74300 -1- -2- How to Protect and Promote the Nutrition of Mothers and Children: Case Studies in Latin America and the Caribbean Table of Contents Case Studies Haiti: Humanitarian Response to the 2010 Earthquake and Child Nutrition 2 Guatemala: Management of Emergencies 8 Haiti: Tackling Malnutrition with Ready-to-use Local Food Products 12 Honduras: Community Nutrition Volunteers Promote Child Health and Nutrition 16 Services in the Wake of Hurricane Mitch Peru: Community Kitchens Optimize Nutrition Support to the Poor 20 Guatemala: The Coffee Crisis and the Monitoring of Child Growth 24 Haiti: Humanitarian Response to the 2010 Earthquake and Child Nutrition Marie Chantal Messier1, Ismael Ngnie Teta2, Michele Doura3, Joseline Marhone Pierre4, and Mohamed Ag Ayoya5 Situation before the earthquake The rates of undernutrition among children <5 years of age in Haiti before the earthquake of January 12, 2010 were among the highest in Latin America and the Caribbean. In 2005, one out of three children <5 was stunted (chronically undernourished), one out of 10 was wasted (acutely undernourished), and six out of 10 were anemic. Children are at the greatest risk of undernutrition in the first two years of life, a period of rapid growth and development. In Haiti, about 25% of children were born with a low birth weight. The prevalence of child wasting among Hai- tian children was highest between 9-11 months of age, and three-quarters of all anemic children were between 6-23 months of age (1). Prior the earthquake, poverty and food insecurity were widespread: 76% of people lived with less than US$2 a day, and 54% lived in extreme poverty (2). Over half of all households were food insecure (3). One expression of this situation was the great dis- parity in nutritional status across the country: rates of child stunting were nearly twice as high in rural areas (28%) as in urban areas (15%), and seven times higher in the poorest families (34%) than in the rich- est (5%) (1). 1 Senior Nutrition Specialist, World Bank-Washington, D.C. 2 Nutrition Specialist, UNICEF-Haiti. 3 Head of Nutrition Unit, WFP-Haiti. 4 Nutrition Director, Ministry of Health-Haiti. 5 Chief of Nutrition, UNICEF-Haiti. -2- Interventions after the earthquake The direct and indirect effects of the earthquake UNICEF, WFP, PAHO, and numerous international and heightened the vulnerability of mothers and children national NGOs. Assistance to families consisted of food to undernutrition. Shortly after its occurrence, the rations, health and nutrition services, access to water Government provided affected families with crucial and sanitation as well as workfare and cash-transfer humanitarian assistance, with the support of the in- programs. ternational community—including the World Bank, Emergency interventions to prevent and treat child undernutrition and reduce the risk of child mortality included: • Education and counseling on recommended infant and young child feeding practices, including the protection and promotion of optimal breastfeeding practices; • Blanket distribution of ready-to-use supplementary foods for children and women; • Micronutrient supplementation of mothers and children with iron-folic acid supplements, vitamin A supplements, iodine capsules, and deworming tablets; and • Integrated management of acute malnutrition. Among the logistical arrangements set up to deliver these interventions were: • 107 “baby tents� and “baby friendly centers� to provide a safe space for mothers to breastfeed, IYCF counseling, and artificial infant formula for young orphans and children whose mothers were unable to breastfeed; • 159 community-based outpatient therapeutic feeding programs for children suffering from severe acute malnutrition without medical complications; • 28 stabilization centers in hospitals for children suffering from severe acute malnutrition with medical complications; • 240 supplementary nutrition sites for children suffering from moderate acute malnutrition; • Mass campaigns for the distribution of micronutrients and deworming medicine; • Basic maternal and child health services (in particular immunization) in health facilities; and • Contracting of NGOs to provide safe drinking water, hygiene, and sanitation services in camps. -3- The achievements attained during the first year as a result of these interventions included the following (4, 5): 1. 49,000 pregnant and lactating mothers received services in the baby tents; 2. 83 percent of mothers who attended the baby tents practiced exclusive breastfeeding for 6 months; 3. 102,000 orphans or children whose mothers could not breastfeed received ready-to-use infant formula for 6 months; 4. More than 1 million children 6-59 months of age (85% of the target children in the country) received vitamin A supplements, deworming tablets, and iodine supplements, as appropriate; 5. More than 500,000 pregnant women received iron-folic acid and iodine supplements; 6. More than 11,250 severely wasted children were treated; 7. More than 33,790 children 6-59 months were treated for moderate acute malnutrition; 8. 178,719 children 6-59 months received blanket supplementary feeding for the prevention of malnutrition; 9. 113,984 pregnant and lactating women received food as part of maternal and child health/ supplementary feeding; 10. More than 1.9 million children were immunized; 11. More than 680,000 people were provided safe drinking water; and 12. More than 11,300 latrines were built. -4- Subsequent shocks after the earthquake While families were still living under very precarious by the poorest families and seriously threatened the conditions, humanitarian and cash-transfer assistance nutritional status of vulnerable groups, especially to affected poor families started to decrease during pregnant mothers and young children. As a result, the the second half of 2010. In addition, Haitians had to nutrition interventions listed above were expanded deal with the successive brunt of soaring food prices to the rest of the country; zinc supplementation was and costs of living, a cholera epidemic, and the effects added to the treatment of diarrhea, including cases of Hurricane Tomas, which compromised the harvest of cholera in children; and supplementary feeding to of key staple crops. These shocks relentlessly exacer- prevent malnutrition among children exiting the chol- bated the already severe hardships being experienced era treatment centers was provided. Nutrition situation after the earthquake Short-term impact A standardized monitoring and assessment in relief and transition (SMART) survey (6) conducted four months after the earthquake (May-June 2010) in af- fected areas showed that the nutrition situation in children remained stable compared to that observed before the disaster. The prevalence of acute mal- nutrition among children 6-59 months of age varied from 2.49% to 5.62%. Severe acute malnutrition was between 0.47% and 1.50%. The report did not provide chronic malnutrition rates. Mid-term impact A second SMART survey conducted in 2012, slightly more than two years after the earthquake (7), showed a decrease in the prevalence of malnutrition levels compared to data for 2005-2006 (1). The stunting rate in children 6-59 months of age was 23.4%. Acute and severe acute malnutrition rates were 4.1% and 1.0%, respectively. These results suggest that the interven- tions and delivery mechanisms set up in response to the crises had a mitigating effect on child malnutri- tion in Haiti. -5- Lessons learned Success factors The rapid response and application of evidence-based, cost-effective interventions focusing on protecting nutritional status in the first 1,000 days proved to be protective against further increases in the preva- lence of acute malnutrition among young children exposed to successive shocks. • Timely availability of sufficient resources (earmarked and non-earmarked) facilitated the implemen- tation of interventions, efficient procurement of products, and strengthening of national institutional capacity. •Mobilization and deployment of qualified, experienced in-country technical assistance in nutrition was highly valuable in supporting the Ministry of Health in the design and implementation of emergency and recovery response as well as in updating nutrition security policies and programs. • An efficient coordination mechanism, co-led by the government and the United Nations Nutrition Cluster, with the support of numerous international organizations, allowed for better allocation of resources, identification of coverage gaps, sharing of knowledge and best practices in the field, and sustainability of the interventions into the recovery period. • Protection, promotion, and support of optimal infant and young child feeding practices—in particular, exclusive breastfeeding and intense hygiene promotion—likely protected a large number of young children from cholera. •Donation and distribution of artificial infant formula were carefully monitored by the National Nutrition Coordination Committee. •Blanket distribution of specific products adapted to the needs of pregnant and young children contrib- uted to containing malnutrition. • Rigorous monitoring and evaluation, implemented in a timely manner, revealed the adequacy of the nutrition response. •Positive results heightened political interest in increasing investments to improve nutrition security. -6- Opportunities for sustained reduction of malnutrition While levels of acute malnutrition never reached emergency thresholds, chronic malnutrition—which reflects chronic nutrition deprivation—has remained a silent crisis in the country for one in three children <5 years of age. Large gaps remain in access to health and nutrition services for children in hard-to-reach rural areas and for those living in overpopulated urban slums. The strengthening of health systems and the creation of a network of services are needed to assure that all children are reached. Results-based financing of the health sector and household development agents are promising initiatives to extend service coverage. • Acute malnutrition remains a concern in some pockets across the country, particularly in remote and isolated areas. Scaling up community-based management of malnutrition would be a cost-effective intervention. •Mechanisms to monitor food and nutrition security for real-time information and decision making are critical, and partners of the National Food Security Coordination and the Ministry of Health are working on developing such mechanisms, possibly including the use of mobile technology. • Further strengthening institutional and local capacities is important to scale up prevention, targeting, and early identification of vulnerable children, as well as to ensure timely and appropriate management/referral of cases of undernutrition. Efforts are being undertaken to provide nutrition training programs in Haitian universities in collaboration with academic institutions from other countries. Policy and program implications •Ininclude countries prone to crises and emergencies, national nutrition and food security policies and strategies should plans to protect the nutritional status of vulnerable populations, with particular emphasis on inter- ventions aimed at optimizing nutrition during the first 1,000 days of life. • Attention should be paid to “recipient� households that provide shelter to displaced victims, to prevent food insecurity caused by the additional people they are feeding. • Timely implementation of a rigorous nutrition surveillance or monitoring and evaluation system should be ensured to assess the nutritional status of the population, identify vulnerable populations, and evaluate the effectiveness of the delivery of various nutrition interventions. • Services should be extended, either through partnerships or results-based financing mechanisms, to achieve adequate geographic coverage and access to care by individuals living in the most remote rural areas and urban slums. • Long-term capacity of the health system and communities should be strengthened to reduce rates of child stunting in Haiti. • Recovery and national capacity building should be an important part of the humanitarian response, for which governmental and partners’ capacity should be strengthened to ensure adequate nutrition interventions are provided to children and pregnant and lactating women. • Coordination and communication among all partners—governmental institutions, UN agencies, international organizations, non-governmental organizations, local entities, and community based organizations—should be considered essential to effectively deliver nutrition interventions. -7- Guatemala: Management of Emergencies Context Santizo M., Quezada R, Yerovi Y, Paz E, Esquivel I.6 High levels of inequality and poverty in Guatemala the Government declared a “state of public calamity� were among the findings of a United Nations study in to address the crisis of food and nutrition insecurity 2009, conducted after the climatic phenomenon “El facing the country. At the time 410,780 families or Niño� resulted in a prolonged dry season with irregular some 2.5 million people were at risk from food and rainfall, especially in a strip of Guatemalan territory nutrition insecurity, including at least half of all chil- known as “the dry corridor� for its semi-arid lands, dren and adolescents <18 years of age. degraded, low-crop yield, and recurrent periods of drought. That year, agricultural production in mu- In response to the Government’s call for international nicipalities in nine departments in this strip were the cooperation, the United Nations established a Nutri- most affected, rendering residents increasingly vul- tion Cluster led by UNICEF and including WFP, UNFPA, nerable to food insecurity and, therefore, at greater and various NGOs that make up the “Humanitarian risk of worsening nutritional problems. In late August, Network.� The Cluster then proceeded to plan inter- the media began reporting increasing numbers of cas- ventions to manage acute malnutrition in Guatemala es of acute malnutrition. As a result, a month later, with the aim of saving children’s lives. 6 UNICEF -8- Interventions The Cluster conducted an initial assessment of the sit- uncomplicated acute malnutrition at community lev- uation with regard to food insecurity in the country el with the participation of the Ministry of Health, and, on that basis, designed a plan to prevent morbid- other community health and nutrition programs, food ity and mortality associated with acute malnutrition security municipal councils and community leaders, in children <5 years of age. The main strategy was and hospital personnel handling cases of severe acute to provide comprehensive care for the treatment of malnutrition. Humanitarian actions focused on: • Acquisition of supplies to save the lives of children < 5 years of age with acute malnutrition (mod- erate and severe). • Immediate identification of acute malnutrition without complications at the community level and with complications at the hospital level. • Public information, education, and communication with emphasis on counseling to detect danger signs and learn appropriate feeding practices, with the aim of promoting the nutritional recovery of children and women of childbearing age. Results: • Therapeutic formulas (F-75 and F-100) were acquired and distributed in hospitals for the treat- ment and nutritional recovery of 1,000 children with severe acute malnutrition in the most af- fected area. • 4,000 were provided oral rehydration sachets. • Over 200 health and nutrition professionals were hired and trained to assure adequate response to the crisis. • Exclusive breastfeeding and adequate complementary feeding were promoted through local me- dia. • A communication plan was developed to teach mothers how to prepare nutritious porridge with local foods, through community demonstrations. • The lives of at least 4,000 children < 5 years of age were saved. -9- Lessons learned The Nutrition Cluster is a very important entity to coordinate ac- tions during emergencies. It is important that the Nutrition Cluster know in advance which institutions work where and what kind of inputs are pre-positioned. Risk management plans need to be ready at the local level in ad- vance of emergencies. Although emergencies occur every year in Guatemala, the emergen- cy response often fails to incorporate the management of malnutri- tion among its priority actions. - 10 - Recommendations for policy change Community leaders and those working in entities that deal with emergencies should have some basic knowledge about the im- portance of protecting nutritional status in unstable times, so that immediate action can be taken to promote breastfeeding and to protect children <5 years of age, especially exclusive breastfeed- ing in children < 6 months of age. Such knowledge is particularly critical, because one of the first foods donated during emergen- cies is powdered milk, and there is as yet no regulation to control these donations. - 11 - Haiti: Tackling Malnutrition with Ready-to-use Local Food Products Clark Matthews7, Marie Chantal Messier8, Peter Policy Implications and Recommendations Holland9, and Lora Iannotti10,11 bPrevention and treatment of malnutrition requires sus- tainable, scalable, multisectoral approaches. Chronic undernutrition significantly im- bComplementary food supplements can be cost-effective pedes a country’s development and eco- in addressing chronic undernutrition. nomic growth. In Haiti, before the Janu- ary 2010 earthquake, approximately one in bBetter nutrition outcomes can contribute to faster eco- nomic growth and higher rates of return on investment. three children <5 years of age was stunt- ed—an indicator of chronic undernutrition. bNutritious supplementary foods can be produced local- ly, contributing to economic development and poverty Stunted children do not fully develop phys- reduction. ically and mentally, which in turn reduces their capacity to become successful and bProvision of these foods should be accompanied with other health and nutrition services, such as growth productive adults. Thanks to a local ini- tiative in northern Haiti, a new nutritional promotion, education regarding optimal child feeding supplement is showing promise in efforts practices, vaccinations, and hygiene. to tackle the country’s twin challenges of bDelivery requires innovative solutions to reach the most chronic undernutrition and unemployment. vulnerable children. bMonitoring and evaluation is essential to ensure the effi- ciency of intervention. Innovative products to prevent chronic undernutrition In the last few years, various food-based products inhibits microbial growth and allows safe storage at have been developed to deal with the different forms home even in tropical climates. They do not require of undernutrition, in both the treatment and the pre- dilution or preparation and can be consumed directly vention stages. They are primarily fortified, ready- from the package or combined with meals. Ready-to- to-use food products that consist of peanuts, oil, and use therapeutic foods (RUTFs) are calorically dense milk and that provide a concentrated form of energy, and are used for the treatment of acute malnutrition, fat, protein, vitamins, and minerals. These products whereas ready-to-use supplementary foods (RUSFs) have a long shelf-life and contain no water, which contain fewer calories, yet still have a full comple- 7 World Bank, HDNED. 11 Christine McDonald provided editorial support. 8 World Bank, LCSHH. 12 Chronic undernutrition refers to a child with a low 9 World Bank, LCSHE. height for age. The condition is also referred to as 10 Washington University. growth retardation or stunting. - 12 - The Costs of Undernutrition in Haitian Children and the Rationale for Investing to Prevent It Annually, Haiti loses over US$56 million in GDP to vi- tamin and mineral deficiencies, and approximately one-third of child deaths are due to undernutrition, mostly from increased severity of disease (1). Prior to the earthquake, one-fourth of infants were born with a low birth weight, and three-fourths of children 6-24 months of age were anemic. Children less than Source: Nutriset, 2012 36 months of age are the most affected by chronic undernutrition, with two-fifths of children suffering ment of vitamins and minerals, and are intended for from growth retardation (2). the prevention of chronic undernutrition. RUTFs have been used in Haiti for many years for the treatment Poor infant feeding practices contribute greatly to of acute malnutrition. The use of RUSFs for the pre- these alarming rates of undernutrition. Only 41% of vention of chronic undernutrition has, however, until infants younger than 6 months are exclusively breast- now been limited. fed, and 68% of children aged 6-24 months are not fed according to the three recommended infant and Nutributter is an RUSF, a 20-gram package of which young child feeding practices, namely diet diversity, provides about 100 kilocalories and 100% of the daily adequate feeding frequency, and receiving breast- recommended intake of key vitamins and minerals. feeding or milk products (3). Feeding children highly The product is suitable for children 6-24 months of nutritious foods is a daily challenge for Haitian fami- age and should be used to complement, not replace, lies, as nutrient-dense foods are often unavailable or continued breastfeeding and a varied diet of local unaffordable. Poor dietary quality and high rates of foods. infections are compounding factors that exacerbate rates of undernutrition in the country. A study to assess the effectiveness, feasibility, and acceptability of distributing complementary food The first 1,000 days of life is a stage of crucial growth supplements was funded by the World Bank in 2011 and development, during which undernutrition can and carried out by the George Warren Brown School most effectively be prevented. After the age of 24 of Social Work at Washington University, in collabora- months, the consequences of chronic undernutrition tion with Edesia, a US-based producer of Nutributter, become irreversible, and a child’s cognitive develop- and Meds and Foods for Kids (MFK), the local manu- ment suffers. facturer of ready-to-use foods based in Cap Haitien. As per MFK’s model, the food supplements were de- The Copenhagen Consensus has ranked nutrition in- livered in conjunction with an integrated package terventions among the most profitable of social in- of services that includes education about exclusive vestments. Moreover, evidence for investments in breastfeeding for the first six months of life to reduce early childhood development (ECD) demonstrates the prevalence of chronic undernutrition, improve that rates of return on such investment can be sub- anthropometric measures, and promote cognitive de- stantially higher than the rates for remedial human velopment in early childhood. development interventions (4). - 13 - Developing a Local Solution to Chronic Undernutrition MFK is a registered non-governmental organization vided into mother-infant pairs and randomly assigned that has operated in Haiti since 2003. As part of the to one of three groups: 1) integrated package (IP) World Bank grant, MFK implemented a randomized only; 2) IP plus Nutributter for three months; and 3) controlled trial of Nutributter to determine the ef- IP plus Nutributter for six months. Infants in groups fectiveness of providing RUSF in tandem with other 2 and 3 start receiving Nutributter between 6 and 8 health and nutrition services to prevent chronic un- months of age. dernutrition. The study also aimed to determine the viability of a market for locally produced Nutributter, The study will be completed in November 2012, and its which would involve local farmers and agribusiness. findings are expected to be presented in early 2013. Initial findings suggest that the use of RUSF in Haiti The trial began in June 2011 and is being conducted can successfully lower micronutrient deficiencies in in Fort St. Michel, a large slum area on the northern young children and contribute to improved nutrition coast of Haiti where 32% of children <5 years of age security, which will ultimately improve ECD outcome are stunted. A total of 350 participants are being di- indicators. - 14 - Benefits of preventing malnutrition with local production of RUSF It is highly cost effective to prevent malnutrition The estimated unit cost of production of Nutributter through the provision of a small amount of fortified is US$0.08-0.12, which equates to US$9.60-14.40 per complementary food to enrich the nutrient density four-month treatment of a child (excluding costs of a young child’s diet. Averaged over a year, associated with the initial investment). complementary food for the prevention and treatment of moderate malnutrition costs about US$0.11-0.22 per Local production of these complementary foods child per day (including distribution/delivery costs). can also contribute to creating local employment in On the other hand, community-based management the short term. In response to increased demand of severe acute malnutrition is an expensive for these foods, MFK is investing in a larger, more intervention, which costs US$200 per child treated. efficient factory that will lead to greater economies The cost savings of complementary foods is estimated of scale, increased output, and a positive impact on to be US$500–1,000 per disability-adjusted life-year the national economy, by sourcing products from local (DALY) saved, while community-based management farmers, employing and training Haitian workers, and of acute malnutrition is US$41 per DALYs saved (5). supporting local agribusinesses. Program and policy implications The results of the Nutributter study will allow policy remote populations that suffer the highest rates of makers to see how the provision of a low-cost, locally malnutrition; quality assurance so that, as it increas- produced nutritious product can have a beneficial im- es, local production of complementary foods contin- pact on children’s health and nutritional status while ues to be in accordance with international standards; improving their development outcomes. and rigorous monitoring and evaluation to assess im- pact and continue to inform policy with evidence. The study also demonstrates how effective invest- Lastly, supporting sustainable local production and ment in agriculture and agri-businesses can contrib- achieving economic development will require pur- ute to better human development outcomes while poseful coordination across multiple sectors and with creating jobs and fostering economic development. farmers and agribusinesses, research and develop- The prospects for successfully scaling up this innova- ment, effective service-delivery, and monitoring and tion are good. In the Haitian context, where peanut evaluation. paste is already a staple, Nutributter fits well into food-consumption practices. Implementation of sup- Over the long term, the benefits of local food produc- plementary food products for children, to be effec- tion extend beyond the prevention of undernutrition. tive, should be accompanied by education about op- It can contribute to better educational outcomes and timal infant and young child feeding practices, such thus enhance job prospects in adulthood. Fostering as breastfeeding, and health interventions such as nutritional security in children means that the next vaccinations, growth monitoring, and early childhood generation of Haitians will better reach their poten- stimulation. tial as a smart, strong, and healthy workforce. In a country such as Haiti, with high unemployment and As is the case with any small business looking to grow, low productivity, this low-cost, high-return interven- the next phase presents some challenges: the lack of, tion holds the promise of becoming a game-changer. and need for, innovative delivery strategies to reach - 15 - Honduras: Community Nutrition Volunteers Promote Child Health and Nutrition Services in the Wake of Hurricane Mitch Marcia Griffiths13 The Situation In late October 1998, Hurricane Mitch left Central America reeling from its destruc- tion. In Honduras especially, the storm ravaged large portions of the country with high winds, dumping over five feet of water in one week. According to USAID calcula- tions 5,000 people were killed and as many as half the inhabitants were temporarily displaced. Many of the most-affected areas were already suffering from isolation, underdevelopment, and high levels of child undernutrition. Description of the intervention during the emergency response AIN-C is a community-based program that prioritizes A few months prior to Hurricane Mitch, Honduras, growth promotion. It has been adapted from earlier through the Maternal and Child Health Department programs in Asia that had been shown to be effective of the Ministry of Health, had launched a communi- in preventing malnutrition in young children. Its core is ty-based child care program—atención integral a la the prevention of undernutrition in infants and children niñez—comunitaria� (AIN-C). The five health areas <24 months of age. AIN-C is centered on individual, where AIN-C was first introduced were also within family, and community actions to improve child health the zone most affected by Mitch. and nutrition by focusing program actions, whether by the household or community, on maintaining ade- quate monthly growth in all children <2 years of age. Each community that initiated the program had se- The program approach features community volunteers lected several community volunteers (monitoras) called monitoras, who weigh and counsel caregivers of to be trained in its key activities and to serve as all children <2. They also refer children found to have the link between the community and the program. problems to the nearest health center. The program Among the monitoras’ first activities was the con- combines and strengthens health and nutrition actions duct of a census of all children <24 months of age. to prevent and reduce the prevalence of malnutri- They then began a monthly program of tracking and tion and illness in young children. AIN-C also provides promoting adequate growth in all children, through a platform for other child health interventions, such weighing, counseling, and, when indicated, refer- as immunizations, newborn care, and the integrated ring children to the health facilities. management of childhood illness (IMCI). 13 The Manoff Group. - 16 - Though the program had just begun, the support that was gathered from 35 communities with the AIN-C its volunteers offered during the emergency response program selected at random from two health areas proved invaluable in those communities. In the after- affected by Mitch. The community censuses with nu- math of Mitch, as relief workers were trying to docu- tritional status taken in July/August of 1998 (a few ment the situation, these trained monitoras already months before Mitch) showed a 19% prevalence of un- had a census of the children in their communities as derweight in <2-year-old children. Almost a year later well as scales with which they could quickly assess the the community censuses from these same communi- nutritional status of children to determine the com- ties in May/June of 1999 showed a 14% prevalence of munities’ nutritional needs. They were also available underweight. While trend data from non-AIN-C com- to distribute food rations; make sure that families munities is not available, it would not be expected to with young children and others in great need received see underweight fall in the immediate aftermath of appropriate support; and advise caregivers on child a disaster such as Mitch. And, in fact, a study among feeding practices, the importance of using clean wa- resettled families showed that they were confronting ter, and the management of diarrhea. a nutritional crisis in July and August of 1999, some nine months after the hurricane. It is probable that Anecdotes abound about the importance in the re- the monitoras’ work helped avert a serious nutrition lief efforts of the monitoras and other community crisis during the emergency. agents. A few months after the disaster, information - 17 - AIN-C as a useful platform for reconstruction efforts A portion of the reconstruction money given to the In the communities supported with reconstruction Government of Honduras by USAID went to expanding resources where AIN-C operations had been conduct- AIN-C from five to 11 health areas. The reconstruction ed for at least 6 months (43 of 275 communities), program began by training the health officials in each BASICS—a USAID-supported child survival assistance new area, and they in turn rolled out the program. program—did a quick assessment, collecting routine Within a matter of months, over 1,000 monitoras had growth information (weight-for-age) on children <12 been selected and trained and were working in about months of age, i.e., those for whom a short exposure 275 communities identified as the most in need within to the program would produce the greatest effects. the catchment area of every center in the new health Even before the end of the reconstruction period, re- areas. sults showed a 50% reduction in underweight among infants <12 months even though the mean age of the PERCENTAGE OF children at the time of the second measure was about CHILDREN WITH WEIGHT a month older (see table below). FOR AGE < -2 SD First Measurement Second Measurement Girls <12 months 8.4% (20/239) 3.5% (5/141) Boys <12 months 6.8% (18/264) 4.1% (7/172) Total 7.6% (38/503) 3.8% (12/313) In the table above, of note is the significant decline in the number of children weighed between the first and the second measurement, which could mean that the program was not registering new children and that families in the aftermath of the disaster were not at- tending as regularly as needed. - 18 - Lessons learned • Community programs, like AIN-C, can be an efficient mechanism to protect young children’s nutrition and provide an important channel for the government or other assistance agencies to funnel support to communities in need during a period of crisis or emergency. This is because community workers know the families and those who are most vulnerable; they are willing to be called upon to help their communi- ty; and they can provide educational support to families to ensure rapid recovery among young children. • Community-based growth promotion programs such as AIN-C can be strengthened and scaled up, and they are a good investment, in the aftermath of an emergency or during a time of economic crisis, to swiftly deliver services to affected families. Community agents can carry important information to the community and can distribute food, nutrition and health supplements such as micronutrient powders and oral rehydration salts for young children, as well as hygiene and water purification products. •Community volunteers can prove useful for efficient targeting. Since they know who the neediest fami- lies are, they can be the central link to ensure that food and programs are targeted correctly. Care must be taken, however, to ensure the credibility of the monitoras and their impartiality. There must also be good communication from the authorities on the temporary nature of assistance, such as food rations, in order to maintain the community’s willingness to participate in community activities and with the monitoras once assistance is withdrawn. •Monitoring of data collected by the monitoras and linking them to national health information systems is crucial for rapid and effective nutrition response. As are other countries, Honduras is piloting the use of cell phones, to speed up data sharing and increase the cost-effectiveness of the program. - 19 - Peru: Community Kitchens Optimize Nutrition Support to the Poor The Situation Marcia Griffiths14 In the late 1960s and throughout the 1970s, the urban centers of Peru experienced a population explosion, with rural dwellers moving in large numbers to cities in search of jobs. With no place else to go, these mi- Faced with economic stress and high food prices, grants established “young towns� (pueblos jovenes) women formed groups in these towns and began to around the outskirts of cities, the number of which buy food in bulk from wholesalers to get better pric- grew from 100 to 600 in 20 years. These towns lacked es. In the short term, they began cooking together as services, and often their populations, with poor Span- well, and their so-called “common pots� gained pop- ish-language skills, found it difficult to cope in the ularity, giving rise to the community kitchen move- unfamiliar urban environment. ment. Description of the intervention The community kitchen movement in Peru is an ex- ticipants are remunerated for time spent in service of ample of innovative schemes designed by the people the kitchen. The hours of free work that a family con- who are most affected by the crisis as a means of tributes to the operations allow them to take either coping in the easiest, most sustainable way possible. free or reduced-price meals from the kitchen. Other Community kitchens are generally organized by wom- people who do not volunteer their time can benefit en leaders, and run by women who are the consistent from most kitchens by paying for their meals. The cost users of the kitchens, although others may join on a of the meals prepared by the kitchens is affordable, more temporary basis. The women buy food in bulk to as it is below the cost of the same meals if they were get cheaper prices from retailers, and then on a giv- prepared by that individual or family on their own; en day they cook meals together for the participating the lower cost derives from the ability of the kitchens families, others who purchase meals, and often for to obtain food at reduced prices or from donations widows and orphans in the community. One study (1) and from the fact that the families do not have to found that women spent one full day every two or pay for cooking fuel. In the study cited above, it was three weeks in the community kitchen. The kitchens found that about 35% of the food at the community allow participants to serve their families from one to kitchen was obtained at a reduced price, and about three meals a day. Each kitchen calculates how par- 7% was donated (1). 14 The Manoff Group. - 20 - From a grass-roots approach to a social safety net When Peru experienced severe macroeconomic ad- offered community kitchens subsidies and food com- justment in the 1990s, which was coupled with a steep modities. In addition, to maximize their service to rise in unemployment and spiking food and electrici- the poor, many kitchens were able to obtain multiple ty costs, the government and many donors channeled sources of funding from donors. Those “enhanced� their support through the community kitchens. As the kitchens continued to provide food, but also offered number of people seeking inexpensive meals rose, the classes to women on nutrition and on home econom- government subsumed the community kitchens under ics topics, such as “best buys� and food preservation. its social program to increase the buying power of the The community kitchens thus proved to be a critical poor and help them cope with rapid inflation. It then safety net, providing meals at little or no cost. Nutritional benefits of participation in community kitchens Community kitchens helped prevent many families ate more beans (a common donation to the kitchens), from going hungry during years of intense economic eggs, and dairy products when they participated in hardship in Peru, according to numerous anecdotal the kitchen program than when they did not, although reports. When donated foods became available, the their consumption of fruits and vegetables was about mid-day meal served by the community kitchen in- the same as those who did not participate (1). creased from about 690 to 1,036 Kcal/meal—certainly enough to make a major contribution to a person’s While the kitchens can improve diet diversity, they daily calorie requirement. Even more important was can also be a channel to target improved intakes of the composition of the meals and who benefitted most specific nutrients. Another study demonstrated that, from them nutritionally, namely women and possibly by distributing iron tablets to women and adolescent young girls, as they were the ones who worked in the girls and increasing their use of iron-rich foods, includ- kitchens and had easiest access to the food. Many ing legumes, iron intakes were significantly increased women took their meals home and mixed the kitchen among those who used the kitchens: on average, 18% meal with additional food to feed the family, espe- for women and 11% for adolescent girls (2). cially during the worst of times. Only about 10% of children <4 years of age were receiving food from the kitchen; the rest were getting other food prepared at home. Women primarily, but their families as well, - 21 - Benefits beyond food Participants noted that working with the women’s Stability of the population participating in the com- group in the community kitchens improved their be- munity kitchens and the ability of the community lief that they could make a difference for their family kitchens to target those most in need were also iden- and community. Many women gave testimonials about tified issues. The participants were quite mobile, how they used skills learned in the kitchens to start moving constantly to find employment; nevertheless, their own businesses, thus helping their communities a core of women dedicated to the kitchens remained, develop economically. providing stability for the programs (3). Mobility is the main challenge Participants noted that working with the women’s Stability of the population participating in the com- group in the community kitchens improved their be- munity kitchens and the ability of the community lief that they could make a difference for their family kitchens to target those most in need were also iden- and community. Many women gave testimonials about tified issues. The participants were quite mobile, how they used skills learned in the kitchens to start moving constantly to find employment; nevertheless, their own businesses, thus helping their communities a core of women dedicated to the kitchens remained, develop economically. providing stability for the programs (3). - 22 - Lessons learned • Community kitchens are an efficient approach to reduce hunger among the poor during times of high eco- nomic stress. They provide a social safety net and can have a nutrition effect when carefully planned. • Governments and donors can easily use this community scheme to directly scale up assistance to the poor and provide a sustainable solution in the face of economic crisis and high food prices. • Community kitchens adjust to the labor market and general economic conditions; hence targeting of the poor and most in need through community kitchens is self-selective. The kitchens can expand and shrink as participants continually assess the trade-off between unpaid work in exchange for free or inexpensive meals and the pursuit of opportunities in the labor market. •Community kitchens can enhance women’s skills, leadership, and economic power and can be used to orient them to useful social services. They build peer-support among women, who learn to cope together with difficult and often new circumstances of unemployment and poverty. Women also acquire new skills, which can then be applied to starting a business or to increasing their employability. •Community kitchens can be easily scaled up and replicated to other settings, including developed countries. Several communities in Canada have set up community kitchens for poor populations, particularly in urban settings. - 23 - Guatemala: The Coffee Crisis and the Monitoring of Child Growth Existing community-based programs that moni- tations. In Guatemala and elsewhere, some families tor child growth can serve as an early warning sys- moved, while others stayed on or near the planta- tem during times of severe fluctuations in weather tions, protested the closings and layoffs, and tried to or employment. Periodically, the price for coffee on make do until better times. Workers began to support the world market fluctuates dramatically, as it did their families by any means possible, including stop- when Vietnam and other Asian countries sold a plen- ping cars to exact a toll on the mountain roads near tiful supply of good beans on the market and drove the plantations. down the price of coffee. This deflation caused cof- fee growers in Central America to drastically cut the In the middle of the crisis most policy makers were amount of coffee they harvested, which in turn meant focused on the economic and security situation, not mass unemployment for day laborers on coffee plan- the festering health crisis until community nutrition workers sounded the alarm. These volun- teer workers weigh young children every month (see the Honduras AIN-C case study) and assess the numbers of children in their community who have failed to gain ade- quate weight. Within a month and a half of the coffee crisis, health centers in the area were receiving reports from the volunteers citing high numbers of children who were not growing adequately –that is, they were failing to gain weight. When these reports reached the health centers, they sent teams to the affected communities to assess the situation. Those teams determined that a significant proportion of the young children, in a very short period of time, was suffer- ing from acute malnutrition. In communities where no child had been acutely malnour- ished (low weight for height), 12-18% of the young children in affected communities were thin. As a result, food was rapidly mobilized and distributed to families with pregnant women and young children to avert a seri- ous nutrition emergency. Again, the case of coffee workers in Guatemala demonstrates that investments in a community nutrition program, even when focused on prevention, pay off in times of crisis. - 24 - - 25 -