COMPASSIONATE TRUST SERVICES (COTS)

Find below the UNICEF press release that highlights real issues affecting households in Uganda that have been present for a long time but are now effectively ignored by “life saving UNICEF” save for its journalistic presentation, which is an introduction to an orientation course for trainees on a malnutrition/nutrition workshop/seminar, It further confuses the public by claiming HIV/AIDS as the cause of malnutrition even when they have ably put forward its true causes.

The cost of this two page press release could buy two chickens for every house with a 3-month pregnant woman in 4 rural districts of Uganda. This would ensure egg protein for the mother and child for one year and half. This is the simplest way of tackling malnutrition, but one that UNICEF would never advocate for. They need a catastrophe to a appeal for relief aid dollar$ and, with HIV/AIDS, they are in business.

Read and judge the rhetoric below for yourself. Skewed as it is, it cannot reach the rural majority – where the few educated people such as teachers, the police and health workers cannot afford to buy this paper that costs almost half an American dollar. Worse still it was produced in English cutting off over 50% of the population who can neither read or speak this language! Even if the information reached them, it does not contain any practical information for any family member in any household to take action.

We have interspersed the critique of COTS’ Mr. Peter Kasule in italics.

Unicef – MALNUTRITION IN UGANDA – United Nations Chidren's Fund

1. A healthy looking young lady walks into a child care unit well dressed with seemingly expensive hair do and a distinct make-up rubbed over her lips and eye brows. She is not alone but also carrying a child with scanty, light and brown hair who looks malnourished. One would definitely not be sure whether the child belonged to that woman just because the difference between them is enormous.
   
   Critical analysis—The Expert UNICEF nutritionist determines the health of the mother on the clothes, hairdo and make-up while on the child he takes care not to mention clothes, or if the baby has plaited hair with beads or if at all it is naked. It is abusive to think a mother will spend all her money on cosmetics leaving her baby to starve. Has UNICEF ever carried out any education program on the importance or dangers of cosmetics to a mother in relation to healthy living and proper use of resources at household level for the well being of children?
   
2. Strolling through Kisenyi, the oldest and most famous slum in the outskirts of Kampala city, you cannot help but notice hundreds of grim-faced children and lanky youth with bulging stomachs, yellowish and flaky skin lounged longed on the verandas of shabby houses painted with graffiti.
   
   Critical analysis— UNICEF headquarters in Uganda are less than 3km from their “oldest and most famous slum of Kisenyi” where hundreds of children like insects throng the verandas. One wonders as to how many social workers from UNICEF and volunteers at community level have been trained to help the wretched mothers of Kisenyi on good nutrition, family planning, hygiene , sanitation and safe water provision with UNICEF aid. Kisenyi slum is so near UNICEF Uganda country officethat the staff can afford to stroll and have a tourist view of the realities of malnutrition, poor sanitation, overcrowding, poor housing and come back to the air conditioned and make this panoramic view the main paragraph of the press release.
3. Most children in Uganda start life with an acceptable weight but they do not grow as well as expected and become malnourished particularly during the first three years of life. Malnutrition develops when the daily foods of child do not provide all the essential nutrients the body requires for proper growth and development. This leads to an increased risk of illness, lower cognitive development, poor pregnancy outcomes and eventually increased risk of death.
   
   Critical analysis— UNICEF highlights the dangers of malnutrition but cannot provide practical steps like pointing out the different local food stuffs rich in the necessary nutrients that can be easily grown or obtained cheaply in the large Owino market bordering Kisenyi Slum where the young children run to collect rotten mangoes, and extend this knowledge for the entire population of Uganda. This is very disturbing for UNICEF's nutritionists, failing to provide guidance in a country with very rich soils and ample rainfall all the year round.
4. A compromised nutritional status makes more vulnerable for infectious diseases, and illness further deteriorates the nutritional status through decreased intake and additional loss of nutrients. Malnutrition contributes to about 40-50% of all child death in developing countries. For a country as Uganda, with an Under–5-mortality-rate of 147 deaths per 1,000 live births, about 150,000 child lives could be saved each year by an improved nutritional status. Recognising the central role nutrition plays in health and development, nutrition programming is essential part of UNICEF’s Early Childhood Care and Development program.
   Critical analysis—UNICEF should take a step further beyond workshop/seminar theories and do prctical pilot demonstration gardens, food preparation that can explain how nutritional programming(the meaning) as an essential part of UNICEF's Early Childhood Care and Development programme translates into reversal of malnutrition to an ordinary person living in Kisenyi or in the furthest and remotest district of Kisoro or Arua. It is disheartening that since UNICEF opened its offices in Uganda the country is still suffering 40-50% child death due to malnutrition.
5. Programs to improve the nutrition status of a population target two basic forms of malnutrition, Macro-nutrient and micro-nutrient malnutrition. Macro-nutrient deficiency or Protein Energy Malnutrition (PEM) is the clssical form of malnutrition caused by lack of proteigns, carbohydrates and other energy containing nutrients in the daily diet. PEM leads to low weight for age (underweight), low weight for height (wasting) and eventually low height for age (stunting).
   Critical analysis—This specific paragraph is very academic befitting a medical/nutritionl school or College or for top health managers’ training workshop and seminars. But, how can this PEM help the general public (lay people) e.g. the lanky youth of Kisenyi, come out of this vicious cycle of malnutrition and de-register from the statistical releases beautifully recorded and shelved in the immaculate libraries that they will never visit.
6. The 1995 Uganda demographic and Health Survey (UDHS) reports 33.3% children under 48 months of age to be short for their age (stunted), 25.5% with low weight-for age (underweight) and 5.3% too thin for their weight (wasted). It is important to note that these figures do not include children who are mildly malnourished. If mild malnutrion is included, then the percentage of malnourished children (stunted, underweight and wasted) will be much more.
   Critical analysis—What interest does the ordinary person have in the percentage rise or fall apart from being the victim of the well fed researchers who have no interest in interventions but are always keen to go back and update their statistics to present in another conference. Since 1995 is there statistical data and sustainable activities of interventions to compare and evaluate the government efforts and NGO’s especially UNICEF’s contribution to get plausible and positive percentages of hope. Will more money and manpower be committed to the next Demographic and Health Survey without the public knowing the benefits and gains of the 1995 survey? How is the public or specific communities brought to understand the research results and their participation to take positive action beyond an hour or two of the survey questioner.
7. Mildly and moderately malnourished persons do not have obvious clinical signs of malnutrition that are known to parents or caregivers and may be missed even by health workers if hey rely only on the physical appearance. Yet all malnourished persons are at increased risk of dying from common childhood illnesses and may suffer from other sub-clinical consequences of compromised nutritional status.
   Critical analysis— Medical and Academic stuff befitting nutritional students or monitors. It looks to be part of a representative’s proposal presentation to a national or international nutritionist symposium. A piece of work of how to detect the conditions and how to correct them through dietary provision of natural available foods by the care givers and health workers would be more educative and empowering than this.
8. Micro-nutrient deficiencies, often occurring in combination with PEM, are characterised by Vitamin or mineral specific consequences such as blindness in case of Vitamin A deficiency (VAD) and goitre, an enlarged thyroid gland, for Iodine deficiency. These clinical signs of malnutrition have since long been studied, while understanding of more hidden sub-clinical consequences of micro-nutrient deficiency stems mainly from the last decade. The most common and well studied micro-nutrient deficiencies are Vitamin A Deficiency (VAD), Iron Deficiency Anemia (IDA) and Iodine Deficiency Disorders (IDD).
   Critical analysis— If these PEM conditions have long been studied and no action taken, of what use is the understanding of “more hidden sub-clinical consequences of micro-nutrient deficiency stemming from the last decade” by the healthy researchers to the unfortunate malnourished study subjects?
9. Vitamin A Deficiency (VAD) impairs the immune response of children and therefore contributes to high morbity and mortality due to preventable infectious dieases. Latest research reveals that improving the Vitamin A status of a deficient population may reduce the under-5 mortlity rate by 25%. In advanced stages, Vitamin A Deficiency can cause blindness. UNICEF is one of the partners in the Global initiative for the elimination of VAD and has played an important role in Uganda integrating A Capsule supplementation with the National Immunisation Days against Polio. Ways are being sought to deliver Vitamin A Capsules every 6 months to all children between 6 months and 5 years of age as an effective strategy for child survival.
   Critical analysis— How effective is the Vitamin A capsule administered during Polio immunisation in reversing malnutrition for a child breast- feeding from a malnourished mother? What are the miracles and wonders does this capsule do in combination with the vaccine, despite the numerous problems caused by vaccines in malnourished and diseased children, before the next immunisation round? Instead of UNICEF strenuously seeking ways of delivering the capsule, which ways might include 4-wheel drive vehicles, attendant allowances and monitoring teams and probably with a TV crew to record the occasion, in some remote village where the children are likely to hide and miss this potion, why not carry out a humanitarian act of supporting local authorities to pass by-laws for growing food crops. Educating and supporting the growing of specific nutritious food crops, delivering simple watering cans and horse pipe, and for dry areas accessing mules or horses instead of 4 wheel drive cars, to collect water from distant wells, streams and dams for irrigation would ensure the prized goal "FOOD SECURITY and deal a blow to PEM malnutrition and its attendant sub-clinical consequences.
10. Iron Deficiency Anaemia (IDA) affects large numbers of children and women in the developing world and is prudent in virtually all developed nations as well. Irrespective of the prevalence level, anaemia is a debilitating condition and is a very common cause of ill health among women during pregnancy and after delivery. Iron supplementation to all pregnant women is among interventions such as malaria control and deworming, an integrated component of the UNICEF supported anaemia control program.
    Critical analysis— How is “Iron supplementation to all pregnant women” achievable in a country like Uganda where the majority of women do not go for the required antenatal visits, but deliver quietly in their rural homes? Only a few with complications and the means of transport turn up at health centres that are largely short of medical staff, equipment and essential drugs including delivery kits?
11. Iodine Deficiency Disorders (IDD) are brought about due to lack of sufficient iodine in the body. Iodine deficiency has long been known as the cause of goitre, and enlarged thyroid gland, but consequences reach much further than that. IDD is the world's greatest single cause of preventable mental retardation and other consequences are defects in the nervous system, impaired hearing and vision, reproductive failures, nutrition stunting and increased childhood mortality. In its effort to eliminate IDD from the world, UNICEF supports universal salt iodization programs in more than 100 countries world-wide where IDD is a problem.
    Critical analysis— What is the status of IDD in Uganda? Is Uganda part of 100 countries where IDD is a problem? How are Universal iodization programs carried out by UNICEF and other partners? How can a common man detect that his diet is deficient in Iodine and what practical steps can he take to contribute to UNICEF efforts to eliminate IDD from the world?
12. Basic causes of malnutrition are poor food intake and infectious diseases. In Uganda, most people's frequency of food consumption is very poor and improper feeding practices are another important determinant of malnutrition.
    Critical analysis— This paragraph lacks reference to ways one can learn how to improve poor food intake and improper feeding, nor does it list sources of information. A pamphlet with a dietary food pyramid and intake frequency would do a lot.
13. When a baby is born, it is very important that he/she is fed on only breast milk for the first six months. Breast milk contains a natural protector against infection and it provides all macro- and micro-nutrients the baby needs. The unique composition of the breast milk plays an important role in the development of the babies brain from the very beginning.
    Critical analysis— Excellent paragraph.
14. In Uganda however, the introduction of liquids such as water, juice, formula and solid foods, takes place far earlier than the recommended six (6) months, interfering with the many advantages of exclusive breast-feeding.
    Critical analysis— Who recommends when to introduce the water and juice? And what work has UNICEF done to correct this?
15. Formative communication research showed that child care givers lacked knowledge about quality and composition of food for children, timing and frequency of meals and had misconceptions about feeding during sickness and continuation of breast feeding when the mother falls pregnant. Most caregivers give dilute porridge of low nutrient density and because they believe the child's stomach is very small, they give too little to the children.
    Critical analysis— Where can a mother turn to and get knowledge about quality and composition, timing and frequency beyond presentation of the findings of formative communication research?
16. Most Ugandans claim poverty and lack of available food as the reason for such poor feeding practices although quite often the foods are available in their gardens. 70% of the households have chickens (eggs) yet lack of available protein-rich foods was cited as one of the main reasons that children are malnourished.
    Critical analysis— Is it realistic to say there is food n the garden yet elsewhere claim there is not enough food? Do these Ugandans grow the food as flowers or shrubs not knowing that it is edible and nutritious? If seventy percent of households have chicken where do the eggs go? It is very clear that Uganda does not export eggs, where does the 70% egg production go? Unless this is cooked up data one is led to believe that Ugandans grow food and keep domestic animals such as chicken for fun. What endeavours have been put in place by UNICEF to educate Ugandans about correcting this seemingly unbelievable ignorance?
17. A household's source of drinking water is associated with child nutrition status directly through its impact on hygiene and the risk of diarrhoeal diseases. It is indirectly a measure of health. Access of water without an adequate supply of food quality water, a household’s personal domestic and food hygiene are compromised and the risk of pathogen contamination (and thus diarrhoeal diseases) increases.
    Critical analysis— A good point, except that it does not explain how a household can get safe water from accessible water.
18. High fertility rates, especially when accompanied by short intervals between births, are also detrimental to children's nutritional status. Most families have scarce resources to provide adequate nutrition and health care for their children. As the number of children per woman increases, fewer resources are available for each child. High fertility also has a negative impact on women's health, thus increasing the chances that a mother may not be able to breast-feed or care for her children adequately.
    Critical analysis— Excellent exposition. Before any child is born what are the available resources that a mother has? In particular, a mother without education, no technical skills, reliant on the hoe and on unpredictable weather in a highly exploitative capitalistic scenario?
19. The last two decades have witnessed dramatic changes in the conceptualisation of the problem of malnutrition. Food shortage has been seen as the main cause of malnutrition for many years, but food alone is not the only factor. Children have manifested signs of malnutrition even in situations of abundance of food, proving that more factors play a role.
    Critical analysis— Is there a community in present Uganda with abundant food where the children are malnourished? Growing a single crop like Maize and failing to get market to obtain money to access other necessary food staff does not in any way mean there is abundance of food. It explains the poverty people talk of. A community grows a certain crop that does well in that given area but cannot get access to markets to obtain money. There are no storage facilities so the food is wasted. In old times people used to barter, but with introduction of money lack of markets increases poverty and explain malnutrition due to dependence on one food crop. Have the dramatic changes happened in UNICEF’s way of doing research or helping people to reduce malnutrition?
20. Although the multiple causality of the malnutrition problem is complex, its causes can be reduced to manageable clusters to reflect the most important factors in a given situation. The conceptual framework for nutrition, developed by UNICEF in the late 1980's shows food, health and care as basic underlying causes of malnutrition and is a tool widely used in assessment, analysis and action planning for improved nutrition.
    Critical analysis— Can UNICEF highlight the multiple causes beyond what it has described above and how they become complex? Just a mere jargon of words such as multiple causality, complex, manageable clusters, conceptual framework, are meaningless if they cannot be translated into practical and understandable terms such as which food to eat, for what purpose, how often and in what quantities. The is not a question of a tool to use for analysis, assessment and action planning. Just tell the people the foods they are supposed to eat, the best way to prepare them and then monitor their health, rather than providing tools to analyze their malnutrition!
21. Food here refers to food security at the household level. Sustainable access to safe food of sufficient quality and quantity, paying attention to energy, protein and micro-nutrients, is important. Household food security depends on having financial, physical and social access to food distinct from mere availability.
    Critical analysis— Mention unsafe food, educate about safe food–this is the bottom line of physical and social access that will even give rise to financial access. Many malnourished people are being persuaded to grow coffee. It is hypocrisy for UNICEF to fail to market and transport fresh maize to Britain where the cost of one cob that is less than 250 grams is ten times the cost of 1kg of coffee in the Ugandan market.
22. Health includes access to health services, as well as a hygienic and sanitary environment with access to safe water. Since malnutrition manifests as a health problem, an essential element of good health is access to curative and preventive health services by all community members.
    Critical analysis— A cure would be the accessibility and knowledge of the right food available in a given community–it also covers prevention. Hygiene and sanitation are not health services but human development activities. The advocating of drug treatment is the cause of sustainable poverty, disease and malnutrition. This does not call for Polio Immunisation with the attendant Vitamin A Capsule and the debt burden of delivering these from Europe to the remotest area of Uganda once a year. This is absolute exploitation and hoodwinking the people at the time when they look at you for help. Everything Africa needs and Uganda in particular to solve malnutrition is in Africa. We are just lacking honesty and speaking the pain truth. It is dollar meddling and nothing else.
23. Care refers to several clusters of caring practices from care giver to care receiver. It includes care for women during pregnancy and lactation, breast-feeding and complementary feeding, home health practices, psychosocial care and food preparation. The care element came to the fore after many years of trying to understand why malnutrition can be prevalent when food and health services are available.
    Critical analysis— If food is available and health services are in place then what is care? If health services do not contain education but mere dispensing of drugs, do you call that health services? How can ‘care’ of which education is a basic component be separated from health services?
24. Realising that malnutrition is a problem to be solved, rather than subject to be studied, it is important that the multiple causality of malnutrition be known and understood at all levels where action should take place, including the community. Households should be enabled to address the problem of malnutrition at its various levels, realising the importance of proper food, health care and fighting malnutrition.
    Critical analysis— How do you FIGHT malnutrition- do you fight it in the trenches, get helicopters or hire mercenaries? What is the use of militaristic jargon and theoretical verbalism without practical steps at the personal and household level?
25. Secondly having agreed on the causes of malnutrition, there is need to analysis the key duty bearers in relation to addressing the nutrition problem. Parents other household members and the community may feature as key responsible people for addressing the nutrition problem. Actions of supportive nature at the district and higher levels of fulfilling nutritional rights should be done such that levels of accountability are also clarified.
    Critical analysis— If “Multiple causality of the malnutrition problem is complex...that can be reduced to manageable clusters to reflect the most important factors in a given situation”. What has the public agreed with UNICEF on the causes of malnutrition? What do they have to analyse, what are actions of a supportive nature that the district and other high levels have to account for? This is to the best of my knowledge the basis for unending workshops by the healthy discussing the wretched of the earth who know nothing about what happens in these workshops.
26. Lastly, key duty bearers should be facilitated to act such that good nutrition is guaranteed. This kind of facilitation could be economic, human and organisational resources.
    Critical analysis— Thus the researchers should be facilitated to produce more workshop material and lastly the parents can receive Polio Immunisation and Vitamin A capsule once a year to protect them against malnutrition. And then they lived happily ever after!
27. A important confounder in the picture of nutrition in Uganda has become the problem of HIV/AIDS. As a disease, HIV/AIDS could be included in the disease of immediate causes of malnutrition, but its impact is far reaching and is eroding all other conditions of nutritional security. The toll of HIV/AIDS in Sub-Sahara Africa is very high with over 22 million or two thirds of the world's total living with AIDS.
    Critical analysis— HIV is thought to be a virus that many believe will kill someone after many years of poor feeding, lack of safe water, unhygienic condition, lack of proper medical or health service in face of endemic infections, psychosocial stress and trauma caused by stigma and systematic segregation. AIDS by its definition therefore becomes a condition or a consequence of the above. Is this a super disease that can be politically explained like the European Union with a single currency? How can it be among the immediate diseases of malnutrition when the factors of malnutrition have taken their toll for many years? How does AIDS erode poor food intake, how does it interfere with the knowledge of good feeding? How many millions are malnourished with total and mild malnutrition in Africa causing ill health without HIV/AIDS as an explanation?
28. HIV has an impact on caring practices, caring capacity, household food security and provision of basic services including health services. In households where the bread earner is infected with HIV/AIDS, food security is affected due to decreased engagement in productive action. Children with HIV are more prone to disease, thus leading to higher prevalence of opportunistic infections including Tuberculosis. Severe wasting is a common feature of the presentation of AIDS. Specific direct relationship between nutrition status and HIV/AIDS have also been shown, for instance a decline vitamin A status due to HIV infection.
    Critical analysis— How does HIV compare with PEM, VAD, IDA, and IDD and their prevalent 40-50% of child death as opposed to the 30% of HIV positive children from only positive mothers. Despite the fact that the testing kits clearly indicate that “a positive test does not mean HIV infection without a sexual history of the test victim”, how does HIV infection decrease Vitamin A status of children given Vitamin A capsule once or twice a year during Polio immunisation programs?
29. The possibility of mother to child transmission of HIV through breast-feeding has had major consequence to UNICEF's efforts to promote, protect and support breast-feeding. The importance of breast-feeding for child survival, growth and development is confounded by the small but prevalent risk of HIV infection through breast milk. Recent research projects have shown that specific interventions during pregnancy and lactation can reduce HIV transmission from mother to child by half.
    Critical analysis— What consequences have HIV/AIDS had on UNICEF efforts to promote, protect and support breast feeding when over 90% of rural mothers in Uganda where 80% of the population lives exclusively breast-feed and do not know any relationship between UNICEF and Breast-feeding practices as the document tries to portray it. It is UNICEF fanning the hysteria and disturbing the peace of rural folk with their theory of mother to child transmission of HIV. HIV has not undermined your efforts but has promoted your research train of complex multiple causality of the malnutrition problem and may hasten the ways of delivering Vitamin A capsule during Polio Immunisation. If breast milk contains HIV how does the Nevirapine dose shortly before birth and a few doses after delivery cleanse the breast milk of HIV which a child is going to feed on for six month? Does it mean that the mother is cleared of the HIV virus and probably within a month or two if she tested she would be negative? Does this wonder drug taken in a single dose stop the highly replicating HIV from sneaking into breast milk again and cause havoc to the innocent child? This is too much of medical genocide! Give us the truth not toxic Nevrapine to kill mother and child!
30. “The threat posed by HIV/AIDS is enormous. The nutrition community, including all the relevant sectors, must have foresight to support interventions that will lead to prevention of HIV/AIDS in order not to further undermine the gains in nutrition,” says Dr. Lyorlumun J Uhaa, Head Health and Nutrition, UNICEF Kampala.
    Critical analysis— Dr Lyorlum J Uhaa is thanked for supporting Nevirapine to boost the international community of donors to undermine breast-feeding and market the pharmaceutical formula for maximum AID$ dollars for increased maternal and infant mortality rates in Africa and blame the existence of a Vitamin related antibody on a killer virus. Bravo UNICEF in the noble cause of saving mothers from breastfeeding!
31. Generally, malnutrition has multiple causes and so it is important to have a well-guided analysis in each situation to help in programming the necessary efforts. Solutions to malnutrition will not coe from those who are affected by the problem but from those who support the efforts to address nutritional problems. We need to work with communities facilitating a process of consensus building on causes of the problem, and jointly identify and strengthen capacities to support implementation of actions against the problem of malnutrition.
    Critical analysis— Definitely solutions cannot come from people suffering from the malnutrition problem. Their fate has been mapped, they can't write a good proposal to Bill Gates, or the Rockefeller Foundadtion for they don't understand their problems properly. It is you the well fed computer wizards who can talk with Collin Powell on a mobile phone and experts on nutrition that can address the nutritional problems of the wretched of the earth that you have studied for a long time and discovered many complex causes that need to be analysed. Only then can you go to work with communities to build consensus that their problem is complex and jointly identify and strengthen capacities to implement actions of Malnutrition sustainability against malnutrition problem.

Copyright © COTS, Wednesday, June 20, 2001.