Drought resistant 'banana' - Field Exchange - Emergency Nutrition ...

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contents31220265••••••••••••15•••••••••1922•24•2Field ArticlesEnset – The ‘False Banana’as Food SecurityPotential of Using QBmix toPrevent MicronutrientDeficiencies in EmergenciesVulnerability Mapping inUrban AfghanistanInfant Feeding Alternativesfor HIV Positive Mothers inKenyaResearchAdequacy of ReplacementMilks for Infants of HIV-Infected MothersGrass Pea Consumption andNeurolathyrismRefugee Participation inCamp Health ServicesStarvation and FutureCardiovascular DiseaseEffect of Displacement onGrowth of Children in NigeriaInvesting in Nutrition toReduce PovertyDietary Assessment of CampRefugeesImpact of Dietary ZincSupplementation on PEMCarbon Dioxide Production inAcutely Ill MalnourishedChildrenHIV/AIDS and HumanitarianActionNutritional Status of HIV+Pre-School Children inSouth AfricaTaking forward research onadult malnutritionNews & ViewsCourse on Saving Lives andLivelihoodsWHO/TALC materials on theManagement of SevereMalnutritionNutrition in emergenciesworking group, SCN 2004New Measuring Scoops forF75 Therapeutic MilkECOWAS Nutrition Forum onNutrition and HIVEquity in Donor AidAllocation to IraqTraining in Public Health inEmergenciesUpdate from Food Security,Livelihoods & HIV/AIDSWorking GroupFAO/WHO Meeting Warn ofContaminated Infant FormulaLettersEvaluationLessons From SCUKEvaluation in DRCAgency ProfileNutriset29 People in aidFrom the EditorThe more cynical amongst us in the emergencynutrition sector may sometimes be heard complainingthat there is nothing new in this professionand that we just keep re-inventing the wheel - ‘theproblems are the same, as are the solutions.’However, a cursory glance over this issue of FieldExchange gives lie to any such claim. There areplenty of new developments. For example, the pilotingof a newly developed product called QBmix (amicronutrient rich condiment) by MSF amongstIDPs in Angola to help combat the endemic pellagraproblem that has plagued this population for anumber of years (see field article by EvelynDepoortere). The study shows that QBmix mayoffer a cheaper, and logistically simpler, alternativeto fortified CSB, as a means of preventing furtheroutbreaks. There is also a field article in this issueabout an indigenous crop grown in south andsouthwest Ethiopia - ‘Enset’ (or false banana) andbeing promoted by the development agency SelfHelp International The crop appears to have manypotential uses which have a positive impact on foodsecurity. According to the author, there may bepotential for promoting this local drought resistantcrop in other food insecure areas of Ethiopia and fordisseminating knowledge widely about its potentialfor reducing food insecurity. This issue alsocarries a summary of a study concerning theconsumption of green peas in drought prone areasof Ethiopia. Consumption of this wild food, especiallyin drought periods, is associated with neurolathyrism(a neurodegenerative condition).However, the study shows that incidence is reducedwhen the affected population simultaneouslyconsumes food aid in the form of cereal. Thefindings support the case for targeting food aid inthese vulnerable areas, not just to the poorest, butalso to those likely to increase their consumption ofthis legume.There are also research findings reported in thisissue, which, although not entirely new, add to analready considerable body of knowledge. Forexample, a study of the longer term impact of thesiege and resulting famine in Leningrad during thesecond world war shows that the legacy of starvationis not just limited to growth impairment, butalso future cardio-vascular health. There is also astudy on ration adequacy amongst Thai refugees.This shows, yet again, how poor ration quality forfood aid dependent refugees is directly responsiblefor the high levels of stunting and micronutrientdeficiencies which have existed amongst this populationfor a number of years The inadequacy of themicronutrient content of home prepared replacementmilks as a breastmilk substitute – an ongoingconcern of many in infant feeding circles - is highlightedin one summarised research piece byRollins et al in South Africa. In this setting, infantformula is considered an appropriate and viableoption for feeding infants of HIV positive mothers.However, a field article by Tom Oguta and his teamin Kenya finds that home-adapted animal milksmay be the preferred breastmilk substitute, andonly available option, for carers of infants whosemothers are HIV positive. While current internationalguidelines recommend fortification of homeprepared milk with micronutrients, in practice,these are often not locally available.Take any sample of Field Exchange and it isapparent that there is a continuous steam of importantinformation and ideas provided by new researchand pilot interventions, which should, at leasttheoretically, help inform better practice.Unfortunately, much of this information neverfinds its way into the published literature. In spiteof what cynics may say, there is still much we don’tknow. Where we have good quality research thereis often a need to collate disparate research findingsinto a sufficient body of coherent evidence to makea case and advocate for change. Emergency rationadequacy for refugees and findings like those fromthe Thai refugee study are obvious examples whereit appears that we have not reached a critical massof evidence to effect change.As editor of Field Exchange it is becoming increasinglydifficult to leave out articles and research onHIV related issues. This issue of Field Exchangecarries a field article on infant feeding practicesamongst HIV positive mothers in Kenya, asummary of a review of the impact of HIV on crisesand humanitarian work, and research on predisposingfactors to malnutrition amongst HIV positivechildren in eastern Cape, South Africa. There is alsoa report on the AAH/Oxfam co-chaired meeting ofthe HIV, food security and livelihoods workinggroup.The multifaceted interface between HIV andnutrition is becoming increasingly recognised andreflected in HIV/nutrition programming, especiallywhere the HIV pandemic is most pronounced,e.g. southern and Eastern Africa. There is agrowing trend towards using food aid in much ofthis HIV programming. The use of food aid is beingincreasingly advocated, especially following emergencyprogrammes under protracted relief andrehabilitation arrangements (PRROs). Food is thereforebeing incorporated into Prevention of Motherto Child Transmission programmes (PMTCT),Home Based Care (HBC), TB treatment (DOT),Orphan and Vulnerable Children programmes(OVC) and Neighbourhood Child Protectionprogrammes (NCP). There appear to be multipleroles for food aid in these programmes with avariety of objectives proffered, e.g. nutritional, foodsecurity, incentive to comply with treatment, incentivesfor volunteers, protection, etc. However, thereis often a lack of clarity over exit criteria, how foodaid will be integrated with other packages and littlethought or attention as to how these programmeswill be monitored and evaluated. While there maybe a rationale for food aid in many of theseprogrammes, there is the very real danger that foodmay be used uncritically with little attention givento impact. Furthermore, in some cases it may bethat food aid actually has a negative impact, e.g.undermines the volunteer ethos.There is a long history of uncritical and ultimatelyineffective use of food aid in longer term nutritionprogramming, e.g. supplementary feeding.Some critics of current developments are alreadyimplying that use of food aid in HIV programmingmay be an attempt to introduce development foodaid (which has dwindled over the past three decades)by the back door. It is essential, therefore, thatthis relatively new area of programming is introducedcautiously and based on pilot studies. Wheresuccessful, interventions can be rolled out, providingmonitoring and evaluation mechanisms are inplace. There can be no excuse for failing to applylessons from the past regarding the use of food aidin longer term nutrition interventions to this newera of HIV/AIDS and nutrition programming.Finally, we enclose in this issue the first ENNSpecial Supplement. This supplement, and subsequentones that are planned, are meant to collatecutting edge field experiences in rapidly developingsubject areas. A letter written by one of theauthors in this issue of Field Exchange (AnnaTaylor), highlights why targeting is such an importantsubject and where clarity is urgently needed.The next ENN Special Supplement will be onCommunity Based Therapeutic Feeding programmes.We hope you enjoy this issue of Field Exchange.Jeremy ShohamAny contributions, ideas or topics for future issuesof Field Exchange? Contact the editorial team onemail: marie@ennonline.net

Sodo district, Ethiopia. G. Jacob, 2003 Sodo district, Ethiopia. G. Jacob, 2003Manual processing using traditional bladed wooden instrumentsareas, Self Help established demonstration plotson a small scale, in conjunction with Ethiopia’sAgricultural Research Institute in the Marako,Sodo and Dodota project areas. Over a period,the crop performance was monitored and assessed.Farmers in the locality were given theopportunity to visit demonstration sites and seefor themselves the potential of Enset and itsmany uses. Following these initial demonstrations,contact farmers from amongst those interestedwere selected. These farmers were providedwith the necessary seed stock, along withpractical training on the growth of Enset in theirregion. Their plots, in turn, became demonstrationsites visited by farmers in their locality. Acertain proportion of seedlings was made availablevia contact farmers, as a way of getting theirinterested neighbour started with the crop.Revolving seed fund mechanisms of this kindare a feature of many of Self Help’s agriculturaldevelopment activities.ConstraintsThere have been obstacles facing those engagedin promoting the propagation of Enset, themost fundamental being it takes three to fiveyears for the plant to achieve maturity. While afive year old plant can yield 40 kg of food,farmers who harvest after a single year canexpect a yield of just one kg from the pseudostem– the bowl of the tree which is processed forfood.Enset crops shading coffee plantsAlthough it is estimated that there arecurrently upwards of 10 million people insouthern Ethiopia consuming Enset in their diet,there are historic and cultural reasons whyothers in the country do not. During the reign ofEmperor Haile Selassie (1930-1975), theEthiopian Ministry of Agriculture launchedmajor initiatives to increase food production.The emperor gave strict instructions to focus oncereal crops and income-generating crops, suchas coffee, while the Enset plant was ignored. Thesituation for Enset did not improve under thesubsequent Socialist Derg regime (1975-1991),whose research projects had insufficient funds,and did not examine the potential of a crop.There have been cultural barriers to the popularityof Enset too. Many urban Ethiopiansregard a crop, which is used by southerners foreverything from food, bedding and clothing tohouse building and fodder, as little more than apeasant food.A number of factors have acted to change thisperception, however, and market forces - whichhave seen the price of Enset remain stable whilecereal grain prices have climbed -has been asignificant one. Not to be under-estimated,either, has been the realisation that famine can,and has been, averted at times of drought, inareas where the Enset crop is being grown andprocessed by rural communities.Field ArticleThe future of EnsetThere is a concern in Ethiopia that stocks ofEnset have been depleted. In many parts of thecountry, it seems that the Enset plantations havenot recovered from the harvesting of youngimmature plants which occurred during the1980’s, when hundreds of thousands of peoplefrom northern Ethiopia were displaced to thesouth of the country – and required Enset fortheir very survival. However, according to SelfHelp’s African director, Dr. Awole Mela, Ensethas, on balance, been hugely valuable to theirsustainable rural development work in SouthernEthiopia. Not only has it given rural householdersa greater level of food security, it has providedvaluable shade for the growing of othercrops, and has also helped to reverse soil degradationin otherwise vulnerable areas. Upwardsof 80,000 farmers in this project area are nowsuccessfully growing the crop.A 1997 publication, produced by theAmerican Association for the Advancement ofScience, in collaboration with the AwassaAgricultural Research Centre "The Tree AgainstHunger," has done much to raise awareness ofthe potential and future prospects of Enset, bothin Ethiopia and elsewhere. In the same year asthis was published, the Ethiopian governmentformally recognised the importance of the cropto the people of Southern Ethiopia, and declaredEnset ‘a national crop’ worthy of significant researchand development funding.For further details, contact: George Jacob, SelfHelp Development International, Hacketstown,Co. Carlow, Ireland.Tel: +353 (0)59 6471175, Fax: +353 (0)59 6471292,email: george@selfhelp.ieweb: http://www.selfhelp.ieSelf Help Development Agency is an Irish-baseddevelopment agency, involved in the implementationof long-term development projects inAfrica. The agency has field offices in Ethiopia,Malawi, Eritrea, Kenya and Uganda.4

ResearchAdequacy of Replacement Milks for Infants of HIV-Infected MothersSummary of published research 1Feeding recommendations for infants ofinfected HIV-mothers in developing countriesremain controversial. As HIV can betransmitted to the infant by breastfeeding,the World Health Organisation (WHO) recommendsthat, “when replacement milk is acceptable,feasible, affordable, sustainable and safe,avoidance of all breastfeeding by HIV-infectedmothers is recommended; otherwise, exclusivebreastfeeding is recommended during the firstsix months of life 2 . However, little is known aboutthe nutritional adequacy and feasibility of thevarious breastmilk replacement options recommendedin related training materials 3 . A recentstudy aimed to explore suitability of the 2001feeding recommendations for infants of HIVinfectedmothers in a rural region in KwaZuluNatal, South Africa, especially with respect toadequacy of micronutrients and essential fattyacids, cost, and preparation times of replacementmilks.Nutritional adequacy, cost, and preparationtime of home-prepared replacement milks containingpowdered full cream milk (PM) and freshfull cream milk (FM) and different micronutrientsupplements (2 g UNICEF micronutrient sachet,government supplement routinely available indistrict public health clinics, and best availableliquid paediatric supplement found in local pharmacies)were compared. The costs of locally availableingredients for replacement milk were usedto calculate monthly costs for infants aged one,three, and six months. Total monthly costs ofingredients of commercial and home-preparedreplacement milks were compared with eachother, and considered in the context of the averagemonthly income of domestic or shop workers.The time needed to prepare one feed of replacementmilk was simulated by local HIV and infanttraining course participants for a rural homestead,without electricity, gas or water but close to astream and shrubs (1-2 minutes walk away).When mixed with water, sugar and eachmicronutrient supplement, PM and FM providedless than half (50%) of the required amounts ofvitamins E and C, folic acid, iodine, and seleniumand less than 75% of zinc and pantothenic acid.PM and FM made with UNICEF micronutrientsachets provided 30% of the required intake forniacin. FM prepared with any micronutrientsupplement provided no more than 32% vitaminD. All PMs provided more than adequateamounts of vitamin D. Compared with thecommercial formula, PM and FM provided8–60% of vitamins A, E, and C, folic acid, manganese,zinc, and iodine. Preparations of PM andFM provided 11% of the minimum recommendedintake of linoleic acid and 67% of the minimumrecommended αlinolenic acid, per 450 ml mixture.It took 21–25 minutes to prepare optimally 120ml of replacement feed from PM or commercialinfant formula and 30–35 minutes for the freshmilk preparation. For an infant requiring 6-8feeds per day, a carer would need 2.5 hours perday to prepare replacement milks, without takinginto account time taken to feed the infant. PM orFM costs approximately 20% of monthly incomeaveraged over the first six months of life andcommercial formula cost approximately 32%.The authors conclude that no home-preparedreplacement milks in South Africa meet all estimatedmicronutrient and essential fatty acidrequirements of infants aged under 6 months.Commercial infant formula is the only replacementmilk that meets all nutritional needs. Theauthors suggest that revision of replacement milkoptions given in WHO/UNAIDS/UNICEF HIVand infant feeding training course materials areneeded. If replacement milks are to provide totalnutrition, preparations should include vegetableoils, such as soybean oil, as a source of linoleicand αlinolenic acids, and additional vitaminsand minerals.1P.C. Papathakis, N.C. Rollins. Are WHO/UNAIDS/UNICEFrecommendedreplacement milks for infants of HIV-infectedmothers appropriate in the South African context? Bulletinof the World Health Organization, March 2004, 82 (3),pp164-1712World Health Organisation. New data on the prevention ofmother- to-child transmission of HIV and their policy implications:conclusions and recommendations. WHO TechnicalConsultation on behalf of the UNFPA/ UNICEF/WHO/UNAIDSInteragency Task Team on Mother-to-Child Transmission ofHIV. Geneva: World Health Organization; 2001. WHO documentWHO/RHR/01.28.3WHO, UNAIDS, UNICEF. HIV and infant feeding counselling:a training course. Geneva: WHO/UNAIDS/UNICEF;2000. WHO document WHO/FCH/ CAH/00.2–4F. LambeinGrass PeaConsumption andNeurolathyrismField of green pea grown in EthiopiaSummary of published paper 1Neurolathyrism is a neurodegenerativeand irreversible spastic paraparesis 2that can be crippling and lead tocomplete dependency. This disordercan be caused by excessive consumption of thedrought resistant pulse, grass pea (Lathyrus sativus)3 . All major famines and chronic food shortagesin Ethiopia from the mid-1970s onwards havebeen accompanied by reports of neurolathyrismepidemics. A recent research study examinedwhether addition of food-aid cereals to grass peafoods reduced the risk of neurolathyrism duringsevere famines.During the epidemic in Ethiopia between 1995and 1999, a neurolathyrism surveillance systemwas set up in Delanta Dawint, one of the mostaffected districts. The research team conducted acorrelational study of the amount of food aid thatreached the population. They also compared, in aretrospective case control study, the types of grasspea preparations and cereal mixtures consumedby all people who developed the condition (identifiedthrough the surveillance system) and bycontrols in Asim Elana, a severely hit village.Information on the proportion and type of cere-Lathyrism patient in Ethiopiaals added to grass-pea foods was obtained fromthe female household member who prepared food.This information was collected for six monthsbefore the first detected case, and until the end ofthe epidemic. The enumerators classified theproportion of food aid cereal to grass pea as atleast one third or less than one third. Spearman’scorrelation coefficient was calculated to assess theassociation between the incidence of neurolathyrismand the amount of cereal food aid distributed.Between September 1995 and December 31st2000, a total of 2035 new cases of the conditionwere detected in Delanta Dawint district (periodprevalence of 12.3 per 1000). There was a significantnegative correlation between new cases per1000 and the per-person amount of food aid distributed.The food aid mainly consisted of wheat andmaize, with limited supplementary rations ofvegetable oil. However, delivery became irregularand delayed and the amount of food aid fell,which coincided with the peak of the epidemic in1997 when 1454 new cases were reported.In the case control study, the consumption ofgrass pea in roasted, boiled and raw, unripe seedF. Lambeinform was associated with an increased risk ofneurolathyrism, whereas no raised risk was notedfor the fermented pancake, unleavened bread andgravy preparations. Cereals are sometimes mixedwith grass pea in the boiled, fermented pancakeand unleavened bread forms. Use of cereal andgrass-pea flour mixtures for these preparationsreduced the risk of paralysis if they containedmore than a third cereal. The addition of wheatand maize to grass-pea preparations couldcompensate for the deficiency of methionine andcysteine, as well as diluting the concentration oftoxin.Susceptibility to neurolathyrism varies amongindividuals and communities, and an increasedrisk of paralysis is associated with the male sexand young age. The study controlled for the effectsof age and sex in the logistic regression analysis,but was unable to control perfectly for socioeconomicvariables and interfering acute-illness episodes.The study authors highlighted how reportswere showing that only grass pea was resisting thecurrent drought in most neurolathyrism proneareas, and that the population is increasinglyrelying on this pulse. The authors concluded thatfood aid should therefore not be restricted to thealmost starving, but should also be urgently sentto people in neurolathyrism prone areas beforethey are forced into exclusive grass-pea consumption.Dietary information, education and communicationon safe grass-pea preparations are alsoneeded.1Getahun, H, Lambien F, Vanhoome M, Van Der Stuyft P(2003). Food-aid cereals to reduce neurolathyrism relatedto grass-pea preparations during famine. The Lancet, vol362, Nov 2003, pp 1808- 1810. Full text available free onlineat: http://www.thelancet.com/journal/vol362/iss9398/2Increased muscle tone leading to weakness of both lowerlimbs3The clinical symptoms of neurolathyrism are identical tothose of 'konzo', a crippling disease caused by overconsumptionof insufficiently treated cassava (Manihotesculenta). See Field Exchange 16, Suspected toxic ingestionoutbreak in central Afghanistan, pp7-9, August 20025

Carbon Dioxide Production in Acutely Ill Malnourished ChildrenSummary of published paper 1ResearchArecent study set out to test the hypothesisthat the rate of carbon dioxideproduction is less in marasmic childrenwith acute infection whencompared to well-nourished children, but greaterwhen compared to uninfected marasmic children.The study took place at Queen ElizabethCentral hospital, in Blantyre, Malawi. Using astable isotope tracer dilution method, rates ofcarbon dioxide production were measured inchildren aged 12-60 months while receivingfeeding. Results from 56 children were compared,28 with marasmus and acute infection, 16with marasmus, and 12 well nourished withacute infection. Those with acute infection hadmalaria, pneumonia or sepsis.Well nourished children with acute infectionproduced more carbon dioxide than marasmicchildren. However, the rate of carbon dioxideproduction in marasmic children with acuteinfection was not greater than in uninfected children.The observed rate of carbon dioxideproduction was greater than that which could beproduced from the dietary intake alone.The study concluded that marasmic childrendo not increase energy expenditure in responseto acute infection, as well nourished children do.The data suggest that children with proteinenergymalnutrition and acute infection expendless energy, largely due to a lower body temperatureand the absence of fever. Although notraising body temperature in response to acuteinfection conserves scarce nutrients, it also determinesthat the immunological benefits of feverare not realised. Fever activates cellular immunity,stimulates the acute phase response, enhancesiron sequestration and is associated withbetter survival. The clearance of the malariaparasite is also accelerated by fever.Dietary energy intake in the 44 marasmic childrenstudied was 350 kj/kg/day (84 kcal/kg/d),the level recommended for malnourished childrenfrom experience in treating malnourishedchildren in Jamaica. The data from the rate ofcarbon dioxide production suggests that tomatch energy expenditure, intake should havebeen increased by 25% to about 440 kj/kg/day(105 kcal/kg.d), when the thermic effect of foodis considered. Current standard recommendationsare that during the initial phase of treatment,severely malnourished children shouldreceive 336-420 kj/kg/day (80-100 kcal/kg/d).Further research is needed to determine whetherincreased dietary energy improves the responseto acute infection, and whether these childrenmight be better served by increasing their dietaryintake.1Manary, M et al (2004). Carbon dioxide production duringacute infection in malnourished Malawian children.European Journal of Clinical Nutrition, vol 58, pp 116-120HIV/AIDS andHumanitarianActionSummary ofpublished report 1The Humanitarian Policy Group (HPG)have just published a report whichexamines the implications of HIV/AIDSfor understanding crisis and the role ofhumanitarian aid. It focuses on the humanitarianresponse in southern Africa in 2002 and 2003.In reviewing the literature, the report sets outhow the disease has clear negative impacts onfood security at household level and that theseimpacts are complex, wide-ranging and genderspecific.In particular, it highlights that:• HIV/AIDS is one of many factors contributingto underlying vulnerability• HIV/AIDS creates particular types of vulnerabilities,through affecting predominantlyprime-age adults, clustering in households, isgender specific, and through interacting withmalnutrition• HIV/AIDS undermines the ways in whichpeople have traditionally coped with famine• HIV/AIDS may increase mortality infamines, as people with AIDS will be lessableto cope with reduced food intake andadditional disease burdens• Issues associated with crisis may add to therisks of transmission of HIV/AIDS andcontribute to the spread of the epidemic.However, it is also argued that original researchis limited, tending to focus on agricultureand there is little information about the scale ofthe impact of HIV/AIDS on food security atnational and regional levels. The report stressesthe importance of understanding how theimpact of HIV/AIDS interacts with otherfactors, such as drought and conflict, to createacute humanitarian crises. All these factors mustbe considered when providing humanitarianrelief in the context of a HIV/AIDS epidemic.The process whereby HIV/AIDS negativelyinfluences outcomes in an emergency has beendescribed as ‘new variant famine’.The report asserts that the argument thatHIV/AIDS significantly contributed to thesouthern Africa crisis came about gradually, butmay have been over-emphasised and that otherequally or more important factors risked beingneglected. There has been concern on the part ofcertain donors and NGOs about how HIV/AIDSis being used to justify a need for continuedhumanitarian aid in some countries, and therehas been scepticism about the underlying empiricalevidence of the links between HIV/AIDSand food insecurity. The level of current datameans that the scale and severity of HIV/AIDS’contribution to both acute and chronic food insecurityis simply unknown.Considering the numbers affected and dyingwith HIV/AIDS in sub-Saharan Africa, theauthors consider HIV/AIDS a humanitarianproblem and a long-term crisis, which requiresboth a humanitarian response to suffering and along-term perspective. They raise a number ofchallenges in responding to this situation:i) Considering HIV/AIDS as a health crisis inits own right, in terms of massive andincreasing levels of mortality and morbidityover a period of decades, requires a longtermresponse encompassing prevention,care,treatment and mitigation.ii) Increasing underlying vulnerability,HIV/AIDS adds to the impact of othershocks, triggering acute crises more easilyand complicating recovery.iii) HIV/AIDS, as one of many contributoryfactors to long-term and chronic foodinsecurity, poverty and destitution, adds tothe existing need for safety nets and longtermwelfare, as part of the overall responseto poverty.The report author acknowledges that theseare not new challenges and there is a danger of‘AIDS exceptionalism’, privileging AIDS overother diseases in health systems or focusingunduly on the impact of AIDS in food securityprogrammes. It is further argued that the overallresponse to HIV/AIDS needs to take place overdecades, and requires a rethinking of relief1A transcript of the meeting and the published reportHIV/AIDS and humanitarian action. Paul Harvey,Humanitarian Policy Group, HPG Report 16, April 2004 areavailable online at http://www.odi.org.uk/hpgmodalities, development modalities and of thelinks and interaction between humanitarian aidand development actors. The report finds arange of practical questions and challengesaround programming of humanitarian aid in thecontext of an HIV/AIDS epidemic (see box).Programming challenges in the contextof HIV/AIDS• Incorporate analysis of HIV/AIDS andlivelihoods impact into early warningsystems and assessments• Emerging types of vulnerability due toHIV/AIDS should be considered inassessment (e.g. widows, elderly,orphans) and targeting (e.g. urbanand peri-urban areas)• Targeting and the delivery of aid mustbe sensitive to the possibility of AIDSrelatedstigma and discrimination• The HIV/AIDS epidemic reinforces theexisting need for humanitarianprogrammes to be gender-sensitive• Emergency interventions must aim toensure that they do not increasepeoples susceptibility to infection withHIV/AIDS• Food aid in the context of HIV/AIDSshould review ration sizes and types offood, and assess delivery and distributionmechanisms in the light ofHIV/AIDS related vulnerabilities, suchas illness, reduced labour and increasedcaring burdens• Labour intensive public works programmesshould consider the needs oflabour constrained households, theelderly and the chronically ill• HIV/AIDS reinforces the need forhealth issues to be considered as partof a humanitarian response• Support to agricultural production(including seed distribution) shouldrecognise adaptations that people aremaking in response to HIV/AIDSThe author reiterates that humanitarian reliefshould remain focused on saving lives and alleviatingsuffering in response to acute crises.However, in the context of a HIV/AIDS epidemic,HIV/AIDS issues need to be ‘mainstreamed’by aid agencies, both internally in terms of trainingand organisational policies, and externallyin terms of how humanitarian aid programmesare structured and delivered.9

ResearchNutritional Status ofHIV+ Pre-SchoolChildren inSouth AfricaSummary of unpublished researchNursing health professional doing clinicalinvestigation at Livningstone HospitalBy Liana Steenkamp, Dr Jill von derMarwitz, and Charlene GiovanelliLiana Steenkamp is a nutritionist currently basedat the HIV/AIDS Centre, University of PortElizabeth and since 2001, has been involved in HIVrelated research and training. She previously spent10 years working in various nutrition sectors of theDepartment of Health.Dr Jill von der Marwitz is Co-ordinator at theHIV/AIDS Centre, Faculty of Health Sciences,University of Port Elizabeth, Port Elizabeth, SouthAfrica.Charlene Giovanelli is a dietitian currently based atLivingstone hospital, Port Elizabeth.The contribution of M Minnaar, Sr Oliphant and DrMAI Khan in carrying out this study is gratefullyacknowledged.Sr Oliphant, South Africa, 2003In paediatric AIDS, nutritional status seems tobe of greater prognostic value than any particularopportunistic infection 1 . A number ofstudies conducted amongst HIV infected childrenin South Africa have found underweightprevalence figures of 25-30%, and figures of 55-60% for stunting 2,3 . These are much higher than theaverage percentages in a national survey conductedon children below 6 years of age, which indicatedthat 10% were underweight and 23% stunted4 .In the Eastern Cape, where the prevalence ofpoverty, TB and HIV is amongst the highest inSouth Africa, a recent study set out to determinethe impact of risk factors on the prevalence ofmalnutrition amongst HIV infected children. Itwas hoped that such information would assistdecision makers in the formulation of optimalnutrition strategies to limit the impact ofHIV/AIDS on the health of children.The study took place at the immunology(outpatient) clinic at Livingstone Hospital, in theEastern Cape, South Africa, between June andAugust 2003. One hundred and two HIV infected 5children, between the ages of 18 and 72 months,were included in the study. The children were ona standard regimen, receiving antibiotic (co-trimoxazole)prophylaxis, treatment of opportunisticinfections, therapeutic dosages of Vitamin A everyfour to six months and a daily multivitaminsupplement. None of the children received antiretroviraltreatment, as such treatment did not formpart of the government’s protocol for treatment atthe time of the study. The study was undertakenwith the informed and written consent from eachsubject’s parent/caretaker.Socio-demographic and nutritional data werecollected by trained, registered dietitians, assistedby a translator when necessary. This includedanthropometric measurements of height andweight, mid upper arm circumference (MUAC)and triceps skinfold thickness.Clinical assessment data, to determine the indicesof morbidity, were collated with the assistanceof registered health care professionals, whichincluded a paediatrician and a registered nurse.FindingsNutritional statusThe children in the sample (mean age 40.7months) had a mean weight-for-age Z-score(WAZ) of –1.96 (SD=1.57), a mean height-for-ageZ-score (HAZ) of – 2.48 (SD=1.6) and a meanweight-for-height Z-score (WHZ) of –0.66(SD=1.53). Although half (50.9%) of the childrenwere underweight (WAZ < -2) and 58.8% werestunted (HAZ < -2), only 21.5% had a WHZ below–2. Eight children (7.8%) were severely malnourished(WHZ

Liana Steenkamp, S AfricaTaking forward research onadult malnutritionSummary of ongoing researchBy Laura Wyness, Researcher,University of Aberdeen, UKPRENResearchSkin lesions in a HIV positive child withmalnutritionSkin lesions in a HIV positive childwithout malnutritionstatus is acceptable. A large group which isvulnerable with low WAZ scores, but relativelygood WHZ scores, may therefore bemissed. The study indicates that in theabsence of comprehensive nutrition assessment,simple markers, like the presence ofchronic diarrhoea and loss of appetite, canbe used to refer these patients for a moredetailed nutritional screening to determinewhether they qualify for nutrition interventionin the form of supplementation.Education forms the cornerstone ofpreventative therapy and it is vitally importantthat parents/caretakers receivecomprehensive and accurate information.Patients seen by the health care providersmust be given health education at antenatalclinics regarding infant feeding and thedangers of early mixed feeding, especially ifinfants are HIV positive. Alternative remediesare currently aggressively beingpromoted in the popular media in preferenceto sound nutrition practices, which iscontributing to a great deal of uncertaintyamongst health care workers about alternativecomplementary therapies. This studyindicated no nutritional benefits are derivedfrom such practices. Nutritional managementof disease complications, in particulardiarrhoea and anorexia need to be addressed,as these variables indicated a significantrelationship with malnutrition andwasting.For further information, contact: LianaSteenkamp, HIV/AIDS Centre, Faculty ofHealth Sciences, University of PortElizabeth, PO Box 1600, Port Elizabeth,6000, South Africa.Email: lianast@iafrica.com1Sun WY, Sangweni B. Rationale for NutritionSupport of Children with HIV/AIDS fromSocioeconomically Disadvantaged Families.Journal of Applied Nutrition. 1997; 49: 88 – 93.2Hussey, G and Eley, B. Nutritional managementof Measles and HIV infection in children,1126 – 1136, Encyclopaedia of Human Nutrition,1998, Academic Press, London.3Eley B, Sive A, Abelse L et al. Growth andmicronutrient disturbances in stable, HIV-infectedchildren in Cape Town. Annals of TropicalPaediatrics 2002; 22: 19 – 23.4South African Vitamin A Consultative Group(SAVACG). Anthropometric, vitamin A, iron andimmunization coverage status in children aged6 – 71 months in South Africa, 1994. SouthAfrican Medical Journal. 1996; 86: 354 – 357.5As confirmed by Enzyme-linkedimmunosorbent assays.Liana Steenkamp, S AfricaAdult malnutrition was initially put on theagenda of the United Nations StandingCommittee on Nutrition (UNSCN)Working Group on Nutrition inEmergencies meeting in April 1999. The current positionof research in this area is that there is no consensuson standards or indices to assess malnutrition inadults in complex emergencies. At the UNSCNmeeting in 2001, research priorities, identifying stepsto improve the assessment of adult malnutrition,were agreed. Since then, the thematic group on adultmalnutrition within the working group has becomingincreasingly active. Work is now being taken forwardthrough a unique academic – NGO (non-governmentalorganisation) partnership, inter-linked by PREN(Partners for Research in Emergency Nutrition), arecently established collaborative research group atthe University of Aberdeen, (figure 1).Working in partnership with NGOs, bilateral andglobal organisations, PREN aims to carry out muchneeded epidemiological and evidence-based practiceresearch, driven by questions from the field, withinthe area of malnutrition in complex emergencies. AMemorandum of Understanding (MoU) has beendeveloped to provide assurance to all members involvedin the project on issues such as data ownership,publication, confidentiality and management of thearrangement.Figure 1: Project Partnership Working.HumanitarianScientific AdvisoryGroup (HSAG)HSAG is a neutral research platform and includes:• UNSCN Nutrition in Emergencies AdultTheme Group.•Emergency Nutrition Network (ENN)• Epicentre• Centre for Disease Control (CDC)NGOs Project Support Group includes membersof the participating NGOsPREN, University of Aberdeen.Questions atPopulationSurvey LevelQuestions atFeedingCentrePopulationLevelPRENNGOs(Project SupportGroup)Table 1AimsThe aims and objectives of the project were definedover several months through discussions betweenPREN and the HSAG. The main aims of the projectare first, to carry out a robust, standardisedSystematic Critical Literature Review (SCLR), toexplore the indicators of nutritional status availableto assess severe adult malnutrition. Secondly, to developtechniques for assessing routine, retrospectivefield data on severe adult malnutrition that has beencollected by different NGOs. This form of data isbeing used, as it will include a broad range ofcontexts and populations. This work will help achievethe third aim to develop a model to aid the assessmentof severe malnutrition in adults during complexemergencies.LiteratureThe SCLR will search for, quality assess andsummarise the evidence identified in the publishedand unpublished literature on methods currentlyused, and methods that could be used, to assess thenutritional status of adults during a complex emergency.The methods of nutritional assessment mayinclude anthropometric and functional indications,clinical signs, and contextual or situation indicators.Initial SurveyIn the initial stages of this project, a survey wasconducted to investigate the type of data collected byNGOs, the problems experienced when collecting thisdata and the format of the data. A total of 27 NGOswere contacted and asked to complete a questionnaire(response rate 60%). The findings from this surveywere used to inform the planning of the project.The current stage of the project is to request routineretrospective field data on severe adult malnutritionfrom NGOs. To facilitate the preparation of thedata for analysis, data from a few NGOs will beinitially requested, with other NGOs being contactedas required. The data initially requested will consistof databases of Therapeutic Feeding Programmes(TFPs) and nutritional surveys (on database andhardcopy, if available). Context variables will besought from Food Security Reports and Head ofMission Reports.Data AnalysisDescriptive statistics of each NGO’s dataset will becarried out and findings reported back to that particularNGO. Analysis of the data will be carried out attwo levels. The specific questions that the data willbe used to address are shown in table 1.Why do you find significant numbers of severely malnourished adults in some crises andnot in other crises?Do context factors give a direction of risk of severe malnutrition in an adult population,taking different levels of anthropometric measures as the dependent variable?Can context factors inform/help interpret and generalise findings from specific surveysdone in specific contexts?On a descriptive basis, analysis will be carried out on two levels, i) Acute and ii) Acute-onchronicemergency situations. Each level will aim to take into account the prevalence ofco-morbidities (e.g. HIV/TB).Are the associations found at the population survey level also seen at the TFP populationlevel, (i.e. what context factors characterise the situation in a TFP with significant numbersof severely malnourished adults)?How are context factors associated with different levels of anthropometric measures?This exciting partnership work hasenabled research on severe adult malnutritionto be actively taken forward.Completion of this project is planned aroundthe end of 2005. The project group willensure regular dissemination between fieldand academic areas.Project Research QuestionsFor further information contact: Laura Wyness,PREN Researcher (l.wyness@abdn.ac.uk) andDr Jane Knight, PREN Project Leader, (PREN@abdn.ac.uk)University of Aberdeen, Department of Public Health,Medical School, Polwarth Building, Foresterhill,Aberdeen AB25 2ZD, Scotland UK.Tel: +44 (0)1224 551883 Fax: +44(0)1224 55092511

Field ArticlePotential of Using QBmix to PreventMicronutrient Deficiencies inEmergenciesMSF/Epicentre, Angola, 2003Household survey on how QBmix is usedBy Evelyn Depoortere, EpicentreEvelyn Depoortere is currently a medical epidemiologistfor Epicentre. Previously she worked on severalMSF missions, including Southern Sudan during the1998 famine.The contributions of Sandra Simons (medical coordinator,Angola), Ann Verwulgen (field coordinator, Kuito), Dr. PaulinaSemedo (Coordinator of the National Nutrition Programme) andSophie Baquet (Nutrition Advisor, MSF-B) are gratefully acknowledged.Thanks to the MSF team of interviewers in Kuito, namely AldinoGilles, Amelia Vita, Azevedo Antunes, Custodio Albano, DanielAlfonso, Isabel Domingas, Manuel da Saudade, Maria do Ceu,Ventura Sozinho, and Veronica da Costa. Also, the assistance ofMs. Rita Kakwarta, Provincial supervisor for Nutrition, in thesupervision of the teams, is appreciated.Box 1A guide to PellagraPellagra is caused by Niacin (Nicotinic acid) deficiency. The condition can befatal and is often associated with other B vitamin deficiencies. Niacin (vitaminB3) is a water-soluble vitamin widely distributed in plant and animalfood, but in very small amounts. Rich sources of niacin include groundnuts,fish, meat and pulses. The body can synthesise niacin from the amino acidtryptophan.The recommended daily requirements range from 13 to 15 mg nicotinic acidequivalent for women and 16 to 19 mg for men. During pregnancy andlactation, an additional 2 and 5 mg nicotinic acid respectively, are required.For infants and children, 6 and 11 mg daily are recommended, respectively.The initial clinical features of pellagra are non-specific and include anorexia,prostration, weight loss, headache and a burning sensation in the mouth.The fully developed syndrome, described by the "three D's", consists ofdermatitis, gastrointestinal symptoms (diarrhoea), and finally mentalimpairment (dementia). The dermatological signs are usually most prominent,symmetrically affecting sun exposed areas like the arms (“pellagragloves”), the cheeks in a butterfly distribution, and the neck and upperchest (“Casal’s necklance”). Eventually the fourth 'D' can occur - death.When a niacin and/or tryptophan - deficient diet is consumed, the lead-timefor developing signs of pellagra is about 2 to 3 months.Populations consuming maize or sorghum and little else are at risk of pellagra.Niacin deficiency is now endemic at very low levels amongst the ruralpoor in Africa where maize is the principal cereal. Examination of ruralhealth centre records may show a few cases - especially during the 'hungryseason'. However, outbreaks of pellagra have only occurred in recent yearsamongst emergency affected populations, including Mozambican refugeesin Malawi, Bhutanese refugees in Nepal, emergency-affected populations inAngola, and refugee returnees to Mozambique.Strategies to prevent outbreaks of pellagra in emergencies include diversifyingthe general ration to include bioavailable sources of niacin, fortificationof foods when maize is a staple food in the ration, allocation of surplus foodsto allow food sale or food exchange for another food commodity, vitamintablet supplementation, and cultivation or production of foods by the affectedpopulation.Adapted from: Pellagra and its prevention and control in major emergencies.WHO/NHD/00.10 Available online at http://www.who.int/nut/documents/pellagra_prevention_control.pdfThis article describes an assessment by MSF of using a micronutrient-richfood product, QBmix, in Angola and outlines possiblestrategies for the future in preventing micronutrient deficiencyoutbreaks in emergency affected populations 1 .Since the 1990s, Médecins Sans Frontières-Belgium (MSF-B)have worked in Kuito, Angola, as well as in several IDP(internally displaced person) camps around Kuito town.One of these camps, Kaluapanda, was established in March2002 and has an estimated population of 4,400 people. During thisperiod, MSF have been involved in a number of large scale emergenciesin Kuito. However over the past year (2003), the situationhas become much more stable, with the displaced populationbeginning to return home. The current MSF programme focuseson treatment of malaria and TB. MSF have also been implementinga pellagra treatment programme, which at the time of thestudy described in this article, was receiving 20-30 new patientsevery week. Most of those in this treatment programme wereliving in the city.Between June 1999 and November 2002, there were fouroutbreaks of pellagra in Kuito town 2 . A total of 3859 cases wererecorded during this period. During the first two outbreaks in1999, the displaced population was the main group affected, withan attack rate of 4.7 per 1000 population. During the latter twooutbreaks (2001 and 2002), it was the resident population whowere most affected, with attack rates of 7.1 (in 2001) and 5.5 (in2002) per 1000 population. In all outbreaks, women aged 15 yearsand older were the largest affected group.Strategies to deal with micronutrient deficiency disease outbreakslike these, include food fortification, dietary diversificationand supplementation (see box 1). However, these strategies allhave inherent difficulties. For example, fortification requires that1Micronutrient supply in emergencies. Logistic feasibility and population acceptabilityof food supplementation with QBmix, Kuito, Angola. Evelyn Depoortere,January 20042See Field Exchange 10, A Pellagra Epidemic in Kuito, Angola, by Sophie Baquetand Michelle van Herp12

Field ArticleBox 2Profile of QBmixTable 1Acceptance of QBmix in pellagra patients and displaced familiesin Kuito, AngolaQBmix is manufactured by Nutriset. Ithas a shelf life of one year after manufacturingdate, but studies are ongoingto improve this. It is recommended tostore the product in a cool, dry place,below 30°C.Use: QBmix is added to the family meal,like a condiment, after cooking only (notto destroy the vitamins). Preparationguidelines state to prepare the meal asusual, add QBmix® to the dish and mixwell.Recommended dose: One 210 g sachetmeets the needs of 10 people for 2weeks. A daily intake is not necessary -21 g per person for a period of 2 weeksis sufficient (1.5 g/day) in 2 or 3 intakesper week. Overdosing is unlikely due tothe very salty taste.One 1.5 g dose of QBmix contains 7 mgiron, 400 mg folic acid, 34 mg selenium,7 mg zinc, 600 mg vitamin A, 1.2 mgvitamin B1, 1.3 mg vitamin B2, 16 mgniacin, 5 mg vitamin B5, 1.3 mg vitaminB6, 2.4 mg vitamin B12, 90 mg vitaminC and 10 mg vitamin D. The equivalentof the height of the screw top gives 1.5 gof QBmix.Adapted from the Nutriset QBmixguidelines for usageall people vulnerable to deficiency consume thefood ‘vehicle’, while the use of supplementtablets or capsules may place a considerablestrain on an already overworked local healthsystem.The recent development of QBmix 3 , a mineraland vitamin rich condiment, offers an alternativeto the above strategies (see box 2). In order toassess the feasibility and acceptability of usingQBmix in an emergency-affected and food aiddependent population, MSF-B and Epicentrecollaborated with the Nutrition Department inthe Ministry of Health to test the product out inAngola. Specific objectives of the study were to:• compare the overall cost involved of usingCorn Soya Blend (CSB) and QBmix 4• describe advantages and difficulties relatedto introduction and use of QBmix• describe the population’s perception andacceptance• make recommendations to MSF regardingthe integration of QBmix in their futureresponse to nutritional emergencies.Frequency of QBmix use• Every day• 2 or 3 times a week• OtherEasy to use QBmixEasy to add right quantityUsed screw top as measureAdded QBmix after cookingQBmix left overLike to useLike the sachet (packing)Easy to doseClottingLike the textureLike the colourLike the smellLike the tasteToo saltyRefused by familyFamily wants moreSomeone felt unwellnPellagra patients(n = 116)Displaced families(n = 232)*% n %10893.122998.77 † 6.12 ** 0.976.031.310.900.0109 †94.0232100.0111 †96.5228 ‡98.711296.622797.811599.122898.38069.05322.8115 †100.0232100.0114 †99.1232100.0111 †96.5232100.032 **27.831.311397.4232100.0116100.0232100.011296.6232100.0116100.0232100.054.300.010 †8.741.711094.8229 **99.6* The one family who did not use the QBmix is no longer included in the denominator† One missing value, ** two missing values, ‡ three missing valuesTable 2Comparison of CSB and QBmix needs for 1000 persons for 30 daysTotal quantity 1800 kg 3000 kg 45 kgVolumeBuying priceInternational transportNational transport (truck)• MSF truck• Rented truck60g CSB/p/d72 bags 120 bagsQBmix215 sachets738,72 euro 1231.2 euro 361.2 euro3600 euro 6000 euro 90 euro• 28 euro• 223.2 euro100g CSB/p/d• 16.8 euro• 372 euro• 0.42 euro• 5.58 euroSource: MSF-B logistics in Luanda, Feasibility and costs assessment, Kuito, Angola, October 2003Note: Prices originally given in US dollar, were converted to euro at the rate of 1.25 USD for 1 Euro.Study designTwo different groups were sampled for thestudy. The first group consisted of pellagrapatients admitted in the MSF treatmentprogramme, while the second group targetedrecently displaced families dependent on externalfood aid, and therefore at risk of micronutrientdeficiency disease.As the two target populations were different,they were treated as independent samples.Overall, 116 of the 168 pellagra patients who hadreceived QBmix, and a random selection of 233displaced families in Kaluapanda, were interviewed.Acceptability of QBmix was assessed througha questionnaire administered during a populationsurvey and was expressed as the proportionof families that used the product correctly andliked it. A total of 10 interviewers were trained toadminister the questionnaire. Questions addres-sed included confirmation that families receivedQBmix, verification of how it was used, whetherit was accepted by the family, and what was theperceived usefulness of the product.Feasibility was based on estimating themicronutrient needs of 1000 people for 30 daysand the weight, volume and transport costscompared to CSB. Caloric value (which is relevantfor CSB but not QBmix) was not considered.Accept ability and feasibility of usingQBmixBoth groups, in general, reacted positivelyand liked QBmix (see table 1). The large majorityused it correctly, adding it only after cooking,and using the screw top as a measure. Five pellagrapatients (4%) (but no displaced families) saidit tasted too salty, while seven (6%) said it madethem feel unwell or sick. A small proportion ofthe pellagra patients (12.9%, n=15) and displa-ced families (5.2%, n=12) said they wouldnot be prepared to buy it on the market, andvarious reasons were given for this (alsotable 1). Only one family did not use theQBmix at all because they did not like it.All pellagra patients and displaced familiesconsidered QBmix to be good for health.Between 15% (patients) and 27% (displaced)said they did not add salt to a meal withQBmix.Table 2 shows a comparison, in volumeand cost, between CSB and QBmix. In orderto meet micronutrient needs for a food aid3QBmix is a registered trademark and is part of arange of products patented by IRD/Nutriset4The World Food Programme (WFP) policy dictatesthat fortified Corn Soy Blend (CSB) is provided forpopulations completely dependent upon food aid and,therefore, at risk of micronutrient deficiency disease13

Field ArticleMSF/Epicentre, Angola, 2003dependent population, 60 100g/person/day ofCSB are needed compared to 1.5g ofQBmix/person/day. Thus for the equivalentmicronutrient supply for 1000 people for 30days, 40-66 times the weight of CSB is neededcompared to QBmix. CSB needs to be transportedby ship, which takes about 3 weeks to arrivein Luanda and 2-3 weeks for custom clearance.For QBmix, transport can be by plane (and thereforequicker) or ship.Storage conditions for CSB andQBmix are similar, both needingdry conditions. CSB comes in plasticbags of 25 kg, while QBmixcomes in aluminium sachets of210g (70 sachets in 1 carton box).QBmix must be stored below 30Centigrade. The shelf life for CSB isbetween 6-18 months but vitamincontent declines over time. Shelflife for QBmix is at least 12 months,during which time the micronutrientcontent remains stable.As required quantities of CSBare much greater, there is a timeelement involved in setting upappropriate distribution systems,whereas sachets of QBmix can begiven out quickly. However, givenits unfamiliarity, it does take timeto explain why and how to useQBmix. For beneficiaries, it isobviously easier to take home afew sachets compared to a 9-15 kgbag.DiscussionNearly all QBmix recipientsfound it easy to use, liked the tasteand smell and would like to havemore of it available in the future.Moreover, they would be ready tobuy the product on the market if itwere available. The majority ofsachets were empty and manypeople spontaneously asked toreceive more. Also, experience has shown thatpeople in sub-saharan African like salty tastes,e.g. QBmix has been used to prepare meals in aprison in the Ivory coast after an outbreak ofberiberi and was well accepted.Compared to CSB, the volume and weightneeded is considerably less for QBmix, leadingto lower international and national transportcosts. However, CSB also provides calories(380kcals per 100g) and people are familiar withit. In contrast, QBmix has few calories andpeople are unfamiliar with it, so resources areMSF/Epicentre, Angola, 2003needed to explain the role and use of theproduct.The results of this study cannot be generalisedor extrapolated to other situations. Forexample, in Afghanistan, mothers in a therapeuticfeeding centre did not like an earlier versionof the product. A standardised questionnaire haslimitations, e.g. it may not capture all the informationavailable from respondents.Furthermore, recipients were in a position ofDistribution of QBmixdependence on food aid so they may have notfelt free to say what they really thought. Theymay have been afraid of being excluded fromfood distribution and felt that if they said whatwas expected, this would ensure they receivedthe product again.In the pellagra group, interviews were notnecessarily conducted with those who preparedthe meal. It was the patient who received theQBmix who was interviewed, so that the informationwas second hand.Strategies for the futureIn Angola, the need for QBmix has becomeless relevant, as fortified maize is scheduled fordistribution and the situation is increasinglystable, with more people having access to adiversified diet. In other situations where MSFintervenes, QBmix and/or other products nowon the market such as Topnutri-Fam , a nutrientconcentrate that comes in the form of powder,may be more appropriate, and clear operationalindications have now been defined. Even thoughthese products are not the solution,they do provide one possible tool toprevent micronutrient deficiencieswhere there are no other sources ofvitamins or minerals.In large-scale emergencies, whenthe general ration programme iserratic, or unbalanced in terms ofmicronutrients, ready-to-use micronutrientsupplementation productsshould systematically be distributedto vulnerable populations. This typeof supplement can also be used inother situations. For example, forhospitalised patients, patients in TBor HIV treatment programmes, or ina prison setting, where the productcould be systematically added toprepared meals 2 or 3 times perweek. Although medical humanitarianagencies may not be directlyinvolved in the distribution of generalfood rations, they do have a rolein ensuring people have an adequatesupply of micronutrients. Activitiesfor such agencies could, therefore,involve lobbying for the use of thisform of micronutrient supplementationwith those agencies resourcingand/or implementing nutritionalinterventions, and social marketingin order to promote and explain theuse of this type of product.When introducing this type of newproduct onto the market, clear andadapted information should be given to thetarget population. For example, specifically forQBmix, key information to give at the time ofdistribution should include the following practicalmessages:• the mix contains vitamins and mineralsessential for health• use one screw top per person• use every day if possible, but 2-3 times perweek is sufficient• salt can be added if desired• the mix should be added to the meal aftercooking.In order that the recipient population fullycomprehend the role and significance of aproduct like QBmix, ‘reference’ persons from thecommunity should be appointed who can bereferred to at all times.In conclusion, new products are now availableon the market, which should facilitate theprevention of micronutrient deficiencies in foodaid-dependent populations in emergencies. Aidagencies should be aware of the existence ofthese products and be ready to use them whenindicated.For further information, contact: EvelynDepoortere, Epicentre, p/a MSF-Belgium,Dupréstraat 94, 1090 Brussels, Belgium. Email :evelyn.depoortere@brussels.msf.orgExplaining the use of QBmix5Produced by DANature Foods/Compact AS, Norway.14

Course onSaving Livesand LivelihoodsThe Feinstein International Famine Centreat Tufts University is presenting a twoweek intensive course for humanitarianprogramme managers focusing on nutrition,public health and community-based animalhealth interventions in complex emergencies. Inaddition, specialists in gender, refugees, humanitarianlaw, rights and principles, and livelihoodswill offer in-depth sessions.Entitled Managing Fundamental Interventionsin Complex Emergencies, A Course For ManagersOf Refugee And Relief Operations, the course isbeing held at the Crowne Plaza in Montreal,Quebec, Canada, August 22 - September 4, 2004News & ViewsCourse fees are $3,800 per person and includeairport transfers to/from hotel, tuition,room, breakfast, lunch, and course materials,but exclude airfare, dinners, laundry, telecommunicationor other personal expenses.Applications can be obtained and submitted to:Saving Lives & Livelihoods Course, FeinsteinInternational Famine Centre, 126 Curtis Street,Medford, MA 02155 USATel: 1-617-627-3423, fax: 1-617-627-3428, email:estrella.alves@tufts.eduhttp://www.famine.tufts.eduWHO/TALC materials on theManagement of SevereMalnutritionGiven the recent debate and rapidly evolving developments in the managementof severe malnutrition, knowledge of current guidelines and trainingmaterials and how to access them is essential for field workers. Alisting of recent materials on the management of severe malnutrition, distributedby WHO and TALC, is being included in this issue along with detailson pricing, language and contact addresses.Item DateTitleType material AuthorsDescriptionDistributorApproximate priceLanguage**1 1999Management ofsevere malnutrition:a manual forphysicians and othersenior healthworkersManual 60 pages.WHOInternationally agreed guidelines on the managementof severe malnutrition in young children (andbriefly in adults and adolescents) for health staffworking at central and district level.NHD/WHOUS$20.70 orSwFr 23.00 (16.10)* Eng,Fre, Span, Port2 2000Management of thechild with a seriousinfection or severemalnutritionWHO/FCH/CAH/00.1Manual with 20-pagechapter ‘SevereMalnutrition’ + appendices.WHO-IMCIIMCI guidelines for senior health staff responsiblefor the care of young children at the first referrallevel in developing countriesCAH/WHOSwFr 15.00 (10.50)*Eng, Fre, RusTALC£3.50 +pp Eng3 2000 Treatment ofSlides + notes forSet of 24 teaching/learning slides for staff in TALCseverelyfacilitator.health centres, hospitals and emergency feeding From £5.50 +pp Engmalnourished children Schofield/Ashworth/Burgess programmes.4 2001 Improving themanagement ofsevere malnutrition5 2002 Training course onthe management ofsevere malnutritionWHO/NHD/02.0462003Caring for severelymalnourishedchildrenTraining modules (300pages) on CD-ROM.Ashworth/Schofield(LSHTM) &Puoane/Sanders (UWC)Training guides and 7modules with supportmaterial including a video.WHOBook 82 pages.Ashworth/BurgessTrainers’ Guide for those running training workshops.It tells how to plan a workshop and containscourse materials, handouts and transparenciesthat participants can use to train their own staff,especially nurses. Clinical setting not required.Instructor and Participant Guides (with exercisesand photos) for 3-day orientation course forinstructors and 6-day training course for seniorhealth workersBased on items 1, 2 and 4 and written for nursesand other health professionals working in resource-poorsettings. Sets out the 10 steps and brieflyexplains the rationale for each one. Includes howto involve mothers in care.LSHTM & UWCFreeTALC (see item 7 below)EngNHD/WHOEng, Span(Fre/Port under prep.)TALC£3.15 +ppEng7 2003 Caring for severelymalnourishedchildrenCD-ROM.TALCContains items 3, 4, 6 and a list of relatedwebsites.TALC£4.50 +pp (includes hardcopy of item 6 – CD-ROM 15not sold separately) Eng8 2003 Guidelines for theinpatient treatmentof severelymalnourished childrenHandbook 48 pages.Ashworth/Khanum/Jackson/SchofieldNHD/WHOPractical 10-step treatment guidelines similar tothe malnutrition section of item 2. Support materialfor item 5.NHD/WHOUS$ 9.00 orSwFr 10.00 (7.00)* EngAbbreviations, Addresses and Websites• CAH - Child and Adolescent Health andDevelopment, WHO, 1211 Geneva 27,Switzerland. Fax: +41 22 791 4857,email: cah@who.int,http://www.who.int/child-adolescenthealth/publications/pubIMCI.htm.• IMCI - Integrated management of childhoodillness• LSHTM - London School of Hygiene andTropical Medicine, Nutrition and PublicHealth Intervention Research Unit, KeppelStreet, London WC1E 7HT, UK.Fax: +44 207 958 8111,email: ann.hill@lshtm.ac.uk,http://www.lshtm.ac.uk/nphiru• NHD - Nutrition for Health andDevelopment, WHO, 1211 Geneva 27,Switzerland. Fax: +41 22 791 4156, email:khanums@who.int,http://www.who.int/nut/publications.htm• pp - post and packing• TALC -Teaching-aids At Low Cost,PO Box 49, St Albans AL1 5TX, UK.Fax: +44 1727 846852, email: info@talcuk.org,http//:www.talcuk.org• UWC - University of Western Cape, Schoolof Public Health, Private Bag X17, Bellville7535 Cape, South Africa.Fax: +27 21 959 2872,email: tpuoane@uwc.ac.za ordsanders@uwc.ac.za,http:// www.soph.uwc.ac.za• WHO - World Health Organisation;Marketing & Dissemination, 1211 Geneva 27,Switzerland. Fax: +41 22 791 4857, email: publications@who.int,http://bookorders.who.intAdditional materials are also available fromseveral other organisations. Relating to infantfeeding in emergencies, Module 1, InfantFeeding in Emergencies for emergency reliefstaff, is available and accessible online or inprint form from ENN. An online version ofModule 2, Infant Feeding in Emergencies, forhealth and nutrition workers, will soon be availablefrom ENN, and will include a section onmanaging severely malnourished infants agedunder 6 months. ENN has also recently publishedan interagency workshop report,Community based approaches to managingsevere malnutrition.For further details, email: office@ennonline.net,or see online at http://www.ennonline.net.15

News & ViewsNutrition inemergenciesworking group,SCN 2004At the 31st Standing Committee onNutrition (SCN) session held recentlyin New York (21-25 March, 2004),progress of the Nutrition inEmergencies Working Group (NEWG) wasreviewed. Chaired by Saskia van der Kam(Médecins Sans Frontières), work was presentedin six subject areas (theme groups). The contributionof the NEWG activities to the realizationof the Millennium Development Goals, thecentral theme of the 31st session, was also consideredat the meeting.Adult malnutritionBradley Woodruff (CDC) and Jane Knight(University of Aberdeen) presented a joint researchinitiative by University of Aberdeen(leading), Partners Research EmergencyNutrition (PREN), the Humanitarian ScientificAdvisory Group (including ENN, CDC,Epicentre) and the NGO Support Group. Thestudy aims to explore and develop a model toincrease the generalisability and robustness ofcurrent indicators of severe adult malnutritionduring complex emergencies, by literaturereview (published and unpublished) and analysisof data including context. Agencies wererequested to forward any related informationincluding reports, raw data, patient cards,surveys and articles.Community based therapeutic care (CTC)Kate Sadler (Valid International) outlined theconsiderable progress made in managing severemalnutrition in a community setting. Workingplans for this group are to consolidate communitytreatment of severe malnutrition, includingan intervention framework, and to develop anapproach to managing severely malnourishedinfants.Food securityRita Bhatia (WFP) outlined WFP’s goals forfood aid in emergencies including plans to integrateeducational support and gender disparityreduction into programming. WFP is also examiningthe efficacy of in country fortification offood aid in order to improve ration quality.Fathia Abdallah (UNHCR) and Andrew Seal(Institute of Child Health, London) outlinedhow UNHCR is investigating micronutrientdeficiency assessment methods, improvingmicronutrient supplementation (specifically theuse of iron cooking pots to increase the ironconsumption), and the development of nutrientanalysis software. In addition, several NGOs areinvestigating ways of fortifying food rations ofinternally displaced populations, refugees andpeople living with HIV/AIDS. Research onpersistent micronutrient malnutrition in longtermAfrican refugees was also presented, whichfound a high prevalence of anaemia and irondeficiency associated with dietary iron insufficiency,and vitamin A deficiency. A key recommendationwas to include simple methods ofmicronutrient surveillance in routine operations.Care practices in emergenciesCare practices in emergencies were highlightedas an underdeveloped sector amongst agenciesworking in emergencies. Cecile Bizouerne(ACF) presented research findings from Sudanand Afghanistan, which explored mental andsocial issues in caring practices.Recommendations included compiling informationon the type of mental and social supportgiven by agencies in nutritional programmes,and using these to inform how we can adaptways to address care practices in emergencies.Marie McGrath (ENN) presented an updateon training materials on infant feeding in emergencies,on behalf of a core inter-agency groupinvolved in their development . Module 1, InfantFeeding in Emergencies, for relief staff, has beenevaluated and is being widely used as resourcematerial and in training. Module 2, whichtargets health and nutrition workers, has a greatertechnical content and is nearing completion,including sections on managing malnourishedinfants under six months, and artificial feedingin emergencies. Plans include targeting andevaluating both modules, and identifyingfunding resources to develop a third trainingmodule, on complementary feeding in emergencies.Gaps in the evidence base for managingsevere malnutrition in infants under six monthswere highlighted 1 .Nutrition and diseaseIn view of the the many emerging issues andinitatives relating to nutrition and HIV/AIDS, itwas decided that a representative of the nutritionin emergencies working group join theNutrition and HIV/AIDS working group, toencourage a working link between the twogroups.Capacity developmentAwritten update on capacity developmentfor nutrition in emergencies was submitted byAnnalies Borrel (Tufts University). This includeda list of available courses, which have a focus onemergency nutrition, and is available onNutritionNet (www.nutritionnet.net), and willbe updated in June 2004. Other initiatives includethe publication of the second edition of theSphere manual, and the ongoing SMART project.Plans for the SCN 2005The NEWG will be chaired by FathiaAbdallah (UNHCR) and Caroline Wilkinson(ACF France). Each of the theme groups whichcomprise the working group are represented bya focal person(s). In 2005, a larger meeting isplanned just before the SCN annual meeting, asthere are many issues to be discussed in depth.For further information or to contribute to theactivities of the working group, contact FathiaAbdallah, email: fabdallah@unhcr.org orCaroline Wilkinson, email: ecw@acf.imaginet.frAfull report on the NEWG meeting can befound at http://www.unsystem.org/scn/1See http://www.ennonline.net for fuller update on infantfeeding in emergencies activities presented at SCNNew MeasuringScoops for F75TherapeuticMilkTo respond to frequent requestsfor measuring scoops for thepreparation of small quantitiesof F-75, Nutriset with theapproval of UNICEF, are includingmeasuring scoops in every carton of F-75.The Nutriset measuring scoops arered with the NUTRISET logo printedon the handle.Preparation of F75 therapeutic milkusing the red NUTRISET scoop:Mix one level measuring scoopful ofNutriset F-75 therapeutic milkpowder in with 20 ml of water.This dilution is only valid for F75.To dilute Resomal or F100 therapeuticmilk using the red scoop, a differentdilution is required. For further informationon dilutions, contact ChristelleLecossais, Product Manager,email: clecossais@nutriset.frECOWAS Nutrition Forum onNutrition and HIVThe West African Health Organization(WAHO), a specialist agency of ECOWAS(Economic Community of West AfricaStates), will hold its 9th Annual ECOWASNutrition Forum, from the 20-24 September, 2004in Cotonou, Benin. The Forum brings togethernutritionists from the 15 member states ofECOWAS, and partners who support the forum.The main objectives of the forum are to:• Develop common, pertinent and appropriatestrategies for preventing nutritional problemsin the ECOWAS sub-region• Promote information and experience exchangeamongst nutrition actors, and the operationalisationand strengthening of nationalnutrition networks in ECOWAS member states.The forum devotes a day to providing a technicalupdate for participants on a pertinent nutritionissue in the region. The technical theme for thisyear’s forum will be “Nutrition and HIV/AIDS”.In spite of considerable efforts made in the managementof persons living with HIV/AIDS(PLWHA), the prevention of mother-to-childtransmission of the HIV virus and access to antiretroviral drugs, the involvement of nutritionistsin the planning and implementation of nationalAIDS control programmes remains relativelyweak.The technical update sessions will:• Provide participants with the most recentscientific and political orientations around thesubject of nutrition and HIV• Facilitate exchange of experience, best practiceand lessons learned among actors andpartners working on the theme• Identify strategies for strengthening thecapacity of nutritionists in the region insupport of national AIDS control programmes,specifically in relation to providing nutritioncare and support for PLWHA and preventingmother-to-child transmission of the disease.For more information, contact: Dr Ismael Thiam.WAHO Nutrition/Child Survival Specialist,WAHO, 01 BP 153 Bobo Dioulasso, Burkina Faso.Tel 226-97-57-75, Fax: 226-97-57-72,E mail: ismaelthiam@hotmail.com orwahooas@fasonet.bfhttp://www.nutritionecowas.org.In Benin, contact: Dr Raima Moudachirou,National Nutrition Focal Point of Benin,E mail: imamoudachirou@hotmail.com16

Equity in Donor AidAllocation to IraqNews & ViewsDaniel Pepper/WFP, 2003Two short articles in a recent issue of the Lancet question theoverall level of aid given and pledged to post-conflict Iraq 1,2 . One author(Singh) highlights the uncritical appraisal of the 33 billion dollars allocatedand pledged at the US-driven, and UN endorsed, Madrid donorconference in October 2003. He argues that many countries in Africa,south America and Asia are beset by lower levels of human development,deadlier pandemics, higher infant mortality rates and greatersocial instability than Iraq. Like Iraq, Rwanda and Sierra Leone are wrackedwith continuing political instability and strife, yet the internationalcommunity failed to react with the swiftness and urgency it has shownit is capable of in the case of Iraq. Singh asks if the threat of terroristopportunism in Iraq is being cited as a reason for the urgency in donoraid to that country, then why is the same reasoning not being used torally massive aid to Somalia, where lawlessness is just as bad and thecountry offers a likely centre for terrorist activities? Furthermore, lifeexpectancy and child mortality in Somalia paint a grimmer picture thanin Iraq. Singh asks whether other countries are being sidelined for strategicreasons, i.e. the mounting casualties incurred in Iraq by troops, andthe draw on workers from developed countries. In July 2003, the totalamount pledged to the Global fund to fight AIDS, TB and Malaria, sinceits creation in January 2002, stood at 4.7 billion dollars. Inexplicably,some countries pledged more to Iraq in 2 days, at the behest of the USA,than they have contributed to the fund since its inception.Singh suggests that rich donor countries do not have infinite fundsand that an inequitable or disproportionate allocation to Iraq now, couldbeget and exacerbate donor shortfalls to other needy nations in the future.Conversely, if future aid to other countries in need will not be affectedby the pledges to Iraq, another disturbing question is raised; whyhave such swiftly pledged and generous funds not been raised for otherneedy countries in the past? Is it because the world’s most powerfulcountry was not doing the soliciting?A piece written in response to this article by staff from the WorldHealth Organisation (WHO) broadly agrees with these points. Theauthors draw attention to the June 2003 Sweden convened meeting, entitled‘Good Humanitarian Donorship’. This meeting endorsed a series ofprinciples of good practice amongst donors. One of these principles wasidentified as the need to ‘allocate humanitarian funding in proportion toneeds and on the basis of needs assessments’. The WHO piece arguesthat donor pledges at the Madrid conference were generous but necessary.However, support for Iraq’s recovery and reconstruction should notbe provided at the expense of other crises. They further conclude that itwould be excellent if the UN system and World Bank were to be in aposition to undertake a cross-sectoral, standardised needs assessment,similar to the one done in Iraq, for every post conflict nation, followedby a high level Madrid-style reconstruction conference. Such an approachwill make good donorship a reality, hasten the repair of vital systemsthat bring lifelines to crisis-affected people, and accelerate progresstowards fulfilment of the millennium development goals.David Gross/WFP, 20031Singh J (2003). Is donor aid allocation to Iraq fair? The Lancet, vol 362, Nov 15th2003, pp 1672-16732Nabarro D, Loretti A and Colombo A (2003). Increased equity in post-conflict reconstruction.The Lancet, vol 362, Nov 15th 2003, pp 1673Photos from top:Loading food aid in IraqDistributing food aid in IraqTraining in Public Health in EmergenciesThe next Public Health in ComplexEmergencies training programme will takeplace between 26th July and 7th August inThailand, and 1-14 November at the Instituteof Public Health, Uganda.This two-week residential course focuseson critical public health issues faced byNGOs working in complex emergencies. Thegoal of the course is to enhance the capacityof humanitarian assistance workers and theirorganisations to respond to the health needsof refugees and internally displaced personsaffected by these emergencies. Participantswill master key competencies in a range ofsectors including epidemiology, communicabledisease, nutrition, reproductive health,protection & security, psychosocial issues,and coordination.For more information, contact Lorna Stevens,email: shortcourse@theirc.org,http://www.theirc.org/phceThe training programme is implemented by WorldEducation, Inc., Columbia University MailmanSchool Of Public Health, International RescueCommittee, American University Of Beirut, AsianDisaster Preparedness Centre, and the Institute OfPublic Health, Makerere University17

News & ViewsUpdate fromFood Security,Livelihoods& HIV/AIDSWorkingGroupAn AIDS orphan collects her food rationAsecond meeting of the FoodSecurity, Livelihoods &HIV/AIDS Working Group(WG), co-chaired by RebeccaBrown (AAH) and Laura Phelps(Oxfam), was held on Tuesday 20thApril 2004. The premise for the WG,which first met in December 2003, wasto fill a perceived gap and provide anongoing forum for exchanging views,skills and knowledge about FoodSecurity and Livelihoods in the contextof HIV and AIDS 1 .The meeting began with a summaryby the co-chairs of the main points ofthe previous meeting, with introductionsincluding Mick Matthews,Secretariat of the UK Consortium onAids and International Development.New agency members to the group,Concern Worldwide, CAFOD and TearFund, gave short presentations on theiragency experiences relating toHIV/AIDS, while SC UK presented ona guide to the many issues needing tobe considered when carrying outassessments or planning interventions.Concern WorldwideDescribing Concern’s approach to18mainstreaming HIV/AIDS, Paul Rees-Thomas outlined a recent internal auditthat found an awareness of HIV/AIDSpolicy within the organisation, progressin terms of personal awareness, e.g.development of a critical illness policy,with further work needed, andongoing, on mainstreaming HIV/AIDSin programmes throughout the Concernnetwork 2 .Other areas considered relevant to theWorking Group included:• A Livelihoods Policy based uponlabour reduction approaches.• Consideration of proxy indicatorsas an aid in targeting vulnerability.• Exploring geographical andregional differences.• Community based approaches tomanaging severe malnutrition, mayoffer a potential entry point tocommunities of people living withHIV/AIDS (PLWHA).• Comparing emergency responsemodels as a platform for medium tolong-term responses.• Looking at local productioninitiatives since emergency feedingactivities are ultimately notsustainable in the longer term.John Cosgrave, Zimbabwe, 2003CAFODAnn Smith described how CAFOD is a partnership-based organisationworking primarily with and through field partners, withregional offices in Harare and Nairobi. There is a four person HIVSupport Section although this is about to be restructured. HIV isnow being mainstreamed into thinking in all aspects of CAFOD’swork. Since 1994/95, CAFOD have consistently worked at incorporatingHIV perspectives into emergency response. However,translating theory into practical implementation has been a slowprocess. There is still a discrepancy between what CAFOD aresaying and what they are doing. Food distribution through homebased care programmes has now reached the point where there isuncertainty as to the way forward while efforts are being made toaccount for HIV in livelihoods programming.Tear FundHIV is Tear Fund’s main strategic priority and is mainstreamedacross the 4 pillars of the agency’s strategy: disaster management,advocacy, community development and pro-poor economicempowerment. Amy Slorach described how this developed froman internal review and pressure from partners for Tear Fund.Demands from partners have included the need for a differenttype of food basket to address the needs of people living withHIV/AIDS, and the need for more sophisticated targeting of foodbaskets linked to household size. Ongoing questions for TearFund include how to integrate HIV/AIDS into food security andother programmes, how to address the issue of sustainability, andhow to address the issues for partner organisations affected byHIV and AIDS. Tear Fund has engaged ACET consultancy to workwith partners and a report will be produced shortly which will beshared with other agencies.Save the Children UKMichael O’Donnell presented some key points from a draftpaper 3 , intended for both managers and technical staff working oneither food security or HIV/AIDS and reproductive health. Itfocuses on the economic impact of AIDS, highlights the linkagesbetween HIV/AIDS and reproductive health, and considers howto translate these linkages into programming.The remainder of the meeting explored whether there is a needfor a working group and, if so, what should be the focus of activity.Key points to emerge were:• Before undertaking external advocacy, the group shouldcarry out some internal research to highlight commonalitiesamongst the agencies involved. Internal summaries oforganisational strengths and weaknesses in terms ofHIV/AIDS programming would be useful.• There is a need for the WG to focus on more specific fields ofactivities within the sector. Exploring a specific issue at eachmeeting was suggested as one way of maintaining focus.• The group could provide a forum to stimulate and engagein discussion about how we understand the problems andaddress solutions. Sharing the Working Group thinkingwith field partners would be valuable to get guidance onwhat the group should be considering.• Potential joint projects between agencies should be explored,and may simply mean defining pieces of work each isdoing and comparing and sharing the resultsThe meeting concluded that there is a need to document thewealth of field experience, especially in high HIV prevalenceareas, and use this to develop an advocacy or programming tool.It was agreed that operating within the UK Consortium structurewould facilitate the working group’s activities. The nextmeeting is scheduled for July 20th, and will likely focus on termsof reference for working within the Consortium, identifying nextsteps and further sharing of agency experiences.For further information, or to contribute ideas on what you thinkthe group should be looking at, contact: Laura Phelps, email:lphelps@oxfam.org.uk or Rebecca Brown, email:r.brown@aahuk.orgProceedings of the working group meetings can be viewed onthe UK Consortium website, http://www.aidsconsortium.org.uk1See Field Exchange 22, HIV/AIDS and Food Security, summary of meeting, p22-232Further suggestions from discussions:A Toolkit, Guide for NGOs managing HIV/AIDS in the workplace is produced bythe UK Consortium and available from the websitehttp://www.aidsconsortium.org.uk.Also Plan International suggested as a reference for mainstreaming HIVthroughout organisations, see http://www.plan-international.org3Presentation by Michael O’Donnell, SC UK based upon draft paper, FoodSecurity, Livelihoods & HIV/AIDS: A Guide to the Linkages, Measurement &Programming Implications. Available from – Michael O’Donnell,email: m.o’donnell@savethechildren.org.uk

News & ViewsFAO/WHOMeeting Warn ofContaminatedInfant FormulaPeople caring for infants at high risk ofinfection should be warned thatpowdered infant formula is not a sterileproduct, a joint Food andAgricultural Organisation (FAO) and WorldHealth Organisation (WHO) meeting hasconcluded, and recently highlighted in a BMJnews piece 1 .Attended by experts, the joint FAO/WHOworkshop on Enterobacter sakazakii and othermicro-organisms in powdered infant formulafound that intrinsic contamination of powderedinfant formula with E sakazakii andSalmonella had caused cases of infection andillness in infants, including severe disease, andcould lead to serious developmental sequelaeand death.Neonates (up to 4 weeks of age), particularlythose born prematurely, with low birthweight,or immunocompromised babies, wereconsidered to be at greatest risk of E sakazakiiinfection. Infants of HIV positive mothers werealso at risk because they may require infantformula and may be more susceptible to infection.E sakazakii has been implicated in outbreakscausing meningitis or enteritis. In the fewoutbreaks reported, the death rate amonginfants who contracted the disease rangedfrom 20% to over 50%, while some survivorsexperienced severe lasting complications. Thebacterium has been detected in a range offoods, but only powdered infant formula hasbeen linked to outbreaks of disease. Its prevalenceis unknown.The expert meeting recommended thatcarers, particularly of high risk infants, shouldbe encouraged to use commercially sterileliquid formula or formula that has undergonean effective decontamination procedure, suchas using boiling water to reconstitute formulaor heating reconstituted formula.The meeting was called in response to arequest made by the Codex Committee onFood Hygiene for scientific advice to be used inthe revision of the Recommended InternationalCode of Hygienic Practice for Foods for Infantsand Children. On the basis of its findings, theworkshop recommended that the code shouldinclude microbiological specification for Esakazakii in powdered infant formula.A summary report of the joint FAO/WHOworkshop on E sakazakii and other microorganismsin powdered infant formula isavailable athttp://www.who.int/foodsafety/micro/meetings/feb2004/en/1News extra. FAO/WHO meeting warns of contaminationof powdered infant formula. BMJ 2004;328:426 (21February). See online athttp://bmj.bmjjournals.com/cgi/content/full/328/7437/426-d?etocDear EditorI was amazed, and greatly disappointed,to read the report of the workshopon Community Based Approaches toManaging Severe Malnutrition, and thepiece on this subject in Field Exchange,March 2004, pp 16-19. Why was there nomention, whatsoever, about any of themicronutrient deficiencies? These almostinvariably accompany severe proteinenergymalnutrition, and therefore constitutea very important part of "severemalnutrition". All those concernedshould surely know that deficiency ofvitamin A, iron, iodine, and zinc, andpossibly others, are responsible in largepart for the very high rates of mortalityand morbidity among young childrenand pregnant and lactating women, andothers, in developing countries. I find itironic that on the very next pages youhave printed an excellent article by DrAndre Briend, which rightly drawsattention to the scandal, and reflects anarea in which I was actively involved inover several decades, in trying to combatthe criminal micronutrient inadequacy ofmany refugee rations. The most startlingfeature of Table 1 in Dr Briend’s article isthe absence of both vitamins A and C.Even to this day, there are constantlyrecurring reports of frank scurvy andDear EditorThe targeting of food aid is widelyassumed to be the most effective andefficient way of ensuring that the limitedfood aid resources available in emergenciesreach those who need them most.Targeting is conducted at multiplelevels - from the selection of countries,down to the selection of individuals whowill receive it and those that won't. Foodaid targeting is a central aspect of thefood aid system, which is itself drivenby multiple objectives: shifting surpluses,keeping world prices high, humanitarian,political contract between countries,etc. This means that the quantityand quality of food aid at any givenemergency is unlikely to be commensuratewith the need experienced by thoseaffected by the emergency. Within thiscontext, humanitarian agencies are oftenrequired to target food aid to the householdsor individuals that need it most.In most emergency situations, it is notpossible to target food aid more specificallythan to geographical areas 1 . Thecontexts where within-community targetingof households is possible are veryfew, unless costly administrative systemsare put in place (which out-weigh thecost savings of targeting). Wide implementationof feeding programmes, oftenin the absence of a general householdration, can ensure that certain individualsreceive food (there are few guaranteesthat these individuals will consumethe food). These programmes rarelycontribute to the longer term viability ofthe household and targeted individualsnon-blinding and blinding xerophthalmia.Yours faithfullyDonald S. McLaren, MD, PhD, FRCPThe ENN would like to point out that thereport referred to in the letter above was theproceedings of a meeting summarised by theENN, and included with issue 21 of FieldExchange. While micronutrient deficiencieswere discussed at the meeting, the main focusof discussions was around the ‘new’ strategyof addressing severe malnutrition throughcommunity based care. It should also be notedthat all diets used in projects described in theDublin report used foods that were highlyfortified with all micronutrients (along theWHO recommendations for F100 rehabilitationdiets). Nonetheless, Dr. McLaren’s letter,and the article by Andre Briend to which herefers, do highlight how we can never becomplacent about micronutrient deficiencies.Sadly, the steady flow of articles about micronutrientdeficiency outbreaks in humanitariancrises received by the ENN and oftenpublished in Field Exchange bear testimonyto this.are likely to experience very low recoveryrates because, in fact, the targetinghas failed and food is shared or replacesthe normal diet. Food for work is rarelypractical in an emergency, because of theadministrative burden it carries.Targeting according to socio-economiccriteria can only feasibly be done usingcommunity managed approaches andonly then, in stable communities, whereneeds vary considerably between householdsand food is sufficient to addresshouseholds' food deficit.In practice, however, these approachesare applied in many emergencysituations. Monitoring and evaluation isvery poor and rarely documented.Inclusion and exclusion errors areundoubtedly huge in many contexts butgenerally ignored. Therefore, the mythof the appropriateness of targeting inemergencies continues.Isn't it time we challenged the perceivedwisdom, made a clear statement ofwhen it may be appropriate to targetfood aid in emergencies and when it islikely to fail, and began to explore otherways of targeting resources at individualsand households who need themmost, e.g. cash, market intervention, etc?Anna TaylorNutrition Advisor, SC UK1See ENN Special Supplement on Targeting FoodAid in Emergencies, Taylor and Seaman, 2004Letters19

Field ArticleVulnerability Mapping inUrban AfghanistanBy Heloise Troc and Erin GrinnellHeloise Troc is a food securityofficer, working for ACF forover 3 years. Her field experiencesinclude acting as afood security co-ordinator inLiberia and Afghanistan.Erin Grinnell is an anthropologistwho has been working forover two years with ACF as afood security officer in Burmaand Afghanistan.Thanks to the entire ACF field team for their contribution and support during this assessment, andto Lisa Ernoul, ACF HQ, for her work on this field article.Figure 1Livelihood Zones in Kabul CityVulnerability LegendThis article describes vulnerability mappingcarried out by ACF in Kabul, and how it hasbeen used to inform programming and tailorinterventions in the field 1 .A. Central Bazaar - - -B. High Services Residential + + +C. Medium Serviced Residential + +F. Serviced Destroyed + +I- -D. Poor Serviced - East -E. Poor Serviced - South -G+C+ +F+ +G. Good Income - West +H. Remote North -I. Peri-urban - -Most vulnerable - - -Least vulnerable + + +B+ + +A- - -H-E-ḎI- -ACF, Based on Automated InformationMapping System (AIMS)The past 23 years of unrest inAfghanistan have had a significantimpact on Kabul, with up to 60% ofhousing destroyed and infrastructuredecimated. Since the fall of the Taliban, therehas been a massive return of refugees toAfghanistan, mainly coming back fromPakistan and Iran, and placing an enormousstrain on municipal resources. In 2002, a totalof 393,582 refugees and internally displacedpeople (IDPs) arrived in Kabul in a matter ofonly ten months. The Central StatisticsOffice’s current estimate of numbers in thecity is 2,799,300 persons.Action Contre la Faim (ACF) has beenworking in Kabul for eight years, implementingnutrition, food security, water and sanitation,and medical programmes. In light ofthe returning population, a vulnerabilityassessment was undertaken by ACF betweenOctober and November 2003. The assessmentaimed to provide an overview of themain determinants of vulnerability 2 , as wellas map vulnerability in the city, and so providequalitative and quantitative informationthat could be used both by ACF and otheragencies, to guide programming. This type ofassessment has rarely been carried out in apost-conflict urban setting.% Malnutrition706050403020Figure 2 Nutritional surveillance in Kabul, 1995 – 2003GlobalchronicSeverechronicGlobalacuteSevereacuteMapping methodVulnerability can be delineated by twotypes: structural vulnerability and inherentvulnerability. Structural vulnerability isdetermined geographically by where onelives, which affects access to, and availabilityof, health services and quality of services,including water and sanitation and housingconditions. Inherent vulnerability is determinedby the socio-economic characteristics ofa family or household, in particular, being awoman of childbearing age, lack of regularincome and renting accommodation.100Nov May Dec Jun Dec Feb Feb Oct Mar Aug Aug Nov95 96 96 97 97 99 00 00 01 02 03 03Time of Survey/Assessment1Kabul Vulnerability Mapping, January 2004, ActionContre la Faim, Afghanistan. Internal report.2In this article, vulnerability refers to the degree ofsusceptibility to a threat, risk or shock as well as theability to cope and recover from these threats, risksor shock without jeopardizing one's future well being.(Ref: Grace, 2003. One Hundred Households inKabul: a study of winter vulnerability, coping strategies,and the impact of cash-for-work programmes onthe lives of the ‘vulnerable.’ Afghanistan Research andEvaluation Unit (AREU), Kabul).20

In addition to reviewing ACF and externalagency reports on Kabul, two levels of mappingwere used to explore types of vulnerability in thecity:i) Mapping livelihood zones. Livelihoodzones are zones that share similar characteristicssuch as sources and level of income, access toservices and infrastructure, as well as the waypopulations respond to food insecurity orshocks, using the resources and opportunitiesavailable to them.ii) Mapping highly vulnerable gozars (neighbourhoods)within the city zones.The livelihood zone mapping was based onpurposive sampling of representative neighbourhoodsin the city. Unlike rural populations,where livelihoods are determined largely byagro-ecological factors and access to markets,urban livelihoods are also shaped by communityassets in a given neighbourhood, i.e. services,infrastructure and housing.Baseline information on the city’s infrastructure,including electricity coverage, water andsanitation, health centres, roads and markets,was aggregated to provide a score with which todelineate relatively homogenous livelihoodzones. Zones comprised of districts (numbered1-16). A series of workshops were then held withrepresentatives from ACF Kabul’s technicaldepartments, in order to define key criteria ofvulnerability for Kabul city. Using these criteria,the team ranked the different neighbourhoods inthe city through qualitative scoring, and delineatedrelatively homogenous zones.FieldworkFieldwork took place over a three weekperiod in October 2003. Depending on the size ofeach livelihood zone, one to two neighbourhoods(gozars) were selected to represent the zone.Once selected, the team then underwent furtherdata collection at the community and householdlevel. On average, 50 household interviews(randomly selected) were conducted in eachzone. A total of six extensive group discussionswere also held with women throughout the city,to gain an understanding of women’s specificvulnerability. At least one male focus groupdiscussion was also conducted in each livelihoodzone.The team identified the most vulnerablegozars, regardless of their zone location, to ensurea qualitative coverage of these areas. Focusgroup and semi-directive interviews wereconducted in these gozars, to develop a profile ofliving conditions and coping strategies.In parallel, discussions were also held withreturnee families in different parts of the city.ACF carried out a systematic screening at Pol ECharki encashment centre 3 and the team metwith several returnee families, to understandtheir living conditions upon arrival in Kabul.Main findingsThe assessment allowed ACF to draw a mapof the livelihood zones (see figure 1).Howeverwithin the livelihood zones, vulnerabilitiesvaried. The inner city area (Zone A-centralBazaar), for instance, had serious house destructionbut enjoyed nearby services and job opportunities.One of the most significant factorsdetermining the level of vulnerability of an areain the city of Kabul was its relation to the urbanplan, laid out in the late 1970s. This city ‘masterplan’, as it is known, determined the quality ofroads, drainage and sewage networks, the levelof water provision and the quality of housing.Under serviced areasEleven gozars stood out within their zones ashighly vulnerable. These neighbourhoods physicallylie outside the boundaries of the city‘master plan’ and are not, therefore, included inany present or future scheme to improve accessto basic services. However, the large number offamilies in these gozars rules out any possibilityof either expelling or relocating inhabitants. Theoriginal urban plan, laid out in 1978, was onlymeant for a population of 2 million people. Thesevulnerable gozars are not really targeted by themunicipal authorities, although exceptions havebeen made for drinking water projects. Currentwater access, and above all, sanitation conditionsin these areas raise serious public healthconcerns and need immediate intervention, e.g.water access, night soil and refuse collection.Within these 11 highly vulnerable gozars, fiveappeared to be specifically at risk due to theirphysical location, i.e. they were hillside communitiesor new settlements in dry riverbeds. Thelack of available land in the city has pushedpeople to settle in more and more precariouslocales. Hundreds of new houses being built illegallycan be seen all over the city, the majorityperched on steep hillsides. These are characterisedby greater exposure to environmentalhazards, poor water and sanitation, with latrinesbeing difficult to empty. They are also at higherrisk in case of earthquake or flooding.Status as a returnee does not seem to determinevulnerability. Indeed, many people returningfrom Pakistan and Iran arrived with assets. Theyalready had social networks in Kabul, they receivedsignificant assistance from international andnon-governmental organisations, and had atleast one able-bodied male in the household.Similarly, those in temporary settlements werefound to be no more vulnerable than othergroups.Field ArticleNutrition and food security analysisIn November 2003, ACF conducted a nutritionand household food security survey. This confirmeda consistent decrease in levels of severemalnutrition (see figure 2), especially over thepreceding year. The survey also highlighted anannual peak in prevalence of malnutritionduring the summer months, which was probablylinked to the increase in diarrhoeal diseases alsoobserved at this time of year (see figure 3). Thechanges in prevalence of diarrhoea occur slightlyearlier than changes seen in prevalence of malnutrition.Food security had improved over the last year.Out of 526 households surveyed, 53% affirmedthey were able to eat more than the same timelast year. Yet food remained a significant concern,ranked third after income and owning one’s ownhouse as the main preoccupation. Food was alsothe primary reason people gave for taking loans.As the bulk of Kabul’s population is almostexclusively dependent on purchase of food, thelack of regular incomes directly affects food securityat a household level. People regularly reducefood quality, i.e. stop buying eggs or meat, whenfaced with insufficient income. In the poorestareas, i.e. central Bazaar (A), low serviced east(D), and in remote north (H) in figure 1, there arefewest vegetable gardens and therefore evenmore limited self- reliance. Indeed these threezones are also the most crowded, with some ofthe lowest average salaries.Household informationResults from the household level data collectionshowed an overwhelming reliance on dailywaged labour throughout the city. One third ofall primary income earners were unskilled,waged labourers. In seven of the nine zones, over30% of the household’s primary income earnersrelied on daily wage labour. Once again, zones A,D and H were more at risk compared to others,with more than 40% of family’s primary incomeearners being dependent on daily wage labour.In the areas with the poorest housing, like centralBazaar, or where there is a lack of services, likepoor serviced east (D), income levels werelowest. Besides the actual amount of earnings,the insecurity linked to daily labouring rendersthe household more vulnerable to unexpectedshocks and decreases coping capacity.Discussions with informants revealed that theirregularity of income was seen as even more ofa problem than the limited daily wage rate.3An encashment centre is a centre set up by UNHCRthrough which the entire returnee population should passin order to be registered for humanitarian assistance.Figure 3Comparison of number of admissions to ACF SFCs and the numberof diarrhoea cases diagnosed in ACF MCH (Aug 2001 – Aug 2003)30002500No. of admissions2000150010005000Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug.01 02MONTHS03Admissions in ACF SFCDiarrhoea cases in ACF MCH21

Field ArticleEvaluationFigure 4Average household income and cases of diarrhoea by zoneUS $120100806040204540353025 % offamilies2015105Tim Hetherington/Network Photographers, 20010A B C D E F G H IZoneNo diarrhoeaAverage weekly income per family per area0A number of coping strategies were identifiedin focus group discussions and householdinterviews. These included:• buying food on credit• borrowing money from relatives• taking loans• sharing accommodation• renting out rooms in own house to others• reducing food diversity• women secretly saving small portions ofhusbands daily allowance• sale of jewellery• sale of assetsThough no conclusions can be drawn, thereis a striking correlation between the averageincome in a given area and the percentage offamilies who do not have children under fivewith diarrhoea (see figure 4).In summary, the main household constraintsidentified were financial insecurity andirregularity of income opportunities for themajority of the population, increasing insecurityin housing due to increased demand,dependence on the purchase of food, and theTable 1At-risk- Dispersed extremely vulnerableneighbourhoodsGozar Gah (District 7)Cement Khana (District 16)Deh Afghanan (District 2)Afshar Selo (District 5)Deh Dana (District 7)Shaharak Khurassan (District 16)Dewan Begi (District 5)22Recommended interventionsrelated to vulnerabilityassessment findingsZone A: District 1- Extremely high global vulnerabilityUrgent need for assistance to Saraji,Bagh Ali Mardan, Reka Khana, ShorBazar, and Kohi ChindawolSanitation: latrine rehabilitationHealth and hygiene educationIncome generation and skills trainingLobbying for housing securityZones D, H and G: Districts 7, 8, 9, 16and north of District 10- Outside master plan, overall lack ofservicesWater provisionSanitationHealth educationIncome generationLobbying for housing securityneed to borrow or take out loans to meet foodneeds.Conclusions and recommendationsAt the time of the assessment, the perceptionof most of those in Kabul was that theircurrent situation was positive with noticeableimprovements, especially in the provision ofservices. ACF’s recommendations arising fromthe assessment translate into geographic andsector specific interventions, first concentratingon the highly vulnerable zones – A, D, Hand G respectively, and at risk vulnerablehouseholds, with comprehensive programmesrelated to health, water and sanitation, incomegeneration and housing capacity (see table 1).The food security analysis component of theassessment highlighted a number of issues.Insecurity of regular income is the one mostsignificant threat to livelihoods in Kabul wherethe majority of the population has to purchasefood with no, or limited, alternative food sources.Unskilled workers (those working in construction,as porters, physical or manual labour)cannot depend on finding work on a regularbasis, especially in winter. Demand for labourfluctuates with the markets and seasons.Subsequently, they are the least able to copewhen shocks occur. Similarly, civil servantsreceive a modest salary and have been knownto go unpaid for months at a time. Efforts topromote regular income among vulnerablegroups should therefore focus on strengtheningexisting coping strategies.The main ACF recommendations for strengtheningfood security are:• Skills training for unskilled workers• Developing sustainable income-generatingactivities: stability of income over timeshould be favoured over one shot cashinputs that are limited in time• Developing sustainable income generatingactivities for women in the home• Identifying constraints to kitchengardening in the most vulnerable gozarsand developing kitchen garden projects inthese gozars• Supporting and encouraging education atall levels, for both boys and girlsEven though the influx of newcomers isreceding, Kabul remains a very attractive cityfor many, with people continuing to arrivefrom rural areas. The very high populationconcentrations justify continued support to thecity, with a specific focus on neighbourhoodsdeprived of sufficient services.For further information, contact: Lisa Ernoul,Head of Food Security Services, ACF Paris.Email: lernoul@actioncontrelafain.orgA 13 year old boy engaged in co-operative farming in DLessonsFrom SC UKEvaluationin DRCBy Anna Taylor,Nutrition Advisor, SC UKSummary ofinternal evaluationSave the Children UK (SC UK) beganimplementing emergency health and nutritioninterventions in eastern DemocraticRepublic of the Congo (DRC) in 1998, withinitial activities in North and South Kivu andNorth Katanga. The current programme ofwork began in June 2002, when the geographicalfocus was confined to a number ofhealth zones in North Kivu. The rationale forthis refocusing was to strengthen managementof the programme and better monitor

g in DRCits impact. An evaluation wascarried out in November 2003 andwas conducted as a participatoryprocess involving SC UK’s healthand nutrition team and governmentpartners.Information was gatheredthrough:• A review of programmedocuments• Key informant interviews• Group discussions with thehealth and nutrition programe• Observation visits anddiscussions with staff andpatients at nine SC UKsupported health/nutrition/cholera facilities, and twoother health centres in a totalof six health zones• A review of registers andpatient records at each of thefeeding centres visited• Group discussions withcommunity health volunteersinvolved in cholera preventionwork in Kyondo and nutritionactivities in Masisi (KibabiTherapeutic and SupplementaryFeeding Centres (TFC/SFC))Key findingsSince June 2002, SC UK’s emergencynutrition and healthprogramme in eastern DRC hasmade considerable progress inimplementation of planned activitiesand delivery of inputs/outputs. Box 1 details the mainprojectactivitiesof the programme.The programme has contributed to enhancedskills and capacity of government and NGO staff- especially in nutrition and cholera prevention,improved access to basic health and nutritionservices, and greater involvement of communities,including children, in health, nutrition andHIV/AIDS interventions. Implementation of theNational Nutrition Protocol is well underway.Routine monitoring reports suggest that therapeuticand supplementary feeding centres haveachieved Sphere Minimum Standards on severalkey indicators.On the other hand, the performance andquality of the work has been constrained by anumber of factors, not least the wide geographicalspread of the programme, engaged in adiverse range of activities and often lacking inclear focus. Difficulties working at a distancethrough poorly motivated government partnersand the absence of a ‘Protocol’ (memorandum ofunderstanding) with Provincial/Zonal HealthBureaux to delineate roles and responsibilitiesbetween SC UK and government have alsohindered progress. Other limitations have includedweak logistics support for the programmeactivities, reported problems with cash flows tocarry out the work, and weaknesses in managementand administration capacity internally andin government structures. Episodes of insecurityhave also hampered activities.The decision to work through existing structures,in partnership with local governmentauthorities, local NGOs, UN agencies and otherinternational agencies was appropriate for thecontext of eastern DRC. A significant strength ofthe programme approach has been the flexibilityto switch to and from an emergency mode, whilefollowing developmental principles - for example,the flexibility to open and close nutritioncentres according to findings of nutritionsurveys and local needs in specific localities. Theproject has adapted to the changing needs andpolicies of government as the national securityand political situation improved. It has alsoseized opportunities for working with andthrough local NGOs.The evaluation highlighted a number of gapsand weaknesses in project design. Key amongstthese were the following:• The large number of activities and widegeographical spread of the programme wereambitious, given SC UK’s understanding ofthe constraints of working through partnersin the context of chronic complexemergencies.• There has been insufficient understanding ofthe impact of training on the knowledge,skills, attitudes and practice of the healthstaff and supervisors in the workplace.• The critical question of the long-termrecurrent costs of maintaining and staffingthe newly constructed nutrition facilities(e.g. Kitatumba, Bulembo) does not appear tohave been considered in the project design.• The activities selected did not adequatelyaddress gender related issues or othernon-economic factors affecting decisionmaking processes at household level.• There has been lack of clarity over whetherthe intention was to try and reach as manycommunities and community basedorganisations (CBOs) as possible, or to usethe experience in a few selected areas as ademonstration for advocacy and influencingpurposes. Consequently, there is a risk ofallowing project staff to initiate activities inmore communities than can reasonably bemanaged.• The project plan to train families and supportstaff for integrated livelihood activities callsfor a very different set of skills andexperience than is usually found in anemergency health and nutrition team.• The appropriateness of the seeds and toolsdistribution component in collaboration withthe Food and Agricultural Organisation(FAO) is questionable. It appears that nostudies were conducted by FAO or others tofind out if seeds and tools were needed, ifpeople had land for cultivation, or indeed, ifseeds and tools were an appropriate meansof reducing the recurrence of malnutrition inthe DRC context.Lessons learnedAmongst the many lessons learnt, the followingwere key to nutrition programming:Arealistic assessment of the capacity, skills,time and resources required to implement aproject in a context such as eastern DRC is essentialat the design stage. A programme with aBox 1Evaluationwide geographical spread and many differentactivities and partners makes heavy demands onmanagement and logistics. Supervision andsupport carried out at a distance is costly, particularlyif it involves travel by air.The investment in time, skills and resources toensure a high quality of service at therapeuticand supplementary feeding centres should notbe under-estimated, particularly where servicesare implemented through local partners.A clear, comprehensive National NutritionProtocol is an important tool for improving themanagement of severe malnutrition. However, asystem needs to be developed so that TFC staffcan provide feedback on the practical lessons,observations and issues from implementation ofthe Protocol. This information could be used toinform further refinement of the Protocol atnational level.Health officials/hospital directors need toappreciate the importance of ensuring that TFCsare staffed by teams of nutritionists and nursestrained and supervised to implement theNational Nutrition Protocol. The practice of rotatingnew nurses to a centre each month is not aneffective strategy. The management of severemalnutrition calls for a combination of nursingand nutrition skills, these skills can only be builtover a period of time working in feeding centres.When planning rehabilitation/constructionwork for health/nutrition facilities, it is importantto consider the full package of requirementsto meet international standards for emergencies.If it is not possible for the project to support allaspects of the package (e.g. water and sanitationfacilities, incinerators), steps should be taken totry and secure support from government,communities or other agencies.The recurrent cost implications of constructingnew buildings should be careful consideredbefore finalising plans. Temporary structures forfeeding centres may be a more cost effectiveoption.Prompt analysis of nutrition survey data isessential for mounting a timely response to highlevels of malnutrition. If there is limited capacitywithin the government system for this work, SCUK could offer technical support.For further information, contact Anna Taylor,Nutrition Advisor, SC UK, email:A.Taylor@scuk.org.ukMain project activities• Construction/rehabilitation of health and nutrition facilities at selected sites• Provision of essential equipment and recurrent supplies (medical/non-medical)• Training and support to health staff on topics such as nutrition, choleraprevention/management, disease surveillance, malaria, rational drugprescribing, vaccination, supervision systems and PRA/PLA techniques• Facilitating vaccination activities in areas where coverage rates are low• Strengthening early warning systems for communicable diseases• Awareness raising on HIV/AIDS among youth/school children• Conducting nutrition surveys/screening for malnutrition, and establishing,supporting and closing feeding centres• Distribution of seeds and tools provided by the Food and AgriculturalOrganisation (FAO) and training local agronomists and community volunteersin improved agricultural techniques• Studies to get a better understanding of the health/nutrition situation andneeds of communities• Pilot activities such as operational research on community financingmechanisms,community nutrition and early warning systems to test outapproaches for scaling up or replication by others• Documentation and dissemination of lessons learned and advocacy23

Agency ProfileNutriset, 2004Loading onto trucks at the Nutriset siteOn a freezing cold Tuesday inFebruary, at nine o’clock in the morning, I wasthe only person to get off the Eurostar service atFrethun, Calais. Met by Beatrice Simkins (incharge of NUTRISET’s international communicationand development), we embarked on a twohour drive through fairly uninspiringNormandy countryside until we arrived at theNUTRISET premises nestled amongst fields ofcows and horses. The distinctive blue and whitebuilding, although out of place in such a ruralsetting, seemed somehow appropriate for anorganisation which is unique in the humanitarianfield.On my arrival, I was introduced to two of thedirectors, Isabelle Sauguet and Michel Lescanne.Michel, who is the founder of NUTRISET, originallyworked in the Research and Developmentsection of a dairy industry. He had long wantedto set up a department specifically for developingfood aid products within the industry but‘met with resistance’. Hence the birth of NUTRI-SET.NUTRISET was established in 1986. It is aprivate company and was the first company toproduce a fortified milk based product for nutritionalrehabilitation of the severely malnourished.The now ubiquitous F100 and F75 therapeuticmilks produced by NUTRISET were developedout of the work of the ACF ScientificCommittee. NUTRISET’s primary aim is toproduce food exclusively for humanitarianemergencies. It is independent of any financialor industrial lobby and food is only provided forNGOs and UN agencies. NUTRISET has aproduction capacity of around 30 metric tons aday, with 35 staff working in production, logistics,development, finances and quality and research.As Isabelle explained, ‘all new staff receivelengthy instructions about the ethics of NUTRI-SET and the fact that it is primarily geared24Address:NUTRISETTel: +33 (0)2 32 93 82 82Fax: +33 (0)2 35 33 14 15Email:nutriset@nutriset.frInternet:www.nutriset.frFormed: 1986Director:Michel LescanneHQ staff: 32Annual budget(2003): Turnover of10 million eurotowards helping children through humanitarianrelief.’NUTRISET has a large research and developmentsection, which devotes itself to improvingand adapting products to emergency conditions.In other words, ‘developing products that canwithstand lengthy transport, harsh climates andcan be used in areas where there is limited orcontaminated water supplies’. Much of thedepartment effort goes into improving productspecification, e.g. increasing the shelf-life ofproducts. Isabelle described how NUTRISETmay occasionally be contacted by agencies whohave not been able to use donated therapeuticmilks due to excessive orders or mis-planning,i.e. predicting demand that never materialised.“This happened recently in Zimbabwe. Agenciesmay be worried about expiry dates and wastage.In these situations, NUTRISET are able to issue achecklist of questions and tests, which if followed,can show whether the product’s shelf-lifecan be extended. If the product is still viableNUTRISET will re-issue a certificate with anextended shelf-life”.After dressing up in sterile clothing (blue andwhite), I was shown around the productionplant. On the day of my visit, the plant was idlewith no batches due for production. This allowedme to see the plant and hear about itsworkings and the rigorous quality controlmeasures that are in place – food science wasnever my strong point.NUTRISET receives support from the Frenchgovernment agency for innovation (ANVAR) todevelop products. However, if successful (and sofar, most products have been), then the loan hasto be repaid. Technical advisors include a nutritionist,biochemist and polymer scientist. Thecompany is involved in many research projectswith NGOs and academics striving to improvefood products for emergencies. A large proportionof profits are re-invested in research, with80% of products developed through research.Products are either standardised or customised.Products 1 can be classified under four headings;i) Foods for treatment of severely malnourished,e.g. therapeutic milks (F100 and F75),Plumpy’nut, ReSoMal, therapeutic CMV(Minerals and Vitamins Complex)ii)Supplementary food for the generalpopulation, e.g. SP 450iii) Micronutrient supplements, e.g. QBmix,zinc tablets, Plumpy’sauceiv) Foods for infants and young children,including a special food for children bornto HIV+ mothersCurrent new products include QBmix, designedto prevent micronutrient deficiencies (especiallyNiacin, B1 and C). This is an aromaticpaste, which is a condiment for meals (see fieldarticle in this issue). NUTRISET are also workingon designing new alternatives for infant milkformula for HIV programmes.1All products are patented by Nutriset

NUTRISET have introduced quality controlstandards that combine food and pharmaceuticalindustry standards. The factory follows theHazard Analysis Control of Critical Pointssystem (HACCP), which is acknowledged goodmanufacturing practice. There have been anumber of successful audits by French governmentand clients. Each product has to receive aNUTRISET certificate of conformity beforedispatch and all products are traceable to batchnumbers and raw materials in case of problems.NUTRISET have five packaging lines and areable to respond to emergencies all year round byworking 1-3 shifts per day. The strategic locationof the factory provides easy access to mainEuropean ports and airports and NUTRISEThave their own customs clearance on site byspecial agreement with French customs. Thisobviously saves time. The company maintainsstocks of fresh finished products, allowing it tomeet any order immediately (around 40 tons ofPlumpy’nut and 100 tons of F100). NUTRISETcan organise transport to final distribution pointsif required, although “agencies like MSF want touse their own logistics systems”. They can set upa 24 hour or day crisis unit if needed and loadproduce within an hour. When there are largeemergencies, extra temporary staff will be recruited(many regularly work for NUTRISET). AsMichel remarked “all staff feel responsible andthere is a ‘hands on deck’ mentality when there isa need to prepare large quantities of foodurgently”. Their turnover of products is of about80% to Africa and 4% to Middle East countries,with the remainder going elsewhere.Isabelle explained that “as NUTRISET is aprivate company with only three directors, thereis a lot of autonomy and little prospect of theideals of the organisation being compromised”.Unlike agencies in the public sector, they are ableto work in areas they want to work in and thefinancial independence of the company meansthey don’t have to look for funds to other shareholderswho may subvert direction.Agency ProfileNUTRISET are constantly developing newproducts to assist in research. For example, thereis currently a study in Malawi on a productbased on the idea that amino-acid deficiency is acause of Kwashiorkor. Another study is ongoingin Malawi on selenium and B vitamin tablets andtheir impact on HIV positive adults. A thirdstudy in Tanzania is comparing the impact of acombined zinc and iron tablet with placebos.Nutriset has developed quick dispersible zinctablets for World health Organisation (WHO)studies on diarrhoea in India, Zanzibar andNepal. This is now leading to a technology transferin Bangladesh for scaling up nation wide. TheWHO wants Nutriset to transfer this technologyto other countries also.Isabelle and Michel both agreed that the twobiggest, and not unrelated, problems thatNUTRISET face are the perception that they arelike some kind of money seeking agribusiness,and the difficulties of getting NGOs to startusing new products. Some donors are reluctantto fund NGOs for trials. MSF seem to be anexception and readily try new products.Having spent a day meeting staff and beingshown around the production plants and researchand development areas, I was dropped offat the nearby medieval city of Rouen to spendthe night before catching a train back to London.My over-riding impression of NUTRISET is thatit is a unique entity, which although run alongcommercial lines, fulfils an essential role in apublic sector arena where risk taking and innovationis unusual, unless born out of the necessityof crisis. Basically, NUTRISET stands or fallson the basis of producing affordable foods thatdo the job. Therein lies their accountability. In aprofession where the knee-jerk perception of theprivate sector is negative, NUTRISET wouldseem to offer a refreshing antidote and an idealmodel for potential private and public sectorpartnership.Nutriset, 2004Production line at the Nutriset factoryMarie McGrath, Sierra Leone, 1998Putting Nutriset packagingto good use in Sierra LeoneNutriset, 2004Packaging at the Nutriset factory25

Field ArticleKACODI, Kenya, 2003Infant Feeding Alternatives forHIV Positive Mothers in KenyaBy Tom Oguta, Abiud Omwega and Jaswant SehmiA mother engaged in pottery as an economicactivity in Obera VillageHOMA BAYDISTRICTTom Oguta is currently a PhD student ofNutrition at the University of Nairobi. He hasworked as a Research Officer at KIRDI (KenyaIndustrial Research & Development Institute) inseveral research programmes, includingHIV/AIDS & Infant Feeding studies, food securityevaluations and micronutrient-fortified foodefficacy studies in Kenyan children.Dr. Abiud Omwega is a Senior Lecturer in theApplied Nutrition Programme, Department ofFood Technology and Nutrition, University ofNairobi. He has worked with many NGOs andCBOs to develop community based nutritionprogrammes, including those for the care andsupport of people affected with HIV/AIDS.Dr. Jaswant Sehmi is a Lecturer in theDepartment of Food Technology & Nutrition atthe University of Nairobi. She has wide experiencein food analysis, nutrition surveys, epidemiologicalstudies (including HIV/AIDS) andmonitoring of clinical & malnutrition cases.Based on Reliefweb Map centreKENYAThe co-authors would like to express sincere thanks to UNICEF-Eastern & Southern Africa Regional Office (ESARO) for financingthis study, and to Homa Bay District Hospital Management for thelogistical support they provided during the study.The HIV pandemic sweeping southern Africa and other parts of sub-Saharan Africa is increasingly being perceived and described as a chronicemergency. Innovative and relatively new types of nutrition/food security/HIVprogramming are emerging to address the growing HIV crisis.These include PMTCT, MTCT plus, OVC and NCP programming andhome based care. Many of these programmes are being rolled out underProtracted Relief and Recovery Operation (PRRO) arrangements inregions recovering from recent emergencies, i.e. southern Africa. However,as these programmes are relatively new, there is enormous headway to bemade in defining optimal design and practice.The article below describes astudy undertaken to help inform PMTCT programming practice. It highlightsthe dilemma for HIV positive mothers between using home preparedformula (in this case using cow’s milk) which is extremely poor in micronutrientcontent, and infant formula which is nutritionally better but maybe impractical for many contexts in terms of cost, supply and sustainability(ed).Mother-to-child Transmission (MTCT)rates for HIV are estimated at 25-45% in the primarily breastfedpopulation of Sub-Saharan Africa.In Kenya, an estimated 300,000 newborn babiesare at risk if HIV infection every year, withbetween 75,000 and 135,000 infants actuallyinfected. Over 75% of these do not even celebratetheir fifth birthday. If a mother is infected withHIV, it may thus be preferable to replace breastmilkto reduce the risk of HIV transmission toher infant.For infected mothers living in poor conditionsin developing countries, however, it is importantto consider very carefully the risks related to notbreastfeeding and whether there are alternativefeeding methods. In a rural community, whereaccess to clean water and sanitation is inadequate,where families are too poor to afford enoughfuel to prepare food and to sterilise feedingbottles or to buy sufficient infant formula, deathsfrom diarrhoea and respiratory infections couldfar outnumber those from HIV. The problem isfurther aggravated by cultural or social stigmasthat a community may attach to substitutefeeding and to HIV/AIDS in general. Hitherto,there has not been good data available on therelative risks and benefits of different feedingoptions.As part of a concerted effort within Kenya toprevent MTCT of HIV, a collaborative programmewas initiated in three pilot sites where HIVpositive pregnant women were identified andprovided with free anti-retroviral (ARV) drugand infant formula feed regimens. In order toinform this study, the Applied NutritionProgramme at the University of Nairobi wasasked to conduct a study on alternative feedingpractices in one of the project sites (Homa-BayDistrict) 1,2 .The purpose of this study was to assess thefeeding alternatives for infants born to HIVpositivemothers in the context of vertical transmissionof HIV. The specific objectives of thestudy were:• To explore the prevailing alternative feedingpractices in the community and among theHIV- positive mothers.• To explore the factors affecting mother’sdecision and choice of the various feedingoptions.ARVMTCTNCPOVCPMTCTList of abbreviationsAnti-retroviralMother To Child TransmissionNeighbourhood Care ProgrammesOrphans and Vulnerable ChildrenPrevention of Mother to ChildTransmission1Other parts of the study, not including this article, havebeen accepted for publication in the East African MedicalJournal.2Case Study: Infant Feeding Alternatives for HIV positivemothers in Homa Bay District, South Western Kenya.OGUTA Tom J, OMWEGA Abiud M and Sehmi Jaswant K.26

Profile of study groupThe study population consisted of an observationgroup of HIV positive mothers with childrenaged 0-2 years old in Homa-Bay DistrictHospital, and selected respondents from therural population as case studies, key informantsor focus discussion members. Homa-Bay district(with a population of about 350,000) is inhabitedby the Luo ethnic group and is one of the Kenyandistricts with the highest HIV prevalence (24%).A number of socio-economic factors are thoughtto have contributed to the rapid spread ofHIV/AIDS in this community:• Widow inheritance/remarriageAs the majority of the population do not knowtheir sero-status, the cultural practice of remarriageis likely to favour the spread ofHIV/AIDS.• Fishing industry and migrant fishermenMost people involved in the fishing industry inthe district either stay away from their familiesor are single. Others are widowed having losttheir spouses, probably from AIDS, and gone toseek a source of livelihood at the beaches.• Concept/ belief of ChiraBelief in the concept of chira (death or cursearising from failure to abide by traditions) isrampant and even when death occurs as a resultof AIDS, some people still believe that it was as aresult of chira and therefore no special precautionsare taken against possible transmission ofHIV by prospective sexual partners.• PolygamyThe cultural ideal that a man should have manywives is still widely held by many people in thedistrict and more than 50% of married womenField Articlelive in polygamous unions. Having multiplepartners is one of the recognised risk factors forspread of HIV/AIDS.Information gatheringUsing qualitative research tools, four focusgroup discussion (FGD) sessions were conducted,with eight members in each session (16women and 16 men). The women participantswere aged 18-45 years while their male counterpartswere between 20-54 years old. Five experiencedand/or elderly women, aged 45-75years, participated in key-informant interviewson areas related to traditional and contemporaryalternative feeding practices.Eleven HIV-positive mothers were observedand monitored. An additional four women participatedas case studies who, for various reasons,Table 1Alternatives to maternal breastfeeding considered for feeding infants of HIV positive mothers in Homa-Bay DistrictOption Characteristics Indications/ Contra-indicationsCommercial infantformula/ formula milkHome prepared formulaUnmodified cow’s milkEarly cessation ofbreastfeeding and heattreatmentof expressedbreastmilkPasteurised breastmilkWet nursingBreastmilk banksBased on modified cow’s milk or soy protein.Closest in nutrition composition to breastmilkMade with fresh animal milks, dried milk powder or withevaporated milk.Additional micronutrients, like iron, zinc and vitaminsA, C and folic acid are requiredUnmodified cow’s milk is not recommended for infantsunder six months of ageEarly cessation of breastfeeding and heat-treatment ofexpressed breastmilk reduces the risk of MTCT. Earlycessation reduces the length of time for which an infantis exposed to HIV through breast milk.The optimum time for early cessation of breastfeeding isnot known.Pasteurisation of expressed breastmilk involves heatingto about 65oC for 30 minutes, or boiling and thencooling in a refrigerator or cold water.Heat-treated expressed breast milk is still nutritionallysuperior to other milks, though heat-treatment reducesthe level of the antibodies.Wet-nursing is practicable in some traditional settingswhere a relative breastfeeds the infantMay be an option in some settings, for example as asource of breastmilk for a short time especially for thesick and LBW newborn.The family has reliable access to sufficient formula, cleanwater, fuel, utensils, skills and time to prepare itaccurately and hygienically.Care is needed to avoid over-concentration orover-dilution.Unmodified cow’s milk could be considered as anexceptional option by the HIV positive mother when thesupply of cow’s milk is reliable and affordable for the sixmonths; the family lacks resources, time and fuel tomodify cow’s milk to make home prepared formula; thefamily will be able to offer extra water and monitordehydration; and commercial infant formula is notavailable/affordable for the family.It is advisable for an HIV positive mother to stop breastfeedingas soon as she is able to prepare and give herinfant adequate and hygienic alternative feed (WHO,1998)*. It could be a good option for those who find itdifficult for social and cultural reasons to avoid breastfeedingcompletely.May be a good option especially for sick and low birthweight (LBW) babies in a hospital settingUNICEF/UNAIDS/WHO recommends that wet-nursing beconsidered only when a potential nurse is informed ofher risk of acquiring HIV from the infant in question;she has been offered HIV counselling & testing; shevoluntarily takes a test and is found to be HIV negative;and when wet-nursing takes place in a family contextwith no payment involved.7It should be certain that donors are screened for HIVand that donated milk is correctly pasteurised.* HIV and Infant Feeding. UNAIDS/WHO/UNICEF. Guidelines for Decision Makers. WHO, Geneva, 1998. Recently updated 2003. Full text available at http://www.who.intTable 2Comparisons and Contrast between AIDS and Chira1.2.3.4.5.6.7.AIDSIs recent, never heard of or hardly known 20 years ago.Mostly caused by sexual contact with an infected person irrespectiveof the social approval of the relationship between the persons.Has no known cure. It is a final clearance to death (fatal).Treatment cannot prevent the resulting death.Has multiple rather than single opportunistic infections (associatedillnesses) including diarrhoea, TB, skin infections, loss of hair, etc.Can be diagnosed in the hospital.Is prevalent among the sexually active youth and reproductive age.There is severe weight loss (wasting).ChiraIs traditional and is as old as the Luo tradition itself.Results from a divergence/deviance from the social norms, eventhough this can be, but not necessarily related to, sexual contact.Is curable, by administration of manyasi – a herbal preparation tocleanse against social/cultural evil done by an individual.Mono-symptomatic, the commonest being gradual weight loss by aseemingly healthy individual, but if many, then comes sequentiallywith diarrhoea only coming in advanced stages.Cannot be scientifically diagnosed in medical laboratory, but thevictim’s health continues deteriorating.Knows no age. Even children can suffer because of their parents’misdeeds.There is severe weight loss (wasting).27

Field Articlewere using different feeding methods - see table1 for infant feeding options considered 3 . Two ofthe four women were HIV positive, of whom oneopted for infant formula and one continuedbreastfeeding. The remaining two were nottested for HIV- the first used cow’s milk to feedher infant, while the second woman was a wetnurse.Culture and knowledge of HIV/AIDS andMTCTThe respondents were asked a number ofquestions about HIV/AIDS, e.g. whether it ispreventable and curable, and possibility of transmissionfrom mother to child. The key-informantsand members of the FGD were also askedfor differences, or similarities, between AIDS andchira (see Table 2)The FGDs found that women do not haveauthority over their sexual lives. The Luo culturalnorms demand that a woman must haveparticular sexual contact with her husband tomark certain events like planting, harvesting,marriage and death rituals. One womancomplained loudly:“How can you stop the spread of HIV/AIDS whensome of our men move all over the villages inheritingwidows even where it was stronglysuspected the husbands died of AIDS? To makeit worse, they do it secretly and the wife only discoverslater when the damage has been caused!”Alternative infant feeding practicesamongst case studiesThe four case studies are summarised in Table3, and illustrate alternative feeding methods aspracticed in the study area. They show examplesof cow’s milk feeding, wet-nursing, formulafeeding and breastfeeding among those withunknown sero-status and confirmed sero-statuscases of HIV.The four case studies looked at socio-economicprofile, feeding choice, health and environmentconditions, and knowledge of MTCT.Education varied from no formal education tosecondary level. Number of births ranged from1 – 11. Feeding choices were influenced by practicalities(e.g. mother died and so was wetnursed, or infant formula was provided free andso was used) and social influences (e.g. HIVpositive mother feared stigmatisation if she didnot breastfeed). The household conditions variedfrom poor, to acceptable. The health and nutritionalstatus of the infants also varied, fromwasted to well nourished. Three of the fourwomen had good knowledge of how HIV maybe transmitted in breastmilk and how feedingchoice can influence transmission. All acceptedcow’s milk and milk powder based feeds, andinfant formula as feeding alternatives. Three ofthe four accepted wet nursing, while only oneaccepted expressed breast milk/heat treatedmilk as an option.Infant feeding practice and beliefsamongst the HIV-positive mothers(Homa-Bay District Hospital)Cow’s milk feeding was practiced bythe majority of the HIV-positive mothersas an alternative to breastfeeding.Knowledge regarding dilution was verypoor, with some mothers over-dilutingand others over-concentrating renderingthe practice inappropriate.Attitudes to surrogate breastfeedingare governed by rigid cultural norms. It isbelieved that a wet-nurse should not havesexual intercourse until the baby is oldenough (about 3 years), otherwise thebaby, if touched (‘soiled’) by such aperson, would die. Consequently, elderlywomen who have reached menopause arepreferred as carers, in the belief that theyare more likely to abstain from sexualintercourse.However, the increase innumbers of orphans due to HIV/AIDS3The PMTCT programme provided free infantformula and ARV only to mothers who wereregistered into the programme and counselled atthe district hospital. However, the case studiesincluded other women who did not have access tofree infant formula supplies.Table 3Summary of case studiesCharacteristicsCasesCase ICase IICase IIICase IVSocio-economicprofile• Aged 210• Married, polygamous family• Primary education• Peasant farmer with annualincome of about Ksh.12,000 (US$ 155)• Given birth 3 times and haslost 2, last born, a boy was3 weeks old• Aged 27• Married, monogamous• Secondary education• Runs a business with annualincome of more than Ksh.60,000 (US$ 770)• Given birth 4 times all alive.Last born 5 years old.Surrogate daughter is 2months• Aged 21• Married, monogamous• Primary education• Runs retail business withannual income of aboutKsh. 15,000 (US$ 195)• Given birth once, first born,a boy aged one month• Aged 34• Married, monogamous• No formal education• House wife with annualfamily income of about Ksh.24,000 (US$ 308)• Given birth 11 times andhas lost 4, last born, a boywas 2 months old.Feeding choice• Cow milk, due to breastinfections• Baby has never beenbreastfed• Milk is donated bygrandmother• Milk is boiled and dilutedwith a pre- boiled water• Dilution ratio is 1:1• Fed on demand using aspoon• Left- over taken by themother• Wet-nursing, mother diedafter delivery• Has to bathe and take acleansing herbal concoctionbefore she can breastfeedthe surrogate daughter• Introduced cow milk aftergrowth faltering• Milk is bought, boiled anddiluted with pre boiledwater• Dilution ratio is 1:1• Baby fed 8 times a dayusing a cup• Left-overs taken by otherchildren• Breastfeeding• Fears not to breastfeed forpossible stigmatisation bycommunity and hostilityfrom the spouse• Breastfeed on demand• Good attachment, butsuckling is not effective• Complements with cow milkdue to growth faltering• Milk is bought, boiled anddiluted with a pre- boiledwater• Dilution ratio is 1:1• Milk is fed 3 times a dayusing a cup• Left- over taken by themother• Infant formula• Opted for on advice fromthe hospital• Formula is donated by thehospital freely• Feed reconstituted with apre- boiled water and fedon demand using a cup• Occasionally boiled water isgiven to the baby• A few times the baby hassuckled from his motherwhile she is asleep• Left- over taken by themotherHealth/environmentalconditionsMTCTKnowledge• Mother non- tested for HIV• Mother is sickling andsuffers breast infections• Delivered under a TBA, birthweight not established• Baby looks healthy, but hasnot received anyimmunization• Latrine available, butmother does not was herhands regularly• Drinking water fetched froma borehole is not treated• Has some knowledge aboutMTCT but does not know itis preventable• Accepts wet-nursing,formula, cow milk and milkpowder as possible feedingalternatives• Surrogate mothernon- tested for HIV• Mother is well and healthy• Baby has episodes ofdiarrhoea and slow growth• From a birth weight of 2.7kg, the baby weighs 4.1 kgafter 6 weeks• Mother maintains highsanitary and hygienicconditions• Has high knowledge aboutMTCT- timing oftransmission and prevention• Accepts wet-nursing,formula, cow milk and milkpowder as possible feedingalternatives• Mother is sero-positive forHIV and counselled• Mother looks healthy andpositive• Baby is withdrawn andwasted• From a birth weight of2.9 kg, the baby’s weight isdown to 2.7 kg after 6weeks• Baby has thrush in themouth• Mother maintains highsanitary and hygienicconditions• Has high knowledge aboutMTCT- timing oftransmission and prevention• Accepts formula, cow milk,milk powder andexpressed/heat treatedbreast milk as possiblefeeding alternatives• Mother is sero-positive forHIV and counselled• Both look healthy andpositive• Baby has normal growth• Mother maintains highsanitary and hygienicconditions• Has high knowledge aboutMTCT- timing oftransmission and prevention• Accepts formula, cow milk,and milk powder as possiblefeeding alternatives28

has led to more younger women wet-nursing.This is accepted, provided the surrogate motherbathes before she touches the baby every timeshe is involved in any sexual intercourse or thewet-nurse and the baby take some manyasi(herbal concoctions for cleansing purposes) toguard/protect against chira affecting the baby. Incertain cases, mothers argue that wet-nursing issafe without these practices provided the baby isclosely related (by blood) to the husband of thesurrogate mother, e.g. wet-nursed by a co-wife. Itis accepted that wet-nursed babies are morelikely to survive than the ones fed on other alternativefoods.The idea of expressing and/or heating breastmilkwas alien and unacceptable to mothers.Ideas about this included, it is not normal to milka human, breastmilk cannot be expressed toproduce enough to satisfy the baby, milkingwould make the breasts painful, and that breastmilkis so volatile that on heating all of it wouldevaporate.The infant formula milks were believed to begood, in that they are hygienic and prepared tosuit the baby’s nutritional needs. However, theyare expensive and are not available in the localmarkets.All of the 11 HIV positive subjects reportedthat if they were to choose, given their serostatus,cow’s milk would be the most viablebreast milk alternative due to its availability andaccessibility. However, eight of the eleven alsobelieved that infant formula would be the bestoption if it could be provided cheaply and madeavailable.Conclusions and recommendationsThe choice of a breastmilk alternative isinfluenced by many factors, among themknowledge of MTCT, wealth, cultural attitudes(stigmatisation) and information attained fromhealth facilities. Whilst wet-nursing may be apracticable infant feeding alternative at familylevel among the non-tested mothers, it was notfor these HIV positive mothers. The use of infantformula as a breastmilk alternative by HIV positivemothers is limited by its cost, but would bethe most suitable if it were provided freely or ata subsidised price. Cow’s milk was the mostpracticable breastmilk alternative in the studyarea. It is culturally acceptable, common/familiarand relatively accessible (produced orpurchased) to many. However, micronutrientsupplements were not available locally, at thedistrict headquarters or through the PMTCT.Field ArticleBased on our findings, we recommend thatmothers attending antenatal care should besensitised regarding vertical transmission ofHIV.Counselling of HIV positive mothers on cow’smilk feeding would be appropriate for thosewho produce the milk or have sufficient moneyto buy it, and PMTCT programmes should endeavourto improve the supply of cow’s milk in thearea. The women should also be guided on howto prepare and modify cow’s milk and micronutrientsupplements should be made available forthem.The UNICEF/UNAIDS/WHO recommendationthat any potential wet-nurse should beconfirmed HIV-negative and well informed ofher risk of getting HIV from the infant is supported.For further information, contact Tom JosephOguta, P.O. Box 30650- 00100, Nairobi, Kenya.Tel: 254-020-535966/ 630149 or 0722392499.Fax: 254-020-555738E-mail: ogutajoseph@yahoo.com ortjoguta@anp-uon.ac.ke7People in AidValid International, 2004Valid International, 2004Concern team in SudanOffa Team 2 in EthiopiaHelp Age International, 2004Course participants at Help AgeInternational Course on Ageing inAfrica, held in Februrary 2004,in Kenya29

Peole in AidSCNBetween 21-25 March, 2004 the 31st session of theStanding Committee on Nutrition (SCN) was held in New York.ENN, SCN, 2004ENN, SCN, 2004Anne Sophie Fournier (AAH USA)and Charlotte Dufour (Groupe URD)ENN, SCN, 2004Emily Levitt (Cornell Uni), Andrea Moreira (SCN) and Lidan Du (Cornell Uni)ENN, SCN, 2004Lane Vanderslice, Thomas Marchione (USAID)and Jeremy Shoham (ENN)ENN, SCN, 2004Moses Sinkala (Zambia) and Lackson Kasonka(University teaching hospital, Zambia)ENN, SCN, 2004Lane Vanderslice, Robin Brinkley (USAID), Cheryl Jackson (USAID)and Alberta Rost (US Dept Agriculture)ENN, SCN, 2004Fathia Abdallah (UNHCR), Marie McGrath (ENN)and Hussein Mursal (SC Uganda)Kiersten Israel-Ballard (Uni of California, Berkeley),Jay Ross (Linkages/AED) and Judy Canahuati (FFP)30

On 20th April, 2004 a meeting was held by the Food Security, Livelihoods& HIV/AIDS Working Group (see this issue of Field Exchange).Peole in AidFrom left to right:Paul Rees Thomas(Concern),Tamsin Walters(CAFOD),Micheal O'Donnell(SC UK)and Paul Harvey(ODI)(in background)J Shoham, 2004From left to right:Nick Mathers(UK AIDS Consortium),Laura Phelps(Oxfam),Rebecca Brown(AAH),Amy Slorach(Tear Fund)Tara Shoham, Isobel Sauguet, Michel Lescanne and Beatrice Simkins,pictured during the ENN vist to the Nutriset site in FranceEditorial teamDeirdre HandyMarie McGrathJeremy ShohamDesignOrna O’Reilly/Big Cheese Design.comWebsiteJon BerkeleyContributors for thisissueGeorge JacobEvelyn DepoortereHeloise TrocErin GrinnellTom OgutaAbiud OmwegaJaswant SehmiLiana SteenkampDr Jill von der MarwitzCharlene GiovanelliLaura WynessAnna TaylorDonald S. McLarenAnn BurgessThanks for thephotographs to:George JacobEvelyn DepoortereLisa ErnoulTom OgutaFernand LambeinOrapin BanjongYasuo TanakaJerermy ShohamValid InternationalNutrisetLiana SteenkampChristelle LecossaisEsrrella AlvesKamela UsmaniField Exchangesupported by:One of the pictures on the cover of the reportof the Dublin meeting, circulated with the lastissue of Field Exchange, was incompletelyacknowledged. The picture of a young infantwith a mother in North Dafur, South Sudan in2001 was taken by Yvonne Grellerty, duringan evaluation with SC UK.Yvonne Grellerty, S. Sudan, 2001The Emergency Nutrition Network (ENN)grew out of a series of interagency meetings focusing on food andnutritional aspects of emergencies. The meetings were hosted byUNHCR and attended by a number of UN agencies, NGOs, donorsand academics. The Network is the result of a shared commitmentto improve knowledge, stimulate learning and provide vital supportand encouragement to food and nutrition workers involved inemergencies. The ENN officially began operations in November1996 and has widespread support from UN agencies, NGOs, anddonor governments. The network aims to improve emergencyfood and nutrition programme effectiveness by:• providing a forum for the exchange of field level experiences• strengthening humanitarian agency institutional memory• keeping field staff up to date with current research and evaluationfindings• helping to identify subjects in the emergency food and nutritionsector which need more researchThe main output of the ENN is a tri-annual newsletter,Field Exchange, which is devoted primarily to publishing field levelarticles and current research and evaluation findings relevant tothe emergency food and nutrition sector.The main target audience of the Newsletter are food and nutritionworkers involved in emergencies and those researching this area.The reporting and exchange of field level experiences is central toENN activities.The TeamJeremy Shoham (Field Exchange technicaleditor) and Marie McGrath (Field Exchangeproduction/assistant editor) are both ENNdirectors.Rupert Gill is the new ENN administrator, basedin Oxford. Rupert has worked previously in thefield with Merlin, ACF and Oxfam in log/admin andwater/sanitation.Dan George is the new ENN finance assistant,working part-time in Oxford.On the coverProcessing local Enset plantsSodo district, Ethiopia.G. Jacob, 2003GENEVA FOUNDATIONto protect health in warThe Emergency Nutrition Network is a company limited by guaranteeand not having a share capital.Registered in England and Wales number: 4889844Registered address: Unit 13, Standingford House, Cave Street,Oxford, OX4 1BA, UKENN Directors: Jeremy Shoham, Marie McGrath31

Emergency Nutrition NetworkUnit 13, Standingford HouseCave Street, Oxford, OX4 1BA, UKTel/fax: +44 (0)1865 722886Email: marie@ennonline.netwww.ennonline.net