Hi Alex I did face this challenge when i was running CMAM in Uganda, Karamoja. We also observed that these same mothers who starve their children in order to remain in OTP were also double registered especially in near by health centers. To solve the problem we had to intensify counseling for any mother whose child failed to gain weight for 2 consecutive weeks and we realized a lot of improvements. I understand that the problem you are facing is different as it involves protection rations.

Thanks for your reply, Actually the problem is also that being in Somalia, most of the activities are done in remote which complicates the quality of the community mobilisation component... We are planning to reinforce it but we will need something more concrete with a rapid impact...

Hey Alex, am managing nutrition programs in South Sudan and were too are facing a similar situation, improved sensitization did not give much result as mothers simply noded yes but did otherwise at home. A new strategy put in place, When the mother is noted to either be starving the child intentionally, selling the RUTF or distributing to other children, meeting is held between the mother and the area chief or gol leader and the nutrition workers. This has actually yielded some results. thanks.

Thanks, this could maybe work in some parts of Somalia, I guess...

From Peris Mwaura: Thanks Alexandra, One of the other things you can try is to engage mothers/caretakers in the program in a sensitazation program. Let them discuss the health and nutrition problems they face and come up with feasible solutions themselves and you can facilitate this. I realised that they come up with constructive ideas on how to have nutrition security for their children and to extent their households. There is the need to empower the mothers to take charge of the nutrition of their children and their families as well and I know Somalia is a complex context... Regards.

Hello Alexandra, I had the same issue in Ethiopia. Unfortunately, I am not sure if there is a ‘right answer’. What I did: I talked to the mothers who were doing this and I explained the risks of starving their child. I was surprised to note they were not aware of how dangerous this is-they see the benefits of doing this, but not the risks. Getting advice from a counsellor before you talk to them will help you better express the idea while not causing unnecessary psychological harm. In your case, you cannot be physically present, you can coach your staffs to talk to the mothers. Each mother, one on one, if possible- it does make a difference. In Bangladesh, where I was working in 2007, we were extremely lucky to have a counsellor for mothers who did not attend to their childrens' needs. From this experience (this was not a study) counselling yielded very positive results on more than 60% of the cases referred within as fast as approximately 2 weeks. I hope this helps a little.

Hi Alex,! :-) Two things: Care practices and inclued the father into the treatment, as the person before me said, just talking in group with the mother's and including the father also when is possible is really greatfull, it's what they did in 2005 in Niger, and into the baby tent I think in Haiti in 2010. Good Luck C.

Dear All, Thanks again, your propositions are very interesting but not all of them could be used in a context like Somalia... As I mention, I agree that this needs indeed a strong behavior change and community mobilisation but it will require time to show any impact...I wanted to know if any activities like graduating mothers with a gift once the child is cured , letting know the mother will have it only once could work... Youwould tell me that it is not sustainable but I am not sure that we can always think of sustainability in Somalia ;-(

Dear All, Thanks again, your propositions are very interesting but not all of them could be used in a context like Somalia... As I mention, I agree that this needs indeed a strong behavior change and community mobilisation but it will require time to show any impact...I wanted to know if any activities like graduating mothers with a gift once the child is cured , letting know the mother will have it only once could work... Youwould tell me that it is not sustainable but I am not sure that we can always think of sustainability in Somalia ;-(

From Ann Burgess: Martha hi. I would like to suggest to the Editors of the South Sudan Medical Journal that we prepare a short and diplomatic 'note' about this tricky issue. Would you be able to help if they agree? If so, email me direct at annpatriciaburgess@yahoo.co.uk

A remarks ... Extraordinary claims need extraordinary (i.e. very strong) evidence. Some recollections ... I saw something like this about 20 years ago in a highly politicised context. It was a small and tightly organised political protest rather than spontaneous mass behaviour. I have seen "child rental" (mothers lending SAM children out to other mothers) a few times. I did not suspect "voluntary" starvation but admit that it is possible that this did occur. This was always with a relatively small number of "rentals". The cheating was occasionally on a large scale but the number of children involved was usually small. So, again, not a mass behaviour. The usual response was indelible marking (e.g. GV in the ear) at distributions. I have seen punitive responses (i.e. removal of ration cards) in some IDP / refugee contexts. I have also seen "dead souls" scams in which NGO workers make up beneficiaries in order to steal fuel, drugs, food &c. This was typically accompanied by odd claims about problematic behaviours in the beneficiary population (e.g. I have been given misinformation about satanic child abuse cults twice as well as "child rental") designed to misdirect investigations. Questions ... (1) How do you know that this is happening on a large scale (i.e. a large enough scale for it to be a major concern)? (2) What is the role of detergent? An observation ... My first response is not to blame the beneficiaries but to blame the providers. If this is a real mass behaviour and there is some rationality behind the behaviour (there usually is) then something must be very (VERY) wrong with the pattern of programming to force people into taking such desperate measures to access basic commodities. This suggests (to me) a large unmet need and that a full-basket general ration may be needed. If basic HH food needs are met (e.g. by a general ration) then any necessity to resort to "voluntary" starvation should disappear. Perhaps what you are seeing is an extreme case of simple old-fashioned pauperisation caused by a long period of ill-concieved and / or badly delivered aid. The organisation of our programming may be causing this behaviour. If this is the case then counselling, awareness, &c. will not solve the problem. Bolder reform is needed. Just my tuppence.

The detergent/soapy water is being given to the child so that the child gets diaarhoea and lose weight. These are just anecdotal reports but we think they need to be investigated fully. Agree with Mayatt on the need to establish the extend of the problem. We have set up a taskforce to look into various data sets and see if we can ge something from it. A particular credible organization in Somalia has reported an increase in relapses in the last three months from 8% to 17% and is also concerned that this could be linked to the same problem highlighted above.

Thank you for that. The relapse data is interesting. 17% is high. Is it common to discharge to community (i.e. no support) or into SFP? Might be an idea to discharge into SFP if available since having a SAM child is a good marker for risk.

Leo, thanks for jumping in... Mark, to answer to your questions: 1) How do you know that this is happening on a large scale (i.e. a large enough scale for it to be a major concern)? As I mention in my question (We are trying of course to triangulate the information through registers (this will also require FGD)), despite this issue having been reported by the protection cluster to the nutrition one, we are investigating to evaluate the veracity of the information as well as its scale... This has not been reporting in our program but discussed during the nutrition cluster meeting and a small taskforce has been formed to look at the situation and the enn forum appear to me as a best way to get experience sharing on this... (2) What is the role of detergent? Leo answered to that... Regarding your observation: I fully agree that a lot of wrongful actions have been perpetrated in Somalia for several decades most of the time with good intention but with poor analyzis of the possible negative impact. In this case, the use of protection ration might be one of the causes of this problem (once again if proven right ) and the goal of our taskforce will be to find solutions to mitigate this problem... Thanks,

Thank you Alex. Please keep us informed of what you find.

Hi Alex, I have come across these practices in Northern Uganda several occasions included recently during an evaluation of SFP I conducted in the area. One strategy that seems to work is to use peer pressure and local authorities. Agree with the locals to expose the culprits publically so that they feel rejects. In the mean time these people are communicating some thing else; they could be worried of their household food security situation. Probably livelihood strengthening initiatives need to be provided for communities with stable security. As it is said human behaviour is rational, punishment alone may not work.

I am disturbed by the posts about “ideas to prevent Mothers from starving their children”. It reminds me of a letter from Nelson Mandela (September 2004) – the relavent quotes are: "Hunger is an aberration of the civilized world... Families are torn asunder by the question of who will eat. As global citizens, we must free children from hte nightmare of poverty and abuse and deprivation. We must protect parents from the horrifying dilemma of choosing who will live." It is quite a common practice in crisis situations in my experience – as is extensive sharing of RUTF (if all prescribed was taken the rate of weight gain would be at least 14g/kg/d). With 2 weights above target weight as a discharge recommendation, if staff tell mothers that “next week your child will be discharged as s/he is above the target weight” many children lose weight by the next week so that they remain in the program (these data are easily collected). We also see child-substitution which particularly occurs when a child dies; this is one reason for underestimation of mortality (also a reason to measure height – if there is a sudden improbable change in weight then impossible height change can indicate that it is not the same child - and then probing often shows that the original child died). The stimulus for development of RUTF came from Yvonne Grellety in North Uganda in 1996 where mothers refused to come to the TFC because they insisted on remaining at home to prevent their older children being kidnapped by the LRA – they were making the choice of who would live and who would die in their families – how ghastly to be faced with such decisions - hence the urgency for development of home treatment. These are usually decisions made under conditions of real stress which aid workers, agencies, donors and planners have never personally faced and often to not consider. Where it occurs commonly it is just as much a call for greatly increased relief for the whole family as is a high prevalence of GAM or SAM. It is a survival strategy for the family – which many aid workers want to circumvent to get better results for their programs without seeing the bigger picture or having empathy for the dilemmas faced by the beneficiaries. Under other circumstances it occurs where mothers and the community consider that the child is no longer at risk and not very different from the other children in the community – they have “almost recovered” , look like the child next door etc. here it is a coping strategy. In my opinion the mothers are NOT culprits, should NEVER be shamed, punished or efforts made to ostracise them – they are to be understood and helped. Perhaps we need many more anthropologists to live with the beneficiaries and guide us. Which one of us would like to be faced with the “Mandela Dilemma”!

very well said michael how many SQUEAC reports do we have to read that tell us that a major barrier to access to CMAM programmes is a judgemental attitude by staff at treatment centres mums do not harm their children for fun; they are facing desperate life & death decisions for their families - the fact that they may try extreme measures to keep their child in the programme reflects their belief in the fact that treatment for malnutrition works...we are obliged to try and understand and respect the reality of their day to day lives and adjust our programmes accordingly to meet their needs

The full text of the letter from Nelson Mandela can be found in the ENN resource library here: [url]http://www.ennonline.net/resources/902[/url]