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A Review of the advances and challenges in nutrition in conflicts and crises over the last 20 years

Abbreviated version of unpublished paper

Food distribution at the ICRC kitchen in Tonj.

By Frances Mason and Anna Taylor

This paper is a shortened version of the complete paper presented at the ACC/SCN Symposium on Nutrition in Conflicts and Crises in March 2002.

Introduction

The main purpose of this paper is to assess the principal advances made over the past years in nutrition in conflicts and crises and to propose direction for further advances in the field. The term 'advances' refers to developments in technical knowledge and nutrition policy and practice. The Project Cycle Management is used as a framework for presenting these advances and the challenges that remain. It is hoped that this will contribute to the development of a plan of action for the international community that will accelerate the pace of advances in the field of emergency nutrition: advances that will lead to significant improvements in relieving the suffering, death and degradation of disaster-affected communities. The first step in this process would be a plan of action developed through the collaboration of bilateral agencies, UN Agencies, and NGOs through the UN ACC/Sub-Committee on Nutrition.

Background

This paper is not able to provide significant detail on how the advances described took place, but it is essential to emphasise the important role that interagency collaboration has played in furthering the sharing of technical knowledge and improving the policies and practice of nutrition in conflicts and crises.

Table 1 describes the key developments in interagency collaboration and policy development. Many of these were initiated by interagency meetings held since 1988. These meetings provided a forum for improved coordination, mutual understanding and enhanced analysis of the constraints within the humanitarian system. A central focus of the interagency work was the move towards Public Nutrition indicating a shift from the individual to the population level and from a narrow set of technical interventions to a wide range of strategies, policies and programmes to combat malnutrition (Harinarayan 1999). The interagency group has also provided a catalyst for a number of initiatives that have enhanced policy formulation and practice guidelines.

Analysis and assessments, advances

As the paradigm of public nutrition began to be established in the early 1990s, UNICEF developed a conceptual framework for understanding the causes of malnutrition. The framework was later adopted by a wider group at the International Conference on nutrition in 1992 (Shoham 1999) and has been instrumental in ensuring an understanding of malnutrition that goes beyond inadequate intake to include the range of food security, care and health factors that contribute to malnutrition. Analysing these processes in specific contexts has created opportunity for intelligent nutrition programmes which address real rather than assumed causes.

There is also increased understanding of the importance of the analysis of epidemiological data alongside that of anthropometric data. Measles coverage data has become a fundamental component of regular data collection within anthropometric surveys and the importance of assessing mortality indicators in conjunction with malnutrition has become more widely recognised.

While the assessment of malnutrition in children under five years and the estimation of prevalence has become routine work for many emergency nutritionists, there remain substantial gaps in understanding how to measure acute malnutrition in other age groups, namely infants (<6 months), adolescents, adults and the elderly. This is due to the inadequacies of reference population data and interethnic variation. In the last few years the limits of our understanding of how to measure these groups have become more widely discussed and the research agenda has become clearer.

Table 1: Interagency Collaboration
ADVANCES MADE OBJECTIVES OF ADVANCES
Information sharing and interagency learning
Mid 1980s: Memoranda of Understanding (MoUs) and Letters of Agreement between UN organisations, intergovernmental and NGOs and national entities. To facilitate co-operative action and to ensure accountability vis a vis respective responsibilities to beneficiary populations
1990s: ACC/SCN Working Group on Nutrition in Emergencies linking to Interagency Group. To share information; assist in the harmonising and alignment of agency actions & identify critical issues for SCN participating bodies
1993: ACC/SCN RNIS Refugee Nutrition Information System To provide information and analysis on the nutritional status of refugee and displaced populations to key decision makers
Mid-Late 1990s: The Interagency Group meetings: Impacts of this include: shift of emphasis to public nutrition and standardisation of procedures and protocol To share experiences and knowledge, and to move away from the concept of owning knowledge. Opportunities to contribute to the improvements in standardisation of procedures and protocols
1996: Emergency Nutrition Network (ENN) set up Field Exchange (primary output of ENN). To provide a networking mechanism for those working in the humanitarian food and nutrition sector and to institutionalise agency programme experience.
1996: Infant Feeding Interagency Groups developed and referred To formulate a coherent, appropriate and widely acceptable policy and strategy statement for humanitarian agencies and to identify practical tools to assist agencies in the implementation of policy
1997: NGONUT To allow a prompt forum for sharing experiences and questions amongst a global group of nutritionists.
Standards of Operation
1998: The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response (Sphere 2000) To provide a practical framework for accountability by connecting the principles of humanitarianism to standards of service delivery and an operational tool or reference to help structure the planning and management of emergency programmes.

 

Table 2: Analysis and assessment
ADVANCES MADE OBJECTIVES OF ADVANCES
1980s: The emphasis placed by Amartyr Sen's work (Sen 1981) on accessibility of food as well as availability transformed analytical thinking. To improve the effectiveness of programmes aimed at preventing malnutrition
Mid 1980s: Growth and development of early warning systems sometimes alongside nutritional surveillance: (eg FEWS, FIVIMS, FEWSNET). To provide macro level data on food availability to identify countries facing acute food insecurity
Early 1990s: Food Security and Livelihoods Analyses: improved methodologies, analyses & coordination. Save the Children: Household Economy Approach WFP: Vulnerability Assessment and Mapping Oxfam & Care: Livelihoods Assessment To improve analytical base for programming and move from an understanding of food availability to food access.
Mid 1990s: Anthropometry: an increasingly widespread use; use of standard indices including z-scores; increased research (although still very limited) into the role of anthropometry in adolescents, adults and the elderly. To ensure greater standardisation of use of indices and cut-offs. To provide an influential factor for resource allocation.
Food Aid ration quality
Late 1980s: Agreement among major relief agencies to increase daily food ration from 1500 to 1900 kcals/pp/pd.
Mid - late 1990s: Internationally agreed guidelines and policies (WFP/UNHCR 1997). The improvements include: minimum energy content of food ration for populations entirely dependent on external food aid was increased to 2100 kcals/pp/pd.
1990s: Improvement of the nutritional quality of the ration (WFP/UNHCR 1997; US Department of Agriculture 2000, WHO, 2000)
Reduction in acute malnutrition and crude mortality, particularly amongst children under 5 years. Standardisation of protocols and methodologies. Improvements in the professionalism of work. Reduction in mortality from acute malnutrition. Reduction of micronutrient deficiencies amongst food aid dependent populations.
Food Aid delivery and distribution
1997: UNHCR food distribution guidelines (UNHCR 1997) - the first guidelines to assist in designing appropriate distribution systems.
Mid 1990s: WFP made policy commitments to giving women direct access to and control over food aid (WFP 1998). Improved tools for geographic/community/household based targeting (eg by SC/UK, VAM by WFP)
2000: Review of principles and practice of food distribution in conflict (Jaspars 2000).
To improve efficacy and standardisation of distributions. Ensuring that women control a family's food entitlement. Improved targeting of food aid
To improve self reliance in long term refugee situations
To assist humanitarian agencies in developing a principled approach to food distribution.
Livelihood support
Alternative interventions to address food crises have become more widely documented including: Food interventions: food for work and food vouchers; income support: cash grants, cash for work, cash vouchers and microfinance; market support; and livelihood support: both agricultural and livestock To save livelihoods as well as lives
To maintain dignity amongst the affected populations
To improve the long term impact of programmes
To ensure relevance of programme to context
Selective Feeding Programmes

1997: Guidelines on standard treatment protocols, entry and exit criteria for selective feeding (Oxfam 1997, MSF 1995/2002, WHO 1999, ACF 2001)

Early 1980s: Oxfam feeding kits and manuals were developed.

Therapeutic feeding:
Mid 1990s: Specifically adapted products for treating severe acute malnutrition were introduced:
1997: Prudhon Index: (Index to assess the risk of mortality for children treated for severe malnutrition) (Prudhon et al 1997). Increased attention given to the care aspects of severely malnourished cases, e.g. activities to motivate children to take food and medicines; to ensure that siblings stay together (UNICEF 1997 and WHO 1999).

Standard guidelines on assessment and treatment of acute malnutrition to ensure sustainability of a programme by the host country and refugees themselves.

Standardisation of programme implementation.

 

 

Improve efficacy of treatment of severe acute malnutrition.
To support decision making on the appropriate approaches for the treatment of severe malnutrition (eg type of feeding centre).
To improve the mental welfare of severely malnourished individuals in order to have a more effective recovery.

 

Analysis and assessments, challenges

Despite consensus on appropriate anthropometric survey methodologies, there remain frequent examples of poorly conducted surveys or assessments which serve to misinform rather than inform decision making (Collins 2001). Common mistakes include fundamental errors on sample selection, unclear and untransparent presentation of data and failure to include assessment of oedema. These errors reflect poor human resource capacity and the failure of those agencies responsible to utilise technical expertise in nutrition.

The importance of clear case definitions for micronutrient deficiencies, adequate sample size, and, where possible, biochemical confirmation during micronutrient deficiency assessments has been widely recognised. However, challenges for implementation and the lack of validated field-friendly sample collection and analysis technology exist still.

There remain substantial shortfalls in the adequacy of response to early warning information resulting in early warning systems that have not been as useful in preventing emergencies as had been hoped. While the increased use of anthropometric data in planning emergency response can be regarded as progress, prevalence of malnutrition is usually apparent relatively late in a crisis and yet is a measure that is increasingly being used to trigger decisions. This raises ethical questions and highlights the need for comprehensive food information systems which monitor early indicators of a food crisis.

Food aid, advances

Since 1989, the proportion of global food aid allocated to emergencies has increased from one eighth to one third in 1999 when it equalled 4.7 million MT (IASC 2000). In 2000, 86% of WFP food aid went to emergency activities, the highest proportion for 23 years. While the proportion of food aid allocated to emergencies has increased, the overall quantity has varied substantially through the 1990s due to intermittent appearance of global surpluses.

There have been enormous advances at donor level (bilateral and multi-lateral) with regard to provision of food aid and other resources for food and nutritional emergencies. Many of these advances have grown out of identification of the political, institutional and bureaucratic constraints which affect donors in extremely specific ways.

The implications of the potential negative effects of food aid have also begun to permeate donor thinking in recent years. The ODI Humanitarian Policy Group and NutritionWorks (Jaspars 2000a) reviewed the principles and practice for food distribution in conflict and made the following key recommendations:

Food aid, challenges

In spite of the many advances in recent years in the emergency food aid sector there are innumerable challenges to be overcome. Once again a few examples will have to suffice here.

Food aid resourcing. The politicisation of food aid in emergencies is at times scandalous. The mismatches in food aid allocation between emergency affected populations is a profound embarrassment to those working in the humanitarian aid sector. The geopolitical factors underpinning these imbalances are plain to see. This problem extends beyond food aid. For some countries, the international response has met less than 10% of estimated needs. For example: Eritrea in 1998 received less than US$2 for every person affected by the emergency; the former Yugoslavia received US$166 per person. (IASC 2000).

Bureaucratic impediments to efficient release of funds for purchase of food aid or other resources to support food security are also at times scandalous.

Micronutrient Deficiency Diseases. Despite a huge reduction in the number of reported outbreaks of micronutrient deficiencies since the policy decisions of the early 1990s there have been a number of recently reported outbreaks. However, it is important to note that most data comes from refugee and displaced populations and it is likely that outbreaks in resident populations have remained under-reported and unchanged. Difficulties still faced in addressing micronutrient needs through provision of fortified foods in emergency situations are the pipeline constraints in the early stage of an emergency, the reduced shelf life of fortified commodities and the cost of fortified blended food in comparison to unfortified staple grains (Bhatia & Thorne-Lyman 2001). There are still unresolved issues and questions surrounding fortification, specifically where fortification should take place (i.e. within or near to the affected country or in the donor country) and which food vehicles should be chosen.

Livelihood support, advances

Over recent years there have been notable attempts to further the experience and understanding of humanitarian agencies in the effectiveness and appropriateness of interventions aimed at supporting livelihoods without the use of food aid. Examples of these are seen in table 3.

Livelihood support, challenges

Despite the significant lack of official policies or guidelines on livelihood support approaches, donors and humanitarian agencies are increasingly exploring different modes of food security support in emergencies. However, there is little guidance on appropriateness of types of livelihood intervention in relation to stage, type and scope of an emergency and implementing agency resources and capacity. Furthermore, as donor funding opportunities and mechanisms diversify and change and in the absence of clear donor policies on livelihood support, bureaucratic difficulties can multiply making it harder for NGOs to access resources quickly and efficiently. A remaining challenge to effective livelihood programming in conflict-related emergencies is the conflict itself.

Selective Feeding Programmes, advances

Recent years have seen considerable advances and consolidation of existing knowledge in relation to the treatment of severely malnourished children (see Table 3). Despite improved understanding of the pathophysiology and treatment of the severely malnourished child, the median case fatality rate of children in hospitals in non-emergency settings has remained unchanged over the last 50 years and is on average 20 - 30%, with highest levels of 50-60% (Marchand 2000). However, analysis of children in a number of therapeutic feeding centres in Africa, during emergencies, shows a case fatality rate of 9.6% (Grellety 2000).

Efforts have begun to support sustainable forms of treatment of severe malnutrition in emergencyaffected countries. A study comparing centres treating cases of severe malnutrition in Liberia showed that the chief factor determining the rates of mortality was the adequacy of the management and training skills of the senior staff (Marchand 2000). This example demonstrates the importance of longer-term efforts to build capacity at the national level in countries that are frequently affected by disasters.

In addition to technical advances, progress has been made in giving recognition to the importance of care and stimulation for children during rehabilitation from severe malnutrition, to promote recovery. In past emergencies these programme components were often overlooked.

Selective Feeding Programmes, challenges

While significant technical advances have been made in the management of severe malnutrition, challenges remain regarding how and when to intervene. There is a particular need to improve the integration of interventions within the Health Ministry of the countries concerned and to increase national capacity building to manage severe malnutrition.

Much consideration is being given to the role of 'athome' treatment of the severely malnourished. The challenge for improving the outcome and appropriateness of home based treatment remains how to ensure that mortality rates for all children remain low while designing programmes that are appropriate to the operational, environmental and socio-economic context. Studies show that detailed analysis of data collected prospectively in real-life service settings can lead to major improvements in the management of severe malnutrition. The Prudhon Index can be used to assess expected mortality, giving room for greater focus on ways to reduce mortality.

There are also several key technical challenges to existing treatment protocols for malnutrition. The effects on patients afflicted with HIV/AIDs provides a significant challenge to those treating severe malnutrition. Understanding of how such patients can be cared for in feeding programmes and within the community remains limited in emergency contexts. Finally, despite the comprehensive best practices guides (Shoham 1994), there is very limited understanding of the efficiency and efficacy of supplementary feeding programmes.

ADVANCES MADE OBJECTIVES OF ADVANCES
1993: Methodological guidelines for evaluations were created (eg Overseas Development Institute). To improve standardisation of methods.
1996: Introduction of multi-donor funded evaluations of crises and subsequent responses. To improve objectivity of the undertaking and analyses of the evaluation.
Repositories for evaluation findings have been set up eg ALNAP and the ENN Field Exchange (1996) To improve institutional learning and ensure interagency sharing.
Monitoring and Evaluation is now included at the design stage of programme planning To ensure that monitoring and evaluation have the adequate resources and time provisioned.
1997: Indicators defined for Monitoring and Evaluation to see that standards are being reached (eg Sphere minimum Standards). To standardise indicators to allow for comprehensive comparisons.

 

Monitoring and evaluation, advances

In the early 1990s the UNICEF 'Triple A' Cycle (Assessment, Analysis, Action) was conceived within the developmental setting of Iringa in Tanzania. Like the conceptual framework, this cycle has been influential in the emergency sector too. Alongside these developments, the use of the Logical Frameworks in which monitoring indicators and sources of verification must be specified has gradually been taken up by donors, and in turn agencies, to the point where the presentation of logical frameworks is now mandatory for th e majority of funding applications. These initiatives reflect the growing importance that agencies are placing on monitoring and evaluation. Donors are now increasing the availability of resources for these activities. This appears to come hand in hand with the advanced awareness of the need for accountability of our work in humanitarian contexts.

The Sphere project has also created a valuable impetus to monitor the context in which interventions are made, conduct evaluation and institutionalise learning.

Monitoring and evaluation, challenges

There is a significant dearth of thematic evaluations. For example there has been no comprehensive 'overview' impact evaluation of emergency supplementary feeding programmes.

Impact indicators (usually primarily quantitative) are prioritised in monitoring and evaluations, often at the expense of process indicators (Toole 1999). Too great an emphasis is placed on anthropometric and mortality indicators as a means of monitoring and evaluation. There is little agreement on appropriate indicators for early warning, recognising that deterioration in nutritional status is usually a late indicator of a crisis.

In many contexts where agencies have previously worked for many years under relatively stable conditions, at the onset of an emergency, there is frequently a substantial lack of base-line data available. The gathering of baseline information in emergency prone communities is an essential component of emergency preparedness.

One of the regular findings of independent evaluations, e.g. CDC, bilateral government evaluations, and material submitted to Field Exchange, is that there are still enormous difficulties with uptake/implementation of best practice by implementing agencies. There may be many reasons for this, such as absence of guidelines at project level, poor training of field staff and lack of technical support by headquarters staff.

Conclusions and recommendations

This paper has attempted to highlight the work of NGOs, donors and the UN as complementary parts of the humanitarian system over the last 20 years. The paper shows that those active in the emergencies sector recognise the importance not only of technical solutions, but of social, economic and political determinants of both the problem in the first place, and also the role of social processes in implementing effective interventions.

Some generic recommendations can be made which will contribute to the development of a plan of action for NGOs, donors and the UN Agencies through the Sub-Committee on Nutrition:

Other recommendations that must be prioritised by all agencies include:

In 2001 there were 79 emergencies classified by the US Government (OFDA 2002). Affected populations in very recent years are still showing extremely alarming rates of malnutrition - up to 70% global acute malnutrition in 1998 in southern Sudan (Maxwell 2000) and micronutrient deficiency outbreaks still occur. While there have undoubtedly been advances the humanitarian situation in the twenty first century leaves no room for complacency.

Bibliography

Bhatia R, Thorne-Lyman A. (2001) Food Aid in Emergencies and Public Health Nutrition. Paper presented at the 17th International Congress on Nutrition, Vienna, Austria.
Collins S (2001) The dangers of rapid assessment. Field Exchange Emergency Nutrition Network (ENN) Issue 13: 18- 19.
Grellety Y. (2000). Management of Severe Malnutrition in Africa. Aberdeen: University of Aberdeen, 2000. Harinarayan A (1999) What is Public Nutrition? ENN (Emergency Nutrition Network) Field Exchange (8): 13.
Jaspars S. (2000) Solidarity and Soup Kitchens: A review of principles and practice for food distribution in Conflict. Humanitarian Policy Group. Report 7. August 2000. Marchand E. (2000) Severe Malnutrition: going from Emergency to Post-Emergency Management. MSc Thesis, Dept of Medicine and Therapeutics, University of Aberdeen.
Maxwell S (2000). The application of minimum standards during crisis: A practitioner's perspective, southern Sudan 1998/9. ENN (Emergency Nutrition Network). Field Exchange: 2000 (11): 15-18. OFDA (2002), Internal Records.
Prudhon C, Golden MH, Briend A, Mary JY (1997) A model to standardise mortality of severely malnourished children using nutritional status on admission to therapeutic feeding centres. European Journal of Clinical Nutrition. 51 (11): 771 - 777.
Sen A. (1981) Poverty and Famines: An Essay in Entitlement and Deprivation. Clarendon Press.
Shoham J (1994) Emergency Supplementary Feeding Programmes. Good Practice Review 2. Relief and Rehabilitation Network. Overseas Development Institute. London.
Shoham J (1999) A Review of the 1998/99 Community Managed Emergency Feeding Programme in Singida and Dodoma Region of Central Tanzania. DfID, Nairobi.
Sphere (2000) The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response. 2nd ed. Geneva: Sphere.
Toole M. (1999). An overview of nutrition in emergencies: past, present, and future. Report of Meeting of the Working Group on Nutrition in Emergencies
UNACC/SCN (2000) 4th Report on The World Nutrition Situation. Chapter 5 Nutrition of Refugees and Displaced Populations. United Nations Administrative Committtee on Coordination.
UNHCR (1997) Commodity Distribution; A Practical Guide for Field Staff. UNHCR, Geneva. WFP (1998) Gender Mainstreaming in WFP: An Integrated Assessment. Rome: WFP.
WFP/UNHCR (1997). Memorandum of Understanding on the Joint Working Arrangements for Refugee, Returnee and Internationally Displaced Persons Feeding Operations. Rome and Geneva.
WHO (1999) Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. Geneva: WHO.

This paper was made possible through the support provided to the Food and Nutrition Technical Assistance (FANTA) Project by the Office of Programme, Policy and Management in the Bureau for Democracy, Conflict and Humanitarian Assistance (DCHA) and the Office of Health and Nutrition of the Bureau for Global Programs Field Support and Research at the U.S. Agency for International Development, under terms of Cooperative Agreement No. HRN-A-00-98-00046-00 awarded to the Academy for Educational Development (AED). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.
For further information contact ENN: Fiona@ennonline.net

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