Civilian adults and children make up ninety percent of war victims (UNDP, 1995). According to UNICEF's State of the World's Children, in the conflicts of the past decade two million children have been killed, four to five million disabled, twelve million made homeless, more than one million orphaned or separated from their parents and ten million have been psychologically traumatised (UNICEF, 1996). In Liberia, WFP estimated that 300,000 people have died as a result of the conflict, illustrated in Box 1. In southern Sudan, it was estimated that there were 220,000 excess deaths in 1993 (OLS, 1993), and in Rwanda an estimated 5–800,000 people were killed within a period of three months in 1994 as a result of civil war and genocide (Joint Evaluation of Emergency Assistance to Rwanda, 1995).
| BOX 1 |
| Effect of conflict on the population in Liberia |
 |
| Approximately 300,000 people are estimated to have died as a result of conflict due to violence and hunger. An additional 800,000 people are living as refugees outside Liberia. The dark bars show the expected population in 1996 in Liberia based on the 1984 census and an expected 3.3 percent annual growth rate if there had been no conflict. The stripped bars show the estimated population of Liberia both inside and outside the country once the victims of war have been subtracted. As can be seen, the population of Liberia shows a decline once all refugees outside the country are taken into consideration. |
Many conflict situations are characterized by widespread malnutrition and death among vulnerable groups (i.e. children, women, and the elderly). In Liberia, prior to the conflict, acute malnutrition was reported to be 1.6 percent, but since the start of the conflict in December 1989, malnutrition levels of 10–50 percent have been reported. The increases in malnutrition followed periodic upsurges in the scale of conflict and displacement of segments of the population (Box 2).
| BOX 2: |
| Nutritional status data before and during conflict |
 |
| Information on the nutritional status of children in Liberia before the war is limited. In 1976, a national nutrition survey reported that 1.6 percent of children were wasted and 18 percent of children were stunted, i.e. acute malnutrition (wasting) was not a serious problem before the war in Liberia. Among children who were malnourished, kwashiorkor (oedema) was relatively common; in 1984, 90 percent of all cases of malnutrition admitted into Phoebe Hospital, Gbarnga, were identified as kwashiorkor. Other nutritional surveys conducted before 1989, with the exception of one, have reported similar result.1 The nutritional surveys were done in different regions in Liberia at different times, but they highlight the general deterioration in nutritional status that has resulted from the conflict as compared to pre-war data. In the 1995 study, 37.1 percent of the children had kwashiorkor and 19.1 percent were marasmic (SCF/UK, 1995b). |
Similar trends in the determination of nutritional status have been found in Somalia, Sudan and many other countries. They are precipitated by the loss of access to food through displacement, insecurity, looting and military taxation, as well as the impact of disease in an environment in which health services are reduced or destroyed, the caring structures have broken down within society, and trauma has increased.
The pre-conflict socioeconomic conditions of a country, reflected in terms of the Gross National Product (GNP), health standards, educational levels, and access to food also substantially determine the nutritional outcome of the conflicts on children. As can be seen in Table 1, the mortality rate for children under 5 years of age in the former Yugoslavia in 1990 was 22/1,000 live births; in Iraq it was 143/1,000 live births, in Liberia it had been 200/1,000 live births and in Somalia it was 211/1,000 live births. Mortality rates are inversely related to female literacy, and positively related to the percentage of the daily per caput food requirement that people on average consume as well as the GNP. While standards prior to war do not prevent malnutrition during a conflict, they will influence the nutritional impact of the conflict. For example, the nutritional status of children has been positively correlated with female literacy in many countries and many of the benefits of female literacy for nutritional status will continue even during conflict (UNICEF, 1996).
Table 1: Comparison of four countries in conflict
| Country | CMR (<5 years age (1991) | Female literacy (%) (1990) | GNP US$ (1990) | Calorie supply % (1988–90)* |
| (Former) Yugoslavia | 22 | 88 | 3 060 | 140 |
| Iraq | 143 | 49 | 2 340+ | 128 |
| Liberia | 200 | 29 | 450+ | 98 |
| Somalia | 211 | 14 | 150 | 81 |
+ Data refer to years other than indicated in heading.
* Daily per caput calorie supply as a percentage of requirement.
Source: UNICEF State of the World's children (1993).
Reports on malnutrition in Bosnia and Herzegovina (former Yugoslavia) and Iraq show that although the situation has deteriorated and malnutrition has increased, levels of undernutrition have not yet reached the shockingly high levels seen in Africa, such as in Baidoa, Somalia, in 1992, or in the “hunger triangle” - the area including Waat, Ayod and Kongor - of southern Sudan in 1993, or in the refugee camps in Goma, Zaire, in 1994, or in parts of Liberia in 1995.
Apart from growth failure and weight loss, as presented in Box 2, malnutrition may lead to diseases and even disability as a result of lack of consumption of micronutrients, which occurs specifically in displaced and refugee populations which are depending on food assistance (Annex 2). In a survey in a long standing Somali refugee camp, for example, where nutritional and general health status was considered satisfactory and stable, a high prevalence of anaemia due to nutritional deficiencies was found (Dunbar, 1984). Other nutrition-related deficiency diseases were reported, such as scurvy (vitamin C deficiency) in Sudan in 1991, and pellagra (niacin deficiency) in Mozambique in 1992 (Toole and Waldman, 1993). Vitamin A deficiency is another common problem in emergency and conflict situations, resulting from the lack of consumption of vitamin A rich foods. This deficiency disease is particularly hazardous since it may result in permanent blindness as well as aggravating diseases, such as measles (Toole et. al., 1989). Micronutrient deficiencies are usually associated with poverty and situations where people have become destitute.
Both chronic and acute malnutrition will reduce children's resistance to common endemic diseases and thus increase morbidity, physical disability, and mortality. In addition to affecting growth and development, malnutrition influences children's ability to be educated. All of these factors have a serious negative impact on their future social and economic wellbeing.
Malnutrition and death among children and their families within armed conflict situations can be directly traced back to inadequate dietary intake and disease. There is a strong link between severe malnutrition and child mortality, but in famine and armed conflict not only the severely malnourished die, the majority of children who die are not severely malnourished (Young & Jaspers, 1995). Death often occurs because of a health crisis when populations are displaced and are exposed to an unhealthy environment, often with overcrowding and a subsequent increase in infectious diseases such as diarrhoea and measles.
At the national level, a re-allocation of budget resources, as is shown in Box 3, may cause severe constraints for households and affect their capacity to obtain access to food and health services, because government resources are being spent on warfare instead of maintenance of health and sanitation services, education or food production. This will severely hamper a family's ability to provide appropriate food and health care for their children. Where government services have broken down, these constraints will be even more severe.
| BOX 3: Budget expenditures on war and health |
| During the civil war in the north of Ethiopia, following the annexation of Eritrea in 1974, the defense budget, according to official Ethiopian statistics, increased from 11.2 percent in 1974 to 36.5 percent in 1990/1991 of the national budget. The proportion of the national budget allocated to health, on the other hand, declined from 6.1 percent in 1973/74 to 3.5 percent in 1985/86 and 3.2 percent in 1990/91 in Ethiopia. In Eritrea, the per caput spending on health facilities declined even more, largely due to the Government of Ethiopia's decision to close many health facilities in that region for political reasons (Kloos, 1992). |
At the district or institutional level, problems are likely to arise following destruction of the health and sanitation infrastructure and the loss of personnel who have been killed or fled. Similarly, the support to food production may have been undermined through, for example, the breakdown of agricultural extension services and input distributions, including subsidies. In the former Yugoslavia, the destruction of water and hydro-electricity plants caused serious constraints in the winter, where people suffered from lack of heating, lack of cooking fuel and reduced access to clean water.
The underlying causes for malnutrition at household level are: inadequate household food security; an unhealthy environment and insufficient access to health services; and inadequate maternal and child care (Figure 1).
Figure 1: Causes of Malnutrition and Death
Adapted from UNICEF conceptual framework.
In order “… to achieve a satisfactory nutritional status particularly of children, it is essential to ensure continued access to sufficient supplies of a variety of safe foods at affordable prices and of safe drinking water so that all people, especially the poor and vulnerable groups can have nutritionally adequate and safe diets” (FAO, 1992).
For children, nutritional status depends not only on the food available within the household, but also on the priorities of the family, knowledge of available foods and how to make the best use of these foods within the family, feeding practices (specifically breast-feeding and weaning practices), caring practices and proper methods of distribution of food within the family. In addition, the health environment and availability of health services will also affect the nutritional status of the child.
To assess the impact of armed conflict on the nutritional situation of children, an understanding of how households attempt to survive such periods is required. This involves both an understanding of the major factors causing people to become vulnerable to malnutrition in conflict situations and people's coping mechanisms to overcome the crisis.
2.3.1 Vulnerability
The concept of vulnerability refers to the long existing factors which affect the ability of a community or a household to respond to the events taking place during a conflict. They may be understood in terms of physical deprivation and material poverty. How people in the society view themselves and their ability to influence their environment also affects their degree of vulnerability. Some societies may be more susceptible in conflicts. For instance, the way a society is organized can affect its ability to cope with such situations.
Armed conflict usually gives rise to a change or an increase in needs. In this case, “needs” refers to the immediate requirements for survival or recovery from the calamities. The distinction between vulnerability and needs is relevant for several reasons: vulnerabilities generally precede disasters, contribute to their severity, impede effective disaster response and may continue afterwards. Needs, on the other hand, often arise out of the crisis itself, and are relatively short-term. Most disaster relief efforts tend to concentrate on meeting immediate needs, rather than on addressing and lessening vulnerabilities (Anderson & Woodrow, 1989).
In human nutrition, vulnerability is often expressed in terms of those who are “at risk” of malnutrition. Physiologically vulnerable groups are well-defined and include children under five years of age, pregnant and lactating women, and the elderly. In addition, in relief settings, agencies generally define people as vulnerable according to whether or not they are displaced; whether a person is a “medical case”(i.e. under treatment because of disease, disability, or severe malnutrition); whether they are emergency cases (i.e. refugees, displaced and homeless people) or are socially disadvantaged cases (e.g. elderly people, single women, orphans and unaccompanied minors) (Pankhurst, 1984).
This concept of vulnerability holds true in all societies around the world. What creates the difference between societies regarding the risk of malnutrition among those groups, or even the whole population are the livelihoods (i.e. opportunities to be employed, to produce, to earn) and the environmental health (i.e. water, sanitation, climate) (Mourey, 1994). It will be obvious that increased vulnerability at all levels, of all people, will have negative implications for child care and child nutrition. The effects of displacement and child participation in conflict specifically, are described to illustrate how increased vulnerability may lead to an increased risk for malnutrition in children.
Displacement
Widespread displacement is often a major effect of conflict, causing large population groups to become vulnerable to both disease and malnutrition as well as social disruption. In Liberia, it is estimated that at one time or another 80 percent of the population has been displaced. In Afghanistan, WFP estimates that approximately 3 million people are refugees or displaced, out of a total population of 17 million (1995). Displacement can be to another country in which case people are viewed as refugees2. Within their own country, people can be displaced and live in camps or urban centres, these may be within their home area or outside. In addition, there may be returnees, refugees who on their own or with the support of the United Nations High Commission for Refugees (UNHCR) are repatriated to their country3 but not necessarily to their original home areas.
The impact of displacement on availability and access to food, nutritional status and health depends on many factors. Frequent displacement reduces people's ability to support themselves and can increase the trauma and stress within the community which may adversely affect the caring practices of children (Box 4).
| BOX 4: Rose's story |
When the war spread throughout Liberia, Rose went into the bush and stayed there during May and June 1990. Other people stayed there longer but the soldiers were looking for nurses to treat them and Rose, a nurse, was forced to work treating the soldiers. At least she had access to food because of this. In 1991, Médecins sans Frontières-France (MSF-F) established health and nutrition programmes in the Margibi area and conditions improved. In 1992, the MSF-F programme was phased out and Save the Children Fund-United Kingdom (SCF-UK) took over the health programme. By this time people were again self-sufficient in food and in October/November were beginning to harvest. In October 1992, “Operation Octopus”4 started and there was a large influx of people into the area from Bomi Hills. The influx was due to the conflict between the United Liberation Movement for Democracy in Liberia (ULIMO) and the National Patriotic Front of Liberia (NPFL). People from Bomi Hills were sent behind the line by the NPFL to Margibi. People were forced to go there to increase the number of people living in the NPFL area even though there was no food. Because of the influx of people, food stocks in the area ran out earlier than expected and by the end of the year people had started to eat palm cabbage and roots. Those people who were not from the area did not know the bushes and wild foods that could be collected and eaten. Rose, along with many others, ran back to the bush and stayed there till March 1993. People were eating mainly cassava roots and palm cabbage with potato greens and cassava greens. The leaves of the sweet potato and cassava plants are popular foods in Liberia. Some also are bush yam and sweet potato roots. Palm butter and oil were scarce. Men did not travel far to look for palm nuts because of the insecurity. When they did collect palm nuts they were often stolen from them. “Some people ate mushrooms found in the high forest (i.e. virgin forest), some of the mushrooms were known and people experimented with others by first giving them to animals to see what happened. Some people died eating the mushrooms,“It made them very drunk and killed them”. Other foods eaten included green leaves called Barbor John (an old woman had told Rose that it had been eaten before and that it tasted nice). In 1993, there was a lot of “swelling” (oedema), it was seen first in children but gradually it extended to the adults5. In September 1994, at the time for harvesting, there was an increase in fighting in the area leading again to high rates of malnutrition in 1995. Rose felt that this year (1995) the situation was much worse because “In previous years when people fled they returned later to find their houses still intact but last September (1994) more houses were burned or destroyed… People are also more depressed. They were trying to settle themselves and re-establish their farms and the harvest was due soon, they had worked so hard to bring themselves up and then the Gbarnga war came and houses were burnt”. |
If people are displaced for long periods, they may establish farms and businesses in the new community. Alternatively, they may become more dependant on relief items, a concern frequently voiced by both displaced people and organizations working with them. People living in well-established camps often have better services than the resident population or the populations displaced into a community rather than camps (Box 5).
| BOX 5: Mortality and health status among displaced and resident populations of Kabul, Afghanistan |
In 1993, a comparison of households was made in an attempt to determine the effects of the civil war on the population's health and mortality. One group of households was identified as “displaced” indicating that they were living in camps/schools, with a mean of fifteen people sharing one room. The other group were “residents” living in Kabul, with an average of two persons having one room at their disposal. In addition, residents were divided into short-term residents (people living less than ten months in their current housing) and long-term residents (living longer than ten months in their current housing), because it was found that even the resident population had to move regularly. In each of the groups, approximately three hundred households were interviewed. War trauma, gunshots or rocket explosions were the most common causes of death in both the displaced and the resident populations; mortality rates were 33 percent and 43 percent, respectively. This was due to the ongoing fighting at the time. However, when the data for children under five years were separated from the total study population, potentially preventable diseases such as diarrhoea, measles, or acute respiratory tract infections caused 68 percent of the deaths in displaced children, and 50 percent of the deaths in resident children. Malnutrition, measured by mid- upper-arm circumference (MUAC) was moderate: 7 percent in displaced and 5 percent in resident children. Among children, the highest mortality rates were found among short-term residents, they were 2.6/10,000/day compared to 1.9/10,000/day in displaced children and 0.6/10,000/day among the children of long-term residents. Although malnutrition was not substantially higher than among long-term resident children, the children in displaced households and short-term residents were at an increased risk of death, compared to long-term residents, with the young children in the short-term resident group being at highest risk. The findings suggest that the most vulnerable people in Kabul were not only the people who were displaced, but short-term residents as well. The study concluded that the provision of basic public health measures would lead to a decrease in mortality among both displaced and resident populations and that organizations should not focus exclusively on displaced persons during humanitarian relief operations (Bradford, 1994). |
A large influx of displaced people can put pressures on the infrastructure, health and sanitation facilities, as well as the food resources of the resident community, thus, increasing the vulnerability of the latter group. This causes the social relations between displaced and resident populations to suffer. Whether the displaced people are familiar with the area where they seek refuge will influence their capacity to adapt and to re-establish their ability to ensure that sufficient food is available for all household members. Pastoralists displaced to agricultural areas or urban people displaced to rural areas require additional support to re-establish themselves. Last but not least, access and security within the area of displacement may be problematic. Populations may be inaccessible for relief organizations. This may be because access has been denied by one of the parties to the conflict and there may be insecurity. Infrastructure, such as roads and airports, may have been badly damaged or the access routes may only be usable during dry weather.
Child participation in conflict
During normal times in virtually all countries, sub-groups of the population may be socially and economically disadvantaged, having less status and power within society. In conflict situations, this type of discrimination is frequently exacerbated and this increases the vulnerability of children belonging to such a sub-group. Social and economic injustice motivates both adults and children to take up arms, sometimes with the vision of realizing changes in the long-term, but often simply to obtain food for the day in an attempt to assure survival. Joining an armed group sometimes appears to be the better of the bad alternatives for refugees, the internally displaced, the homeless, the orphaned, and especially the fearful (Goodwinn-Gill & Cohn, 1994).
There is the general assumption that child soldiers are not at risk of malnutrition. In Liberia, it was said that since child soldiers had weapons, they were able to acquire food. They were often connected to a commander who looked after them and they ran errands for him. The child soldiers were usually fed as they were very close to the “big people”. Obviously, these children can be extremely vulnerable to malnutrition when the conflict is going badly. In Liberia, “Child soldiers are well-treated when they are needed - to protect the leaders, or in the front line - but when they are not needed they are left on their own. After Operation Octopus in Liberia, many children were found starving and mad in the swamps” (UNICEF, 1994).
There is little information available on the nutritional status of child soldiers who are often as young as eight or nine years old. There have been efforts to encourage armies to ensure that children under the age of fifteen years are not recruited. However, there have been several instances where such minors, usually boys between seven and eighteen years of age, have been found severely emaciated either living together in camps or schools or walking through the bush to refugee camps outside the country, as is illustrated in Box 6 for a situation in Sudan.
These children have left home for a number of reasons. Some left because of the war and the physical threat of violence. In 1986–89 in southern Sudan, many young men and boys fled their homes in Bahr El Ghazal and the western upper Nile and went to the refugee camps in Ethiopia because there were regular reports of the government militia attacking, looting and destroying villages. Some of the boys joined the SPLA and others stayed in the camps and attended school. Others left home because of famine, or in search of education. Still others went to join the military.
Without protection, these children are extremely vulnerable to political expediencies because of their young age, and their suggestibility. This is why they may be exploited for political purposes. If the children are not at risk politically, they may still suffer from poor caring practices and lack of social support.
| BOX 6: The youth in Lafon, south Sudan |
In July 1994, four distinct groups of people could be found in Lafon: the local population, displaced people, a military camp and a group of displaced children and young adults. From the latter group many were initially recruited by a commander of one of the military factions, and brought in three groups of 200 to a military camp in Magire. Some of the youngsters were told that they would go to school, others left their homes because of hunger and food shortages in the family. On the journey to Magire, which took one to two months by foot, the children and young adults witnessed many horrors: they were ambushed by another faction, saw fighting and killing on route, went hungry and ate wild leaves and grasses on the journey and saw friends die of hunger. In Magire, they received food but it was insufficient. After two to three months, as the children became sick and malnourished they were slowly released and sent to Lafon, a relief point. In Lafon, relief food was initially provided to all groups of people, local and displaced, except the military camp. However, following a good harvest, the local population was excluded and only the displaced people, including the group of minors and young adults, received food rations. Some UN and NGO staff felt strongly that when the youth were taken from Magire to Lafon, they were kept in a separate camp in order to attract food to Lafon for use by the military. Following concerns that the group of minors and young adults from Magire were not improving their nutritional situation as they should, and reports that food was being looted from them by the military, an NGO arranged to watch the distribution of food to minors on a weekly basis and the minors began to improve. However, by the end of November 1994 the situation had deteriorated dramatically. The security in Lafon was poor and the political situation was tense, particularly following a change in the local commander. The military continued to loot food from the group of displaced minors and young adults. A large number of them were found severely malnourished, many were lying in a filthy room with faeces all around the compound, barely able to move, most had diarrhoea and skin lesions. Seventy-five of the youth, between the ages of 15–25 years, were all identified as severely emaciated and malnourished; all were severely anaemic; and 50 percent reported bloody diarrhoea. (UNICEF/OLS, 1995). At that stage, an emergency hospital was established and the 75 severely malnourished children and young adults were admitted, of whom three were in a critical condition. Another 47 of the group of displaced youth were reported to have died between July and December 1994. The remaining youth (between 12–15 years) and a 5 year old child were admitted to a programme of intensive feeding and care. A re-unification programme that had already been initiated was accelerated and 450 children were flown home in December. |
2.3.2 Coping strategies
Coping strategies are methods which people adopt to protect their resource base and to improve their access to food in difficult years when there is a shortfall in the availability of food. The long-term objective of the household is to maintain its economic and social viability after the crisis has passed. There are several ways in which households attempt to improve their access to food and to protect their livelihoods during crises (e.g. drought, famine, conflict) (Corbett, 1988). The first is through insurance mechanisms - households attempt to increase their access to extraordinary resources, such as alternative sources of food or income by collecting wild foods, obtaining remittances from relatives abroad, working for others in the locality or farther away, and reducing their consumption. These have a relatively low cost for the long-term livelihood of the household and may be mechanisms that are used regularly during “the hunger gap”. The second method is the disposal of productive assets - this occurs when the food deficit is much more severe and this erodes the resource base of the household. A third scenario is destitution - if all assets are disposed of, and the family has no access to resources, the family members will be weakened by hunger and will not be able to work on other people's farms because the work is not available as everybody is in the same situation.
In deciding which tactics to employ, the economic and the social costs of each action are carefully weighed. The three levels of household response - minimizing risk, absorbing risk, and taking risk - correspond to the increasing impact of famine and also represent increasing vulnerability to economic and social failure. When coping with famine which is not related to conflict, there is usually a pre-crisis stage, during which people are aware of the crisis to come, and during which time they can take preventive measures. Households coping with war try first of all to deal with direct risks, i.e. endangered peoples' lives and possessions.
In Rwanda, mass violence resulted in mass population displacements in 1994 in a time span of just a few days. This resulted in deadly conditions due to massive outbreaks of cholera and then dysentery in what later became the camps in Goma and Bukavu in Zaire. In Bosnia-Herzegovina, one of the initial coping mechanisms was the flight of women and children, seeking refuge elsewhere, whereas the men stayed behind, either to join the Bosnian armed forces, or to protect their houses and community (Curtis, 1995). Other responses in urban centres in Bosnia included: the enlargement of household size as the formation of extended families allows people to pool resources and to share the tasks of caring for children; the sale of commodities, mostly durable consumer's goods, to replace the lost income following loss of prewar employment; food smuggling; migration for work; searching for credit; using long-term productive assets, such as savings and stealing, begging and prostitution.
However, when violence within conflict is extreme many of the economic and social networks that households normally employ during times of crisis may be shattered. In these cases, coping strategies may differ from those listed above because the community is no longer available as a safety net for the household. For example, during the war in Mozambique the rural population in large parts of the country led a rather nomadic life. In the areas bordering Zambia and Tanzania, many people sought refuge across the border in the camps established there. Many people did not stay permanently in the camps but travelled back and forth over the border on a daily basis, even during serious periods of conflict. The camps were used as a comparatively safe shelter where people would spend the night, whereas during the day time they would return to Mozambique to work on their fields (De Winter, 1995).
Coping strategies vary according to cultural habits, knowledge and beliefs, for instance, the need to adapt to risk during famine can lead to young children missing meals in some cultures, while in others (for example, Bosnia) this was considered as a last resort, mothers preferred to see everyone else go without meals before the children's intake was reduced (Curtis, 1995).
There has been very little work done on the impact of coping strategies on children either in famine or in conflict situations. Coping strategies are geared towards protecting household livelihoods, that is, the long-term security of both children and other family members. However, many such strategies may also be deleterious to children's immediate health needs as they often entail a reduction in both the time spent on caring for children and in food intake in the short-term. Yet, the protection of household livelihoods is equally important for children's growth and development over the longer term.
