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close this bookEmergency Management (United Nations Children's Fund, 390 p.)
close this folderWorkshop Session
View the documentSession 0: Opening Session
View the documentSession 1: Course Introduction*
View the documentSession 2: Perceptions of Emergencies
View the documentSession 3: Simulation*
View the documentSession 4: Principles of Emergency Management
View the documentSession 5: Early Warning & Pre-Disaster Planning
View the documentSession 6: Assessment
View the documentSession 7: Programme Planning
View the documentSession 8: Water & Sanitation
View the documentSession 9: Health
View the documentSession 10: Food and Nutrition
View the documentSession 11: Media Relations
View the documentSession 12: Supply and Logistics
View the documentSession 13: Children in Especially Difficult Circumstances
View the documentSession 14: International Relief System
View the documentSession 15: Funding
View the documentSession 16: Key Operating Procedures
View the documentSession 17: Applications of Emergency Manual and Handbook
View the documentSession 18: Training of Trainers

Session 10: Food and Nutrition

Learning Objectives

- Describe the nutrition needs which arise in emergency situations

- Be familiar with assessment both for food production and nutritional status as distinct from growth monitoring but in relation to baseline data

- Be aware of interrelationships between health/water and nutrition

- Identify UNICEF's role in food and nutrition programmes as complementing those of FAO, WFP and other organizations

Learning Points

1. Information needed and data collection techniques for nutrition in early warning, needs assessment and operations planning.

2. Causes of immediate and short-term, medium-term and long-term problems regarding food and nutrition and suggested solutions.

3. There are the three types of feeding programmes:

- Rehabilitation for the severely undernourished
- Food supplementary - general distribution
- Targeted food supplements to groups at risk

4. Describe UNICEF's role, policies and techniques in addressing how:

- to ensure availability of necessary basic food to all;
- to treat severe malnutrition
- to expedite the re-establishment of local food production, processing and distribution

5. Describe how UNICEF has/should complement FAO and WFP, and WHO efforts (examples).

6. Describe how to ensure appropriate food for "vulnerable groups".

7. Possibilities of specific vitamin deficiencies, especially Vitamin A and Vitamin C, and what to do about them.

8. Critical issues of the politics of food aid/family food production/distribution/ethics/morality of supplementary feeding programmes.

Possible Learning Methods

- Lecture
- Case study: Province of Sucros
- Group Exercise:

Pages 62-64. Describe "possible programme interventions" for UNICEF in the area of food and nutrition. Comment on those interventions in regard to:

a) Whether the suggested interventions are realistic considering UNICEF's resources and present emphasis on CSDR

b) Which of the above interventions are more applicable to your country/region and why

c) From your experience in emergency operations, which of the above interventions were applied successfully. Give examples.

Required Reading

- "Assisting in emergencies", Chapter 8
- David Alnwick "Notes for discussion of nutrition issues", UNICEF Nairobi, May 1986

Supplementary Reading

- Assisting in emergencies", Annex 2-7
- Food Quantity calculation techniques

Speakers' Preparation Aids

- Nutrition in Emergencies: Dr Omowale's notes

***

Reading

TITLE: "Notes for Discussion of Nutrition Issues," DMC/UNHCR EMTP
AUTHOR: David Alnwick

SESSION: FOOD AND NUTRITION

***

EMERGENCY MANAGEMENT WORKSHOP

Nairobi - May 1985

NOTES FOR DISCUSSION OF NUTRITION ISSUES

David Alnwick
UNICEF
Nairobi

OBJECTIVES OF SESSION:

For participants to become aware of issues relating to nutritional needs of refugees, malnutrition. Its causes and ways of alleviating it.

Options for meeting nutritional needs with advantages and disadvantages of each option. Current knowledge and its limitations.

Sources of further information, advice and assistance.

OVERVIEW

Talk:

Elements of nutrition.

Malnutrition - especially child malnutrition and its multiple causes.

Specific problems of refugees liable to make child malnutrition more common.

Methods for assessing and monitoring nutrition.

Options for providing adequate nutrition - short term, longer term.

Treatment of malnutrition.

Difficulties in assessing food requirements - food needs vs other needs.

Methods for assessing adequacy of food provisions. Characteristics of particular foods.

Short term expedients vs longer term development issues in improving nutritional status and maintaining adequate nutrition.

Case study - exercise.

Discussion - Roundup.

These brief notes are intended to supplement and as a background to the material contained in the UNHCR and the UNICEF Emergency Manuals which should be thoroughly studied and kept for reference.

Elements of nutrition

Food is primarily used as a source of energy. All types of food provide energy. If a person is receiving insufficient food, he will be receiving insufficient energy. Such a person will loose weight, become less active, and eventually die (for healthy adult this will take quite a long time).

Children, pregnant and lactating women and old people have special requirements, over and above the requirement to maintain their bodies at a constant desirable weight and to be as active as they would wish.

Children and pregnant women are laying down tissue - this is growth. Extra energy is needed for this growth. If food intake and hence energy intake is insufficient, this growth will not occur or not be adequate. Children who receive insufficient food will not grow adequately - they will be smaller than they should be for their age, babies will be born small, more babies will die before, during or shortly after birth.

Of course, other things are needed by the body apart from just energy. Everybody knows that protein is needed for growth. A diet which does not contain enough protein will not allow a child to grow well. This fact was emphasized much in the past. What was less emphasized was that a diet which does not provide enough energy will not allow a child to grow well either. Quantity is just as important - maybe more important that quality. This is an important point, in the past much emphasis was placed on "balancing the diet" to get the quality right, while people were becoming malnourished because they were simply not getting enough food.

Vitamins and minerals are also needed for good nutrition and health. These are needed not just for "protection" against infection although this is one important function that many vitamins and minerals help to maintain. Vitamins and minerals are also necessary for the body to effectively use the energy and protein in food.

Finally, in this thumb nail sketch of nutritional requirements, we should note that the nutritional value of food not eaten is zero. The food has to be prepared in such a way that people will eat enough of it. A perfectly balanced and adequate diet that tastes bad and which people will not eat will be useless. This is particularly true with young children, where the large bulk of food that a child needs to eat may be a major constraint, and with sick children, who may eat especially tasty or well prepared foods but not other foods.

Foods and nutrients.

In any classical introduction to nutrition, we would generally start by describing what foods contain what nutrients. I will start the other way round. Most foods contain most nutrients, a11 foods contain energy, nearly all foods contain protein - with the exception of refined manufactured foods such as sugar and oil and animal fat. Many foods contain a useful mixture of vitamins and minerals as well.

Contrary to popular opinion, I believe that in most societies, certainly in Africa, the diets that people habitually eat are nearly always mixed diets, consisting perhaps largely of a cereal, some vegetable and occasionally an animal product. People have chosen these diets by tradition and experience, not on the advice of western trained nutritionists, and they have survived and prospered.

Why then are small children malnourished in Africa, even in places where there appears to be plenty of food, no drought or famine, and where people have not been displaced?

Malnutrition - especially child malnutrition and its multiple causes.

The chart contained in "Pacey and Payne" provides a useful summary of the multiple causes of malnutrition.

The child’s food intake depends on many factors, especially his health, the number of times he is fed each day, and the nutrient density of the food given to him. These factors depend in turn on other factors.

Although this chart attempts to look at the causes of malnutrition in general we can see that many of the factors identified will likely be aggravated in a refugee situation

Note especially: Poor living conditions, crowding, poor water, not enough water, mother's time - especially in broken families, situations where mothers have to work or collect water, fuel - as well as the obvious factors of a shortage of food.

Types of malnutrition.

The most common type of malnutrition is caused by an inadequate intake of food. Not enough food leads to not enough energy and not enough protein and not enough vitamins and minerals. If this type of malnutrition is the problem, giving people a little extra protein, or a little food which is particularly rich in some vitamin or other will not be of much use.

An inadequate intake of food results in adults losing weight and children failing to grow at an adequate rate. This type of malnutrition or undernutrition is often called "Protein-energy malnutrition, PEM" or "Energy -Protein malnutrition" to be more trendy.

The most common manifestation or sign of an inadequate food intake in children is a failure to grow adequately. This failure to grow may not be easily detected. A three year old child who has not grown well will look just like a two year old child who has grown well. The majority of undernourished children have no other obvious signs, no red hair or flaky skin or bleeding gums.

If the child's intake of food is particularly drastically reduced, the child will get very thin, bones will show and there will be very little fat under the skin. This condition of extreme thinness is called marasmus. Some undernourished children develop a disease known as Kwashiorkor. The distinguishing feature of this disease is oedema, or swelling, especially of the feet and hands, sometimes legs and face. In the later stages of this disease the child's hair may change color to browny red if black, the skin changes color and flakes off, large burn like sores may appear and the child becomes extremely miserable. The exact causes of Kwashiorkor are unknown, and it is not clear why some children develop Kwashiorkor and some don't although they both may eat identical diets. In the past, Kwashiorkor was regarded as being a sign of a diet that was deficient in protein but adequate in energy. This diagnosis has been challenged. Infections and toxic substances such as aflatoxin and cyanide (In some foods such as cassava) as well as protein and perhaps vitamins may all play a role in the development of this disease but in what exactly way we are not sure. For recent detailed (but fairly technical) review see Golding M. "The consequences of protein deficiency in man and its relationship to the features of Kwashiorkor", in Nutritional Adaptation in Man, Eds Sir Kenneth Blaxter and J.C. Waterlow, Libbey, London, 1985. For a more readable but rather out of date article see Payne, 1974, New Scientist, (attached).

We could imagine diets deficient in any one of a dozen or more specific nutrients and have some idea about the specific diseases associated with them. However, in public health terms in Africa these deficiencies occur most frequently when people are not getting enough of any kind of food, and increasing the overall amount of food people eat may be as important in preventing these deficiencies as taking specific measures to provide foods (or supplements) rich in the particular nutrients identified to be lacking. There are however four deficiencies of specific nutrients which are widespread throughout Africa and which may be exasperated in a refugee situation:

VITAMIN A

A deficiency of this vitamin has been long recognized to result eventually in blindness. Blindness associated with inadequate vitamin A is particularly likely in children following infections such as diarrhea and measles. Recently, evidence from studies in Indonesia indicates that marginal deficiency of vitamin A may result in a markedly increased rate of illness and death in children. Vitamin A may play a very important role in resistance to infection, and ensuring adequate intakes of vitamin A may be a very effective way to reduce young child mortality. (See article from "State of the Worlds Children. 1986, attached)

The early stages of vitamin A are not easy to recognize without some training. They may include night blindness - an inability to see well in low light levels - mothers may report that their children knock themselves in the house at night, and dryness and lack of lustre in the eye. Later stages may include "Bitots spots", small patches of a white frothy substance which sticks to the eye and eventually ulceration and severe and obvious damage to the eye. Children can go blind extremely fast due to vitamin A deficiency they succumb to an infection such as measles.

Deficiency of vitamin A may be associated with low fat diets, fat aids absorption of the vitamin. Rich sources of vitamin A (or its precursor) are dark green leafy vegetables, red and yellow vegetables, and animal products, especially liver.

Vitamin A is stored in the body and supplementation is relatively easy. It is advisable to supplement all new arrivals, especially children. Suggested levels for supplementation are given in the emergency handbook. It is important to note that (unlike the water soluble vitamins - vitamin C for example) too much vitamin A may be dangerous, so steps need to be taken to make sure that children and pregnant women do not get too much vitamin A inadvertently in a supplementation program. This danger only arises with the use of concentrated sources of vitamin A - not with foods rich in the vitamin. Dried milk should be fortified with vitamin A - Check.

ANAEMIA

Anaemia is a low level of hemoglobin, the red pigment in the blood that absorbs oxygen and carries oxygen to the tissues. Anaemia can have multiple dietary causes, and non dietary causes such as parasitic infection with hookworm or malaria.

Anaemia affects especially women of reproductive age and young children and is widespread in tropical Africa.

Most foods contain iron, but iron is poorly absorbed from plant foods and eggs. Meat is the best source of readily absorbed iron. Dark green vegetables, legumes and whole grains are the best plant sources of iron. Vitamin C aids absorption.

Folic acid, another vitamin important for preventing anaemia, especially during pregnancy, is found in fruits, vegetables and liver, prolonged cooking destroys this vitamin. Supplementation for pregnant women would be the best policy.

Iodine, Goitre, Cretinism.

A major public health problem in many parts of Africa is caused by eating food which contains little or no iodine. This lack of iodine in food is caused by a lack of iodine in the soil and this occurs especially in mountainous inland regions.

Refugees may come from an area where goitre is a problem, or they may move into a camp in a goitrous area and start to develop goitre if they stay there for a prolonged period. The disease is very amenable to prevention and treatment by supplementation. Salt can be iodized - probably the best alternative in a camp would be to provide a ration of iodized salt.

Vitamin C deficiency.

This was generally said to be rare in the tropics, but over the last few years scurvy due to a low dietary intake of vitamin C has been shown to be very prevalent in refugee camps in Somalia, Sudan and Ethiopia.

The early signs of scurvy in these camps were not the same as those described in standard textbooks. Inability to walk due to pain in the legs was a common early sign.

Scurvy is easily prevented by a small daily intake of vitamin C. Vitamin C is only present in fresh foods however and the supply of these may be a particular problem in refugee situations. In such cases supplementation by vitamin tablets may be an acceptable alternative, vitamin C rich drink powder might be acceptable to children. Dry food aid commodities contain little or no useful vitamin C. Dried skimmed milk contains a small amount of the vitamin, but much of this is lost during storage, especially if stored at high temperatures. Corn Soy Milk (CSM) is fortified at the factory with vitamin C, but again a substantial amount of this vitamin will be lost if the CSM is stored for long at high temperatures. More of the vitamin will be lost during cooking, so short cooking times will help.

The best method of ensuring a supply of vitamin C would be to make provision for refugees to grow green leafy vegetables, whole grain, maize, sorghum, millet, wheat, or beans when soaked and left moist will sprout. The sprouts or shoots will contain significant amounts of vitamin C although the vitamin was absent in the dry grain and this may be an activity worth promoting.

OPTIONS FOR PROVIDING ADEQUATE NUTRITION - SHORT TERM. LONGER TERM.

My feeling is that we should aim to tackle the problem at the family or household level as an overall aim or objective not dismiss this as an alternative until the possibilities of achieving it have been carefully studied and found to be impossible to carry out. This perhaps seems an obvious or naive sort of statement but I am sincerely worried that refugee situations are sometimes seen as opportunities, particularly perhaps by well intentioned "western" agencies, to take away the responsibility of feeding children from "ignorant uncaring parents", and put all the children together in a big tent and make feeding them the responsibility of the agency.

I believe that while this may be necessary in the short term, in the long run it is a disaster.

I believe we should advocate for all families to be allocated enough food for all of their members, including food suitable for feeding young children. Families will also need to be assisted to obtain the necessary fuel, pots, etc to cook it. This would be the best way of maintaining and improving the nutrition of children.

Feeding children at school might be desirable, and there may well be a need for the therapeutic management of severely malnourished children. We should be very careful, however, before rushing into supplementary feeding programs and consider whether our resources would not or could not be better used equipping the family with the means to look after its own children.

All too often supplementary feeding programs become substitute feeding programs, where the food is given to the child separately rather than together with food the child would otherwise receive at home. The parents regard the responsibility for feeding the child as resting with the feeding center. Often the large feeding certers needed to supplementary feed all the children end up being poorly managed and many children get only small quantities of poor food, watery porridge, with much of the oil, milk and sugar provided going somewhere else.

This is not to say that all supplementary feeding programs are bad or that such programs are never necessary. It has been said that a shortage of food nearly always occurs during the early stages of an emergency situation, and providing carefully supervised rations of prepared food to selected individuals may be a good way of managing a small amount of food in the initial stages of an emergency. Such a programme should not, however, be too protracted, and neither should its success detract from the importance of obtaining sufficient food for the family to cater for itself at as early a stage as possible in the emergency.

Treatment of malnutrition

This is now reasonably well understood. Even severely malnourished children can be reasonably quickly rehabilitiated with a very high success rate.

It is not my intention here to go into details, but the treatment starts with rehydration, starting on dilute food, then proceeding to a diet very high in energy (for this purpose oil and sugar are very important - the food donor must understand that sugar may play a vital role in providing an energy rich diet for undernourished children and is not just for sweetening tea). The key activity is closely supervised frequent feeding. Severely malnourished children may need feeding every two or so hours at first, night and day. Special measures such as a nasogastric tube, may be necessary.

Requires skilled staff, high staff patient ratio. Need for medically qualified staff to treat other illnesses. Therapeutic feeding is not a programme that should be started without detailed consideration as to the costs, management and supervision. Alternatives, such as referring severely malnourished children to a hospital that has the expertise should be considered.

Special foods are rarely necessary however. Nearly all children can be successfully rehabilitated on a high energy milk mix made from the common food aid commodities: dried skimmed milk, oil and sugar. A vitamin and mineral supplement will be needed.

See Protein and "Malnutrition", Anne Ashworth, Editorial, Journal of Tropical Pediatrics, Dec 1985, attached.

Difficulties in assessing food requirements - food needs vs. other needs.

Average requirements vs. difficulties of distribution. If total food supplied equals total requirements are things okay? - almost certainly not. Discussed further in case study. If the average amount of food being distributed is just enough for the average requirement, some people are almost certain to be dangerously short of food, due to inequities in distribution.

Methods for assessing adequacy of food provisions.

Discussion - How much food remains in stock - a few days after and many days after a distribution.

Nutritional status of children is not a very good guide to adequacy. There may be much hunger, with reduction in activity, but little measurable malnutrition. On the other hand, there may be a high prevalence of malnutrition in the presence of adequate quantities of food due to a high prevalence of diarrhea.

Characteristics of particular foods

Blended foods, - expensive - available from only one donor, no local substitutions, may be thought of as magic food.

Dried skimmed milk - milk powder - Distributing in its dry form may be very dangerous. May be seen as a breast milk substitute. Demand vitamin A enriched DSM.

Local exchange and barter possibilities. Sugar and oil good - low bulk - high value.

Short term expedients vs. longer term development issues in improving nutritional status and maintaining adequate nutrition.

In long run, health and nutrition programmes in refugee situations should follow national guidelines.

OPTIONS FOR ENSURING ADEQUATE NUTRITION FOR REFUGEES

Listed in approximate decreasing order of desirability in medium and long term.

A. Providing refugees with land and means to produce food with large food handout to last until first harvest and smaller distributions thereafter.

Advantages to refugees.

Obvious - Maintain dignity, ability to work, to choose what they grow and eat, possibility of producing excess for other needs.

Disadvantages to administration.

Also rather obvious - Any agricultural activity may be seen by both refugees and surrounding people as conferring some rights to the land with all that implies. In initial stages at least this likely to be politically highly undesirable and unacceptable.

Disadvantages to agencies.

Long term programme, not very good for whipping up enthusiasm among donors.

B. General Food Distribution

Distributing to head of each household sufficient food for the whole family for a substantial period of time.

Advantages to the refugees.

Providing quantity of food is adequate and some food suitable for preparation for young children, should ensure adequate nutrition for all family members. Some education may be necessary regarding unfamiliar foods.

Maintains dignity of family and structure of family. Preparation of food, eating etc. may be crucial to this. Responsibility for feeding of child rests with mother/parent - is this not best person to take this responsibility?

Young children can be fed early in the morning and late at night.

Provides some income equivalent for essential non food purposes, since trading of less valued food items inevitable.

Advantages for administration and agencies.

Requires least amount of administration, supervision, organization. (Note this may not be an advantage for an agency wishing to have a high profile - being seen to be very busy helping!)

Possible disadvantages for administration and outside agencies.

Confers a considerable degree of decision making and economic power on families. Trading of food will inevitably occur. Reduces total dependency of families, as they may start to develop alternative options which may be politically undesirable.

Food can be packed up and taken elsewhere, allowing refugees to wander in search of work. Food might even be smuggled to undesirables.

Large quantities of fuel needed, may degrade environment unless provided for.

Any trading of food will inevitably be seen as abuse or evidence of excess by naive donor public and media.

C. DISTRIBUTION OF COOKED MEALS - SUPPLEMENTARY FEEDING

In any cooked meal system, it will probably be decided that special provision will have to be made for the children, hence supplementary feeding programmes will also be set up.

Advantages to refugees.

May ensure that most deprived get access to food. Weak and sick and those without families may receive food.

Disadvantages to refugees.

Crates total dependency, maximum amount of degradation and humiliation. Weakens family structure.

Children can only be fed at fixed times, perhaps not with other members of family.

Having to queue three times a day for food may prevent other useful activities.

Possible advantages to administration

Cooked food cannot easily be carried elsewhere which keeps refugees in their place. Food cannot easily be smuggled and given to undesirables.

Total control and dependency maintained.

Possible advantages to some agencies

Plenty of high profile work to be done by agency staff, especially feeding thin children. Photogenic, high media profile, very good fund raising possibilities.

Plenty of opportunity for meaningless weighing and measuring to be carried out, plenty of scope for feeling that something is being done about the nutrition situation.

***

Speaker’s Aid

TITLE: Nutrition in Emergencies
AUTHOR: Omawale

SESSION: NUTRITION

***

NUTRITION IN EMERGENCIES

I. PRESENTATION

1.1 Learning Needs

(i) Identify the most common types of food and nutrition emergencies.

(ii) Identify the characteristics of those most vulnerable to malnutrition.

(iii) Identify the common indigenous strategies for coping with the threat of a food and nutrition emergency.

(iv) Identify the role of nutrition vis-a-vis other sectors.

(v) Identify information needs and acquisition methods in early warning, needs assessment and operations planning.

(vi) Identify the advantages and disadvantages of the 3 types of feeding programs.

(vii) Identify UNICEF's role vis-a-vis other agencies: FAO, WFP, NGOs.

(viii) Identify UNICEF's role and techniques in addressing how

- to ensure availability of necessary basic food to all;

- to treat those suffering severe malnutrition;

- to expedite the re-establishment and "emergency proofing" of household food procurement (local production, processing, distribution).

(ix) Identify critical issues of the politics of Food Aid and Supplementary Feeding Programs: relief vs development, etc.

(x) Identify opportunities in nutrition emergencies for advocacy, development, etc.

1.2 Key Issues

(i) The nature and causes of vulnerability to food and nutrition emergencies as determinants of appropriate intervention.

(ii) The need to support indigenous strategies for coping with the threat and advent of food and nutrition emergencies.

(iii) The importance of treating infections which commonly accompany malnutrition.

(iv) The importance of identifying the priority dietary needs for most efficient resource use.

(v) The nature of relief can facilitate rapid transition to development or inhibit it.

1.3 Outline

(1) PEM MOST COMMON FORM OF MALNUTRITION IN EMERGENCIES

Sometimes aggravated and complicated with infections and other illnesses like uri, measles, malaria - vitamin A deficiency, vitamin C deficiency, anemia, IDD.

(Annex 7)

(2) VULNERABILITY RELATED TO INADEQUATE HOUSEHOLD FOOD SECURITY: I.E., INADEQUATE FOOD ENTITLEMENT + POOR ACCESS TO HEALTH AND RELATED SERVICES.

(Chapter 8)

(3) SOME COPING STRATEGIES COMPENSATE FOR INSECURITY & POOR ENTITLEMENT:

Multiple Occupations
Diversified Cropping
Stocking (Barns, on the Hoof)
Informal/Traditional Savings
Appropriate Technologies (Including Gathering)

Migration of individuals for Work
Migration of individuals for Food
Migration of Families for Food

(4) LINKS WITH OTHER SECTORS & AGENCIES:

Health

(Who) - Infections

Other Social Sectors

(WFP/FAO) - Employment

Transport, etc.

Water/Fuel/Food/Transport

(Chapter 8)

(5) INFORMATION NEEDS

(Chapter 8, Annex 4) (UNHCR:, Fig. 8-1)

(6) THE 3 TYPES OF FEEDING PROGRAMS:

(Annexes 5 & 6, Annex 3)

(7) FOOD AID, ETHICS AND THE TRANSITION TO DEVELOPMENT

(8) OPPORTUNITIES FOR ADVOCACY AND BEHAVIOURAL CHANGE

Child Feeding Practices
Identifying Causes of Vulnerability

II. CASE STUDY

2.1 BACKGROUND

The emergency situation developed in the Province of Sucros which has a population of 2 million, international attention has been alerted by widely published reports of extensive un employment, starvation, a measles outbreak and many deaths from diarrhea and malnutrition.

The Province has several Km of sea coast and a port. Virtually all of the people are of one ethnic and linguistic group although a few people speaking a different language migrated there in an early period of economic boom.

The infant mortality before the crisis was officially estimated to be 72/1000 and it was also estimated that 17% of children under 6 years old were suffering from moderate or severe (Grades II or III) malnutrition. The hospitals are in the urban areas where health centers also tend to be concentrated. Consequently, the 80% of people living in the rural areas have virtually no access to them. For the same reason immunization coverage is very low in the rural areas and the Province's malnutrition estimate is based on the weighing of only 25% of the children with whom the health system has contact.

The Province's economy is based almost exclusively on the production and export of raw cane sugar. This industry provides almost all of the employment and income in the rural areas and stimulates the commercial and service sectors in the urban areas. The cultivation is on extensive plantations, some having their own sugar producing factories. The production is labor intensive and the work force is predominantly unskilled: cane cutters, weeders, etc. Wages are paid on an output basis (e.g. tons of cane cut) and employment is seasonal, varying according to the needs of the planters. The average cane cutter earns about $tars 9/day in season and less during the off season. Two years ago the international prices of sugar fell sharply and the Province's economy nose dived. Production was cut back and employment became scarce.

Many plantation owners who had taken large bank loans during the boom times felt behind in their repayments and a few even migrated abandoning the plantations. It is believed that many had not used the loans for sugar production as proposed but diverted the money to other uses including banking abroad. This is typical of the excessive corruption which permeates all administration, having been sanctioned and nurtured by the previous government,

The cane workers' families live in small groups of 5-6 households each at different points of the plantation. They do not own the land, but live there by permission of the owner with whom they have a patron-client relationship. The owner, apart from providing the only livelihood opportunity, can be expected to arrange and pay for medical treatment of ill family members or to extend small loans against future earnings. Literacy is low and many parents do not know the ages of their children. There are no social organizations for the workers' families although a trade union exists and has been steadily gaining membership and support since the beginning of the crisis. A few NGOs, with links to the sugar planters, exist as do several international service organizations (Lions, Rotary, etc.).

The staple food is rice in which the country is self sufficient. Rice is no longer produced in the province, having long been displaced by sugar production. Some fishing is done in coastal areas but the Province gets most of its other food - vegetables, legumes, fruit, meat - from other provinces. Domestic water comes from wells sunk by the plantation owners who usually allow workers to draw water pumped from such wells. Trees on the nearby mountains used to supply worker's homes with cooking fuel, but they are now denuded and are being increasingly replaced, but this purpose, by the fibrous waste produced in the sugar mills.

The political situation in the Province has been unstable for years with a growing insurgency problem. Since the start of the crisis unemployed youths have joined the insurgents in increasing numbers and the trade union is believed to have links with them. Both unions and insurgents demand land reform as a priority Government action. This has led to a dialogue between planters and Government, the latter proposing Government which has proposed that as part of a restructuring of the economy 30% of the land should be allocated to other cash crops and 10% should be reserved for food crop production by the workers. Some of the more liberal land owners have expressed a willingness to give small portions of land to workers if the Government would settle their outstanding debts with the banks in return.

The crisis developed over the last two years and manifested itself in increased migration of people in search of livelihood in the urban areas as well as in growing numbers of children appearing in health centers and hospitals with severe malnutrition. Two local NGOs have been operating assistance programs during the last year and advocating for the official recognition of an emergency. The government was at first reluctant to admit the existence of an emergency but now an alarming number of deaths due to measles, diarrhea and malnutrition have been widely reported and international assistance is being requested.

One NGO operates a Supplementary Feeding Program with week-end take home rations and week day on-site feeding of children under 6 years of age. Some plantation owners have donated sites for this feeding and children are brought by anyone who hears about the program and knows of those in need. The weights of children have been taken and nutrition education has been given to the mothers who bring children to the feeding sites. The table below shows the results of an analysis of the weight changes of children who have been in the program during the last 11 months. The NGO is also advocating that sugar workers produce (on plantation land) vegetables for home consumption. Oddly, they report that families participating in the feeding do not seem keen to engage in the vegetable production. However, some sugar workers are already enthusiastically producing and selling vegetables, earning up to $tars 9/day in this way.

Another NGO has been doing both on-site feeding and distribution of take home packages for those unwilling to come dally. Unfortunately, the Government has accused them of allowing some of the donated food to go to the insurgents. A bilateral agency is now also proposing to support the extension of the feeding program to include all school children and has invited the collaboration of UNICEF.

2.2 PROBLEMS/ISSUES

1. What do you think of the idea of the school feeding program? Should UNICEF be involved?

2. What does the data in the table tell about the current SFP? What lessons can we learn about this experience?

3. Is there a role for other sectors in combating the malnutrition problem in this emergency?

4. What information would you like to have in order to assess needs and solicit support? How would you go about acquiring it?

5. How would you deal with questions of confidence in the validity of the malnutrition information, given the fact that many parents do not know children's ages?

6. What strategies would you adopt to deal with the problem of malnutrition in this contest - low levens of community organization, endemic corruption, etc.?

7. What should be done to prevent the recurrence of this type of emergency and what are the relevant issues relating to food aid in this situation?

III. GROUP CONCLUSIONS/DEBRIEFING & SUMMARY (6:15 - 17:00)

IV. ADDITIONAL REFERENCES

JOURNAL

International Journal of Disaster Studies and Practices, International Disaster Institute, London, U.K.

ARTICLES/BOOKS

Jackson, A. Against the Grain: the Dilema of Project Food Aid, Oxford: Oxfam, 1982.

Sen, A. Poverty and Famines: an Essay on Entitlement and Deprivation. Oxford, Clarendon Press, 1981.

Cutler, P. Detecting food emergencies. Lessons from the 1979 Bangladesh Crisis. Food Policy (August: 207-224, 1985)

Handbook for Emergencies. Part One: Field Operations. Geneva, UNHCR, 1982.

DAILY EVALUATION FORM

Day _______________
Session ____________

1. In your view, what were the key points learned in this session?

2. Comment on the application of these within UNICEF and your situation.

3. Suggest any additional critical points that should have been covered.

4. Do you have comments on the suggested reading?

Suggest any additional information sources for sessions of the day.
Texts:
Persons:
Case Studies:
Film:
Other:

5. Comment on the learning methodology (lectures, group work, films) used in the session.