Therapeutic Feeding in an Insecure Area
Author: Kathy Carter, Nurse/Nutritionist and Acting Programme Manager for Oxfam in Liberia.
Liberia has a history of virtually continuous civil war since 1989. Some say that 75% of the population of 2 million are or have been displaced during that time. The most recent agreement between the warring factions (Abuja Accord 2, signed in August 1996) allowed for disarmament (Nov. 22 '96 to Jan. 31 '97) followed by elections which resulted in the election of Charles Taylor as President.
High levels of global malnutrition, initially estimated to be over 80 %, were found in Tubmanberg, Bomi County, when UNHACO1 and NGOs2 gained access to the area mid-September, 1996. In early October, in response to other NGOs claiming that projected needs may have been more than they could deal with, and following an interagency assessment, Oxfam began a therapeutic feeding programme in neighbouring Cape Mount County at Vonzula, approximately 80 miles west of the capital, Monrovia.
The INGO3 experience of losing lots of goods in the looting of the April 1996 unrest, and of factions repeatedly disregarding access and security agreements with the humanitarian community, led INGOs to work together to present a common policy on humanitarian assistance. This was achieved through regular meetings for information exchange and by the formulation of a Joint Policy of Operations (JPO). The JPO included recommendations such as minimal inputs (e.g., no new vehicles to be purchased by NGOs), concentrating on life saving activities, and aiming to 'do no harm' (e.g. no food distribution in areas where fighters were known to loot).
UNHACO staff negotiated access to previously closed areas, co-ordinated assessments and remained a valuable source of information for NGOs in Cape Mount County.
Up to the time I left Liberia at the end of January 1997 there had been little disarmament of Ulimo-J, the faction in control of most of Cape Mount County. During my time with the Oxfam programme, although there were no checkpoints, there was continued intimidation and harassment of civilians by fighters in Vonzula village and surrounding areas. This included forced labour, robbery, looting under threat of house burning, beatings or death. Although Oxfam stores were never looted, local Oxfam staff running the feeding centres were harassed in the same way as members of the local population. Between October and January, the Oxfam Monrovia team was temporarily detained three times by fighters at or on return from Vonzula, but each time released without harm.
As is normal for Oxfam, we set up a security protocol from the beginning, which included the following:
- daily vehicle and fuel checks
- regular radio contact system with the base radio, continually manned
- daily checks with UN agencies and other NGOs for information on safety on the road
- travelling in convoy where possible with UNHACO and other INGOs
- regular meetings with UN agencies and other NGOs to share information and present a consistent response to security incidents
- field team leaders having the responsibility for the decision to stay or leave the field, although this could be vetoed by the programme manager in Monrovia.
|Admission Criteria: Vonzula Therapeutic & Supplementary Feeding Programmes|
|Admission criteria at the start of programme||Admission criteria for those in dry distribution programme (from Jan.'97)|
a) children < 70% Wt/Ht and or oedema
b) clinically malnourished adults with grade 3 oedema
|a) malnourished chlidren < 75% Wt/Ht
b) clinically malnourished adults with grade 3 oedema
|SFC||a) under five year olds
b) older children clinically malnourished
c) lactating women
d) clinically malnourished adults and pregnant women who were included soon after commencement of programme
In line with the JPO, Oxfam did not allow armed escorts or weapons in NGO cars or facilities and never offered or promised gifts or payment in order to be allowed access to run programmes.
At times Oxfam felt it important that dissatisfaction be expressed to faction fighters. This expression was required when, for example, Oxfam workers were co-opted for labour, Oxfam tools were 'borrowed' or treatment of civilians was particularly bad. As a rule Oxfam left exchanges with faction leaders to UNHACO staff both at field and Monrovia level, recognising with other NGOs that negotiation can lead to legitimisation of a corrupt authority. On the other hand, when UNHACO staff were not available at field level, the local supervisor and/or team leader would speak with the local fighter leader (e.g. to ask for the return of workers or tools). To ignore an incident in these situations could also be seen as condoning or legitimising the faction's acts.
What follows are some observations on the issues faced by staff and beneficiaries of Oxfam's Vonzula Programme between October and January.
Insecurity Makes Adequate Assessment Difficult
Lack of security off the main road meant that Oxfam could see only those who came to Vonzula village, thus a baseline survey was not possible.
However, there were enough severely malnourished people to warrant setting up the Vonzula therapeutic feeding centre (TFC). Within one week there were 170 beneficiaries in the TFC and 296 in the supplementary feeding centre (SFC). The supplementary feeding programme was started several days after the TFC was established and, unlike the therapeutic feeding programme which targeted all age groups, only targeted under fives. Blanket supplementary feeding of under fives rather than targeted feeding of malnourished children, was felt to be most appropriate as there was no general ration. The ration was milk and biscuits and supplied around 650 kcals as an on-site feed in two meals. Registration in the SFP eventually peaked at approximately 700.
Insecurity Affects the Scope of Community Outreach
From week two Oxfam employed Community Health Workers (CHW) to find malnourished people from villages and refer them to the feeding centre. The CHWs were from local villages but were given several villages each to cover, not necessarily their own. Women CHWs preferred to travel with male colleagues for safety while visiting villages, and reports of the diversion of male Oxfam staff by fighters to dig cassava were common. In early December the head CHW recommended suspension of CHW activities as he felt it was too unsafe to go from village to village. The fighters, who were mostly boys from outside the area, but based in the various villages, had become suspicious of the CHWs and were restricting their movement, perhaps due to increased information collection by the CHWs, or to increased tension at the start of disarmament. If CHWs had been selected by each village rather than employed by Oxfam, they would have been known to the fighters and, perhaps, would have had more freedom of movement.
Insecurity Influences Decisions on Intervention Strategy
Lack of freedom to move and farm freely appeared to be the major cause of food insecurity. Despite the need for food, seeds and tools, the local population did not want these items to be distributed, as they knew that they would be looted. At the end of September food distribution in Sinje, 8 miles from Vonzula, had led to the massacre of more than 20 civilians and looting of food. In view of this a general food ration distribution for Vonzula was ruled out, pending improved conditions which would make general food distributions and longer-term interventions viable. Oxfam therefore started with on-site therapeutic feeding, but planned to continue monitoring the food and security situation with a view to setting up a kitchen for cooked food distribution to self selected members of the general population.
However, fear of intimidation en-route from the local villages to the centre, plus the outbreak of a cholera epidemic, effectively reduced the numbers attending. There had also been an improvement in the food security situation with the recent harvest, and those registered in the TFC appeared to be recovering well4. Taking all these factors on board, it was felt that a kitchen to distribute cooked food to the general population was not justified.
TFC beneficiaries received five meals a day based on special therapeutic foods, and took home high protein biscuits5. Five meals is less than normal but in the circumstances we felt it to be unsafe and impractical, for staff and beneficiaries, for the TFC to be open longer.
After being forced to suspend the programme for two weeks in late December for staff security, Oxfam scaled down to feed only the severely malnourished via weekly dry distributions of SP-450 Nutriset porridge6. ACF had used this porridge successfully for TFC dry distributions in Tubmanberg, where at the time, food distributions to the population were likely to be looted by fighters. Initial reports were that it was not a preferred commodity for looting by fighters, perhaps because of its similarity to 'porridge for babies'.
The Effects of Insecurity on Programme Design and Access
Beneficiaries who were particularly ill or who needed overnight care were occasionally transferred to MSF or ACF inpatient therapeutic feeding programmes in Monrovia. Sixty severely malnourished children and adults were transferred in the first week, after a rumour of an imminent attack in the next town. This attack could have resulted in Vonzula itself becoming the frontline between factions. The decision to transfer these beneficiaries was controversial; the attack might not have happened (it did not) and access might have continued unhindered. Furthermore, those transferred for in patient therapeutic feeding might have added to Monrovia's unsupported internally displaced population, if separated from their families. We attempted to mitigate this by employing a referral nurse who assisted in tracing relatives or arranging transport to return to Vonzula. Most of those transferred chose to remain in Monrovia.
In the second week of the feeding programme there was a cholera outbreak in Vonzula and in the surrounding villages. On one crucial day at the beginning of the outbreak Oxfam was advised by the UN Security Officer not to travel to Vonzula because of poor security. Had we travelled to Vonzula we could have improved the organisation, continued staff training, supervised staff activities and provided needed supplies, especially lifesaving intra-venous fluids and oral rehydration salts (ORS). We took the security advice and did not travel. On that day fourteen people died.
Security Incidents Require a Response - but in what Form?
An Oxfam security protocol was put in place at the start of the programme. Oxfam collaborated effectively with other agencies to seek united responses to security incidents (e.g. fighting on the road, detention of a vehicle) or harassment (e.g. forced labour). This took the form of reduction in exposure time, sharing information, travelling in convoy, joint NGO & UNHACO visits to meet fighter commanders and joint suspension of humanitarian assistance. Humanitarian assistance was suspended in response to direct threats to NGOs or local civilians, or in response to direct intimidation.
In the second month Oxfam limited 'exposure to risk' for the Monrovia based staff by reducing visits to the field to twice a week for two to three hours per day. Half the visit time was taken up with discussions on security. This adversely affected ongoing training and the quality of information collection.
Negotiation by field staff at field level with fighters for the return of staff or equipment was not always fruitful. 'To whom do you speak?' is a key question. In Vonzula, unlike other places, the local elders held no sway over the fighters. The fighter 'on the ground' would co-operate one day and not co-operate the next. Negotiations at a higher level by UN staff were not always useful, as the fighters would often follow their boss's wishes only when he was present. Local Oxfam staff asked us on several occasions not to take issues higher for fear of local retribution if disciplinary action was taken (e.g. three were threatened with death and escaped with just a severe beating for allowing ECOMOG7 Peacekeeping Representatives in to see the feeding centre).
Two of the three incidents where people and vehicles were detained were defused just by talking and negotiating on the spot by those involved rather than through intervention from ECOMOG or others. Factions were sensitive to ECOMOG involvement, as in the previous year there had been direct fighting between the local faction and ECOMOG troops.
Would more negotiation have reduced harassment? Or would more negotiation have given fighters greater recognition and standing as 'the authorities on the ground'? Could we also have offered a certain number of staff for labour each week in exchange for full staffing levels and peace the rest of the time? This could have led to more Oxfam workers digging cassava for the fighters. It could have led to even more being demanded of Oxfam by the fighters.
Press statements from the whole humanitarian community (via UNHACO) concerning local civilian harassment were seen by local workers as putting them at risk of retribution from fighters. A release by UNHACO to local and international press on this subject necessitated us closing the centre for two weeks in late December. In January a radio statement affirming the existence of human rights abuse, which might have put public pressure on faction leaders, could not be broadcast as I feared for staff safety in the field. The staff supported this decision.
The programme was suspended in late January, due to uncertainty over security around disarmament deadlines; the risks to staff in this case were thought to outweigh any benefit from continuing the programme. Suspension of humanitarian aid in this area did not alter the amount of intimidation by fighters of NGO local staff or civilians, and possibly even led to an increase in civilian harassment.
Summary of Lessons
- it is crucial, a matter of life or death, to listen to the local population's assessment of their own needs, as well as the most appropriate way in which those needs should be met. This should direct what type of intervention should be made and how it is undertaken
- even in the most insecure areas early establishment of a system of information collection is vital. In our situation, this may have been more effective if the CHWs had been selected by each village rather than employed by Oxfam, possibly giving them more freedom of movement
- ideal treatment regimes (e.g. number of meals per day) may need to be modified to ensure optimum security for staff and beneficiaries
- we should never assume that we can visit a project as planned. For this reason early training of local staff in technical, preventative health/hygiene and management is vital
- in an insecure situation time in the field should be maximised in order to target beneficiaries most in need with what assistance is possible. Information collection is a key part of this effort to find creative ways of dealing with food insecurity
- negotiation is not always fruitful
- listening to those who work in a given location is vital to assessing the security of their environment and in deciding programme direction
- risks of working in an insecure situation need to be carefully weighed against the benefits of humanitarian action and the 'protective' role for civilians of an NGO presence.
The feeding programme established in Vonzula led to the concentration of a number of people in an insecure area which in turn increased the opportunity for harassment of civilian and NGO staff by local fighters. Also, the intervention was short-term and arguably had little lasting effect. However, lives were saved without major adverse consequence, and a certain amount of civilian intimidation was undoubtedly prevented by Oxfam's presence. On balance, despite the difficulties, I firmly believe it was right for Oxfam to take this humanitarian action for the population around Vonzula. This was borne out in my last meeting with the local elders when I realised that Oxfam had treated at least half of them for malnutrition and cholera.
See also the Post Script to this article.
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Reference this page
Kathy Carter (1997). Therapeutic Feeding in an Insecure Area. Field Exchange 2, August 1997. p16. www.ennonline.net/fex/2/area