Caring for Unaccompanied Children under Difficult Circumstances
by Jean Long, Ros O'Loughlin, Annalies
Jean Long and Ros O'Loughlin worked
for Concern in Kisingani (DRC) in the fall of 1997, establishing the programme
described below. Annalies Borrel is the agency's HQ Nutritionist.
Generally, emergency interventions are
conceptualised as having an impact on nutritional status through a combination
of strengthening food security, health service provision and providing
or supporting caring practices. However, there is currently a debate about
what constitutes caring practices in emergency programme interventions.
The authors of this article would propose that caring acts as a catalyst
or effect modifier, which increases the effectiveness of the intervention
and/or allows an intervention to be delivered in a more sensitive manner.
The following case history intends to demonstrate the caring process and
practices utilised to make the treatment of severe malnutrition among unaccompanied
children more effective in Kisangani, Democratic Republic of the Congo
From May to July 1997, Concern Worldwide
was responsible for the general welfare of unaccompanied Rwandan children
while in transit from the DRC to Rwanda. The background to this situation
is described in detail in the article on Responding to the Crisis in Congo
Zaire: Emergency Feeding of Rwandan Refugees in Issue 3 (January 1998)
of Field Exchange. The registration of these children and preliminary
preparations for tracing was the responsibility of Save the Children, UK
and UNICEF. At the time, the internal situation within the DRC was complex
and often dangerous for the refugees. Concern Worldwide (Concern),
an international NGO, with experience in child care was requested to prepare
all unaccompanied children for return to Rwanda. All children were
to be repatriated to Rwanda within 60 days, and initially within 48 hours
of arrival in the Kisangani transit centre. However, it was assumed that
the children's health and nutritional status was sufficiently adequate
to allow them to make the onward journey. There was no reliable information
to indicate otherwise.
In early May 1997, following Concern and
other NGOs arrival in the transit camp, it was realised that at least 30%
of the unaccompanied children were not fit to travel, given their current
health and nutritional status. There was, however, pressure by both
the military authorities and UNHCR to repatriate the children, unless they
were suffering from medical complications. At this stage, severe
malnutrition was not necessarily considered a medical condition requiring
immediate intervention by the authorities. As an international humanitarian
organisation Concern felt its priority was to ensure the best possible
outcome for each unaccompanied child. Concern therefore established
a screening facility which determined whether children required: emergency
medical care, therapeutic feeding or outpatient care. Emergency medical
care facilities were available in a Medecins Sans Frontieres International
(MSF) field hospital. However, initially there were no facilities
for the treatment of severe malnutrition. Concern were aware that
stabilising the children before repatriation was critical to prevent excess
mortality, especially as nutrition rehabilitation facilities available
in Rwanda were inadequate. UNHCR initially allowed Concern five days
to stabilise the severely malnourished children. Following subsequent discussions,
there was agreement that the children could remain as long as it took to
achieve full recovery.
The Kisangani Therapeutic Feeding Centre
Over six hundred severely malnourished
unaccompanied children were treated in the TFC during the 12-week period,
27% of the admissions had nutritional oedema and 42% had MUACs less than
110mm. The average length of stay was 15 days, although 27% had a
length of stay greater than 21 days. Seventy eight percent of the
children admitted recovered, while 9% died, and 13% defaulted. Thirty three
percent of the children were admitted to hospital for a short period during
their stay in the TFC. The prevalence of: oedema, MUACs less than
110 and medical conditions indicates that these children were in very poor
condition on arrival in the TFC. The condition of the children
in the TFC was further complicated by their traumatic experiences and there
was evidence of, disorientation, withdrawal, extreme grief, and other behaviours
indicating a high degree of psychological stress. War injuries were
common among the children and there were some incidences of pregnancy among
Constraints to Care Provision
There were many constraints to providing
adequate care for these severely malnourished unaccompanied children
in the Kisangani Therapeutic Feeding Centre (TFC)
* The children had no mothers to provide
care and advocate for their children's needs, and their siblings, if present,
were often as ill themselves, and were equally traumatised by their recent
* the lack of locally qualified health
staff with experience in caring for the severely malnourished. Language
barriers were another major constraint for the Zairian staff as they did
not speak the children's language, Kinyarwanda.
* Organisations (UNHCR and other NGOs visiting
donors visiting the centre), did not fully comprehend the strict treatment
regime required to stabilise these children, for example, they often distributed
high protein biscuits to the children who required a low protein diet.
They often accused centre staff of not providing adequate quantities of
food for the children, although their diets were calculated individually
and in line with international guidelines.
* Separation of siblings was another key
issue in the centres. Initially UNHCR staff would collect the well children
from the centre and mistakenly take siblings of the malnourished children
still residing in the TFC. This created difficulties for the organisations
responsible for tracing and fostering, not to mention further traumatising
the children. There were also occasions where well siblings that were being
repatriated collected their malnourished brother or sister. This contributed
to a high default rate.
Examples of the caring process
The main caring interventions provided
by Concern during this period included employing, training and supporting
local women who worked in shifts as carers.
The training covered the clinical management
of the severely malnourished children including a special emphasis on the
importance of creating a secure and comfortable environment for the children.
This included maintaining the child's physical comfort (including hygiene
and warmth), explaining treatments, conversing with the children and motivating
children to take the food and medicines provided.
The activities of these local women
were child based rather than task based, and the same worker was allocated
to the same group of children on each shift. At a later stage of
the child's recovery, exercise and play became important caring interventions.
Technical skills and language barriers were overcome through recruiting
health care staff and translators in Goma. This facilitated
carer communication with the children . Conversation between carer and
children was actively encouraged.
The caring staff needed continuous support
and supervision in these difficult circumstances to ensure quality of care.
When feasible the older siblings cared for their younger malnourished siblings
while others were cared for in the adjoining unaccompanied children's centres.
There was continual advocacy by Concern,
to ensure that siblings were not separated and also to maximise the time
for recovery prior to forced repatriation .
This article set out to highlight
the importance of caring practices in promoting nutritional recovery amongst
malnourished children: These practices are catalysts/effect modifiers which
improve intervention outcomes, and can be adapted to a given situation.
However, these practices can be resource intensive. There was little
doubt amongst those involved in the programme that caring practices in
this TFC increased the speed and quality of recovery among these children
in very difficult circumstances. Our observations also indicated
that through caring practices, the majority of children, particularly,
those who were traumatised made a complete recovery. Other indicators
of recovery, apart from achieving the target weight for height, included
children: smiling; taking an interest in their surroundings; paying attention
to their appearance; regaining their dignity; interacting and conversing
with other children and the staff; playing; beginning to tell their story;
starting to form friendships and to trust the adults providing care in
This article does not mean to imply that
parental participation is unnecessary in the nutritional recovery of their
malnourished children. Instead, it is intended to show that
excellent nutritional outcomes can be achieved through investing in the
provision of caring practices, many of which would normally be undertaken
by parents, when children are separated from their parents during
Taken from Field Exchange Issue 4, June 1998