The first aim in an emergency is to provide relief interventions. Rapid responses are usually required, especially in situations where normal government channels are weakened or destroyed.
Responses to a crisis situation may be initiated or in some instances, formalized following a needs assessment. Types of assessments include rapid appraisals, nutrition surveys, and morbidity and mortality surveys, which are usually conducted by international relief agencies and NGOs. The macroeconomic assessments, such as crop and food supply assessments are carried out by organizations such as WFP and FAO. The nature and types of information collected usually influence the response to the assessment.
6.1.1 Types of data needed
There is a tendency to collect nutritional status data and mortality data to demonstrate that a problem exists without collecting sufficient information on possible causal factors such as household food security, morbidity patterns or caring practices. This was demonstrated in Baidoa, Somalia, in 1992, where, as in other famine disasters, there were extremely high rates of malnutrition and mortality. The main causes of death were diarrhoea and measles resulting from large population displacements into urban centres and camps. Food relief programmes were implemented fairly rapidly but an appropriate response to health needs by community-based programmes and mass immunisation campaigns took much longer to implement.
An assessment, including an analysis of the causes of malnutrition and conditions in the camps, might have assisted in the development and implementation of appropriate responses and averted some of the deaths. Also, more time should have been spent listening to local health professionals who predicted that outbreaks of disease would occur in the camps if appropriate measures were not taken (African Rights, 1994). One organization's review of its emergency health programme suggested that too much of its effort was put into supplementary feeding when it arrived in Somalia in early 1992. It would have been more prudent to put emphasis on measles vaccination at that time (Richardson, 1995).
Where malnutrition is related to poor access to food, it is necessary to have a sufficient understanding of how people usually obtain their food (that is, the food economy), in order to identify the most appropriate solutions. High rates of malnutrition in general call for food relief. However, emergency interventions should not be limited to addressing immediate needs, they must ensure that the actions lead progressively, and as early as possible, to post-emergency rehabilitation. Relief and rehabilitation measures should be taken in such a way that they strengthen the resilience of households and rural economies.
To understand the local food economy, it is important to examine, first, how people “normally” survive, for example, where do they usually get food. This should include the identification of local support structures for vulnerable members of the community as well as local coping mechanisms. Second, the impact of conflict on people's access to food should be assessed. This should include the determination of the effects of conflict on community support structures and coping mechanisms which arise as a result of the conflict or from natural disasters such as drought or floods that may be exacerbated by the conflict in the country (SCF/UKa, 1995a). This information can then be used to identify an appropriate package that will help strengthen household food security, without eroding traditional support structures and coping mechanisms or posing the risk of dependency.
6.1.2 Quality of data collected
The quality and comparability of surveys is frequently a controversial issue, particularly in nutrition, morbidity and mortality surveys, as is highlighted in Box 12. Following a review of survey methods used in Somalia in 1991–1992, the Centers for Disease Control (CDC) concluded, “While the results of some studies may have influenced policy and programme management decisions, their effects may have been limited by failure to adequately document results and by differences among studies in objectives, design, parameters measured, methods of measurement, definitions and analysis methods” (Boss, Toole and Yip, 1994). Similarly, a review of nutritional surveys conducted in southern Sudan found wide variations in the age/height cut-off points used and reporting styles, making comparisons between surveys difficult (MacAskill, 1993).
Poor quality assessments reduce the ability of relief organizations to effectively target resources to those most in need (Section 6.2). In armed conflict situations this is of concern because poorly targeted resources may be interpreted by the armed factions as a favouring of one side over another, rather than as support to the most needy people regardless of where they live or to which group they belong. This has led to resources being distributed equally between armed factions in order to appear unbiased, rather than to the intended beneficiaries, that is, civilians and children based on their assessed needs.
|BOX 12: The quality of surveys|
In May 1995, a household food security and nutritional status survey was conducted in southern Sudan (WFP-Sudan, 1995). The mid upper arm circumference (MUAC) of a total of 2,481 children under five who attended a clinic were measured at a central point and children were classified as being “adequately nourished”, “moderately” and “severely malnourished or oedemas”. They found that 54 percent of the children were moderately or severely malnourished (oedema not included).
“The nutritional survey shows the situation in Jagei as being worse than in Jikany. The people look better, but in fact are worse… There are a lot of diseases due to protein-energy malnutrition in children. This would imply that milk is not forming any significant role in the composition of the diet, nor is fish (Ibid).”
However, the report states that in Jagei cattle were in abundance. On the general condition of the population, it was reported that they were, “visually fair but the nutritional survey shows ‘very bad’” (Annex 4). The team recommended that food be “despatched without delay”. Information from other sources indicated that there was not a serious problem in the area and large quantities of food were not distributed (Ibid).
The above assessment illustrates several problems: measuring children at a central point introduces a bias as children are not randomly selected; the risk of measurement error when using MUAC is very high; the survey did not explain the categories used to define malnutrition and there have been a variety of cut-offs for MUAC in the past10; the data for each site visited were summarised (Annex 4) and then averaged over all sites without weighting for population size. The report gives no clear reason as to why malnutrition caused disease and assumptions appear to be based on the nutritional status data without reference to available household food security (HHFS) or health information.
Food relief is a common response to emergency situations which are characterised by high rates of malnutrition. It can be provided in different ways, the most general approaches are distribution of general rations and selective feeding programmes, aimed at targeting the most vulnerable groups.
In recent years, however, there has been a slow move away from the concept that food relief is a solution in itself, to a more constructive approach that looks at food relief as part of a wider strategy that aims to improve the household food security and health status of a population, and to strengthen the resilience of households and the rural economy. There was a growing concern that food relief was damaging, as it can replace traditional coping mechanisms and support structures within the community. It was felt that it creates dependency and damages local production (Box 13) and that it failed to address the underlying causes of lack of food within the community.
Food relief was frequently inadequate, particularly in situations where there was insecurity or limited access. It was sometimes badly timed and disruptive. It was given in poor locations and, in some instances, led to an increase in disease. In 1993 in Waat, southern Sudan, food aid distributions attracted a large number of people to a site with inadequate water supplies. Overcrowding and inadequate water and sanitation led to an increase in diarrhoeal disease.
6.2.1 Feeding programmes
Two types of feeding programmes are most commonly established when malnutrition rates in the community are high: The first is therapeutic feeding which aims to rehabilitate severely malnourished children. These children usually require medical care as well as intensive supervised feeding. The second is supplementary feeding programmes (SFPs). These programmes aim to treat moderate malnutrition. These SFPs provide either cooked or dry ration distributions. In some circumstances, SFPs have been used to compensate for an inadequate general ration.
|BOX 13: Selection of appropriate relief foods|
|In Liberia, the preferred cereal is rice. This was initially provided in the ration, but has recently been replaced with bulgur wheat. Bulgur wheat was a relatively unknown cereal and was initially extremely unpopular, it was said that, “It makes the stomach to be running”. There were a number of reasons for the change from rice to bulgur: bulgur wheat was significantly cheaper than rice on the world market; the losses prior to distribution would be reduced because it was a less attractive food; the cereal would be self-targeting, that is, only those who needed it would register for a ration. By removing the competition created by free rice, local rice production would be encouraged. Markets would be supported and the commercial importation of pre-cooked rice which was preferred in the urban areas to the local “country” rice would be fostered. (WFP/Liberia, 1995).|
Both types of programmes have a role to play in emergency situations when there are high rates of malnutrition among children or other population groups. However, when operating feeding programmes, clear programme aims need to be drawn up and the type of programme needs to be well-defined. In addition, the programme should be run by experienced staff.
There is a continued debate over whether supplementary feeding programmes should provide cooked food on a daily basis or a dry ration distribution on a weekly or fortnightly basis. The most common arguments in favour of distribution of cooked food are that the children are actually fed with the desired amount of food, without the risk of spillage or sharing of food by other family members. The weight gained by the malnourished child who is receiving cooked food is satisfactory. On the other hand, the distribution of dry rations is logistically easier and less labour intensive. The food is usually shared with the other family members or part of it may be sold, as a result the desired benefit might not accrue to the malnourished child.
However, the assumptions concerning feeding programmes which distribute cooked food frequently ignore the realities. Attendance at on-site feeding centres is often poor with surveys suggesting that in many programmes less than 50 percent of the malnourished children actually attend the centres (Annex 8). Possible reasons for poor coverage by cooked food feeding programmes, highlighted in one survey conducted by SCF/UK in Somalia, include people's reluctance to walk more than a very short distance to feeding facilities. In the areas for displaced populations, every small settlement wanted their own centre which would provide some employment to the community. This made people reluctant to make use of existing facilities, preferring to wait for their own centre. Many mothers said they were too busy to spend time in the centre with the malnourished child when they have other children to care for, and most mothers stated that they would prefer a dry ration to wet feeding (SCF/UK, 1993). In Liberia, poor beneficiary coverage at feeding programmes with cooked food was reported. This was because most families did not know about the feeding programme, in other words, effective community outreach was lacking (WFP/Liberia, 1995).
The quality and management of feeding programmes is sometimes poor11. A poorly managed programme may provide no benefits for malnourished children and in some instances, may contribute to an increase in disease. Overcrowded feeding centres, lacking basic sanitation and hygiene, with inadequate water supplies, poorly mixed food which is not energy dense, may lead to the spread of disease and insufficient food intakes by the malnourished children.
In too many situations, children are considered separately from the family and feeding programmes are established without considering other options that may improve children's immediate and long-term access to food. Other options include improving household food security; reducing women's workload through improving access to water, firewood, etc. allowing them more time for caring for children; as well as supporting improved caring practices and improved use of health services.
6.2.2 New approaches to adequate responses to malnutrition
In some countries, there has been a shift from purely “re-active” programming, that is, a response to high rates of malnutrition and mortality, to a combination of re-active and preventive responses. These approaches maintain a capacity to respond to an emergency, but at the same time try to address some of the underlying causes of malnutrition and mortality existing within the society. The step to include preventive planning (that is, interventions that avert malnutrition in children) within interventions in response to armed conflict, acknowledges that many people often live in a such a state for many years, and in some cases over several generations.
The underlying causes of malnutrition may have existed before the conflict and the conflict may exacerbate the poor nutritional situation of children. For example, the habit of giving water to a baby in the first few weeks after birth is not harmful if the water is clean but this practice will be dangerous when the water is dirty because the protected water supplies have been destroyed. Some causes of malnutrition stem directly from the conflict. For instance, there is insufficient food due to crops being destroyed or looted. Some factors causing malnutrition may even contribute to the start of a conflict. For example, if there is an unequal distribution of resources and services within the country. If malnutrition within conflict is to be averted, each of the types of causes noted above will need to be addressed. The first two types of causes can to a greater or lesser extent be addressed within each conflict. The unequal distribution of resources and services will probably only be finally resolved when the conflict itself ends.
In order to address the causes of malnutrition within a conflict, household food security, health, caring practices and vulnerability need to be considered and addressed as appropriate. Southern Sudan is one of the areas where there has been such a move towards utilising food relief as part of a wider strategy aimed at supporting communities' household food security mechanisms, thus making a more lasting impact on health and nutrition (see Box 14). Food aid can contribute to household food security in several ways. It may provide an additional source of food for a population which then makes other inputs effective. For example, it may enable the local population to have sufficient energy to plant larger farms once seeds and tools are distributed. Food aid may support the development of markets and enable the population to exchange relief food for other foods and non-food items that are essential (e.g., tools, etc.). By providing an additional source of food it may help the households to cover expenditures on administration taxes, including military taxes (MacAskill, 1994). More importantly, if provided in a timely fashion, food aid may reduce displacement and prevent people from losing their livelihoods, or, it may enable people who are displaced to return to their home areas and farms. In addition, food assistance can help reduce inter-tribal tensions or looting which tend to increase when resources are scarce.
Conflict frequently denies people their basic rights through the gradual or rapid erosion of their livelihoods and capacity to care for themselves. This may exacerbate the discrepancies between people within the country, that is, those living in areas of conflict and those living in areas of peace. Over time, the peace process may become far more complicated as the underlying cause of many conflicts, unequal distribution of wealth and power, is increased during the conflict.
The level of malnutrition or needs in the community are not the only factors which stimulate responses during complex emergencies. Access to food assistance or other resources is frequently influenced by a number of conditions described below. Ultimately, the response is dependant on a combination of the following: donor commitments, political interest and public concern. The communications media often makes a major contribution to increasing public awareness of the negative impact of conflict on the nutritional situation of children.
|BOX 14: Re-active and preventive programming during conflicts - southern Sudan|
In southern Sudan, the assistance programme has shifted from one that responded to crises with food relief to one intending to develop an understanding of how people survive by looking at the food economy of households. This approach has led to short term interventions being linked with mid and long-term interventions aimed at achieving the Operation Lifeline Sudan (OLS) goal of helping the people of southern Sudan during the current conflict through measures to support their survival, protection and development12.
The programme focuses on household food security (HHFS) through support to livestock production, fishing, agriculture, health, education and capacity building. Food relief is used both as an emergency response and in programmes aimed at strengthening HHFS.
The livestock programme has concentrated on rinderpest vaccination13 and approximately 5.1 million vaccinations have been done since 1989. The programme is now training Community Animal Health Workers (CAHWs) to treat other animal diseases and developing a cost recovery programme for some basic drugs/treatments.
Fish is an extremely important source of food. It is usually consumed after the harvest in the dry season. This allows the grain to be stored until later in the year when part of the family moves back to the village away from the swamps to prepare the land for planting. At times of insecurity when people hide in the toic, fish may be the main source of food along with water lily. The fishing programme has initially concentrated on the distribution of hooks and fishing line, some are given free and others are distributed via community or bush shops where they are exchanged for dried fish. The fish is then transported by plane to areas of need, it is sent to feeding programmes, hospitals and camps.
The agriculture programme initially started with the distribution of seeds and tools and is now supporting the local production of seeds. Vegetable seeds were introduced to improve the quality of the diet. Technologies for oil processing, soap making, improved storage and fuel wood development were also promoted.
In all programmes training is becoming an important component and curricula are being developed for teachers, health workers, agricultural extensionists and community animal health workers.
Logistical difficulties can limit the outreach of an operation, including the lack of availability of transport and the type of transport available. For instance, cereals if appropriately packaged, can be air dropped but it is not possible to air drop tins of oil. In the early half of 1993, insufficient air transport meant that relief needs in the ‘hunger triangle’ in southern Sudan could not be met. Also, accessibility may be limited. Many places cannot be reached during the rainy season, other places may be inaccessible due to insecurity and the level of conflict. The availability of proper storage facilities will depend on both the level of resources at hand and security. There is no point in storing large quantities of relief items in an area that is insecure.
The level of insecurity will have a major impact on the type of relief programme established. Some relief items may be less secure than others. Certain types of relief may lead to an increase in insecurity or insecurity may prevent relief programmes from being established (Box 15).
|BOX 15: Security and relief interventions|
|Relief - leading to an increase in insecurity|
|A nutrition survey conducted in Bardhere in Somalia in November 1995, found that 22.1 percent of the population under 5 years of age was either moderately or severely malnourished (wasted) (AICF, 1995). This was a result of loss of access to the markets in Baidoa following the attack on Baidoa by one of the war lords, and a poor Gu harvest in August and September (less than 50 percent of pre-war levels). WFP responded by taking in 200 mt of food relief, however this was looted (WFP, 1995). Non-governmental organizations (NGOs) were also put under pressure by local staff to establish feeding programmes and, following the nutrition assessment, expectations of food relief were raised. However, the increase in expectations also led to an increase in insecurity and international staff had to leave the town for several days.|
|Insecurity preventing relief|
|In September 1994, following an outbreak of fighting around Gbarnga in Liberia, the International Committee of the Red Cross (ICRC) and other NGOs working in the rebel-held area had all their equipment and vehicles looted and they had to leave until security improved in 1995. When the NGOs finally returned to the area in April and May 1995, malnutrition had increased dramatically to 56.2 percent (SCF/UK, 1995b).|
|Some relief items are more insecure than others|
|In 1992, in both Mogadishu and Baidoa, kitchens were established by ICRC as a method of distributing the general ration, this was self-targeting and was somewhat safer for malnourished adults who would have been at risk of attack if the food had been distributed as a dry ration.|
|Some foods are more valuable than others in Somalia. The items in the general ration are extremely marketable. The supplementary food (UNIMIX) for small children was much less desired. In July 1995, UNICEF staff reported that it was selling in the market for US$4 for a 25kg bag.|
The political and military situation is an important determinant of relief operations. In Liberia, the Economic Community Monitoring Group (ECOMOG) and the Economic Community of West African States (ECOWAS) peacekeeping force, supported by the UN, put a blockade on the rebel-held areas in 1993 which prevented any relief from entering. During this period a relief convoy was bombed and all relief stopped for several months. When agencies finally gained access to the rebel-held areas, malnutrition rates had again soared.
In November 1995, during the conflict in southern Sudan, factions based in Ayod and Waat would not allow relief flights into the places held by the other faction. In this area, there was much fighting and displacement of the civilian population, which started around the time of the harvest. Also that month, no relief flights into the south from Kenya were permitted. Flights were still not being authorized in December 1995 despite the fact that a large number of NGO staff were stranded in the field.
Finally, a narrow perception in which a food shortage is seen as the only cause of malnutrition can lead to an overemphasis on food relief to the exclusion of other interventions. All of these factors can either prevent or delay the delivery of appropriate relief to civilians and add to the deterioration of the nutritional situation of the population and of children in particular.