Revised MSF Nutrition Guidelines
by Saskia van der Kam, MSF Holland, Senior Nutritionist
The MSF nutrition guidelines for use in emergencies have recently been revised. The new guideline will be available in January 2001. The main changes to the guidelines occur in the sections on i) analysis of food insecurity situations, ii) the relation between assessment of food insecurity and nutritional interventions, and iii) the treatment of severe malnutrition.Field exchange will highlight these revisions in three consecutive articles. This first article summarises key points in the new section on:
Analysis of a food insecure situation
The new nutrition guidelines adopt an interdisciplinary approach to assessment and advocates using the UNICEF conceptual framework for analysis so that the assessment focuses on food security, health and care.
The new guidelines define three sequential stages in the transition from food security to famine. These are elaborated below. Every situation is different. The speed with which the stages progress from one to another can vary greatly depending on the nature (or the origin) of the crisis, its context, the range of coping strategies that are adopted, and the aid that is delivered.
People adopt a range of strategies (coping mechanisms) to cope with reduced access to food. In the latter stages of the process, coping mechanisms become exhausted so that the priorities of the individual and community shift towards survival.
Stage 1 - Food insecurity: 'insurance strategies'
During this first stage, the responses developed by the population are reversible and in principle do not damage future productive capacity.
People anticipate problems and adopt insurance strategies planned in advance to minimise the effects of food shortages, enhance productive capacity and preserve their productive assets. People's responses are characterised by diversification of activities, longer work hours and focussing on increasing income and limiting expenditures. The caring capacity for the nonproductive members of the community (elderly, children, sick) will be reduced. For example when men migrate to the city for temporary work, women become the head of the household and have more work and therefore less time to care for children. People also reduce their food intake, without this immediately being a threat to health. Therefore an increased level of moderate malnutrition may be seen.
Examples of insurance strategies
- crop diversification for farmers
- livestock diversification for pastoral populations, sale of excess livestock, long distance grazing
- sale of non productive assets (utensils, jewellery, charcoal, furniture)
- labour migration (search for temporary employment in towns)
- diversification of informal economic activities
- reduction of food intake (reduced meal frequencies and smaller quantities eaten)
- change in diet (consumption of wild foods, cheaper foods etc.)
- reduction of expenditures on health care (and water purchase)
- reduction of social support to the community, (relatives and neighbours)
- reduction of time available for care
Stage 2: Food crisis: 'crisis strategies'
The responses in the next stage 'food crisis' are less reversible as households are forced to use strategies that reduce their productive assets and threaten their future livelihoods.
At this stage, the households or individuals are obliged to develop new strategies to meet their food needs. All surpluses have been sold and all potential for increasing resources by diversification of activities have been exhausted. People have to sell goods that are essential for their future livelihoods. Additionally, economising on health and water resources results in a poor health environment which can be made worse by gradual migration of the skilled and educated of the community (nurses, teachers etc.) In a food crisis, the prevalence of acute global and severe malnutrition as well as mortality rates associated with them, is elevated. An increased risk of mortality in moderately malnourished individuals can be attributed to a deterioration of the health environment, which increases the risk of infections.
Example of crisis strategies for a settled population
- sale of productive assets (tools, seeds, livestock)
- massive slaughtering of livestock
- mortgaging of farmland or house
- sale of farmland, house, sale of land rights, harvest rights,
- exchange of livestock for staple food
Breakdown in social structures:
- prolonged migration, men do not return from seasonal migration or are enrolled in armies.
- further cuts in use of water, firewood and health services
- community structures (mutual help systems) collapse
- Skilled and educated people (health staff) migrate
- decrease of community funds for funerals and weddings
- reduction of support to the non-productive members of households (small children, elderly, disabled)
- marginalisation of non-productive individuals, (orphans, beggars, etc.
Stage 3: Famine: distress strategies
Famine is the last stage of this process. In nearly all cases, it is linked to war and conflict. It is characterised by excess mortality and high malnutrition in all the age groups of the population, complete destitution, social breakdown and distress migration as people abandon their homes in search of food. All coping mechanisms have been completely exhausted. The people are dependent on food aid for immediate survival. Famine situations can result from inadequate relief assistance during the food crisis stage. Relief assistance has been too little, too late, not well targeted, not well organised or co-ordinated and often diverted. This is frequently linked to serious constraints such as high levels of insecurity or lack of political commitment (at international, national or local level).
The combined effects of insufficient food intake and poor health environment are important factors leading to famine and death among moderately and severely malnourished people. In fact, the majority of deaths (in absolute number) occur amongst individuals who are not severely malnourished. One of the main underlying causes of famine mortality is deterioration in the health environment. In addition to an adequate provision of food, access to curative health care, environmental sanitation and shelter can avert many deaths.
An assessment should try to locate a deteriorating food and nutrition situation on the continuum of moving from food security to famine. The table below helps to determine the stage of the process of moving from food insecurity to famine. Each stage will not necessarily show all characteristics, but the table helps to illustrate which stage a situation has reached and in what direction the situation is likely to develop.
|Specific characteristics of food insecurity, food crisis and famine|
|Food insecurity||Food crisis||Famine|
|Mortality rate||Normal||Increased or high||Extremely high|
|Population movements||Seasonal migration||Population displacement +/-||Distress migration|
|Global malnutrition rate||could be increased||Increased||Extremely high|
|Mortality related to moderate malnutrition||Low||Elevated||High|
|Severe malnutrition rate||Low||Moderate or high||High|
|severe malnutrition in adults||Low||Low/moderate||High|
|Livelihood changes||Temporary||irreversible||Complete destitution|
|Selling of capital assets||none or very limited||Important||Exhausted or very limited|
|Activity diversification||Normal or slightly increased||Increased +++||Exhausted or limited|
|Reduction of expenditures||Reduced||Reduced +++||No more possibility to reduce.|
|Food availability||Normal or slightly decreased||Reduced||Rare or none|
|Food accessibility||Slightly reduced||Reduced||Severely reduced or none|
|Dependence on food aid||Low||High or moderate||Complete|
|Reduction in caring practices||Low||Moderate or high||High|
Locating a situation on the food security/famine continuum helps identify the most appropriate type of intervention. In a food insecurity situation the focus of interventions should be on preservation of livelihoods to prevent people sliding into food crisis and famine, e.g. food for work. Early warning systems are crucial at this stage. Support can be given to existing health structures to shore up treatment of individual cases of severe malnutrition.
In a food crisis situation it is crucial to prevent further movement along the continuum by ensuring enough food. E.g. general food distribution. As the social caring systems comes under pressure provisions should be made to support special vulnerable groups, e.g. elderly, orphans, under five's in general. Selective feeding programmes like therapeutic feeding centres and supplementary feeding centres can be installed. Health care systems and water resources may also require support.
In a famine situation, the primary goal is to ensure survival, to reduce mortality. The major focus is on general food distributions, supplementary feeding programmes, blanket feeding, and therapeutic feeding and mortality surveillance.
In the next issue Field Exchange there will be a further article based on revisions to the MSF guidelines. This article will elaborate further on choice of nutritional strategies and programme designs in relation to context.
1inspired by H.Young, S. Jaspars. Nutrition Matters. Intermediate Technology publication, London. 1995.
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Reference this page
Saskia van der Kam (2000). Revised MSF Nutrition Guidelines. Field Exchange 10, July 2000. p20. www.ennonline.net/fex/10/revised