Nutrition, Disease and Death in Times of Famine

In this article we review the relationship between malnutrition and mortality, and the interaction of morbidity, with the aim of clarifying the health risks of malnutrition in situations of famine and food insecurity. Apart from reviewing what is known about this relationship, we highlight areas where further research is needed. Among refugee and famine affected populations living in camps, there appears to be a close association between high rates of malnutrition and excess mortality. Results from communitybased prospective studies of malnutrition and mortality among individuals conclude that as nutritional status declines the risk of death increases, although the discriminating power of different nutritional indices and the strength of the association varies considerably in different locations and at different times. These differences are attributed mainly to the different prevailing patterns of morbidity and growth failure, which are influenced by both environmental and social factors. In situations of famine and population displacement, the deterioration in the health environment increases exposure to infection and is likely to raise the threshold of nutritional status which corresponds to an increased risk of mortality. This has important implications for nutritional assessments and interventions.     

Food Aid and Nutritional Programmes During the Rwandan Emergency

In contrast to several other recent emergencies¹, the response of the international relief community to the Rwandan emergency appears largely to have prevented widespread malnutrition and related mortality. While it is true that aspects of the response in the food and nutrition sector were in various ways open to criticism and may have contributed to unnecessarily high levels of wasting in some camps at various points in time, the appalling excesses of famine witnessed in other recent African crises was not revisited during this emergency. Indeed, the main factors contributing to mortality and morbidity during the Rwandan emergency were violence and epidemics rather than lack of food and nutritional support.     

Malnutrition and Poverty in the Early Stages of Famine: North Darfur, 1988–90

In this article we report findings on the relationship between malnutrition and poverty during a period of acute food insecurity in Darfur, Sudan. Children of rich and poor families were equally likely to be malnourished, which is explained in terms of people's responses to the threat of famine. This finding has important implications for targeting interventions in the early stages of famine. Appropriate interventions at the early stages of famine are livelihood and income support to the most vulnerable. The entitlement theory of famine causation assumes that the poor are most vulnerable, and become malnourished and die during famines. In this article we show that this assumption does not hold. Even though poverty is the root cause of malnutrition, it does not follow that anthropometric status can be used to target individual poor families, or even that targeting the poor is appropriate in famine situations.     

An Examination of the 1990-91 Famine in Sudan

Shortly before and during the harvest of 1990, a series of warnings were issued by concerned international and UN agencies that Sudan would experience a very poor harvest followed by an acute food shortage over the period 1990-91. The 1990 harvest was estimated to be similar to that obtained in 1984. After the very poor harvest in 1984, Sudan experienced a major famine during which deaths may have numbered in the hundreds of thousands. There were fears that this experience might be repeated in 1990 - 91. By the time of the subsequent 1991 harvest, it was clear to all that a severe food crisis had been experienced. There were severe shortages of water and food and very high malnutrition rates of children were noted by UNICEF across a wide range of areas. Despite these adverse indications, starvation deaths were probably numbered in thousands, rather than hundreds of thousands. Famine mortality, which may include deaths from famine associated disease, was similarly low. The initial predictions, it now seems, may have over-estimated famine mortality almost one hundred times. Several potential explanations of the over-estimate are examined. These include prediction errors, government and donor responses to the drought such as food aid and immunization, and traditional community and household level coping strategies in times of food shortage.     

The social context of childcare practices and child malnutrition in Niger's recent food crisis

In 2004–05, Niger suffered a food crisis during which global attention focused on high levels of acute malnutrition among children. In response, decentralised emergency nutrition programmes were introduced into much of southern Niger. Child malnutrition, however, is a chronic problem and its links with food production and household food security are complex. This qualitative, anthropological study investigates pathways by which children are rendered vulnerable in the context of a nutritional 'emergency'. It focuses on household-level decisions that determine resource allocation and childcare practices in order to explain why practices apparently detrimental to children's health persist. Risk aversion, the need to maintain self-identity and status, and constrained decision making result in a failure to invest extra necessary resources ingrowth-faltering children. Understanding and responding to the social context of child malnutrition will help humanitarian workers to integrate their efforts more effectively with longer-term development programmes aimed at improving livelihood security.     

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.     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.     

The Prevention and Mitigation of Famine: Policy Lessons from Botswana and Sudan

Botswana and Sudan experienced consecutive years of drought in the 1980s. Sudan faced a large decline in food entitlement and nutritional deterioration, which translated into famine in 1984/85. Botswana, on the other hand, nearly compensated income losses and averted nutritional deterioration and famine-related deaths. There are important lessons to learn from the famine prevention experience of Botswana. Its strategy for dealing with drought and famine combines policies of steady economic growth with supplementary poverty alleviation and drought relief programs. To provide continuity and stabilization of market operations in times of distress, the country channels sufficient food through market chains, provides price support to preempt market collapse and augments the income of consumers through public income transfer programs to prevent demand failure. In addition, it maintains a responsive and accountable political system and a decentralized participatory administrative structure. While Sudan should develop policies that are compatible with its own environment, it is crucial that it recognizes the critical role of public action in promoting growth, alleviating poverty, and providing timely relief responses in times of anticipated growth failure.     

Reducing vulnerability to drought and famine: developmental approaches to relief

In this paper we present salient lessons learned through the International Relief/Development Project about the relationships between disasters and development. We discuss approaches to famine response and prevention, including the impact of global food distribution efforts on the capacities of people affected by famine and offer criteria for planning famine relief so that it will promote systemic, long term development of these capacities. We first describe a collaborative research project which showed that it is possible for international famine assistance either to promote the capacities of people who suffer from famine so that they are better able to handle future food crises, or to leave those it purports to help worse off and even more vulnerable to subsequent disasters. We then illustrate alternative strategies for promoting development in the midst of crisis by presenting information about a number of famine response programs and analyzing their impact on capacities and vulnerabilities.     

Food as an instrument of war in contemporary african famines: a review of the evidence

Famine is conventionally portrayed as a natural disaster expressed in terms of food scarcity and culminating in starvation. This view has attracted criticism in recent years as the political, legal and social dimensions of famine have become more clearly understood. This paper draws upon these criticisms to understand the particular conditions of famine creation in conflict situations. Following an examination of six contemporary African famines, it is suggested that the use of food as a weapon of war by omission, commission and provision has contributed to the creation of famine in recent decades. Despite the optimism for peace engendered by the demise of the Cold War, the momentum for conflict would seem to be sustained by internal factors, including economic and environmental decline, political instability and ethnic rivalry. Within these conflicts, the strategic importance of food is likely to remain central. This study highlights the need to link concerns with food security and public health to those of development, human rights and international relations.     

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.     

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.     

Northern Sudan in 1991: Food Crisis and the International Relief Response

By the end of 1991, less than half the amount of relief food requested for North Sudan at the beginning of the year had been delivered. Despite ample evidence of social and economic stress and high rates of child malnutrition, many donors felt that relief needs had been exaggerated, and were unwilling to accept that relief assistance was urgently needed. The feeble response of the main food aid donors is explained initially by the politics of relief in 1990/91, which seriously delayed the launch of the relief operation. These problems were compounded by an oversimplified understanding of famine among some sections of the relief community, and by the orientation of the international relief system to crisis indicators. Toward the end of 1991, donors argued that despite the shortfall in relief assistance there had been no deaths from starvation, and therefore local people had 'coped' better than expected. This paper challenges that view by arguing that excess deaths did occur, but went unnoticed and unremarked. Local people's 'coping strategies', which supposedly 'saved the day', actually had very negative and sometimes fatal consequences.     

中国近代灾荒史理论探析

中国近代灾荒史是中国灾荒史的断代史.中国近代灾荒史作为一个研究的有机系统,是由灾害、灾荒、灾因、灾荒社会问题、灾荒救治等子系统组成,各系统又有自己的组成要素,这些架构了中国近代灾荒史的学科体系.中国近代灾荒史与灾害学、社会学、经济史、政治军事史、外交史之间有密切的关系,深入研究中国近代灾荒史,加强灾荒史教育,对今天防灾...     

Famine intensity and magnitude scales: a proposal for an instrumental definition of famine

Ambiguities in current usage of the term "famine" have had tragic implications for response and accountability in a number of recent food crises. This paper proposes a new approach to defining famine based on the use of intensity and magnitude scales, where "intensity" refers to the severity of the crisis at a given location and point in time, while "magnitude" describes the aggregate impact of a crisis. The scales perform three operations on "famine": first, moving from a binary conception of "famine/no famine" to a graduated, multi-level definition; second, disaggregating the dimensions of intensity and magnitude; and third, assigning harmonised "objective" criteria in place of subjective, case-by-case judgements. If adopted, the famine scales should contribute to more effective and proportionate responses, as well as greater accountability in future food crises.     

Malnutrition among the Akamba of Kenya -Problem or response to a problem?

Two recent studies amongst the Kenyan Akamba are contrasted to illustrate how malnutrition can be regarded either as a response to a problem in the local environment, or as the problem itself, arising from general conditions of poverty and ignorance. Differences in methodology are compared and it is shown that nutrition studies often ignore local factors in reaching conclusions on nutritional status. Consequently, nutrition policy recommendations provide general solutions of limited value. It is suggested that factors in the local environment which may cause malnutrition be investigated by hypothesis testing, in order to provide specific information for community-based action.
The category of the poor is not merely inadequate for evaluative exercises and a nuisance for causal analysis, it can also have distorting effects on policy matters. On the causal side, the lack of discrimination between different circumstances leading to poverty gives rise to a lack of focus in policy choice.     

Mortality and morbidity in refugee camps in eastern Sudan: 1985-90

Civil war has disrupted life in Ethiopia since the 1960s and many people have sought refuge in Eastern Sudan, particularly during the famine emergency of 1984–85. UNHCR has provided the main financial support for the refugee programme, but began scaling down operations in 1990. Nearly 300,000 refugees still live in camps and benefit from food and health programmes. Health services are co-ordinated by the Sudanese Refugee Health Unit which operates a centralised health and nutrition surveillance system with the co-operation of the NGOs responsible for health care in the camps. A revision of the monthly reporting system and the establishment of a computer database in 1990 provided an opportunity to review the situation in the camps over the five years since the emergency. Child death rates for example, appear to have been reduced to levels below those expected in rural Africa. Patterns of mortality, morbidity, and nutritional status are outlined here and point to the general effectiveness of the health care programme. The surveillance system can, however, be used to identify those camps which have persistent problems, while monthly comparisons with the situation in previous years can provide early warning of deteriorating conditions.     

Nutritional risk factors for older refugees

This study describes risk factors for poor nutrition among older Rwandan refugees. The most important areas of nutritional risk for older refugees are: physical ability and mobility; income and access to land; access to appropriate food rations; meeting basic needs such as water, fuel, shelter; equal access to essential services (food distribution, health services, mills, feeding programmes); and psycho-social trauma. Women and older elderly (> 70 years) are significantly more often in disadvantaged positions, such as having poor socio-economic status, poor health, poor mobility, lower food intake, diminished social status, respect and social network. Older refugees are at higher risk than younger refugees and at higher risk than older people in stable situations. They should remain in good nutritional and general health for their own well-being and that of their dependants. In addition to an adequate diet, a support network seems to be an important preventive aspect.