Nutritional interventions in 'open situations': lessons from north-western Sudan

Humanitarian organisations are increasingly confronting ‘open’ situations, where access to, and coverage of, beneficiary populations is complicated. Aranka Anema argues that such situations demand a more flexible approach.

Humanitarian agencies have been progressively standardising the planning and management of emergency programmes and responses. In the field of nutrition, standardisation has contributed to advances in inter-organisational agreements on protocols for nutritional assessments, feeding, surveillance and monitoring. These standards have been invaluable to the implementation of nutritional programmes in traditional ‘closed’ emergency settings, where populations are located in centralised areas such as refugee camps. However, there are concerns about the efficacy and appropriateness of certain protocols in ‘open’ situations, where resident and displaced populations are geographically dispersed.

Dissatisfaction with standard procedures in unconventional settings has prompted humanitarian organisations to experiment with alternative approaches in the field. In January 2002, Médecins Sans Frontières (MSF) conducted a workshop to evaluate lessons learned from its 2001 nutritional intervention in West Darfur, Sudan. The goal of the evaluation was to determine which nutritional strategy was most effective and appropriate given the ‘open’ setting, and establish context-specific operational strategies for future interventions in north-western Sudan.

Choosing an appropriate nutritional strategy

One of the greatest challenges for humanitarian organisations in Sudan is to implement intervention strategies that prevent nutritional deterioration, without affecting local coping mechanisms or the food economy of patients’ families by instituting dependency. There is no universal approach to nutritional interventions. Determining an appropriate nutritional intervention requires consideration of context-specific factors, including:

• the stage of food insecurity;
• the nutritional and medical status of the population;
• the socio-political environment (war, population displacement, camps, the health environment, or presence of NGOs in the area);
• the size of the population and its access to the programme;
• the anticipated evolution of the crisis;
• the feasibility of implementation (human resources and logistics, for instance); and
• the potential side-effects of different interventions.

Since it is difficult to obtain an all-encompassing view of a nutritional situation (i.e., including an analysis of all of the above), humanitarian organisations also rely on previous field experience to determine appropriate strategies. MSF has been conducting health and food programmes in Sudan since 1978, when it responded to a refugee crises on the Ethiopian border. It has been working in Darfur intermittently since 1984. In recent years, widespread food insecurity and famine across north-western Sudan have called for the implementation of various programmes: general food distributions to entire populations; blanket feeding programmes targeted at vulnerable groups, such as women, children, the elderly and the socially marginalised; supplementary feeding programmes for moderately malnourished individuals; and therapeutic feeding programmes for the severely malnourished.

MSF’s 2001 intervention in West Darfur

West Darfur has a population of 1.6 million, 90% of whom live in isolated rural areas. The region is affected by sporadic tribal conflict and poor rainfall, resulting in sudden market fluctuations, livelihood changes and displacement. The national health system is barely functional. Primary health care is limited and inaccessible; drug supply and vaccination coverage are low; and the number and level of training of medical staff are below what is required. The combination of geographic isolation, erratic rainfall, socio-political instability and an ineffective health system renders inhabitants particularly vulnerable to medical and nutritional problems.

In December 2000, the Food and Agriculture Organisation (FAO) and Save the Children (SC)-UK reported alarming food shortages in western Sudan. Livestock prices were plummeting and grain prices rising as a consequence of crop failure. Local populations were increasingly working for lower wages, selling productive assets and pursuing alternative income-generating activities. Humanitarian aid was deemed imperative to avoid wide-scale loss of life. The issue for MSF was to determine whether to initiate a general food distribution to cover the entire population, and a blanket feeding programme targeted at vulnerable groups, or to adopt an alternative approach. Theoretically, a general distribution would ensure that food becomes available to the entire population. It would cover the population’s immediate basic food needs, prevent deterioration of nutritional status, maintain and restore regular livelihoods, ensure food security and prevent mortality. A short-term blanket programme would ensure support to families by targeting children under five years of age, and support other vulnerable groups, for example pregnant and lactating women, the elderly and the disabled, in case of insufficient food accessibility or an incomplete food distribution.

In the end, it was established that a general food distribution would be too complicated for MSF to implement effectively in West Darfur’s ‘open’ setting, because of restricted logistical and human resource capacity, lack of political support from the Sudanese government and difficult access to the rugged terrain. MSF had no pre-established food pipeline in the area, and few staff for the delivery of rations. Institutional links between MSF and other organisations in West Darfur were limited. The Sudanese government did not recognise the potential for crisis, and was therefore unwilling to support programme implementation. Logistic capacity was constrained due to complicated geography and a lack of roads in some areas; beneficiary populations could only be reached by camel during the rainy season.

These operational difficulties were compounded because the scope and severity of the nutritional crisis in Darfur was itself unclear. This was a consequence of differing inter-organisational assessment findings. Variations in methodology and cut-off points (Mid-Upper Arm Circumference (MUAC) versus Weight-for-Height) and geographic differences in nutritional status (between North and West Darfur) caused SC-UK to report high malnutrition rates, while MSF reported only moderate ones. Based on the rationale that malnutrition causes reduced immunity and increased risk of infection, MSF-Holland carried out a measles vaccination campaign coupled with emergency preparedness measures, such as delivering foodstuffs and materials, before the rainy season. These initiatives were supported by a nutritional surveillance to verify the effectiveness of the campaign, and identify trends in nutritional status, internal displacement and coping capacity. MSF-H vaccinated 18,000 children, and by August 2001 determined that the situation was sufficiently stable to close the programme.

Lessons learned

The nutritional situation in West Darfur in 2001 proved relatively stable. However, given Darfur’s ten-year history of food shortage and famine, there is a good chance that a similar or worse nutritional situation will occur in the future. Previous famines in Darfur reveal that mortality is caused more by the health consequences of displacement, for instance communicable disease, than by a lack of food alone. MSF-H agreed that a proactive or preventative approach to nutritional interventions may be necessary in some areas of Sudan to prevent distress migration and deterioration of livelihoods, and thereby avert morbidity and mortality.

Participants at the MSF-H Darfur evaluation workshop agreed that future nutritional interventions in Darfur should include three preventative steps:

1. Nutritional interventions in Darfur will be accompanied by basic preventative and curative healthcare. MUAC assessments will be conducted in conjunction with the provision of vitamin A, measles vaccinations and a deworming campaign.
2. Once MUAC findings confirm early-warning information from reliable organisations such as WFP, FAO and SC-UK, Emergency Preparedness (EPREP) will be initiated. This may include the stocking of long-shelf-life therapeutic foods, such as BP100 and UNIMIX or BP5, and lobbying for food distribution by relevant institutions, such as WFP and the Sudanese government.
3. If the situation calls for an intervention, MSF-H will implement an ‘Upgraded Supplementary Feeding Centre (SFC)’. An Upgraded SFC is a cross between a decentralised Therapeutic Feeding Centre (TFC) and a regular SFC. It provides the functions of a normal SFC, namely medical care and fortified food supplements to moderately malnourished individuals. In addition, it provides Phase 1 intensive medical and nutritional care (diagnosis, treatment, follow-up and monitoring) to severely malnourished individuals, and treats specific complications and diseases associated with severe malnutrition. After one week, once severely malnourished patients are clinically stable, the Upgraded SFC would coordinate a ‘decentralised’ take-home Phase 2 programme. This would include the provision of small quantities of take-home rations, for instance plumpynut and ready-to-use therapeutic food, and weekly hospital follow-ups.

Conclusion

‘Open situations’ complicate access to, and coverage of, beneficiary populations. While formal standards and references are helpful in guiding humanitarian agencies, there is a need to expand beyond the knowledge we have acquired, and develop flexible strategies to complement standardised nutritional procedures and protocols. MSF-H’s evaluation workshop offers an opportunity to reflect upon operational lessons learned, and develop effective context-specific strategies for future interventions.

Aranka Anema is a medical anthropologist at MSF-Holland.

References and further reading

Aranka Anema, ‘Lessons Learned in West Darfur: Challenges in Assessment Methodology’, Field Exchange 16, 2002.

MSF Nutrition Guidelines (Paris: MSF, 2002). The Management of Nutrition in Major Emergencies (Geneva: WHO, 2000).

Alex De Waal, ‘Famine Early Warning Systems and the Use of Socio-Economic Data’, Disasters, vol. 12, no. 1, 1988.

Minimum Standards for Food Security in Disaster Response: Report of an Inter-Agency Workshop (Oxford: Oxfam, 2001).

Brian Thompson, Coping with Chronic Complex Emergencies: Bahr al-Ghazal, Southern Sudan (Rome: FAO, undated); available on the FAO website at www.fao.org/docrep/X4390t/x4390t05.htm.

Steve Collins, ‘Changing the Way We Address Severe Malnutrition during Famines’, The Lancet, vol. 358, 2001.