ENN attended the Global Nutrition Cluster (GNC) annual gathering in Brussels in early July (Tanya Khara as Technical Director, Isabelle Modigell and Linda Shaker-Berberias as ENN consultants and myself as staff nutritionist). This is a key event in the calendar for nutrition actors in the humanitarian sector - a chance to take stock of progress in countries of operation and steer the course of future action at country, regional and global levels.

A key theme brought out during the three days was the need to build capacity - of the GNC itself (more about that later) and of government systems. Experiences of Southern Africa’s response to Cyclone Idai were shared, illustrating the need to engage on the humanitarian development nexus (HDN) to ensure in-country capacity to respond at both ends of an emergency. In Malawi, the integration of community-based management of acute malnutrition (CMAM) into the routine public health system and contingency planning for surges in need, paid off. In the face of the cyclone, the system absorbed increased needs efficiently and rapidly using stock-piled supplies of ready-to-use therapeutic food (RUTF) and global acute malnutrition (GAM) rates remained constant. In Zimbabwe, the government also acted rapidly and decisively - mobilising its own resources to provide nutritionists on the ground in key locations and quickly extending protocols to provide RUTF to moderately malnourished children to prevent their deterioration. Mozambique, where the bulk of the disaster hit, was the country where existing capacities were most depleted by the disaster and where the largest magnitude of need was faced. A different story was therefore reported, of a response that, whilst government-owned, lacked capacity in several key areas and importantly, lacked sufficient external support to deal with worsening GAM rates after ‘early recovery’ was declared. Experiences highlighted the need to invest in and capitalise on development programming, particularly with regards to emergency preparedness and the links between wasting and stunting, to enable countries better to cope with surges in need and ensure the least disruption possible to ongoing services.

Time was given to discuss the need for comprehensive nutrition responses that go beyond community-based management of acute malnutrition (CMAM) to provide a package of high impact nutrition interventions (HINIs), including among others the promotion of optimal infant and young child feeding (IYCF), micronutrient supplementation and salt iodisation. A GNC analysis of Nutrition Cluster HINIs across 15 countries showed some areas to be distinctly lacking. However, this analysis lacked information about the broader context in these countries, including ongoing routine services, which somewhat limits the usefulness of results. A key question is, how can the emergency nutrition sector work with governments, development actors and the private sector to ensure that the whole package is provided? Where HINIs existed pre-emergency, what can nutrition cluster partners do to prop these up and sustain them during crisis? The voice from government representatives in the room was clear - work with us and through us and help build our capacity to respond quickly and effectively and provide sustained change.  

A very topical discussion was facilitated on day two around innovations in CMAM programming. Examples were given of several country contexts where CMAM protocols are being adapted and simplified protocols trialed. These examples and more are written up in Field Exchange (FEX) 60 - the special edition on the ‘continuum of care for acute malnutrition’. The key UN agencies (WHO, UNICEF, WFP and UNCHR) stated clearly their position that global CMAM guidance remains unchanged. However, the caveat was given that flexibility is needed to adapt protocols in exceptional circumstances. Beyond the global guidance, it is apparent that governments and agencies are already innovating in response to needs on the ground and conducting a number of important research studies to assess the effectiveness of these approaches. What does this look like? What are the nutritional impacts? What works? There is still so much that we don’t know. There was a strong push from the floor for rigorous, longitudinal research to help us to answer some of these questions, in particular how to identify those children most ‘at risk’ and provide appropriate support, to feed back into international guidance. This resonates strongly with recommendations made by the FEX editorial team in FEX issue 60 in reflecting on the evidence amassed from programmers and researchers. Participants were invited to continue discussing this on en-net’s new discussion forum on simplified protocols, developed to complement a community of practice on this topic just launched by the State of Acute Malnutrition.

Also on day two, and echoing issues raised by countries on day one, a strong case was made by Linda Shaker-Berberi, on behalf of the ENN-coordinated infant feeding in emergencies (IFE) Core Group, to provide for the needs of non-breastfed infants during emergencies. In a world where 59% of infants under six months are not breastfed this is clearly a priority. The group highlighted that when emergencies strike in situations where non-breastfed infants are present we have a duty to respond to their needs in equal measure to those of the breastfed child. This is something that the current system does not allow for. A presentation from Nutrition Cluster Coordinator for the Democratic Republic of Congo (DRC) illustrated that, in the context of the Ebola virus disease (EVD), breastmilk substitutes (BMS) were provided to infants separated from their mothers, according to national protocols. Questions raised included, what can we learn about handling BMS from this situation going forward? And, in the case of EVD, what further guidance and support is needed with regards to IYCF? This topic has been identified as a priority action area by the recently launched Global Technical Assistance Mechanism for nutrition (GTAM) (see below) around which a technical group now exists.

Day three focused on a new mechanism that among other things, aims to help us as a global system to more systematically and transparently answer some of the more technical of these questions. Progress on the development of the GTAM, which has been in the pipeline for some time, was presented by the coordinating group (UNICEF, World Vision, GNC, the Technical Rapid Response Team (Tech-RRT) and ENN). The mechanism aims to provide global level technical assistance and expertise to fill gaps at country level by providing answers to technical questions based on existing guidance, consensus driven guidance where it is lacking (through global thematic working groups) and ground level expertise. It is early days still for the GTAM and many questions remain, some of which were answered during the meeting and some of which still need to be answered, but in general it was good to see positive expectations for this initiative.

Finally, the meeting gave cause to celebrate the achievements of the outgoing GNC coordinator, Josephine Ippe, who, after 10 years, is moving on to pastures new. It is clear that she has led the GNC with great humility and strength, leaving behind a much stronger cluster than when she arrived. In particular, she has seen the potential in individuals and drawn together a group of committed, passionate people, dedicated to providing a better service for communities affected by crisis and to the further professionalisation of the Nutrition Cluster. The mantel is now passed to Stefano Fedele, who will take over from Josephine later in July. There is no doubt that Josephine leaves large shoes to fill. However, this is a changing landscape and one that will no doubt require different shoes completely. Stefano’s aim is to begin by listening - an excellent place to start.

Chloe Angood - Nutritionist, ENN