A. Quantity of available food
B. Type of food available
C. Shortcomings outside the realm of food
D. Lack of understanding of context
E. Special case of IDPs
A conceptual framework that is useful for understanding causes of malnutrition among young children in emergency settings is shown in figure 5. The immediate causes are inadequate dietary intake and disease. To date, the RNIS has focused on malnutrition, mainly as reflected in wasting and oedema. Some attention has been given to causes, such as diseases or low food availability. The RNIS Reports are now beginning to look more closely at underlying and basic causes.
Figure 5: Conceptual framework of the causes of malnutrition
Displaced populations are heavily reliant, or completely dependent, on general food aid rations. The distribution of rations inadequate in food energy in these cases can lead to malnutrition. Failures in the past to provide adequate rations have been due mainly to problems of food supply, delivery, or distribution.
The supply of food aid depends on donations. Annual appeals are made to donors for each on-going emergency. These appeals are based on the location and estimated numbers of beneficiaries at the time, but conditions change rapidly. Complex emergencies are characterised by prolonged crises that rise and fall in intensity. Target populations move, often repeatedly, and numbers of beneficiaries change rapidly as new areas are accessible or inaccessible. These uncertainties make both planning and adherence to plans difficult. This was illustrated in Liberia in 1995, and in Zaire in 1996.
In addition, donor dissatisfaction with beneficiary enumeration, especially in conjunction with evidence of food aid sales, has led them to refuse to make or fulfil pledges. This was reported in Ethiopia and Zaire in 1996.
Timing of the receipt of pledges from donors also affects when food is delivered to beneficiaries. Even when, over the course of an appeal, full resources are available, there have been examples when periods of severe commodity shortages have led to ration shortfalls. This has mainly been due to a lack of timely fulfillment of food and monetary pledges, as seen in Angola in 1994 and 1998, and Liberia in 1994 and 1997.
Political circumstances also influence how and where assistance can be administered. Where embargoes are enacted, such as those in Burundi and Sierra Leone in 1997-98, humanitarian aid was exempted. Nevertheless, restrictions on fuel and food imports hampered efforts to deliver aid. Frontier closures not only prevented refugees from crossing to safety, but also made transport of aid to refugees in Tanzania and Zaire more difficult and expensive throughout 1996. Flight bans, common occurrences in Southern Sudan, severely limit the delivery of aid. Government constraints on the movements and economic activities of the displaced in Goma, Zaire and Tanzania in 1996, and Kenya in 1997 limited the possibilities for displaced households to achieve self-sufficiency.
Local transport capacity is often not enough to support sudden rises in demand, as was reported in Tanzania in 1997 and Burundi in 1994, or local ports cannot handle the large volume of food aid (Burundi - 1995, Zaire - 1996). Emergencies force people into locations where inadequate road systems are subjected seasonally to further deterioration during heavy rains. This has impacted on ration deliveries in many places, including Kenya and Tanzania.
Especially when assisting internally displaced populations, conditions of insecurity halt or delay deliveries (e.g. Angola - 1993-94, Burundi -1996-98, and Liberia - 1996-97) and force personnel to abandon activities. Such reports were common, for example in Burundi in 1996 and Rwanda in 1997. Losses from looting, banditry or diversion by military factions (e.g. Angola - 1995, Liberia - 1996, Zaire - 1996) reduced food supplies before arrival at emergency distribution sites.
After food has reached the final delivery point, there may be further problems. The way in which food aid is distributed influences beneficiaries’ access to food, and, consequently, the nutritional status of the population. Equitable distribution is not guaranteed. In Tanzania in 1997 and Ethiopia in 1998, distributions to groups of families seemed to lead to inequitable ration receipts at the household level. Subsequent adjustments to these distribution systems are discussed in section V B below.
The consequence of shortcomings in food supply, delivery or distribution is that general rations agreed upon in annual planning do not always correspond to the food that reaches beneficiaries. Figures 6 and 7 compare a planned ration with that actually delivered based on food monitoring in Kenya and Tanzania.
Figure 6: Food Deliveries in Dadaab Camps, Kenya, over time and based on food basket monitoring
Figure 7: Food Deliveries in Tanzania, over time
Even when general rations are distributed regularly and provide adequate food energy, protein-energy malnutrition, micronutrient malnutrition or both may still appear. In these cases, problems often relate to the type of food provided - the quality, its acceptance by the beneficiaries or its appropriateness for use.
Until about 1995, the typical food aid basket included only basic commodities (cereal, pulse and oil), and provided insufficient levels of micronutrients. This, combined with the fact that people often arrive at camps with micronutrient malnutrition, means deficiencies of vitamins C and A, riboflavin (B2), thiamin (B1), niacin, and iodine have been noted in RNIS Reports over the past five years. Reports of anaemia2 were also noted.
2 Iron deficiency occurs when the amount of iron absorbed is insufficient to meet requirements, and if prolonged, results in iron deficiency anaemia.Frequently, the diagnoses of micronutrient deficiencies have been questioned. Misdiagnoses in Bangladesh of persistent cases of angular stomatitis as a vitamin deficiency were finally confirmed in 1998 when response to treatment with antibiotics indicated that symptoms were due to infection. It is difficult to understand why there was such a delay (6 years) before antibiotic treatment was tried. In Nepal, elevated incidence of symptoms of multiple micronutrient deficiencies (i.e., scurvy and beri-beri) has persisted for nearly as long, in spite of the introduction of fortified blended food, parboiled rice and fresh fruit and vegetables in the general distribution. The reasons have not yet been identified.
The lack of suitable foods for young children was associated with preschool malnutrition in Ethiopia (1996) and Sierra Leone in 1998. Fortified blended food is suitable for feeding young children because it is easy to prepare, palatable and nutritionally dense. In the past, this commodity has frequently been absent or reduced in distributions because supplies were exhausted or in short supply. Some example of this include Kenya and Zaire in 1994-95.
The cultural unacceptability of the ration commodities, difficulty in digestion of foods, the lack of milling capacity and unsuitability of rations for children have led to low consumption or sales and exchanges of food aid. Some examples noted in RNIS Reports include Tanzania in 1997-98, Liberia (1998) and Ethiopia in 1997.
Disease and inadequate supplies of non-food items often contribute to malnutrition. Sometimes they are even more important than food-related factors.
Generic “health problems” were cited as the primary cause of prevalent wasting in Sierra Leone (1994). The effects of a shortage of water and poor sanitation were blamed in Zaire (1993) and over-crowding and unhygienic conditions were contributing factors in Burundi (1997). A deterioration in nutritional status was attributed to diarrhoea, over-crowding and poor water supply, not lack of food in Tanzania (1994). Diarrhoea was also a contributing factor to deteriorating status among Afghan children in Pakistan (1996). There was an association between measles and malnutrition/oedema in Liberia (1994).
Anaemia associated with malaria has also been noted as a problem in some areas, for example in Tanzania in 1998 where anaemia and malaria together accounted for the most deaths.
Efforts to acquire non-food necessities, such as fuel or soap, can affect diet and health.
· Faced with a shortage of fuel, as was the case in Tanzania in 1995 and Zaire in 1996, women and children search the environment for wood and other combustible materials. They may be away from home for extended periods while small children, including breastfeeding children, are left alone with nothing to eat. The fuel gathered may be insufficient so that either the food is undercooked, or the number of meals is reduced. At times, especially when there is rain, it is not possible to gather any fuel; other times the search is futile. This may mean that families go the entire day with no food or leftovers are eaten without re-heating.Photo courtesy of UNHCR. Kenya/Refugees from Somalia/Dagahaley Camp· Fuel gathering often creates tension between displaced and resident populations. Residents have threatened to retaliate for the loss of their fuel resources by attacking food supplies for the displaced (Tanzania - 1995). Women and children are put at risk of injury, rape, or death while gathering. Resulting debilitating injuries, loss of life, trauma and household division consequent to rape, can permanently reduce household capacities.
· Without both soap and water, personal and environmental hygiene cannot be maintained. Illness and its nutritional consequences follow. As an example, in Zaire in 1995, an inadequate supply of soap for domestic hygiene hampered efforts to prevent the transmission of dysentery. Wasting and mortality rates soared and most deaths were associated with diarrhoeal diseases.
· To acquire non-food essentials not provided by the international community, recipients of food aid who lack money and other resources that can be sold, are often forced to sell or barter their food (e.g. Ethiopia - 1998). Sales of this nature were identified as a major cause of malnutrition among Sudanese schoolboys in Kenyan camps in 1997.
UNHCR/22044/05.1992/P. Moumtzis
Too often, those involved in relief view emergency-affected populations as faceless masses. However, understanding the population - their lives before the emergency and how they have changed, the problems they are facing and the actions they are taking to overcome them - would allow for the “tailoring” of assistance to satisfy the particular needs and sensibilities of the beneficiary population. In addition, contextual advantages and disadvantages could be taken into account.
There has been much discussion about populations becoming dependent on relief and much rhetoric about their need to become self-sufficient. Some host governments have allowed refugees access to land for farming, such as in Uganda and Guinea. During resettlement and rehabilitation, food-for-work and income-generating projects become the primary pathways through which food aid is channelled and seeds, tools and other inputs are disbursed to encourage agriculture. However, there have been few reports of interventions by international agencies to support initiatives towards self-reliance during displacement. In our experience, only negative incentives, for example reduced rations, have been cited to motivate self-help efforts (e.g. Cote d’Ivoire - 1995).
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‘Internal displacement, affecting some 25 million people worldwide, has become increasingly recognised as one of the most tragic phenomena of the contemporary world. Often the consequence of traumatic experiences with violent conflicts, gross violations of human rights and related causes in which discrimination figures significantly, displacement nearly always generates conditions of severe hardship and suffering for the affected population. It...denies access to such vital necessities as food, shelter and medicine...’ Guiding Principles on Internal Displacement, Commission on
Human Rights at its 54th Session, Geneva Feb., 1998.
(E/CN.4/1998/53/Add.2) |
