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Cablegate: Status of Food/Nutrition in Zimbabwe

R 260753Z NOV 08
FM AMEMBASSY HARARE
TO SECSTATE WASHDC 3746
INFO AMEMBASSY PRETORIA

UNCLAS HARARE 001055


AIDAC

AFR/SA FOR ELOKEN, LDOBBINS, HIRSCH, HARMON
AFR/SD FOR HSUKIN, SGOINGS
OFDA/W for KLUU, ACONVERY, LMTHOMAS, TDENYSENKO
FFP/W for JBORNS, ASINK, LPETERSEN
PRETORIA for HHALE, PDISKIN, SMCNIVEN

E.O. 12958: N/A
TAGS: EAID ZI
SUBJECT: STATUS OF FOOD/NUTRITION IN ZIMBABWE

-------
SUMMARY
-------

1. Following alarming news reports of severe malnutrition, vitamin
deficiency disease and deaths among children and adults in Zimbabwe,
country and regional USAID/Food for Peace staff visited primary
health care facilities in four Zimbabwean provinces to verify
reports. Findings were not adequate to definitively refute or
support claims of pending disaster, but they suggest that, in
general, despite clearly worsening food insecurity, the nutritional
situation at present is not significantly different from the same
time last year. New vulnerable groups are emerging from the ranks of
salaried workers who can no longer rely on this resource to sustain
them and their families. UNICEF and NGO partners as well as USAID
and WFP are actively monitoring and responding to the nutritional
situation in Zimbabwe. A nutritional surveillance exercise led by
UNICEF is underway, and results are expected by the end of November.
Country and regional Food for Peace staff have increased monitoring
and joined the United Nations Nutrition Cluster Emergency Working
Group. UNICEF has put its programs on emergency footing and has
requested additional staff to bolster support for management of
cases of severe malnutrition, providing training and therapeutic
foods. NGO partners are expanding their roles in delivery of
services. At present, Post is not recommending changes to current
response until more concrete information is available that better
defines unmet urgent needs. END SUMMARY.

----------
Background
----------

2. During the period Oct 28-November 2 Country and Regional Food
for Peace (FFP) staff visited 15 primary health care facilities: two
government hospitals, seven mission hospitals, and six rural
clinics. At least one facility was visited in each of the four
provinces of Matabeleland South, Matabeleland North, Midlands,
Masvingo and Manicaland. (NOTE: This method of sampling does not
allow assessment of the status of individuals who did not seek
health care. There are many reports of people who have lost
confidence in the health system and just stay at home. END NOTE.)
Sites were chosen for accessibility and proximity to areas of news
reports of malnutrition and were concentrated in areas of high
cereal production deficit. Thus, they do not represent the situation
in Zimbabwe as a whole.

3. FFP undertook the visits in response to news reports of severe
malnutrition, vitamin deficiency disease (pellagra), and deaths
among children and adults in Zimbabwe. The visits sought
information that would indicate whether the prevalence of
malnutrition has risen strikingly since the last round of
nutritional surveillance (July 2008) and, if so, to get impressions
about the underlying cause(s).

4. At all locations, most people interviewed expressed concern
about food shortages; they are very concerned about low/no cereal
production and poor food availability, and described heavy reliance
on wild foods (e.g., fruits, roots, and other foods traditionally
eaten during times of scarcity.)

5. At a Manicaland hospital, a Sister in charge noted that the
situation was "not much different from last year." She said that
people were "used to" having no harvest and coped by getting food
from neighboring districts or from food aid agencies. Information
from the NGO Medecins Sans Frontieres (MSF), which works in the area
(Buhera district), somewhat confirmed her statement. The local
health staff and MSF jointly measured weight and height of under-5s
in August on Child Health Data, and results indicated a prevalence
of global acute malnutrition (wasting) of only 5.1 percent (greater
than 10 percent suggests the possibility of generalized food
shortage.) Still fearing the worst, all rural clinics in the
district were equipped for outpatient therapeutic feeding.
Admissions rose at first, presumably because of the increased
proximity of service, but in recent weeks enrollment had dropped
again.

6. Few health personnel were forthcoming with statistics. They had
been advised by government officials not to share information. Most
were willing to share some qualitative observations; a few showed us
growth monitoring charts or monthly report forms; and some
information could be gleaned from posters displayed on the walls.

7. However, the statistics routinely collected at the health
centers are not sufficient to interpret the nutritional situation
definitively. The growth monitoring data records "weight for age"
(underweight) information for under-5s who come for immunization - a
biased sample representing only children whose parents are concerned
enough to bring them for vaccinations. Underweight is not as good a
measure of acute distress due to food shortage or illness as is the
prevalence of wasting ("weight for height," measuring thinness.)
Notable is that since underweight includes wasted children, the
prevalence of underweight will always exceed the prevalence of
wasting.

8. Monthly reports include the number of cases of marasmus,
kwashiorkor, and pellagra, by age category, but the number of people
who were seen is not recorded, and thus, there is no way to
calculate prevalence that would be useful to compare one period to
another.

9. A house-to-house survey of children and adults, with measurement
of both weight and height plus indicators of micronutrient
deficiency, like the nutritional surveillance exercise currently
underway (see below) is needed for a more valid interpretation of
the population's nutritional status.

10. A comparison between growth monitoring data that was accessed
from Manicaland clinics in September 2007 and September 2008 showed
no significant difference. In the clinic with highest rates of
underweight children, the percentages ranged from 3-9 percent in
2007 and 3-12 percent in 2008, with the peak of 12 percent in
February 2008. In both August and September of 2008, the percentage
was 6 percent. In the other clinics visited in the same district
(Makoni), the range of percentages was lower (2.4-6.8 percent.)

11. Nevertheless, in most hospitals, staff felt that the number of
admissions of severely malnourished children was higher this year
than last. A doctor in one hospital in Midlands Province said there
was a multi-fold increase in the number of cases admitted for
outpatient treatment (OTP) compared to last year, but these figures
are likely to be confounded by the fact that the national OTP
program has only been fully developed and resourced over the course
of the past few months. Generally, more cases present when they know
treatment is offered.

12. At all locations, health personnel attributed much of the
severe wasting and kwashiorkor among children to AIDS (40-70
percent, depending on location), based on confirmed tests. At
hospitals in Midlands and Matabeleland North Provinces (Lupane,
Nkayi and Kwekwe Districts) they noted that 60-70 percent of the
malnourished children were sick with AIDS, TB or diarrhea.

13. Some health workers noted a potential link between diarrhea an
malnutrition, but most believed that malnutritin preceded diarrhea,
not vice versa. Only in Maabeleland North did staff report that
they noticd a recent increase in cases of diarrhea - anecdotaly
linked to consumption of un-washed wild foodsand short water
supplies. Generally, acute respratory infection was the most
common illness amog those seeking treatment.

--------------------
Adult Malnutrition
--------------------

14. In Masvingo and Manicaland Provinces staff reporte some
wasting among adults, but only among those beginning anti-retroviral
treatment, which induces nausea and anorexia, and those with
symptomatic AIDS.

15. Adults also presented with cases of pellagra, a form of
malnutrition caused by niacin deficiency, in most of the locations
visited (notably in only one of the six sites visited in
Manicaland). At most of these locations, health personnel said that
most individuals affected were elderly. They saw no association
with HIV status. We noted that cases of pellagra also appeared on
2007 monthly reports that were viewed, indicating this phenomenon is
not necessarily new.

16. Pellagra is associated with a poor quality diet, and is most
common in areas of poverty where maize is the staple food (most
other cereals provide sufficient micronutrients, particularly
niacin, to avoid pellagra.) In Zimbabwe, the emergence of pellagra
suggests over-dependence on maize (curious in a situation where
maize is scarce) and the exclusion of other niacin-rich foods such
as ground nuts, meat, milk, eggs and sweet potatoes. The higher
occurrence among the elderly may be due to impaired absorption of
nutrients due to age.

-----------------
Hospital Salaries
-----------------

17. Three facilities reported that retaining staff was difficult
(50 percent staff levels) and those that did remain were difficult
to control. A nurse's monthly salary was reported at between
Z$50,000 and Z$100,000 (one loaf of bread cost Z$60,000 at the
time). Transport costs to the banks ranged from Z$150,000 to
Z$200,000. Twenty kilograms of maize meal was as much as Z$300,000.
Many staff went to town to collect salaries, but had not returned
due to the costs and low salaries. Staff that remained at the
facilities often dropped all work as soon as rumors were heard that
there was food available locally. Several of the nurses interviewed
were visibly lethargic and tired. All nurses/aids were at a loss as
to how to provide for their families. Every single person
interviewed requested that either WFP's or C-SAFE's targeting
criteria be reevaluated as they did not qualify for food aid as job
holders. (COMMENT: While having a job is not exclusionary as a
rule, people with jobs are often excluded by their communities
during the targeting and registration process. As reported above
however, having a job no longer means having the ability to cope
with the current situation. END COMMENT.) Staff said their salaries
bought literally nothing or they simply left the salary in the banks
to "rot" as they couldn't afford transport. They said that they
could no longer maintain themselves. Staff noted that they are
dealing with sick people all day and now at greater risk of
infection since they are physically weak and hungry. "Who is going
to take care of the sick when things get worse as the hungry season
progresses" was a comment made by a forward thinking nurse.

18. At the other facilities, while some staff complained about
their salaries and the difficulties extracting it from the banks,
they all looked fit and were energetic. Like other Zimbabweans,
they are managing somehow by means that we don't understand.

-----------------------
Expanding Vulnerability
-----------------------

19. At the end of each interview we asked if they had access to
seeds and fertilizers for their own home fields. All responded that
they have not seen any on the market and communities were concerned
about these shortages with the rains quickly approaching. Given the
shortage of agricultural inputs and the early onset of this hungry
season, it is probable that Zimbabwe now faces a prolonged period of
need - 18 versus the normal nine month period.

20. The Mission and its partners have, despite delays caused by the
NGO ban, begun to distribute in the most affected areas of the
country. The problem is that areas that were once of a lower
priority are now increasingly vulnerable largely because there are
few alternative sources of food and no money. Urban conditions are
desperate as these people have relied on commercial markets and have
few prospects to produce their own food.

-------------------
Analysis of results
-------------------

21. The data collected are not sufficient to support or refute
recent reports of exceptional elevations in malnutrition due to
massive food shortages. Generally, the findings imply that, despite
feelings of heightened food insecurity, even in the areas of great
cereal deficit, the nutritional situation does not differ
dramatically from the same time last year. The data from the three
hospitals in Matabeleland North and Midlands Provinces are most
suggestive of deteriorating nutritional status, though the
underlying cause (i.e., food shortage vs. illness or caring
practices) is not clear.

22. However, the approach to data collection taken, i.e.,
canvassing a small sample of health service facilities that yielded
largely qualitative information, cannot support conclusions that can
be broadly generalized. Pockets of acute distress and individuals
who do not seek care could easily be missed.

23. There are numerous international relief agencies that
specialize in health and nutrition (e.g., MSF, ACF, Helen Keller
International) currently operating in various parts of Zimbabwe.
Most of their programs focus on supporting the failing health system
in the context of HIV/AIDS, which necessarily includes treatment of
severe malnutrition. These agencies are best positioned to
recognize signs of pending disaster, and would normally alert the
donor and emergency relief communities if increased incidence of
malnutrition were observed. Significantly, none of these agencies
has alerted USAID or UNICEF (the typical first responder in the
coordination of such emergencies) of significantly rising incidence
of malnutrition. This does not mean that malnutrition is not
present in communities, but in the absence of comprehensive
surveillance mechanisms, the relative silence of these expert
"watchdog" organizations suggests that widespread malnutrition is
not a concern at this time.

----------------------------
Zimbabwe Reasonably Prepared
To Treat Severe Malnutrition
----------------------------

24. At the beginning of the food security emergency in southern
Africa, UNICEF supported capacity building in the 60-70 hospitals
that treat severe malnutrition in therapeutic feeding units. At the
insistence of the Ministry of Health (MOH), hospital staff members
were trained only to follow a therapeutic feeding protocol using
milk enriched with locally-produced commodities (oil, sugar).
However, economic conditions over the course of the past eight
months led to a collapse in the implementation of this protocol.
Milk, oil and sugar are no longer readily available.

25. Responding to this collapse, a few months ago, UNICEF convinced
the MOH to accept the use of imported therapeutic foods,
specifically F-75 for stabilization followed by plumpy nut (F-100)
until patients recover. UNICEF flew in an initial stock of F-75.
Plumpy nut was already a familiar product used in a UNICEF-supported
program of community-based treatment of severe malnutrition.
Additional stocks of plumpy nut have been supplied by the Clinton
Foundation. The therapeutic foods currently in or on their way to
Zimbabwe are sufficient to rehabilitate 10,000 severely malnourished
individuals.

26. UNICEF, in cooperation with the MOH, is training staff in the
new protocol using F-75 and plumpy nut. This training must be
accomplished before the products are delivered. Training has been
completed in four rural provinces: Mashonaland West and East,
Matabeleland South and Manicaland, plus the cities of Harare,
Bulawayo and Chitungwiza, and is partially accomplished in other
provinces. Training has been temporarily on hold while nutritionists
were involved in the UNICEF-led nutritional surveillance exercise.
Notable was that 60 percent of facilities visited in Masvingo,
Matabeleland North and Midlands - provinces where training hasn't
been completed - were following the new protocol and had therapeutic
foods in stock.

27. UNICEF fully stocked the units at hospitals with trained staff
with both F-75 and plumpy nut. As supplies have been used up, some
hospitals have experienced difficulties with re-stocking because,
due to the breakdown in telephone coverage and prohibitive costs of
travel, they are unable to communicate their needs to suppliers.

28. The primary constraint to progress in the roll-out of the new
protocol has been that only about half of the MOH staff have been
turning up for training. Apparently, the cost of bus fares has
deterred others.

------------------------------------------
On-going Plans for Assessment and Response
------------------------------------------

29. With support from UNICEF and partner NGOs, the MOH is currently
conducting a new round of nutritional surveillance. (The last was
in July.) All data collection teams were expected to return from
the field by November 19 to begin data analysis. In this round, the
sites were selected to be representative at the Provincial level.
(The previous represented only seven districts presumed to be among
the worst cases.) This means that the results should uncover a
change in a general trend within a province, but it will not pick up
localized "hot spots." Any hint of a rising trend will be
investigated further with focused nutritional surveys that will be
more useful in identifying causes and defining the magnitude and
nature of appropriate response. We should have preliminary results
from UNICEF by the end of November, giving donors and emergency
relief organizations much better insight on the situation and
guidance on potential changes to response methods, if needed.

30. Nutrition partners have increased the coverage of outpatient
treatment of malnutrition, especially in areas where, due to poor
food availability, they expect malnutrition to rise. Next week
World Vision will conduct an anthropometric survey in Matabeleland
North (Bubi, Lupane and Nkayi Districts) to assess the need there.
They recently opened nutrition activities in Gwanda District in
Matabeleland South.

-------------------------------------
USAID/FFP Actions and Recommendations
-------------------------------------

31. No major changes to current response are recommended at this
time until more concrete evidence emerges that the needs are
different from planning estimates and pipeline requests. While post
is concerned about the potential fluidity of the situation, it also
understands the competing demands for food in the continent's other
dire food emergencies.

32. It should be noted that Food for Peace and partners closely
monitored the development of the last agricultural season and, when
the harvest failed were already prepared to respond. From FY08 and
FY09 funds, the USG has contributed more than US$211 million to
support food assistance in Zimbabwe during the present hunger
season, including 178,500 MT of food commodities. This represents
about 76 percent of the international food aid for Zimbabwe for this
season - an unusually large proportion compared to most other
emergency contexts. Post requests that AID/W undertake a demarche
to encourage other donor and non-traditional donors to increase
their commitments.

33. The Harare-based FFP Officer, a nutritionist, has joined a
newly-formed small group of specialists commissioned by the United
Nations Nutrition Cluster to work on an emergency preparedness and
response plan for the sector. The group met for the first time on
November 18. Agenda items included: plans for assessment and
surveys to follow on the November nutrition surveillance, links
between nutrition and food aid programs, contingency planning for
rapid rises in reports of malnutrition, strengthening the treatment
capacities and protocols for severe malnutrition and infant feeding
in emergencies.

34. Post is taking several steps to increase monitoring of
nutritional status. FFP's Food Security Specialists, who regularly
monitor food aid activities and food security conditions, will now
include interviews at rural health centers about nutritional status
in their field visitation plans. The regional FFP Advisor will
continue to make frequent monitoring trips to Zimbabwe to assist the
in-country team in its efforts to increase scrutiny of the
conditions and programs. FFP will continue to monitor the situation
closely and maintain a high level of participation in the
contingency planning exercise. To prevent malnutrition due to
water-borne illness, OFDA continues to make water, sanitation and
hygiene as a primary focus of their funding in Zimbabwe.


MCGEE

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