|Emergency Supplementary Feeding Programmes - Good Practice Review 2 (ODI, 1995, 122 p.)|
|6. Typical Scenarios|
It is far more usual for those displaced from rural areas by war, drought or economic hardship to migrate to large urban centres where economic opportunities are perceived as greatest rather than to other rural locations. Such populations may not move into camps but may prefer to establish homes in the urban periphery/shanty towns. This population group is likely to inhabit the lowest economic stratum of urban life and will be the first to be affected by deteriorating urban economic conditions.
The shanty towns are areas which are likely to be poorly served by basic amenities. The nearest health centres may well be some distance from the displaced population. When an emergency SFP is established it is thus likely to be established through existing MCH facilities. It may therefore be prudent to adopt a dry take-home ration system in order to limit the time required for participation. The need for a form of emergency SFP which imposes limited opportunity costs on accompanying carers is strengthened by the likelihood that many of the urban displaced will be involved in some form of economic activity which is essential to their survival (Annex 3).
Conflict and its effects on urban SFPs
In some war situations resident urban populations can be virtually cut off from the outside world and living in a near state of siege, e.g. Kuito in Angola, Juba in Southern Sudan. The town may be accessible to outside relief agencies only by air, which in turn depends upon flight permission from the warring factions. In this type of situation populations can be isolated for many months, so that when relief agencies finally gain access they discover a population in a state of extreme distress. This may have resulted in very high mortality rates amongst the most vulnerable, e.g. young children and the old, with the remaining older population now in nutritional decline and many adults showing varying degrees of malnutrition. Alternatively, dwindling food reserves may result in a situation where adults sacrifice their own consumption to that of their children. Nutritional surveillance data in Sarajevo have shown that most weight loss amongst the population occurred in adults and the elderly and was partly attributable to the preferential feeding of children when food resources were scarce. In such a situation there may be an urgent need to establish emergency therapeutic and supplementary feeding facilities for adults as well as children (Annex 4).
Another scenario is that of civil war, the urban centre being relatively secure (i.e. a long way from the front) but receiving many war-displaced migrants, a large proportion of whom are in transit. The town may also be subject to periodic outbreaks of violence and insecurity as food convoys attempt to reach it or because of the general level of disorder and weaponry amongst the urban population, e.g. Baidoa in Southern Somalia.
One common feature of operating supplementary feeding in this type of situation is that the provision of general rations by the international aid community may be highly problematic. The problem is lack of safe access. Thus, agencies will frequently find themselves operating in the context of an inadequate or completely absent general ration. The consequences of this are that it may be impossible to discharge individuals from the SFP as there is no general ration at home so they would rapidly be re-admitted. The programme will then increased very quickly in size, so that it will need to be streamlined in order to be made manageable. In the initial stages it may not be possible to carry out the majority of normal data collection. For example, weight-for-height measurements may need to be replaced by more rapid screening using MUAC. It may also prove impossible to enrol all severely malnourished children in therapeutic feeding, with the result that many of the less extreme cases may have to be enrolled in the SFP. As indicated previously, this may be an additional argument for operating an on-site SFP so that such cases can be carefully monitored.
In fact, on-site feeding is often felt to be particularly justified in situations of insecurity, as there is a higher risk of looting where dry take-home rations are given. Mothers taking home one- or two-week supplies of supplementary foods would be put at risk. Even in situations of extreme insecurity it is rare for a feeding centre with large numbers of women and children to be attacked. Also, war-displaced populations are frequently without basic cooking utensils as they may have had to leave their homes suddenly. However, these advantages of on-site feeding may have to be weighed against the lesser outreach of such programmes. In areas of insecurity, it may be very difficult and dangerous for mothers/carers to travel regularly to a feeding centre (Annex 3).
This type of urban SFP may also need to accommodate sudden large waves of displaced people, many of whom may be in a very poor nutritional condition. Feeding centres might therefore need to admit large numbers of very serious cases. In the event that this overwhelms resources, eligibility criteria may need to be altered so that only the most severe cases are admitted. Thus, entry criteria for SFPs may need to be changed from 80% weight-for-height to 75% weight-for-height or 13.5 cm to 13 cm MUAC.
As with an urban siege scenario, a situation may arise where, after a long period of poor general ration provision to an area, the population is in a state of extreme stress. This may have resulted in very high mortality rates amongst the most vulnerable groups, e.g. young children and the old, with the remaining older population now in nutritional crisis and many adults showing varying degrees of malnutrition.
Another slight variation on this scenario may arise where the supply of general rations has continuously been interrupted because of insecurity, ambush and looting, while supplementary and therapeutic feeding programmes for children have been allowed to continue partly because the food commodities are at less of a premium and partly because the warring factions accept that such programmes are not legitimate military targets. In such circumstances the need for therapeutic and supplementary feeding for adults may be urgent (Annex 4).
However, as explained in Chapter 2, the difficulty with targeting adolescents, adults and the elderly in SFPs is that there are no properly tried and tested methods for assessing malnutrition amongst these age groups. Currently, there is some research on using proxies for height in the elderly, e.g. demi-span, although there has been no field testing in emergency situations. It seems likely that a long process of devising appropriate measurement techniques and defining local standards of risk will be needed before such measures can be used in the field. In the meantime agencies will have to go it alone but should not let lack of consensus about methods of defining risk in adolescents and adults prevent targeting these other groups for emergency selective feeding programmes.
Adult-only therapeutic feeding: Baidoa, Somalia
Because of the high levels of severe malnutrition found amongst adults in Baidoa in Somalia in 1992, one NGO established therapeutic feeding facilities for adults only. Separate facilities were considered necessary as the heavy demands of re-feeding severely malnourished adults were seen to be detracting from the care that should have been given to severely malnourished children. This pioneering work found that there were many problems in measuring and weighing severely malnourished adults. First, such individuals often had contractures (inability to extend limbs) due to being inactive for a long period, it was therefore impossible to measure height. Second, very severe cases were unable to stand on the scales unassisted. BMI measurements were therefore found to be inaccurate. Furthermore, such measurements were not found to be associated with outcome, i.e. the lower the BMI, the greater the likelihood of death. Instead, visual assessments of malnutrition in conjunction with evidence of particular disease states were found to give a more accurate prognosis.
Requirements for data collection and analysis need to be carefully reviewed in conflict situations. Training local staff in data collection and analysis may be especially pressing where insecurity is likely to lead to the periodic evacuation of international aid agency staff, in order to ensure continuity of information. Situations can also arise where the beneficiary population are in a rapid state of flux as its members are in transit to some other location or return periodically to their village to undertake some activity. Feeding centres will then experience very high rates of default which will be impossible to follow up. This type of situation might determine that less emphasis be given to data collection until the population served is more stable, or alternatively that evaluation criteria are adjusted to account for the high rate of flux.