Mass MUAC Screening by community nutrition volunteers (CNVs)

For those of you following our blog I, Christine, am managing three nutrition sites that provide curative and prevention services to children under 5 years and all pregnant and lactating women (PLWs) in our catchment area. These nutrition sites are located in 3 of the camps that make up the larger refugee camp with a population currently of over 1 million displaced Rohingya from Myanmar.

Our 3 camps cover a population of over 70,000 people of which close to 20,000 are in our program. In the past year we served over 18,000 children and 4500 PLWs. We are in the process of doing a mass MUAC screening exercise to figure out if we indeed have all the eligible children and PLWs that we should be providing services to actually enrolled in our program. This is what is technically called determining coverage.

The MUAC tape

I'm assuming most of you are not familiar with measuring rates of malnutrition in a population as this is not something that is ever done in the USA or other countries with high levels of development.  The standard method of doing this in a quick and fairly easy way is to do a mass MUAC screening. MUAC stands for mid-upper arm circumference and is a measurement that is used to give an indication of nutritional status. The measurement is done with a glorified measuring tape with color bands on the tape corresponding to nutritional status. The tape is wrapped around the mid point of the upper arm and pulled through the white end where there is a window that displays the centimeter measure and corresponding color.  

Checking for children under 5 years of age

The goal of the mass MUAC screening is to identify and screen every child under the age of 5 and PLWs in the catchment area. Steps in the process involve visiting every household and finding out who is under the age of 5. This is done with a stick and a mark on the stick for 110 cm. Any child under 110 cm is considered under 5 years. 

Checking for edema

Once identified the child is then checked for edema – a common sign of a more serious form of acute malnutrition. This is done by pressing down firmly on the tops of both feet for 3 seconds and then removing one’s fingers. If an indention remains then edema is present. 

Determining where to place the MUAC tape

The third step is to identify the mid way point on the upper arm. The child bends their arm at a right angle and the measurer finds the bone at the top of the shoulder and the bone on the elbow. Then the halfway point between those two points is marked on the side of the child’s arm. 

Wrapping the MUAC tape around the arm to see
nutritional status and tallying it on the form

This is the spot where the tape measure is wrapped around to determine if the child is in the red (acute malnutrition), yellow (moderate malnutrition) or green (healthy) section of the MUAC tape - a quick and easy way to screen children in a community and get what is considered to be a proxy GAM rate (Global Acute Malnutrition) rate. The child's MUAC is recorded on a simple tally sheet. On the top section are all children receiving nutrition services. On the bottom section of the page are children who are identified to not be receiving nutrition services. They are then referred to our nutrition site to be enrolled in our program.

Volunteers with a decorated bamboo measuring stick

This exercise has taken about 10 days in total to complete including the initial training focusing on the forms that needed to be filled out. To get a better sense of the logistics involved we have community nutrition volunteers (CNVs) that are assigned to sub blocks in each of the camps in which we work. All together we currently have 140 CNVs throughout the 3 camps with each one responsible for 60-200+ households. They were paired up to do this exercise and together needed to visit every single one of the households in their own and their partner’s assigned block. The CNVs are quite used to their own areas and visit each of their households monthly. This is just an additional exercise to make sure no households and eligible children or women are being missed. To make sure that children were not afraid of the bamboo measuring sticks as a team we worked one evening to do some decorating!

New volunteers learning to use the MUAC tapes

PLWs in our program are also screened using the MUAC tape. Obviously the bands used for children are different than those used for adults. We had to take on some female volunteers to help us do the MUAC screening of PLWs in our program since men are not allowed to touch women. One of the challenges of doing this with females in this setting is that it is necessary to remove the clothing on the arm to get a good measurement. In our nutrition sites, where this is done when women come on a biweekly basis, we have one whole side of our nutrition site that is female only – that includes curtained cubicles to offer privacy to the women while being measured. In the community this is done privately in people's homes.

This exercise was just completed on Wednesday. Now we need to enter all the data that has been collected and find out our coverage rates (in the humanitarian aid world the standard in a refugee camp should be >90% coverage) as well as our proxy GAM rates. This will give an indication of malnutrition rates. However in the nutrition sites we also measure all children's height and weight which is another measurement looked at to determine malnutrition rates.

WFP (World Food Program) provides all the food commodities that we are distributing to children and women coming to our nutrition sites. They are involved in quite a few other services in the camp. I just found out yesterday that they are sponsoring a program called WFP storytellers. Here is a link to one of the storytellers. 

https://www.youtube.com/watch?v=NWiDmAmW24M#action=share

Praise: 

• The Mass MUAC survey has been completed
• Recent funding has come through from two different organizations for our health and nutrition programs

Prayer:

• For a 2 day refresher training for all 52 nutrition staff on June 23-24
• For refugees around the world. June 20th was World Refugee Day. 

Medair Logs Workshop 2019

In early April we had a Medair Logistics workshop in Dubai. Logisticians from all of the Medair programs around the world came together to discuss different aspects of logistics - from the new procurement software that Medair will be using to negotiation skills. We also talked about a lot of

Medair logisticians from around the world!

nuts and bolts issues such as how to avoid disallowances with donor auditors.

One of the reasons we held it in Dubai is that this is one of the few countries in the world where Afghans can get visas.

It was an amazing group of people! Here are some of the nationalities represented: Kurdish, British, Afghan, Cameroonian, South African, Dutch, Syrian and Bangladeshi (my senior logs officer, Juwel, attended with me – he is in the middle on the other side of the table that I am at). So it was really amazing to interact with such a diverse group of people doing amazing work in all the different countries where Medair works and at headquarters!

Logistics (logs) varies so much from one country to another. The South Sudan program, for instance, is one of the most complicated logistics programs (along with Afghanistan and the Democrat Republic of Congo). South Sudan and Afghanistan are both long-running programs, which means that there are multiple bases in each of these countries. So logs often is buying at a central location (like the capitol city) and then expediting to far flung bases around the country. In South Sudan a lot of that expediting happens by air cargo, which is obviously quite expensive. In Afghanistan there are places in the highlands were all supplies are moved by horses. In comparison, Bangladesh is a pretty simple program. We have one base alone. And we have good enough roads to move all our supplies with trucks and other vehicles.

Simulation NSAG

One aspect of the learning during the workshop was negotiation training. There is, obviously, a lot of negotiation involved in logs. One of the primary procurement principles we live by is “best value for money.” So we are negotiating to get that best value for the money that both donors, and individuals like yourselves, give to the Bangladeshi program. But while we were at the workshop a Cameroonian colleague relayed to me how he had had to negotiate with an armed faction in a neighboring country for the release of a couple of his staff who had been taken hostage. This picture is from the simulation we did during the negotiation training. This simulation had to do with negotiating with Non-State Armed Groups (NSAG). My colleague from Afghanistan played the part well! But the training was really helpful! Negotiations are not something that I would say I am necessarily naturally gifted in. So it was really helpful to learn more about negotiating methods and styles.

The things that we learned at the workshop will definitely help my team to better execute our duties. I am grateful for the learning opportunities!

Prayer points:

1. Pray for Medair logs personnel around the globe: for integrity, for strength and for grace to offer others.
2. Pray for Christine as the UN Food Programme project reporting system weighs on her these days.
3. Pray for Rohingya and Bangladeshi alike as almost all celebrate Eid al Fitr over the next 3 days (https://en.wikipedia.org/wiki/Eid_al-Fitr)

Time recently came out with a great exposé on the Rohingya. Check it out!

http://time.com/longform/rohingya-muslims-exile-bangladesh/

A Rohingya photographer

I just want to quick send out a blog in order to share the following link with you:

https://rohingyavision.com/life-through-the-eyes-of-a-rohingya-photographer/

Our comms guy just shared this link with us today. And I am sharing it with you because it tells of some of the difficulties of being a Rohingya youth in the refugee camps. You have to be highly motivated (like this young man) to continue to learn and to grow.

I recently learned that the average amount of time that a person remains a refugee is 17 years! The Rohingya have been here for 2 years thus far.

What he says about education is true. Beyond pre-school education, little else exists. And so the plight of youth is really dire.

And he highlights the fires as well. Here is a picture that one of our staff took of a fire on the 24th of April. He describes well the challenges that fires pose (because he lives that reality).

I think this gives you a better idea of the reality of Rohingya youth! Thanks for continuing to pray for them! 

Home renovation

Building on the hillsides - photo by Tamara Berger

Have any of you done any home renovation recently? We did a ton of this the last year before leaving for Bangladesh. His brother, Jay, helped Phil (actually Phil lent the grunt labor and Jay lent the expertise) to frame up our basement in preparation for renting out the main part of our house. Our brother-in-law Rod may have spent more time at our home than at his own helping with the finishing of the basement. And we did some renovation of our upstairs to make it into an apartment for our family while we rented out the main floor and the basement.

Well, Medair is helping do home renovation for the Rohingya refugees (but as you might imagine, this doesn’t look at all like the home renovation that you or I might do in the States). When the refugee homes were first built over a year ago for some, the upright bamboo poles were simply stuck into the ground. As you can imagine, that bamboo is now rotting, calling into question the integrity of the entire home. So the objective is to upgrade so these homes to be able to resist high winds during the upcoming monsoon and cyclone seasons.

We have shown you, in previous posts, photos of the construction of the Nutrition clinics that Christine manages. The homes of the refugees are built in a similar fashion out of bamboo, usually with tarpaulin roofs.

And a huge part of Phil’s job in logistics is to manage procurement. So he and his team (particularly his colleague Juwel) have been working at purchasing the materials that the Shelter team needs to help facilitate refugees upgrading their own homes.

Schematic for the new anchoring system for Rohingya homes

Here is a diagram of how these upright bamboos will now be anchored in the ground:

There is a “helix” which is essentially an augur that the refugee family (and the objective is to have the families rebuild their own homes with some assistance from Rohingya who have been trained in these building practices) will screw into the ground to a depth of a little over half a yard. This will serve as the anchor. Then a round cement block with a hole in the middle is sunk partially into the ground with the helix “stem” coming up through the middle of the block (which is solid other than the hole in the middle). The upright bamboo (each house will receive 8) - which will then constitute the corner or side main uprights of the home - is inserted over the stem which has an eyelet at the top. The bamboo rests on top of the block so that it is no longer in contact with the soil, prolonging its life span. And holes are drilled on each side of the bamboo so that a bolt can be inserted through the bamboo, go through the eyelet in the augur, essentially bolting together the entire unit. Then the families will construct their homes around this foundation with woven bamboo mats as walls and tarpaulin roofs held in place by both bamboo mats and lengths of bamboo running over the top of the tarps to hold it in place.

One of the blocks we broke apart

So yesterday Phil and a Shelter colleague, Hans, put in a few hours working on the procurement of the blocks that will be used as described above. The Shelter team was concerned that some of the blocks might not have been built to their specifications (proportions of sand, gravel and cement; whether the two iron bands have been put in the block, etc) that team had given to the vendor. When we contacted the vendor with our concerns, he said that we could come to where he is making the blocks, he would mix up the cement mixture in front of us, and make the blocks in front of us. So we did that yesterday and marked the blocks so that we can use them as a comparison with the blocks which have already been delivered to our warehouse. Then we went to the warehouse to break some of the blocks that they were concerned about to see whether the blocks had indeed been built to our specifications. Hans seemed to enjoy pounding on these blocks with a hammer to break them open! And we were pleased that as the blocks have cured, they seem to be as hard as we had expected.

Our hope is that these new improved foundations will give the Rohingya better safety during the upcoming storm season. 

Please pray/praise: 

• For the Rohingya as they face the monsoon/cyclone seasons again in what is essentially temporary housing. 
• That we can get all the procurement of these shelter items for the construction to happen in a timely manner. 
• For international staff that have various family issues making it difficult for them to continue in their roles. 
• For what seems to be an inordinate amount of still births in the camps and all that may surround that issue.

News from the Shire

Our home/office nicknamed "The Shire" or "Alcatraz"

Wow! There has been a lot of water under the proverbial bridge since our last post. We almost cried when we saw 6 comments this morning in reaction to that last blog.  Thank you all for your prayers, your kind words of affirmation, and just news from people who are dear to us. You have no idea how much this means to us!

We particularly want to thank you for your prayers during the move to our new base in the rice fields of Court Bazar! This process was as hard as Phil anticipated it would be! In fact, we are still working some of the details out. Phil had been having regular contact to prepare things with the landlord in advance of the actual moving day (we knew we were really pushing him to get things done faster than he would have if we were not moving in). But the day that we showed up with all our office furniture and documents the workers were still living in our offices and there was still finishing work to be done! There was no turning back at that point, so we moved the furniture into the offices (knowing that it would be safe), stuffed all our documentation in a shop out front of our building (in which the landlord had been storing building supplies) locked the door, and prayed the Lord would take care of

More rice paddies around us

the rest! The next day the workers had moved out, and finishing was moving forward!

One of the minor details to be worked out was that, in the beginning, we had to use the jerry rigged electrical connection that was pulled from someone’s house, across the rice paddies on bamboo poles and into our building. The official electrical connection from the utility company had not yet been hooked up. And our generator had not yet been delivered. So we were a bit limited in electrical usage for a bit! But now the generator is online. We have received the electrical connection (though we still need to get more transformers to increase our capacity). And we are cooking with gas (literally and figuratively).

Honestly, the landlord has been very good at working with us. I am so thankful for Mr Nurul Absar’s cooperation. And I am thankful for your prayers. It is humbling to think of how those prayers have sustained us through decades of ministry around the world!

Phil has loved the challenges of the new job. Since he took over as Logs manager, there have been some failures, and there have been lots of successes. He always tells the team that they win or lose as a team. So they celebrate the wins, and correct the losses!

Christine’s work in nutrition - Funding remains a challenge for the nutrition programs. As the

Get the idea? - we are literally surrounded by rice

Rohingya refugee situation moves from the initial immediate emergency related to the huge influx of refugees to a transitional phase of semi-permanency the broader global interest has shifted to other more immediate crises. Partial funding has been received for continuing to run the 3 nutrition sites that provide support to children under 5 and PLWs (pregnant and lactating women). But the uncertainty of funding is causing us to strategize around all the different possibilities including looking at how to cut back on nonessential services.

The Rohingya face significant challenges these days. The government here has said that the Myanmar government has not put in place structures and provisions allowing the Rohingya to return. These stories tell more about this government’s plans in the face of that: https://www.dhakatribune.com/bangladesh/rohingya-crisis/2019/03/03/rohingya-relocation-to-bhasan-char-to-start-by-mid-april and https://www.thedailystar.net/rohingya-crisis/news/un-envoy-fears-new-crisis-rohingya-if-moved-bangladesh-island-1713532.

Prayer points:

• Pray for God’s good purposes for the Rohingya to be accomplished in all aspects of their lives so they can flourish materially, spiritually and emotionally. Also pray against the principalities and powers that would hold them hostage.
• Pray for funding for Medair’s programs in Bangladesh
• Praise for our move to what we, as Medair staff, call “The Shire” – a peaceful home in the middle of flourishing rice paddies

Advent in Bangladesh and other news

It has been too long since our last blog post. In the meantime we had a wonderful Advent season here in Bangladesh! We decided as a Medair team that we wanted to do a Advent devotional together, and found one written by Dietrich Bonhoeffer! Many of the writings were from Christmas sermons he had given, then complemented by writings to family, friends and his fiancée from prison before he was executed by the Nazis. This was really a meaningful addition to work and a great preparation for Christmas. One of the things that Christine & I love doing is adapting Christmas traditions to wherever we are living. So it was fun to find a Christmas tree of the same variety that we once had in Benin!

Our colleague, Robert (from Uganda), has pizza for the 1st time!

We had a lot of meaningful team time. We had a pizza meal together one evening. And on Christmas morning we had a brunch together (which included Christine and Phil's world famous cinnamon rolls - they must be world famous as we have made them around the world!) before our gift exchange. About half our colleagues were gone over the holidays. But we loved celebrating with the ones who were here!

On of the benefits of having a few days off around the Christmas season (primarily because our programs were shut down for a week because of elections here in Bangladesh) was that we were able to talk with all three of our kids who were in Minnesota over that time period. Anna's parents live in the Twin Cities, so Nathan and she were there for around 10 days. And so for around a week we talked with various combinations of kids each morning and each evening (we are currently exactly 12 hours ahead of MN, so our day was happening during their night). This was so special for us as we miss them so much! It was difficult to be away from them this Christmas, but speaking with them so often helped dull the pain of the absence a bit! This is a picture that we took on FaceTime during one of our conversations.

(from left to right - in case you don't recognize them)
Lydia, Annika and Nathan

 You may have been read about the Rohingya in international news over the last 3 months as well. There was an aborted attempt to resettle a first group of Rohingya back in Myanmar when they simply refused to go. There was an outcry from the international community over what appeared to be a rushed effort (https://www.medair.org/42-ngos-warn-return-refugees-myanmar-now-dangerous-premature/). There have also been persistent reports of repression of their people in their home country and settling of other ethnic groups in Rohingya villages that were burned during the crackdown of 2018. All this has had a very sobering and unsettling effect on these people alongside whom we are walking.

Please pray/praise:

1. Praise God for a wonderful Christmas time and relatively uneventful elections here in BGD.
2. Pray for last issues to be resolved with our new landlord as we need to move into our new office/accommodation nearer the camps by the end of the month.
3. Please keep the Rohingya in your prayers, that God's vision of shalom for them would be accomplished!

A wedding celebration - Going the extra mile

Christine with Osman at the bride's House

Yesterday we attended the wedding celebration of one of our nutrition staff. His name is Osman and he is the Outreach Supervisor in Camp 16 where we have one of our nutrition sites. His job is to supervise the 52 community nutrition volunteers (CNVs) we have in Camp 16. These CNVs visit regularly the women and children who receive food from our nutrition site. They share health and nutrition messages and generally look out for the well being of these families.

When we arrived at the house of the bride, we found Osman sitting at a huge table. Around the table were all of the male volunteers - 44 of them - eating together in this joyful celebration! Now, you have to realize that the CNVs are all Rohingya refugees. Most have been living in the camp for over a year now, and, like all Rohinga are not allowed to leave the camp. Osman and the CNVs managed to get special permission from the camp authorities to leave the camp and attend this wedding celebration in Cox's Bazar. Osman organized a bus to bring them into town - a trip of about 2 hours one way - so they could join him on this special day.

The Rohingya CNVs at table with Osman

Christine was literally speechless when we arrived and saw all of the CNVs sitting together with Osman around the table. Osman's job as an outreach supervisor with these CNVs is obviously more than just a job for him. Osman's desire to have them at his wedding celebration, and making that happen, is really an example of going the extra mile. This is an illustration of the love of our staff for the people they serve.

In Medair we like to share stories about going the extra mile. We are humbled to work with staff who live that out, not just in their work life, but their personal life as well.

Elizabeth, one of Christine's Managers, with the Bride

As we approach the end of the year please pray for the ongoing work of the nutrition staff and all the volunteers as we are at the end of project cycle. We are hopeful for renewed funding in the new year. But we don't yet have enough assured funding for the entire year.

Prayer points:

1. Funding for health and nutrition programs for next year.
2. A smooth handover of two Medecins Sans Frontières (MSF) clinics  to Medair as of the 1st of January. 
3. For the country of Bangladesh as it heads towards elections on the 29th of this month - there is much uncertainty around these elections.