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.     

Cholera in Sudan: An account of an epidemic in a refugee camp in eastern Sudan, May-June 1985

In 1985 cholera has been a serious problem in the horn of Africa, particularly affecting the many famine victims and refugees in that region. In this paper the history of cholera in Africa is briefly summarized, as is the background to the current refugee situation in eastern Sudan. A cholera epidemic involving 1,175 cases in two adjacent refugee camps in eastern Sudan is described. In this epidemic there were thirteen inpatient deaths and thirty-eight known home deaths from cholera. The management of the epidemic is described in detail. Overall an average of 8 1. of intravenous fluid was used per case, a higher figure than was anticipated, probably because of the unexpected degree of vomiting and the shortage of trained nursing staff.
The relationship between cholera and malnutrition is explored and hypochlorhydria is suggested as the main reason for the increased susceptibility to cholera among malnourished populations. It was observed that severely malnourished adults and children appeared to nave less severe diarrhoea with their cholera, presumably because of reduced mucosal surface area and poor enterocyte function. Finally possible means of aborting cholera epidemics are discussed.     

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.     

Zimbabwe's Child Supplementary Feeding Programme: a re-assessment using household survey data

In 1992-3 and 1995-6, Zimbabwe used a Child Supplementary Feeding Programme (CSFP) to combat child malnutrition during drought-induced emergencies. Previous evaluations of the CSFP relied on routine administrative data and key informant interviews and made only cursory use of available household survey data. These evaluations concluded that the CSFP was effective in preventing an increase in malnutrition among children under five, especially in 1992-3. The more-detailed analysis of household surveys provided in this article suggests that CSFP coverage was generally patchy and disappointingly low, especially in 1995-6. There is little evidence that children from poor or nutritionally vulnerable households got preferential access to supplementary feeding. The CSFP failed to feed many malnourished and nutritionally vulnerable children even in areas where the programme was operating. Household survey evidence suggests that the CSFP's impact on nutritional status was likely marginal, especially in 1995-6.     

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.     

Targeting the Vulnerable: A Review of the Necessity and Feasibility of Targeting Vulnerable Households

This article examines whether it is possible to target vulnerable households within a geographically defined area. It looks first at the justification for targeting and then reviews recent practical experience in actually trying to reach vulnerable groups. As complex emergencies increasingly last longer, strategies to target vulnerable households are common in the protracted phase of the emergency. While this is often necessary because of a decline in resources, it is not always justified by an improvement in nutritional status or food security of the beneficiary population.
Common target groups are the poor and the malnourished, but in complex emergencies these are not always the most vulnerable. Moreover, recent practical experience has shown considerable difficulties in targeting the poor. Methods to target the poor rely on community-based relief committees, whose priorities are not necessarily the same as those of external agencies. This paper gives examples of such targeted assistance programmes in Kenya, south Sudan and Tanzania. The paper concludes that situations where targeting vulnerable households is justified and feasible are extremely limited. It is suggested that if targeting has to be done because of scarce resources, this should be done on a geographical basis and on the basis of nutritional status. Case-study material shows that it is essential to understand the political determinants of vulnerability and to design methods that will reach the most vulnerable.     

Targeting the vulnerable: a review of the necessity and feasibility of targeting vulnerable households

This article examines whether it is possible to target vulnerable households within a geographically defined area. It looks first at the justification for targeting and then reviews recent practical experience in actually trying to reach vulnerable groups. As complex emergencies increasingly last longer, strategies to target vulnerable households are common in the protracted phase of the emergency. While this is often necessary because of a decline in resources, it is not always justified by an improvement in nutritional status or food security of the beneficiary population. Common target groups are the poor and the malnourished, but in complex emergencies these are not always the most vulnerable. Moreover, recent practical experience has shown considerable difficulties in targeting the poor. Methods to target the poor rely on community-based relief committees, whose priorities are not necessarily the same as those of external agencies. This paper gives examples of such targeted assistance programmes in Kenya, south Sudan and Tanzania. The paper concludes that situations where targeting vulnerable households is justified and feasible are extremely limited. It is suggested that if targeting has to be done because of scarce resources, this should be done on a geographical basis and on the basis of nutritional status. Case-study material shows that it is essential to understand the political determinants of vulnerability and to design methods that will reach the most vulnerable.     

The 1998 Flood in Bangladesh: Is Different Targeting Needed During Emergencies and Recovery to Tackle Malnutrition?

Bangladesh suffered the century's worst flood during July-October 1998 and appealed for assistance. To provide information for appropriate interventions to tackle nutritional problems, a rapid assessment survey was conducted to look at the nutritional situation, problems encountered by the community, their coping mechanisms and rehabilitation priorities in six rural areas. The survey was repeated after four months to measure the outcome of activities during the flood and the necessity for future assistance. There were 3,048 children measured in both surveys (1,597 and 1,451). The sample of most interest was a sub-group of 180 children present in two previous independent surveys. The analysis found that while moving from the crisis period to post-flood phase there was evidence of a 'crossover phenomenon' in the recovery pattern of nutritional status. Sixty-eight per cent of the children who were malnourished (WHZ < -2SD) during the crisis period (18 per cent) recovered enough to cross the cut-off point and became normal after four months. Another 8 per cent of children (9 per cent of all normal) who were normal during the crisis period, after four months had deteriorated to be malnourished. Thus, despite there being a shift in the overall distribution of nutritional status, there has been another shift that reduced the net effect. Subsequent episodes of diarrhoea, access to food and loan burden had also influenced the recovery pattern of the children's nutritional status as evident from the statistically significant associations. These findings raise questions about targeting acute malnutrition during emergencies, and using the same criteria during both the crisis and rehabilitation phases.     

Reflections: Resolving conflicting demands within disaster risk and recovery

This ‘reflection’ describes conflicting experiences, drawn from the author’s career in varied aspects of disaster risk management and recovery (1973–2016) delving into his memory, Ian Davis explores conflicts he has felt in four parallel roles he has adopted as architect, NGO board member, academic and the personal challenges he has faced working within the humanitarian sector. After describing these encounters, some practical solutions are suggested. The reflection concludes with a suggestion that at the root of these conflicts there is a need for people working in the humanitarian field to become more accountable in a downward direction towards those they seek to serve, who often lack power and influence. These include an architect’s clients, the beneficiaries of an NGO’s concern, an academic’s students or trainees and more broadly an ethical challenge that the author strives after, to regard his work as a vocation, highlighting the need for service to others rather than self-promotion.     

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.     

大型海啸灾害后重伤员批量护理风险建模研究

大型海啸灾害等自然灾害的发生产生了大量重伤员,所以研究大型海啸灾害后重伤员的批量护理风险建模极为重要。通过大型海啸灾害救治流程预案启动和重伤员批量护理实施方法两部分研究大型海啸灾害后重伤员批量护理方法,并提出通过前馈控制性管理防范护理风险。提升护理风险管理的科学性以及全面性。通过护理风险防范预案提升重伤员护理质量将大型海啸灾害后批量重伤员护理风险降至最低。通过护理风险防范预案提升重伤员护理质量等降低重伤员批量护理风险的措施,使得大型海啸灾害后的急救工作可快捷有序完成,赢得重伤员抢救的黄金时间。     

Livelihoods,power, and food insecurity: adaptation of social capital portfolios in protracted crises—case study Burundi

The failure of food security and livelihood interventions to adapt to conflict settings remains a key challenge in humanitarian responses to protracted crises. This paper proposes a social capital analysis to address this policy gap, adding a political economy dimension on food security and conflict to the actor‐based livelihood framework. A case study of three hillsides in north Burundi provides an ethnographic basis for this hypothesis. While relying on a theoretical framework in which different combinations of social capital (bonding, bridging, and linking) account for a diverse range of outcomes, the findings offer empirical insights into how social capital portfolios adapt to a protracted crisis. It is argued that these social capital adaptations have the effect of changing livelihood policies, institutions, and processes (PIPs), and clarify the impact of the distribution of power and powerlessness on food security issues. In addition, they represent a solid way of integrating political economy concerns into the livelihood framework.     

Representing Refugees: The Role of Elites in Burundi Refugee Society

Among Burundi refugees in Tanzania, men who have a university education and know English or French are most likely to represent their concerns to officials, particularly those from UNHCR. Officials consequently learn about the perspectives of refugees from these men. Based upon findings from two years of field, research in Tanzania, the history of relations between ethnic Hutu elites and the peasantry in Burundi is outlined and it is explained why education has assumed such pronounced significance in Burundi refugee society. The use of ethnicity as a political tool for elite refugees is also described. It is concluded that elite refugees may not, as is often claimed, represent the refugee majority.     

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.     

Moving from the 'why' to the 'how': reflections on humanitarian response in urban settings

Given the rising numbers of crises in urban settings, Médecins Sans Frontières (MSF) is currently shifting its focus from 'why' it should intervene to 'how' it should intervene effectively in these contexts. Beyond communities affected by natural disasters and epidemics, MSF has chosen to target populations in urban settings that are affected by violence or by marginalisation and neglect: these groups appear to suffer the greatest number of severe threats to their health and well-being. Recent reflection within MSF has identified a number of key operational challenges to confront in order to respond efficiently to the needs of these populations. These include: appropriate assessments; measurable indicators of vulnerability and impact; pertinent operational approaches and medical strategies; adapted security management; and responsible closure of activities. This paper summarises the main lessons learned from working in urban settings with the principal aim of mutual sharing and understanding.     

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.     

THE DEVELOPMENT AND PRACTICE OF EMERGENCY AND DISASTER MEDICINE IN THE UNITED STATES

Accidents and sudden illness constitutes a major public health problem in many countries. Emergency medicine had developed as a vigorous new specialty in the U.S. and has fully integrated itself within the American medical and hospital system to provide improved emergency medical care. Emergency medicine plays a central role in disaster medical services, planning, and management and is the only specialty in American civilian medicine that includes disaster medicine as a primary field within its domain. Now that the basic framework of emergency medicine has been established, the American College of Emergency Physicians is implementing a nationwide training program on disaster planning and management for emergency physicians.     

大同—阳高地震灾害评估及灾因分析

本文记述了大同—阳高地震震害情况,同时对造成灾害的原因进行了分析,认为此次地震震级不大而损失严重的主要原因除了与地震持点和发震构造有关之外,还与当地民舍抗震性能差、施工质量低有直接关系。     

Food Security in Protracted Crises: Building More Effective Policy Frameworks

This paper considers the principal elements that underpin policy frameworks for supporting food security in protracted crisis contexts. It argues that maintaining the food entitlements of crisis-affected populations must extend beyond interventions to ensure immediate human survival. A 'policy gap' exists in that capacities for formulating policy responses to tackle the different dimensions of food insecurity in complex, fluid crisis situations tend to be weak. As a result, standardised, short-term intervention designs are created that fall short of meeting the priority needs of affected populations in the short and long term and only partially exploit the range of policy options available. The paper discusses key attributes of agency frameworks that could support more effective policy processes to address longer term as well as immediate food security needs. Additionally, it points to some main challenges likely to be encountered in developing such frameworks and, with the participation of beneficiaries, translating them into effective action.     

Why the poor pay with their lives: oil pipeline vandalisation, fires and human security in Nigeria

Since its discovery in Nigeria in 1956 crude oil has been a source of mixed blessing to the country. It is believed to have generated enormous wealth, but it has also claimed a great many lives. Scholarly attention on the impact of oil on security in Nigeria has largely focused on internal conflicts rather than on how disasters associated with oil pipeline vandalisation have impacted on human security in terms of causing bodily injuries and death, destroying livelihoods and fracturing families. This paper examines how pipeline vandalisation affects human security in these ways. It identifies women and children as those who are hardest hit and questions why the poor are the most vulnerable in oil pipeline disasters in this country. It recommends the adoption of a comprehensive and integrated framework of disaster management that will ensure prompt response to key early warning signs, risk-reduction and appropriate mitigation and management strategies.