United Nations System
Standing Committee on Nutrition

Working Group on Nutrition in Emergencies

held at SCN's 32nd Session, 13 and 16 March 2005, Brasilia

Co-Chairs: Caroline Wilkinson, Fathia Abdalla. Rapporteur: Paul Rees

1. Pre-meeting before SCN session

1.1 Background

Based on the recommendations from 2004 SCN meeting by nutrition in emergencies group members’ and followed by subsequent consultations with members, it was suggested that three priority areas (infant feeding, community therapeutic feeding and assessment in emergencies) should be discussed in depth. Because of the limited time and wider topics to be discussed in the main session it was agreed that a pre meeting be held on 13 March 2005, preceding the SCN meeting in Brasilia. A one day meeting was held at Bay Park Hotel with the following objectives.

1.2 Objectives

• To discuss and harmonise matters related to the three above mentioned topics among stake holders
• To highlight the main issues arising from the discussion of the topics and make recommendations
• To outline future plan of the working group
• To comment on the Brazilian case study in relation to realization of rights to adequate food in emergencies

The meeting was well attended by the group members (20 participants), focal points of the group task forces, chairs of breastfeeding and complementary feeding, HIV/AIDS and nutrition, food security and some members of SCN steering committee groups and bilateral community.

1.3. Main discussion points

Infant feeding update

• Suggestions were made as to changing of the cover and image of the modules to project global issues in the area infant feeding
• There is still some confusion on feeding of infants born to HIV/AIDS positive mothers in regard to replacement feeding, and treatment of severely malnourished HIV/AIDS positive children
• Need for capacity building and training, policy makers involvement, wider dissemination of the modules, strategic partnership, pre-emergency training, link more with HIV/AIDS issues, bring infant feeding among agencies priorities, explore available research information with NGOs

Community Therapeutic Care Update

• Transition between emergency and development
• Integrate CTC protocols in IMCI current nutrition component
• Use of MUAC as admission criteria to CTC programme
• Use of manufactured therapeutic food as apposed to local production and sustainability and quality control issues
• Production and dissemination of CTC manuals
• SCN can play a role in moving CTC even further
• Step forward includes inclusion of CTC in PHC, dissemination of training materials and more discussion on the topic by agencies involved

For details on the agreed recommendations on main topics discussed mainly infant feeding in emergencies including related HIV/AIDS element and community therapeutic care (see the group work plan attached). The topic on assessment during emergencies from SMART perspective was not discussed instead the group had a lengthy discussion on evaluating the group current work and its coming work plan. The group was convinced that nutrition in emergencies working group should continue its important work with the following suggestions:

• The group recognised the limitation of time (1.5 h) allotted for working groups to allow in-depth discussion and as such the group will continue to meet once a year at the SCN meeting with objective of information sharing and update. However, in addition the group will meet separately during the year or hold Pre-meeting during the weekend preceding the SCN meeting as this one.
• The current task forces will continue their activities based on the group work plan incorporating new elements including mainstreaming of human rights and monitoring and evaluation, capacity building and advocacy.
• More follow up on the recommendation and action taken by each responsible focal points and agencies through active communication through out the year
• A lot of the group work is cross cutting in nature and more coordination is required with other working group including HIV/AIDS and nutrition, breast feeding.
• The group needs to be more active in moving nutrition issues in emergencies forward especially active communication during emergencies e.g during Tsunami taking the work done by infant feeding task force as a good example.
• A third Co-chair for the group is to be selected from bilateral community (UN-NGO-Bilateral)
• A meeting to be organised before the next SCN meeting either on an ad hoc basis linked to another meeting where a significant number of working group members are present, or as a pre meeting the weekend before the next SCN meeting.
• The group appreciated SCN secretariat support and assistance towards the preparation of the group pre-meeting

2. Working Group Main Session 16 March- 11:30-13:00

For main topics presented refer to the attached agenda. Please note that tentative session included in the agenda on the assessment from SMART initiative work was not discussed due to time factor and absence of key people working on the initiative.

2.1 Progress towards the Group’ 2004 Recommendations

At the beginning of the session group chair (UNHCR) gave a brief summary on the group pre-meeting, it was also noted that main task forces of the group includeTreatment of Malnutrition, Food Security-quality issue (Micronutrients), Mental & social issues in Care Practices, Infant & Young Child Feeding in Emergencies, Nutrition & Diseases (Related HIV/AIDS), Capacity Development for Nutrition in Emergencies. In this respect a review was made on the progress made by the task forces towards 2004 recommendations. The task forces remain active through out the year, both infant feeding in emergencies and community therapeutic care have held consultations on their respective topics and WHO held additional consolation on treatment of severe malnutrition. Collaboration was established with HIV/AIDS and nutrition working group, in this regard ACF is engaged in search on severe malnutrition and HIV/AIDS in Malawi and UNHCR, WFP and UNICEF have jointly developed a guide for Integrating nutrition in HIV/AIDS in refugee settings. The task force work on adult malnutrition continues (see the brief shared by Partners Research Emergency Nutrition-PREN, available of WG webpage). In relation to micronutrients monitoring in the general food ration the version 2003 software (NutVal) was updated in 2004 by ICH, WFP and UNHCR (available on agencies websites or agencies nutrition focal points). However, the need for a field friendly method to complement the current field guides still remains.

2.2 Main Presentations and discussion

Right to adequate food in emergencies The group chair (ACF) made linkages between nutrition in emergencies and this year’s SCN theme and noted the importance of the Rights to Adequate Food in the Emergency and that the Right to Food remains an important and critical to all those working in emergencies. Clearly there are many violations that actors observe in emergencies including the use of food as a weapon. This amongst other manifestations has contributed to many of the famines seen in the past and we must acknowledge as well as those in the future. This is reflected in the legislation including Art 5 DC 12 citing the use of food as a political weapon and giving special attention to the responsibilities of the state in Art 38/39. Furthermore we can see the voluntary guidelines presented in numerous sessions as being of clear and crucial importance within the emergency setting. Guide 10 on nutrition lends strength to the guidelines when working with populations in danger. In addition, FAO presented Chapter 16 which looks specifically at the Right to Food in Disasters which also looks at defending populations when political manipulation of food access exists and also highlights the illegality of deliberate destruction of livelihoods assets. The responsibilities of occupying states with regard to accessibility to food is also cited within that Chapter. This relates not only to nutritional requirements of IDP populations but also to the more complex scenario of neutral access to food and food aid between warring parties. FAO undertook review of existing legal guidelines and their relation to the rights to adequate food. These are available though there are particular factors within emergencies that should be reiterated. The protection of particular vulnerable groups, the crucial role of participation of stakeholders and institutions, important environmental issues, landmines and internal state influence on the access to land and livelihood assets. Recommendations: The group to be actively involved in realisation to development of right to adequate food in emergencies

Infant Feeding in Emergencies Module 2 and the four booklets as training and resource materials The content of these resource materials was explained including how Breast Feeding works, supportive care, assessment of mother and child pairing, basic help to improve infant feeding and more skilled help. Recommendations: Set-up of an orientation group / session, widen the audience and ensure the element of living documentation, greater tapping into field experience and the NICS/RNIS publications, develop module 3 on complementary child feeding and finally look into greater financial backing. WHO reminded the group of the availability of complementary documentation of WHO guidelines on Infant Feeding Emergencies, Guidelines for in-patient care and Training on the management of severe malnutrition. - Dissemination of the modules (including workshop) - Widen the audience of the modules - Pursue research to fill evidence gaps & regularly update the modules - Begin work on Module 3 on complementary feeding - Update Operational Guidance

Update on Community-based Therapeutic Care

FANTA has introduced the up date on Community-based Therapeutic Care CTC). The facilitator reminded the group that CTC is part of the continuum of care for the management of severe malnutrition. It is complementary to the work and guidelines generated on centre and hospital based management. CTC is based upon experience as well as increasingly documented evidence. The Washington workshop was an opportunity to review and discuss work conducted in the nearly two years since the original Dublin conference that initiated a wider debate amongst academics, implementing agencies, bi-lateral partners and ministries alike. A similar profile was seen in Washington. FANTA, SC-US and Concern Worldwide were cited as providing organisational, technical and financial support to the meeting. Valid International was also cited as providing technical assistance. The DC workshop allowed important discussion on many issues including the inclusion of preventative methods and programming as well as how CTC can be applied to HIV/AIDS programming. The facilitator briefly explained the rationale behind the use and development of RUTF (ready to use therapeutic foods) for treating severe malnutrition as well as its complementary use to supplementary foods also integral to CTC implementation. The process of developing CTC was described as proofing of a concept. Validation is on going, Sphere standards are utilised to judge performance. The facilitator described areas of conversation around RUTF within the workshop such as quality control, cost assessment and analysis and issues of sustainability. The workshop highlighted the need for greater inclusion of Primary Health care analysis and programming, investigated the possibilities of greater use of PD Hearth and positive deviance preventative methods as well as introducing frameworks for a Code of Practice and the development of minimum standards. The connection and up coming meeting with WHO looking at the inclusion of CTC protocols within the IMCI guidelines and that these aimed to complement the existing Guidelines on In-patient care. The major needs can be summarised as the Code of Practice, Mechanism for information exchange, the link with preventative care, with primary health care, the development and procurement of RUTF and the continuum of care for those living with HIV/AIDS. ENN will report on the meeting and presentations can currently be found on FANTA, ENN and Concern Worldwide websites.

Recommendations

• Expanding CTC experiences (protocols, manuals, lessons learned…) to wider emergency partners.
• Pursue mechanisms pertaining to best practice of the Community Therapeutic Care (CTC) approach to managing severe malnutrition (including the 4 priorities cited at the recent Washington conference in February 2005)
• Work with WHO and other UN agencies for the integration of CTC and home based care protocols into IMCI and WHO guidelines.

Quality of food aid relating to Micronutrients

WFP reiterated the prevalence of micronutrient deficiencies including goitre, pellagra scurvy and those more difficult to identify such as riboflavin. The facilitator presented the data on WFP fortification activities and stated that WFP Policy Papers were now available on fortification, nutrition in emergencies and mainstreaming food and nutrition programming. Fortification had occurred during the recent Southern African crisis as well as Angola and Afghanistan. A review of recent fortification in Zambia and Bangladesh reiterated the importance of sensitisation within the community as to the objectives, activities and positive outcomes of fortification. The challenges for fortification similar to Ready to Use Therapeutic Food (RUTF) were management and supervision, quality control, sustainability, legislation as well as the constraints of assessments methods. UNICEF has referred to Availability of Guide to Multi Vitamin in Emergencies . Recommendations - Document the available evidence of micronutrient status in Emergency situations and review the tools and methodologies used to collect and monitor these. - Review strategies to address micronutrient deficiencies

Discussion

At the end of all presentations questions raised included: - Which minerals were used in the WFP fortification, how labelling could be introduced for these products, especially for populations dependent on these foods. - Concerns over dependency of product produced in France, what alternative RUTF are being developed with local foods? Does the soon to be developed management of severe malnutrition in the community risk conflicting with documents such as TALC published management of severe malnutrition by Anne Burgess for example. - Considering that case fatality in non-emergencies is in many places higher than emergencies what lessons / mechanisms can this group generate for non-emergency contexts. - What is the future for F75 and F100? Announcement that US congress in considering a proportion of $1.2 billion would be distributed in cash form. What could the consequence be for locally produced foods? - Pellagra outbreak prevention strategies: food fortification versus locally available food and food diversity -Statement that Chapter 16 was a compromise and inclusion of all legal elements was difficult. There was recent experience of UNICEF talking to warring parties; the experience and lessons need to be more widely disseminated.

Responses by Facilitators:

1. Milk products stable on demand whilst RUTF has risen 3 threefold according to Nutriset. Alternatives are underway focusing on replacing the most expensive product of milk; price estimates show cost has been halved. Overall, the scale up will take time, which will also drive demand for use of products. We should also consider the importance of the pressure and need from the HIV/AIDS community. FAO: Would like to be more engaged in this issue relating to sustainable foods, income generation and small business.
2. Shelf life, quality control, and storage condition of fortified food are critical and need to meet the international standards
3. Reiterated initiatives to include transition and PHC experience and programming to investigate sustainability of CTC activities within PHC units in transition, post emergency, protracted emergency as well as further development contexts. Further info on evidence available in recent ENN supplements.

Conclusion

The group chairs would like to thank all the group members and the task forces focal points for your active participation and valuable input through out the group work including pre-meeting and main session. The group active work is been well appreciated. Some of the immediate actions that require your attention:

• Identification of Co-Chair from bilateral community to make a total of three Co-chairs for the group • Communication with the task force focal points to follow up on action plan and determine timing for feedback • Reinvigoration of the theme groups based on identified needs and objectives and incorporate new elements 1) mainstreaming of human rights 2) monitoring and evaluation 3) capacity building • All members to review the work plan attached and provide any comments by 28 April • Creation of a task force to provide a forum for discussion and improvement of the quality of nutrition information collected during emergencies to be facilitated by the identified focal point • Close collaboration between Co-chairs and SCN Secretariat and hence group members

Attachment 1

Working Plan for the SCN Nutrition in Emergencies Working Group 2005 - 2006