The Management of Severe Malnutrition in Burundi: An NGO's Perspective of the Practical Constraints to Effective Emergency and Medium-term Programmes

The NGO, Action contre la Faim (ACF), has been operating in Burundi since 1994, where the situation has dramatically hampered humanitarian programmes. These include poor security resulting in an inability to maintain 24-hour care for the severely malnourished and poor access to the beneficiaries, all within a politically and economically unstable context. However, ACF has been able to capitalise on lessons learnt and reflect on ways to move forward, which have included the improvement of their capacities in the treatment of severe malnutrition and the integration within broader disciplines and national structures.
The protocols for the treatment of severe malnutrition currently used in Burundi have been developed as a result of the research of ACF over the past five years. Other aspects of the nutrition programme remain to be further developed. These include, for example, an improved capacity to care for severely malnourished adolescents and adults; and also a better knowledge of the beneficiaries to allow for stronger links between the provision of treatment and support for their longer-term food security.     

The management of severe malnutrition in Burundi: an NGO's perspective of the practical constraints to effective emergency and medium-term programmes

The NGO, Action contre la Faim (ACF), has been operating in Burundi since 1994, where the situation has dramatically hampered humanitarian programmes. These include poor security resulting in an inability to maintain 24-hour care for the severely malnourished and poor access to the beneficiaries, all within a politically and economically unstable context. However, ACF has been able to capitalise on lessons learnt and reflect on ways to move forward, which have included the improvement of their capacities in the treatment of severe malnutrition and the integration within broader disciplines and national structures. The protocols for the treatment of severe malnutrition currently used in Burundi have been developed as a result of the research of ACF over the past five years. Other aspects of the nutrition programme remain to be further developed. These include, for example, an improved capacity to care for severely malnourished adolescents and adults; and also a better knowledge of the beneficiaries to allow for stronger links between the provision of treatment and support for their longer-term food security.     

Nutritional Assessments, Food Security and Famine

The widely held view that malnutrition is a late indicator of famine is challenged on the basis of evidence that people often deliberately reduce their food intake as an early response to inadequate food security. This broadens the possible interventions in response to high malnutrition rates to include measures to support livelihoods under threat of collapse. In the late stages of famine, social disruption and distress migration often result in a degraded health environment which may raise the threshold of nutritional status associated with an increased mortality risk. It is important to assess the underlying causes of malnutrition and the associated health risks. At present, the main objective of nutrition surveys is usually to obtain a reliable estimate of the prevalence of malnutrition among children under five years of age, with little analysis of the underlying causes of malnutrition. Experience from the 1984-85 famine in Darfur led to the development of an alternative approach to nutritional assessment which could be applicable elsewhere in Africa. The combination of quantitative and qualitative methods was particularly valuable as a means of gaining a wider and deeper understanding of the nature of the nutritional situation.     

Hunger, poverty and food aid in Sub-Saharan Africa: Retrospect and potential

Frustrations and failures will continue to mount if we do not immediately summon the courage to revise the ways we think and take action-as well as maintaining essential services to support life and health … Saving hundreds of thousands … who are at risk of dying from malnutrition or infection is an immediate imperative. But it must be only one stage in the progress toward other activities, and one element in the truly comprehensive approach… The main intent of this paper is to explore aspects of the nature and evolution of poverty in Sub-Saharan Africa with special reference to food and hunger and their interaction with macro-economic policy. An attempt is made to outline the overall context within which food aid needs to be used in order to have a greater developmental impact. Following an Introductory Section I, Section II provides a sketch map of how recession and lagging food production - with cyclical weather crises superimposed - affect the human condition of poor people. Section III reviews die interaction between "standard" IMF stabilization and World Bank structural adjustment strategies and poverty/hunger. Improvements in the design of stabilization and adjustment programmes, and of the inter-relationship with them of emergency programmes, can be identified. A number turn on the broadened and more innovative or catalytic use of food aid. Section IV reviews aspects of facing a continuing series of emergencies and of designing life support programmes to facilitate rehabilitation of the households directly affected as well as of the national economies. From this base it explores a series of elements in achieving renewed development. The concluding Section seeks to explore the strengths, limitations and potentials of food aid in the context set by the previous sections. The standard criticisms of food aid appear to be overstated and/or to relate to particular modalities or approaches rather than to anything intrinsic. A number of criteria for improving the effectiveness of food aid - especially in respect to rehabilitation, recovery and renewed development - are set out.     

The Changing Nature of Conflict and Famine Vulnerability: The Case of Livestock Raiding in Turkana District, Kenya

The context of famine in Turkana has changed in recent years as the role played by livestock raiding in contributing to famine has increased. External responses to famine in Turkana have largely been drought driven, for example, food assistance and livestock restocking programmes, which have failed to meet the real needs of herders. The role of armed conflict in the form of raiding has been overlooked as a common feature of societies facing famine and food insecurity.The traditional livelihood-enhancing functions of livestock raiding are contrasted with the more predatory forms common today. The direct impact of raiding on livelihood security can be devastating, while the threat of raids and measures taken to cope with this uncertainty undermine herders' livelihood strategies. Self-imposed restrictions on mobility negatively affect the vegetation of both grazed and ungrazed pastures and restrict the available survival strategies. Predatory raiding leads to a collapse in the moral economy. Some implications of this for relief and development policy are considered, including approaches to conflict resolution.     

Determinants of coverage in Community‐based Therapeutic Care programmes: towards a joint quantitative and qualitative analysis

One of the most important elements behind the success of Community‐based Therapeutic Care (CTC) programmes for the treatment of severe acute malnutrition has been their ability to achieve high levels of coverage. In CTC, coverage is measured using the Centric System Area Sampling (CSAS) method, which provides accurate and reliable estimates of programme coverage as well as information on the primary reasons for non‐attendance. Another important feature of CTC programmes is their use of socio‐cultural assessments to determine potential barriers to access and to develop context‐specific responses. By analysing data on non‐attendance provided by CSAS surveys, in conjunction with data from socio‐cultural assessments, it is possible to identify common factors responsible for failures in programme coverage. This paper focuses on an analysis of data from 12 CTC programmes across five African countries. It pinpoints three common factors (distance to sites, community awareness of the programme, and the way in which rejections are handled at the sites) that, together, account for approximately 75 per cent of non‐attendance.     

Methods of increasing food self-sufficiency following disasters in the commonwealth Caribbean*

In the Caribbean, catastrophic events take their toll on food availability through loss of food crops and livestock, disruption in the channels of distribution and loss of foreign exchange earnings from export crops, which are used to procure imported foodstuffs. Nutritional consequences such as the protein energy malnutrition among children, pregnant and lactating women and hard-working males and females are likely to follow. Choice of crops and livestock systems following disasters should be such as to allow for a rapid rehabilitation of the agricultural production and distribution system to eliminate prolonged dependence on food aid. Opportunities should be provided for balanced meal plans including staples, legumes, vegetables, food from animals, fruits, oils and fats. These issues are addressed in this article.     

Social capital and food security in post-conflict rural Lira District,northern Uganda

While a strong relationship has been established between social capital and food security in the research literature, it is uncertain whether this holds in post-conflict situations. This study examines associations between social capital and food security in post-conflict Lira District, northern Uganda. Since factors affecting food security are complex, we explored the roles of households' characteristics in food security outcomes. Data were collected from March to July 2011 through face-to-face interviews with 221 heads of household in rural Lira. Using multinomial logistic regression, a strong positive association was identified between social capital and household food security. The study also found significant associations of food security with sex, education of household head, amount of cultivated land, and farm and home possessions. The results of this analysis can aid the design of food security programmes that empower poor people while targeting the most vulnerable groups, thereby promoting sustainable development in post-conflict communities.     

The Impact of a Reduced and Uncertain Food Supply in Three Besieged Cities of Bosnia-Hercegovina

Nutritional status and household food security were longitudinally monitored in three besieged cities of Bosnia-Hercegovina (Sarajevo, Zenica and Tuzla) during the winter and spring of 1993 to 1994. The objectives were to provide early warning of a deterioration in the food and nutrition situation and identify particularly vulnerable groups so that action could be taken to prevent potential undernutrition and target resources to the most needy. Before the cease-fire, which came into effect at the end of February 1994, trends in various indicators (weight loss, decline of household food stocks, rising food prices, reduction in food aid distribution, sale of possessions) suggested that the situation was deteriorating. Access to food improved as a result of the cease-fire, however, which was reflected in improvements in indicators of food security and weight gain. The impact of, and response to, the food emergency differed between individuals, households and locations; the elderly were found to be more nutritionally vulnerable than children or adults, households with the least access to resources were the most food insecure, while the city of Zenica appeared to be particularly hard hit. The findings show the effects of an uncertain and reduced food supply on a previously well-fed healthy population in an industrialised country. The value and constraints of an Early Warning System set up to monitor trends in an emergency in a European context are discussed.     

Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status

Longitudinal comparison of anthropometric data from cross-sectional surveys is commonly used to assess nutritional status in relief operations. In a refugee camp in Sudan, assessment indicated a high level of childhood malnutrition, but nutritional status appeared relatively unchanged between cluster sample surveys in January (26.3% below 80% of median weight-for-height) and March 1985 (28.4% below 80% of median weight-for-height). However, in this interval, which was marked by irregular food supplies and relatively low energy (calorie) intake as well as by a high incidence of diarrhoeal disease and measles, nearly 13% of all children in the camp died. This deceptive appearance of stability in nutritional status in the face of high mortality may be explained by ongoing nutritional deterioration ("replacement malnutrition") among surviving children. These findings demonstrate that collection and analysis of mortality data are essential for the correct interpretation of anthropometric results during periods of uncertain food supply.     

Matching Food Security Analysis to Context: the Experience of the Somalia Food Security Assessment Unit

This case study reviews the experience of the Somalia Food Security Assessment Unit (FSAU) of operating a food security information system in the context of a complex emergency¹ In particular, it explores the linkages between selected features of the protracted crisis environment in Somalia and conceptual and operational aspects of food security information work. The paper specifically examines the implications of context characteristics for the establishment and operations of the FSAU field monitoring component and for the interface with information users and their diverse information needs. It also analyses the scope for linking food security and nutrition analysis and looks at the role of conflict and gender analysis in food security assessment work. Background data on the food security situation in Somalia and an overview of some key features of the FSAU set the scene for the case study. The paper is targeted at those involved in designing, operating and funding food security information activities.     

Food aid and development in southern Sudan: implications of the Comprehensive Peace Agreement for response planning

In the post-Comprehensive Peace Agreement (CPA) era a greater impact on the unacceptably high prevalence of child malnutrition is more likely to come from additional investment and attention to education, health, hygiene, sanitation and childcare practices than from expanded food aid interventions. The negligible impact of food aid on malnutrition, although most commonly challenged on the quality of needs assessments, is equally attributable to the timing of deliveries, and a dysfunctional distribution system. Comparatively few resources have been allocated to strengthen skills for assessing, analysing and understanding community priorities, local economies, and social safety nets. A more thoughtful allocation of scarce funds could have more impact if a range of alternative responses was considered. Participation in and commitment to a more independent livelihoods analytical forum would improve communication with the new government, local leaders and other partners, as well as providing a platform for reaching consensus on both humanitarian and development planning over the next five years.     

Disasters, Family Tracing and Children's Rights: Some Questions About the Best Interests of Separated Children

Large numbers of children get separated from their families and communities in disasters. Family tracing is an attempt to find the families and assess if the children can be reunited. This paper examines how questions about the rights of children arise in the context of family tracing. It then looks at the challenges posed by effective and child sensitive tracing to both emergency and development programmes. The paper suggests that traditional coping mechanisms within communities are part of the social infractructure which all disaster intervention, including family tracing programmes, need explicitly to build on and repair.     

Rapid Nutrition Surveys: How Many Clusters are Enough?

On the basis of theoretical considerations, population-based nutrition surveys of 30 clusters of 30 children should provide reasonably valid estimates of the prevalence of malnutrition with at least 95 per cent confidence that the estimated prevalence differs from the true value by no more than 5 per cent. In areas of famine in Africa, where an urgent need often exists for rapid nutritional assessment to determine the extent and severity of the problem, visiting 30 sites is often logistically difficult. To determine the effects of using fewer than 30 clusters on the validity and precision of the estimated level of undernutrition, we used data from the 1983 Swaziland National Nutrition Survey and from rapid nutrition surveys performed in 1984 and 1985 in Burkina Faso, Guinea, and Niger. Fewer than 30 clusters may result in point prevalence estimates that differ dramatically from the true prevalence and, in most instances, are less precise. In contrast, little is gained by collecting more than 30 clusters. In summary, around 30 clusters provides relatively valid and precise estimates of the prevalence of undernutrition, and every effort should be made to obtain the logistic support required to study this number of clusters.     

Monitoring Local Food Security and Coping Strategies: Lessons from Information Collection and Analysis in Mopti, Mali

Save the Children Fund (UK) established a local food security monitoring project in the Mopti region of Mali, which was operational between 1987 and 1993. This article describes some of the lessons learnt from this experience of monitoring food security and coping strategies. It illustrates how coping strategies can be an important element in tracking vulnerability in the Sahel, but that interpretation is complex and there are limitations to their use. Secondly, consideration must be given to the institutional context in which information systems are set up. Information providers must be linked institutionally to response mechanisms, to ensure that data are fed systematically into the design, implementation and monitoring of appropriate response.     

Composite indicators for famine early warning systems

Traditional famine early warning systems use a host of indicators to predict food crisis situations, from rainfall and increased rate of marketing of household durables to the behavior of birds and animals. Although many of these indicators are valid in general, limited understanding of the sensitivity and specificity of the distress signals makes food crisis prediction a highly subjective exercise. In order to make the system more effective and credible, we need to identify a limited number of 'composite' indicators, which naturally summarize most relevant food-related information contained in the specific predictors of food crisis. Considering the chronology of the food production and consumption chain, three composite indicators specific to three different stages of the chain have been identified. The satellite data based Normalized Deviation of Vegetative Index (NDVI), prices of major food grains, and malnutrition rates are found to be correlated not only with the quality and quantity of inputs of this process but also with the final outcome. Both NDVI and price data are widely used as important predictors of food crisis by famine warning systems. What we have demonstrated is that improved sensitivity of the indicators is likely to be due to their inherent capability of summarizing information from various specific measures. Child malnutrition rates also summarize inputs and outputs of the food consumption process very effectively, and therefore should be able to predict community level food crisis in an efficient manner. The empirical results confirm this conjecture by showing that malnutrition rates can predict food crisis probability three months into the future with a high degree of specificity. The use of 'composite' indicators not only simplifies the problem of aggregation, but is also likely to yield forecasts that are highly specific and sensitive.     

Malnutrition and anaemia among Somali refugee children in long term camps

In a long term Somali refugee camp where nutritional and general health status of children is now considered satisfactory and stable, a randomized community based survey of 300 children under five years was undertaken. Results indicate that the prevalence of protein-energy malnutrition is rising again: 17.3% of children are <80% median weight/height and 1.7% are <70%median weight/height. In addition, there is a high prevalence of anaemia: 50.5% have a haemoglobin level <9g% and 10.8%≤6g%. This cannot be explained by chronic malaria as the spleen rate is only 2%. Stool examination of 161 children show 29.8% to have evidence of Giardia Lamblia infection but this is not statistically correlated with either anaemia or with protein-energy malnutrition. Other potentially pathogenic parasites are uncommon and no hookworm is seen. Examination of blood films of anaemic children shows hypochromia as a striking feature.
It is concluded that nutritional deficiencies are a likely major factor in the aetiology of the anaemia. Both protein-energy malnutrition and anaemia seem related to the weaning period. Food rations for refugees, although adequate for short term needs, may be qualitatively deficient for long term subsistence, especially as regards young children.     

Resilience from the ground up: how are local resilience perceptions and global frameworks aligned?

Numerous resilience measurement frameworks for climate programmes have emerged over the past decade to operationalise the concept and aggregate results within and between programmes. Proxies of resilience, including subjective measures using perception data, have been proposed to measure resilience, but there is limited evidence on their validity and use for policy and practice. This article draws on research on the Decentralising Climate Funds project of the Building Resilience and Adaptation to Climate Extremes and Disasters programme, which supports communities in Mali and Senegal to improve climate resilience through locally controlled adaptation funds. It explores attributes of resilience from this bottom‐up perspective to assess its predictors and alignment with food security, as a proxy of well‐being. We find different patterns when comparing resilience and the well‐being proxy, illustrating that the interplay between the two is still unclear. Results also point to the importance of contextualising resilience, raising implications for aggregating results.