Tag: Sierra Leone

U.S. Food Aid (Part 3): Lessons from Tufts University’s “Food Aid Quality Review”,

July 17, 2026   This is the third in a series of briefs about U.S. Food Aid, recognizing the shift of programming to the U.S. Department of Agriculture.

Every year, for over a half century, the United States has shipped more than a million tons of food to hungry people in dozens of countries.  During this time the underlying products barely changed.  In 2009, USAID’s Office of Food for Peace (FFP) commissioned Tufts University’s School of Nutrition, in Medford (near Boston), Massachuseets to ask basic questions about how effective these foods are.   The resulting twelve-year “Food Aid Quality Review” (FAQR), was anchored by two principal investigators, Patrick Webb, and Beatrice Lorge Rogers, working with a team of Friedman School of nutrition faculty and students, and a stakeholder network spanning dozens of NGOs, implementing partners, and UN agencies across more than 40 countries.

Tufts University’s Friedman School of Nutrition Science and Policy’s FAQR, in partnership with USDA and the Department of Defense’s Natick food research laboratories, had three phases over twelve years:

Phase I (2009–2011): a diagnostic review of whether U.S. food aid products, programming, and institutional processes reflected current nutrition science.

Phase II (2011–2016): development and field-testing of reformulated products, including a large randomized prevention trial in Burkina Faso.

Phase III (2016–2021): a randomized treatment trial in Sierra Leone, supply-chain and packaging research, bioavailability science, and the institutionalization of the reforms across USAID and USDA.

The founding evidence base came from a survey of 64 responding USAID implementing-partner field offices across 40 countries, supplemented by expert panels and a formal public-comment period on the draft report.  This included extensive consultations with agencies, field trials (working with NGOs), facilitating product alignment among USAID, USDA, the World Food Programme, WHO and UNICEF, and interaction with the the congressionally established Food Aid Consultative Group (FACG), whose membership spans academicians, advocacy organizations, commodity groups, and NGOs.

The flagship Phase I report, “Delivering Improved Nutrition: Recommendations for Changes to U.S. Food Aid Products and Programs” (Webb, Rogers, Rosenberg et al., 2011), was built on a survey of 64 implementing-partner field offices across 40 countries (an 81% response rate), plus expert panels and public comment — the first systematic, evidence-based review of Title II food aid products in the program’s history. It organized its findings around three pillars: product quality, programming quality, and process quality , the idea that better food alone would not fix a broken system unless targeting, procurement, and delivery improved alongside it.

From there, Tufts led two of the largest field trials ever conducted on specialized nutritious foods:

      • Burkina Faso (2014–2017): a geographically randomized prevention trial with roughly 6,100 children aged 6–23 months, comparing four foods for their effect on stunting and wasting.
      • Sierra Leone “Four Foods” study (2017–2018): a cluster-randomized treatment trial with 2,683 children aged 6–59 months, testing recovery from moderate acute malnutrition, alongside sub-studies on body composition and gut health, and a novel 1.2 kg consumer package.

The headline finding surprised many in the field: the newer, more expensive, reformulated products did not outperform the upgraded standard corn-soy blend. In Burkina Faso, no food fully prevented growth decline, and a novel corn-soy-whey blend actually performed worse than standard CSB+ with oil. In Sierra Leone, recovery rates were statistically similar — around 62–65% — across all four products tested. In both trials, cost, not effectiveness, was what separated the products: CSB+ with oil was consistently the cheapest and therefore the most cost-effective option, at roughly $122 per child in Burkina Faso versus $140–$245 for the alternatives.

Tufts also stood up the REFINE database (Research Engagement on Food Interventions for Nutritional Effectiveness), an open-access knowledge-sharing platform built by Friedman School faculty, staff, and students together with a team from the World Food Programme.

KEY INSIGHTS and CONCLUSIONS

Regarding commodity quality, FAQR concluded that U.S. foods used in aid had “barely changed in decades” and were out of step with modern nutrition science, and (among other things) recommended adding a dairy-protein source (whey protein concentrate, WPC80) to fortified blended foods, upgrading micronutrient premixes, and adding lipid-based ready-to-use foods to the approved product list. USAID adopted uniform micronutrient specifications across 21 products, upgraded the micronutrient content of 8 products, developed 4 entirely new products, and set the first global minimum nutrient premix standard for ready-to-use foods.

  •  About programming quality, FAQR found that programs were commonly judged by tonnage shipped or numbers of people “fed,” not by nutrition outcomes achieved, and that a single “one-size-fits-all” ration could not meet the very different needs of infants, pregnant and lactating women, wasted children, and people on HIV treatment. It developed decision trees to match specific products to specific purposes and emphasized the first 1,000 days of a child’s life (conception to age two) as the priority window for specialized nutrition programming.

  •   When looking at process quality, FAQR found that the many hand-offs of food from procurement to delivery were poorly coordinated across agencies, and it recommended a standing interagency committee, stronger quality-assurance feedback loops, and later, in a 2021 review of 26 commodity incidents between 2018 and 2020, a formal Commodity Incident Management System with real-time, end-to-end traceability “from producer to consumer.”

FAQR‘s most durable legacy may be less about any single product than about how Food for Peace (today, USDA) should make decisions. Several implications carry directly into current and future food-aid policy:

  •   Cost-effectiveness, not unit cost, should drive product choice.  The central empirical finding,  that the cheapest option (CSB+ with oil) matched or beat costlier, more sophisticated products in both prevention and treatment trials, to treat moderate malnutrition is a standing rebuke to the assumption that newer and more expensive automatically means better.  USG programs should keep asking “cost per case of malnutrition averted,” not “dollars per ton shipped,” when choosing among products.   The FAQR’s Malawi Feasibility study (2013-14): tested increases in fortified vegetable oil (FVO) to Corn Soy Blend (CSB) from the usual ratio to 30g FVO:100g CSB, along with family education and repackaged 2-kg bags.  Finding: caregivers could achieve the ratio; intervention was more cost-effective than standard programming.

  •   Freight and procurement costs, not formulation, usually decide the winner. Because product price and international freight, not nutritional efficacy, drove most of the cost differences observed in the field trials, decisions about where to source, how to package, and how to ship deserve as much scrutiny as decisions about what goes in the bag.

  •   “Fit for purpose” should stay the organizing principle, not a slogan. No single food worked for every beneficiary group in FAQR’s trials. Continued investment in decision tools that match a specific product to a specific nutritional objective, context, and beneficiary,  rather than defaulting to one flagship commodity, is what the evidence actually supports.

  •   Interagency and international harmonization needs active maintenance, not a one-time fix. The alignment FAQR achieved among USAID, USDA, WFP, UNICEF, and WHO specifications reduced confusion for manufacturers and implementers, but harmonized standards drift apart again without a standing mechanism (like the FACG or an interagency committee) to keep revisiting them as new evidence and new products emerge.

  •   Supply-chain quality control deserves the same rigor as nutrition science. FAQR’s 2021 finding that losses are rare (under 1% of U.S.-sourced food) but that the health risk from what does slip through is high,  combined with weak, uncoordinated incident tracking, points to unfinished business: a real-time, end-to-end traceability system was recommended but not fully built out before the project closed in 2021.

  •   Evidence infrastructure needs a permanent home. REFINE was built specifically because, before FAQR, a lack of evidence on which foods to use and how to deliver them was a genuine gap, not a rhetorical one. Sustaining REFINE, or something like it, as a living, continuously updated evidence base, rather than letting it lapse once grant funding ends,  is the clearest way to keep future USG food-aid decisions grounded in current science rather than institutional habit.

Other Recommendations:

•   Increase the processed food portfolio in the food aid basket.

•   Adopt “feed-the-colon” strategy to promote gut health.
•  Improve the stability of vitamin C.

•    Use water as a vehicle for fortification of water-soluble vitamins.

•  Formulate foods to accommodate the elevated micronutrient needs of beneficiaries with infections.

The main FAQR finding that upended conventional wisdom was not that U.S. food aid needed fancier, costlier products; it was that a smarter, evidence-driven version of what USAID already had,  better targeted, better formulated, and more honestly costed, outperformed the alternatives. That is the standard FAQR leaves behind for whatever comes next in U.S. government food assistance.

The USG largely accepted and adopted FAQR’s recommendations. USAID adopted uniform micronutrient specifications across 21 products, upgraded the micronutrient content of 8 products, and developed 4 new products. They also formally added lipid-based products, such as Ready-to-Use Supplementary Foods (RUSF), to their approved list of commodities. USAID adopted the recommendation to add an animal-source protein, specifically whey protein concentrate (WPC80), to fortified blended foods (FBFs) like Corn Soy Blend (CSB) to improve protein quality and bioavailability. This led to the creation of upgraded products like CSB+ and Corn Soy Whey Blend.

….

SELECTED PUBLICATIONS

Michael Joseph et al. , 2019, Enhancing the Nutrient Bioavailability of Food Aid Products,  explores current processed foods for malnourished children and recommends adding defatted toasted wheat germ (DWG) or synthetic amino acids (following ideal protein concepts) as cost-effective soy alternatives to boost protein efficiency; diastatic malt (0.25% barley) to enzymatically thin porridges, raise solids/energy density, degrade phytates, and improve mineral/protein digestibility; omega-3-rich oils (e.g., canola) with antioxidants; and prebiotic oligosaccharides (scGOS/lcFOS blends) plus yeast cell-wall components for gut health and mycotoxin binding.  Further, processing upgrades such as extrusion, compaction of FBFs for better shelf life/transport, and optimized milling/dehulling further enhance matrix performance, noting that changes can improve cost-effectiveness and health outcomes (e.g., recovery from wasting).

Griswold, Langlois, Manary, Rogers et al.  2020, Comparative Cost-Effectiveness of Four Supplementary Foods in Treating Moderate Acute Malnutrition in Children 6-59 Months in Sierra Leone  found no significant differences in recovery rates from moderate acute malnutrition  among the four supplementary foods tested: CSB+ with oil, CSWB with oil, SC+A, and RUSF, observing unadjusted graduation rates of 62–65% and no observable differences after covariate adjustment in its sample of 2,653 children.  Cost per recovered child ranged from $90–$94 across arms from the program perspective, with no discernable differences in cost-effectiveness.  Caregivers’ opportunity costs were lowest for RUSF but did not alter the overall conclusion of similar cost-effectiveness.  The study observed that intrahousehold sharing occurred at similar rates (~25%) across all foods and was unassociated with recovery, as was adherence to recommended recipes.  Direct observation confirmed that actual consumption of the supplement by the target child was positively associated with recovery; sustained recovery at four weeks post-discharge was lower for RUSF (73%) than CSB+ (81%), and presence of environmental enteric dysfunction (EED) reduced recovery rates independently of food type, with no food-specific differences in body composition changes.

Ilana Cliffer et al, 2019 Comparative Cost-Effectiveness of 4 Supplementary Foods in Preventing Stunting and Wasting in Children 6-24 Months.  In Burkina Faso, FAQR conducted a 3-year, clustered, four-pronged trial with random assignment to determine the effectiveness and cost-effectiveness of four different supplementary foods for the prevention of stunting and wasting in children aged 6 to 23 months. This trial enrolled 6,112 children, with roughly 1,500 per study arm, making it one of the largest randomized controlled trials of supplementary foods. The trial compared Corn Soy Blend plus (CSB+), CSWB, LNS, and a super cereal product, following children monthly during the supplementation period and measuring growth, morbidity, and dietary intake outcomes.  The authors found that children receiving CSWB performed worse over time but because it was shared with other household members more frequently and was consumed by the intended child less often.  RUSF was the most expensive, largely because of its higher commodity and packaging costs. Flour products required more caregiver time for preparation and feeding, so adding the value of caregiver time substantially increased their total societal cost.  Nevertheless, CSB+ with oil was the most cost-effective option. It was the least expensive and was at least as effective as SC+ and RUSF, and more effective than CSWB.

Griswold, Schmall, Webb, Rogers et al.  2021  Additional Analysis of Two Field Studies Comparing Four Supplementary Foods for Treatment or Prevention of Malnutrition, FAQR.  The authors discerned that Mid Upper Arm Circumference (MUAC) and Weight for Height (WHZ) measures of malnutrition differ more than previously thought in identifying children.  The disagreement between the measures is both by gender and age.  The report strengthens the case for dual‑criterion admission (MUAC + WHZ).  Authors also found that children whose malnutrition became worse, even after program enrollment, could be identified within the first few weeks, and should be flagged.  Programs can introduce early intensified support for children showing stagnation in the first month.  Predictors of such decline included fever, diarrhea, vomiting, or cough, even if they had no illness at enrollment.  From the data in Burkina Faso, the authors identified that children with the worst stunting had consistently slower growth velocities from early infancy onward, not sudden drops, meaning that support should be continuous.  Surprisingly, the authors found that at the family level, dietary diversity, water treatment, latrine use, ration sharing, and caregiver engagement did not predict whether a child improved from wasting malnutrition sustainably.

FACET.  FAQR the Food Assistance Cost-Effectiveness Tool (FACET) for Supporting Specialized Nutritious Foods (SNF) Programming Decisions, a novel interactive decision-support instrument designed to help funders and implementing partners integrate cost-effectiveness analysis into nutrition program design.  FACET was designed as a computer-based interactive tool that guides users through three categories of input parameters: program specifics (such as target population, duration, and coverage rate), cost
components (including procurement, transport, storage, distribution, monitoring, and overhead costs), and nutrition impact measures (such as changes in anthropometric outcomes, micronutrient status, or
dietary adequacy). The tool generates a range of cost-efficiency indicators, including cost per beneficiary per day, cost per kilocalorie delivered, and cost per unit of specific micronutrient delivered, as well as more complex cost-effectiveness ratios that link program expenditures to measurable
nutritional outcomes. FACET was published in the journal Current Developments in Nutrition in 2020 and has been made freely available to the international nutrition community through the FACET4SNF
website.

Lauren Thompson,  AudreyKarabayinga,; Beatrice Rogers, Patrick Webb, . 2021. The Potential Value-Added to USAID of Open Access Data on Food Assistance for Nutrition. Report to USAID. Boston, MA: Tufts University finds that supposedly open-access datasets in food assistance for nutrition research are either inaccessible, lack necessary documentation, or are too heterogeneous to be useful for pooled secondary analyses. Consequently, the FAQR recommends that funding organizations implement tougher data-sharing guidance and infrastructure, such as requiring comprehensive data management plans and the curation of complete datasets with accompanying documentation, to make open data truly meaningful and reusable.

see also:  https://evidencesummit2.wordpress.com/resources/

 

 

Ebola Control Lessons from Past Outbreaks

June 18, 2026    Food insecurity the Democratic Republic of Congo (DRC) has formed a vicious circle this year with the latest Ebola virus outbreak, now the 17th recorded and the largest to date in terms of people infected.

The Adventist Development and Relief Agency (ADRA) is an example of an NGO that has been providing large scale food assistance in eastern DRC and has addressed the current and past outbreaks of Ebola with community education, hygiene promotion, and water, sanitation, and hygiene.

Lessons from the earlier West African Ebola outbreak include the value of self-isolation (self quarantine of people who may have been exposed to Ebola) which was a critical measure to interrupt transmission, and, in turn, self-isolation depended on aid agencies providing ample food aid to compensate the family for lost income.   Today, the World Food Programme is doing the same thing, providing food aid to contacts and patients in DRC.

The map below shows the current spread, in 2026 of the virus, and possible future routes of spread.

In the West Africa outbreak there were 11,323 recorded deaths but probably over 30,000 actual deaths, where the majority of Ebola cases were never reported.  The United States Government alone spent some $2 billion on that earlier Ebola response.  The United Kingdom spent £667 million (roughly $850 million–$1 billion at 2014–2016 exchange rates), and the World Health Organization spent some $500 million.

The USAID evaluation of that outbreak response was commissioned by Jeremy Konyndyk, then Director of the Office of U.S. Foreign Disaster Assistance. Writing in the New York Times on June 13, he warned that the current DRC outbreak could become the worst ever.  He reports that the Centers for Disease Control and Prevention (CDC) projects that more than 20,000 cases may occur by late August. Konyndyk notes: “As bad as this situation is, we have a playbook for addressing such crises. But it requires a huge team effort.” He calls for specialized clinics, large‑scale contact tracing, safe burial management, and adequate personal protective equipment for health workers. However, he cautions that “security has deteriorated markedly as the government has lost control of large parts of the area.”

With clear relevance for the current global Ebola outbreak, a series of lesson‑learning roundtables were held in 2017 at George Washington University, Harvard University, and the Uniformed Services University of the Health Sciences. These discussions were part of a lessons‑learning evaluation requested by USAID and were intended to reflect on operational challenges during the West African Ebola crisis.  Each roundtable included seasoned emergency practitioners who had overseen or implemented programs in Liberia, Sierra Leone, and Guinea during the lethal 2013–2016 outbreaks.

The Harvard Roundtable concluded that the greatest challenges in the Ebola response involved trust, including community skepticism and occasional violence. One participant warned that “we are setting ourselves up for the same problems all over again.” Families were initially reluctant to cooperate with referral systems in which infected relatives were taken away with little explanation. As one participant noted, once treatment centers were introduced and communities saw that Ebola was not always a death sentence, and that patients could both enter and leave safely, community transmission began to decline. Another participant observed that promising “Community Care Centers” were denied or delayed funding unless the NGO also staffed a larger hospital. Others emphasized that faith‑based organizations were often more effective at face‑to‑face engagement with communities.

The 2016 lessons roundtable held with U.S. military representatives highlighted the indispensable role of the U.S. Navy’s Mobile Diagnostic Laboratories (MDLs) in West Africa. Operated by the Naval Medical Research Center (NMRC) in Guinea and Sierra Leone, these PCR‑based laboratories provided the only rapid diagnostic capacity early in the outbreak. The U.S. Air Force also played a critical role in airlifting doctors and epidemiologists across Liberia during the fall of 2014.

The roundtable at George Washington University’s Milken Institute School of Public Health, composed largely of NGO headquarters emergency coordinators—generated two major cautions about international response. First, although each NGO had developed new guidelines and standard operating procedures for Ebola‑type emergencies, there was no funding to package, archive, or preserve these materials for future use, and many were already being lost. There was no forward planning for how such lessons might be applied in future outbreaks, including today in the DRC.  Second, although not on the agenda, participants volunteered that their organizations now have serious reservations about having responded at all, given the massive legal and duty‑of‑care liabilities they incurred. Donors urged NGOs to respond, but were unable to shield them from punitive audits afterward.

Key lessons about reducing transmission of Ebola in West Africa in 2014-2016 were published from a USG-commissioned  evaluation  which looked at all donors, UN agencies, NGOs, academia and other actors.  The reports from that evaluation are linked below.

Four key lessons jump out from the research:

First, the aid response of separating family members with symptoms of Ebola had the unintended effect of discouraging honest reporting or referrals, such that the total official death count across West Africa was much lower than the true cause of death.

Second, what mattered the most in interrupting transmission was when local populations observed deaths of people they knew which led them to take seriously new changes in behavior (not touching the bodies of people wiht Ebola).  This was the essential change that had to occur.

Third, much of the efforts overall by aid agencies had less of an effect in “bending the curve” of the epidemic than the simple communications by the families and communities affected.

Fourth, while many health professionals died early in the outbreak, attention to protecting them, including provision of protective gowns/gloves and equipment was necessary for further work to be achieved.

Food and Nutrition:

Food aid functioned less as a nutrition intervention and more as an enabler of disease control.  Its main value was making isolation and quarantine viable. Qualitative data indicated that food distributions to isolation and treatment units, facilitated by Food for Peace (FFP), improved the effectiveness of isolation, quarantine, and  response actions at community-based sites of transmission. FFP food distribution played a critical role in supporting isolation and restrictions on mobility,  in response to warnings from implementing partners about food shortages among quarantined communities.

The scale was significant:  through the end of 2014, USAID awarded nearly $35 million in food assistance to WFP through the Office of Food for Peace.  Examples include WFP providing all patients discharged from the Guékédou treatment unit in Guinea with a 60-day food ration on leaving, and continuing general distributions of 45-day rations (rice, oil, pulses, salt) in affected communities.

 The proportion of quarantined households that received food support was roughly similar across all three countries, between 60 and 70 percent.  In Guinea, quarantined families with Ebola cases were more likely to have received food support in urban areas (89%) than in rural areas (53%),  part of a broader urban bias the evaluation flagged in how supplies were targeted. Notably, the reports treat food almost entirely as rations/in-kind support for isolation; there is essentially no analysis of nutritional outcomes per se.

Behavior change

Behavior change was identified as one of the most decisive factors in bending the epidemic curve — arguably more than clinical capacity. The most effective USG-funded activities were nationally-led incident management and coordination, social mobilization, and safe human remains management; as OFDA scaled up community engagement — health education, household isolation, hygiene kits, community outreach, adapting safe burial practices, and involving local leadership — a downward trend in new cases is clearly seen in the data.

The substance of the behavior change effort was straightforward but hard to achieve: much of the social mobilization effort was oriented toward changing simple behaviors such as shaking hands, other physical contact, washing hands, and the handling of infected persons and dead bodies. The key lesson was sequencing — which donors under-prioritized at first.  Whereas  early priorities focused on facility-based responses, case isolation, treatment, and safe burial, donors and NGOs failed to prioritize social mobilization and community-level responses.  Key lesson: social mobilization is the most relevant at the outset of the response.  Aid agencies should hire and deploy anthropologists.

When trusted local actors led it, the payoff was fast:  one Government of Guinea informant noted that within 1–2 months of accelerated social mobilization, the number of prefectures reporting social resistance dropped from 27 to 4.

A cross-cutting theme among evaluators were that while more than 90% of activity monitoring targets were reported as achieved, this reflected only activities and reveals little about actual change in bending the epidemic curve,  a major limitation in analyzing the USG contribution.

These reports, led by the independent evaluation organization IBTCI were available on the USAID Development Experience Clearinghouse until a year ago when the Administration dissoved it.  They are accessible via these links below:

 Synopsis:     https://www.worldhunger.org/wp-content/uploads/2026/06/Synopsis-of-Ebola-West-Africa-Evaluation.pdf

        Coordination:  https://www.worldhunger.org/wp-content/uploads/2026/06/Ebola-Response-Eval-4-Coordination.pdf

        Effectiveness:  https://www.worldhunger.org/wp-content/uploads/2026/06/ebola-ibtci-eval-effectivenes-1.pdf

         Relevance:   https://www.worldhunger.org/wp-content/uploads/2026/06/Ebola-evaluation-Relevance-of-response-3.pdf

        Components:   https://www.worldhunger.org/wp-content/uploads/2026/06/Ebola-evaluation-vol.-2-effectiveness-of-components-2018.pdf

A 2020 review of some selected lessons about the West Africa and DRC Ebola responses, largely non-medical, was commissioned by ALNAP here, focusing on community trust and messaging.

at the same time, ALNAP recommends these infection and control guidelines from WHO.

An earlier article about pandemics and hunger was published by Hunger Notes here.   A Hunger Notes interview about Covid-19 and hunger also addresses these relationships.