New findings question the extent of a nutritional crisis among the estimated 150,000 internally displaced people scattered in sites around eastern Chad yet even as aid agencies in the area publicly dispute each others’ malnutrition data, all agree that the spat must not distract attention from the hardship people there are suffering.
“It is unfair to the beneficiaries to go on in this battle of numbers,” said Alessandro Loretti, the World Health Organization (WHO) coordinator of emergency response and operations, who recently returned from Chad. “The fact is that we have a critical situation on our hands. There is no reason for complacency.”
A dozen international NGOs are working in the vast wilderness of eastern Chad to provide emergency shelters, food, and water, even while attacks continue by various rebel and other armed groups and the rainy season makes many of the already isolated areas harder to reach.
With the logistical difficulties that NGOs face, reliable data has been difficult to come by.
That is why in May the French arm of the aid organisation Médecins Sans Frontières (MSF) undertook a survey in five sites for displaced people in which it found four children under five are dying per 10,000 every day, double the rate that signals an emergency, according to WHO thresholds. MSF also said that 20 percent of children under five suffer from acute malnutrition at four of the sites it assessed.
But since then the Italian NGO Cooperazione Internationale (COOPI) has undertaken its own survey. “We have shown through a nutritional screening that the situation is under control,” said the head of all the COOPI projects in Chad, Giacomo Franceschini who said COOPI has been screening thousands of children.
The MSF nutrition data have been widely publicised by the media. MSF published a press release on 8 June highlighting the continuing emergency in eastern Chad. It said that levels of malnutrition are so high because people who have been internally displaced have received inadequate rations of water and food. It also criticised the Chadian government which it said had “refused” to allow MSF to open a paediatric hospital in Goz Beida, close to where most of the displaced are living.
MSF warned that malaria cases and epidemic diarrhoeal diseases were likely to increase during the rainy season, as well as malnutrition. “Given the foreseeable deterioration in the situation it is urgent, in order to avoid a catastrophe, to increase hospitalisation capacity, improve the water supply and respond to the nutritional problems,” it said.
It is the nutritional angle of MSF’s campaign, however, that has made headlines. French publications including Le Monde, L’Express and Le Point, reproduced a Reuters news report in early July titled ‘Famine threatens thousands of refugees in the east of Chad’, even though none of the aid groups have mentioned ‘famine’ and the dispute over malnutrition is focused not on refugees but on internally displaced people.
COOPI meanwhile has openly disputed MSF’s figures on nutrition in a press release issued 2 July. It states that in the sites it surveyed around the town of Goz Beida only seven percent of children suffer from malnutrition, noting that WHO only considers a 10 percent malnutrition rate an emergency. “We are well below the 10 percent,” said Franceschini, who oversees COOPI projects in Chad “The situation is not as bad as it seems.”
“That’s not true at all,” countered Isabelle Defourny, head of MSF programmes in Chad. “We’re talking about a nutritional situation that isn’t good and we fear that it will continue to deteriorate.”
The survey conducted by Epicentre, MSF’s research and epidemiological survey centre, used the so-called Z-Score system which measures the weight and height of children and compares the results to international standards.
COOPI, on the other hand, used a mixed system. It starts with a system that measures ‘middle upper arm circumference’, known as MUAC. Then, if those results suggest malnutrition, it also measures children’s height and weight.
“We’ve been using this method since 2004,” said COOPI’s Franceschini “The numbers have always been considered valid. I don’t know why they’re being questioned now.”
Both systems are internationally recognized. The MUAC system is often used for quick assessments; the Z-Score is a more thorough technique. It tends to produce results that show higher levels of malnutrition than does the MUAC system.
WHO has endorsed MSF’s numbers. “WHO takes [MSF’s] Epicentre survey very seriously as a welcome and useful sound of the alarm for a situation which threatens to get out of hand at any moment,” Loretti, WHO’s coordinator, said.
Loretti called COOPI “arrogant” for assuming that malnutrition in the area is not a serious problem. “The moment that [COOPI] says the situation is ‘under control’, they are getting out of their league and they are in fact passing a message that is not true.”
“It’s irresponsible of COOPI to take this position. I think they should be ashamed of themselves,” he added.
Loretti explained how he thought COOPI came up with what he considered to be a mistaken result: “The COOPI findings are resulting from a surveillance-based system which is very good but is clearly not reaching far enough or deep enough in the community.”
For its part, COOPI said it has considerable knowledge of the area having run projects in Chad for nearly 15 years. It runs the only hospital within a 200 km radius of Goz Beida and has regularly screened and treated children in displaced sites for malnutrition.
Moreover COOPI said it screened more than 10,000 children in June in order to come up with its result, while MSF had surveyed only around 1,000 children in May.
Aid groups at war
The differences between MSF and COOPI have turned into a a kind of “war” according to the head of health and nutrition for UNICEF in Chad, Bechir Aounen, which has raised concerns among other actors. “Whether it’s 7 percent or 20 percent, our first priority is responding to malnourished children,” he said, adding that the two agencies had carried out their research for different purposes, in different sites, and so the two groups’ results should not be compared.
“We are working to better assure coordination of nutritional activities in the future with the goal of harmonising protocol and methodologies,” he added. Since the divergent results have emerged, UNICEF has tried to persuade MSF and COOPI to undertake joint research.
“Unfortunately, each one didn’t want to work with the other,” he said.
Nick Ireland, Oxfam West Africa’s Regional Emergency Adviser in Dakar, who has worked with NGOs in emergencies for a decade, said agencies’ predetermined agenda’s can often be a cause of conflicts between them. “Every organisation has its own mandate and way of working,” Ireland said. “Often the biggest problem is that the headquarters emergency desks catapult people into an emergency and they will have preconceived ideas of what they will do”.
“If you have been set on a track to do something then the last thing you want to do is to sit around with people who say you should not be doing that.”
To try to bring about some consensus on the issue UNICEF, along with the WHO, the World Food Programme (WFP) and Chadian ministry of public health are currently analyzing results from their own recent enquiry. The preliminary results in six sites confirm the MSF figure of 20 percent malnutrition rate for children under five.
Still the consensus is not there. A WFP spokesperson in Dakar said that from the preliminary results WFP plans to increase its food rations to displaced people in the coming months from 1,800 to 2,100 kilocalories per person per day. But UNICEF’s Aounen said he would not classify the situation in Chad as a crisis. “The situation is worrying but I personally do not see it as a crisis yet,” he said.
What all parties can agree on, including Franceschini, the head of COOPI in Chad, is that the displaced people in eastern Chad are living on the edge. There is not enough water, food or latrines in the region, Franceschini said. “Certainly there are improvements to be made.”