Public nutrition in emergencies: an overview of debates, dilemmas and decision-making

This paper introduces and discusses the main themes and issues arising from the workshop 'International Public Nutrition in Emergencies: The Potential for Improving Practice'. Good co-ordination within the nutrition sector of the international humanitarian response system has led to a range of achievements in recent years. Major constraints to improving programme impact remain, however, including misconceptions about the scope of nutrition among the wider humanitarian system, which tends to give it a narrow focus on malnutrition and feeding people. In contrast to this limited view, the Public Nutrition approach brings a more broad-based emphasis to assessing and responding to nutritional problems in emergencies, and takes into account the wider social, economic and political causes of malnutrition. Six case study presentations illustrated the various components of a Public Nutrition approach, including in-depth assessment, analysis and tailoring programmes accordingly. Additional presentations considered the nature of vulnerability, the concept of Public Nutrition, the responsibilities for addressing nutritional problems and some of the operational tools and frameworks in current use. Participants agreed on the necessity of raising levels of awareness and understanding among all actors in the humanitarian sphere about the impact of their actions on nutrition. Strategies for achieving this included developing better multi-sectorial working relationships and also strengthening relationships with donors and key decision-makers in the humanitarian system. Other related strategies included institutional learning, training and capacity building, particularly in relation to institutions based in developing countries and building upon initiatives such as the Sphere Project, which has successfully brought together the various actors within the humanitarian system in order to improve quality of response.     

A Measure of Uncertainty: The Nature of Vulnerability and Its Relationship to Malnutrition

Terms such as 'vulnerability' and 'insecurity' are used widely in the general nutrition literature as well as in work on humanitarian response. Yet these words are used rather loosely. This paper argues that more clarity in their usage would benefit those seeking a bridge between development and humanitarian problems. Since vulnerability is not fully coincident with malnutrition, poverty or other conventional indices of human deprivation, public action must be based on a better understanding of the nature of crises and human uncertainty beyond physiological and nutritional outcomes. More attention is needed to be paid to the context-specific nature of risks, the capacity of households to manage such risks and the potential for public action to bolster indigenous capacity through targeted development investments, not just relief.     

A measure of uncertainty: the nature of vulnerability and its relationship to malnutrition

Terms such as 'vulnerability' and 'insecurity' are used widely in the general nutrition literature as well as in work on humanitarian response. Yet these words are used rather loosely. This paper argues that more clarity in their usage would benefit those seeking a bridge between development and humanitarian problems. Since vulnerability is not fully coincident with malnutrition, poverty or other conventional indices of human deprivation, public action must be based on a better understanding of the nature of crises and human uncertainty beyond physiological and nutritional outcomes. More attention is needed to be paid to the context-specific nature of risks, the capacity of households to manage such risks and the potential for public action to bolster indigenous capacity through targeted development investments, not just relief.     

Nutritional response to the 1998 Bangladesh flood disaster: Sphere minimum standards in disaster response

In this study we use a cross-sectional survey to evaluate the nutritional response to the 1998 Bangladesh Flood Disaster by 15 relief agencies using standards developed by the Sphere Project. The Sphere Project is a recent attempt by agencies around the world to establish universal minimum standards for the purpose of ensuring quality and accountability in disaster response. The main outcomes measured were resources allocated to disaster relief types of relief activities and percentage of agencies meeting selected Sphere food aid and nutrition indicators. Although the process of nutritional response was measured, specific nutritional and health outcomes were not assessed. This review found that self-reported disaster and nutritional resources varied widely between implementing agencies, ranging from US $58,947 to $15,908,712. The percentage of resources these agencies allocated to food aid and nutritional response also varied, ranging from approximately 6 to 99 per cent of total resources. Agencies met between 8 and 83 per cent of the specific Sphere indicators which were assessed Areas in which performance was poor included preliminary nutritional analysis; beneficiary participation and feedback; disaster preparedness during non-emergency times; monitoring of local markets and impact assessment. Agencies were generally successful in areas of core humanitarian response, such as targeting the vulnerable (83 per cent) and monitoring and evaluating the process of disaster response (75 per cent). The results here identify both strengths and gaps in the quality of humanitarian response in developing nations such as Bangladesh. However, they also raise the question of implementing a rights-based approach to disaster response in nations without a commitment to meeting positive human rights in non-disaster times.     

Public Nutrition from an Approach to a Discipline: Concern's Nutrition Case Studies in Complex Emergencies

The Public Nutrition approach, like that of Public Health, is context specific. It places an emphasis on populations rather than individuals and is inter-disciplinary in nature. Both approaches seek to understand the complex aetiology of a clinical outcome such as malnutrition within the widest possible framework. Public Nutrition uses the UNICEF conceptual framework and adapts and expands it. The authors of this article argue – through the examination of a number of case studies taken from the work of Concern Worldwide (hereafter referred to as Concern) in southern Sudan, Rwanda, Angola, Tanzania and DRC – that there are two critical constituents of the Public Nutrition approach. These are: a contextual analysis (including the use of surveillance information for programme design and advocacy) and community involvement at all stages of the project cycle. Some of the key obstacles to the adoption of the Public Nutrition approach are identified by illustrating two practical programme settings. For the Public Nutrition approach to be more widely used, the authors recommend a number of key strategies including the further dissemination of case studies and the clarification of the scope and boundaries of the approach. These strategies will enable Public Nutrition to evolve both as a practical programme framework as well as an academic discipline.     

Public nutrition from an approach to a discipline: concern's nutrition case studies in complex emergencies

The Public Nutrition approach, like that of Public Health, is context specific. It places an emphasis on populations rather than individuals and is inter-disciplinary in nature. Both approaches seek to understand the complex aetiology of a clinical outcome such as malnutrition within the widest possible framework. Public Nutrition uses the UNICEF conceptual framework and adapts and expands it. The authors of this article argue--through the examination of a number of case studies taken from the work of Concern Worldwide (hereafter referred to as Concern) in southern Sudan, Rwanda, Angola, Tanzania and DRC--that there are two critical constituents of the Public Nutrition approach. These are: a contextual analysis (including the use of surveillance information for programme design and advocacy) and community involvement at all stages of the project cycle. Some of the key obstacles to the adoption of the Public Nutrition approach are identified by illustrating two practical programme settings. For the Public Nutrition approach to be more widely used, the authors recommend a number of key strategies including the further dissemination of case studies and the clarification of the scope and boundaries of the approach. These strategies will enable Public Nutrition to evolve both as a practical programme framework as well as an academic discipline.     

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.     

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.     

The moral sense of humanitarian actors: an empirical exploration

This paper examines humanitarianism's moral positioning above private and political interests to save lives and alleviate suffering. It does not aim to assess the legitimacy of this stance, but rather to probe the way in which humanitarian actors relate to this moral dimension in their everyday work. It investigates empirically humanitarian ethics from the perspective of humanitarian actors, drawing on interviews conducted in Beirut, Lebanon, in 2014. As it is exploratory, three key conceptual innovations were required. The first of these is the introduction of the tools developed to consider a neglected reality: humanitarian actors’ ‘moral sense’ vis‐à‐vis the humanitarian sector's ‘moral culture’. Second, the study shows how the sector's moral culture is structured around the notion of ‘concern for persons in need’. Third, it analyses the way in which the sector and its actors handle the asymmetrical relationships encountered daily. Ultimately this paper seeks to valorise humanitarian actors’ creativity in their common practices and explore potential challenges to it.     

Between international donors and local faith communities: Intermediaries in humanitarian assistance to Syrian refugees in Jordan and Lebanon

This paper explores the crucial part that faith‐based organisations (FBOs) play in acting as intermediaries between international donors and local faith communities (LFCs) implementing humanitarian relief projects for Syrian refugees. Humanitarian responses to the mounting Syrian refugee crisis have coincided with greater collaboration between international donors and LFCs. This cooperation often is facilitated by a complex web of non‐state intermediaries at the international, national, and local level. This study probes the breadth of roles of these intermediaries, drawing on primary data from case studies of two Christian intermediaries supporting Christian LFCs as they deliver aid primarily to Muslim Syrian refugees in Jordan and Lebanon. The results of the study are connected to the wider literature on LFCs in humanitarian response, revealing how intermediaries address issues of accountability, capacity‐building, impartiality, neutrality, and professionalism. The paper concludes by offering suggestions for further research on intermediaries as key actors in the localisation of humanitarian assistance.     

Still falling short: protection and partnerships in the Lebanon emergency response

The Israeli–Hezbollah conflict in the summer of 2006, although brief, had a lasting impact on the region and prompted an intense humanitarian response. The conflict raised challenging questions for the United Nations (UN) about how to assist a middle‐income yet extremely vulnerable population in a context where global and local relations are highly politicised. This paper focuses on two key questions that emerged from the humanitarian response. First, how can humanitarian agencies, and particularly the UN, improve the protection of civilians, and was what they did in Lebanon enough? Second, how can humanitarian agencies create partnerships with local actors and still remain true to core humanitarian principles when local actors are fiercely divided along confessional lines and influenced by external actors, and when some, such as Hezbollah, are parties to the conflict? This paper argues that despite the importance of protection and partnerships to the humanitarian response, their role in the UN emergency response still falls short.     

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.     

Putting affected people at the centre of humanitarian action: an argument for the principle of humanitarian subsidiarity

The humanitarian system has grown organically over the course of a generation to become a complex system bound by a common primary mandate. Its guiding principles provide it with a unique identity and separate humanitarian actors from other aid-related stakeholders. However, all of the evidence suggests that humanitarian actors will extend their reach and engage in new and unprecedented ways with an expanded mandate in years to come. Now, more than ever, they are challenged to retain the moral high ground and to put disaster-affected people at the centre of humanitarian action. Consequently, this paper proposes that the humanitarian system introduce a new principle: humanitarian subsidiarity. It moves the conception of subsidiarity beyond meanings ascribed by the Catholic Church and the European Union and links it instead to the attributes of agency, accountability, and trust to find accommodation with the core humanitarian principles of humanity, impartiality, neutrality, and independence.     

The humanitarian common logistic operating picture: a solution to the inter‐agency coordination challenge

Although significant progress has been made in developing the practice of humanitarian logistics, further improvements in efficiency and effectiveness have the potential to save lives and reduce suffering. This paper explores how the military/emergency services’ concept of a common operating picture (COP) can be adapted to the humanitarian logistics context, and analyses a practical and proven approach to addressing the key challenge of inter‐agency coordination and decision‐making. Successful adaptation could provide the mechanism through which predicted and actual demands, together with the location and status of material in transit, are captured, evaluated, and presented in real time as the basis for enhanced decision‐making between actors in the humanitarian supply network. Through the introduction of a humanitarian logistics COP and its linkages to national disaster management systems, local communities and countries affected by disasters and emergencies will be better placed to oversee and manage their response activities.     

Humanitarian governance and resilience building: Ethiopia in comparative perspective

Humanitarian governance is usually understood according to the classic, Dunantist paradigm that accords central importance to international humanitarian agencies. However, this is increasingly paralleled by ‘resilience humanitarianism’ that focuses, among other things, on including national actors in humanitarian governance. This article views humanitarian governance as emerging through interactions between authorities, implementing agencies and communities. It is based on interactive ethnography in five countries by Partners for Resilience (PfR). Using the Theory of Change (ToC) tool, it analyses the various interpretations and priorities of actors involved in humanitarian problems, solutions and programme governance. For example, PfR had a ‘software’ focus, aiming to unlock communities’ potential for resilience, whereas communities and authorities preferred to receive tangible ‘hardware’ support. The findings highlight the crucial role of local authorities in shaping humanitarian aid. This is especially pertinent in view of the international agenda to localise aid, which requires the understanding and support of national actors in order to responsibly protect the vulnerable.     

The Sphere Project: The Implications of Making Humanitarian Principles and Codes Work

In 1996, in recognition of concerns about humanitarian response efforts, non- governmental organisations (NGOs) launched the Sphere Project, the first collaborative initiative to produce globally applicable minimum standards for humanitarian response. The aims of the Sphere Project are to improve the effectiveness of humanitarian efforts and to enhance the accountability of the humanitarian system, primarily to those people who have a right to protection and assistance in disasters, as well as to agency members and donors.
This paper discusses the purpose of the Sphere Project, the unique process that brought it about and the major concerns that have been raised about its practical application. Finally, the paper considers the implications of this for improving the impact of humanitarian response and for future initiatives given the process that Sphere has begun. It argues that improved accountability does not start and stop with NGOs. They are just one element of a wider humanitarian response effort and more needs to be done to improve the system as a whole.     

The Sphere Project: the implications of making humanitarian principles and codes work

In 1996, in recognition of concerns about humanitarian response efforts, non-governmental organisations (NGOs) launched the Sphere Project, the first collaborative initiative to produce globally applicable minimum standards for humanitarian response. The aims of the Sphere Project are to improve the effectiveness of humanitarian efforts and to enhance the accountability of the humanitarian system, primarily to those people who have a right to protection and assistance in disasters, as well as to agency members and donors. This paper discusses the purpose of the Sphere Project, the unique process that brought it about and the major concerns that have been raised about its practical application. Finally, the paper considers the implications of this for improving the impact of humanitarian response and for future initiatives given the process that Sphere has begun. It argues that improved accountability does not start and stop with NGOs. They are just one element of a wider humanitarian response effort and more needs to be done to improve the system as a whole.     

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 impact of workplace exclusion on the humanitarian response to the refugee crisis in Lebanon

A contemporary issue of major concern is the millions of people fleeing homelands owing to political and socioeconomic challenges and seeking assistance elsewhere throughout the world. An effective response to this crisis includes support models that meet the various needs of refugee populations. In the complex system of humanitarian action, aid workers, among a multiplicity of actors, are the most important assets. This study utilised an inclusion–exclusion theoretical lens to examine the impact of their workplace experiences on activities in the context of the refugee crisis in Lebanon. In-depth interviews were held with 36 humanitarian practitioners, representing five international organisations that are involved in refugee aid programmes in the country. The study led to a new understanding of the link between inclusion and exclusion and the effectiveness of the humanitarian response to emergencies. In addition, it yielded new insights into apprehension about the national–international divide and its consequences for humanitarian assistance.     

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.