Issue 10 Editorial
Dear Readers,


Over the past ten years large-scale outbreaks of pellagra have only occurred amongst populations dependent on emergency food aid. The most recent outbreak in Kuito, Angola highlighted in this edition of Field Exchange is the largest since the outbreak in Malawi among Mozambican refugees in the early nineties. Unfortunately Pellagra is not the only micronutrient deficiency disease to have been reported amongst food aid dependent populations in recent years. There have also been epidemics of scurvy, beri-beri, angular stomatitis and severe anaemia. The question is, why are these eminently preventable diseases allowed to develop amongst populations under international care and protection?
It is not as if we lack policies and strategies to prevent outbreaks or deal with them when they occur. Current humanitarian aid policy dictates that if an emergency affected population is entirely dependent on the emergency ration, fortified blended foods like Corn Soya Blend (CSB) should be added to the ration to remedy micronutrient shortfalls. In the longer term efforts are to be made to fortify one of the main ration commodities with micronutrients. So where do things go wrong?
In the Kuito case, it took several months to agree that fortified CSB should be added to the general ration after the outbreak of pellagra begun. It then took a further six months for the CSB to arrive. The fact that the outbreak in Kuito was not predicted - suggests that the assessment of the level of dependency on the general ration was flawed. The subsequent late provision of CSB may have been due to a variety of factors - cost, logistics or limited availability. Clearly we have not learnt sufficiently from past 'outbreak' experiences. The tragedy in Kuito now provides an opportunity to put that right.
The experience of Kuito in conjunction with past outbreaks highlight where efforts need to be focused to prevent future epidemics of micronutrient deficiency disease. First, the process and method of assessment of dependency on the general ration is often weak and insufficiently focussed upon micronutrient intake. Review and revision of both the process and method is therefore a matter of urgency. Second, there is a need for greater transparency about the difficulties of obtaining fortified blended foods for populations dependent on food aid. This is not the first time there have been problems in providing CSB. Potential impediments could be explored and identified at the start of any given emergency, and alternative strategies, e.g. fortification of cereals or oil, put in place and ready to implement should CSB provision prove problematic.
It is difficult to think of excuses for pellagra outbreaks amongst populations receiving food aid. The fact that the diversity and adequacy of emergency general rations supplied around the world seems to depend at least in part, on geopolitical factors and cultural affinity between donor and beneficiary populations raises the issue of political commitment. Susanne Jaspar's article on food rations in Kosovo in this issue, 'Let them eat cake', demonstrates yet again the glaring inequities in global food aid. While no-one is seriously advocating the provision of chocolate bars and cake as part of the general ration, as occurred in Kosovo, it is obvious that with enough political commitment the Kuito outbreak could prove to be an 'end-chapter' in a long history of preventable disasters.
This edition of Field Exchange also carries an evaluation by Oxfam of their emergency intervention in response to drought and flood between 1996-8 in Wajir district, Kenya. A key finding of the evaluation was that the most costeffective component of the intervention, which included provision of general rations, livestock restocking and food for work, was the cash for work project. This finding is potentially very significant.
There has been a long, albeit largely theoretical, debate about whether the provision of cash rather than food in emergencies would be a more costeffective form of intervention. Food aid still dominates in emergencies (80% in the current horn of Africa appeal). Cash could be provided as payment for work (cash for work) or simply in place of the general ration. Advantages of cash provision would be that large quantities of food do not have to be procured and moved long distances while the cash would allow recipients freedom to purchase other essential commodities apart from food e.g. fuel, shelter, water, livestock fodder and service crippling debt repayments. Shipping and other transactional costs amount to roughly 60% of food aid costs, while an estimated 50% of food aid is sold soon after delivery. Another potential advantage is that cash provision would inject effective demand into collapsing local markets. There are however certain unknowns with this type of intervention: the effect on security in conflict situations, the effect on gender resource control i.e. it may be easier for women to control donated food resources than cash. It is also unclear whether the injection of large quantities of cash into a food scarcity situation would lead to inflation. Equally, unclear is the extent to which donor governments would be happy to furnish humanitarian agencies with cash for distribution to individuals rather than cash which is tied to the purchase of food aid sometimes within the donor country. What is clear is that further studies are necessary and long overdue.
Finally, it is with a certain amount of regret that we publish Field Exchange's first anonymous article. To date agencies have been particularly open and transparent and have shown their commitment to learning through endorsing the publication in Field Exchange of articles written by their staff about field level experiences. These accounts have highlighted both positive and negative aspects of agency intervention. In this instance however the agency did not want to be recognised through this article in view of the sensitivity of the programme. The author has therefore edited the article in such a way so as the agency and country programme cannot be identified. The article contains valuable lessons, which should be documented and available to anyone establishing a Therapeutic Feeding Programme.
Editors,
Fiona O'Reilly
Jeremy Shoham
More like this
FEX: A pellagra epidemic in Kuito, Angola
By Sophie Baquet and Michelle van Herp Sophie Baquet is the headquarter nutritionist in MSF Belgium and Michel van Herp, Headquarters epidemiologist in MSF Belgium. This...
FEX: Potential of Using QBmix to Prevent Micronutrient Deficiencies in Emergencies
By Evelyn Depoortere, Epicentre Evelyn Depoortere is currently a medical epidemiologist for Epicentre. Previously she worked on several MSF missions, including Southern Sudan...
FEX: Recurrent pellagra in Angola
Summary of report* Since March 1999, successive waves of people have arrived in the town of Kuito, Angola, displaced by fighting in their native Bie province. As a result,...
FEX: The use and acceptability of micronutrient enriched foods
A study by Oxfam, UNHCR and Micronutrient Initiative. Emergency general rations supplied by the international aid community have frequently failed to supply adequate amounts...
FEX: Use of case definitions and awareness of micronutrient deficiencies
Summary of Unpublished Study* Afgani boy with swollen and bleeding gums typical of scurvy. Micronutrient deficiencies have been reported in emergencies in populations who are...
FEX: Issue 15 Editorial
Two of the field articles in this issue of Field Exchange address to varying degrees the subject of advocacy. The dictionary definition of the word is 'recommendation' or...
FEX: Compliance problems with vitamin pill distributions
Unpublished report A pellagra outbreak hit war affected Kuito town, the capital of Bie Province in Angola in the second half of 1999 (see article in this issue of Field...
FEX: Outbreak of micronutrient deficiency disease: did we respond appropriately?
By Dianne Stevens, Patricia Araru and Buwa Dragudi, Save the Children (UK) Dianne Stevens is a nutritionist with a Masters in Public Health and Tropical Medicine. She has been...
FEX: Towards the Overdue Elimination of Deficiency Disease Epidemics
By André Briend Andre Briend is a medical doctor, working for the Institut de Recherche pour le Développement (IRD), a French public research institution with a mandate to...
FEX: Appropriate Vitamin C Fortification Levels for CSB?
Report summary : The Institute of Medicine In 1995 the Senate Appropriations Committee Report directed USAID to initiate a pilot programme to increase the vitamin C content of...
FEX: Further perspectives on scurvy outbreak
View this article as a pdf This is a poscript for the field article 'Scurvy outbreak among South Sudanese adolescents and young men - Kakuma refugee camp, Kenya,...
FEX: The Nutrition Situation of Refugees and Displaced Persons
Summary of the ACC/SCN Refugee chapter by Jane Wallace The quarterly 'Reports on the Nutrition Situation of Refugees and Displaced Populations' (RNIS) are compiled and...
FEX: Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018
View this article as a pdf Read the postscript to this article here. Summary of research1 Location: Kenya What we know: Refugee populations dependent on food assistance are...
Resource: Inappropriateness of general food ration for older infants & young children
Case study from: INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES GIFA/ENN PROJECT (2003) Researchers: Mary Corbett (Evaluation of Module 1) and Marie McGrath (Collation of case...
FEX: Persistent Micronutrient Problems among Refugees in Nepal
by Janack Upadhyay This article describes nutritional aspect of emergency food aid in Bhutanese refugee camps in Nepal; the author was regional Food & Nutrition...
FEX: Issue 22 Editorial
The more cynical amongst us in the emergency nutrition sector may sometimes be heard complaining that there is nothing new in this profession and that we just keep re-inventing...
FEX: Micronutrients - The Basics
Taken from draft guideline material prepared by Fiona Watson, Institute of Child health, London. Micronutrients are essential for life and are distinct from macronutrients...
FEX: Iron and vitamin A deficiency in African refugees
Summary of published research1 Haemacue survey in Tanzania Five cross-sectional surveys were conducted in refugee camps in north and east Africa between 2000-2002 to assess...
FEX: Postscript to 'Outbreak of micronutrient deficiency disease'. By David Fletcher, WFP Kenya
by David Fletcher, Deputy Country Director, WFP/Kenya WFP Kenya would like to address some of the points made in the article entitled, "Outbreak of micronutrient deficiency...
FEX: From the Editor
There is no single theme for this issue of Field Exchange but lots of interesting and wide ranging material. A good place to start this editorial is to note the short research...
Reference this page
Fiona O’Reilly and Jeremy Shoham (). Issue 10 Editorial. Field Exchange 10, July 2000. p1. www.ennonline.net/fex/10/fromtheeditor
(ENN_3427)