The ability to feed oneself and one's family adequately is a human right. The right to adequate food is realized "when every man, woman and child, alone or in community with others, have physical and economic access at all times to adequate food or means for its procurement". This implies the "availability of food in a quantity and quality sufficient to satisfy the dietary needs of individuals, free from adverse substances, and acceptable within a given culture", and the "accessibility of such food in ways that are sustainable and that do not interfere with the enjoyment of other human rights".[1]
Violation of this right, as often occurs in situations of conflict and crisis, can lead not only to a loss of dignity, but also to increased vulnerability to food and nutrition insecurity and other abuses. Examples of violation include: blockades of food supplies; destruction of economic and social infrastructure, food crops and stores; appropriation of assets; discriminatory employment practices; and refusal to grant passage for humanitarian assistance.
The 2004 revision of the Sphere Handbook (Sphere Project, 2004) provides minimum standards for food security, nutrition and food aid. These are a practical expression of the right to food, and reflect the core content of that right, contributing to its fulfilment around the world.
The right to adequate food is more than the right to be fed. Sovereign States and the international community are obliged to respect, protect and fulfil this right by supporting individuals', households' and communities' capacities and efforts to achieve sustainable food security. This long-term approach is reflected in one of the commitments of the World Food Summit Plan of Action (see Box 1).
Box 1: World Food Summit: Commitment Five
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The World Food Summit Plan of Action committed States to: ".... Endeavour to prevent and be prepared for natural disaster and man-made emergencies and to meet transitory and emergency food requirements in ways that encourage recovery, rehabilitation, development and a capacity to satisfy future needs." |
Source: FAO, 1996b.
Realization of the right to food necessitates a shift away from a welfare approach to humanitarian assistance towards an approach that builds understanding of why the right to food is being violated. Such an understanding can lead to the identification of different stakeholders' obligations and responsibilities at different points in a crisis situation, and to awareness of the need to promote accountability of all stakeholders.
Box 2: Livelihoods
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A livelihood "comprises the capabilities, assets (stores, resources, claims, and access) and activities required for a means of living; a livelihood is sustainable which can cope with and recover from stress and shocks, maintain or enhance its capabilities and assets, and provide sustainable livelihood opportunities for the next generation." |
Source: Chambers and Conway, 1992.
A household's assets include:
the natural resources (land, water, wildlife, forests, flora) that it has access to and/or control over;
human capacity in terms of labour power, health and nutritional status, skills and knowledge;
social assets, which reflect the claims or reciprocity among households, neighbours, kin, the community and the State; and
economic assets, which include productive resources and infrastructure (tools, machinery, livestock, buildings, transport), as well as stores (savings, liquid assets stocks, small-stock, jewellery).
Box 3: A case study from Somalia: pastoralist livelihoods
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The pastoralist production system in Somalia has developed in a context where the natural resource base comprises extensive arid lands. In addition, climatic unreliability and soil type cause spatial and temporal variations in the availability of crucial natural resources, such as browse and pasture. The main productive asset is livestock of varying species mix and herd composition. Mobility is the main strategy for managing livestock assets. Mobility in turn depends on the social structure, which is based on a strong territorial clan system that mediates access to grazing resources. Extensive knowledge about environmental management, and livestock husbandry skills are part of the human capacity resource base, and are used to make decisions based on multiple choices aimed at achieving a favourable livelihood outcome. The major determinants of these choices are rainfall, range resource conditions and access, animal disease, marketing options and political insecurity. |
Source: Adapted from FSAU Somalia. October 2001.
Box 3 describes how pastoralist groups in Somalia combine their various assets, and illustrates how important it is to interpret a household's food security strategies in the context of its overall decisions and strategies aimed at meeting a variety of needs. Food is only one of a range of interrelated needs that influence household decision-making and choice of activities. Households balance competing interests and associated risks in order to subsist in the short and longer terms. For example, people may choose to go hungry to preserve their assets and future livelihoods. Children may be withdrawn from school in order to earn income, herd animals or cultivate the family's fields. Food may be withheld from some family members in favour of others who may be considered more important for the future of the family as a whole. The ways in which a household can manage its assets to achieve positive livelihood outcomes are also influenced by institutional and policy processes at the meso and macro levels.
Livelihoods involve multiple strategies, and are dynamic in that they respond to external and internal influences. Negative external influences are referred to as "shocks", which are brought about by exposure to different types of hazards. In crisis situations, it is important to identify the potential short- and long-term risks to different livelihood systems, and to understand how an ensuing shock would affect nutritional well-being. Shocks can be categorized as:
environmental: drought, floods, hurricanes, landslides, pollution, fire;
social: breakdown of State public health and welfare services (e.g. safety net provision), collapse of informal/community/kinship support mechanisms;
economic: unemployment, market failure, price increases, export restrictions, policy changes;
political/conflict: destruction of physical infrastructure and social networks, displacement/seizure of assets, kidnapping, violence and rape;
human or animal disease epidemics: HIV/AIDS, malnutrition, red locust outbreak, and animal diseases such as Rift Valley fever or foot-and-mouth disease.
Box 4 describes the types of shocks that pastoralists in the Gedo region of Somalia faced in 2002.
Box 4: A case study from Somalia: pastoralist livelihoods and shocks
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Pastoralists make up 60 percent of the population of the Gedo region of Somalia. In 2002 they experienced a culmination of the following shocks:
The impact of these shocks led to:
The absence of a national government or authority had an impact on the ability of many Somali groups to cope with macroeconomic factors such as border closures, the livestock ban and the privatization of common resources (e.g. water points or "berkads"). |
Source: Adapted from FSAU Somalia. February 2002.
In a disaster, all of a population may have been exposed to the same risk, but the vulnerability and resilience of some households and/or specific members of a household to the impact of a shock on their food security will vary.
Box 5: Vulnerability
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Vulnerability refers to the full range of factors that place people at risk of becoming food-insecure. The degree of vulnerability of individuals, households or groups of people is determined by their exposure to the risk factors and their ability to cope with or withstand stressful situations. |
Source: FAO, 2000.
A household's vulnerability to food insecurity depends on the resource base that it had prior to the crisis and its ability to engage in various coping strategies. Not all types of shocks will affect a household in the same way. Moreover, the impact of a shock will be experienced in various ways depending on the socio-economic status of the household and its individual members. Box 6 describes how the socio-economic status of different types of Somali pastoralist households determined their capacity to respond to a shock.
A coping strategy is a short-term response to such shocks as abnormal declines in access to food. A successful coping strategy is reversible and should not incur unacceptable costs. The relative ability of the poor to cope with shocks and stresses is a measure of their resilience. Poor people are less likely to have savings to fall back on, assets to sell and/or the social claims network or kin to help them to recover. They often lack the resources necessary to take advantage of migrant labour opportunities (which require the payment of intermediaries) or to escape potential conflict zones with their assets and families.
Box 6: A case study from Somalia: pastoralist livelihoods and socio-economic differentiation
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"Economic options as well as social rank play key roles in defining the capacity to respond to a shock". Livestock ownership is the main determinant of prestige and wealth, as well as the main determinant of food security. Not only are livestock sold, but they also provide income, food and raw materials in the form of meat, milk, ghee, hides and skins. Animals play an important role in cementing kin and social relationships through dowry and blood feud payments. In Gedo, the poorer strata provide herding labour for better-off herd owners. This allows better-off livestock owners to live in towns and split their large herds across different areas, where they are reared by the poorer pastoralists in exchange for milk. Household economy analysis[2] has found that in a "normal" or "reference" year, poorer pastoralist households are more dependent on purchases derived from income-generating activities such as casual labour or the exploitation of bush and fish resources. Middle or mode pastoralist households, who have larger herds, are able to acquire almost half their food from their livestock. In times of drought, although poorer groups have fewer options, they can more easily adapt to the available alternative sources of income, as they are less constrained by herd-related labour activities. Links with either urban or international environments also constitute an important asset. The expandability of these options varies from one situation to another. However, as pastoralists become more dependent on the market for food, they are increasingly exposed to the effects of a volatile market. This particularly affects the poor, who have to sell proportionately more of their products on the market in order to obtain enough income, compared with other groups. Such dependency is exacerbated in times of drought, when economic differentiation within a society becomes far more acute. |
Source: Adapted from FSAU Somalia, February 2002.
The strategies adopted by severely drought-affected populations have been observed to follow a specific order, which starts with reducing the number of meals eaten and increasing the consumption of wild foods. This is followed by labour migration and the sale of larger assets such as livestock, tools, housing and land. Box 7 describes some of the coping strategies used by Somali pastoralists.
Box 7: A case study from Somalia: pastoralist livelihoods and coping strategies
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Herds and flocks remain close to the homestead in the clan areas during the "Gu" or rainy season, when water and pasture are abundant. During the "Jilaal" or dry season, when water and pasture are constraints, households use the strategies of migration and herd splitting to subsist. Fathers and elder sons in the household move to distant ranges with the hardier animals, while mothers and younger children remain at the homestead with young pigs, as well as pregnant and some lactating camels and cattle. In very dry years, this milk herd ("nugul") may also have to move to better pasture areas. This obviously has implications when women and children do not move with the herd and are left behind with no source of milk, or when they do move and lose their access to health and school facilities. |
Source: Adapted from FSAU Somalia, February 2002.
Conflict situations reduce the options for coping strategies and increase the vulnerability to food insecurity. Repeated displacement, population concentration, and pressure on natural resources can lead to permanent changes in the local food security system; for example, loss of land may lead people to become casual agricultural labourers, or loss of pastures and herds may result in pastoralists seeking employment in the urban informal sector. These are termed "adaptive strategies" as they cannot easily be reversed. They may be relatively successful or they may contribute to a downward spiral of impoverishment.
The term "coping" may be inaccurate or imply an optimistic viewpoint (one household's coping strategy is another's crisis strategy). Even when coping strategies are effective in preserving vital assets, the costs of coping to those affected are great and can lead to a deterioration in people's health status and to functional impairment. Strategies such as reducing meal frequency, changing meal composition, preferential feeding, and altered caring practices will result in differing nutritional outcomes for various members of a household. Other activities (e.g. involvement in the sex trade, begging and the sale of blood) can be personally degrading, immoral or illegal, and may result in the breakdown of family and community structures. An understanding of the available coping strategies, who is involved, the stage at which strategies are applied, and the consequences and costs involved (in terms of nutritional well-being and livelihoods) is important in analysing the severity of an emergency's impact. Box 8 describes the process of destitution among pastoralists.
A newborn calf about to be weighed by ILCA Research Station staff
Box 8: A case study from Somalia: pastoralist livelihoods and destitution
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The following are some of the more extreme coping strategies adopted by Somali pastoralists:
The poorest population groups consist mainly of internally displaced persons (IDPs), the destitute (who have lost their assets during conflict), and very poor pastoralists and agropastoralists who have dropped out of traditional social networks. These very poor groups are viewed as the key agents of environmental degradation, as they collect fuelwood and construction materials and produce charcoal. |
Source: Adapted from FSAU Somalia, February 2002.
The characteristics and resilience of a household's livelihood strategy are key determinants of its food security status. Food security is concerned primarily with access to nutritionally adequate food at the household level, and is a prerequisite for adequate dietary intake. In the 1970s, the theoretical debate regarding food security focused on food availability or food supply. However, the recognition that some groups of people face food insecurity and famine conditions even where food is available has created an understanding that a household's ability to obtain food is determined by its "exchange entitlements". A household's food entitlements are derived from its own production, income generated in exchange for labour, the gathering of wild foods, community support (claims), assets, transfers (remittances, inheritance), migration, etc. If these entitlements are eroded or collapse, food security is at risk. This highlights the need to understand how households obtain access to food. Figure 6 (on p. 127) provides an example of a livelihoods model that can help to visualize the relationships between different livelihood strategies and their outcomes.
Box 9: Food security
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Food security is defined as existing when "all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life". Food security is defined as existing when "all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life". |
Source: FAO, 1996b.
Access to adequate quantities of a wide variety of safe, good-quality nutritious foods by each individual is the core element of the concept of food security. An understanding of how people obtain food and feed themselves on a daily basis is vital for the effective design and implementation of activities and programmes aimed at strengthening people's ability to acquire adequate food supplies. "Access to adequate food" means that families and individuals are able to acquire - through their own production, purchase, bartering, food for work (FFW), gifts, food aid or loans - enough food to provide the right nutritional content and quality. A nutritionally adequate diet contains sufficient energy from staple foods (e.g. cereals, roots and tubers), fat/oil, legumes, adequate amounts of protein (from meat, fish, game, dairy products and legumes), and adequate amounts of micronutrients (vitamins and minerals) from vegetables, fruits, meat and fish. Box 10 shows how the pastoralist production system in northwestern Somalia provides household food security through the utilization of milk production for own consumption and sale. However, this pattern of food utilization does not provide an adequate and balanced diet for all wealth groups throughout the year.
Box 10: A case study from Somalia: pastoralist livelihoods and household food security
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Food utilization among Hawd pastoralists in northwestern Somalia showed the following characteristics:
Average daily consumption showed that the availability of micronutrients is insufficient for some of the year for middle wealth group households, and for all of the year for poor wealth group households. While energy and protein levels were only adequate or near adequate, fat availability was generally high, owing to milk intake. Camel milk contains larger quantities of iron and vitamins A and C than cow milk does. For the poor wealth group, however, all nutrients apart from fat were low in the dry season. Vitamins A and C are of particular concern for this group, owing both to the limited milk availability during the dry seasons and to the lack of other dietary supplements such as vegetables. Although there is a substantial improvement during the rainy season, the availability of vitamins A and (particularly) C is still low, as this group does not consume sufficient milk to cover all its needs. |
Source: Adapted from FSAU and FAO 2002.
Food security also implies stability and sustainability of access to food. Stability means that enough food is available on a continuous basis, including when households face a stress such as crop failure, fluctuations in food prices or seasonal changes in cash income or food production. Sustainability means that enough food is available for the long term.
For sustainable food security, the methods used to obtain or prepare food must:
Even when a household has access to sufficient food to meet all its dietary needs, not all of its members will always be adequately nourished. Actual nutritional well-being depends on a range of other interrelated factors, which besides food security include health and sanitation, adequate supplies of safe water, adequate methods of food preparation and allocation, and care of vulnerable individuals within the household.
Box 11: Nutrition security
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Household food security can lead to good nutritional status when individual household members are nutritionally secure. The condition of nutrition security combines:
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Source: FAO, 1997a.
Appropriate intervention strategies to protect and promote good nutrition must be based on an understanding of the location-specific causes of malnutrition and the relationships between malnutrition and livelihoods. The case study of Somali pastoralist livelihoods illustrates how households combine a range of assets to obtain their livelihoods, and how different shocks can have an impact on both the livelihoods and the dietary status of family members.
Rural Life. Young Swazi rural couple and baby inside their dwelling
FAO/9679/F. Botts
Figure 1: A conceptual model of the causes of malnutrition in emergencies
Source: Adapted from UNICEF Framework of Underlying Causes of Malnutrition and Mortality
Figure 1 provides a complementary tool for understanding how the causes of malnutrition operate at the individual, household and community or national levels. The model shows how the immediate causes of malnutrition are the combination and interaction of inadequate dietary intake with infection. Three clusters of interrelated factors influence this interaction: insufficient household food security, inadequate maternal and child care and feeding practices, and insufficient health services and an unhealthy environment. Food security, health and care are all necessary, but each alone is insufficient for improved nutritional well-being.
For most households in crisis situations, food may be scarce and lack variety. These are the characteristics of a nutritionally inadequate diet. The factors that can influence dietary intake are discussed in the following subsections.
Milk distribution at a centre for refugees who lost their homes after a volcanic eruption
FAO/23437/M. Bleich
Changes in food availability and access
In crisis situations, the availability of and access to food depend on: opportunities for agricultural production; purchasing power and market access; the availability of and access to wild foods; and the foods that are available through general ration distributions. Disasters can lead to the loss or erosion of livelihoods owing to one or a combination of: crop failure, the looting of food stocks, the loss of livestock and draught power, burnt-earth tactics, market failure, and unemployment. Drought or floods may deplete or destroy food stocks. Markets may be inaccessible or undersupplied as a result of military action. Wetland areas, forests and communal land - which are common property resources for pasture, wild plants and foods containing valuable micronutrients - may become inaccessible or unsafe. The loss of livelihoods can mean that food availability and access are reduced, become less diversified or change completely.
Changes in food habits and practices
The physical dislocation caused by an emergency can disrupt food habits and practices. For pastoralist groups, the loss of livestock can mean a sudden change from a milk- to a cereal-based diet. During food relief distributions, new or different forms of foods may be introduced without consideration of their additional processing needs (e.g. conversion of grains into flour), cooking times and fuel requirements (e.g. for legumes and pulses). In addition, it is also necessary to provide advice on preparation and nutrition to explain how new food items can be adapted to existing food habits and practices.
Households may have little access to traditional foods that are suitable for feeding vulnerable groups. In some cases, affected populations or particular sub-groups may be totally dependent on relief rations to meet their food needs. The risk of inadequate dietary intake increases if these rations are inadequate and/or irregular.
The coping strategies of many societies include consuming wild foods, such as fruits, nuts, berries, leaves, roots, grasses, insects and small animals. Although wild resources have important potential as a source of food, inadequate processing and/or consumption of these foods over extended periods may lead to toxicity or illness.
Box 12 provides an example of the role of wild foods in the coping strategies of southern Zambian populations. This area has diverse livelihood systems, which showed different levels of resilience during the 2001/2002 drought. Parts of Southern Province are always chronically vulnerable to food insecurity. In general, livelihood systems were affected to varying degrees by a combination of the following "shocks":
Nutrition surveys implemented in parts of Southern Province in late 2002 found that the acute malnutrition rates for children under five years had remained stable. Although the area had experienced large shortfalls in staple crop production, a range of coping strategies including the use of wild foods helped to protect young children from a deterioration of their nutrition status.
Box 12: Changes in dietary habits as a response to maize production shortfalls in Zambia
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Meal patterns The normal meal pattern includes maize meal porridge/gruel with sugar in the morning, while at midday and in the evening families eat nshima (a stiff porridge made from maize meal) with vegetable relish (rape, cabbage, groundnuts, beans or occasionally chicken) and wild fruits such as mawii (Strychnos cocculoides). When the survey was conducted in October 2002, families with limited maize meal were first reducing the number of meals and the quantity of food prepared (e.g. one meal with nshima usually in the late afternoon or evening). This one daily meal was usually of maize meal gruel, as this stretches the maize meal further. Households with no maize meal used the stored grits/chaff from pounding maize to make porridge or gruel. The chaff is normally stored to be used to make beer or chibwantu. Families with neither maize meal nor chaff made porridge from ground mungongo nuts (Ricinodendron rautanenii) and changa (a wild vegetable that is collected and preserved at the beginning of the rainy season). Another alternative was to mash and strain mbula fruit (Parinari curatellifolia) and add it to maize meal porridge as a sweetener. In the absence of maize meal, the mbula fruit liquid was eaten alone. Wild foods that are not consumed in normal years include siboyani, which is a yamlike tuber that is normally consumed by wild pigs. The tuber is peeled and cooked for a long time. Children also dive in lagoons for the potato-like roots of water lilies (Nymphaea nouchali). These also require long cooking times. Mayangayanga are onion-like bulbs found in the plains, but elderly women comment: "these are poisonous - they need to be cooked from midday until the evening". The elders are well aware of which wild foods are toxic. Although the consumption of wild foods is normal, the fact that the total diet of many households is comprised of wild foods, and that reliance on wild foods as the main food source started earlier in 2002, indicates stress. Women also have to rise earlier and earlier in an attempt to be in time to gather fruits dropped from trees over night. |
Source: Care International Zambia, 2002.
Changes in food preparation and allocation practices
Household members' nutritional knowledge influences how well scarce food resources are managed. During crisis situations, traditional knowledge of the selection, processing and preparation of foods may no longer be valid. Carers' ability to prepare suitable and safe meals with the foods available therefore depends on their acquisition of new nutritional knowledge. Existing social and cultural attitudes and practices influence how food is allocated within a family, and determine whether working adults or nutritionally vulnerable infants and children are given priority for food.
Food processing and preparation require equipment that may have been left behind or stolen. New foods or forms of foods may require different or additional processing techniques. Certain crops (e.g. bitter varieties of cassava) or wild roots may require time-consuming processing to eliminate toxins. Lack of adequate water storage containers may lead to contamination, poor food hygiene practices and food safety risks. Food may be lost (through insects, rodents, mould, and microbiological and chemical spoilage) because of inadequate storage facilities and/or inappropriate processing and preservation techniques. Foodstuffs must therefore be kept clean, dry and safe from pests, and storage utensils must be available. Food preparation also requires time, as well as access to water and fuel.
Box 13 provides an example from Mozambique of how the impact of war can influence the choice of staple food varieties and processing techniques. The box also highlights that, while research on breeding cassava varieties that are acyanogenic and/or have protein-rich roots may help address this problem, it should be within the context of ensuring a balanced diet and should also consider intra-household food distribution issues.
The Mozambique study found that most of the people affected by Konzo were children over three years, and women. This finding is interesting in the light of more recent research investigating the possible link between low protein intake and cassava poisoning. Intra-household food distribution may put women and young children at a disadvantage when sharing the relish dish that accompanies cassava. If protein intake is more than adequate for both general metabolic requirements and cyanide elimination, toxic effects are lessened or even eliminated, even when cassava is not properly processed.
Box 13: Changes in food preparation practices: Konzo associated with war in Mozambique
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Konzo (Spastic paraparesis) is a medical condition that affects the central nervous system. It is associated with eating inadequately processed cassava. In the northern district of Mogincual, agriculture is based on small family holdings with cassava as the main food crop. The normal cassava variety has a two-year cycle between planting and harvesting. Processing normally involves sun-drying for between one and three weeks, followed by storing for use throughout the year. Civil war disrupted agricultural production; people fled, or could not spend as long in their fields. Bitter cassava varieties became more favoured, as they are higher-yielding, have a shorter growing cycle and are less likely to be consumed by monkeys and wild pigs. When people returned to their homes after 1992 they had to harvest cassava earlier than usual. They took short cuts in processing by peeling and pounding the tuber and then sun-drying it for only a few hours. This method does not lower cyanohydrin concentrations adequately. The ensuing Konzo epidemic lasted two years - the last year of the war and the first of peace, with peaks each year during the cassava harvest. The culprit in cassava toxicity: cyanogens or low protein? Proteins contribute to the elimination of certain dietary toxins. With the help of the enzyme rhodanese, the human body detoxifies cyanide by forming thiocyanate. When the body is regularly exposed to cassava cyanogens, the increased synthesis of rhodanese makes extra demands on its reserves of amino acids, the building blocks of proteins. To detoxify 1.0 mg of hydrocyanic acid (HCN) the body needs a daily supply of about 1.2 mg of dietary sulphur (S) from S-containing amino acids (SAA). If the demand for rhodanese and SAA is prolonged, as in the regular consumption of cassava, and the diet is inadequate, the synthesis of many proteins vital for bodily functions may be impaired, leading to the development of protein deficiency diseases. Whenever a chronic disease has been linked to cassava consumption, the victims have also been found to suffer from protein deficiency, suggesting that there is a relationship between the two. |
Sources: Summary of published paper in Cliff et al., 1998; and Padmaja, 1996.
The transformation of food into a safe, culturally acceptable, nutritionally balanced diet requires a number of practices and resources that may be jeopardized in crisis situations. Adequate care for mothers and children at the household and community levels is necessary to promote survival, growth and development. Such care includes activities related to food preparation, breastfeeding and complementary infant feeding practices, hygiene practices, care for women, psycho-social care and home health practices. The resources needed include food, knowledge, income, time, and supportive attitudes and relationships.
Changes in breastfeeding and complementary feeding practices
In crisis situations, existing positive breastfeeding practices may be threatened by maternal malnutrition, anxiety and trauma, increased availability of breastmilk substitutes, and lack of counselling and support for HIV-positive women.
Box 14 highlights some of the issues regarding infant feeding in emergency situations, where there are few or no established practices for dealing with them. The pervasive belief that infant formula milk is required, and the lack of data about local feeding practices, together with inadequately trained field staff and a lack of clear guidelines for infant feeding, create a situation in which it is difficult to implement a workable compromise between accepted best practice and the options that are available.
The following are some of the common problems regarding infant feeding:
Infant formula feeds are distributed when they are available, and the form available may not necessarily be the most appropriate for the situation. Issues such as avoiding the distribution of brand-labelled products are either not understood or felt to be irrelevant when these are the only products that are on offer.
Supplies are often provided without instructions, with instructions in only the language of the country of origin or with badly translated instructions.
Supplies are distributed in incorrect quantities, to incorrect age groups and to mothers who do not have the necessary information or are not in the right environment to use the products safely.
Box 14: Infant feeding in emergencies: experience from former Yugoslavia
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The belief that stress prevents a mother from breastfeeding was innate and reinforced by families and health professionals. Local medical staff stated that 70 percent of women could not breastfeed, and that infants were dying because no infant formula milk was available. The humanitarian community at all levels responded to these expressed needs by sending infant formula and weaning foods. Discussion and internal reflection highlighted the following issues:
Field staff in former Yugoslavia acted in the ways that they felt were best to meet the needs of mothers and infants during the war. Even where there is knowledge or experience, a field worker faced with a hungry infant and a distressed mother does not have sufficient time to give individual breastfeeding counselling and ongoing support. |
Source: Adapted from Walshe.
One compromise would be to give infant formula with preparation instructions in the local language, and no brand name on the label in order to avoid providing free advertising for formula companies. This does not always happen in practice. It is sometimes recommended that no infant formula should be provided. However, there is insufficient evidence to show that this approach encourages mothers to return to or initiate breastfeeding. Guidelines on infant feeding in emergencies have been developed since the former Yugoslavia experience.
Infants from the age of six months onwards may face increased risks of growth faltering when semi-solid foods are first introduced into their diets. In crisis situations, the resources needed to manage this period may not be available or may be extremely limited. These resources include: a variety of suitable foods (energy-and nutrient-dense and soft) that can be fed four to six times a day; clean food, utensils and environment, in order to avoid infection; and time and affection from the mother and other family members, to contribute to psycho-social development. When these resources are not available, mothers may provide breastfeeding only to nourish their infants, thereby increasing the risk of malnutrition.
Disruptions to child care and feeding practices
Sick, anorexic or traumatized children often lose their appetites, and need to be encouraged to eat, which in turn requires time, patience and food variety. In situations of displacement and disruption, mothers may have to spend long hours queuing for food assistance, so they have relatively less time for selecting and preparing nutritious meals and responding to children's emotional needs. In crisis situations, the capacity to supervise infants and children may be affected by the division of families and the breakdown of kinship ties. There may be fears that warring factions will kidnap adolescent boys and girls.
Changed psycho-social context
Psychological health care includes stimulation and support for the intellectual development of young children, and the treatment of post-traumatic disorders. Family and cultural caring practices may be affected during crises. This may be especially relevant in emergencies where traumatic experiences have led to withdrawal, depression, anxiety and despair, which have a profound effect on appetite and the care of self and others. There may also be severe constraints on other caring behaviours, such as: the poor health and psychological state of mothers and other family members; the absence of key family members; the break-up of families; and changes in autonomy and control of resources. Social support networks and the normal mechanisms and channels for inter-generational transfer of knowledge and skills may have been broken through the prolonged separation of immediate family members and the severance of extended kinship ties. This can lead to inadequate knowledge of breastfeeding and complementary feeding practices, and to anorexia in young children. In some cultures, individual and/or family privacy and practices of seclusion are important for the family's physical and psychological well-being. Women and young girls may often find themselves in circumstances where they are subjected to sexual violence.
Changes and challenges to women's roles, status and rights
Care is usually the responsibility of adult females, mainly mothers, and the ability to give adequate care is frequently affected by women's multiple responsibilities and heavy workloads. Men's culturally and socially defined roles often limit their ability and readiness to undertake domestic duties, child care and food processing and preparation. This situation may be exacerbated in complex emergencies, as up to 80 percent of displaced persons and refugees are women and children. This leads to a dramatic increase in the number of women heads of households with responsibility for meeting the needs of both children and ageing relatives.
The health care of women can also be compromised through inadequate gynaecological, paediatric and counselling services. This lack affects women's ability to care for themselves and their dependants. Social and cultural patterns of subordination determine women's access to resources and decision-making bodies, and in crisis situations these patterns are likely to be accentuated. Many culturally defined coping strategies involve reduced food consumption to protect livelihood assets. These may be household decisions, where the local cultural perspective gives lower importance to good nutrition outcomes.
However, the cultural perspective should also be seen within the context of power and gender relations, where lower-status household members (women, adolescent boys) are often the most affected by coping strategies.
In crisis situations, the health infrastructure (buildings, staff, medical supplies and equipment) may have collapsed or been destroyed through lack of investment, floods, hurricanes, etc. or the intentional strategies of warring factions. Water points may become polluted (e.g. by dead animals) or deliberately poisoned. Caring practices with respect to health and sanitation may be compromised through:
inadequate preventive and curative medical services.
The health problems that can increase as a result of inadequate hygienic practices include scabies, conjunctivitis, intestinal parasites, diarrhoea and acute respiratory infections (ARIs). Nutritional requirements may increase in cold weather, unless adequate shelter is provided.
Infection and ill health
The underlying diseases in crisis situations are the same as those at other times: diarrhoeal diseases (malaria), measles, intestinal parasites, ARIs, TB, and sexually transmitted diseases (STDs). These diseases are likely to follow seasonal patterns and vary with altitude. The relationship between malnutrition and morbidity may vary according to the context. Increased wasting is not always associated with increased mortality when public health conditions remain the same. However, the same level of wasting may be associated with raised mortality rates if the sanitary environment has deteriorated and access to health services been reduced. Increased mortality in an emergency is often associated with a health crisis such as a measles or cholera epidemic. Exposure to and transmission of disease increase as a result of displacement, overcrowding, pressure on water, poor sanitation and health provision, and the erosion of normal coping strategies (e.g. access to traditional wisdom, herbal medicines, etc.) The risk of HIV infection rises in emergency situations, when populations are on the move and social and political systems break down.
In many emergencies, affected population groups may already have been chronically food-insecure and/or in poor nutritional condition before the onset of the emergency: displaced populations may experience extended periods of hunger during their flight from conflict zones; and humanitarian interventions may be delayed because of isolation or physical access problems. A crisis situation may threaten adequate dietary intake, and people's requirements for water, sanitation and health may often be seriously compromised.
Malnutrition and infection
The simultaneous presence of malnutrition and infection results in an interaction that increases the impact of either state existing alone. Dietary deficiency diseases may reduce the body's resistance to infections and adversely affect the immune system so that the body has reduced ability to defend itself against infections. Some dietary deficiency diseases, such as vitamin C and vitamin A deficiencies, cause changes and damage to the skin and mucous membranes, thereby decreasing resistance to invasion by pathogenic organisms.
Infection, in turn, affects nutritional status. It causes increased breakdown of tissue protein and mobilization of amino acids, especially from the muscles. Recovery depends on an increased intake of protein in the post-infection period. When accompanied by fever, infections often lead to loss of appetite, and therefore reduced intake. Parasitic infections can have an adverse effect on nutritional status through the loss of iron. Diarrhoea is an important factor in precipitating malnutrition, and is particularly common in children of weaning age. When complicated by dehydration, diarrhoea can be fatal. Other diseases, such as xeropthalmia (caused by vitamin A deficiency), can be precipitated by diarrhoea, which causes depletion of retinal stores. Common childhood diseases such as measles have a higher fatality rate in poor environments, where the children who develop them are more likely to have poor nutritional status, lowered resistance and poor health.
HIV/AIDS also accelerates the vicious cycle of inadequate dietary intake and disease that leads to malnutrition. As a result of their altered metabolisms, HIV-infected individuals have higher nutritional requirements for energy than uninfected individuals do. During the asymptomatic phase, energy requirements increase by 10 percent for adults and adolescents. During the symptomatic phase, energy requirements increase by 20 to 30 percent. (WHO, 2003). Adequate intakes of such micronutrients as vitamins B, E and C, vitamin A and selenium are important for preserving immune function. HIV/AIDS-infected individuals may find it difficult to meet adequate nutritional requirements owing to loss of appetite and anorexia (which lead to reduced intake), and diarrhoea and malabsorption (which reduce the physiological utilization of nutrients). This leads to the weight loss that is characteristic of people with AIDS. The onset of AIDS - and even death - can be delayed in well-nourished HIV-positive individuals, and energy-and micronutrient-rich diets help to develop resistance to AIDS-related opportunistic infections in patients.
The loss of livelihoods, together with the disruption of social and cultural norms, has a negative impact on the availability of, access to and utilization of food. This can lead to increased levels of malnutrition, which is manifested as macronutrient (protein, energy) and/or micronutrient deficiencies. In the case study described in Box 15, the culmination of various shocks on the livelihoods of Somali pastoralists led to a severe deterioration in the well-being of families.
Box 15: A case study from Somalia: pastoralist livelihoods and malnutrition
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In December 2001, a nutrition survey was carried out in Belet Hawa district of Gedo region, southern Somalia. Global acute malnutrition (< -2 Z-score weight for height [WFH]) was found to be 37 percent, with severe acute malnutrition (< -3 Z-score WFH) of 8 percent. The various shocks to livelihoods had culminated in a precarious food security situation. The impact on family well-being was exacerbated by fragile water systems, weakened health services, low immunization coverage and a high incidence of communicable diseases such as measles, diarrhoea and upper respiratory infection (URI). The situation was of continuing volatile civil insecurity together with interruptions to the food aid pipeline. The FSAU Nutrition Update noted: "Every year we wait until the human suffering indicator - malnutrition - confirms the food insecurity information. When we are convinced that a problem exists, we reluctantly recommend food aid along with the wise words 'food aid is not the answer'. But where are the interventions that aim at reducing the ever-increasing vulnerability of the people of Somalia? Unfortunately there are very few." |
Source: Adapted from FSAU Nutrition Update, December 2001.
A child stands beside carcasses of cattle destroyed by drought near the village of Ross-Bethio
FAO/11233/Y. Muller
Protein-energy malnutrition occurs when individuals lack sufficient quantities of food to meet their energy and protein needs. The main sources of energy are cereals, roots and tubers, oils and fats. Important sources of the protein needed to supplement that provided by cereals include pulses, legumes, and animal and dairy products. For infants and young children, in particular, inadequate dietary intakes of these foods can lead to acute malnutrition or wasting (low weight for height). Eventually, after months or years of inadequate diet, children will fail to grow normally, and become stunted (i.e. shorter and smaller than well-fed children of the same age) or chronically malnourished. Underweight children are more susceptible to infections, and may develop severe acute or chronic malnutrition. This may take different clinical forms ranging from marasmus to kwashiorkor and combinations of the two. Signs of marasmus include extremely thin legs and arms, a sunken "old person's face", a distended abdomen, and a tendency to feel miserable and cry a lot. Moderate to severe malnutrition (below -2 standard deviations of the World Health Organization/National Center for Health Statistics [WHO/NCHS] reference median weight for height) is one of the main causes of high rates of childhood illness and death. The signs of kwashiorkor in children include swollen legs, arms and face (because of oedema, or fluid in the tissues), a "moon face" (the skin is pale and thin and may peel) and hair that is pale and straighter than normal. These children may also be very unhappy or apathetic. Some children show symptoms of marasmus and kwashiorkor at the same time (i.e. they are extremely thin but may also have oedema of the legs, arms and face). Unless they receive therapeutic feeding and medical treatment, children with severe malnutrition are likely to die. Adults affected by malnutrition have a low body mass index (BMI) or nutritional oedema.
In crisis situations, a reduction in the diversity and quality of the food supply, together with the need to alter customary cooking practices, can bring about different food consumption habits and practices. This may have an impact on the availability and bio-utilization of micronutrients. The most common micronutrient deficiencies include vitamin A deficiency, iron deficiency anaemia, and iodine deficiency diseases (IDDs). Scurvy resulting from vitamin C deficiency, pellagra due to niacin deficiency, Beriberi due to thiamine deficiency and riboflavin deficiency are also observed under certain conditions.
Vitamin A deficiency is one of the most serious childhood nutritional diseases and is often associated with protein-energy malnutrition. Vitamin A plays an essential role in vision and eye health, and is recognized as a critical factor in child health and survival. It is the main cause of irreversible childhood blindness.[3] Vitamin A deficiency leads to lower immunity, and therefore increased rates of illness and death. Measles, diarrhoea and other diseases - which commonly occur in emergencies as a result of overcrowding and poor sanitation - are more severe and may become life-threatening among vitamin A-deficient children. Vitamin A-rich foods include dairy products, oily fish, and dark-green and orange fruits and vegetables. Fats and oils help the absorption of vitamin A, and are thus necessary to ensure that large amounts of the vitamin are absorbed. In crisis situations, these foods may be in short supply, out of season, unavailable or too expensive.
Iron deficiency anaemia adversely affects: the cognitive performance, behaviour and physical growth of infants, pre-school and school-age children; the immune status and resistance to infections (of all age groups); and the use of energy sources by muscles, and thus the physical capacity and work performance of adolescents and adults. Specifically, iron deficiency anaemia during pregnancy increases peri-natal risks for mothers and neonates, and increases overall infant mortality. Iron deficiency anaemia is widespread and a major public health problem, even in normal situations. Every age group is vulnerable. However, the high-risk groups for anaemia are women (especially during pregnancy and soon after delivery), babies, young children and adolescents (especially girls). The main sources of dietary iron include:
Folate deficiency may also cause anaemia, as well as other disorders such as increased susceptibility to infections, low birth weight, foetal malformations, delayed growth in early childhood and adolescence, delayed sexual development, and increased risk of heart disease. Folic acid is present in all foods of plant and animal origin, particularly liver, leafy vegetables, fruit, pulses and yeast.
Iodine deficiency results in a variety of disorders including goitre (thyroid enlargement), impaired learning ability and reduced mental function (cretinism) and reproductive complications (still births, abortions and infant deaths). Iodine deficiency occurs mostly in mountainous areas and where soils have low iodine content. Iodated salt is often used as a strategy for the control of IDDs, but iodated salt may not be easily accessible in crisis situations.
Vitamin C deficiency causes scurvy, decreased resistance to infections and poor healing. Vitamin C increases the absorption of iron, so it is advisable to consume iron-containing foods with foods that are rich in vitamin C (e.g. guavas, citrus fruit, papaya, mango and some green vegetables) in the same meal.
Niacin deficiency (pellagra) occurs in people with very poor diets that consist mostly of maize, for example refugees and prisoners (e.g. Mozambican refugees in Malawi). Women, old people and children are particularly at risk. Men may get enough niacin from drinking beer. Pellagra results in skin problems, and some people have severe diarrhoea or mental changes. Groundnuts are a good source of niacin, and maize and sorghum flour can be fortified with niacin.
Niacin, riboflavin and thiamine usually occur together in foods, but in different proportions depending on the food source.
Riboflavin deficiency results in lesions around the mouth, dermatitis and red eyes and lips. Good sources of riboflavin include liver, milk, eggs and whole grains.
Thiamine deficiency (Beriberi) can occur when a population's diet consists of predominantly polished white rice, with no thiamine-rich sources such as nuts, beans, wholegrains and yeast-based products (e.g. beer).
Zinc deficiency results in delayed growth and decreased resistance to infections; the richest sources of bio-available zinc are meat products. Diets based on wholegrain cereals may be zinc-deficient, not only because of low zinc intake, but also because phytates in cereals inhibit zinc absorption from the gut.
The short-term implications of malnutrition include weight loss and growth faltering. In children, undernutrition impairs learning ability and school performance. Long-term chronic malnutrition, or stunting, is associated with impaired mental development. Stunting has intergenerational implications. Stunted girls who reach motherhood are more likely to give birth to low-birth-weight babies (< 2.5 kg.), who in turn are more at risk of becoming malnourished.
For adults in general, malnutrition, anaemia and iodine deficiency lead to poor health, impaired physical and mental performance, and lower productivity. This increases vulnerability to future food insecurity through reduced physical capacity and work productivity. This combination of factors contributes to the perpetuation of poverty.
Undernutrition makes people more susceptible to illness and disease. Morbidity and mortality risks increase in situations of overcrowding, where there is inadequate environmental health and sanitation. The condition of stunted children can worsen rapidly at the onset of complications such as diarrhoea, respiratory infections and measles, and can lead to increased rates of death. High rates of illness reduce work time, both directly and indirectly, owing to the need to care for family members who are ill.
All these consequences increase the demands on medical, public health and food assistance in crisis situations. The consequences of poor nutrition for human well-being are a constraint to recovery and development in the medium to long terms.
Short-term behavioural responses to energy stress and the impact of malnutrition on mental development can be compounded by the psychological traumas experienced in conflict situations. Following war, many people feel shock, guilt, suspicion and hatred as the victims and/or perpetrators of violence. The fear of violence, particularly against women, may continue. There may be high emotions and expectations, with people wishing to rebuild quickly, revert to traditional roles and put immediate events behind them. Disillusionment and a feeling of powerlessness can occur when a reversion to normality does not happen as quickly as anticipated, or when traditional roles are no longer relevant.
People need to be physically and psychologically strong before they can look beyond day-to-day survival and plan for the longer term. As described in the previous section, poor nutrition compromises people's ability to use opportunities to rebuild their livelihoods. A person with poor nutritional status cannot work as hard; low productivity means low income, and so a person's ability to make a living and obtain food for the family is less than it would be with good nutritional status. Poverty is perpetuated by the physical and mental deficits caused by malnutrition.
In situations that oscillate between crisis and stability, people are less able to restore their productive capacities and rebuild their lives. Where malnutrition is widespread, family, community and national recovery and development are severely constrained.
In order for malnutrition to be reduced sustainably, actions and interventions are needed that address the contributory causes. Strategies and actions directed at satisfying immediate needs at the individual level (e.g. nutritional rehabilitation through intensive care and therapeutic feeding) should be matched by actions at the household and community levels. Strategies should be designed in a way that assists households to realize their rights to food and to ensure the nutritional well-being of their members, not only in the short term but also in the medium to long term. The underlying causes of shortfalls in realizing the right to food may need to be addressed through the clear identification of right bearers and duty bearers for a range of interdependent rights. Such rights may include the right to exist (e.g. for marginalized and persecuted groups), the right to utilize natural resources, and the rights to employment, education, health, water, shelter and food.
A rights-based approach to improving food security and nutrition can only be successful if it pays attention to both the outcome and the process. Integrated multidisciplinary approaches are often more effective than single-sectoral activities in reinforcing household food security, improving overall nutritional status and increasing family income, especially among disadvantaged families and communities. Key to this is strengthening civil society organizations' capacity to increase awareness and contribute to the debate about existing cultural and contextual duties and rights to food. The organizations can then develop mechanisms that allow them to advocate on their own behalf. Networking and partnerships among government institutions, multilateral agencies and non-governmental organizations (NGOs) can be used to create an environment in which the right to food can be fulfilled at different stages in a crisis, and to ensure accountability at different levels.
A focus on food and nutrition security in crisis situations has two important advantages:
It acts as an entry point for different sectors to address the multi-causal nature of malnutrition, thereby bringing together contributions from nutrition, health, education, agriculture, trade and transport in a complementary manner.
It can provide a coherent focus that ensures continuity when flexible combinations of short- and long-term interventions are required.
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[1]
General Comment 12, adopted in 1999 by the Committee on Economic, Social
and Cultural Rights, the treaty body for the International Covenant on Economic,
Social and Cultural Rights. [2] See glossary for a description of the household economy approach (HEA). [3] Vitamin A is a key precursor in the biosynthersis of rhodopsin, which is required by the retinal photoreceptors responsible for vision under low levels of illumination. |
