least 30% of the unaccompanied children were not fit to travel, given their current health and nutritional status. There was, however, pressure by both the military authorities and UNHCR to repatriate the children, unless they were suffering from medical complications. At this stage, severe malnutrition was not necessarily considered a medical condition requiring immediate intervention by the authorities. As an international humanitarian organisation Concern felt its priority was to ensure the best possible outcome for each unaccompanied child. Concern therefore established a screening facility which determined whether children required: emergency medical care, therapeutic feeding or outpatient care. Emergency medical care facilities were available in a Medecins Sans Frontieres International (MSF) field hospital. However, initially there were no facilities for the treatment of severe malnutrition. Concern were aware that stabilising the children before repatriation was critical to prevent excess mortality, especially as nutrition rehabilitation facilities available in Rwanda were inadequate. UNHCR initially allowed Concern five days to stabilise the severely malnourished children. Following subsequent discussions, there was agreement that the children could remain as long as it took to achieve full recovery.

The Kisangani Therapeutic Feeding Centre (TFC)

Over six hundred severely malnourished unaccompanied children were treated in the TFC during the 12-week period, 27% of the admissions had nutritional oedema and 42% had MUACs less than 110mm. The average length of stay was 15 days, although 27% had a length of stay greater than 21 days. Seventy eight percent of the children admitted recovered, while 9% died, and 13% defaulted. Thirty three percent of the children were admitted to hospital for a short period during their stay in the TFC. The prevalence of: oedema, MUACs less than 110 and medical conditions indicates that these children were in very poor condition on arrival in the TFC. The condition of the children in the TFC was further complicated by their traumatic experiences and there was evidence of, disorientation, withdrawal, extreme grief, and other behaviours indicating a high degree of psychological stress. War injuries were common among the children and there were some incidences of pregnancy among young girls.

Constraints to Care Provision

There were many constraints to providing adequate care for these severely malnourished unaccompanied children in the Kisangani Therapeutic Feeding Centre (TFC)

* The children had no mothers to provide care and advocate for their children's needs, and their siblings, if present, were often as ill themselves, and were equally traumatised by their recent experiences.

* the lack of locally qualified health staff with experience in caring for the severely malnourished. Language barriers were another major constraint for the Zairian staff as they did not speak the children's language, Kinyarwanda.

* Organisations (UNHCR and other NGOs visiting donors visiting the centre), did not fully comprehend the strict treatment regime required to stabilise these children, for example, they often distributed high protein biscuits to the children who required a low protein diet. They often accused centre staff of not providing adequate quantities of food for the children, although their diets were calculated individually and in line with international guidelines.

* Separation of siblings was another key issue in the centres. Initially UNHCR staff would collect the well children from the centre and mistakenly take siblings of the malnourished children still residing in the TFC. This created difficulties for the organisations responsible for tracing and fostering, not to mention further traumatising the children. There were also occasions where well siblings that were being repatriated collected their malnourished brother or sister. This contributed to a high default rate.

Examples of the caring process

The main caring interventions provided by Concern during this period included employing, training and supporting local women who worked in shifts as carers.
The training covered the clinical management of the severely malnourished children including a special emphasis on the importance of creating a secure and comfortable environment for the children. This included maintaining the child's physical comfort (including hygiene and warmth), explaining treatments, conversing with the children and motivating children to take the food and medicines provided.
The activities of these local women were child based rather than task based, and the same worker was allocated to the same group of children on each shift. At a later stage of the child's recovery, exercise and play became important caring interventions. Technical skills and language barriers were overcome through recruiting health care staff and translators in Goma. This facilitated carer communication with the children . Conversation between carer and children was actively encouraged.
The caring staff needed continuous support and supervision in these difficult circumstances to ensure quality of care. When feasible the older siblings cared for their younger malnourished siblings while others were cared for in the adjoining unaccompanied children's centres.
There was continual advocacy by Concern, to ensure that siblings were not separated and also to maximise the time for recovery prior to forced repatriation .

Conclusions

This article set out to highlight the importance of caring practices in promoting nutritional recovery amongst malnourished children: These practices are catalysts/effect modifiers which improve intervention outcomes, and can be adapted to a given situation. However, these practices can be resource intensive. There was little doubt amongst those involved in the programme that caring practices in this TFC increased the speed and quality of recovery among these children in very difficult circumstances. Our observations also indicated that through caring practices, the majority of children, particularly, those who were traumatised made a complete recovery. Other indicators of recovery, apart from achieving the target weight for height, included children: smiling; taking an interest in their surroundings; paying attention to their appearance; regaining their dignity; interacting and conversing with other children and the staff; playing; beginning to tell their story; starting to form friendships and to trust the adults providing care in the centre.
This article does not mean to imply that parental participation is unnecessary in the nutritional recovery of their malnourished children. Instead, it is intended to show that excellent nutritional outcomes can be achieved through investing in the provision of caring practices, many of which would normally be undertaken by parents, when children are separated from their parents during conflict situations.