Symposium: Nutrition in the Context of Conflict and Crisis

The 29th Session of the SCN was held in Berlin (Köpenick), Germany at the Dorint Hotel on 11-15 March 2002. The Session was hosted by the Federal Ministry for Economic Cooperation and Development (BMZ), the Government of Germany, in collaboration with the German Foundation for International Development (DSE) and Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ)

This year's Symposium on Nutrition in the Context of Conflict and Crisis took place on 12-13 March. The Symposium s goal was to raise awareness of the critical importance of nutrition before, during and after crises and conflicts. It set out to do this through four specific objectives:

· to promote cooperation amongst UN agencies, NGOs and bilaterals

· to promote greater understanding and linkages in food and nutrition policies used in development and humanitarian situations.

· to provide a forum for discussion on achievements and new challenges needed to improve nutrition situations, and

· to highlight basic human rights and humanitarian principles as the basis for nutrition programming.

A statement (see back cover of this issue) was prepared for endorsement by the UN Secretary General. This statement urges better coordinated action between UN agencies, bilaterals and NGOs in emergency situations. Most importantly, it reflects the Symposium's recurring themes found below and lists recommended actions for the SCN.

The 6th Dr. Horwitz Lecture, given by Soha Moussa, provides a personal and technical account on the importance of keeping schools open during crisis and conflict. This lecture serves to remind all those involved in emergency work of the emotional and psychological effects that violence, insecurity and uncertainty can have on a child.

To summarize, the following themes emerged during the Symposium:

· There has been significant progress in a number of technical areas in emergency nutrition. However, these advances are poorly implemented

· Nutritional needs can and should be addressed through a range of interventions, including broad-based livelihood approaches, selective feeding programs, and health programs

· The humanitarian imperative is a central tenant of emergency relief interventions, but it is undermined by the politicization of aid, especially food aid. The humanitarian imperative needs to be divorced from political and foreign policy objectives

· The human rights approach promotes equitable distribution and emphasizes human dignity. This approach is a shift away from the notion that emergency relief is a charitable gift, which denies dignity

· There is a moral dilemma and an inherent tension between access to affected populations and cooperation with corrupt regimes. In situations of insecurity, while negotiating access, there is a risk of legitimizing governments or quasi-governments

· The professionalization of NGOs means they are increasingly taking on the mandate of capacity building as part of their emergency response. Yet, the appropriateness of capacity building is context specific and, as a minimum, agencies should respect the International Red Cross and Red Crescent Movement and NGO Code of Conduct and attempt to build disaster response on existing local capacity

· Refugee populations are often better off than local populations. During emergencies, the host governments are not well equipped to handle displaced populations. Solutions are still needed to reconcile the standard of living of the emergency-affected, refugee, or displaced populations, and the needs of the host government population

· Agencies risk disrupting social structures by inappropriate targeting and blanket protocols, calling for knowledge and in-depth context analysis. Blanket protocols risk being culturally insensitive and more evidence is needed to support the effectiveness in targeting certain groups. Vulnerability assessments must consider the multiple risks facing people in conflict without singling out individual criteria for targeting

· Agency specialization can lead to gaps in mandates. The conceptual framework currently in use promotes multisectoral interventions to address nutritional needs. Eventually, certain agencies find it very difficult to cover all the sectors, leading to specialization and gaps in mandate. Therefore, coordination of actions between agencies is needed to ensure that none of the emergency needs of an affected population are missed

· The term do no harm is inappropriate. There are positive and negative effects of action, therefore, the goal should be to minimize the bad and maximize the good aspects of aid and emergency relief.

The German Foundation for International Development (DSE) is an institution for international dialogue and training following the policy guidelines of the Federal Government of Germany. DSE's development efforts focus on an exchange of political experience through workshops and conferences and on further professional training for specialists and executives from developing and transitional countries. The activities of the Foundation are mainly commissioned by the Federal Ministry for Economic Co-operation and Development (BMZ). The scope of its mandate, however, also allows DSE to act on behalf of other organisations. The DSE Centre for Food, Rural Development and the Environment (ZEL) contributes to rural development, food and nutrition security, management of natural resources and of development projects in partner countries. The Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH is a government-owned corporation for international cooperation with worldwide operations. GTZ's aim is to positively shape the political, economic, ecological and social development in our partner countries, thereby improving people's living conditions. Through the services it provides, GTZ supports complex development and reform processes and contributes to global sustainable development. The GTZ was founded in 1975 as a corporation under private law. The German Federal Ministry for Economic Cooperation and Development (BMZ) is its main financing organisation. GTZ also undertakes commissions for other government departments, for governments of other countries, for international clients such as the European Commission, the United Nations or the World Bank, as well as for private-sector corporations. The GTZ operates on a public-benefit basis.

SYMPOSIUM OVERVIEW: BREAKING THE LINKS BETWEEN CONFLICT AND FOOD INSECURITY IN COMPLEX EMERGENCIES

Ellen Messer and Marc Cohen

The papers and perspectives from the Symposium on Nutrition in the Context of Crisis and Conflict reflect what is old and new in humanitarian thinking and action, both in the principles that guide and regulate the rhetoric and behaviors of donor and implementing-agency bureaucracies, and in what concepts motivate the technical interventions on the ground. In aggregate they expertly address all three dimensions of nutrition-food, health, and care-and all three aspects of food security-availability, access, and utilization.

The contributors, all policy makers and practitioners, recognize and seek new ways to overcome the sometimes fragmented rather than holistic responses to food crises, while at the same time they emphasize the need to identify more diverse and creative ways for the affected communities to mobilize resources to protect food security and prevent destitution. As illustrated by Young et al.'s community-based approaches, there are multiple and complementary avenues to reach and assist the food insecure, in particular women, for example, through preferential targeting to improve technology in what is traditionally women's work, and by increasing women's access to elevated levels of resources as their portion within traditional economies visibly dominated by men.

Similarly, Jonsson et al. demonstrate that decisions to provision vulnerable populations in the context of illegal actions by states or non-state actors can and do involve tradeoffs, but life-saving projects based on human rights principles can try to meet individual demands and needs for essential food, water, and medicine without giving full and extra support to unlawful authorities. Unfortunately, we have few examples of such actions and evaluations of their political implications, or successes and failures. In many militarized contexts, codes of conduct notwithstanding, humanitarians still find it impossible to avoid hiring armed guards and providing food, incomes, and vehicles to combatants, who fuel further conflict.

Although the more polemical papers on principles argue against a politicization of aid (which appears to be almost inevitable because both violations and defense of human rights tend to take place in the political arena), the more practical reports on livelihood-security and human rights strategies suggest ways humanitarians can work around rights-abusive governments and offer new ways to reach and engage networks of females and males struggling to gain livelihood and maintain stable lives with dignity in unsettled times.

Moussa's thoughtful contribution on the use of food for education argues creatively from hard experience that schools and school feeding, especially in contexts of political instability, are multi-functional. Such programs, by their very regularity and existence, always bring to the table extra-nutritional meanings and values, as they contribute to social and psychological welfare and a sense of connectedness that goes well beyond the immediate access to food. Education of girls has also been shown to deliver intergenerational nutritional benefits.

Happily, these discussions demonstrate that linkages between conflict/conflict-prevention and food insecurity/food security in the post-Cold War era are beginning to be addressed by peace and food-security advocates both inside and outside of government and relevant international agencies, which increasingly recognize and accept the critical inputs of NGOs. The explicit commitment of the German government through its Ministry for Economic Cooperation and Development, to policies ensuring sustainable food security and prevention of conflict, along with USAID's reorganization, and renewed attention to 'interactive pillars' that include agriculture and trade in interaction with conflict prevention, humanitarian assistance, and democratization, suggest that governments are widening their scope of action to address complex food-security and conflict issues together, and also to increase integration of NGO and private actors and actions.

In addition, actions by UN agencies following up the activities of the World Food Summit, suggest that nations and the UN system as a whole at last are taking human rights seriously in implementation of humanitarian assistance.

These efforts may be slowly bridging the gap between those diplomatic agents and agencies that engage in conflict prevention and peace making, and those who seek to protect food and livelihood assistance. But the structural causes of crises and conflicts, including the politics of food, still do not enter seriously into most diplomatic discussions, which are handled by separate departments. Equally, the conflict-potentiating effects of aid, including who will control scarce resources such as irrigation water, improved seeds, or other technologies-in addition to land-require careful analysis in each situation, and are always political. While the principle that humanitarian agencies and aid should eschew politics is right in spirit, crisis situations, such as the demand for refugee feeding, are inherently political, and the politics of food, which cannot be wished away, must always enter into combined food-security/conflict-prevention strategies in order to prevent future crisis.

For the most part, these presentations were not addressing conceptual questions of whether conflicts are caused by food insecurity, or the more theoretical questions of whether people engage in violence and warfare primarily because of ethnic animosities or perceived resources deprivation. Nor were they addressing how UN agencies, governments, or NGOs might intervene in situations of impending crisis to avoid conflict. But the case studies on livestock protection do illustrate what appear to be successful strategies for preventing or mitigating the impacts of conflict, and assuring the benefits of those resource savings are widely shared across households and communities. Both relief and development policies stand to benefit from such gendered approaches, which seek to protect food security and livelihoods as a deterrent to conflict, whatever its causes.

Contact: Ellen Messer ellen.messer@tufts.edu and
Marc Cohen m.j.cohen@cgiar.org

NUTRITION IN THE CONTEXT OF CRISIS AND CONFLICT

Karsten Hinrichs
Director, Federal Ministry of Economic Co-operation and Development, Bonn

It does not take much to appreciate the relevance of a Symposium on Nutrition in the Context of Crisis and Conflict. We all recall the pictures of hungry children in Afghanistan and their empty and fearful eyes as they look at the cameras and into an uncertain future. We also vividly recall the stream of hungry, fearful refugees being rejected at the borders. At the same time we see pictures of areas covered with small food parcels and lorries full of foodstuffs that cannot get to affected regions because of conflict. After reading in Süddeutsche Zeitung on 12 February 2002 that Afghan mothers are happy if their children get a place in an orphanage because they are simply unable to feed them, I know that the theme of this symposium is a right and important one.

The Trouble Spots Worldwide

Since the end of the Cold War, 103 armed conflicts have taken place, of which 88 are and were conflicts within states¹. Old conflicts have broken out afresh, often intensified by ethnic and religious tension. At the end of 2000, some 24m people were dependent upon international humanitarian aid for their survival as a result of armed conflicts in developing and newly industrialized countries. Aid organizations often report rising acute malnutrition of refugees and internally displaced persons (IDP)². The UN estimates the number of refugees and IDP to be around 35m, of which, 80% are women and children³.

Africa is where most of the conflicts rage and, at the same time, the continent where the share of hungry people is the largest. In East Africa, political conflicts and wars have exacerbated hunger in Rwanda, Burundi, Eritrea, Ethiopia, Somalia, Sudan and Kenya. In Central Africa, the people in the Democratic Re-public Congo are suffering from the expansion and intensification of the civil war. The fertile regions in the east that used to produce in abundance, can no longer feed their own population. In West Africa, Liberia and Sierra Leone remain the biggest hunger crisis spots. Sierra Leone is attempting to recover from eight years of brutal civil war and has started reconstruction, but even the UN peace-keeping forces have not yet been able to re-establish peace throughout the country⁴.

Although in other regions of the world the connection between conflict and hunger is not as equally pronounced and widespread, conflicts contribute to exacerbating the food situation in Palestine, Indonesia, East Timor, Colombia, and some south-east European countries.

The Vicious Circle Between Crises And Hunger

Most of these armed conflicts take place in regions heavily dependent upon agriculture. As a consequence of civil war and displacement, fields can no longer be cultivated and whole regions lie fallow. Conflicts cause hunger, but at the same time, hunger can also cause conflicts.

Armed conflicts destroy crops, cattle herds and land; they ruin a country's infrastructure and markets. Further, they destroy the ecological and social resources needed for food production. A study by the International Food Policy Research Institute found that in 14 Sub-Saharan African countries food production in years of war fell distinctly short of that during peace years⁵. Thus in Angola, production was reduced by almost 50%, with an average reduction in all conflict-affected countries of 12.3%. The FAO used a similar method to estimate the conflict-induced losses of agricultural yields. During 1970 to 1997 losses amounted to US$121b⁶. This accounts for more than 75% of the total support given by the international donor community to Sub-Saharan countries afflicted by conflicts. Figures like these reaffirm that it would be much more appropriate, and preserving of human dignity, to prevent conflicts rather than to provide emergency aid.

Agricultural losses do not stop with conflict. Land-mines are one of the cruellest tragedies hampering the path towards peace in a country. The Red Cross estimates that 24,000 civilians are either killed or brutally maimed each year by land mines⁷. In some countries the bulk of the arable and grazing land is mined, making food production impossible. Thus, it would be possible to expand usable farmland in Cambodia by 135% if the country were fully demined. As long as there is no drastic change in this situation, poverty and hunger will continue to be a permanent threat.

Apart from mines, food is also used as a weapon. In the wake of food sieges, food reserves and production capacities are destroyed and hunger prevails. In southern Sudan, where both government and rebel troops apply these tactics, some 2.5m people were dependent upon emergency food aid in July 1999. Hutu guerrillas from Rwanda have abused their control over the distribution of food aid in refugee camps to expand their own political power⁸.

FAO provides evidence for these practices in its description of the world food situation. Most of the ten countries showing the poorest food situation (Somalia, Afghanistan, Burundi, Eritrea, Haiti, DR Congo, Mozambique, PR Korea and Niger) were or still are affected by war-like conflicts and/or are faced with natural disasters⁶. Sufficient food for the population will remain intangible as long as wars are waging and conflicts prevail.

Crises, Conflicts And Wars As A Result Of Injustice, Poverty And Hunger

Quite often warlords or the ruling political class capitalize and abuse ethnic differences, using them deliberately to escalate violence. This mixing of different interests is described as politicized ethnicity⁹. By contrast, civil wars in Central America have been the outcome of protracted food crises and human rights violations. Access to land, and thus access to food, has often been the key demand of rebels. Even today, numerous landless farmers in Central and South America are fighting against an unjust distribution of land, which excludes them from securing their own food. Lack of agro reforms, or misconceived or one-sided reforms, encompass a tremendous potential for conflict. Generally speaking, tension explodes quickly into violent conflicts where economic conditions are deteriorating. People feel that there is nothing more to lose, therefore, they are willing to fight for resources, political power or even recognition.

Development policy is peace policy

Challenges, Possible Solutions And Fields Of Action

Nutrition in the context of crises and conflicts must encompass three aspects:

· managing acute emergency situations and formulating assistance in such a way that it does not intensify impact

· preventing crises and preserving human dignity; and

· combating hunger as a cause of conflict and/or consequence of conflict.

A rapid, coordinated response on the basis of a division of labour by the various players-states, UN organizations (WFP, UNHCR, and others), NGOs, and bilateral donors-is a fundamental precondition for success. The WFP has been, and continues to be, a crucial player during this phase and an important partner of the German government.

Designing emergency assistance in an appropriate manner poses a substantial challenge. Mary Anderson, in her 1999 study 'Do No Harm', has given examples of how aid itself can exacerbate conflicts¹⁰. Donors must take measures to prevent this misuse of food aid from the onset of their planning and implementation. This requires an in-depth understanding of the origins of the conflict and a precise analysis of the participating conflict parties and their willingness to resolve the conflict. Aid should not be given without accountability. Furthermore, planning must take into account the risk of well-intentioned food aid prolonging conflicts.

It is well known that food aid can have a counterproductive effect on market and nutrition practices. Local markets can be destroyed, making livelihoods almost impossible for small farmers, and increasing dependency. Over the past 20 years, donors have contributed massive food aid supplies to the Ethiopian government, neglecting the necessary reforms in the agricultural sector and proliferating dependency amongst farmers. Food aid must be demand-driven. It is not right to take advantage of people's misery through marketing surplus production and using attractive incentives. Food aid should be procured in regional or local markets. The German government has shifted toward this direction: approximately 95% of German food aid is procured in developing countries. Furthermore, German food aid is untied, meaning countries can freely decide what type of procurement is best suited for themselves. In the meantime, this approach is being copied in almost all EU countries and we appeal to other donors to follow suit.

Preventing conflicts from becoming violent

Preventing crises from turning into violent conflicts is something that concerns us all. On 11 September 2001 we were given a terrifying example of what it means to live in one world. No part of the world is safe, no part can cut itself off and protect itself from what is happening elsewhere. The G-8 states account for more than 70% of the world-wide gross national product, but for only about 10% of the world population. While Western menus offers specialities from every corner of the world, 24,000 human beings die from hunger and malnutrition every day¹¹. Southern countries must be enabled to share in world-wide developments. They must be able to live their life in freedom and with human dignity. Peace cannot prevail as long as social marginalization and injustice continues. Development is the most important weapon in the fight against terror, crises and conflicts worldwide.

The German government has declared the prevention and overcoming of violent conflicts to be one of the core objectives of its international policy, and it has been given broad support by society. The basis of the German government's concept of crisis prevention and conflict settlement is an extended security concept comprising of political, economic, ecological and social stability. In this concept, development policy plays the important role of contributing to a reduction of the structural causes of conflict, as well as, to the promotion of mechanisms for a non-violent settlement of conflicts in crisis-prone partner countries through improving the economic, social, political and ecological situation. Development policy is peace policy.

What Can We Do?

Poverty reduction is needed to reduce the structural causes of conflict. Worldwide, more than 1.5b people must live on less than US$1 per day¹². Their poverty is a hotbed for instability and conflict. At the UN Millennium Summit in September 2000 the heads of states and governments agreed to reduce by half the share of extremely poor people in the world population by the year 2015. The German government fully endorses this goal and has developed a Programme of Action 2015 to outline the steps Germany is undertaking to contribute towards realizing this goal.

Good governance (i.e. sound, development-oriented government action) has been an elementary principle of our co-operation. We intend to continue focusing on this in our future work. For example, we will increasingly support those countries that promote a peaceful co-existence of different ethnic groups and religions within their societies, thus establishing mechanisms of non-violent conflict resolution. Likewise, we support the strengthening of rule of law institutions. The German government has strengthened this approach as part of the struggle against international terror and has made available special funds for this purpose.

Examples:

· establishing the Civil Peace Service as a new development cooperation instrument. Trained experts act as mediators to prevent violent conflicts or, once these have ended, to build lasting peace

· supporting co-operation in the areas where potential conflicts could occur over scarce resources, for example, in the field of fresh-water resource management, and

· supporting reconciliation and communication measures, for example, a project in Chad helps settle conflicts between cattle-holders and farmers by means of a committee of understanding.

At the global level the German ministry advocates, within the framework of the WTO negotiations, dismantling of agricultural subsidies and especially export subsidies to avoid an adverse impact on food security (e.g. as a result of the destruction of local markets or subsidized exports). It is important to improve developing countries' access to markets to bolster foreign exchange earnings. Hence, the EU has granted the least developed countries duty-free market access for almost all goods, except arms. The German government is examining further possibilities of improving market access, and we invite other donors to join the EU's initiative 'Everything but Arms'.

Key instruments at the local level are projects enabling people to improve their own food situation on a sustainable basis. These include projects promoting rural development, additional income and the informal sector. BMZ prioritizes the development of rural areas, which is more than just agricultural promotion. Rural areas offer space for up to 80% of the people in developing countries and for some 75% of people living in absolute poverty.

Prospects: Future challenges

Development policy as peace policy must be expanded further. Only by strengthening crisis- and conflict-preventing elements in development cooperation can we put into place long-term structures that ensure the peaceful coexistence of people on a sustained basis. Germany will continue to take an active part in the reconstruction of countries affected by the aftermath of crises and conflicts.

Fighting hunger belongs at the top of the political agenda. This is not only a moral duty, but a necessity if we all wish to live in peace and security. Hence, the German Parliament has asked the German government to play a pioneering role in the combat against hunger. Germany shall:

· maintain our priority to food security and agriculture/fishery

· endorse efforts for an international embodiment of the right to food

· continue our endeavours for a continuous improvement and adjustment of the food aid instrument, and

· endorse the orientation of relevant WTO agreements towards the needs of sustainable food security in the developing countries.

· consistently implement our Programme of Action 2015 to reduce poverty
· increase our attention to Africa continue and further develop the debt remission initiative, and
· give active support to improving development financing.

References:

1. Larson I (1999) Four Million Killed in Post-Cold War Conflicts, Prospects for Peace Increase, Even in Poorest Countries, with Investments in Agricultural Research and Technology. http://www.futureharvest.org/news/02161999.shtml

2. Somalia: UNCT Somalia Monitor 23 December - 13 January (1999) http://www.sas.upenn.edu/African_Studies/Hornet/irin_11499.html.

3. Sherman D (2002) State of the World's Mothers 2002: Mothers & Children in War & Conflict. Save the Children, The David and Lucile Packard Foundation, IKEA.

4. UNU/WIDER (1998) Humanitarian emergencies and warlord economies in Liberia and Sierra Leone. Paper presented at the conference on War, Hunger and Displacement: the Economics and Politics of the Prevention of Humanitarian Emergencies, 15-16 June 1998, Stockholm.

5. IFPRI (1998) Food from Peace, Breaking the Links between Conflict and Hunger: Food, Agriculture, and the Environment Discussion Paper 24. IFPRI: Washington DC.

6. FAO (2000) The State of Food and Agriculture. FAO: Rome.

7. ICRC (1997) Landmines must be stopped. Special brochure. ICRC: England.

8. Commission of the human rights of the US-Delegation (2002) http://www.humanrights-usa.net/reports/droc.html.

9. Murithi T (1998) Alternative Electoral Systems; 'Electoral Systems and the Management of Ethnic Conflict in Africa. Keele University. http://www.psa.ac.uk/cps/1998/murithi.pdf.

10. Anderson M (1999) Do no Harm: How aid can support peace - or war. Lynne Rienner Publishers: London.

11. WFP (2002) http://www.wfp.org.

12. FAO (2000) World Food Day 2000, Information Note.
http://www.fao.org/wfd/img/InfoNote2000-e.pdf

Contact: Karsten Hinrich c/o
schoeneberger.welternaehrung@web.de

WHAT ARE THE CHALLENGES TO IMPROVED HUMANITARIAN ACTION IN FOOD CRISES?

Austen Davis
General Director, Médecins sans Frontières

Food is a daily need. In crisis situations where markets, economies and lives are totally disrupted, finding enough food to eat is a central struggle. The physical need to eat is obvious, but the humiliation and pain of hunger and being unable to feed one's family is often poorly appreciated. Food and nutrition intervention has become the central element of humanitarian crisis response. As the role of crisis intervention has expanded in terms of publicity and political relevance, nutrition in crisis situations has become an important issue for public solidarity and for aid policy. Therefore, it is an important theme for this year's SCN Symposium.

Over 10 years ago in the Martin Forman Lecture, Alan Berg called for more nutrition engineers¹. Mr. Berg argued that while there is always room for more rigorous scientific knowledge, the main failure was not in terms of the coherence of our scientific knowledge, but in the application of this knowledge. The most recent edition of New and Noteworthy in Nutrition reveals that many of the same problems exist today².

Food crisis and the ineffectiveness of the humanitarian 'system'

Food crisis is a major threat in crisis situations. Food crisis is a major cause of instability, ill-health and increased mortality. It contributes to the collapse of economies, livelihoods and increases inequities in already inequitable situations. It is also well appreciated that intervention in crisis situations is dominated by the use of food aid as the major intervention strategy, both in monetary value and volume. Food aid is the organizational logic driving emergency intervention thinking and capacity. Yet, it is well recognized that food aid is probably the most corruptible form of emergency intervention and in terms of providing nutritional well-being-it is a blunt tool.

The dangers are well known to people's immediate and long-term well-being when forced to migrate out of distress and collapse of entitlement. Relief camps may be organizationally reassuring, but they are not healthy or secure places to live. Today, much is known about crisis situations, which is meant to improve relief response. Such advances in knowledge include:

· a need for broad based food, nutrition, health and water interventions, preferably to support livelihoods, but sometimes specifically to reduce morbidity and mortality

· information now available on complex food economies and survival strategies of individuals, households and economic groups

· need to expand food quantities in food baskets and food diversity and quality, and

· quality of interventions may be compromised when coverage is extended.

Correspondingly, there has been a growth of specialist humanitarian funding channels and the development of technical implementation capacity. The much-vaunted humanitarian 'system' that has emerged has developed enormously in its capacity to talk and to meet and to have papers written on important subjects such as protection. Yet, there is still terrible hunger, chronic pipeline problems and major shortages in food basket quantities and qualities. There are still major inequities in the distribution of foodstuffs and services, with resources concentrated in certain politically sensitive areas, while other populations are abandoned. There is still inarticulate migration, shelter, livelihood, nutrition, food and health interventions. In short, the humanitarian 'system' does not seem to be able to significantly reformulate itself to be able to implement lessons learned. It does not seem to have advanced in protecting people and meeting their critical needs while preserving their dignity.

One should be careful with suggesting that the mere existence of hungry people is the failure of the humanitarian system alone hunger is primarily a political issue and humanitarian actors have limited political power. But humanitarian actors have set themselves the task of accessing the hungry and abused and meeting their needs and demanding their protection. So why is the humanitarian 'system' so ineffective?

There is one paradigm that says the 'system' is poorly funded, poorly managed and poorly coordinated. What we need would seem to be greater coherence and leadership of the 'system', through streamlined donor funding, effective coordinating mechanisms, improved information sharing and a common set of technical standards. All the different agencies can be cogs in a single well-oiled machine if someone would only put it together and oil it. This is the prevalent analysis among donors, NGOs and the UN agencies today and for the past ten years. The fact of continued and progressive failure of the 'system' does not seem to provoke a collective challenge to this paradigm. Why have the tremendous advancements in the quantity and quality of resources allotted to humanitarian action not made appreciable differences in our ability to access and protect people in crisis? More resources can always be obtained, better management decisions made, but more of the same would be produced. There needs to be a completely different frame of analysis for the problem and possible actions.

The much-vaunted humanitarian ‘system’ that has merged has developed enormously in its capacity to talk and to meet and to have papers written... Yet, there is still terrible hunger, chronic pipeline problems and major shortages in food basket quantities and qualities...

The meaning of Humanitarian Action

There is a danger in assuming all intervention in emergency or crisis situations is automatically humanitarian. Fifteen years ago, the word 'humanitarian' was hardly used. Most agencies defined their actions in emergency situations as relief operations. But, relief operations were the poor cousin of proper development work. They were the necessary evil before getting back to the serious business of development. In other words, relief was the band aid.

UN agencies were largely absent from the heart of crisis situations. The UN was far more bound by re-did not have the analytic frame, logistic and security apparatus, or staffing to stay in crisis situations. Donors had a difficult time applying their disaster funding mechanisms to the challenges of manmade disaster response. Following increases in available funds and media exposure in the early 90s, different institutions have developed a humanitarian infrastructure and a humanitarian identify. Almost all agencies that seek to do good things today define themselves as 'humanitarian'. As a word it has lost currency, moral intent and political meaning.

Yet, humanitarian ideas and conceptual frames are important for working in man-made crises. They have been developed precisely to do this, so understanding humanitarianism is important in understanding the nature of emergency interventions. The task is to develop better access to ordinary people caught up in the middle of acute crises, in order to assist and protect them, and to help expand their horizon of choice so that they may start to re-establish control and agency over their own lives.

Armed conflict is recognized as an affair of society-a political system trying to win power and influence over another political system. Armed conflict is intolerable as an experience and so the balance between the freedoms of the individual and the requirements placed on the individual by his or her membership in society become strained. Hence, there has been an explicit recognition of the place and rights of 'Man' in society and the need to protect and assist men and women in the midst of war.

States recognize that there may be contradictions by allowing the recognition of 'Man' in war. However, they also recognize it is sufficiently important to sustain an appreciation for human life and human dignity and allow such compromise if they are reasonable. Therefore, they have created the laws of war. If 'Man's' political history is characterized by the use of violence, one of the reasons society has been successful is that men and women have usually been able to generate an ethic of restraint in the use of violence⁴.

If humanitarian action is genuinely aimed at impartially serving those in greatest need (impartiality), if it is humane in its impulse (humanity), if it is provided with independence from any other agenda, be it political or religious (independence), and if it is non-partisan in the social struggle in which it is operational (neutral), then it has the greatest chance of being allowed⁵. It is difficult to negotiate the terms and conditions of access on a case by case basis. Therefore, each case of denial effects the chances of humanitarian action in other contexts.

Humanitarianism is a moral philosophy not a political ideology; personal political preferences do not have any impact on a commitment to humanitarian action. On the other hand, developmentalism is caught up in the right-left debate on the validity of the concept of social justice and the means to societal development. Humanitarian action should be politically irrelevant and unquestionable in motive (historically) to have maximum opportunity for access and assistance.

Peace and development on the other hand are intensely political issues. For peace to be desirable it must be just and must reasonably allow for the balance between the needs of the men and women in society. This delicate understanding of working in conflict is crucial. Current policies linking aid to development, peace and respect for human rights are overly-simplistic and disrespectful of the complexity of affairs in other people's societies. Would the international community dare to impose a rather mediocre package of social services on the people of Ireland or Israel today and call it conflict resolution and peace-building? Despite the very good will of aid officials and their genuine ambitions, the articulation of current aid and political strategies in Africa and Afghanistan today shows a deep lack of respect for the very real and pressing political and social realities of their conflicts and wars.

What this argument proposes is that humanitarian action is grounded in a set of principles designed to promote maximum access to people in crisis and the prioritization of a particular set of objectives relating to alleviation of acute human need and the preservation of dignity. If this argument is accepted, then it is logical that humanitarian action becomes a small and limited ideology grounded in an ethic of self-restraint and not the normal utopian and progressive ideologies found today.

Humanitarian action does not aim to provoke social change; it aims to assist and protect victims and inspire discipline and restraint in the use of force for social change (this does not mean it is unimportant or unpowerful). Humanitarian action is practical and politically realistic. It must be action oriented, it must be non-coercive, it must be provided solely for the benefit of those we seek to assist. Humanitarian action is targeted to humans and not society and, therefore, humanitarian actors must take responsibility for the delivery of their assistance all the way to the beneficiary level. The basic conditions that humanitarian actors require are to have the freedom to assess needs, the freedom to deliver assistance and the freedom to monitor the outcome. If these conditions are denied, humanitarian action is likely to be compromised and sow the seeds for its own destruction.

Challenges to the 'System'

As mentioned earlier, many aid workers and policy officials refer to the international community and the humanitarian system. With the 'system' perspective in mind, systemic type reforms have been suggested, but a system is a group of related units forming a network with a common goal or a single purpose. Do all the humanitarian actors seek this purpose (to assist and protect victims)? When stated that there needs to be greater integration of humanitarian action into political affairs and construction of conditions for peace, such as in Afghanistan today, it is clear that the humanitarian system is not a system. Or if it is, it is not humanitarian. Why was access denied into Kosovo when the Serbs were in control? Why is access denied in Chechnya? Why is there limited access into North Korea? Why is it impossible to reach a major and severely effected proportion of the population in Angola today? Why does nobody even talk of the victims of the conflict in Tripura or Assam? Is it because political leaders or politically inspired individuals see themselves in opposition to the Western political system and see humanitarian action as part of this?

The politicization of humanitarian assistance has been well described and documented^6,7,8. In the 90s, humanitarian action evolved from the poor cousin of development aid to become an organizing principle for much more than humanitarian/emergency assistance providers. While humanitarian agencies demonstrated on television that aid was being delivered, the West was paradoxically reducing aid and diplomatic resource flows to the least developed nations. Humanitarianism also justified an increased legitimacy of interventionism over sovereignty arguments, in order to protect the rights/needs of 'Man' in unjust societies. This contradictory force, on the one hand, used aid to demonstrate engagement where there was none and, on the other, concentrated aid flows to politically sensitive areas where aid was co-opted into the political address of the situation. These contradictory trends created an increasingly political logic to the direction of aid funds (geographically and in terms of activities). In the first situation, humanitarian aid became totally subordinated to higher political/societal objectives and aid became perceived as part of the political interference. In the latter, humanitarian agencies were left witnessing terrible crimes again humanity with no capacity to address the causes of the crisis.

Six aspects of current humanitarian action can be identified which hamper how the 'system' works today.

Political Conditionalities

Humanitarian action is delivered to the victims of crisis. Paradoxically, the authorities who wage war are also those who have to agree to allow humanitarian access. They are held to respect humanity in war and exercise restraint in the use of violence. But in many conflicts today, those who wage war have low-levels of accountability to their citizens and tend to demonstrate limited respect for humanity or restraint in the use of violence against their own people. Civil war is often more violent and less restrained. The objective of war becomes the obliteration of the opposing society and not capture. In many modern crisis situations there is little support from authorities to allow humanitarian action. For humanitarian action to be meaningful it should have a high impact on the life of those it seeks to help and a low impact on a specific party's ability to pursue their political project. They should not allow humanitarian action because there is something in it for them, but because they respect the need for restraint in the use of force and the defence of humanity.

Therefore, imposing conditionalities on humanitarian aid logically should have little leverage over the political party (it is purposefully irrelevant to them) and enormous impact on ordinary victims⁸. The clearest demonstration of the fallacies of such a policy have been shown through the embargoes imposed on rogue regimes, including humanitarian assistance. In 1993, the UN and ECOMOG tried to put an embargo on Taylor-held Northern Liberia. The actions led to countless deaths of starving people and no substantial reduction in Taylor's grip on power. Embargoes from Iraq to Northern Sudan privilege the ruling elite and punish the poor⁹. If there is even less food available due to embargoes and one person has a gun and the other does not-who will eat?

Yet, even unquestionably good conditionalities have been shown to penalise the weak and vulnerable. When NGOs and the UN tried to form a collective front and hold their aid for Afghanistan conditional on the respect for human rights of women, the result was a massive reduction in aid flows, punishing the starving and the sick who were disproportionately women¹⁰.

Humanitarian assistance is a very poor lever on power. If the powerful suspect humanitarian aid is being used to gain leverage over them, they will act to deny the possibility of aid. There is no influence and the possibility of humanitarian action is lost, further contributing to the loss of restraint and lowering the value of what it means to be human at all.

Concentration

Recently there has been a trend towards even more concentration of aid in the most politically sensitive areas to whitewash military interventions and hide the absence of genuine efforts toward nation building. Humanitarian action in such situations is truly a subsidiary to political intervention and a political excuse for avoiding full responsibility in such contexts.

The majority of resources are invested in crises with intense political interest³. This has various effects. Specifically, it diverts interest and resources to a few crisis situations. The numbers of NGOs and expatriate staff committed to Kosovo, E Timor or now Afghanistan, are disproportionate to the commitment to other areas. In addition, in these highly politicized environments the political machine co-opts humanitarian assistance for political ends. The food bombing of Afghanistan by the US on the same night as they began bombing (while hunger and famine were known to be at catastrophic levels for over one year) was clearly not delivered for humanitarian purposes, otherwise food bombing would have occurred earlier.

North Korea has been the recipient of one of the largest food aid programmes of modern times. The US and the EU have funded massive food and medical programmes to counter a reportedly devastating famine under a policy of 'constructive engagement'. However, the famine is heard but not seen and it is increasingly evident that the food crisis is structural and a result of the state structure. UN agencies and NGOs are not allowed to have significant numbers of expatriate staff in N Korea. Most agencies have almost no freedom to assess the needs independently, they are denied the opportunity to directly deliver assistance and they are unable to monitor the impact of assistance^11,12.

Kim Jong-il, the leader of N Korea, has publicly proclaimed that only 30% of N Koreans have to survive for N Korea to reconstruct a victorious society. The state is militarily in control and seems unperturbed by the total collapse of the economy¹³. It is clear what his balance point is between the success of society and the freedoms and well-being of 'Man'. Many of the independent NGOs working in N Korea pulled out because they became aware of the game played to pretend the programme was an effective redress to people's acute needs. It is clear there is a massive structural food problem in N Korea and this probably requires massive and sustained food assistance to reduce mortality and stabilize society. There is significant evidence to suggest that all aid is channelled to members of society favoured by the regime through state man-aged distribution systems and the military¹².

The aid programme no doubt supports some livelihoods, but fails to help those the regime does not value and only serves to stabilize a very dangerous regime. This may be a legitimate political action, in an attempt to reduce chances of a regional nuclear war, but this is the same regime responsible for the famine and complete denial of responsibility to look after its own citizens. Is this a humanitarian programme? What damage does this programme do to the possibility of humanitarian action? How accountable to voting publics is a programme of sustaining a dictator by food, hidden under the guise of a humanitarian mantle? How responsible is the political engagement by international states that seem unable to confront the problem? With this (non)humanitarian programme and lack of democratic accountability in our address of the N Korean problem, is the world hiding behind food as an alibi, avoiding the reality that it has no policy to deal with the horrors of N Korea¹⁴?

Research has shown a progressive increase in the earmarking of donor funds to particular crises. As the majority of humanitarian actors are driven by the availability of government donor money, humanitarian assistance is becoming increasingly selective in quantity and quality³.

Impartiality

If aid is provided according to a political logic, as argued above (non-neutral), it is also difficult to demonstrate that aid is provided on the basis of need alone and the most needy receive the most aid (impartiality). There are substantial differences in the quantities and standards of humanitarian action around the world. It is very moving to see the quality of hard dried grains given out in a typical food ration in Africa (usually too little, too infrequent and without sufficient complimentary quality foods). At first sight, it is hard to believe this is food for humans, however nutritious it might be. In the camps for Kosovars in Macedonia, on the other hand, large numbers of people were queued in a respectful way and rapidly given cloth bags filled with fresh baked bread, peppers, cucumbers, melons and tomatoes. This demonstrates that it is possible to feed large numbers of people in a respectful way and with a humane diet. Some refugee populations, especially in Africa, get a poor deal in comparison to others caught in 'preferred crises.' How do the people in these crises look at humanitarian actors when they arrive? As friends trying to help or as part of a system of discrimination and injustice in which they are caught in?

Coercion

After the end of the cold war, refugees were no longer politically desirable reminders of the failure of the communist world to care for its citizens. Refugee camps became perceived as dangerous breeding grounds for criminals, lawlessness and radical militant action. Refugee programmes developed a life of their own, drawing in endless quantities of assistance. Policy concerns re-oriented to the containment of crisis and the rapid management down of relief flows. As the political control of humanitarian assistance increased, aid was co-opted to push people back into home situations or to move them to other areas.

Sierra Leone has been racked by a terrible war for nearly ten years. During this time, tens of thousands of people fled to Guinea to try and find some semblance of peace and security. Many of the refugees were treated as second class citizens and used for cheap labour, but they were safe. In 2001, preparations were made by rebel groups to destabilise N Liberia. Retaliatory rebel attacks were launched across borders into Guinea and focused on refugee camps in an attempt to catalyse mass movement and chaos. Humanitarian and human rights groups called for the refugees to be moved out of border areas to safety. International powers and the Guinean military had no interest in seeing potential enemies spreading out across Guinea, and tried to contain the crisis. Military, police and civilian militias began victimizing refugees on the basis of ethnic identity, with no proof of their involvement in rebel activities. Men were stopped at check points and stripped for evidence of tribal scarring marks. Many were brutalised, arrested and executed.

Eventually when the situation had calmed down, it became politically expedient to move the refugees. Refugees were told to relocate deep into the forest where there were no alternative sources of income or livelihood, except total reliance on international assistance and leaving them much more vulnerable to manipulation. While this programme offered real safety to thousands of refugees and was eagerly accepted, there was a large number of refugees who did not want to move away from the border. These refugees were told that their camps would be flattened and they would no longer receive assistance if they remained in the border regions. The only way to receive foreign aid is to move to the new camps.

It might be true that insecurity would limit the possibility of provision of regular humanitarian assistance, but to declare no more would be provided was an abandonment. The refugees' only choice was to relocate to new camps and live under uncertain conditions for an unspecified length of time, entirely at the mercy of the aid givers. Is this expanding the choices of refugees and assisting them in managing their own lives and possibilities in terrible times? Given the very erratic and low quality aid programme over the past ten years refugees are reluctant to put the lives of their families in the hands of the international community.

These patterns of coercive manipulation of vulnerable populations dependent on food aid and other assistance have been repeatedly seen over the past couple of years in Iran, Pakistan, or Zambia to name but a few. WFP's own figures show a trend in decline of food support to protracted refugee operations and a major increase in food diverted to protracted displaced persons operations¹⁵. Food is used more within countries to support containment of crisis situations and refugee outflows.

Bureaucratic Imperative

All systems of order and organization develop interests and organizational imperatives, no matter what their objectives. Most professionals in this field have a general desire to have a real impact in assisting people's lives and relieving the misery and humiliation of hunger. However, organizations have their own norms and interests and workers who exercise their own personal interests through these organizational processes. An agency can only be convincingly humanitarian (single minded in its desire to help people today), if it is driven by a humanitarian impulse, or, if it is strictly mandated, monitored and held accountable to that mandate.

In order to have the possibility to enter dangerous areas and deliver resources and stand by people in times of need, the international aid community needs to organize. There has to be a balance between the motivation of the people trying to make a difference and the necessity of the organization to give those in-dividuals power to act. The organizational interests are only acceptable as long as they do not eclipse the humanitarian impulse.

There is an increasingly bureaucratic imperative driving the humanitarian sector today. This is true of donors, UN agencies, international and local NGOs. In the past, UN agencies were largely state funded and relied little on media coverage. Today, the UN agencies are paralysed by intra-agency and inter-agency turf battles, which has become progressively worse in the last decade as they are squeezed for funds. The UN increasingly needs to advertise rather than depend on reliable state support. States support different agencies in different ways over different times. Different themes and agencies become 'flavour of the month'. Different governments are seen to support one agency and to 'own' it, which deters other states from funding that agency. UN agencies act to define their own interests and imperatives, expanding or contracting to fill certain spaces and modes of action or mandate, without a comprehensive analysis of all the spaces that need to be filled.

With changes in the refugee regime and declining political support for sustaining large refugee populations outside of conflict and crisis areas, UNHCR tried to become involved in moving people back. As a result UNHCR displaced UNICEF as the UNs largest non-food humanitarian agency. But as funds and support declined even further UNHCR has now retracted its mandate, responsibilities and ambitions. Who will (re)fill the gap?

There is an increasingly bureaucratic imperative driving the humanitarian sector...different governments are seen to support one agency and to ‘own’ it, which deters other states from funding that agency...cutting at the heart of...humanitarian action and placing peoples’ needs after bureaucratic/agency interests

The bureaucratic imperative is enhanced by the funding patterns and competition between UN agencies and NGOs fighting for media space and funds. The bureaucratically interested agency is peculiarly vulnerable to political manipulation, because it steers towards opportunities for agency advancement, which are easily offered by political (funding) sources. Donor governments have a responsibility to support impartial humanitarian action and should not use funds to create turf battles and competition. This bureaucratic imperative is cutting at the heart of the truth of humanitarian action and placing peoples' needs after bureaucratic/agency interests. This is a major reason why the UN system does not function as a system and why the UN agencies fight desperate turf battles over coordination and areas of responsibilities. This happens particularly in the high profile political emergencies where resources, prestige and career opportunities will be abundant. In the moments of great crisis, the operational logic behind the humanitarian sector is partially driven by institutional interests. The turf battles undermine the ability of agencies to work together and act to create ownership of sectors. It leads to an increasing compartmentalisation of responsibilities and technical capacities. The verticalization of agency capacities means it is far more difficult to generate and implement complex multi-sectoral strategies which we know are critical for supporting livelihoods in crisis situations and reducing distress and mortality.

However good, impassioned and driven to improve the lives of hungry and insulted people professionals may be, if they are working in an agency that has lost the balance between an organizational imperative and the moral imperative of its workers, then that agency is no longer humanitarian in drive. One's work will be swamped and frustrated by a bureaucratic logic that may be hidden behind nice words, but is inherently inhumane, ineffective and amoral.

Technicalization and Cost-Effectiveness

Humanitarian assistance is still about delivering services. Therefore, the majority of professional development, planning and monitoring resources are expended on estimating if the agency is doing its job, delivering materials and providing services. Humanitarian action is a management challenge, which denies the political reality of the lives people are living. It is critical to have close contact with people in crisis situations to understand what they are facing and what are the major limitations in their daily struggle to stay alive. The underlying assumption that governs humanitarian action today is that what matters is delivery of services coupled with a desire to improve cost-effectiveness. This has allowed a focus on notions of quality that only reflect needs as determined by absence of material. These notions of quality do not ask why there are no services and such needs. There are fewer and fewer international aid staff on the ground and insufficient resources to commit numbers of experienced experts in the design, implementation and monitoring of humanitarian programmes. The needs of the vulnerable cannot be respected, protected or reacted to without that proximity.

Who is it that sets the indicators by which agency actions are monitored? If there is no monitoring of the frequency and equity of distribution mechanisms, aid agencies will not place the same emphasis on these quality dimensions of the aid interaction. Working in crisis situations means working in highly corrupt, inequitable and perverse anti-social environments. Many of the institutions of society will be co-opted and predatory in nature, manipulating scarce resources and people's lives to enhance power and wealth. If aid is poured into these social systems without adequate attention to quality aspects, and the quality of the aid relationship and service to the beneficiary, these resources will feed into systems of repression.

A decade ago people would criticize WFP for being a logistics machine, and it remains so today. Without new incentives for enhanced quality of their actions, will they be different tomorrow? In order to further reduce costs of food distribution and avoid the critical nature of some partner NGOs, there is increased use of local and non-transparent organizations. The increased focus on the costs of food distributions has had a major impact in reducing the concept and efficacy of humanitarian intervention, and particularly in understanding the challenges to protection of victims in crisis³.

In Goma, MSF withdrew from the Rwandan refugee camps after demanding increased accountability of food aid and seeing no change. The amount of food was far in excess of the numbers of people in the camps, but people remained malnourished. MSF were prevented from doing a proper registration or from distributing directly to the beneficiary. The organisers of the genocide controlled the food supplies and used the food as a resource to re-build their military capacity. Even though this is well known, these same challenges continue today. In Mazlak camp in Western Afghanistan, WFP provided food for 300,000 people while NGOs estimated the population to be half that. Yet, nutrition monitoring in the camps showed that there was growing malnutrition and the camp residents were progressively more malnourished than new arrivals. Vast amounts of food were delivered to community leaders who had hundreds of ration cards. The leaders then sold these bulk quantities. The food was shipped in and then out of the camps. MSF and ACF have pushed for a proper registration, which was recently accomplished by IOM and the UN to reveal a population of only 110,000 people. The next step must be to move towards individually provided rations and not via corrupted and discriminatory community delivery systems. Community based delivery maybe cheaper, but it is not always the solution to ensure egalitarian distribution of food in emergency situations.

These factors undermine the perception and experience of humanitarian assistance by political actors and beneficiaries. Humanitarian assistance then loses its respect and is either blocked (as in Chechnya today) or is cynically manipulated by local warlords. Furthermore, the aid recipients do not work with aid agencies to achieve maximum benefit from the assistance, but rather work against aid agencies to extract maximum personal benefit. There needs to be an explicit responsibility for the provision of services all the way to the beneficiary: to feed, secure, protect. Can humanitarian action under the current 'system' be humanised, making it truly responsive to differing needs of people caught up in crisis? Can this be done without major changes in structure and putting more people next to the victims?

What To Do

This macro-level critique tries to recognize some of the challenges that effective sector wide humanitarian action. Of course implementing apolitical humanitarian action in the real political world will always present major problems. This critique is not meant to imply that everything is hopeless and nothing can be achieved.

There has been enormous attention and public resources given to humanitarian action. The general public has vigorously understood and supported the humanitarian imperative. The UN and NGOs are significantly involved in the humanitarian debate and committed to action. Access to people in crisis is won and sustained and military and political leaders around the world are aware of humanitarian obligations and allow some form of action. There has been real commitment to improved quality of intervention and many people have given time and energy to push forward knowledge and thinking in how best to intervene in crisis situations.

It is partly because there are so many experienced and committed people in the field of humanitarian action that it is expected and desired rapid improvement in overall capacity to access, assist and protect. It would be naïve to simply ask for greater political investment in addressing the causes of crisis at a mo-ment when investment in the military has expanded rapidly, at the same time as investment in diplomatic representation, civic interaction and overseas aid has collapsed¹⁶. The West has moved towards a militarization of international relations with declined capacity for diplomacy. We should recognize this and reassess the possibilities for good aid in the changing context.

The predominant rhetoric and actions for those who genuinely want to see reform and improvements in our ability to feed people with dignity and restore their own capacity to take control of their lives and reinstate their agency and choice is driven along a notion of technical 'systems' improvement. So there is an agenda: better donor policies, better donor coordination on objectives, better UN management, better UN agency cooperation, better coordination of NGOs, and finally, better integration of humanitarian action within a political framework for the creation of peace and progressive development and participative politics. But the current humanitarian aid environment means that the proposed agenda above will have to work along side such impeding factors such as:

· a decline of political investment in crises in areas of limited political interest

· donor manipulation of humanitarian action (to favour friends or hide disengagement)

· donor funds tied to political conditionalities

· UN agencies funded in a way as to increase internal competition

· no state responsibility for the fulfilment of the mandate of the UN

· no UN capacity to respond to the state agenda,

· a massive diversity in philosophies of action by different actors and host societies

· increased military intervention in some crisis zones,

· betrayal of universal impartiality-and the clear prioritizing of certain victims over others

· the institutionalisation of the humanitarian impulse; increasing public questioning of the humanitarian sector, and

· a vast array of organizations with different ideas, motivations, legitimacies and objectives all called NGOs.

What actions might such a critique suggest? Here are some suggestions, which are by no means exhaustive:

· Food is life and food is dignity. In a survey on mental trauma in Sierra Leone in 2000, MSF found that the majority of people assessed were suffering some form of acute mental stress¹⁷. The causes of stress were multiple and bound up with the collapse of society, fear and experiences of violence. By far the highest proportion of people attributed some of their mental trauma to the debilitating and humiliating effects of hunger. In a country so beset by violent chaos, this illustrates the importance of food as a means to basic dignity of life. The international aid community has a tremendous responsibility and should be motivated to pursue that responsibility

· The current system is not a system, or at least not one driven by humanitarian concerns. It is important to have a greater sense of realism about what the major momentum in humanitarian and political intervention entails, so as to recognize opportunities and threats for the development and promotion of effective humanitarian action. Following a systems-based agenda serves to reinforce a depoliticized and technocratic agenda without much power for change

· The current organization of relief activities is limited by a range of factors including incoherent objectives and perverse funding incentives, as well as political conditionalities tied to assistance. Further work is needed to define how to react to acute nutritional crisis situations in open situations and across different cultures. The challenges of the HIV/TB pandemic must be dealt with and the livelihood and nutritional challenges it creates addressed. Investments can be made into simple means to assess and respond to adolescent and adult acute malnutrition and mortality. Well grounded aid strategies, sound needs assessments and clear and unequivocal action plans, aimed primarily at responding to real needs of people, are compelling arguments for improved practice

· States will try to manipulate humanitarian assistance for their own ends. States have signed the Geneva conventions and have a basic responsibility to appreciate and support vital independent and impartial humanitarian action. The funding patterns of donor governments should reflect on their humanitarian responsibilities. Humanitarian funding should be given to mandated bodies in a manner to promote effective impartial action in support of humanity. Funds should not be provided to mandated agencies (such as ICRC and the UNHCR) on a project basis, as this promotes concentration of funds in certain crisis situations and undermines the impartiality of the specialist agencies. This does not mean that these bodies should not be held accountable, on the contrary, they should be held more accountable to justify their successes and failures on a global scale

· It is unacceptable that the policies of states and UN agencies are so dependent on the personal political ideologies and experiences of senior technocrats. States and UN agencies have formal responsibilities, which should not be open to interpretation. States should enact laws to define and control the use of humanitarian budgets, to enforce separation between the use of humanitarian funds and the pursuit of political interests and to define their humanitarian responsibilities

· Clear categories of intervention in crises should be developed, with concordant principles and clarity of objectives to guide intervention. Not all assistance provided in emergency situations needs necessarily to be humanitarian, but the objectives and mode of operation needs to be clearly stated in order that decisions to act are held democratically accountable. Interventions aim to achieve their true objectives, correct institutional capacities are developed to maximize intended goals and humanitarian action is not degraded by incoherence and degradation of its principles through association

· There needs to be much better reporting on aid flows, achievements and quality indicators. Information must be able to be aggregated so there is increased transparency about what is being done, for what reason and what are the trends. Today, academic observers claim it is impossible to aggregate data on funds and material flows. It is also impossible to review what happens to materials once they have entered a country. Accountability systems need to avoid overlap and focus on real funds and material flows (not pledges), all the way to the beneficiaries

· UN agencies must be given a mandate and then funded in such a way as to enhance cooperation and fulfilment of the mandate. If they fail they should be held technically accountable, whilst states should be held politically accountable. There should be an independent review capacity, to map out the UN mandate, to what degree the UN agencies fill their mandates, and if the sum of UN agency actions fulfills the total mandate. The review capacity should be ongoing and should not just determine gaps and failures, but isolate and identify causes of failure (technical or political), so as to point to the responsible actors and promote reform rather than avoidance

· Humanitarian workers/activists must always be aware of the critical balance between an agency's real drive to meet the needs of people and the bureaucratic interests of the organization. The value of the work of aid agencies must be insisted on and the bureaucratic imperative must be countered

· Food and nutrition crisis is central to understanding the political economy of most crisis and conflict situations today. The dynamics in a crisis situation are deployed to destroy economies, deprive people of opportunities and target the basic productive means in society. Therefore, food and nutrition perspectives are uniquely placed to describe the cross-cutting impacts of crisis and to advocate for broad based and comprehensive response. The SCN must reconstruct an agenda for multi-sectoral and multi-agency action, resurrecting real positive dynamic interaction between the various food and nutrition agencies, with distinct roles and inter-active programming possibilities. If there is limited competition and distinct roles, there should be the possibility for enhanced action and inter-action

· There must be more funding for quality interventions. The meaning of quality must be defined in terms of the degree to which victims are saved and can exercise choice in their own lives. Humanitarian actors should recognize that there is a responsibility to deliver assistance to the individual beneficiary. In having such a field presence, there is a requirement to interact with the beneficiary to understand the diversity of challenges they face. Only an interactive relationship can inspire the crafting of solutions that do not impose assumed good things, but rather help expand the victim's horizons of choice. This will mean increases in programme costs. The argument to increase programming cost must be well constructed and championed and must resolutely serve the vulnerable and not institutional interests

· There must also be greater investment in rapid establishment of epidemiological surveillance in crisis situations, to be able to follow real problems and genuinely monitor progress. Political proclamations by agencies that there is a famine and later that they have averted famine, without demonstration of the facts that they have done so, does not promote learning or better practice. This is agency focused and not people focused, obscuring accountability to improve our actions

· There must be more funding for applied research and the development of appropriate intervention strategies, following good epidemiological surveillance and appreciation of people's needs

· There needs to be sustained peer review and critique of developed knowledge. Too often, we are driven by very circumstantial evidence and personal ideology. Scientific methods and the academic tradition needs to be more widely applied to humanitarian action.

The basic perspectives on food security analysis, famine theory, nutritional assessment and food and nutrition intervention have been established for some time. There is also general consensus that effective reaction to nutrition challenges depends on a multidisciplinary approach strategically and practically coordinating avoidance of migration, health and epidemic control, food security and livelihood support and sustenance of care environments. Humanitarian action is grounded in a set of principles designed to promote maximum access to people in crisis and the prioritization of a particular set of objectives relating to alleviation of acute human need and the preservation of dignity. There are no major gaps in our conceptual knowledge that should inhibit our actions.

There have been some considerable advances in the technical and logistic capacity of the various aid agencies to deliver timely and effective responses to nutritional crises around the globe. However, despite major technical advances there has been little substantive progress in our shared capacity to effectively assist, protect, support and care for the needs of the majority of people in most desperate need. Why is this? The 'community' of donors, UN agencies, NGOs often try to find solutions based on an assumption we are all part of a 'humanitarian system'. But different political and bureaucratic interests, different ideological perspectives, the technical compartmentalisation of aid delivery; and a focus on service delivery and cost-effectiveness ignore important ethical and political considerations. Without a commitment to humanitarian principles the immediate needs of people, using aid to promote agency and not coerce populations, and alignment of the objectives of the humanitarian aid community the 'systems' perspectives will not serve to enhance our capacity.

References:

1. Berg A (1991) Sliding Toward Nutrition Malpractice: Time to reconsider and redeploy. Martin Forman Memorial Lecture, June 24, 1991. Crystal City: Virginia.

2. New and Noteworthy in Nutrition (2002) 36.

3. Macrae J (2000) International Humanitarian Action: A Review of Global Policy Trends. Overseas Development Institute: London.

4. Coupland R (2001) Humanity: What is it and how does it influence international law? International Review of the Red Cross 83 (844): 969-990.

5. Pictet J (1979) The Fundamental Principles of the Red Cross. Henry Dunant Institute: Geneva.

6. Disasters Special Issue (2001) Politics and Humanitarian Aid: Debates, Dilemmas and Dissension. Disasters 25: 4.

7. Disasters Special Issue (1998) The Emperor's New Clothes: Charting the erosion of humanitarian principles. Disasters 22: 4.

8. Leader N and J Macrae (2000) Terms of Engagement: Conditions and Conditionality in Humanitarian Action. A Conference Report. Humanitarian Policy Group Report. Overseas Development Institute: London.

9. Garfield R (1999) The Impact of Economic Sanctions on Health and Well-Being. Humanitarian Practice Network paper. Overseas Development Institute: London.

10. Atmar MH (2001) The Politicization of Humanitarian Aid and its Consequences for Afghans. HPN Newsletter 9 November 2001. Overseas Development Institute: London

11. Evaluation of EMOP DPR Korea 5959. Emergency assistance for vulnerable groups. http://www.wfp.org/index.asp?section=7_1.

12. ODI (1999) North Korea: Conflict Management, Food Aid and Humanitarian Principles. HPN Discussion Paper. Overseas Development Institute: London.

13. Terry F (2001) Feeding the Dictator. The Guardian 6 August 2001.

14. Kristof N (2002) North Korea: The lack of US policy raises the risk of war. Letter to the Editor. International Herald Tribune.

15. WFP (2002) http://www.fao.org.

16. Nye JS (2002) The Paradox of American Power: Why the World's Only Superpower Can't Go It Alone. Oxford University Press: Oxford.

17. Jong K, Mulhern M, Ford N et al (2000) The trauma of war in Sierra Leone. The Lancet 355: 2067-2068.

Contact: Austen Davis austen.davis@amsterdam.msf.org

A world fit for children Outcome document for UNGASS Editor’s Note: These excerpts are taken from the outcome document of the United Nations Special Session on Children, held in New York in April. The outcome document was written and negotiated over a period of about two years, with UNICEF serving as the Secretariat for this lengthy process. The document reflects world leaders’ renewed commitment to children. Declaration 14. Care for every child. Children must get the best possible start in life. Their survival, protection, growth and development good health and with proper nutrition is the essential foundation of human development. We will make concerted efforts to fight infectious diseases, tackle major causes of malnutrition, and nurture children in a safe environment that enables them to be physically healthy, mentally alert, emotionally secure, socially competent and able to learn. Plan of action Goals, strategies and actions 36. We are determined to break the intergenerational cycle of malnutrition and poor health by providing a safe and healthy start in life for all children; providing access to effective, equitable, sustained and sustainable primary health care systems in all communities, ensuring access to information and referral services; providing adequate water and sanitation services; and promoting a healthy lifestyle among children and adolescents.... c) reduction of child malnutrition among children under five years of age by at least one third, with special attention to children under two years of age, and reduction in the rate of low birthweight by at least one third of the current rate. 37.5 Protect, promote and support exclusive breastfeeding of infants for six months and continued breastfeeding with safe, appropriate and adequate complementary feeding up to two years of age or beyond. Provide infant-feeding counseling for mothers living with HIV/AIDS so that they can make free and informed choices. 37.22 Achieve sustainable elimination of iodine deficiency disorders by 2005 and vitamin A deficiency by 2010; reduce by one third the prevalence of anaemia, including iron deficiency, by 2010; and accelerate progress towards reduction of other micronutrient deficiencies, through dietary diversification, food fortification and supplementation.

A REVIEW OF THE ADVANCES AND CHALLENGES IN NUTRITION IN CONFLICTS AND CRISES OVER THE LAST 20 YEARS

Frances Mason, Action Against Hunger/Action Contre la Faim and Anna Taylor, Save the Children UK

The international community is being faced with new injustices and new challenges to ensure the human right for adequate food and nutrition. This paper is intended to remind us of where we have come from in emergency nutrition and to highlight how far we have to go before the rights of disaster-affected communities are respected and upheld.

The main purpose of this paper is to assess the principle advances made over the past years in nutrition in conflicts and crises and to propose direction for further advances in the field. The term 'advances' refers to developments in technical knowledge and nutrition policy and practice. The project cycle management is used as a framework for presenting these advances and the challenges that remain. Specifically, the paper:

· considers the objectives of the advances and describes how well they have been achieved

· determines the challenges and issues that still exist in relation to the advances, and

· provides recommendations on how these challenges might be overcome and issues resolved.

Background

This paper is not able to provide significant detail on how highlighted advances took place, but it is essential to emphasise the important role that interagency collaboration has played in furthering the sharing of technical knowledge and improving the policies and practice of nutrition in conflicts and crises.

Interagency meetings held since 1988 initiated many of the interagency collaboration and policy developments described below. These meetings provided a forum for improved coordination, mutual understanding and enhanced analysis of the constraints within the humanitarian system. A central focus of the interagency work was the move towards Public Nutrition^a, which is a shift from the individual to the population level and from a narrow set of technical interventions to a wide range of strategies, policies and programmes to combat malnutrition². These interagency meetings have also provided a catalyst for a number of initiatives that have enhanced policy formulation and practice guidelines.

^a Public Nutrition is a broad-based problem-solving approach to addressing nutritional problems of populations or communities in which the broader factors of health, water and sanitation and social care play significant factors in the causes of malnutrition, alongside food insecurity. This approach requires a contextual analysis from the macro to the micro levels.

The Interagency Group was instrumental in recommending the establishment of the Refugee Nutrition Information System (RNIS), to be managed by the SCN Secretariat, in 1993. The RNIS project was the first to systematically collect, compile and report on interagency nutrition and mortality data in response to the lack of information on the observed high rates of acute malnutrition and crude mortality in emergency affected refugee and displaced populations. The reports present recommendations and priorities for action, including key constraints to operational response and act as an advocacy tool in raising awareness of the seriousness of particular contexts and often focus on emergency situations that are not covered by the media or have been 'forgotten'.

The Emergency Nutrition Network (ENN), which also originated from an interagency meeting, has become the key forum for information sharing amongst nutritionists working in emergencies. Its primary focus has been to ensure that experiences and lessons learnt are documented so that institutional learning can take place in the short to medium term. The ENN is now funded by approximately 20 agencies (UN, bilaterals and NGOs).

An unprecedented example of interagency collaboration was evident in the preparation of the nutrition chapter for The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response^b. This project aims to improve the effectiveness of humanitarian action and to make humanitarian actors more accountable. The Sphere initiative has stimulated much debate, ranging from enthusiastic support to concern over the limitations it might place on humanitarian action. Beyond the limited number of official Sphere translations that exist, the Sphere project has been translated into 19 languages.

^b The Minimum Standards specify the minimum acceptable levels to be attained in sectors of humanitarian response. Each standard has a set of key indicators which signal whether the standard has been attained. They provide a way of measuring and communicating both the impact, of the programmes as well as the process methods used.

Analysis and Assessments

As the paradigm of public nutrition began to be established in the early 90s, UNICEF developed a conceptual framework for understanding the causes of malnutrition. This was incorporated into their policy, as part of their Triple A approach. This framework was largely based on the Tanzania (Iringa) Nutrition Programme³. The framework was later adopted by a wider group at the International Conference on Nutrition in 1992⁴. This framework has been instrumental in ensuring an understanding of malnutrition that goes beyond inadequate intake to include the range of food security, care and health factors that contribute to malnutrition. Analysing these processes in specific contexts has created opportunity for intelligent nutrition programmes that address real rather than assumed causes.

Assessment of malnutrition and mortality, which is located at the apex of the conceptual framework, has become increasingly widespread in emergency-affected communities, so much so that the prevalence of acute malnutrition (wasting and oedema) of children 6-59 months is now a widely used currency for understanding the extent of the impact of a crisis on populations. This demonstrates the usefulness of anthropometry in providing objective data in situations where information may be limited and also indicates the importance given to levels of malnutrition for understanding the likely impacts on mortality⁵. Standard survey methods are now largely agreed upon in key emergency nutrition guidelines^c and combined with freely available software for statistical analysis, such as Epi-Info, have facilitated comparison of affected populations both spatially and temporarily.

^c Examples include The Management of Nutrition in Major Emergencies World Health Organisation: Geneva; WFP (2000) Food and Nutrition Handbook. World Food Programme, Rome; MSF (1995) Nutrition Guidelines Médecins Sans Frontièrs; Prudhon C. (2001) La Malnutrition en situation de crise, Action Contre la Faim.

There is also increased understanding of the importance of the analysis of epidemiological data alongside that of anthropometric data. Measles coverage data has become a fundamental component of regular data collection within anthropometric surveys and the importance of assessing mortality indicators in conjunction with malnutrition has become more widely recognised. In Burundi in 2001, standardized reporting of the numbers of malnutrition cases in centres and the number of malaria cases, combined with analysis of the worsening food security situation proved to make a strong case for assistance⁷.

Although the assessment of malnutrition in children under five years and the estimation of prevalence has become routine work for many emergency nutritionists, there remain substantial gaps in understanding how to measure acute malnutrition in other age groups, namely infants (<6 months), adolescents, adults and the elderly. This is due to the inadequacies of reference population data and inter-ethnic variation. In the last few years the limits of our understanding of how to measure these groups have become more widely discussed and the research agenda has become clearer.

Progress in assessment of malnutrition has been paralleled by the more widespread establishment of early warning systems in emergency prone countries. Some of these are based on analysis of food supply (e.g. famine early warning systems and more recently FIVIMS) while others use an understanding of access to food. The Vulnerability Assessment Mapping, which is one of the most important emergency management tools used by WFP, is used to improve understanding of food security issues and to identify the most appropriate strategy for addressing food insecurity.

Progress made in the assessment of household food and livelihood security has been extensive both in terms of the development of sound methodologies and in their widespread use across large parts of emergency-affected countries. These methods have moved beyond analysing food balance sheets, mapping environmental conditions and monitoring agricultural production and vegetation to understanding households' access to food. The development of the household economy approach (HEA) for assessing food aid needs by Save the Children UK was a significant part of this process. This approach uses entitlement theory to determine the effect of a shock on different socioeconomic groups in different communities⁸. HEA was followed by the development of other approaches to assessing livelihoods which all hinge on understanding access to, rather than simply availability of, resources with a concern for longer term support of livelihoods and self sufficiency as well as immediate needs⁹. This has allowed for a greater understanding of how individuals and communities cope with food insecurity, particularly through determining the role of community structures and the use of available traditional resources.

Despite consensus on appropriate anthropometric survey methodologies, there remain frequent examples of poorly conducted surveys or assessments that serve to misinform rather than inform decision making¹⁰. Common mistakes include fundamental errors on sample selection, unclear and untransparent presentation of data and failure to include assessment of oedema. These errors reflect poor human resource capacity and the failure of those agencies responsible to take technical expertise in nutrition seriously.

The importance of clear case definitions for micro-nutrient deficiencies, adequate sample size and, where possible, biochemical confirmation during micronutrient deficiency assessments has been widely recognized. However, challenges exist in their implementation and the lack of validated field-friendly sample collection and analysis technology.

There remain substantial shortfalls in the way information generated by early warning systems is used, making them not as effective in preventing emergencies as had been expected. While the increased use of anthropometric figures in planning emergency response can be regarded as progress, levels of malnutrition are usually impacted late in a crisis and therefore ideally should not be used to trigger response. The reliance on anthropometry for response undermines the value of comprehensive food information systems that monitor early indicators of a food crisis in generating timely humanitarian responses.

Interventions

FOOD AID RESOURCING Since 1989, the proportion of global food aid allocated to emergencies^d has increased from one eighth to one third in 1999 when it equalled 4.7m MT¹¹. The remaining two thirds are allocated to project^e and programme food aid^f. In 2000, 86% of WFP food aid went to emergency activities, the highest proportion for 23 years. The increasing proportion of food aid allocated for emergencies should be seen in the context of greatly fluctuating total food aid allocations over the 90s. While the proportion of food aid allocated to emergencies has increased, the overall quantity has varied substantially through the decade, peaking in 1992, declining substantially in the mid 90s to 2.8m MT in 1996 and increasing again in 1998¹¹. The latter increase is unlikely to be sustained and is attributable, as are previous food aid trends, to the appearance of global surpluses and the subsequent increase in programme food aid for Russia¹¹. These recent surpluses (primarily from the US) have also provided impetus for initiatives like WFP's global school feeding programme launched in 1998.

^d Emergency or relief food aid is targeted and freely distributed to natural and man-made disasters.

^e Project food aid is provided on a grant basis to targeted groups to support specific developmental activities.

^f Programme food aid is provided bilaterally for sale in developing countries, the funds being used either as general budgetary support or to finance specific development projects.

The implications of the potential negative effects of food aid have also begun to permeate donor thinking in recent years. WFP recently held a workshop on food aid in conflict¹² that concluded that there was a need to identify and elaborate the principles that guide WFP operations in conflict settings. Further, ECHO recently commissioned a study in southern Sudan, which in part examined the role of food aid in fuelling conflict. DfID also has emerging policies on the potential of food aid to damage local economies¹³. In 2000, the ODI Humanitarian Policy Group and Nutrition-Works¹⁴ reviewed the principles and practice for food distribution in conflict and made the following key recommendations:

· programme situation analyses should include risks to lives and livelihoods, war strategies and war economy and political contracts to determine the risk of diversion of food aid

· agreement with authorities and coordination between agencies should be based on an analysis of accountability of local authorities

· appropriate distribution methods should be identified considering whether beneficiary representatives or local institutions can be relied on to distribute to the most vulnerable and if not whether registration is possible for direct distribution, and

· risks of abuse at each stage of the distribution process should be identified and strategies developed to minimize them.

Bureaucratic impediments to efficient release of funds for the purchase of food aid or other resources to support food security are also at times scandalous. The difficulties currently being experienced within the EU under the new regulation 296 is particularly noteworthy in this regard.

A series of external and internal reviews have identified numerous constraints that WFP face in implementing effective emergency food aid programmes¹⁵

These include:

· lack of resources for the immediate response account (IRA) and international emergency food reserve (IEF)^g

^g The IRA is completely untied cash. The IEFR is a commodity-based facility with an annual replenishment target of 500,000 tonnes. There is an increasing tendency on the part of donors to insist on advance information on where resources given to the IEFR are to be used. Combined with under-pledging of the IRA this means that the WFP has to go back to governments if it needs to reschedule a commodity. At the very least, this increases storage costs, and at the worst can considerably delay emergency assistance.

^· the fiscal cycle of some donors and the length of time it takes to approve appeals for emergency assistance does not coincide with those of WFP, affecting the timing of pledges and whether funds can be made available in advance or not

· increasingly rigorous and complex administrative and accounting procedures substantially increase the lead-time of emergency food assistance delivery, and

· difficulties in obtaining accurate estimates of population numbers in need. Inaccurate population estimates can easily lead to donor under-provisioning.

RATION QUALITY During the famines of the early to mid 80s, refugee populations experienced several outbreaks of scurvy. This lead to the first realisation that the nutritional components of the diets of refugees needed to be considered in the same light as those of 'resident' populations¹⁶. Two meetings in 1991^h,17,18 noted that despite international nutrition guidelines, relief programmes often fail to provide the minimum recommended daily allowances (RDA) of micronutrients such as vitamin A, thiamine, niacin, vitamin C, iron, and folic acid¹⁷. After the early 90s the number of reported outbreaks of micronutrient deficiency (scurvy, pellagra, beri-beri, xerophthalmia and iron deficiency) declined after this period (Figure 1).

^h In November 1991, the Centre for Disease Control (CDC) in Atlanta, Georgia, USA hosted a one-day technical review of micro-nutrient deficiency diseases in refugee populations. In March 1991, an international symposium was held on 'Responding to the Nutritional Crises Among Refugees: The Need for New Approaches.

Source: ENN Field Exchange (Toole 1992)

TARGETING OF FOOD AID Despite evidence of the difficulties of targeting in the late 80s²³, the 90s saw a renewed emphasis on targeting because of increasing application of the relief-to-development continuum model, and a decline in resources with the increasing duration of conflict-related emergencies²⁴. Although there have been well documented examples of appropriate targeting, in most emergency contexts, experience shows that targeting is rarely successful²⁵. The necessary criteria for success include stable, non-conflict situations, and relatively large wealth differentials within communities, where a large proportion of households are targeted and the ability to identify community representatives that can be relied on to target the most vulnerable. There is growing consensus that the greatest gains in targeting efficiency can be made by improving information systems which inform decisions about geographic targeting rather than by refining intra-community targeting systems²⁶.

LIVELIHOOD SUPPORT Over recent years there have been notable attempts to further the experience and understanding of humanitarian agencies in the effectiveness and appropriateness of interventions aimed at supporting livelihoods without the use of food aid. A paper by the British Red Cross²⁷ looks at the potential of cash transfers as an alternative form of relief and concludes that these findings give cause for cautious optimism and point to circumstances in which cash relief can work to best effect. It is beyond the scope of this paper to describe the technical debates surrounding this approach.

Despite the significant lack of official policies or guidelines, donors have begun to explore different modes of food security support in emergencies. Yet, guidelines on the funding of different stages of an emergency are still needed. A negative aspect for NGOs is that as funding opportunities and mechanisms change and diversify, bureaucratic difficulties can multiply making it harder for NGOs to access resources quickly and efficiently. At the same time, unless donor policies and funding strategies for these interventions are clearly formulated and coherent, agencies applying for funds may be unclear about rationales to apply to project proposals and confused by donor responses that as often as not may be based on individual views of decision-makers rather than firm and coherent institutional policies¹³.

SELECTIVE FEEDING PROGRAMMES There has been considerable advance and consolidation of existing knowledge in relation to the treatment of severely malnourished children. Despite improved understanding of the pathophysiology and treatment of the severely malnourished child, the median case fatality rate of children in hospitals in non-emergency settings has remained unchanged over the last 50 years and is on average 20-30%, with the highest levels of 50-60%²⁸. However, analysis of children in a number of therapeutic feeding centres in Africa, during emergencies, shows a case fatality rate of 9.6%²⁹.

Efforts are now underway to address the sustainability of the treatment of severe malnutrition in emergency-affected countries. A study comparing four centres treating cases of severe malnutrition (two therapeutic feeding centres (TFCs), one specialised nutrition unit (SNU) and one day care center) in Liberia, showed that the chief factor that appeared to cause the higher rates of mortality in the SNU, in comparison to the other three centres, was the adequacy of the management and training skills of the senior staff. This example demonstrates the importance of longer-term efforts to build capacity at the national level in countries that are frequently affected by disasters.

In addition to the technical advances, progress has been made in giving recognition to the importance of care and stimulation for children during rehabilitation from severe malnutrition, to promote recovery. In emergencies these components of programmes are often overlooked but their importance is becoming more widely recognized.

Much consideration is being given to the role of 'at-home' treatment of severe malnutrition. TFCs for treatment of inpatients with severe malnutrition in emergencies have played a major part in saving children's lives in the past 20 years. Nevertheless, TFCs, especially in open situations (i.e. resident populations or internally displaced persons not in refugee camps), may have harmful effects on the food economy of patients' families, encourage increased population concentrations around them and create dependence from international agencies³⁰. Furthermore, programme coverage as a measure of the impact or quality of therapeutic feeding programmes is less consistently used.

The challenge is still how to ensure that mortality rates for all children remain low while designing home-based treatment programmes that are appropriate to the operational, environmental and socio-economic context. Studies show that detailed analysis of data collected prospectively in real-life service settings can lead to major improvements in the management of severe malnutrition. Although the Prudhon Index can be used to assess expected mortality, attention should now be focused on ways to reduce mortality.

In addition to the work on home-based care, there are several key technical challenges to existing treatment protocols for malnutrition. Firstly, the misdiagnosis of dehydration and the inappropriate administration of saline solutions to severely malnourished children, as well as early overfeeding, seem to be responsible for many avoidable deaths. This aspect of treatment is not emphasised in any current guideline, training manual or textbook²⁹. Secondly, the nutritional care and support of AIDS patients adds a new dimension to the work of treatment facility staff. Understanding how AIDS patients can be cared for in feeding programmes and within the community in emergency contexts is limited. Finally, despite the comprehensive best practices guides³¹, there is very limited understanding of the efficiency and efficacy of supplementary feeding programmes.

Monitoring and Evaluation

A publication by the Policy Department of Oxfam in the early 80s³² noted a growing resistance to the use of food aid ⁱ. This influential study demonstrated the importance of understanding the context for interventions and monitoring the immediate and wider impact of programmes. This was followed in the early 90s by the UNICEF 'Triple A' Cycle (assessment, analysis, action). Like the conceptual framework, this cycle has been influential in the emergency sector as well. Alongside these developments, the use of the logical frameworks, where monitoring indicators and sources of verification must be specified, has gradually been accepted by donors and in turn agencies, to the point where the presentation of logical frameworks is now mandatory for the majority of funding applications.

ⁱ The publication was mostly concerned with project and programme food aid, not emergency food aid.

Impact indicators (usually primarily quantitative) are prioritised in monitoring and evaluations, often to the expense of process indicators¹⁶. Too great an emphasis is placed on anthropometric and mortality indicators as a means of monitoring and evaluation. There is little agreement on appropriate indicators for early warning, recognising that deterioration in nutritional status is usually a late indicator of a crisis.

In many contexts where agencies have previously worked for many years under relatively stable conditions, on arrival of an emergency, there is frequently a substantial lack of base-line data available. The gathering of baseline information in emergency prone communities is an essential component of emergency preparedness.

One of the regular findings of independent evaluations (e.g. CDC, bilateral government evaluations, and material submitted to Field Exchange) is that there are still enormous difficulties with up take/implementation of best practice by implementing agencies. There may be many reasons for this, such as absence of guidelines at project level, poor training of field staff and lack of technical support by headquarters staff. There may be a number of factors that in turn underlie these constraints, including development agencies 'turning their hand' to emergency work but lacking the institutional expertise and support capacity; agencies trying to maintain capacity in all sectors of emergency food and nutrition (e.g. from therapeutic feeding to livestock interventions), but lacking the capacity to maintain expertise in the diverse array of activities involved.

Conclusions and Recommendations

This paper has illustrates some of the complementary roles that UN agencies, bilateral donors and NGOs can play in preventing and treating malnutrition in conflict and crises. All three groups of agencies have worked together to achieve significant information sharing and collaboration through interagency meetings, the initiation of the Emergency Nutrition Network and the unprecedented collaboration in the writing of the Sphere project nutrition chapter. In all areas of the project cycle, emphasis must now be placed on building capacity.

In assessments, the major advances in methodologies have sharpened analyses and improved programme design. However, information has proven insufficient to always initiate response and the effective translation of assessment recommendations into appropriate action remains constrained.

The proportion of food aid allocated to emergencies has increased over the last 20 years, though it remains low and the availability of this aid still fluctuates according to global food surpluses. WFP and donors have made substantial efforts in improving systems for the provision of food aid. In recent years guidelines have been developed to ensure these advances permeate to the field level. However, the politicization and dysfunctional structures remains a major frustration to humanitarian efforts.

In contrast to food aid programming, therapeutic feeding can be effective in reducing in-patient mortality due to rapid scientific advances and the development of nutritional products. There is increasing scope for innovative programming beyond general rations and feeding programmes in post conflict settings. This allows nutritional programmes to realize their broader cross-sectoral goals.

Prioritising of accountability in programming has greater investment in monitoring and evaluation methods strengthened and lesson learning initiated.

The recommendations generated by this paper could contribute to the development of a plan of action for NGOs, donors, and the UN agencies through the SCN. Some recommendations are made:

· an NGO-sponsored website should be established to enhance accurate media reporting on food and nutrition in humanitarian situations

· extension of the international cooperation and collaboration between international agencies to more regionalised initiatives involving local institutions and local nutritionists should be prioritised. This could be addressed through the existing SCN working groups

· the links between the donor and the practitioner need to be strengthened. Past experiences of failures and successes need to be shared. This requires the development of much stronger relationships between public nutritionists, donors and key decision-makers

· policies need to be translated into practice: All agencies need to ensure a routine incorporation of training modules into their human resource development systems and also to set up effective monitoring and evaluation

· readjustment of policies on the part of all major food aid players and institutions, in order to ensure that humanitarian needs are met adequately. This includes WFP, bilateral agencies-particularly the two largest bilateral food aid donors, the US and the EU-as well as international NGOs who deliver food aid. These agencies should engage in a paradigm shift from food response to nutritional response allowing for the reform of food aid to be consistent with a nutritional imperative

· food aid resources should be part of a more flexible system of response. In such a system emergency food aid would be procured and supplied from the most efficient and timely source for purposes of meeting the assessed quantitative and qualitative nutritional need. Similarly, resources for food should be more readily transformable into non-food inputs for health, livelihood or other inputs required to protect, maintain and recover people from nutritional assaults, and

· monitoring and evaluation needs to consider issues of accountability and a willingness to document mistakes. The Sphere project should be seen as a vehicle to achieve this. Agencies should work together to produce and reach consensus on interim indicators to monitor before anthropometric indicators are likely to deteriorate. This should be underscored by both the ENN and RNIS. Monitoring and evaluation systems must be expanded beyond inputs and outputs-e.g. must include usual threats to livelihoods, an understanding of the changes in the external environment, social, cultural, environmental and fiscal impact of programmes.

References

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