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 
 
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SUMMARY 
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¶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. 
 
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Background 
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¶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. 
 
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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. 
 
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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. 
 
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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