Nourishing People Feeding Hope

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Nourishing people, feeding hope
Acknowledgment of the transcendental worth of every man and every woman is still the first step towards the conversion of heart that underpins the commitment to eradicate deprivation, hunger and poverty in all their forms. Benedict XVI, FAO, World Summit on Nourishment, 16.11.2009
This document is a collection of Best Practises in the Agriculture and Food sector, made possible thanks to a project called Company for Development: Alianzas trans-nacionales entre Actores No Estatles, Autoridades Locales y la comunidad institutional para una cooperacin al desarollo ms eficiente cod.DCI-NSA/2009/205-463 co-funded by the European Union, The first objective of this project, started in November 2009, is to improve the information network and the exchange of best practises of non governmental authorities and local authorities, involved in the AVSI network, also including the following European NGO: CESAL in Spain, VIDA in Portugal, AVSI POLASKA in Poland, FUNDATIA in Romania and SOTAS in Lithuania. The experiences of AVSI Foundation and some of its partners, here mentioned, were presented and discussed in December 2009 in the workshop: Feeding People, Energy for Life with the participation of more than 100 people from different NGOs, connected with AVSI in Europe and in the world, AVSI volunteers in the different countries, university teachers, and academics specialized on these topics.
NOURISHING PEOPLE, FEEDING HOPE Interventions on Food Security, cure of malnutrition and agricultural production Pocket-edition n.10 Edited by Benedetta Fontana and Sheila Berti Authors: Maria Teresa Gatti e Benedetta Fontana, with the collaboration of Chiara Mezzalira, Louisa Adegun Adeyasi, Rossana Stanchi, Adriana Pieiro, Gisela Solymos, Paola Cigarini, Jessica Martin, Omar Macedo, Fiammetta Cappellini, Espedito Ippolito, Riccardo Bevilacqua, Fernando Bonzi, Mauricio Moresco. Copyright AVSI www.avsi.org year 2010 Cover Image AVSI Farmer in Rwanda Graphic Design Accent of design, Milan Photocomposition and printing Pixart ISBN Code 978-88-903534-9-9
AVSI Italia 20158 Milano Via Legnone, 4 tel. +39 02 6749881 milano@avsi.org 47521 Cesena (FC) Via Padre Vicinio da Sarsina, 216 tel. +39 0547 360811 cesena@avsi.org
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Index
Introduction
Maria Teresa Gatti and Benedetta Fontana, AVSI, Milan
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1.
1.1. 1.2.
Health nutritional centres

Chiara Mezzalira and Louisa Adegun Adeyasi, AVSI, Nigeria and Southern Sudan
Southern Sudan: health nutritional centre of St. Theresa Hospital Nigeria, Lagos: health centres for malnutrition cure
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2.1.
Refectories and centres for education and recovery from malnutrition

Mexico, Oaxaca: Refectory - Education on food relief and recovery from malnutrition
Rossana Stanchi, AVSI and Adriana Pieiro, DIJO, Mexico
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2.2.
Brazil, So Paulo: CREN - Centro de recuperaao e Educaao Nutricional (Centre of Recovery and Nutritional Education)
Gisela Solymos, CREN, So Paulo, Brazil
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2.3.
Brazil, Salvador Bahia: COF-Centro de Orientao da Famlia (Family Orientation Centre)

Paola Cigarini, AVSI, Salvador Bahia, Brazil
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Fighting malnutrition projects in the urban and rural field with focus on agricultural production
Peru (Andahuaylas and Huachipa) CESAL Recovery from malnutrition and improvement of agricultural production
Jessica Martin and Omar Macero; CESAL, Peru
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3.1.1. 3.1.2.
In Apurimac Region (Sierra Andina) Methodological notes
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3.2.
Haiti, rural zone in the South and Port-au-Prince: nutritional centres in rural area and urban horticulture in the capital
Fiammetta Cappellini and Espedito Ippolito, AVSI, Haiti
Riccardo Bevilacqua, AVSI, Rwanda
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Argentina, Santa Fe: The experience in urban and rural field

Fernando Bonzi, Mauricio Moresco, ACDI, Argentina
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3.3.
Rwanda: Humure nutritional centre, first development ring of the community
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Introduction
Maria Teresa Gatti and Benedetta Fontana, AVSI, Milan
Even as data demonstrate that the planet is able to abundantly nourish humanity today and tomorrow, we are forced to reflect on the fact that more than a billion people suffer from hunger while the international community has as an objective the reduction of worldwide poverty. Nourish the planet, energy for life is also the theme of Expo 2015 that proposes a debate at an international level regarding topics such as nutrition, health, quality diet for all human beings, giving visibility to tradition, creativity and innovation in the food sector. The debate emphasises the necessity of innovation, of the entire food supply chain, through research, technology and entrepreneurship, in order to improve the nutritional characteristics of the products, their conservation and distribution. The latest world summits on food (FAO) have highlighted how, in front of the concreteness of the problems and the alarming data that the planet is dealing with, it is difficult, for the Big of the world, to react in a concrete manner with actions that can bring effective results, even though the development of agriculture and food security are among the priority objectives of international political action. In this document, given the newsworthiness and importance of the theme, we have thought of presenting some examples of actions that AVSI and some of its partners are implementing in the world on the theme of nutrition and agriculture. Our objective, on one hand, is to offer a concrete contribution to the debate, and on the other hand, to propose a reflection that can help those involved, as well as all partners of AVSI, to judge the experience underway and to compare it with other realities. Comparison with similar experiences, even if realised in contexts that are completely different, allows us to use as a resource the lessons learned and, at the same time, to again challenge development to a higher level. The reflection upon the experience represents indeed a push towards growth and improvement of every single action, widening its horizons, obliging every participant to raise his gaze and challenge himself on every level with the current themes that the world is dealing with or even to suggest new themes and points of view that arise from the experience underway and from the awareness of the civil and social dignity of his own actions. The undeniable connection between food production and nutrition is the common theme that has directed the experiences that we present, even when approached from starting points that are very different from one another. In fact, the AVSI working methodology always starts with the encounter with a person and his needs and not with an abstract idea or theory. For this reason, rather than a medical center with specific treatments to fight malnutrition, the starting point could be an educational action for the mothers of malnou-
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rished children or a community dining hall or an action that supports the cultivation of agricultural products, according to the reality that is encountered and the relationship that is created with the people who, together with AVSI, have decided to take part in this journey towards development. There are experiences that are very different, but are held together by some common characteristics of method: The first characteristic that is highlighted is the creativity and intelligence with which the projects have been designed, to serve the human needs, while remaining faithful and close to the local reality. The first action, therefore, in every project, has been the acquiring of knowledge, from which the responses have been born and then little by little have been adjusted, letting the reality of the situation dictate the rules of the game and not preestablished ideas. For example, in areas with very diverse contexts (urban vs. rural) such as in Haiti (rural zone in the south and urban zone in the capital) and in Africa , (Nigeria, in the metropolis of Lagos and in Southern Sudan, in the mountainous zone 100 Km from the Ugandan border), the interventions with similar objectives have generated projects completely different from one another. These projects range from health care centres for malnutrition to educational, agricultural and training programs. Programs begin with the availability of natural resources, fertility of the land, social resources, ease of access to food, and from the presence of related health problems (such as HIV/ malaria, and TB in Africa); projects are developed by considering a series of factors, the concrete knowledge of which is made possible only through human relationships and involvement. Reading the reports about the various experiences, it is clear that they often start with a hypothesis about the results of a specific action, formulated according to normal logic or even to what has been widely demonstrated by scientific studies and by the current literature. However, instead of generating an expected result, reality shows the contrary, thus making it necessary to understand and analyse the experience and call everything into question, changing the method and the action completely. Flexibility and the ability to analyse everything start from the fact that each of these projects puts at the centre of the action the person and his development and it is precisely from that relationship with the person and with his needs that the action is born. For this reason, the result can only be connected with the actual improvement of the lives of those who are involved. In all of the experiences that are described, the initial action is only a starting point, to enter into relationship with the life of a person in all of its aspects. This has been evident in the Mexican experience at Oaxaca, in which the local partner of AVSI, DIJO (Desarrollo Integral del la Juventud Oaxaquea), had to change its work
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method in more than one occasion in order to be able to improve the indexes of malnutrition of the children, reaching the families in their homes in order to understand the root of the problem. In Brazil, as in Salvador, they had to involve the mothers and give them the chance (through practical sessions) to solve the problem of malnutrition by changing only the diet and the habits of hygiene, without needing to turn to food that would be too expensive or distant from their cultural traditions. In the experience and in the relationship with the reality, the action is not only changed or adapted, but it follows the typical dynamism of human relations that, within a relationship, generates new fruits, new actions, trying always to respond more effectively to the needs of reality and the persons encountered. This is the reason why another aspect that all of these experiences have in common is that the results of the action greatly exceed those that were initially forecast. When one looks at a person in all of his aspects, the impact consists often in a life change that generates unexpected results often throughout the entire surrounding community, since we are dealing with persons who act using all of their infinite resources and potentiality. This is the case, for example, of the Centre of Nutritional Recovery (Centro di Recupero Nutrizionale CREN) of Sao Paulo, where among the unexpected results is, the reduction and ultimately the elimination of violent deaths, in the neighbourhoods in which the project operates. There is also the case of Rwanda, where, from the care of malnourished infants, the intervention that was directed to the education and the responsibility of the mothers led to the opening of a day care centre for the children of that area by the mothers themselves. An aspect, intrinsically linked to the previous ones, is the attempt to bring the beneficiaries to a real autonomy, and to eliminate the dependence that often characterises the interventions of development. Such an attempt is present in all projects although with different methods, The autonomy and the sustainability of the intervention, is not only required by major donors, but is also a fundamental necessity for development, therefore becoming a guarantee for the success of a project, and the avenue to restore trust in the ability to provide for the needs of their family for those who live in hopeless conditions of extreme poverty. All the interventions demonstrate that the results obtained are not fruit of a direct action of the project, but of a change of lifestyle of a family, of a mother, of a farmer, of a teacher, of a nutritionist, of a social worker, of persons who are involved at every level in the relationships that are being transformed. To cure a child is often an emergency and it must be done in the best way possible, with all the available technical means, with efficiency and effectiveness. With respect to the principle of subsidiarity, these projects have made the educative step that precludes replacing the mother or the family, no matter how precarious they may be, but, instead, they give back to them the responsibility of the child, helping them and supporting them so that this will take place in the best way possible. A mother, in fact, when she recovers the capacity to
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look after her own child, besides reaching the expected result in the care of the child, also recovers trust in herself and in life. An example of this is recounted by the social workers of CREN who noticed that in the weekends, when the children returned to their families, the indexes of malnourishment worsened. For this reason, they started to bring the children to their homes and to take care of them there, until they realised that an action of this type, besides not being sustainable over time, deprived the mothers of the possibility of taking care of their own children and thus of conceiving themselves as mothers. An example of overcoming dependency on the project, in an educative process and in a process of making the families responsible, is the intervention in Ruanda, where, next to the malnutrition health care centre, a vegetable garden and a farm were started with the mothers of the children who come to the centre . The mothers work and learn to rear animals and to grow vegetables, producing them for the centre and for their families. They are able to bring home, on a rotating basis, the results of their work, i.e. newborn animals to raise at home and seeds to plant. Another common aspect of these projects is the value given to the local culture and tradition. This is expressed by the emphasis of using foods and crops with an adequate nutritional and caloric value, that are not foreign to the local traditions. They start from the customs of the people, from the celebrations and customs of diverse people, putting technique and innovation at the service of development, according to the natural and climatic conditions of that country. This is the example of the intervention in the rural zone in the south of Haiti, that has reintroduced the growing of nutritionally rich red beans, to sustain the dietary recovery and protein needs of the children, Another is the CREN in Brazil that studies balanced recipes with the ingredients that every family, even the poorest, can obtain. Or again, in Haiti, at Port-au-Prince, they encourage the growth of small urban vegetable gardens on all available spaces, terraces, balconies, roofs of the houses, utilising old tyres or plastic containers, so that the families can produce what they need to feed themselves. Starting from the local culture means also beginning every intervention from what the beneficiaries have already put in place, from their responses or their attempts at responses, trying to reclaim and give value to everything that is positive and, as in the case of the action described in the metropolis of Lagos in Nigeria, to try to shake off bit by bit whatever some habits brought that is not positive. Not to catalogue some local customs as wrong, for example, but to try to adjust them in a more educative way that is more easily accepted by the population. In the Primary Health Care Clinic of St. Kizito (Nigeria, Lagos), for example, it has been preferable to maintain the custom of mothers using their finger to feed porridge to their children, giving value to the beauty and relational importance of that gesture, without feeling required to introduce the spoon or other techniques, but teaching the mothers the importance of the cleanliness of their hands. To share experiences forces us also, as already stated, to compare our actions with the challenges that appear evident in facing the concrete problems, some of them
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highlighted even by these documents. A first avenue for work regards the parameters of evaluation of malnourishment. One perceives, in many cases, that the data on malnutrition, highlighted by various interventions, does not always coincide with the official data of the country in which the action is carried out. This can be caused by various reasons: often the tendency in many developing nations is to minimise critical situations and to not declare the seriousness of the problem; in other cases we are dealing with problems related to a sample, concentrated in pockets of poverty; or in other cases, the parameters used are not consistent: it is necessary that everyone adheres to the scale of the World Health Organisation (WHO Child Growth Standards), adjusted by the Health Ministries of the single countries to the characteristics of the local ethnic groups. A second avenue for our work concerns the translation of the intervention methods into protocols and stable references that can be utilised and reproduced, always maintaining the necessary flexibility of adaptation to every situation. Just as it is highlighted by the experience of Salvador in Brazil or in Lima, Peru, in which the methodological and technical point of reference of the work against malnutrition is born from the experience of the CREN of Sao Paulo, but then the reality of the favela of the Alagados in Brazil and of the Huachipa in Peru have imposed a different method and from this a new action is born. The problem of the various experiences is the model of the nutritional centres: do they follow a health services model or a socio-educative services model? The health dimension requires protocols and levels of service that are very difficult and costly to guarantee and maintain. On the other hand, centres within the most impoverished communities provide precious services to improve access to food and dietary education which have an evident impact. The health approach and the educative approach have to be integrated. An intervention against malnutrition that ignores the health conditions gives uncertain results, but even an approach that concerns only health care without a dimension of involvement of the mother is not lasting. This dual approach is reflected also in the option: therapeutic food or prepared food. Even these two possibilities can be integrated: therapeutic food is very useful in situations of emergency (both in the context of emergency or of a person in an emergency situation). However, as experience has shown, it is necessary that even in the situations of lack of food security, the food has to be as it is in human existence: food comes from the transformation of products of the land and of nature, in quantities and qualities that are suitable for growth. From our experiences regarding this matter, a still fragile relationship emerges between the social-health activity of recovery from malnutrition and the dimension of the agriculturallivestock production and transformation. To feed oneself is the first human need: human activities are born of the satisfaction of this basic need, through a modality that reflects the attention of every human being to beauty,
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truth and goodness. Even the interventions that start from the lack of something, from malnutrition, they acquire enormous potential if they are put into this perspective: food as the basic need of the person, to satisfy it, the person himself concentrates energy and intelligence on its cultivation and the transformation of the products offered by nature. The examples of CESAL in Peru and of AVSI in Rwanda (Humure) and Haiti (both in the rural and in the urban zone) demonstrate the effectiveness of the experiences that are able to integrate the dimension of curing malnutrition with the one of agricultural production. In Peru, at Andahuayalas, this comes from the creation of irrigation canals that benefit seven rural communities, to the prevention and fight against infant malnutrition in the communities, (medical centres) and in the educational institutions, passing through actions of pecuniary agricultural development, of production, transformation and commercialisation of agricultural products, without omitting the training for agricultural producers (workshops in the field for the producers) and the organisation of associations of producers. Civilisations have chosen among the products of nature those that are the most suitable to the nutritional needs of the person and have developed the necessary capacities of transformation. Analogously, next to nutritional recovery, an intervention on food security requires capitalizing on local natural production and its transformation in food that is sufficient and adequate. The experience in the rural area of Haiti of the reintroduction of the red bean has been an emblematic experience, like the one in Peru of the production of the artichoke for exportation or the transformation of milk and its derivatives. Production is the last step highlighted by the rural development experiences proposed by ACDI in Argentina (and Central America) and by CESAL in Peru, in the rural area of Andahuaylas. The majority of people who suffer hunger lives in, or originated from rural areas rich in natural resources, just as it is described in the experiences It is evident, then, that it is necessary to recognize the value of agricultural and livestock work and to reinforce the production and distribution chains by bringing the producer closer to the consumer. That is, food security is not a problem of subdivision of the resources, but of their multiplication. Production is the last step shown by the experiences proposed by ACDI in Argentina
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health nutricional centres
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Context Isohe, village in the County of Ikotos, Eastern Equatorial State (EES), Southern Sudan, is located in a mountainous region, 100 kms from the northern Uganda border. It is part of the Torit Diocesis, and also the capital of the EES. Southern Sudan has been theatre of a civil war that has continued in various occasions for many decades. Since 2005, following a peace agreement, the inhabitants of this region returned from the over-crowed camps, arriving both from outside the country (Uganda, Kenya), and from the surrounding mountains. Many villages are located in the mountains and have begun to be repopulated. The people are able to provide for their familys survival through livestock (a few cows or goats, but only very few families have these means) and agriculture. The population in general lives with a chronic level of malnutrition, exacerbated by physical activity (constant movement for water collection, working the land, carrying weights, especially the women, frequent pregnancies, building and rebuilding the huts, following the animals, etc.), as well as by the shortage of food. There are no obese adults. Among the small children (from 0 to 5 years of age) the malnutrition rate varies from zone to zone, but it is always very high (according to the general indexes of the country, by the Food Security Emergency Action Plan, 12% are severely malnourished and 24% moderately malnourished)1. These indexes are present also in the infants school of Isohe, run by local nuns and supported by AVSI through the Distance Support Program, where a specific intervention aimed at offering to the children medicine against tapeworms and supplements of vitamin A, has permitted the measurement of height and weight of 129 children from 0 to 10 years of age. If we remember moreover that only the children who have the means to go to school (that is, they come from families that are probably more well-off) can go to an infants school, one can imagine that the situation of the surrounding villages is even worse. The fertility of the terrain varies greatly from zone to zone, but the agricultural production depends very much on the rain, and therefore a year of drought immediately provokes famine, because the conservation of the food products has the duration of a season at the most. The same is true for the animals that do not find sufficient forage. Moreover, the power of purchasing animals in times of famine is greatly reduced, further worsening the miserable conditions of the population. In Isohe, in the Dioceses of Torit, there is a rural hospital, the St. Theresa Hospital (approximately 100 beds), where an operating room is being built for surgical and obstetrical operations, managed by the Dioceses and supported by AVSI. Additionally, at Isohe, there is the already mentioned infants school with 200 children and an elementary school run by 2 nuns for another 1,300 children, in collaboration with
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1.1. Southern Sudan: health nutritional centre of St. Theresa hospital
Index Z score adapted for Southern Sudan
the government and the support of the Distance Support Program. The Dioceses of Torit also manages, together with the government, a college (high school) with approximately 800 students. Along the main road, 4 huts-shops sell cigarettes, sugar, some clothing and local beer. Under the trees there is a daily market where the women from the mountains bring their crops to sell (spinach, roots, peanuts, coal and wood). The St. Theresa Hospital also deals with the problem of infant malnutrition. There is a pediatrics ward in which the children are hospitalised. The most frequent pathologies are severe malaria, anaemia, diarrhoea, lower respiratory infections and malnutrition. The hospital has a mobile team able to reach the more isolated villages (there are 5 local periphery units run by the government with the support of AVSI). The mobile team carries out screening on the growth and vaccination of children, check up of pregnant women, malaria prevention with distribution of mosquito nets, integration of vitamin A and health education. In previous years, during the checking of weight of the children by the mobile team, the malnourished children were invited, once a week, to go to Isohe to the Supplementary Feeding Programme SFP, supported before by the CRS (Catholic Relief Services) and now by the programme of the United Nations, World Food Programme WFP, that supplies the food. Since October 2009, due to the food emergency (food security), in collaboration with the Government of Southern Sudan and the support of UNICEF , Therapeutic Feeding Programme TFP, was introduced for Out Patients or for those who were hospitalised in the most urgent cases (In Patients). The objectives of the intervention are: To reduce morbidity and mortality rates caused by malnutrition in children from 0 to 5 years of age; To educate mothers and families on correct alimentation, especially in the first years of life of their children; To provide nutritional and therapeutic intervention to malnourished children in the acute phases;
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To offer integration of supplementary food in the most needy cases (poverty, famine, etc.); To maintain a relationship of accompaniment of the children in the phases of recovery.
The primary activities: Training for the hospital personnel and the mobile team, in particular on the criteria of identification of malnutrition and the principles for managing it. Some of the staff selected for the nutritional programme have carried out a practical internship in Kitgum, Uganda and at the governmental hospital of Torit, where there are Therapeutic Feeding Centres. Selection of the personnel of the nutrition team. Even with the difficulties caused by the high level of staff turn-over and by the poor management of the hospital, AVSI identifies the personnel that will be part of the work team both for the Supplementary Feeding Programme SFP, and for the Therapeutic Feeding Programme, TFP, indicating the various roles. Identification of the cases of malnutrition: this takes place both in the hospital for patients who come with diverse pathologies or for vaccinations, or in the villages, when the mobile team conducts activities such as growth screenings and vaccinations of children and prenatal check ups. Furthermore there is a bi-annual monitoring of all the children under 5 years of age in every village (this activity is carried out in collaboration with the group of agriculture and nutrition of the dioceses.) Classification of the different levels of malnutrition (Very Severe, Severe and Moderate) and successive insertion of the malnourished children in more adequate nutrition programmes, divided into three levels: Hospitalisation of the very severely malnourished children (In Patient Therapeutic Feeding ITF). The children are identified in a situation of serious life risk (children with widespread edema and swelling, children with correlated pathologies caused by malnutrition, children with total lack of appetite).
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The children in ITF follow a government protocol (DRAFT Oct. 09 UNICEF) and they receive an integration of supplementary food, therapeutic food with high nutritional content and they gradually receive increased dosages so that the body, completely malnourished, slowly gets used to the ingestion of food, (F 75, F 100 and Plumpy nut) they receive between 8 to 6 meals a day, according to the various phases, with the supervision of a nurse assigned to the preparation and supply of the milk. Treatment for Out Patients (Out Patient Therapeutic Feeding OTF). The children are identified in situations of serious risk, but without correlated diseases and with appetite. In these cases, the children are visited on a weekly basis, their growth is checked and they receive the necessary food (distribution of therapeutic food for the entire week). Programme of weekly nutritional supplements, for patients with moderate malnutrition (Supplementary Feeding Programme SFP): growth is checked and food is prepared together with the mothers (enriched porridge). Food with high protein and nutritive value is distributed, and the mothers bring it at home and prepare it there (ground corn and soy with vegetable oil, to cook at home. This food is distributed by the World Food Programme of the United Nations). When the patients condition improves, one passes on to the successive phase. AVSI has set up at St. Theresa a food veranda where the mothers are taught how to prepare the food. Here the milk is also distributed and the mothers are helped while they give it to their children. In addition, the mothers learn notions of sanitary hygiene, they bathe their children and the nurses check the childrens appetite
Considerations and methodological reflections The Supplementary Feeding Programme SFP, has been active for three years, while the Therapeutic Feeding Programme began in October, 2009. It is still too early to identify the results concerning the overcoming of malnutrition. The first results certainly need to be singled out for recognizing the problem and for choosing how to deal with it. A fundamental aspect is to look at the diverse components and activities in an integrated way; preparing, training and motivating the personnel involved. A big barrier (besides the barrier of the local reality a dive into pre-history) is the language because of the various dialects. Also, many qualified staff come from Uganda and feel themselves to be superior to those with whom they work. They find it difficult to lower themselves to the level of understanding of the beneficiaries. This local mentality makes it very difficult to deepen relationships with the women. Local language and understanding greatly diminish the possible impact of health education actions. Beyond cases of real necessity and emergency, there persists some perplexity about and the need to deepen the understanding of the usefulness of therapeutic food. Perhaps it is more appropriate to use foods that are prepared locally, with the same nutritional and protein characteristics, that are easier to find and certainly more accepted within the local culture. The concern remains that not only do the therapeutic diets interfere
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with (or prevents) the education of the person they also become unsustainable once the childs has returned home after the hospitalisation. Medical personnel utilise a work method that consists of continual on-the-job training that is not limited to dictating some rules, but insists upon the reasons for which things must be done. They do not, therefore, give things that are already completed, but encourage a process of thought and reflection on how things should be done. Furthermore, the training method begins precisely from experience and practical demonstrations since a technical explanation alone, which does not show a human relationship with the technique, has proven to be inadequate. We have seen for example, that allowing the mother to gain experience, with the help of nursing personnel, on how her child should be weighed, is more effective than simply explaining how this is technically carried out. One notes a sort of resistance by the local personnel to remain in contact with the real situation: there is almost a dream of development, of greatness, because we are talking about a zone that has only recently come out of the war, from a situation of true crisis, in which there is the presence of various NGOs that work with a diversity of methodologies and interventions. It is as if often a situation of expectation is created, as if the workers and the beneficiaries expect everything, as if they would like to work in the conditions of the best European hospitals, with computers, advanced machinery, etc., while the reality is very different. It seems as if a middle ground does not exist. Often, if there is a computer that does not work, or if there are not enough pharmaceuticals, or if the food supplies have not arrived, then they do not even carry out the activities that do not need these elements: they do not weigh the children; or if there is not an examination couch, they do not even improvise with a blanket on a table: or if something breaks, they do not search for a way to repair it, etc. There is an enormous lack of education of the people which is further hindered by the distribution of material goods (soap, mosquito netting, food, etc., even Land Rovers, computers, generators, etc.). One can note the presence of the NGOs that are more interested in reaching certain indicators than in the question of the education and growth of the person. Shared moments for the preparation of food have been designed as a way to involve the mothers, sharing and teaching them also the way to cut the vegetables, to mix them, to cook them, etc., in addition to involving the mothers also in material contribution, whenever possible, to the food supply. A moment that often is very moving is when the mothers offer an egg, a handful of grain or millet. When it is impossible for the mothers to contribute with food, they are asked and encouraged to contribute by helping to keep the veranda clean. The same educational method of sharing takes place with the nurses and collaborators, who often learn by way of imitation, a different way of interacting with the children, even only by looking at how they carry the child in their arms. Seeing that taking care of the child in a specific way makes the child actually stop crying often elicits a change in their behaviour.
Lessons learned One of the main lessons learned from experience, has been that it is necessary to be patient and to respect the times and rhythms of Africa, , because they often are not the same as ours. It is important to believe that, even with times and rhythms that we cannot dominate, when the heart of someone is touched, beneficiary or operator, something inside is awakened, and the results are often unexpected. It is fundamental to remember that in Southern Sudan, the majority of the nurses, just like the rest of the population, until just a few years ago, were directly involved in the war. This means that there is a level of suffering that we often are unable to imagine: if they were not forced to kill, they nevertheless suffered hunger, thirst and they had seen and lived atrocious things. To rebuild in a context that is so marked by suffering, the attention to detail, to human things, to the cry of a baby, is not something immediate, that demands attention. In this context the people are so used to pain and suffering that they face the disease with a certain level of surrender, with the thought that, if this child dies, they will have another one. A lesson learned from this is the necessity of being able to see the person as a whole, as integrated and unitary, that takes into account all the factors in play and all the implied aspects: the mother, the child, the feedings, the therapy, the health education, the emotional level, the relationship, etc., to allow also the continuity of the treatment once the child is discharged and returns to his village.
1.2. Lagos, Nigeria: health centres for the cure of malnutrition
Context The metropolis of Lagos, 15 million inhabitants. A stretch of slums and entire areas on the lagoon with precarious homes built on piles. The people come from the villages, thinking that they will find work and prosperity and they remain at the margins. Malnutrition especially affects children from 6 months to 5 years of age. The cause is often found in pregnancies that are too close to one another and this brings the early suspension of breastfeeding, the main source of calories and protein in the first year of life. In the situations of extreme poverty, weaning takes place only with carbohydrates (roots, yams, manioc, corn) without it being integrated with protein and fat. This is caused primarily by ignorance, or by the fact that the mother works and therefore has very little time to prepare food: already in the first year of life, children begin eating the same food as the adults. Other diseases such as malaria, measles, AIDS and tuberculosis are also co-factors in the vicious cycle of malnutrition/disease. Intervention The Centre of Primary Treatment (St. Kizito Primary Health Care Clinic), built by AVSI in 1991 (project started in 1988) serves the population of a slum (low-cost public housing with high density) Ilasan, and the nearby villages along the ocean and the lagoon. This is a zone of rapid urban development, with an evident striking difference between the very rich and the very poor.
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The nutritional day centre was started together with activities for prevention and primary treatment, in order to face the problem of malnutrition. It has a veranda used as a centre for growth screenings as well as for sanitary hygienic and alimentary education given to the mothers, showing them food preparation that is age appropriate for the child, the distribution of food that is prepared along with supervision of the feeding of the child, distribution of a meal to bring home (dry portion to take home) made up of rice, corn, beans, or a mixture of corn, oil, ground peanuts, soy for the more seriously affected children and for the youngest ones. Here also all the laboratory tests and adequate routine therapeutic care are carried out. When we started to identify the first HIV positive children, we introduced HIV screening for everyone and careful analysis of the indicators of tuberculosis, as a frequent co-cause of malnutrition. The children are then inserted into the therapeutic programmes, in collaboration with other centres (for anti-retroviral therapy). To favour the continuity of the relationship and prevent a relapse into malnutrition, a monthly encounter has been introduced, on Saturday mornings, called the Friendship Meeting, that welcomes children who have only recently overcome malnutrition, HIV positive children or orphans of HIV positive families, with HIV positive adults and pregnant women. It is a moment of celebration, play, checking of growth, a meal together, distribution of food to take home. The objectives of the intervention are: To reduce morbidity and mortality rates from malnutrition in children from 0 to 5 years of age and in adult patients with tuberculosis or HIV; To educate the mothers and the families in correct alimentation, especially in the first years of life of the children; To provide nutritional and therapeutic intervention to malnourished children in the acute phases; To offer integration of supplementary food in the most needy cases (poverty, famine, etc.); To maintain a relationship of accompaniment of the children in the phases of recovery. The primary activities: Selection of the team that works in the aspect of nutrition; Training of the team, principally in the criteria of identification of malnutrition and the principles of its management, principles and foundations of alimentation in the first year of life, breastfeeding, weaning, therapeutic foods, categories of main foods and their nutritional characteristics; Performance of daily growth screening, therapeutic activities for the children according to the condition of their malnutrition. Daily therapy for the severely malnourished children, to then move to twice a week, then to once a week and only once a month until the child is healed, (coming off malnutrition); Home visits that can identify the principle problems in the families and establish a relationship with the mothers;
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Education day for weaning: this activity was born from having identified as one of
the major causes of infant malnutrition the brusque passage from mothers milk to food for adults, without integrating all of the childs nutritional needs for energy and protein in the first year of life. In this activity the mothers are educated in progressive weaning.
Considerations and methodological reflections In the veranda of the primary health care clinic, an environment has been created that is similar to one that is normally utilised by the families of the beneficiaries: there is the attempt to propose a method of cooking and eating that is similar to those of their homes, showing that it is possible to have a level of order, hygiene and attractiveness in that place, even with the simple materials of the local environment. In our clinic we have also planted many flowers and plants and promoted for the families a small family garden for the supply of vegetables (spinach) to the families. We tried to avoid exaggeration by introducing the use of techniques that are different and harder to assimilate: for example, the mothers use their finger to give porridge to the child. We thought that it is not necessary to teach them to use the spoon, but it is sufficient that they are attentive to washing their hands, etc. At the same time, we prefer to not introduce foods that are not locally produced or that are difficult for the families to obtain, but it seems more opportune to individuate, among those normally in use and available on the local market, those which have the necessary protein and caloric components and which respect the tastes and habits of the various tribes (food of the Igbo rather than that of the Yoruba or Hausa, etc.). It has been interesting to note that some of the nurses with small children have introduced for their own children the foods and the preparation methods that we have taught to the
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mothers, just as they have learned a way to involve themselves emotionally in the relationship with the child during feeding. This is important because they themselves, experiencing this kind of change, can transmit the goodness of it to the mothers as well. Some mothers frequenting the nutritional centre were fascinated by the companionship and by the way in which the work was carried out and they involved themselves in the activities of the clinic to the point of being hired. One of our best nurses (Nike), knew us as a beneficiary, and then started to work with us as a volunteer, we then entrusted to her the responsibility of the reception window, now she is finishing university studies. We met her at the nutritional centre because she was the mother of a malnourished child, who now frequents our school.
Lessons learned
A lesson we have learned from this experience is that we have always to begin every intervention, both on the mothers and the health care personnel, starting from what they propose to us, from their responses, trying to recover everything that is positive in these attempts, valorising everything that is useful to the ends of the educational intervention and shaking off bit by bit whatever in certain habits is less positive, going to the roots. (We start from the conviction of the fact that their hearts are fundamentally good and that some traditions and habits have encrusted them). Another important lesson is that of not transforming solidarity into welfarism, and rather trying to always involve the subjects and provoke within them a true sense of being the protagonists, never allowing that solidarity give origin to passivity. Especially among the HIV positive patients, there have been some wonderful examples of solidarity and reciprocal help, favoured also by the activities (Friendship Meeting), in which the beneficiaries offer help to one another, especially offering an alimentary integration in moments of real need.
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refectories and centres for education and recovery from malnutrition
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2.1. Mexico, Oaxaca: Refectory - Education on food relief and recovery from malnutrition
Rossana Stanchi, AVSI, and Adriana Pieiro, DIJO, Mexico
Context Desarrollo Integral de La Juventud Oaxaquea (Integral Development of Youth Oaxaca) DIJO, implement the feeding and food care program. DIJO, a member of AVSI Network, started the program since 2003 in the neighborhood of Monte Alban, in Oaxaca city, capital of Oaxaca State. Oaxaca, along with Chiapas, Guerrero and Tabasco, is one of the poorest states of Mexico, a country that, even if it has registered growth in the recent years, continues to show extreme poverty due principally to social disintegration.
Monte Alban, famous for its archaeological sites, is located on the outskirts of the city, on the slopes of a group of hills. It is one of the most visited pre-Hispanic site and one of the most interesting in America. It is inhabited by just over 3,500 people, many of whom belong to indigenous groups, who came from the Sierra. This area began to form around 1968 with the migration of people from different places of the interiorf the State, that are very poor, and that,before, even less then today, could not offer equal educational opportunities and vocational training. A lot of people have arrived to the capital city looking for jobs or an opportunity to pursue their studies. The Colonia Monte Alban has been growing for the past 35 years thanks to the work of the people who brought from their ethnic communities the custom of tequio. This means that each family contributes to the growth of the community by giving their time (in the construction of the streets, drainage, service centers etc.) This is expressed by donating their manpower for the common work; if their assistance is not possible, they have to give the equivalent amount of money of a days work or a set fee. This area, that is located in a part of the city that continues to grow, has many social problems manifested in the phenomenon of gangs. There are different ethnic groups such as the zapotecos, los mixtecos, los mazatecos, los triquis, and others; twelve percent of the people, especially the elderly, speak indigenous dialects. Their houses are very poor, most of them are one room houses with tin roofs and dirty floors, and an improvised kitchen outside, where all the family lives and sleeps. 25% of the population is illiterate, 55% are under 24 years old and 60 % do not have any medical access.2 The area has a high level of marginalization due to the low quality of the local services, health problems (malnutrition, sickness; such as parasites, lice, gastrointestinal and skin problems) and lack of hygiene. This situation affects more than half of the children in this area, also famous in Oaxaca for having a high number of working children. Many families consist of single mothers; in many cases the father has immigrated illegally
2
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National Institute of Statistics and Geography (INEGI). Counting the National Population and Housing 2005 IRIS-SINCE 2007
to the United States. So the mothers, grandparents or older siblings are in charge of the household economy. In 2003, DIJO, well known in Oaxaca for its educational work to fight and prevent childhood school dropout, settled at Monte Alban, after an invitation of other local NGOs that couldnt respond to the educational needs of the area. The educational problem was not perceived as an urgency among the locals, who gave greater priority to the problem of under nutrition and malnutrition and thus, the small building meant to be the place of after-school program became a refectory, called LA COMPAIA. It started giving breakfast to 50 children. Since then the project, has grown significantly thanks to the distance support program (AVSI), several public and private donors and in 2007 a project co-funded by the Ministry of Foreign Affairs of the Government of Italy and they were able to reclaim the original educational idea of the project. Currently Monte Alban has a psycho-motor group of working with toddlers, a group of preschoolers, and one for after school support for elementary school children, in addition to training and activities for mothers, so they can start their own small business. The refectory The Company has 250 attendees daily. The direct beneficiaries of all activities are about 400 people, 150 families. Since the spring of 2008 they began to structure the feeding program in a systematic way in collaboration with Adriana, who is a nutritionist, and Julieta , who is a nurse and lives in Monte Alban. Adriana started to sit with the younger children and she observed all the activities of their daily routine and checked the menus offered. She soon realized that the children receive surely enough calorie and therefore energy, but the menus were not balanced or varied, nor sufficient, nor safely prepared. It was necessary to balance carbohydrates, proteins, vitamins and minerals. A new beautiful challenge began: to respect the dietary habits and cultural traditions of the inhabitants of Monte Alban and at the same time to balance the menus and give the children the chance to try new foods, to discover new tastes, other than the common vegetable soup, tortillas and beans. She started gradually introducing natural yogurt to rebuild the intestinal flora in children with diarrhea, often amaranth, that thanks to the lysine, promotes growth, and honey, optimal for preventing frequent colds and infections in airways(very high in this area). The hypothesis was: changing the childrens menu and increasing the amount of food they receive during breakfast-the main meal of the daythey would increase their weight and height. The starting point was an initial diagnosis of the population. In this first phase, Gomez and Waterloo parameters were used, but one month after the first measurement, Adriana realized that these endpoints were not adequate: the diagnoses were inconsistent with what she had in front of her. For example, a child of the colony with normal weight was
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considered in a state of severe malnutrition in such parameters. The Waterloo3 and Gomez4 parameters did not seem to be appropriate for Mexican population. She then adopted the official measurement scale of the Mexican Government, the NCHS (National Center for Health Statics Percentiles).5 Before changing the menu in June 2008, we made an initial assessment on 139 children, which gave the following results:
1. Initial Evaluation - June 2008
Status Nutritional Number of Child
Severe Malnutrition Moderate malnutrition Mild Malnutrition Nutrition Normal Overweight Obesity Total
37 47 23 27 4 1 139
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Based on these data we decided to increase the menus according to age groups (preschool, primary school children and adolescents) and to have meetings with the children to talk about food. In the dining room the children have gradually discovered grapes, strawberries, kiwi and many other foods. In this process, we realized the importance that they know what they were eating and they began to know the properties of each food. We started writing the daily menu on a blackboard at the entrance and decided to explain the ingredients in each dish, the properties of each ingredient and the benefits they bring to their health and daily life. We also started to organize meetings with the mothers to explain the importance of eating at home, the benefits of healthy eating, and the damage caused by lack of vitamins, minerals, fruit, vegetables, etc. We have built and maintained a quarterly review of the data of the children. Thus, repeating the measurements at the same group of children a year later, we obtained the following results:
Vazquez G, E, Romero V, E Assessment of Nutrition Status of Children in Mexico. Part 1. Boletin Medico del Hospital Infantil de Mexico. Vol 58. August, 2001. Downs, H. Haffejee, A Nutritional Assessment in the Critacally 111. Current Opinion in Clinical Nutrition and Metabolic Carco Vol 1, No. 3. May, 1998. 5 NOM-008-SSA2-1993, Control of nutrition, growth and development of children and adolescents. Criteria and procedures for service delivery. See: http://www.salud.gob.mx/unidades/cdi/nom/008ssa23.html. Using the NCHS anthropometric indicators were recommended by WHO, which has its own indicators anyway.
3 4
2. Final Evaluation - June 2009

34 51 28 21 5 0 139
Comparing 2008 data with those of 2009 can be observed:

1. Initial Evaluation - June 2008
2. Final Evaluation - June 2009

37 47 23 27 4 1 139
34 51 28 21 5 0 139
On one hand we can observe encouraging changes: 25 children improved their nutritional status. But on the other hand we can see, with a detailed analysis, that 24 children became worse and 90 showed no change.6 This situation has forced us to reflect on the obvious fact that: contrary to what was thought at the beginning, it was not enough to feed the children healthy, with balanced varied menus to improve their situation. This data showed us that it was
6
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25 children improved their nutritional status from: of severe malnutrition to moderate malnutrition: 9 moderate malnutrition to mild malnutrition: 9 mild malnutrition to normal nutrition: 5 overweight to normal nutrition: 1 from obesity to overweight: 1
Worsened from 24 children: mild malnutrition to overweight: 1 normal nutrition overweight: 1 overweight to severely malnourished: 1 moderate malnutrition to severe malnutrition: 4 normal nutrition mild malnutrition: 8 normal nutrition to moderate malnutrition: 3 of mild to moderate malnutrition: 5 from mild to severe malnutrition: 1
not enough. It was necessary to understand what was happening. Reviewing the attendance records of the refectory, it was discovered that 18 of the 25 children who had improved were present at the dining hall 100% of the time. These were mainly children attending school in the morning shift (it is important to note this because it allows us to understand that these are children with a sense of responsibilitythat is rare: they must get up early to go to school and should even get up earlier so they can go to the dining hall. Despite this, there were constant throughout the year). Then, reviewing the records of attendance of the mothers at the meetings about food, it was observed that the children whose mothers were consistently present in these talks-were also those who had shown more concern for their own food at home. We have seen that the improvement in the nutritional status in these cases is also linked to the consciousness of themselves and their children, maturation of the awareness of the value of the person by the mother and then also of their children.7 She then proceeded to consider, case by case, checking the situation of the children with severe malnutrition; here the data showed an unexpected result: attendance of children with severe malnutrition was not inconsistent, as was assumed. The data said that: Children with severe malnutrition attended every day Most of them belong to large families. This probably means that in the large family, it is easier to increase the state of malnutrition, because mothers are unable to adequately feed all the children, many of them are children who work and have to help support younger siblings. In many cases the breakfast served at the refectory is not a supplement food, but the only meal of the day and so it becomes like a drop in the ocean. It had become clear that the work done was not enough, especially because in many cases there was no support from the family. All this seemed to contradict the findings of many studies showing that by simply introducing balanced menus, the nutritional status could improve. Instead the data were saying that it is not possible to make a positive impact on the situation of children if the lives of families are ignored. Other data showed how many other factors play an important role in the nutritional status of children not attributable only to the nutritional aspect:
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Esperanza, the mother of 5 children, has lived since childhood in extreme poverty. She says that when her husband started to take drugs and to steal. She often went to any parties in the colony because she knew her children could eat something. In one of these parties she came into contact with the dining hall. Since ... her children subscribed to the diner, she says It changed my life: they eat breakfast, they teach them a lot of things that I cant I go to work and I am assured that they are happy, they are learning, whereas before they stayed on the streets and fought a lot. Now they know how to use silverware, before they were disgusted by vegetables and now they eat everything. (...) My life is different because Im not concern that my children dont have something to eat and, thanks to the help they receive, they do well in school. The oldest now has the best grades in her classroom and the youngest ones have no problems. I even baptize my children and I thought this would never be possible! Now I have the desire and hope that I never had before, that my children can be someone in life.
Assessment of nutritional status by sex - June 2009

Nutritional Status Male % Female % Total %
20 24 28 25 6 0 103
8.9 10.7 12.5 11.2 2.7 0.0 46.0
28 38 24 23 6 2 121
12.5 17.0 10.7 10.3 2.7 0.9 54.0
48 62 52 48 12 2 224
21.4 27.7 23.2 21.4 5.4 0.9 100.0
These measurements, made in June 2009 at the diner shows how malnutrition in the colony often has a female face: the number of moderate and severe malnutrition in women is 29.5% while the male is 19.5%. This is because in many cases there is the phenomenon of girls-tutors, who must care of their younger brothers and sisters, since they are very small with a heavy responsibility compared with the rest of the family. There is also food discrimination based on gender: in the case of food shortages in families, men are privileged over women. In cases where the young children come from a first marriage, the new children born into the second marriage, are privileged over the older ones, especially when they are girls, they do not receive enough food.
Lessons learned It is fundamental to know the people and the area we work for in order to verify: the availability of local foods time required to find them identify peoples eating habits. For example, in Oaxaca the holiday is often very significant and linked to each Event there is a food tradition. By starting with local customs, it is easier to enter into a relationship with mothers and exchange advice consistent with the traditional cuisine. Know the age range of the children to design the appropriate menus; Understand the economic situation to understand the corresponding food availability.
Revise initial nutritional status of the population Measure weight and height (Standardize measurements calibrate the scale, etc.). Establish how to measure: Organize data Make the diagnosis: The parameters to use (NCHS, designed for Latin American populations). Make a census: cases of severe malnutrition, moderate, mild, normal, and overweight.
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Implementation of the menus Standardize the recipes for each menu. Organize a six-month menu cycle, to allow the introduction of new foods and new ways of food preparation, already known. Standardize the dishes. Adapt the menus according to dietary habits of the population (for example, in the colony, it is not customary to have dinner, then breakfast must have a certain caloric intake. The food at home is usually a soup and chicken with tortillas, then it is important to introduce new breakfast items, like vegetables or fruits, which will not be consumed the rest of the day). Sort the children by age. Establish the portions for each child. In order to understand the benefits of introducing new foods in the diet. 1. Program of monthly meetings with children: The plate of good food8 (Mexican adaptation of the food pyramid) Fruits and vegetables
8
The plato del bien comer (plate of good eating) is a graphical representation proposed by Mexico in the project Mexican Official Norms, which guides the people in the field of healthy food according to the needs and characteristics of the Mexican population (including foods that belong to the culture and the national diet).
Cereals Legumes Animal products Energy Proteins Vitamins and minerals Fats Antioxidants Snacks Water
2.
Quarterly meetings with mothers (to reinforce the lessons given to children) How to improve the eating habits of the family How to include fruits and vegetables in the daily diet of the family Program: Knowledge of the initial nutritional status of the child Malnutrition The plate of good eating Fruits and vegetables Grains and legumes Animal products Fats Diseases caused by poor hygiene Diseases caused by poor nutrition Soy recipes
Regarding the results of the implementation of new menus with vegetables, it is necessary to know that the improvements are observed only in the long term: helping to avoid diseases like anemia, increasing antibodies in the body, and reducing respiratory problems during the rainy season and winter.
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Personalized work with mothers of undernourished children The personal relationship with these mothers is very important because it is difficult to understand what their children eat, so its not advisable to apply a survey (there are never reliable results) but to talk directly with them. This promotes confidence and gradually the mothers reveal many important facts and problems of the family, and it is possible to identify barriers to healthy feeding in the family. You need to know if the mother is present at lunch or dinner, if they know what their children eat, explain to them the effect of sweet drinks and oral health, related to the occurrence of subsequent problems. It is also important to know the working hours of the mother and the schedule of meal time at home.
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The introduction to the children of new menus when they do not like the taste or consistency of certain foods requires patience, because the habits are not acquired from one day to another. It takes time and this should be supported with a constant dialogue with mothers. Very often, because of the extreme fragility of education, mothers give up to the fact that the child does not like vegetables or does not want to eat something and desist immediately from any attempts. The talks on food, whether for children or for mothers, should take less than an hour because they fail to pay attention for long. It is also advisable that the meetings be dynamic and funny, so the ideas are easier to remember.
2.2. Brazil, So Paulo: CREN - Centro de Recuperaao e Educaao Nutricional (centre of recovery and nutritional education)
Gisela Solymos, CREN, San Paolo, Brazil
Description of the context, project, objectives, activities, duration, beneficiaries and results The Centre of Recovery and Nutritional Education (CREN) is located at Sao Paulo, State of Sao Paulo, Brazil. Its activity was launched in May of 1994, operating in the sphere of the fight against infant malnutrition and its treatment in the slums of Sao Paulo. In 1996, CREN opened a second assistance Unit, thus becoming a reference centre in the field of primary nutritional problems in the city of Sao Paulo, directing its attention also to children and adolescents in situations of obesity.
Its objectives are: To promote the recovery of growth and development in malnourished children through appropriate interventions together with the child and his family. To promote the recovery of the nutritional status of obese children through specific interventions together with the child and his family. To develop treatment and cure methods for nutritional recovery. To qualify human resources specialised for work in the field of primary nutritional problems. To carry out studies and spread a methodology in the fight against nutritional disorders and problems. Currently CREN has two assistance and cure units available to it at Sao Paulo (CREN Mirandpolis and CREN Vila Jacu), which offer: Treatment in day hospital for 120 children (0-6 years) suffering from moderate and extreme malnutrition; Out Patient treatment of approximately 2,500 children and adolescents (0-19 years) with malnutrition or overweight/obesity problems; Educative actions together with the treated children and their families; Home assistance at the communities;
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Training of professional figures in a health and educational sphere.

Moreover, there is also a work team that operates in the Favela do Varjo, in the city of Jundia, providing Out Patient assistance and carrying out educational activities for malnourished children and adolescents and their families. In 2008, the principle results obtained have been:
Total persons assisted CREN 2008
Individual Assistance
Community Anthropometrical Census Nutritional and social educator assistance Total Out Patients (942 new cases) Medical assistance Nutritional assistance Social assistance Psychological support child/family Total Day Hospital Medical assistance Nutritional assistance Social assistance Psychological support child/family Nursing care Total Home Assistance Total Group Assistance Total Nursing Service Total services rendered Meals served
Total 4,546 603 5,149 Total 958 3,750 1,951 1,100 7,759 Total 2,518 1,106 2,417 385 99 6,525 Total 624 Total 528 Total 44,326 100,193
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In the day hospital treatment, 22% of the children have been discharged for their nutritional
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recovery. In out patients, the recovery scores have been: + 0,3 z-score Height/Age + 0,4 z-score Weight/Age - 0,65 z-score Weight/Height (obese children in VJ) Moreover, there were 1,460 professional figures trained in the sectors of health and education, belonging to 163 assistance units (day care centres, primary and secondary schools, socio-educative centres, medical clinics of the public network). Principle relevant methodological elements
CREN started its activity in 1994, having as its starting point both the methodological proposal described in very little detail in the specialised literature on the centres of nutritional recovery, and in its own technical experience coming from each of the professional figures involved (nutritionist, psychologist, paediatric doctor, social worker, nurse, pedagogy specialist). In a short amount of time, it was possible to verify that such methods were inadequate for dealing with the cases of malnourished children living in the slums of Sao Paulo, for the following reasons: 1. The specialised literature proposed that the families spend the day at the Centre, in order to be able to educate them and instruct them on the praxis to follow for hygiene, health and nutrition; this helped also to diminish the maintenance costs of the centre itself. However, this has not been possible in our case, because one reason for exclusion of these families was their very low income due to lack of access to the labour market and for this reason, CREN also had to help these persons seek work that could allow them to improve the family income 2. The educative methods and the assistance models that the various professional figures of CREN had acquired during their training did not bring about the hoped-for results. For example, the model of demonstrative lesson provided information to the children and families who were able to repeat them well, but did not use them in their own homes. The model of clinical treatment created a kind of distance between the patient and the health worker and did not offer the necessary freedom so that the patient could understood and follow the indications; welfarism prevented an action that would make the families co-responsible in the treatment (for example, the educators of CREN, seeing that the children lost weight during the weekends, started to take the children to their own homes in order to feed them better). This gave the families the occasion to delegate to the educators the care and attention dedicated to their own children. For this reason then, CREN has taken a different approach to the initial set-up of its work through: The creation of educational laboratories for the children and their families, and of shared spaces for free-time activities. The intensification and the re-planning of the home visits, including also the completion of workshops at the homes of the families being assisted. The continuous training of its collaborators and operators by means of technical meetings and courses. A continuous evaluation system has also been created that monitors the results of each area of action. With an annual timetable, the various professionals present and reflect upon the results of the overall work, and on each area in a more specific way, proposing solutions to face the difficulties that they meet. This system is in permanent construction and restructuring. The essential points of the CREN method are:
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Realism the work method is defined by the object. Reasonableness consideration of all the factors in play. Morality in the dynamics of knowledge to love truth more than oneself. Sharing as a method of knowledge and intervention. Working in partnership, reinforcing the social networks of the family and having a wide
reference system for CREN in such a way that will be able to respond to the needs of the families.
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Experiences of persons and subjects involved I cite a case that highlights clearly what has been stated above: a healthcare worker of the Municipality turned to CREN to request its intervention in a very difficult case of a 9-month-old child who was seriously malnourished. The CREN team went to the slum, at the home of the child, they found a house that was located below the level of the street. Outside it was written Maria and Carlo. The house had no windows, the floor was bare soil and there was a horrible, almost intolerable odour of filth and urine. The mother had a 9 month old child and a 4-year-old boy, so dirty that the CREN collaborators were unable to identify the colour of his skin, and another two children of 7 and 9 years respectively. The initial contact was very difficult, because Maria, the mother, seemed to not understand what was being said to her and she was unable to speak, responding only in monosyllables. The team, however tried to talk with her, to try to understand what her needs were and they set up a visit in the clinic for her with the infant. Little by little, things started to change: the children arrived at the visits clean and Maria started to follow the indications that had been given to her. The visits continued and the team accompanied Maria in the process of registering the 4-year-old in a day care centre and the two older children in primary school, since up until that moment they still had not gone to school. The 9-month-old child rapidly was improving and the house started to become cleaner and more orderly. Carlo, Marias partner, never met with us, but he did what he could to procure clothing and shoes so that the boys could go to school (this was the justification given for not going to school). Maria still demonstrated some cognitive difficulties, yet, her verbal expression greatly improved and she understood that the CREN team only wanted to help her, and not take her children away, as many times had already happened. Spending time with her, accompanying her and helping her in the concrete difficulties had allowed us to know her for who she really is, taking off from her real needs, helping her, until we were able to arrive at what our needs were (nutrition, health, hygiene). For example, we went with her to the day care centre and to the primary school for the registration of the children, since both of these scholastic institutions refused to accept them. The day care centre did not want to accept the 4-year-old because of his agitated behaviour and his terrible hygienic conditions; the childs behaviour significantly improved some time after the start of the intervention. And the primary school did not want to accept the other two children because of the preconceived ideas about them (that they were dirty and without shoes). It was necessary to telephone the director of the school and remind him that it was mandatory to register all of the children. The public medical clinic was unable to intervene in the case because they considered her to be a mother with an intellectual quotient that was too low to be able to take care of her children, but that is not what we had thought.
Lessons learned The most important thing is the human relationship. This can become true if there is a relational space where the self of each professional is educated, in a way that they can establish the same type of relationship with the families. If the intervention does not take off from a relationship with this quality, that is, in which the whole of the person is looked at and embraced, the intervention runs the risk of becoming violent. This is even more important if the beneficiary of the intervention is in a situation of social exclusion, as is the case of the families of children with moderate and extreme malnutrition. However, this is applied also in the cases of obese children and adolescents; they need to be looked at and understood, more than they need nutritional indications. Course Thus, if I had to organise a training course on the treatment of children and families with nutritional problems, I would make a course that is almost completely (90%) practical and experience-based, with dynamics that allow the students to make experience and know what it means: to look in order to know and embrace a person; to know all the factors, etc.
2.3. Brazil, Salvador Bahia: COF - Centro de Orientao da Famlia (family orientation centre)
Paola Cigarini, AVSI, Salvador Bahia, Brazil
Short description The program for the reduction of undernourishment in children is taking care of 340 children affected by serious to moderate malnutrition, and supports their families. The project originated due to a high number of undernourished children among those attending the Joo Paulo II and So Jos Operario, nursery-schools located in Novos Alagados, a southern suburb of the city of Salvador, Bahia, Brazil. Novos Alagados is a large area characterized by a high number of pile-dwellings built by the population along the seaside in the early 70, whose living conditions were marked by high infant mortality, malnutrition, unsafe housing, unhealthy environment and violence. In 1994 a progressive and consistent work of urban up-grading was started, along with a wide range of social and educational interventions, subsequently extended to the region known as Alagados, which led to a progressive change of the area and greatly improved the living conditions of the population. In 2001 the Avsi Foundation and CDM teams implemented a weighing program on 1.050 children aged between 0 and 6; the campaign revealed that 38% of them was undernourished, with 6% or 60 children suffering from severe malnutrition. It should be noted that in 2001 the Ribeira Azul urban upgrading program was not yet completed, and people were still living in pile-dwellings. The 6 % rate of severe undernourishment corresponds to the same 6% percentage of severe undernourishment found during the nutritional control campaign realized in 2006 in the whole North east region (source IBGE, 2006).
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When you see with your own eyes a child suffering from severe undernourishment, this is something difficult to forget: even those who are not expert may easily understand that its an absolutely unreasonable situation of absurd suffering, which could be avoided. The 2001 nutritional control campaign underlined that what we found in the nursery-schools was exactly the mirror of the general situation of the region. All these dramatic experiences - of the mothers, of malnourished children, of family problems found in the nursery-schools that are directly linked to the precarious health conditions of children - moved us to take some actions, in order to help these children, and at the same time to involve the families as direct actors, in view of the clear interrelation between these two elements. In 2005 a three year project was started; it had been promoted by AVSI Foundation and approved and funded by the Italian Dept. of Foreign Affairs; the duration of project, called Family Recovery Centre for children and adolescents at risk, was then extended to four years and allowed the implementation of the activities of the COFCentro de Orientao da Famlia (Family Orientation Centre). Built with resources coming from the Avsi Foundation Tents campaign and from other private donors, the centers operation was also supported by AVSIs distance support program, which is still helping some of the children. The fundamental idea of the COF is of a multi-function structure, where different projects are developed to deal with risky situations that are recurrent in the region of Novos Alagados and Alagados and can seriously affect the healthy development of children and adolescents. These problems have been identified: childhood malnutrition; serious risk situations including the risk of death (violence, sexual abuse, neglect); school drop-out and delay among children and teenagers; with consequent risk of social out-casting and permanent unemployment. The common characteristic of all interventions is the family involvement as the first active element to be considered in the resolution of the problems. A Family Counseling service is also provided to strengthen family consciousness about the childrens problems and needs. At present, the COF is providing outpatient nutritional recovery and health support of undernourished children and supports two community nursery-schools. In addition, it offers manicure training to 30 young mothers of small children. The present donors are the Cariplo Foundation, Emilia Romagna Region, Lombardia Region, AVSI Foundation through the SAD (distance support). A project presented by CDM to SEDES, Secretria do Estado de Desenvolvimento Social e Segurana Alimentar, is now in its final approval stage. Main methodologic elements observed The first element we want to underline is that our main instrument of knowledge is exactly the work we do with the families. Our main method to learn about the reality of our families is the direct action we develop together with them. We frequently repeat that With every new family, a new adventure starts: every situation is different and requires something new. We had an example of this attitude at the end of 2008,
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when we changed our full professional team. The first thing we said to the new staff was: This is the proposal that originated from the work we have carried out so far. Let us start in this way, let us follow it; then you should tell us what you observe to be new during your experience and that calls for a change, and we will create new ways to answer to the new aspects you have found in the problems we are dealing with. We are quoting the main elements that we noted. 1. In the encounter with the families of malnourished children, the first factor to keep in mind is their expectation towards the program. In the majority of cases they expect to receive something material (especially food); in other cases they come for curiosity (the COF is a very nice and well-known place); sometimes they come because they are attracted by the pediatric service; very often they come because they have heard about the experience of other families who are already followed by the COF . At the beginning families are not much concerned about the health problems of their children or they do not have a clear consciousness of undernourishment. This concern is evident in case of premature children, and this is the reason why they come to the centre. We must meet the mothers and the families exactly considering the point of consciousness they have: if they have none, we start from zero, helping them to recognize the state of malnutrition as something real and dangerous for childrens survival. 2. Concerning the lack of awareness about the families nutrition problem, we must consider that in most cases malnourishment is a problem that we bring to their attention. They think that their children are normal and that the low height is a family characteristic. In fact we visit them at home and weigh their children. Starting from this point the question raised what would be the most effective way to meet the families and focus with them the objective of our intervention. We realized that a clear proposal (we need to be explicit on the reasons of our work) makes the support to families easier and helps them to take a position. 3. At the level of team work there is a great consideration on the value of the relationship with every person. For this reason we make frequent and insistent moments of reflection with the professionals, considering their ability to create a relationship as a first essential quality for this kind of work which we consider as a COMMUNITY work. This involves training, regular weekly meetings, continuous informal dialogue at work, constant presence at community level. 4. We work using a laboratory methodology. This means that we create a living space, where we share an experience with the parents and the children, for example preparing a low cost and high nutritional content recipes. During the activity, contents are clearly expressed, but the process of learning involves the practical realization of the activity and the dynamics of human relations (professional and mother; professional and child; mother and son; mothers and mothers and so on). During the last year we introduced the laboratory work by reading a small text and we observed that the more the text deals with life, the richer becomes the discussion and the exchange of experiences. 5. Home visiting was included since the beginning, as a mean to know the real situation
Through the progressive knowledge of the families we could identify some elements that are directly connected to childhood malnutrition. Women loneliness and the violence of men on women are a frequent reality. The general weakness of the relation
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of the families (hygiene, available food, food preservation, water access, etc). Nowadays home visits is part of our normal way of acting and we recognize in this practice a great value. Home visit means going to the house of somebody, talking, observing some details of the home organization, obviously depending upon the persons acceptance; every visit acquires a different value, but all of them create and maintain a link that people experience as true to them. 6. The methodology was entirely created by the professional team at the beginning of the project, starting from two basic factors: an experience to be looked at and from which to start (in this case the CREN-SP); and the direct observation and concrete involvement with the reality we had to work with. 7. In these years of practice, we clearly observed that the family context and the mother-child relationship play a fundamental role in respect to the nutritional problem, both in a difficult family situation and in a more regular family structure. This factor is ALWAYS INVOLVED, as much as the nutritional problem is a reflection of the educational position of the adults towards children. 8. Among the children with malnutrition problems, we also met extremely serious cases of neglect. It is a fact that malnutrition shows a family risk situation, even though this is not true for all families, but unfortunately, an underworld exists. 9. We verify, through the work of the infant psychologists, who carry out an evaluation of the psychological and physical development of the malnourished children,that most of these children present a lack of knowledge, rather than a lack of abilities. This delay is due more to the learning opportunities offered, than to a lack of skills of the children. 10. The contact with families showed that adults have a poor consideration of children. Frequently adults show a sort of discomfort towards their children, which becomes evident in the violent way they scold their children, in the common use of sarcastic expressions which in some cases become an explicit practice of violence. 11. We observed that when a mother starts trusting the person taking care of her child at the COF , also the relation with her child is renewed. It seems as if she needs new eyes to look at the same situation: the situation is the same, the child is the same, but the eyes are looking in a different way. 12. Children respond with enthusiasm and joy to all the activities we propose. 13. We consider the work with the community as an essential part of our action. We have involved all the community bodies with which we get in touch: community nursery-schools, local associations, projects, popular initiatives, sharing the contents and meaning of our work and involving them directly also at operational level (inclusion of children at risk in community nursery-schools, involvement of neighbors, community leaders, community health agents in the most serious cases).
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between men and women is the probable cause of the very common physical violence of men towards women. Its very uncommon to meet a woman who didnt suffer some kind of violence from men. One element that increases violence is the large use of alcohol, justified also by male superiority culture and a degeneration of male behavior. When women depend economically upon men, the situation becomes even more difficult, because economic dependence is also a source of blackmail. It should be noted that these types of problems as well as the violence suffered by women and often by their children too, have not been immediately identified as determinant elements of undernourishment. In fact mothers started to tell us about these problems only after one year of work together, asking for our help. As a matter of fact until trust is established, the actual problems and the most true aspects are not expressed. Only with real trust can a person tell another one about violence, especially when the victims are children. Without trust, the relationship is formal, or based on interests. Children abuse is very common, also among mothers. In addition to physical mistreatment there is a very common ill-treatment due to lack of attention towards the kids. Our children have a very high level of autonomy, because they need to learn how to survive very early. Cases of violence against children are less in number, but they are still high. There are different forms of direct violence against children, especially in case of conjugal conflicts or when the partner living in the house is not the natural father or when one of the parents is an alcoholic. The cases of sexual abuse are many and the situation is very complex, most of the time women dont talk, because they fear mens reactions or they undervalue the problem with the intent to avoid a direct conflict with their partner (example of one of our mothers who was killed by her mate). We also faced many cases of mothers rejecting their children. Rarely do they actually abandon their children, but they have an attitude of unease, of exaggerated punishment and negligence towards the basic needs of their children. This rejection is the other side of the negation of paternity by fathers. Men abandon their children exactly as they abandon women. The male is violent, rude and arrogant. This situation leads to a general disdain of childhood and to the common thinking that infantile things are stupid things. All these elements have an influence on undernourishment for these reasons: When the mother refuses her child, even if this is not a physical neglect, nobody takes care properly of the child inside the family in most cases these are familiar groups. The answers to the current needs of the child, such as food and hygiene, are irregular. Lies are the normal defense of the mothers, for instance in the health centers, they lie about the way they take care of their children, about the nutritional diet, and so on. One a significant example: a mother was explaining to the nutritionist that her 4 years old child did not have her breakfast in the morning because she did not want to and this was the reason that her weight was not improving. The child left the nutritionists room, went to the nearby the social workers room and told her: Do you know why I dont have my breakfast? Because my mother doesnt get up in the morning to prepare my breakfast.
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As we already said, children have a very high level of independence, also at a very early age. Often such independence concerns food too, they have to scrounge for it. We also noted very strong relationships among brothers and sisters, as they perceive their mutual needs and help each other. In many cases undernourishment depends on incorrect nutritional habits. When we propose to one family that we are supporting a new way of nourishing and taking care of their children, often these indications are disregarded. We found that those who follow our indications have a certain personal or family balance. In many cases on the contrary, it becomes evident what Cleuza Ramos (ATS movement, So Paulo) stated at the 2009 Rimini Meeting, namely external factors may change, but the favela remains inside. In other words, there is a way of facing problems that is typical of the favela: one of these aspects is to not take into serious consideration a health problem, or to disregard what they have been told; they are not willing to change their habits which requires the difficulty of changing; here the logic of the favela wins. We found out that 30% of undernourishment in children is a consequence of late weaning. Mothers go on breastfeeding until children are four or five years old. They act in this way for different reasons: as a defense from their husbands (to avoid sexual relations); a rewarding relationship with their child (the baby is considered as the only one who loves me, its a way to lengthen a satisfactory and peaceful moment); last but not least, breastfeeding is the nutritional solution. As a consequence, we developed a team to work with the mothers on breastfeeding. Children are great promoters of correct nutritional habits and practices. In fact we could observe that, thanks to the laboratories and the nutritional education work carried out in the nursery schools, children start appreciating vegetables and fruits, and asking for them. This is a very interesting result of the laboratory and nutritional education activities. Finally, we can affirm that childrens health improves in two cases: when the mother is missing correct information about feeding, so when she receives proper information, she accepts and implements the new orientations and the child gets better. In this case there arent relational problems that influence the mother-child relationship, or the mother is able (or learns how) to put the problems in the right place when the mother experiences other difficult situations (man-woman relations / mother-child relations / coexistence inside the family group, difficult social and economic conditions, etc.), along with the nutritional problem of her child, if within the COF proposal she encounters something good for her, which is the answer to her own problem. In any case, change happens when the mother really start personally trusting one of the members of the professional team.
Description of activities
Methodological approach The proposed intervention has been defined as follows: First step: identification of undernourished children in the areas and community
nursery-schools. The weighing campaign is a work that involves the whole community. In recent years we selected the community nursery schools and new invasion areas, where undernourishment affects 48% of weighed children. Second step: meeting with the families and presentation of the treatment proposal. Third step: intensive intervention, consisting of weekly laboratories ( for a period of one and a half months, subject to the agreement and written approval of parents). Fourth step: during the whole treatment period we offer outpatient visits (nutrition, pediatric, infant psychology, social support, and nursery). Fifth step: laboratories continue at various frequencies based on the different level of malnutrition. At the same time we offer home visits. We propose activities arising from specific problems (weaning, childrens education, women health, groups of parents). Sixth step: during the whole year we propose friendly moments, like tours, cinema, theatre, and childrens parties. At a technical level, the main elements on which we worked are the following. At technical/nutritional level: Introduction of soybean in daily diet. Brazil is the major world producer of soybeans: low cost and high protein contents. After the first year of treatment we noted a definite improvement in weight, but a limited improvement in height. For this reason we started working in the educational laboratories with the available animal proteins: eggs, sardines, offal and milk, we proposed recipes and also food preservation and hygiene. The answers as well as the results were excellent (childrens height increased). In our laboratories we are working with low cost and high nutritional value recipes. We promote active children participation, with particular attention to the look of food, its color, consistence, etc.
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The proposed recipes are in line with local traditions. The pairing of rice and beans,
with an addition of vegetables and little meat, is a perfect nutritional dish. The nutritionist shows how this base (rice-beans) can be integrated with new preparations, using particularly the available vegetables (pumpkin, okra, tomato, chayote). In other recipes the nutritionist works with potatoes, manioc, maize, corn, and other local tubers, used especially for breakfast. We insist on using fruits. We teach mothers and children how to prepare and eat juices, yogurt, salad fruits and so on and we have the children play with sliced fruits. In the laboratories, we work on diluting powdered milk, in order to teach mothers how to dilute it correctly. In fact the use of powdered milk is very common due to the preservation problems of fresh milk. We have worked out a training course on Consumer Education and a course about Nutritional education, using effective images and an immediate language, explaining the concepts with practical examples typical of the context and of daily life. These courses were proposed to groups of families, community associations, teachers of nursery-schools, and community health operators. Health The project offers pediatric assistance to the children. The COF pediatrician is the only one present in the region of Novos Alagados. The social worker and the pediatrician are coordinating their work in respect to health services, considering that the population is excluded from good quality health services. A good network of contacts and relationships has been built in time including a variety of hospitals and outpatient services, thus enabling our people to have access to specialists assistance. We have implemented laboratories on health: we propose to the mothers activities on the basic knowledge of transmittable/infectious diseases/ childhood diseases; the connection between disease and hygiene/ the connection between disease and undernourishment. We experienced that home visits are an excellent approach to health and hygienic matters.
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We evaluate the psycho-motor development of every child. Children with particular difficulties are supported regularly and individually. Support to the child is always provided with the mother present, our focus point is We face the problems emerging from violence in the family and on the child.
Social assistance. The social worker Works to support the family: childrens inclusion in schools, information about the social benefits, inclusion of adults in training and literacy courses. the adult who cares for the child.
Psychology
Listens to the familys problems and supports parents responsibilities. Coordinates the access to health, social and educational services (therapeutic Provides an operative help for the solution of family problems. Maintains continuous contact with the community: associations, community nursery
schools, health centers, and promotes the inclusion of families in the community bodies. communities, alcoholics groups, etc.).
Activities implemented by COF Starting from 2005 through December 2008, the professional team carried out 6 campaigns in the community and nursery schools, weighing a total of 2.210 children; 862 of them (39%) were undernourished. 506 undernourished children have been assisted both as outpatients and at home. 8 community nursery schools were controlled, providing assistance in the area of nutrition, health and hygiene as well as social and educational support, for a total of 800 beneficiary children per year. Two training courses for community health agents have been realized in the District of Suburbio Ferroviario, Salvador, on the subject of energetic protein malnutrition and relevant intervention approach. Series of meetings on the subject of undernourishment and nutrition education were held with community associations, and Consumer education courses geared toward the childrens parents and to community associations. Finally, we organized separate series of movies for parents and for children, in the COF conference hall. In 2007 and 2008 we held two theatre classes each lasting one year, specifically addressed to the mothers of undernourished children; a theatrical presentation concluded the activities of both courses. Relevant events The experience acquired by COF during these years brought to light a few new aspects in our approach: Total elimination of any assistance-oriented attitude. Clarity and technical quality of our proposal are as important as the desire and the availability to share our technician; these elements were expressly included and dealt with in our work. Community valorization and involvement of the resources available within the community. Introduction of animal protein to improve height growth. Identification of multiplying agents within community associations, community nurseryschools, schools, health centers, etc. and the need to work with them to disseminate our proposed contents. Lesson learnt This work and the consequent methodological approach find their origins in a context of urban poverty. Probably in a different context, some of the factors of our approach would change too.
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At Novos Alagados, Salvador, access to food IS NOT IMPOSSIBLE. Salvador is located on the seaside and the sea offers fishes and different kinds of shellfish. The land is fertile and with little effort produces fruits and vegetables (there are natural growing fruit plants, such as banana, mango, papaya). The climate is favorable all the year long; the only really dangerous natural event for the population is the rainy season (from May to July). This climate allows building fragile houses and requires very limited clothing needs. We cannot therefore consider this environment as adverse. The nutritional situation of families gets worst when they do not have a stable albeit informal job, in these cases access to food becomes hard, especially for women living alone. In these situations problems never come alone: these are exactly the situations where problems generate additional problems: from the lack of food, diseases, poor hygiene, along with desperation, resignation, negligence towards their children, that frequently degenerate into alcoholism and violence. During the last three years we observed an incredible increase in drug consumption, which is not limited to adolescents, but extends to youth up to 30 years. At the same time, we note many forms of solidarity among neighbors as evidenced by many of the cases we dealt with. We also noted that there is tendency to avoid purchasing food or to skip meals, in order to save money or use it for other family needs (see for instance the case of CDM caretaker who does not buy his meal); in many cases they use money to buy advertised items (for instance the cellular phone); in case of young people just to buy the things they like or, in few cases of responsible young people, to pay university fees or training courses. In this respect urban agriculture as well as the forms of integration proposed by our educational activities with home food production may represent a very effective and feasible solution, that may contribute to really improve the situation of families. Which are the basic factors making this experience replicable? 1. A professional team who shares this approach to the problem and is available to get involved in the relationship with people. 2. It is necessary to know the families, in order to determine the best work approach fitting the specific situation, and to be equipped with the proper tools to know the families and enter into a relationship with them. 3. A multi-factors view of the undernourishment problem. 4. To carry on the nutritional workshop experience. 5. To continue the special support to the children and families (psychological and social support). 6. To create an integration with activities of urban agriculture, home or community food production. 7. To promote at all times and levels the connection with the local community and all its actors. The community can provide explicit (questions, requests) or implicit suggestions (drawn from observation) on the work to be carried out and on the needs of the population.
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fighting malnutrition projects in the urban and rural field with focus on agricultural production 10
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Context of the alimentary security Peru has a population of 27 million people (distributed in 25 geographical regions), a high Human Development Index (UNPD, 2009), but with 21% of population in extreme poverty, where 24.1% of the children under 5 suffer from chronic malnutrition and 46% suffer from anemia.
In Lima, one of the areas where CESAL operates, 8.3% of children under 5 years suffer from chronic malnutrition and 51% suffer from anemia. In the mountainous region of Apurimac, another area where we work in Peru, malnutrition affects 43% of children under 5 years. Malnutrition is associated with poverty. 35% of children under 5 years from homes in extreme poverty suffer from chronic malnutrition, compared to 13% of children who are not poor. Nevertheless, these indexes also hide big differences between socioeconomic groups, as much in urban as in rural environments. The Ministry for Women and Social Development (MIMDES) of the Peruvian government has drawn up and started the strategy of Food Security 2004-2015 which contemplates the following specific targets: 1. Reduction from 60% to 40% of the percentage of children under 36 months and pregnant women with inadequate nutrition practices. 2. Reduction of homes with a deficit in caloric intake from 35,8% to 25%, narrowing gaps between urban and rural areas. 3. Increase surplus in the Commercial Food Balance. 4. Increase the daily availability of calories per capita coming from national food by 10%. What are the causes of this context? In Peru, national food security is affected mainly by the following factors: Limited access to basic education (basic, primary and secondary education) with higher restriction for girls and women and poor quality of services offered. Limited access, coverage and quality of integrated assistance services for health and nutrition of pregnant women and children (under 36 months and children between 36 and 59 months). Uncoordinated food assistance from other social services. Limited access to basic sanitation services, basic housing and healthy areas (safe water and drainage, solid waste). Limited access to specific individual benefits/ vulnerable families to TBC, HIV, malaria, poverty-stricken elderly people and emergency situations. Disarticulation between social services demand and local offer. Precarious jobs and low incomes. CESALs background and intervention methodology CESAL in Peru develops intervention processes which seek to strengthen food security
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in the areas where it works, starting from food availability among the population until a specific familiar level is achieved in which changes in inadequate nutritional and food habits are attained. These projects are developed in two regions in Peru which present similar features:
Region Area Participants Specific topics Food security Executors
Lima
Marginal urban regions/Squatter Settlements/Poor Sierra Andina/rural farmers communities/ Extreme poverty
Parents/Pregnant women/Children under 3 Parents/Pregnant women/Children under 3
Prevention and fight against infant malnutrition Farming development/ Prevention and fight against infant malnutrition
CESAL
Apurimaca
CESAL/ Asociacin Kusi Warma/ CEPRODECH
3.1. Peru (Andahuaylas and Huachipa) CESAL Recovery from malnutrition and improvement of agricultural production
Jessica Martin and Omar Macedo, CESAL, Peru
3.1.1In the Lima Region (marginal urban regions) In Lima, CESAL works in the district of Lurigancho-Chosica. Low income families, most of them immigrants of other regions live in the outskirts of the city, concentrated in the so called Human settlements.
More specifically CESAL works with families living in an area called Huachipa (Nievera, Jicamarca y Cajamarquilla), located in the western part of the district of LuriganchoChosica. These areas continue to be urban-outlying marginal areas in Lima and thus have specific features (higher poverty rate, less resources and a semi rural character). This district is considered to be the district with the sixth highest poverty rate in Lima in the Poverty Map. The main characteristic of these settlements is the lack of basic services (only 3.7% have access to water and 2% have drainage in their homes), services mainly provided by CESAL which in any case are not definitive but provisional. The families have an average of 5 members and the family income does not exceed 100 euros/month. Only 57% of the active population is employed, mainly in the following activities: craft production of bricks, recycling of waste and breeding of small animals, all of which entail great health risks and a strong environmental impact.
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The socioeconomic, hygiene and sanitation, environmental and housing situation directly affect the health of those living in the area, where children are the worst affected. High rate of respiratory and gastrointestinal illnesses. High rate of malnutrition: 11% of children present chronic malnutrition and 48% are at risk. High rate of mother-child morbidity. High incidence of infectious diseases such as immune resistant Tuberculosis. Other outstanding problems are: high rate of child abuse, high rate of risky behaviors, alcoholism and drug addiction in the families. In this context CESAL started its intervention 10 years ago. In the year 2000 it initiated the program Support to families living in the brick producing settlements (so called Ladrilleras) supported by the European Union. In the framework of this program in 2001 a socioeconomic and environmental survey for all families living in the human settlements of Nievera was conducted. From the information obtained a Plan for Social Development and reduction of Poverty was elaborated setting the guidelines for further interventions: health, housing and environment, education, family, work and civil society. In the sector of health and education, the first intervention was the construction of a health community center (the first in this area), which made it possible to establish daily contact with persons and community leaders and to understand the scope of the problems in this area. Afterwards, through the nursery Alecrim a nutritional recovery program was started with the children participating in the centre through direct actions (doctor, nutritionist) and workshops with parents. From both experiences and having had the opportunity to know about the work of CREN (Centro de Recuperao e Educao Nutricional in So Paulo, Brasil) and the one of UNICEF in the Sierra through its program Buen Inicio, the opportunity arose to start up a decentralized project in other communities through the starting up of communal health centers, the training of 50 voluntary women as health promoters and the setting up of 8 centers for nutritional vigilance for pregnant women and children under 3 years. In 2007 this intervention was increased with training programs for the persons in charge of the communal kitchen and for teachers of primary public schools. All actions being currently executed in relation to health promotion are part of the integrated intervention of CESAL in this area. In education, the intervention in health in primary education is strengthened as well as the teachers capacities to deal with learning problems in primary school which are often related to chronic malnutrition. At the same time, from the Center for Educational Support from CESAL high risk cases are approached in which 60 children participate every year and a follow up has been started with their families from the Office for Family Assistance. On
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the other hand, in the action framework for Basic Housing, different committees have been created in the community as well as a Health Committee which develops medical and prevention campaigns in coordination with the health centers. a. A Project Growing together The project Growing together was initiated in 2005 to support children from their birth up to 3 years of age helping prevent chronic malnutrition and anemia in the communities of Jicamarca, Cajamarquilla, Nievera and Lomas de Carabayllo. This was develop by: Strengthening the communities through the implementation of a communal vigilance system whose objective was to identify and watch over the growth and development of children from pregnancy. These activities are developed by health counselors trained by CESAL and their principal activities are: home visits, nutrition workshops and early stimulation which is taught in the Centers for Nutritional Vigilance and referral to other health centers. Strengthening and accompanying of the community health centers local staff, aiming to improve the quality of attention to mother and child in coherence with public health policies and the actions of public institutions so as to avoid duplicating efforts or
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supplanting the competence of the state and to accompany it and to add efforts to benefit children. The trainings developed covered themes such as Growth and Development, Safe and Healthy Maternity, Integrated Attention to Prevailing Illnesses, Mother Child Nutrition, Natural Methods, and Health Promotion among others. The project addresses four thematic sectors: health, nutrition, hygiene and psychoemotional stimulation. The strategies are fixed, since the nutritional Vigilance Centers promote the health for all the communities through municipal health operators and of the Health Centers.
20.6% reduction of chronic malnutrition and 19.8% decrease of anemia of children In Huachipa, due to the improvement of basic sanitation in the human settlements,
under 3 years. families now have access to safe water, thereby improving the practices and behavior of 60% of the mother-child population.
Results
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Increase of the availability of and accessibility to food among families through agri The improvement of economic conditions thanks to the generation of income
cultural programs in the area. strengthens the productive capacities of young people and thus their access to basic education and health needs. The local staff of the health centers got involved in the Project by becoming a partner in the achievement of the objectives. Implementation of a communal vigilance system in 8 human settlements thanks to the space made available by community leaders and the voluntary work of the health promoters. 49 health promoters attended 286 children through home visits, bringing not only knowledge but also companionship. The commitment of communal authorities, public institutions, health promoters and families to work together in a coordinated way in order to prevent child malnutrition. Increase of parents committed in the care of their children. In general, children participating in activities such as psycho-emotional stimulation presented less health problems. b. Project Conquering Malnutrition Since 2007 to date CESAL has developed this program with local actors maintaining the guidelines of previous interventions and broadening the field of action: Strengthening of communal kitchens by implementing a system of auto vigilance of nutritional quality. Training the partners of the kitchen in management and organization techniques by means of a participative methodology seeking not only to increase know-how but also to generate sustainable changes and a higher involvement of the communal kitchens in health promotion. Strengthening of primary schools and PRONOEIs (Program for children without schooling) in health and nutrition, early stimulation and learning problems and the accompanying of teachers in class as well as workshops with parents. Strengthening of primary schools and PRONOEIs (Program for children without schooling) in health and nutrition, early stimulation and learning problems and the accompanying of teachers in class as well as workshops with parents. Strengthening of communal health centers through local staff training, joint development of campaigns for the promotion of health, development of monitoring tools for pregnant women and children, articulation of local health staff with health promoters and improvement of infrastructures and equipment. Strengthening of families with pupils at risk in the Center for Educational Support from CESAL, improvement of nutritional habits, nutritional vigilance. Results
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pregnant women and they transfer them to health centers and they do activities of early stimulation and health promotion. 59% of mothers participating in the Centers for Nutritional Vigilance improve their good practices. CESAL works in 12 communal kitchens of which 7 offer nutritious and healthy food. Progressive implementation of auto vigilance systems in the 12 communal kitchens 40% of teachers have improved their know-how in health and nutrition management to promote healthy behaviors in 38% of the children that go to primary school. These healthy behaviors are reflected in an adequate hygiene and in periodic assistance at Health Centers and in the use of healthy food. 40% of teachers have improved their know-how in health and nutrition management to promote healthy behaviors in 38% of the children that go to primary school. These healthy behaviors are reflected in an adequate hygiene and in periodic assistance at Health Centers and in the use of healthy food. 5 primary schools and 3 PRONOEIs have included health and nutrition topics in their annual work program topics. 35 professionals are sent to post graduate courses in Health Promotion in which three health centers participate as well as local, municipal and state institutions (Direccin de Salud IV Lima, Gerencia de Bienestar Social de la Municipalidad de Lurigancho-Chosica, Unidad de Gestin Educativa Local VI, Comit Local de Administracin en Salud CLAS de Nievera). A local health plan has been developed with the members of the local committee for Health Administration of Nievera del Paraso, and as a result of the post-graduate course, there will be a Program for Promotion of Community Health with the participation of all local actors. 35% of the children attending the program at school improve their nutritional condition 98% improve their habits. 3.1.2 In Apurimac Region (Sierra Andina) This region, together with Cajamarca y Huancavelica, is considered to be among the poorest in Per. The province of Andahuaylas, the principal area of intervention of CESAL, has a population of aprox. 140.000 inhabitants, of which 65% live in rural areas and 82% of the economically active population are farmers.
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CESAL started its presence in Peru developing projects in the area of water and sanitation in the region of Apurimac, province of Andahuaylas. In this area CESAL has the coordination of projects that it started with specialized local counterparts (NGOs, associations, firms etc.) and strategic public partners (regional government, local governments, ministry, state programs etc.). During the year 2000, an initiative in collaboration with the Municipality of the province of Andahuaylas, CESAL constructed an irrigation canal of 16 Km benefitting 7 rural communities out of 9 in the district of Santa Mara de Chicmo.
Also CESAL began an intense work linked to food security and agricultural and farming development in the district of Santa Mara de Chicmo, developing 13 projects in this region with a total investment of 4 million dollars. From the year 2000 to the present, we have developed the following guidelines: Infrastructure: Construction of small irrigation channels measuring 1 3 Km intended to guarantee water supply for land use. Promotion and spreading of irrigation systems planned to guarantee the adequate use of hydrological resources. Production and commercialization of agroexportable products: artichokes. Production and commercialization of milk products. Organization and strengthening of producers farming associations. Introduction of successful methodologies for the transfer of know how: School of Land Farmers (Escuelas de Campo de Productores - ECAs). Training and technical assistance in all areas mentioned above. Construction and equipment of health centers for mother-child assistance. Program for prevention and fight against childhood malnutrition under 3 years. Program for prevention and fight against childhood malnutrition in primary schools. Results Development and validation of intervention strategy in food security together with the local governments and population. Close collaboration with and involvement of local governments such as province and district. Local authorities recognize the efficiency of CESALs work and their local counterparts in the province of Andahuaylas: subsidy model. Local governments adopt working strategy for themselves and continue the guidelines started: incidence in local public policies. Creation and strengthening of social capital: producers association, mother groups, health counselors among others. Construction of a center for mother-child assistance. Actually managed by the Health Deputy of Apurimac with a capacity to attend to 7.000 women. Reduction in 26,16 percentage points (from 54,38% to 28,22%) in 6 years (2001 to 2007) of chronic malnutrition in children under 3 years of age in the district of Santa Mara de Chicmo. The Regional Administration for Health of Apurimac recognizes and implements communal vigilance as a public policy in its health centers. Increase of access to drinking water from 5% to 60% of the population in the district of Santa Mara de Chicmo. 40 hectares of land plots working with technical irrigation systems. 40 hectares of artichoke production managed through local producers associations and
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4 farming associations from the district of Santa Mara de Chicmo have improved their
practices obtaining quality milk and manage a pilot milk plant which actually processes and supplies milk and dairy products to the social program Vaso de Leche.
sold to processing and agro exporting firms at the Peruvian coast.
2.000 families with children under 3 years 7.000 pregnant women 200 small farmers (cattle) 500 small potato and artichoke producers
We estimate that the direct beneficiaries from these initiatives are:
3.1.3 Methodological notes Food Security: Farming development and prevention as well as fighting against malnutrition. Collaboration with local governments: incidence in public policies. Farming development: effective know how transfer, promotion and spreading of innovative farming techniques, strengthening of capacities, producers organization. Communal vigilance and monitoring of growth and early development: creation of Centers for Nutritional Vigilance , census and mapping of pregnant women and children under 3 years of age, prenatal check ups and monitoring of growth and development of children, home visits, workshops on health and nutrition and early stimulation. Articulation of community work at the health centers. System for Nutritional Quality Auto vigilance and Management of Communal Kitchen. Evaluative quality study of schools, monitoring, follow up and technical assistance at each school, fairs for health promotion of health in schools.
Lessons learnt The main lessons learnt of our work are: In all interventions CESAL, also in health and nutrition sectors, the leading principle have been the relations with persons and leaders of the community who have articulated their needs but also their capacities.
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The first action developed in Huachipa was the construction of a health center. This
Some examples:
necessity, expressed by the community, made possible the acquisition of the building lot so the Ministry of Health could assign health workers to the area. Today, the health center continues to operate while construction continues on the expansion of the second level. Some of the women who are now health promoters were mothers who came to CESAL worried about the nutritional state of their children and who have continued this desire of accompanying other mothers in the same way, a obtain commitment made 4 years ago that continues today.
The teachers at the public educational institutions and Programs for children out
of school receive numerous trainings throughout the year. But also they receive support to manage the difficulties they encounter in school day by day. With the support of health promoters, they have started to elaborate materials, ask parents to come to schools and include in their plans topics such as health and nutrition as a priority for their children. This has made it possible to establish a permanent relationship with the different public authorities such as the Unidad de Gestin Educativa Local IV (decentralized entity of the Ministry of Education) with which an agreement has been signed to continue the work in this area.
From the start, there has been a close collaboration with health personnel to define the
Some concrete examples:
activities for health promotion development in the community, being CESALs staff a support in spreading information, elaborating materials and bringing public health services to remote areas. An agreement has been signed with the Direccin de Salud IV Lima Este (decentralized entity of the Ministry of Health), in which joint annual activities are planned. The rural districts in which CESAL has worked have permitted a flow of information and close collaboration with mayors and local governments in general.
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It is essential to count on outspoken participation of local authorities, but it is still
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more important to keep a close and sincere relationship with the persons involved in the process (mayors, directors, public servants etc.). At a start CESAL was reluctant to work with the communal kitchen, but more than 80% of the population buys their daily food in these centers. The partners have understood the importance of their role in the nutrition of the community and started introducing nutritious food, pay attention to the hygiene and in some cases transfer families to the local vigilance centers or community health centers. The mothers of the Center for Educational Support of CESAL were trained to learn how to prepare more nutritious food without increasing their expenses as well as giving up other food which was not nutritious. Currently every year, the mothers with the participation of the communal kitchen and the health counselors celebrate an Annual Gastronomic Day open to the whole community. It is interesting to observe that in the marginal regions CESAL has its own technical staff who implements projects in food security and malnutrition. Nevertheless, as time goes by the communal health centers have increased their area of intervention (3 currently) and the number of social organizations (vigilance centers, communal kitchen) who intervene in the area, many of them supported and encouraged by CESAL. The networking with all actors makes it possible that all resources and capacities are implemented according to common objectives. In the Peruvian Sierra (region of Apurimac) CESAL counts on highly specialized local partners (Asociacin Kusi Warma) in programs for the prevention and fight against malnutrition in which the same strategy and methodology of intervention (communal vigilance) is shared. Also, in the sector of agricultural development we count with the technical assistance of specialized institutions: Universidad Nacional Agraria, Centro Internacional de la Papa, Mercadeando, etc. meaning that we support the strengthening of the social network in the areas where we intervene. In rural communities in the Peruvian sierra, the parallel model Farming development and prevention and fight against malnutrition has proven to be highly effective. In fact, the strategy developed in the district of de Santa Mara de Chicmo has helped as a basis for CESAL and its partners to start working in other rural areas of the Andahuaylas province with very positive initial results that have encouraged the local government and other authorities.
3.2. Haiti, rural zone in the south and Port-au-Prince: nutritional centres in rural area and urban horticulture in the capital
Fiammetta Cappellini and Espedito Ippolitto, AVSI, Haiti Haiti, once the pearl of the Caribbean for fifteen years has been the least developed nation, the poorest and the most fragile of the American continent. Haiti, which in 1949 was the site of the Universal Exposition, advanced in terms of infrastructure, development, economic growth and cultural identity, is now a fragile and vulnerable country, in search of its identity, afflicted by a poverty that for many brings no hope. AVSI has been active in the country for 10 years, with a presence attentive to understanding the needs and available to put itself on the line in a model of development cooperation that believes in the human element in the person as the motor and protagonist of development.
Haitis basic data Haiti is by far the poorest country in the Caribbean area and of the entire American continent. Between 2007 and 2008 its human development index (already very low: 146th place in the world) has even worsened, making it descend to the 149th position out of 188 countries. The other half of the Hispaniola island, the Dominican Republic, is at the 90th position: an imbalance that is made even more evident by their geographical proximity.9 Haiti has a population that is very numerous in comparison to its territory (more than 9 million people for a population density of 324 inhabitants per square kilometre; in Italy it is 199 inhabitants per square kilometre). Of this population, 35% are unemployed, with peaks of almost 50% in the urban areas. Over 80% of the active population that has a job, works in an informal way, a factor that contributes to rendering the population vulnerable and exposed to risks, among which (there) is food security.10 Exposure to food security risks in Haiti Without a stable and secure job, generally in conditions of insufficiency of means of sustenance, 78% of the Haitian population is in a situation of poverty. Over 50% is in a situation of extreme poverty (that is, they live with less than a dollar a day).11 This means that there are 4 and a half million Haitians who are extremely vulnerable and potentially at risk regarding food security. Of this 4 and a half million, 1 and a half million are younger than 15 years of age12, that means that they are not able to overcome a condition of serious vulnerability, often true hunger. Of the 4 and a half million, 3 million are adults, of which 1 million are completely without
Index of Human Development, United Nations Development Programme UNDP, 2009 Ibid, p. 1 11 Ibid, p. 1 12 Ibid, p. 1
9 10
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any means of supporting themselves13. The Haitian populations exposure to food security risks is thus extremely serious and concerns wide strata of the population that does not possess the means of changing this situation unless they do not receive help and support.
What are the causes? There are various causes of the current situation, in large part attributable to bad government and to a serious political absence, which has not protected the country and the population from adversities. One may add the problems that are difficult to correct, such as: massive abandonment of agricultural land, total dependence on importation of foodstuffs (and therefore the impossibility of controlling their prices), the lack of alternative sources of sustenance.
These factors are also the reasons that have made Haiti one of the countries most affected by the world food crisis of 2008. Another aggravating factor is the exposition of the Haitian territory to natural disasters: for example, 4 cyclones have hit Haiti in September 2008, generating hundreds of thousands of homeless persons, changing the morphology of the country, flooding entire cities with over 3 metres of water, creating new lakes, interrupting all the roads (and the possibility of transporting food from the production areas to the consumers). This vulnerability to natural disasters has its explanation in the very severe environmental deterioration: more than 50% of the Haitian territory is exposed to grave erosion. The uncontrolled cutting of the trees exposes the territory to erosion, renders it quickly unproductive, amplifies the effects of the torrential rains. In a strictly rural perspective, the majority of Haitian farmers own land that is insufficient for the satisfaction of the alimentary needs of their own family, because: it is too small (extreme parcelling of the property) it is under productive (backwardness of the cultivation techniques) it is too frequently subject to flooding or exposed to periods of prolonged water scarcity.
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In the urban zone, instead, the population most greatly exposed to food security risks are those of the inhabitants of the large slums, who live in unhealthy environments, without any access to basic services, in situations of chronic lack of work and serious urban violence.
Malnutrition, effect of lack of food security? The recurrent preoccupation of Haiti is that the grave exposition to the lack of food security is mirrored in a high level of malnourishment. This is however not confirmed by official data.
13
Ibid, p. 1
The State is not able to carry out reliable evaluations and the only reference data are those of the recent investigation carried out on a sample basis of the national territory by the NGO Action Contre la Faim. The results of this investigation do not reveal a worrying situation. This is however in contrast with what has been stated above and it does not correspond to the reality that we observe every day. We have hypothesised the existence of pockets of malnutrition that are not visible, or of a manifestation of the phenomenon that is only partial. We have therefore undertaken our own investigation, in the zones in which we operate, with a door to door methodology. The data reported is of extreme severity, compared to the official data.
Official data overall acute malnutrition 4.3% AVSI Reporting 17.6%
severe acute malnutrition
0.8%
8.3%
This shows that in the zones where we intervene overall acute malnutrition is four times that reported officially and severe acute malnutrition is as much as 10 times higher. Some observations: the standard surveying and those of a sample basis do not identify the real needs, nor the serious vulnerabilities; these results that are so different are in part owed to the fact that AVSI works in particularly difficult zones, but in large part owed to the different methodologies utilised in the investigation (in particular to reveal that the investigation carried out by ACF and the official data are projections of sample investigations, while our data have been 100% reported from the population, with a door to door investigation, realised in a community that is considered to be highly vulnerable.); the results of our investigation are extremely serious, they show an urgent and unfortunately chronic, situation in all of its severity. This data however, also shows malnutrition that is even more serious than the lack of food security alone should generate. Through a social investigation, we have discovered as possible aggravating causes: educative factor: the adults responsible do not know the causes of malnutrition and its effects, they do not know how to prevent it; affective factor: the affective component in the adult-child relationship in Haitian society is at this moment weak and needs to be promoted, supported, launched at every level and with all the resources; relational factor: the connections in the community are less strong, there is less solidarity;
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this allows certain situations of poverty to aggravate until they become unsustainable Our interventions were built starting from these considerations.
Which work approach and why? The complex and complicated situation of the country has imposed upon us a very careful reflection on the way in which to deal with the problem of lack of food security that, as has previously been stressed, is determined by diverse causes, some of which it is impossible to act upon. The approach chosen is the fruit of the reflection that, starting from the presupposition that agricultural growth is fundamental for the reduction of food security problems, has developed around the guiding principles of the work of AVSI in the Developing Countries and to the actual characteristics of the country. The reflection is articulated around the two guiding concepts: knowledge and the centrality of the person. Knowledge implies work, it requires the constant expenditure of energy and resources directed at: understanding the socio-economic context in which one works, recognising the causes of the poverty and/or lack of food security, to be able to then decipher the real needs of the population. The first step has therefore been directed at an effort of understanding the reality that has supplied the elements of analysis and judgment that are indispensable for identifying the correct intervention approach. The decade-long presence of AVSI in Haiti and the work experience consolidated in specific zones and quarters have permitted the reaching of this first step making us even more aware of how much and in what form the problem of lack of food security is strongly connected to the socio-economic, political and environmental factors of the country, as is clearly evident in the introductory part of the document, and how therefore factors that are very difficult to modify play a part. Thus the priority is identified, to favour the growth of agricultural production, which has begun to take a form that responds also to how to reach this objective. The conviction that the centrality of the person is at the base of any type of development intervention has brought us to favour a model centred on the improvement of productive capacity, considering it as a right of the population. Only with a form of support of this type can there be a guarantee of respect of the dignity of the person that, through an improvement of the results of their own work, satisfies their own innate desire to feel useful for themselves and for others, and allows them to feel gratification for the sacrifices made. The support of the agricultural sector thus renders things concrete, in addition to supplying essential production input, also and especially through the organisation of educational activities, and the sharing of community work that favours personal interaction, the exchange of experiences and allows one to place in the centre of the intervention human relations and to create and/or consolidate those social connections that, in a reduced community, represent a fundamental source of wealth and patrimony. Support is thus foreseen even for the activities that are not specifically agricultural: raising of small farm animals, improvement of the access to potable water, sustainable management of the natural resources, considering that the lack of food security has many aspects and should be dealt with by acting upon its various causes.
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The encounter with the reality of the place has brought us to consider that there is a great heterogeneity of the impoverished subjects and lack of food security is linked in way that cannot be disregarded from the context in which these people live. This is why the knowledge of the context and the reading of the reality as a litmus test for the identification of the problems and needs become key steps towards the choice of a means of operating; it will be clear, in fact, that though starting from the same point in common, the work experience on food security of AVSI in Haiti has assumed different characteristics based on the context of intervention. Following are in fact presented two structural interventions based on the diverse characteristics of the areas of implementation.
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Rural zone in the south: food security and fight against malnutrition The department of Southern Haiti presents data of the incidence of poverty and extreme poverty above the national average, respectively of 87% and 69% compared to 77% and 56%. On the average a person in conditions of extreme poverty in the southern region has a daily economic intake of 0.43 USD (official data of the Ministry of Health and Population, data of the National Committee of Food Security CNSA 2008). This situation is produced in a zone of strong agricultural vocation where the majority of the population lives off of the harvests that the land is able to provide. Today, unfortunately the large stretches of land in the Plains of Terbeck and Les Caves, zones of NGO intervention, are not as fertile as they once were, because of the very high levels of environmental deterioration, massive deforestation and therefore the erosion of the soil that has determined a loss of fertility estimable at around 50%. AVSI today, by means of constant educative action and a service of technical assistance supplied to the farmers, tries to give impulse to production, promoting forms of sustainable cultivation that highlight the importance of the agricultural activity, not only as a source of food, but also as a way to protect and conserve the environment. This concept is culturally difficult to accept for a farmer who, when faced with the obstacles of daily survival, is not stimulated towards being motivated at making an effort to revise his traditional agricultural practices; that requires work carried out with methodicalness and constancy, sharing with the farmers the pros and cons of the new and traditional farming techniques. It is necessary to consider that in the zone of intervention, rice constitutes the principle crop, followed by corn and beans. The earnings for a unit of surface area are on the average 50% lower than potential earnings. From a hectare of land cultivated with rice, one obtains, on the average, little more than a tonne of the product (1,350 Kg), but one must bear in mind that the farmers family rarely has at their disposition a piece of property and on the average the size does not exceed 500 m. In the majority of the cases, approximately 70%, the land is cultivated by a rental agreement or in other forms that are like sharecropping. For this reason, the attention is directed on how to best take advantage of the available surfaces by pointing them towards cultivations that can provide a more valid caloric and nutritional supply. The intervention realised
by AVSI aims at providing an integrated support that aims at creating the conditions of alimentary-nutritional security in the zone. The rationale for this type of approach is the realisation that a severely malnourished child, inserted within a programme of nutritional recovery, does not recover a condition of health and normal weight solely through the support given in the nutritional centres operating in the community. This is caused by the fact that, once having returned home, the family does not have the means to feed him constantly. Thus the family needs to be accompanied in a process of improvement of their own productive capacity, trying to impact the socio-economic conditions of the entire community. In this way, it has been decided to establish a system in which the production of the farming families, fruit of the activity favoured by the project (raising of chickens and rabbits, various types of crops), is in part destined to supply the nutritional centres themselves in which the children are treated and assisted. We are speaking of 5 nutritional centres, opened by AVSI in collaboration with the local community in 2007, within the same number of health centres, public and private, that were already in existence. These centres take charge of approximately 20 children a year each, chosen from among those with the most serious nutritional profile and coming from the most vulnerable families. The centres offer a weekly monitoring of the child, with activities of education for the mothers, training on alimentation and recipes prepared together, with then the consumption on the spot of a hot meal. The parents of these children are inserted in a programme of education and support towards agricultural development, for the minimum duration of a year, lasting up to three years in the most difficult cases. In this way the rural families are guaranteed the sales of a part of their products and at the same time they are utilised for the supply of the nutritional centres and in the service of the community. The interventions of food security and fight against malnutrition are thus managed in an integrated form that foresees: Direct support to the families (90 families a year) in terms of: means of production, technical agricultural assistance, programmes of nutritional recovery for the malnourished children and medical sanitary assistance. Educative activity related to malnutrition and agriculture, favouring the encounter and exchange of ideas and contact between persons (community cultivation fields) (approximately 500 beneficiaries) Promotion of forms of sustainable use of resources: increment of the agricultural productivity is linked in an indissoluble way to the containment of environmental deterioration Support of the cultivation of highly nutritional and energetic products: for example manioc that is able to supply more than 1/3 of the daily calories required by an individual and conservable in the long term under the form of bread The creation of a small closed circuit of production and sales that gives the families guaranteed sales of their products at a fair price and at the same time supplies the service of nutritional recovery given to the malnourished children of the community (this is a pilot project which in this moment has about ten farmers involved as producers, the purchaser is the nutritional centre and the beneficiaries are the 90
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children; it is expected to increase in size to at least 30 farmers in the second year).
Urban zone of the capital: urban horticulture In the degraded quarters of the large metropolitan area of the capital malnutrition strikes with equal force as in the rural areas. The cause: the families do not have access to food, which has become too expensive and the local market (near the slum) does not offer quality food products. In a context of such vast and uniform poverty, of deterioration, of lack of hope and trust in the future, economic aid to the families is neither able to be proposed nor sustained in the long term. We have considered that the families, the parents, also need to gain trust in their own abilities to provide for their children, to demonstrate to them and to themselves as well, that no life is a failure, that no situation is insurmountable. The programme of urban vegetable gardens, which has been developed in cycles of six months on diverse projects, has touched in an effective way more than 600 families for a total of over 4,000 persons and it has had positive effects on the food security for at least twice that number. The programme applies to the urban reality the principle of support to agricultural development, giving attention to the diverse context and to the necessity of intensifying the crops, in order to optimise the small space that is available. The principle phases of the project have been:
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action of training and motivation: community terrains have been created for trai-
ning: the inhabitants of the urban quarters for the most part have never been farmers, they lack the experience and the training has to be preliminary and effective; installation of the vegetable gardens at the beneficiaries: through recycled and recovered material of every sort (plastic containers, old tyres, milk cartons, etc), containers of various sizes have been created, in which the soil of suitable quality (created with the help of the agronomist in sites not too far from the homes) is prepared for the cultivation. Every available surface is taken advantage of, from the roofs of the houses to the courtyards, terraces, abandoned buildings. The containers can be placed and moved without too much effort and they can be protected from possible floods; selection of the varieties: the very hot climate does not help, but however we have been able to cultivate successfully at least ten different varieties of beans, giving priority to those that bring nutrients that are absent in the childrens diets, with particular attention to red beans to support alimentary and protein recovery; accompaniment and support of the beneficiaries until they become autonomous: usually the time of the first harvest varies from 4 to 6 months from the entrance in the project. At this point it is important that the beneficiaries know how to manage the harvest, subdividing it among the alimentary needs of the family, the possibility of selling it and the need to stock seeds for the successive cycle. This has been the most delicate phase; transversal educative action: the fight against malnutrition does not end with supplying sources of alimentation, but it necessarily passes through an accompaniment of the parent towards different attention given to the child, through a knowledge of his needs, towards greater adaptation to them. This educative action has been conducted throughout the entire programme. Through this intervention with the community fields, we have been able to train (allowing them to work together on the same terrain) 402 farmers on 14 terrains. The distribution and the training on the diversification of the crops has had as a result that: 1 terrain has 9 varieties 3 terrains have 7 varieties 9 terrains have 5 varieties In this way, the diet of the beneficiaries has seen a very positive change in the rural zone of the south: at the end of the project 40% of the families have 10 different varieties in their own terrain 50% of the families have between 7 and 9 different varieties 10% have between 1 and 6 varieties at their disposition It is necessary to bear in mind that before the project 80% had only 2 varieties. For the urban zone of Cite Soliel, instead, the result is less positive due to the climatic impediments and the composition of the terrain: 13% of the families have 5 varieties available 50% have 3 or 4 varieties available 37% have from 2 to 0 varieties available An investigation on a survey basis of the beneficiaries has shown that
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62% now have animal protein available to them on a daily basis for each member 28% have animal protein available to them once a week for each member of the family.
Prior to the project no family had daily access to animal protein and 20% not even once a week Concerning fresh vegetables: prior to the project 66% of the beneficiaries never ate fresh legumes (0% consumption on a weekly basis). at the term of the project 96% of the beneficiaries have fresh legumes available on a daily basis. of the family
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What have we learned in the course of this experience? In the first place, we have learned that malnutrition is a complex problem that generates a serious vulnerability and it takes time to recover from that. Today we design our interventions to give priority attention to the educative aspect: we stress to our collaborators the necessity, before all else, of explaining to the parents where the disease of their child comes from, how to prevent it, how to correctly take care of him, how to help him, how to be close to him, without ever giving up hope. Many healings today are owed more to the commitment and the dedication of many mothers than to an actual important greater availability of food. We have also learned that the enthusiasm and involvement of the beneficiaries, of the community, are fundamental for the success and the duration of the results. Without active personal involvement, without an intimate appropriation of the actions set into motion, no result assumes importance. Taking off from the results we have obtained, we have learned that food security and the fight against malnutrition can only be considered together, just as the quality and the quantity of the alimentation are indispensable factors, to face the problems of this country with realism: education is fundamental, but it has to be associated also to survival conditions and therefore to food availability. We have also learned that: even forms of direct assistance to the population, hard to frame in a process of development that expects to be sustainable favouring the valorisation of the person and the spirit of initiative of the individual, can find a place in an intervention if they are utilised well. A context characterised by conditions of extreme vulnerability of the population, as those in which we operate, require direct help, but not if it is connected to a logic of gratuity and if it is realised through the rendering of services supplied through the collaboration with local structures (medical dispensaries in the case of the nutritional centres) certainly the potential negative effect can instead be converted into an added value it is the relationship established with the persons that gives life and force to an intervention. In a phrase referred to us by a beneficiary of agricultural support
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you really do respect people one can understand many meanings and feelings, among them probably that of frustration due to having been involved in many interventions with the pretext of supplying help while ultimately failing to listen to the persons or understanding their real needs. Today in Haiti, each one of our interventions in this sector starts with meeting with the community, from a discussion about the needs, means, times and resources which it has available. And after that, an action of sensitising of the community is realised, of timely and persistent education, of accompaniment, of closeness. For us, this means to work side by side, every day, with constancy.
3.3. Rwanda: Humure nutritional centre, first development ring of the community
Rwanda, Setting Rwanda, with 26 338 km2 of land and a population of 9 200 000, possesses one of the highest population densities in Africa: 349 inhabitants per square kilometre. Rwanda is one of the poorest countries in the world, with a monthly average pro-capita income of $100. The number of people who live below the poverty line is estimated to be 60.3% of the total population14. The population of the country is mostly located in rural areas, given that 90% of them are involved in agricultural activities, and that is the sector most important to the economy of the country. The maternal mortality rate is 1 300/ 100 000, while infant mortality is 118/1 000, reaching 203 for children under five years old15. Regarding the African continent, Rwanda is one of the worst hit by the AIDS epidemic: 3.1% of adults are HIV positive16. The number of HIV positive children or HIV-caused orphans contributes negatively to both the countrys direct and indirect economies. Apart from AIDS, the major endemic illnesses that cause a high death rate are malaria, respiratory system infections, diarrhoea, tuberculosis, typhoid, cholera and meningitis, all of which contribute to lowering the immune system, making the population more susceptible to HIV infection. These illnesses also have a negative effect on family planning, as, given the high infant mortality rate, families tend to compensate by having more children to increase the chances that some of them will survive beyond 5 years. This causes pregnancies that are very close together, each time increasing the possibility of high risk deliveries. From a nutritional point of the view, 33% of the population is malnourished, increasing to 48% when considering only children under 5 years old17. Humure is located in the eastern province of Rwanda. The province is subdivided into
16 17
14 15
Riccardo Bevilacqua, AVSI, Rwanda
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Source: UNDP Human Development Report 2009 ibid., p.1 ibid., p.1 ibid., p.1
6 administrative districts. The area is 1 694 square kilometres, and represents 7% of the total area of the country. The population of the province is 712 372 inhabitants, of which 338 047 are men and 374 325 women, while the population density is 421 inhabitants per square metre. The economic situation indicates that 41% of families live in extreme poverty. Gatsibo district is located in the north east of the province and has 70 thousand inhabitants. Access to health services is often conditioned by the vast distances that have to be covered to reach the health centres; this often forces people to resort to those who practice traditional medicine.
The history of the Humure Health Centre What we today call the Humure Health Centre (HC) is a structure created at the beginning of 2000, thanks to a project financed by the Italian Cooperation and built by AVSI (Italian not-for-profit, non-governmental organisation). The Nutrition Promotion Centre was built with the intention of overcoming a serious nutritional crisis which was mostly affecting 0-5 year olds. With the establishment of the activity, it was very clear that the Center was able to cure malnutrition but not able to respond to other needs always connected with malnutrition, but more on the medical side (malaria, diarrhoea, intestinal worms, fevers etc.) Furthermore: The Humure Nutritional Centre (NC) over the years has become a irreplaceable point of reference for the population because the distance between this health centre and the nearest one to it is of 18 km. So based on this it was decided to widen the service by building a surgery unit which, together with the NC, has given birth to a Health Centre. This step forward was made with the important contribution of the Italian NFP organisations Comunit Biellese Aiuti Umanitari (CBAU of Biella) and Futuro Insieme (Verona), and with the collaboration of the local, provincial and national health authorities. At this point other needs appeared, and thanks to the help of other government bodies and organisations (Ministry for Foreign Affairs, Rotary Imperia, SBAU, Futuro Insieme etc.), the Humure Health Centre further developed. That is to say, the building of a maternity ward (constructed by youngsters trained as builders), the creation of a pavilion for the fight against AIDS (consisting of a lab, surgery unit and training room) and the installation of an energy producing system using solar panels. In 2008 the management of the Health service of Humure HC, till that point managed by the AVSI foundation, now being self-sufficient, was handed over to local authority. Recognising the advantages in the approach and methodology of the NC, those same authorities asked AVSI to continue their management of it. After one year of activity, in 2009, the number of malnourished people cured by the Humure NC had reached such a low level, that the control of nutritional services management could be returned to local authority. Today the Humure HC belongs, and to all effects is managed by, the Rwandan authorities. Ex-employees of AVSI continue to work within the structure to ensure the quality of the services provided.
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Support project for the Nutritional Centre AIMS Reduce malnutrition rates. Reduce the incidence of illnesses caused by malnutrition. Increase the agricultural abilities of the poor population. Increase the animal breeding abilities of the poor population. Activities Cure and assistance of the malnourished people in the Nutrition Centre: the NC offers to the malnourished a reference point where they can be cured, and where a special diet is available. Specifically trained staff provides malnourished childrens mothers with information so that they can learn the nutritional values of the various foods available locally, and so that they can introduce them correctly into the diets of their families. Care and production of an exemplary garden: a genuine exemplary garden is regularly cultivated in a land nearby to the HC. This activity, managed by an agronomist, serves to show to the beneficiaries of the NC the importance of crop diversification in order to enjoy a varied diet, and to introduce the very best cultivation methods. Increasing of the production and repopulation of the exemplary farm: chickens, pigs, rabbits, goats and sheep are reared just a few metres from the HC. The aim is to offer
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training to the clients of the NC on the best methods for raising animals, giving them the chance to share the results. The newborn animals are distributed according to a rotational system among the NC user families. Activities and increased production capacity of the HC Associations: in order to run the garden and the farm, 6 associations of mothers of malnourished children in care at the NC have been organised. Each association is in charge of a different type of animal, and they work in collaboration with HC employees. Their work finishes when all the members of the association receive a yield or a product from their work: for example, the association which is managing pigs might finish managing the piggery once each mother has taken home one piglet; at this point those same mothers might take over the management of the chickens, and when each has taken home some eggs and a chick, the rota clicks over again. Thus, in just a few months, each mother will have her own small farm at home and will be able to run it, and will have learnt to cultivate her own small garden. Length: 9 years from 2000 - 2009 Beneficiaries: Humure Health Centre in the administrative district of Gatsibo in the eastern province. Principally the nutrition services of the centre (Nutrition Centre, farm and allotments for the production of the vegetables required by the NC, and the awareness campaign for the mothers of malnourished children) and the associated catchment area (approx. 25 000 people). Results: From 328 cases of malnutrition registered in 2000, only 42 cases were registered in 2009. All outside the intervention area. From 2000 2009, 1 473 children have been treated for malnutrition, of which 1 435 were totally cured (38 deceased) 6 associations were formed from which have sprung two recognised cooperatives. A nursery school has been opened by one of these associations. Main methods While working in the eastern province, we became aware that the malnutrition was not so much caused by poverty, but rather by ignorance regarding effective farming methods, the preparation of balanced meals and an ineffective fighting of intestinal worms. It was therefore strategic to work with the mothers, held to be key players in changing the situation as they are generally responsible for feeding the family. The first thing to be done was educate the mothers on how to prepare balanced meals, with meetings and culinary demonstrations which can easily be repeated within the home. For this reason the mothers were asked to bring to the centre the food stuffs that were easily available where they lived, so that it could be shown that basic nutritional requirements can be satisfied by local food stuffs. In order to complete the picture and to introduce new ways of doing things, it was decided to develop a model farm and demonstration gardens where the mothers could learn through practise. The harvest was partly used in the centre for malnourished children and partly shared among the mothers to take home. The mothers also received a specific quantity of seeds and shoots so that they could apply their new knowledge at
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home. Regarding the farm, there was a rota system by which each individual involved could receive some young animals, to avoid the families being dragged back into the vicious circle of malnutrition. The consequence of this method has been the progressive decentralisation of the interventions. Each mother returning home with her newfound knowledge, seeds and animals made her family an outpost in the area.regarding good nutrition Very quickly our social assistants and our agronomist found out that they were supervising more activities at peoples homes than at the NC itself. Conclusions In order for a development project to be successful, a transformation must take place. from beneficiary to resource, from cost centre to capital. That was how the mothers leaving the Humure NC and returning home were able to transform their families into outposts in the fight against nutritional instability. At the beginning they were the most vulnerable and emarginated families, and now the entire community goes to them for advice on how to farm and rear animals. From outcasts to exemplary citizens whom the local authorities invite others to imitate. Additionally, the families involved have decided to group themselves into 6 associations from which 2 cooperatives have flourished and have been recognised by the Rwandan Ministry for Economics. One cooperative manages coffee farming and other corn. Both are recognised today by the district authorities and are important drivers of development in the area. These cooperatives arent only concerned about income generating activities, but also offer community services. One of them has decided to open a nursery school for the children in their area. An example Dyna initially became involved with AVSI as an agronomist in charge of reforestation in a project financed by the Ministry of Foreign Affairs. Later she was asked to assist the activities of the Humure NC by developing exemplary allotments. She approached her work from a technical standpoint: how to grow crops in the best possible way. But as she got involved with the mothers, children and social assistants, her approach slowly changed. She began to view her work, her usefulness, in a wider context, looking to better the health of the children and their families. It was as if she raised her face from looking down at the hoe and seeds to look the faces of the people she was helping. Her attention is now far more focused on the resources and knowledge of the people than on the seeds to be grown. Taking us somewhat by surprise, she herself asked to participate in a training on Value of life, believing it to be essential for her work.
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Lessons learnt Start from resources that the people have: a food stuff from their fields, plus the desire to overcome malnutrition.
Dont ever think that technical staff cannot become social staff too. Dont rush, and dont believe that change can occur within the same time of a normal institutional project. Investment in the freedom of people brings about some incredible side-effects: from curing malnourished children, to building a nursery school.
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Argentina, Santa F. the experience in urban and rural field

Fernando Bonzi, Mauricio Moresco, ACDI, Argentina
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Man, before being poor, is a man. To consider man a pauper is a reduction, it is like starting from something that is missing and not from what he is. Most of the time it seems that what is missing is more important than what we have today, in a way that we have it today. In a situation of development that is blocked or defined as a vicious circle of poverty, the factor that can generate change and can set in motion the skills present in each human being, in each community is not only a technical accompanying for a specific problem but a true drawing near that involves total reality and not only some factors. On the other hand, if the development is absolutely linked to that of the human being, the approach to the problem (like in the case of malnutrition) cannot be separated from the development of the social dimension and from the relationships of the person. This is true both for the community that is helped and the one who helps; it means to pass from an isolated voluntaristic action, to a work. So, development that can intervene in the social reality with long lasting consequences has to operate at two different levels: 1. A real accompanying to reach an integral approach to the problem. To accompany the people in order to bring a contribution of knowledge means to make a qualitative leap. To be able to discover the order and the aim of all things; 2. To generate one or more social institutions, that after being set in motion can become the engine of development. Development is not possible without subjects who work together and who feel responsible for it. It is not an ethical decision that moves social institutions to experience being together with others and ,to associate with each other,, but because together it is easier to face the difficulties.
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Why is it like this? Where is set the consistency of these two certitudes? Man is a needy creature. He needs to eat, to drink etcBut he also has the desire forTruth, of Justice, of Beauty, of personal realization. This is natural, constituent. The desire is the spark that starts the engine. All the human movements are born from this phenomenon, from this dynamism, that constitutes the man. The desire switches on the engine of the man. So he searches for food and water, for work, for a better house, that is, he moves to satisfy his desires. When he fulfils some desires, new ones appear, that justify and mobilise the growth for what he desires, for a complete satisfaction.
This virtuous dynamism of the human action, this dynamism of the desire and its satisfaction, becomes true in reality. For this reason, the first difficulty that man has to face to enter in this virtuous dynamic is to start from what there is, from what we see and we touch, from the reality and not from what is missing. Many times when we work with poor people, we start from what is missing and this is a problem for development, because the concrete action that results, the instant, is not connected with the satisfaction here and now, but it is connected to the good that will come.
Then, understanding reality is fundamental. Reality has its logic, its law, it has an order, a natural order, objective, independent from the human will, from his intelligence, from his attention or distraction. Moreover this order has an aim, a meaning, a reason for which it exists. For this reason, the fulfilment of the desires directly depends on how man relates with reality, how he treats it, from the position that he has in front of reality. Satisfaction coincides with participation in this order; to be useful to his dynamic, to respect the aim of things. Fullness is to work for this order. When we satisfy these desires, that is, when we are useful and part of this order, we obtain as a consequence, as a product the common good: a house more habitable for man. Therefore the most important thing for this dynamic of desire/satisfaction is to understand reality. It is a problem of knowledge. But to discover the order and the aim of reality demands a critical ability, because there isnt any other path other than that of experience and of the verification of the reality. Along this path, it is important to recognise that is not possible to maintain this tension without a companion who helps you to judge and face the reality.The main method of development is to accompany the creation of social institutions with critical and educational skills to understand the reality and work with an integral approach to the problems in function of this order and discovered aim. The hope and the motivation of ACDI, as an agent of development is based on the certitude that desire is constitutive of all human beings and that in reality there is a
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human possibility to reach satisfaction now, independently from circumstances. For the institution and for the people that are part of it, satisfaction comes from being useful so that other people may participate begin this grand order and may collaborate to generate the common good: a house more habitable for man. ACDI does not have direct experience in the field of Food Security. Our organizations actions are mostly oriented to rural development and to have food for the world. But we planned activities in rural and urban areas in which food insecurity is present (especially for infants) and we recognize in the experience that AVSI has in different countries of the world, the methodological and educative aspects, that we must capitalize upon The certainties described previously, will be verified again when we will need to face this new challenge. From this conceptual context in which the our organizations actions move, and starting from the point of view of the generation of food, which is the field in which we work, we consider that Food Security depends on the following: Availability of the food (i-quantity, ii-adequate quality, iii-stability of supply) Accessibility (price) Use (adequate use of the available food stuff) Biological use (absence of sicknesses or negative stages of the person that affect adequate nutrition) The actions of the last two points, in order to be more effective, are related with health and education on nutritional issues and the conviviality/affection, they are surely similar (from the methodological point of view) for both rural and urban populations and AVSIs experience in these aspects is very broad and rich. But the actions that affect the availability of and accessibility to food stuffs can be different when we work with food insecurity in the rural or in the urban areas. According to the data regarding people that suffer hunger in the world, in this country, the contradiction is that is more hunger in the rural area where the food stuffs are easily accessible for people. According to Von Braun18, that took as an input the data of the United Nation Development Program (UNDP), 80% of the people that suffer hunger in the world live in the countryside and do rural or ichthyic activities. This part is composed by: 50% of farmers with land, 20% farmers without land and 10% of fishermen and goat shepherds.
18
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Von Braun J. (2006) Hunger and Poverty Reduction: policies and programs effectively and efficiently reaching the MDGs and beyond (presentation done by the International Seminar on Development and Vulnerability), Rio de Janeiro, Sept. 4-6, 2006
It is also important to clarify that a consistent part of people suffering hunger in the urban areas is the result of migration from countryside, due to the economic situation, desertification, natural disasters or social conflicts. In this sense, the effective actions to reduce extreme world poverty cannot be disconnected from an action at the rural level; in this way it will be possible to fight the causes of poverty: more accessibility to food stuffs and less migration to the cities. Even this approach has an effect on the environment: the desertification, for example, is caused by misuse or by disuse of certain territories. Increase the production of typical local food (both to better the quantity of food items for personal use, and to produce more staffs, that can be sold, so it will be possible to buy complementary food and other basic goods). Diversify the production (both for the personal use to balance nutrition, andeventually- to diversify the surplus in order to avoid market and climate problems that can affect the nutrition and the income of the farmers that is based on monoproduction). Produce with quality (both to assure the health and good nutrition of the people and to have good products to sell at a good price). In this way, we can see it in Latin America: There are many studies and much research in each country to increase the production of local food. Ci sono per molte difficolt nellassumere le conoscenze e accedere alle tecnologie da parte delle popolazioni rurali povere. This is very evident in Argentina where the investment of the Government in the research and the development of local production - for example livestock - is very high and every year many scientific papers are published with a high impact on productivity and quality of production. The productive indexes of the small producers (80% of the producers who produce 20%of the total production) are the same as the last 50 years, even though some technologies have no cost, such as the adequate administration of natural pasture, health of the animals and of the reproductive cycles.. 2. There are some initiatives to properly market the surplus of local production. Few improvements and poor results. In the north-west of Brazil, in the rural areas, where for a number of years there has been an almost philosophical introduction of organic production, perrmaculture and self sufficient farms as the only productive models for small scale agriculture, there are difficulties in access to the market and in the utilization of the surplus. Even if the product is different (organic, natural etc.)it is necessary to consider other factors in order to reach the market such as: Quantity: in order to have a dialogue with industry and commerce, associations are required. Standardization of quantity: the food stuffs produced by the majority of the small producers and then marketed must respect a method of production in
1.
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order to always be able to offer the same type of products. Quality: the standardized quantity has to offer the guaranteed quality that the consumer wants Commercial knowledge: standardized quantity and generated quality has to be professionally marketed through formal organized structures able to create links and partnership. 3. Many forms of aid exist so that the farmers can diversify production. The criteria in order to introduce new productions, species or variety are not reasonable criteria that they consider all the variables: nutritional (what does the population need according to what today they produce/consume to balance their production?); natural (which are the better cultivations to be introduced according to the climate and the future variation of the climate changes- altitude, soil, present climate conditions, etc..?); anthropological (culture, tradition); and of the market (which are the better varieties according to the demand in order to give value to the surplus?). In Nicaragua, where 85% of the poor people live in rural areas with a high index of food insecurity, that together with kj\ that of Honduras is one of the highest in all Latin America after Haiti, many public programs with big investments tried to cooperate with the food supremacy of the population, promoting new agricultural and zootechnical productions. Unfortunately, many of these new introductions were not well thought out according to the conditions of the place, so, for example they introduced breeds of cattle that were not right for the sourness of that climate or production of fruit that was adequate for eating, but with little commercial value, so it was not possible to market the surplus. We often fear to use the word innovation when we talk about food insecurity as it is something outside the priorities of a family that is not able to satisfy its basic needs. Instead, the poor rural population changes every day: their own survival depends on innovation. If we dont take into consideration the skills and the access to technology and to knowledge that allows to grow/diversify/better the production, the possibility of changes in order to overcome poverty is poor. A new way to conceive innovation is to introduce the notion of innovation as social creation, as a system that involves the interrelation of many. Therefore the effectiveness of an innovations system depends on the quality of the interactions among agents and above all from the processes of social learning that happen during the innovation. The fundamental things is the process and not the product (innovation): it is the social process of learning, the primary responsible for the increased capacity and opportunities of those that either take part in the innovation process or benefits from it. ACDI has observed this dynamic in all those cases in which it promoted associative cooperation among rural entrepreneurs, alliances among the cooperating producers and other actors in the food production chain and then links the integrated production chains with institutions and academia. Only when we started helping the producers, to improve their
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relationship skills they were able to implement in their properties the best practises they have known for many years and employ technologies accessible to them for decades. Therefore, in order for the farmers to take possession of existing knowledge, to access available technologies and to make better use of public infrastructures (irrigation system), it is important to promote the creation of associations among them and link them with different agents present in a territory in all its dimensions: i) empowerment dimension- among producers- ii) integration/alliance among groups of producers and the rest of the actors of the chain, and iii) institutional bonds between the groups of production and their allies with other institutions. The great poor is the one that is alone because he doesnt have the possibilities to understand the reality, the moods and the incapability of being protagonist prevail; a simple mournful audience that ask to the others to solve his problems. Analyzing the problem of the urban Food insecurity, the same one - at the beginningdoesnt seem to be a problem of availability of food stuffs since they are commercially available in quantity, quality and continuity, but it is a problem of accessibility, besides being a problem of use and adequate exploitation, like we said above.
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Having resolved the health and educative aspect of consumption, we can say that the problem of food insecurity for urban people is the value given to the food and therefore we need to work on improving the incomes and the value of the food. The value of the food is given by different costs and usefulness that bit by bit are added by different intermediaries from the countryside until it reaches the hand of the mother who needs to feed her child. On the other side we observed that the rural organizing plans that would like to use their surplus to better advantage, try to reach the consumers directly with their products as a way to take possession of the earnings that are in the hands of other intermediaries. Even if some associative plans wish to produce some specialities or differentiated products for the consumers who can buy more in order to take full advantage of their little surplus, the majority - for structural, production investment difficulties etc.. - cannot produce those products. It seems that the problem of food insecurity in the urban area is the same one of the farmers that would like to sell their surplus in a better way: they would like to have less intermediaries between them and the consumers. If this hypothesis is correct, the answer should be sought in the way in which the producers are organized (cooperative of Producers) in order to develop the skill to establish alliances with distribution enterprises that deliver the products to organized groups of families (cooperative of Consumers). To create associations is to be faithful to what reality is asking.
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itascabili 2 Educare il bambino, in famiglia, in comunit, nel mondo.

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itascabili 5 Unamicizia dellaltro mondo. Dieci anni di sostegno a distanza.

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itascabili 8 Capitale umano Risorsa per lo sviluppo
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AVSI Italia 20158 Milano Via Legnone, 4 tel. +39 02 6749881 milano@avsi.org 47521 Cesena (FC) Via Padre Vicinio da Sarsina, 216 tel. +39 0547 360811 cesena@avsi.org
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Nourishing People Feeding Hope

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itascabili

Nourishing people, feeding hope

Nourishing people, feeding hope

Health nutritional centres

Refectories and centres for education and recovery from malnutrition

Brazil, Salvador Bahia: COF-Centro de Orientao da Famlia (Family Orientation Centre)

In Apurimac Region (Sierra Andina) Methodological notes

Riccardo Bevilacqua, AVSI, Rwanda

Argentina, Santa Fe: The experience in urban and rural field

Rwanda: Humure nutritional centre, first development ring of the community

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

health nutricional centres

Nourishing people, feeding hope

1.1. Southern Sudan: health nutritional centre of St. Theresa hospital

Index Z score adapted for Southern Sudan

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

1.2. Lagos, Nigeria: health centres for the cure of malnutrition

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

refectories and centres for education and recovery from malnutrition

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

2. Final Evaluation - June 2009

Comparing 2008 data with those of 2009 can be observed:

2. Final Evaluation - June 2009

Nourishing people, feeding hope

Nourishing people, feeding hope

Assessment of nutritional status by sex - June 2009

8.9 10.7 12.5 11.2 2.7 0.0 46.0

12.5 17.0 10.7 10.3 2.7 0.9 54.0

21.4 27.7 23.2 21.4 5.4 0.9 100.0

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Training of professional figures in a health and educational sphere.

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope

Nourishing people, feeding hope