When there are no statistics: Emergency Nutrition Programming in Eritrea

Famine and drought pose a regular threat in Eritrea, along with the rest of the Horn of Africa. Consecutive years of drought, high food prices and the global economic downturn all suggest that hunger and malnutrition levels are high. However, unlike in neighbouring countries no reliable national nutrition statistics are available to show this. There have been no comprehensive nutrition surveys since 2005, and World Food Programme (WFP) general food distributions have been suspended since 2006. The activities of international NGOs are restricted.

In August 2008, CAFOD was alerted to a poor rainy season by its local partner in Eritrea, and warned that the deteriorating nutritional situation in 2008 would continue to worsen until the next harvest in November 2009. Unable to conduct a nutrition survey or obtain statistics from others, CAFOD was faced with the question of how to justify a response in the absence of reliable data. Knowing that humanitarian capacity was severely limited and that general food distributions would not be allowed, the agency nonetheless decided to establish a supplementary feeding programme.

This article explains the challenges of operating in an environment where there are no statistics, and how the resulting programme provided CAFOD with a clearer understanding of the context and supporting evidence of the nutrition situation in Eritrea.

Using the evidence available

The evidence that is available paints a dismal picture of the humanitarian situation in Eritrea. In 2008 the kremti rains failed, and as a result people harvested very little or nothing during October and November. A September 2008 forecast by the European Union’s Joint Research Centre (JRC) estimated 2008 cereal crop production at no more than 200,000 MT, barely 30% of the country’s total annual needs. The next main harvest will not be until October and November 2009. Access to water is very poor; only 32% of the population have access to a safe supply. Pastoral areas have also been badly affected due to the lack of pasture for livestock grazing.

Local food prices have escalated and Eritrea is top of the list of countries most vulnerable to high global prices. Commodity prices are very high, many food items are unavailable in the markets and the cost of livestock has dropped in relation to the price of grain. An estimated two-thirds of the population lives below the poverty line, with rates as high as 80% in rural areas. Military mobilisation has depleted the productive labour force, leading to a reduction in the range of household earning opportunities and limiting the income of many households to that of a soldier’s salary, just $20 per month. With the traditional staple food, teff, costing around $8 a kilo, it is an impossible luxury for the majority of households. Even its cheaper replacement, sorghum, is $2 per kilo.

Government policy is another factor. General food distributions have been suspended to vulnerable groups in favour of food or cash for work. Access to food is tightly controlled. Farmers are required to give a certain proportion of their harvest to the government, and the government forbids the transport of food between regions. The harvest collected by the government is allocated to its fair price or rationing scheme, whereby each family is able to purchase a fixed quantity of basic food and fuel items at a lower price. The ration varies according to availability; the current quota for a family of five is 10kg of sorghum and 2.5 litres of oil. This supply is both insufficient and unreliable, but because people are unable to legally purchase more than the ration they are forced to buy what they can on the black market, at much higher prices.

The operating environment for humanitarian agencies in Eritrea remains unpredictable. Fuel is in short supply and therefore rationed. Vehicles require permits to travel. It is difficult for international staff to get work permits. NGOs are unable to import food items, including oil. If imports are possible an import tax of 18.5% must be paid. NGO operations have been reduced, with the suspension of some programmes and the closure of others; 32 international agencies have withdrawn from Eritrea, and only five remain. UNICEF and WHO are the only international actors managing nutrition programmes in Eritrea (these programmes are implemented by the Ministry of Health).

Under these conditions, it is reasonable to expect that nutrition is severely affected, particularly among the most vulnerable groups. In February 2009, the Food and Agriculture Organisation (FAO) reported that 2 million Eritreans required food aid, and that an estimated 75% of the population was vulnerable to inadequate nutrition. According to UNICEF, malnutrition underpins over 60% of under-five mortality in the country, with acute respiratory infections and diarrhoea the main causes. Malnutrition among women of childbearing age is put at 38% nationally, and 53% in the most drought-affected regions. According to a recent UNICEF report, rates of acute malnutrition in Anseba and Gash Barka provinces were above 15%; by February 2009, admission rates to therapeutic feeding centres were already two to six times higher than in 2008. Although comprehensive data is not available for 2009, food prices have risen, the harvest has been poor and the political and economic context has not improved. It is therefore reasonable to assume that the nutrition situation has not got any better either.

The supplementary feeding project

On the basis of this analysis of the food crisis, the challenges of the operating environment and available funding, CAFOD decided to initiate a three-month pilot supplementary feeding programme (SFP) from November 2008 to January 2009. It was hoped that this pilot would demonstrate that CAFOD could operate effectively and enable the gathering of information to present a case to donors for a larger, longer SFP.

The pilot project was supported by the Ministry of Health and local government authorities. It was implemented by local partners in Barentu, Debub, Northern Red Sea and Anseba Regions, through 22 distribution sites in villages and health clinics. The project provided a monthly supplementary food ration to nearly 7,000 moderately malnourished children under five, approximately 3,000 malnourished pregnant women in their third trimester and malnourished lactating mothers of babies up to six months. Beneficiaries received 9kg of supplementary food (DMK) per month. DMK is similar in nutritional value to CSB or UNIMIX, and is produced in Eritrea. It is made from a cereal base (sorghum and millet), chickpeas, peanut paste and mineral mix. The ration would normally include oil, but as oil could not be imported or procured locally it was decided to increase the monthly ration from 7kg to 9kg in order to meet the recommended calorie intake, though it was recognised that the proportion of fat was too low.

Community screening
The local partners identified target areas based on consultation with the Ministry of Health at national and local level, UNICEF, local health services and community leaders. A quota system was used to determine the number of beneficiaries in each area. In the absence of a national nutrition survey, CAFOD recommended that field partners screened all children under five and pregnant and lactating mothers in each target area before the first distribution, to identify and register beneficiaries. The mid-upper arm circumference (MUAC) of all children under five was taken; those under 13cm were weighed and measured. Those with a weight for height (WFH) measurement below 80% were admitted into the programme. Those below WFH 70% were classified as suffering from severe acute malnutrition and referred to therapeutic feeding centres. A MUAC measurement of under 23cm was used as the cut-off point for pregnant and lactating women.

Without a full nutrition survey, it was not possible to establish global or severe acute malnutrition rates. However, the village-based rapid screening, which covered 20,725 children, provided a clearer indication of the nutrition situation. In Anseba zone, of the 9,012 children screened 0.2% were severely malnourished and 20% moderately malnourished. At the start of the project, 517 severely malnourished children in Gash Barka Zone were registered, which is an extremely alarming figure. Although feedback and registration documents from staff suggested that this was correct, CAFOD had no access to the region to verify this.

Factors indicating a food crisis
The supplementary feeding project targeted nearly 10,000 malnourished children and pregnant and lactating mothers. CAFOD conducted a review of the project in January 2009, and the agency continues to request feedback from partners. CAFOD believes that the following factors all point to a food crisis in the areas where the project was implemented. As far as we know, no other agencies are providing supplementary feeding in these areas.

• The SFP was carried out during the three months after the annual harvest period, which is when people usually have the best access to food. It was therefore likely that the food security situation would continue to deteriorate until the expected rains in July.

• During the review we found that, just a few months after the harvest, some households had already started to adopt coping mechanisms to deal with food shortages. These included selling family assets (mainly livestock), travelling long distances to harvest wild fruits and berries and reducing the frequency of meals and the amount of food consumed.

• During the three-month programme, high numbers of beneficiaries travelled long distances, some from areas outside the region of operation, to be registered in the SFP. In some areas, moderately malnourished children and mothers who met the admission criteria had to be turned away due to limited resources.

• The majority of severely malnourished children identified were unable to access therapeutic feeding services due partly to a shortage of services in certain areas, and practical constraints which prevented mothers from seeking medical care for their children. As these children were not receiving any treatment, the SFP had little choice but to admit them despite the fact that it could not provide adequate treatment.

• Analysis of the end of project data reveals low cure rates and a longer length of stay compared with other SFPs. At the end of the project a significant number of children and mothers were still moderately malnourished and in need of continued supplementary food rations. At the end of the SFP in January 2009 there were still 2,381 moderately malnourished and five severely malnourished children in Debub, and 1,786 and 234 respectively in Gash Barka. SFP distribution staff attribute this to the lack of additional food sources within the family and the sharing of the DMK ration. Feedback from beneficiaries confirmed that families had shared DMK as they had little or no access to other food sources. The data and beneficiary feedback indicate that beneficiaries were using DMK as their main food source, rather than as a food supplement.

• At least 50 more severely malnourished children were admitted to health centres between January and April 2009. In Debub zone, 98 severely malnourished children were identified in mid-March 2009, but clinics were unable to admit them due to a lack of TFC supplies. Based on our knowledge of the constraints communities face in accessing TFC services, we believe that many more severely malnourished children have not sought or received treatment.

• During the latest Vitamin A campaign, conducted in early May 2009 by the Ministry of Health, at least 8,486 moderately malnourished children were identified; they have no access to treatment.

Conclusion

CAFOD believes that a food crisis persists in its areas of operation in Eritrea. In the present situation, it is difficult to see how the food security situation can improve, even if rains are adequate. It is reasonable to assume that this may also be the case in other areas where data does not exist, as many of the causes of food shortages are nationwide and there are no other large-scale SFP programmes and no general food distributions. With general food distributions prohibited, there is a strong argument for continuing and expanding supplementary feeding programmes. CAFOD has secured funding from DFID to continue the project until April 2010 and is seeking further funds to increase its scale and duration. We believe that the learning and data from the supplementary feeding project itself provides a better overview of the nutrition situation and is a strong justification for further donor funding.