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.     

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.     

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.     

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.     

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.     

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.     

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.     

Evaluation of Two Kurdish Refugee Camps in Iran, May 1991: The Value of Cluster Sampling in Producing Priorities and Policy

Following the end of the Gulf war in March 1991, Kurdish refugees from Iraq crossed the border into Western Iran. To plan public health interventions and to assist in priority setting for scarce resources, a rapid epidemiological assessment of two camps, Hafez and Kaliche, was conducted in May 1991. A 30 cluster sampling method was used to determine the demographics of the camp population, the morbidity and mortality from certain diseases, and the nutritional status of the children <5 years of age. The estimated population of the camps at the time of the survey was 28,500 and 22,500 for Hafez and Kaliche respectively; children < 5 years of age accounted for approximately 25 per cent of both camp populations. The mortality rate was highest in Hafez and estimated to be 2.5/10,000 per day (95%CI:0.3–5) for adults (> 14 years of age) and 4.9/10,000 per day (95%CI:2.4–7.4) for children. Diarrhoeal and respiratory diseases accounted for major morbidity in both camps with diarrhoea the commonest stated cause of death. Little malnutrition was found but it was greater in Hafez where 6 per cent (19/327) of the children between 1 and 5 years of age had a mid upper arm circumference (MUAC) <12 cm and eleven (5.2 per cent) of the 211 children measured for height and weight were below 80 per cent of the median (95%CI:2.6%;7.8%). The survey identified that morbidity and mortality were less severe than in the Kurdish camps on the Turkish border and provided information for camp authorities to plan appropriate relief interventions.     

Mother's body mass index as a predictor of infant's nutritional status in the post-emergency phase of a flood

Maternal nutritional status is a determinant of child health. This paper studies the association between a mother's body mass index (BMI) and her infant's nutritional status over a one year time frame after the 1998 flood crisis in Bangladesh. The paper uses secondary analysis of data collected from 757 households in seven rural areas of Bangladesh affected by the 1998 flood using multiple-stage probability sampling techniques (n = 143). Logistic regression models were employed to investigate the predictive impact of maternal BMI on infant's nutritional status after controlling for a range of child and maternal factors. An underweight mother was a significant factor with regard to the risk of infants suffering stunting (odds ratio (OR) = 4.45, 95 per cent confidence interval (CI) = 1.04-18.94) and being underweight (OR = 3.51, 95 per cent CI = 1.02-12.05) a year later, but not wasting (OR = 2.09, 95 per cent CI = 0.51-8.67). The findings suggest that there is a post-emergency link between maternal and infant nutritional health.     

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.     

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.     

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.     

Malnutrition and Mortality During Recent Famines in Ethiopia: Implications for Food Aid and Rehabilitation

The 1972-73 and 1984-85 famines varied significantly among different populations within famine areas at the regional, community and household levels. Political and social factors were crucial in this pattern. Evidence from both pastoral and farming areas indicates that the development of community-based resources may be less disruptive socially and economically and result in less morbidity and mortality than dependence on relief shelters. Areas needing further study are identified.     

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.     

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.     

Famine early warning systems and the use of socio-economic data

Famine early warning systems using socio-economic data suffer from several problems. One is that they cannot, and do not attempt to, distinguish between qualitatively different kinds of famine. The second is that they cannot predict these either accurately or early enough. This is because all the socio-economic indicators produce both false positives and false negatives, the indicators themselves are "late" and because interpretation of the data is complex and time-consuming. The third problem is that within the context of a famine that is occurring, these indicators cannot predict excess mortality. The argument is illustrated with examples from the 1984–5 famine in Darfur, Sudan.     

Historical Roots of Famine Relief Paradigms: Ideas on Dependency and Free Trade in India in the 1870s

The principles upon which famine policies are based have changed less than might be expected over the last century. This paper examines the origins of the Indian Famine Codes of the 1880s, which set the administrative and, it is argued, paradigmatic precedent for famine relief in 'developing' countries, managed by 'developed' ones. In particular, the still-current questions of avoiding the creation of dependency through over-generous aid and of relying on free-market solutions to the problems of food distribution are re-examined. Although both of these issues are difficult, it is suggested that strong emphasis on their importance has historically been based on wilful misinterpretation of complex situations. The result has been famine relief programmes which served the interests of 'relievers' (in this case the colonial state) more than the relieved. The nature of famine policy-making is thus reconsidered, with a call for greater appreciation of the role of influential individuals and hidden state agendas. These are as significant today as ever.     

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.     

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.     

Health effects of relocation following disaster: a systematic review of the literature

This paper reviews the literature on the effects of post-disaster relocation on physical and mental heath, and develops a conceptual framework to guide future research. Forty articles were selected for full-text review and incorporation into the conceptual framework. Twenty-four articles were reviewed for results and methodology. These overwhelmingly tracked mental health outcomes. Only four (16 per cent) focused on physical health. Eight of ten showed an association between relocation and psychological morbidity. Certain outcomes (such as mortality, injury and cardiovascular disease risk factors) revealed inconsistent results, but these were rarely studied. Despite the frequency of post-disaster relocation and evidence of its effect on psychological morbidity, there is a relative paucity of studies; the few examples in the literature reveal weak study designs, inconsistent results, and inattention to physical health impacts and the challenges facing vulnerable populations. Further research guided by theory is needed to inform emergency preparedness and recovery policy.