MODULE 1

Introduction to nutrition in emergencies

PART 2: TECHNICAL NOTES

The technical notes are the second of four parts contained in this module. They provide an introduction to nutrition in
emergencies. The technical notes are intended for people involved in nutrition programme planning and implementation.
They provide technical details, highlight challenging areas and provide clear guidance on accepted current practices. Words in
italics are defined in the glossary.

Summary
This introductory module discusses nutrition in emergencies. It explores various classification systems for food and
nutrition emergencies. Where and when nutrition emergencies occur and who are the most nutritionally vulnerable is
reviewed. Different forms of nutrition assessment and responses are outlined. Finally, some of the existing challenges in
the area of nutrition in emergencies are discussed.

Key messages
1. Protecting the nutritional status of vulnerable groups affected by emergencies is essential to prevent acute
malnutrition, disease and death.
2. Malnutrition does not result simply from lack of food but from a complex combination of factors.
3. Several systems exist for the classification of food and nutrition crisis; the Integrated Phase Classification system is
one example which has been adopted by several agencies and governments to analyse and design responses to
food insecurity.
4. Nutrition emergencies are primarily caused by severe shortages of food combined with disease epidemics
though underlying factors such as poor care and feeding practices, and insufficient access to health care and an
unsafe environment all contribute.
5. While Asia and Africa have suffered significant famines over the past 100 years, food and nutrition crises continue
and many countries on both continents have baseline levels of acute malnutrition that indicate emergency
response interventions are required.
6. Acute malnutrition is a major concern during emergencies, but chronic malnutrition and micronutrient
deficiencies are also issues in certain emergency affected populations.
7. Standard guidance exists for nutrition assessments, commonly conducted at the outset of and throughout
an emergency.
8. A range of nutrition interventions are typically implemented in an emergency, both to prevent and treat acute
malnutrition as well as support livelihoods.
9. Existing challenges in the area of nutrition in emergencies include:
a) Lack of commonly agreed classification system for nutritional crises
b) Proliferation of food based products for the treatment of acute malnutrition
c) Limited evidence for an effective model to treat moderate acute malnutrition
d) Challenges in implementation of the Operational Guidance on IYCF in emergencies
e) Constraints to the operating environment
f ) Inadequate skills and expertise in nutrition in emergencies at national level
g) Linking relief, recovery and development efforts
h) Linking nutrition interventions with each other and with other sectors

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These technical notes are based on the other HTP modules as • Sphere Handbook, 2011. http://www.sphereproject.org/
well as the following references and related Sphere standards component/option,com_docman/task,cat_view/gid,70/
in the box below: Itemid,203
• Lancet Nutrition Series, 2008. • IASC Global Nutrition Cluster, http://oneresponse.info/
http://www.thelancet.com/series/ globalclusters/nutrition/Pages/default.aspx
maternal-and-child-undernutrition
• Emergency Nutrition Network publication,
• Integrated Phase Classification system, www.ipcinfo.org Field Exchange. www.ennonline.net/fex
• SMART guidelines, www.smartmethodology.org • United Nations Office for the Coordination of
Humanitarian Affairs, http://www.unocha.org
• Young, H., A. Borrel, Hollard, D. & Salama, P. (2004).
Public nutrition in complex emergencies. The Lancet, 364: • Nutrition Information in Crisis Situations, NICS,
1899-909. http://www.who.int/hac/techguidance/ http://www.unscn.org/en/publications/nics/
training/predeployment/Public%20health%20nutrition%
• Famine Early Warning System Network (FEWS NET),
20in%20complex%20emergencies.pdf
http://www.fews.net/Pages/default.aspx
• Young and Jaspars (2006). The Meaning and
Measurement of Malnutrition in Acute Emergencies.
Network Paper Number 56. London: ODI. http://www.
ipcinfo.org/attachments/Meaning_and_measurement_
of_acute_malnutrition_in_emergencies.pdf

Sphere standard

Food Security and nutrition assessment standard 1: Food Security

Where people are at increased risk of food insecurity, assessments are conducted using accepted methods to understand
the type, degree and extent of food insecurity, to identify those most affected and to define the most appropriate
response.
Food security and nutrition assessment standard 2: Nutrition
Where people are at increased risk of undernutrition, assessments are conducted using internationally accepted methods
to understand the type, degree and extent of undernutrition and identify those most affected, those most at risk and
the appropriate response.
Infant and young child feeding standard 1: Policy guidance and coordination
Safe and appropriate infant and young child feeding for the population is protected through implementation of key
policy guidance and strong coordination.
Infant and young child feeding standard 2: Basic and skilled support
Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that
minimises risks and optimises nutrition, health and survival outcomes.
Management of acute malnutrition and micronutrient deficiencies standard 1: Moderate acute malnutrition
Moderate acute malnutrition is addressed.
Management of acute malnutrition and micronutrient deficiencies standard 2: Severe acute malnutrition
Severe acute malnutrition is addressed.
Management of acute malnutrition and micronutrient deficiencies standard 3: Micronutrient deficiencies
Micronutrient interventions accompany public health and other nutrition interventions to reduce common diseases
associated with emergencies and address micronutrient deficiencies.
Food security standard 1: General food security
People have a right to humanitarian food assistance that ensures their survival and upholds their dignity, and as far as
possible prevents the erosion of their assets and builds resilience.

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Sphere standard (continued)

Food security – food transfers standard 1: General nutrition requirements

Ensure the nutritional needs of the disaster-affected population, including those most at risk, are met.
Food security – food transfers standard 2: Appropriateness and acceptability
The food items provided are appropriate and acceptable to recipients so that they can be used efficiently and effectively
at the household level.
Food security – food transfers standard 3: Food quality and safety
Food distributed is fit for human consumption and of appropriate quality.
Food security – food transfers standard 4: Supply chain management (SCM)
Commodities and associated costs are well managed using impartial, transparent and responsive systems.
Food security – food transfers standard 5: Targeting and distribution
The method of targeted food distribution is responsive, timely, transparent and safe, supports dignity and is appropriate
to local conditions.
Food security – food transfers standard 6: Food use
Food is stored, prepared and consumed in a safe and appropriate manner at both household and community levels.
Food security – cash and voucher transfers standard 1: Access to available goods and services
Cash and vouchers are considered as ways to address basic needs and to protect and re-establish livelihoods.
Food security – livelihoods standard 1: Primary production
Primary production mechanisms are protected and supported.
Food security – livelihoods standard 2: Income and employment
Where income generation and employment are feasible livelihood strategies, women and men have equal access to
appropriate income-earning opportunities.
Food security – livelihoods standard 3: Access to markets
The disaster-affected population’s safe access to market goods and services as producers, consumers and traders is
protected and promoted.

Source: Sphere Handbook, ‘Minimum Standards in Food Security and Nutrition’, The Sphere Project, Geneva, 2011.

Introduction Since then, various food and nutrition crises have occurred
and emergency appeals for funding have grown ever larger,
The large-scale famines that occurred in Africa from the 1960s from 13.1 billion US dollars in 2005 to 15.6 billion US dollars in
onwards alerted the world to the importance of protecting 2010, with a doubling of the number of beneficiaries during
nutritional status during times of emergency. During the Bia- this time1. The amount within this aid committed to the ‘food’
fran War (1967 to 1970), up to 1 million civilians died from fa- sector has doubled from 11 to 22%.2 Funding for nutrition has
mine and fighting. Images of starving children with distended grown significantly; from 2008 to 2010 the amount received
stomachs were shown around the world, horrifying and haunt- for nutrition in countries reporting nutrition as a separate
ing the Western public. A massive humanitarian operation was sector has quadrupled3. The number of agencies working in
launched to deliver food aid and to set up selective feeding emergencies and responding to malnutrition has also grown.
programmes. The Ethiopian famine in the mid-1980s again
caused worldwide alarm and mobilised donors to send aid.

1
OCHA Financial Tracking Services, http://fts.unocha.org/pageloader.aspx?page=search-reporting_display&CQ=cq040411151157dQ3DDBH0s1
2
Nutrition is not a stand-alone category within the appeal format so the ‘food’ sector is used as a proxy for nutrition though it is recognised that nutrition activities
are also often included in other sectors.
3
FNTS disaggregation of Nutrition funding 2008-2010 for countries with designated Nutrition Cluster

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What is malnutrition? Emergencies have an impact on a range of factors that can

increase the risk of malnutrition, illness (morbidity) and death
Malnutrition is a broad term which refers to both undernutrition (mortality), see Box 1 below. If a population has a relatively good
and overnutrition. The main focus of this module is on under- nutritional status at the onset of an emergency, it is important to
nutrition. Individuals are malnourished, or suffer from under- protect this as it can deteriorate with the impact of the emergency.
nutrition if their diet does not provide them with adequate Populations that have a poor nutritional status at the onset of an
macronutrients (protein, fat and carbohydrates) and micro- emergency are, in general, even more vulnerable to widespread
nutrients (minerals and vitamins), or they cannot fully utilize nutritional crises as a result of an emergency.
the food they eat due to illness.
Box 1 illustrates how emergencies may involve the large-scale
There are three types of undernutrition: acute malnutrition destruction of property and infrastructure, a breakdown of
(rapid weight loss or inadequate weight gain due to severe essential services including health services, water supply and
nutritional restrictions, a recent bout of illness, inappropriate sanitation, and migration of large numbers of people. Emer-
childcare practices or a combination of these factors4), chronic gencies can also disrupt social systems. Household access to
malnutrition (inhibited growth in height and cognitive deve- food may become limited, causing displacement, forcing
lopment caused by undernutrition over a period of time) and people to live in over-crowded settlements and families to split
micronutrient malnutrition (deficiency in one or more minerals up. These disruptions can cause loss of earnings and reduce
or vitamins). Acute malnutrition is identified by wasting and/ access to clean water, sanitation and health services. The im-
or bi-lateral pitting oedema (swelling on both sides of the pact on individuals is an increased risk of becoming under-
body). Chronic malnutrition is recognised by stunting, or a nourished and/or sick resulting in a greater likeliness of death.
decreased height for age. Micronutrient malnutrition results
in symptoms specific to the deficient micronutrient. High prevalence of acute malnutrition and mortality rates
continue to occur during emergencies. For example, the
People are also malnourished, or suffer from overnutrition if ongoing conflict and drought in Somalia has displaced
they consume too many calories which results in an individual hundreds of thousands of people. Somalia now has one of
being overweight or obese. the highest national averages of acute malnutrition, 16% (with
4.2% severe acute malnutrition) with some areas reporting a
Undernutrition is the most common form of malnutrition prevalence of acute malnutrition well above 20%. Similar
found in emergency situations. However, while overweight unacceptably high prevalences of acute malnutrition and
and obesity are not typically the focus of an emergency stunting caused by chronic emergencies continue to be
response, it is a problem in countries with long-standing reported in other countries, such as Kenya, Sudan and
refugee populations who are dependent on food aid such as Ethiopia6.
in Algeria, Yemen and the Occupied Palestinian Territories and
in countries with growing economies such as China and India.
The existence of both undernutrition and overnutrition in a Broad-based approach to
population is referred to as the “double burden” of malnutrition tackling undernutrition
i.e. the existence of high levels of undernutrition, especially
among children along with a rapid rise in overweight, obesity Undernutrition does not result simply from lack of food but
and diet-related chronic diseases amongst children, from a complex combination of factors. Hence, broad-based
adolescents and the adult population. approaches to prevent and treat undernutrition are required.
At the one end of the scale, interventions to treat malnourished
individuals and prevent death are essential. At the other end
Importance of nutrition in emergencies of the scale, interventions to ‘prevent’ malnutrition are needed.
Protecting the nutritional status of vulnerable groups affected These preventative interventions can include protecting
by emergencies is enshrined in human rights law.5 Individuals livelihoods and health, ensuring a healthy environment and
who suffer from acute malnutrition are much more likely to food security (the ability of a household to access food). This
become sick and to die. At the same time, sick individuals are broad-based approach is referred to as a public nutrition
more likely to become malnourished. approach.

4
Taking Action, Nutrition for Survival, Growth and Development, White paper (2010), ACF International
5
The right to adequate food, and freedom from hunger and malnutrition is recognised in international law. See Module 21 for a detailed discussion of
international conventions.
6
Nutrition Information in Crisis Situations (NICS) Issue 21, March 2010. United Nations System Standing Committee on Nutrition.

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Box 1: The impact of an emergency on nutritional status

TRIGGERS

Natural disaster
War Political/economic shock
(flood, drought, earthquake)

IMPACT ON POPULATION

Destruction of Breakdown of essential Loss of property and

Large-scale Social
infrastructure services (health, business (houses, land,
migration disruption
(roads, markets, etc.) water, sanitation, etc.) animals, stock, etc.)

IMPACT ON HOUSEHOLDS

Lack of access Residence in Lack of water, Loss of earnings

Families
to land, reduced overcrowded hygiene, and access
separated
access to food settlements sanitation to health services

IMPACT ON INDIVIDUALS

Malnutrition Disease

DEATH

What is an emergency? Some organisations distinguish between ‘loud’ and ‘silent’

emergencies. ‘Loud’ emergencies are those that result from
The term ‘emergency’ is defined in various ways by organisa- catastrophic events such as hurricanes, earthquakes, floods
tions within the international humanitarian community, In and war. Recent ‘loud’ emergencies include the 2005 Indian
general, emergencies are characterised in these definitions as Ocean earthquake and tsunami affecting several countries
‘extraordinary’, ‘urgent’ and ‘sudden’ situations resulting in including Indonesia, the 2010 earthquake in Haiti and the 2011
significant destruction and loss of, or threat to lives. (See Annex earthquake and tsunami in Japan. These events typically re-
1 for several of these definitions.) ceive considerable international publicity although this does
not always translate into an adequate humanitarian response.
The term ‘complex emergency’ has been used in recent years
to refer to a major humanitarian crisis of a multi-causal, essen- ‘Silent’ emergencies on the other hand receive limited inter-
tially political nature that requires a system-wide response. national attention or humanitarian assistance. These emer-
gencies tend to be of little political interest to industrialized
nations, are rarely covered in the media, and can be margin-
alized in donors’ funding decisions. Examples of recent ‘silent’
emergencies include:

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Box 2: The most underfunded emergencies of 2010

In 2010, over US$7 billion was requested through Consolidated and Flash Appeals. Just over $4 billion (63%) was received.
The most underfunded appeals (defined as receiving less than 45% of requested funds) in 2010 were Central African
Republic, Guatemala, Mongolia, and Zimbabwe. The most well-funded appeals (receiving greater than 60% of requested
funds) were Haiti, Afghanistan, Democratic Republic of the Congo, Kenya, Kyrgyzstan, Pakistan, Somalia and Sudan.
However, the most well-funded appeal (Haiti) received only 75% of the total funding requested.

Source: OCHA Financial Tracking Service, 2010.

• Famine in Sudan in 1998, What is a nutrition emergency?

• Violence and displacement in Sudan (Darfur) from 2002 , 7
When does an emergency become a food crisis, nutrition
• Displacement North Korea (2002)8, emergency or famine? While there are no universally accepted
definitions, various attempts have been made to classify the
• Political unrest and displacement in Somalia 2000/2008/ severity of an emergency based on levels of acute malnutrition
2010-119, and (wasting and oedema) in the population as one indicator of
• Violence and deprivation in the Democratic Republic of distress. These classifications suggest that emergencies can
Congo (2006)10. be divided into progressive stages. In the most extreme stages,
the levels of food insecurity, acute malnutrition and mortality
However, recent analysis shows that overall humanitarian are so severe as to classify the situation as ‘famine’.
funding has increased and is being distributed more equitably
across sectors and emergencies. Though, the needs continue The discussion below outlines a few of the recently developed
to grow and are still not matched by resources11. The UN Office nutrition and/or food security classification systems. It is
for Coordination and Humanitarian Affairs (OCHA) collects and commonly agreed among experts that an assessment of a
analyses financial information on all emergencies that have situation should be made based on more than just levels of
requested funding through a United Nations (UN) appeal. acute malnutrition and mortality. A clear analytical process is
Box 2 below details the proportion of funding received for needed to review the situation from a variety of angles and
different emergencies in 2010 highlighting the most under the underlying context.
and well-funded emergencies. A common characteristic of
these under-funded emergencies is that they last for many Classification systems
years and often occur in countries of little geo-political impor- A variety of classification systems at national, regional and
tance to industrialized nations. global level have been developed to classify the severity of
food and nutritional crises. Table 1 outlines the four most
Emergencies cover a wide variety of scenarios. They differ in recent. Each of the classification systems utilises a slightly
terms of: different combination of indicators to analyse and classify
• Length (short-term, chronic) situations, however all of these systems include mortality,
chronic and acute malnutrition. Thresholds, or the classification
• Cause (natural, conflict-related, of the nutritional situation of the population based on the
economic-political, ‘complex’) prevalence of individuals’ nutrition status, are also presented
• Magnitude (number of people in crisis) for each indicator. A full description of these classification
systems is presented in Annex 2.
• Impact (destruction of infrastructure, agricultural,
health and social systems)
• Affected groups (internally displaced persons, refugees,
stable populations)
• Humanitarian response (large-scale response,
no response at all)

7
Humanitarian Exchange Magazine, Humanitarian Practice Network, Issue 20, March 2002.
8
Humanitarian Exchange Magazine, Humanitarian Practice Network, Issue 20, March 2002.
9
Natural Disaster History of Somalia, ReliefWeb , www.reliefweb.int
10
MSF top 10 most underreported humanitarian stories of 2006.
11
ALNAP review of the humanitarian system, Field Exchange Issue 39, 2010.

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What these systems have in common is that they all use the rundi. Key UN agencies, NGOs, donors, and governments alike
quantifiable (numeric) outcomes of mortality and malnutrition have embraced the main value added areas of the IPC
as measures of severity, and link these with qualitative (des- approach, namely the application of normative standards and
criptive) indicators of food security. Where the classifications the process of consensus building around vulnerability
differ is in the thresholds suggested to designate a particular classification, and are actively employing and utilizing the IPC14.
stage of severity as well as the terminology used to classify a
particular situation. For example, ùfamineû is variously declared The IPC is currently going through a revision to develop a
when acute malnutrition has reached more than 20 per cent manual 2.0, following a two year consultative process and one
(Howe and Devereux), 25 per cent (ODI classification), and 30 recommendation is the development of a scale to classify
per cent (FAO/FSNAU Integrated Phase Classification)12. chronic food insecurity. Further, a revised acute scale will also
be developed following recent advances and expert consul-
The term ‘nutrition crisis’ or ‘nutrition emergency’ are generic terms tation. The new scales will be released in late 2011.
used throughout this module to refer to a situation characterised
by high mortality, high levels of acute malnutrition or absolute Many experts agree that it is extremely difficult to set generic
numbers of acutely malnourished individuals, that may or may thresholds for mortality and acute malnutrition to gauge the
not exist in conjunction with conflict. severity of a crisis. The classification of a certain situation using
one of these systems is not prescriptive, and needs to be used
The Integrated Phase Classification system (IPC) is the most relative to local circumstances. (See Modules 7 and 8 on
recent classification system to be developed and it builds Individual and Population Assessment for more detail.).
significantly on other systems. Work on the IPC began in 2004
with an aim to develop a common scale for food security Thresholds for response
classification, which is comparable across countries, making it Each system has a set of thresholds for classifying a situation.
easier for donors, agencies and governments to identify The ODI classification (Annex 2) and WHO decision tree
priorities for intervention before they become catastrophic. (Annex 3) suggest appropriate food and selective feeding
The IPC includes a much wider variety of non-nutrition response options based on various thresholds. The IPC has
indicators such as disease, access to water and conflict. Most developed a more detailed strategic response framework that
recently, maternal under-nutrition (measured by BMI) was not only recommends appropriate food based interventions
recommended as an additional indicator to gauge the overall but suggests responses that aim to:
nutritional situation and level of severity of crisis. This is due to
the strong association between a low prevalence of Body Mass • Mitigate immediate negative outcomes,
Index (BMI) and declines in food security, suggesting low BMI • Support livelihoods and,
is a direct outcome of food insecurity whereas acute malnu-
• Address underlying/structural causes
trition in children is more of a composite indicator comprising
poor health, lack of food, inadequate caring practices13.
The IPC response framework aims to provide a diverse array of
Since 2009, there has been significant endorsement of the IPC response options for different contexts addressing both
model from a variety of partners. There is important buy-in at immediate needs and medium/longer term response. The
top management levels in the UN Food and Agriculture response framework is purposefully not descriptive; it merely
Organisation (FAO), the UN World Food Programme (WFP), provides an overarching framework to ensure the basic
Famine Early Warning System Network (FEWS NET), European elements of a holistic response are identified. See Table 2.
Commission Joint Research Centre (JRC), Oxfam, Save the
As highlighted in the section above, many experts agree that
Children UK and CARE as well as in donor agencies such as
the decision-making frameworks are not prescriptive, and
the European Commission (EC).
need to be interpreted based on local circumstances. Current
While there are still questions regarding the potential of the recommendations are to consider overall trends in global acute
IPC for use in chronic emergency situations, the IPC has ac- malnutrition (GAM) and severe acute malnutrition (SAM) as
hieved “proof of concept” in emergency and disaster manage- part of a thorough situation analysis against baseline levels
ment contexts. The IPC is being used by several governments and context rather than waiting until a certain threshold
that have adopted the approach in their own national insti- has been reached, by which time it could be too late to imple-
tutions such as Kenya, northern and southern Sudan, and Bu- ment an effective response.15 (See Modules 7 and 8 for further
discussion.)

12
All based on the 1977 NCHS growth references (not the new WHO Growth Standards)
13
Review of Nutrition and Mortality Indicators for the IPC: Guidance on Reference Levels and for Decision-making, Helen Young and Susanne Jaspars, September 2009.
14
Integrated Food Security Phase Classification End of Project Evaluation. Frankenburger and Verduijn, 2011.
15
Young, Helen and Susanne Jaspars (2009). Review of Nutrition and Mortality Indicators for the IPC: Reference Levels and Decision-making. Geneva: UNSCN.

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Table 1: Summary of food crises and famine classification systems with thresholds for mortality, acute malnutrition
and stunting

Classification system Level Notes

UN thresholds 2000 Serious Wasting 10-14% (<-2SD WHZ)
Critical Wasting >15% (<-2SD WHZ)
ODI level and type of Chronic (or periodic) food insecurity CMR 0.2-1/10,000/day
food security 2003 Wasting 2.3-10% (<-2SD WHZ)
Stunting >40%
Acute food crisis CMR 0.2-2/10,000/day
Wasting 2.3-10% or increases (<-2SD WHZ)
Extended food crisis CMR 1-2/10,000/day
Wasting 15-30% (<-2SD WHZ)
Famine CMR >2/10,000/day
Wasting >25% (<-2SD WHZ) or
dramatic increases
Howe and Devereux Food security conditions CMR <0.2/10,000/day and
famine magnitude Wasting <2.3% (<-2SD WHZ)
scale 2004
Food insecurity conditions CMR ≥0.2 but <0.5/10,000/day and/or
Wasting ≥2.3 but <10% (<-2SD WHZ)
Food crisis conditions CMR ≥0.5 but <1/10,000/day and/or
Wasting ≥10 but <20% (<-2SD WHZ)
and/or oedema
Famine conditions CMR ≥1 but <5/10,000/day and/or
Wasting ≥20% but <40% (<-2SD WHZ)
and/or oedema
Severe famine conditions CMR ≥5 but <15/10,000/day and/or
Wasting ≥40% (<-2SD WHZ)and/or oedema
Extreme famine conditions CMR ≥15/10,000/day
FSAU/FAO Integrated Generally food secure CMR <0.5/10,000/day
food security phase Wasting* <3% (<-2SD WHZ)
classification 200716 Stunting <20% (<-2SD HAZ)
Moderately/Borderline Food Insecure CMR <0.5/10,000/day
U5MR <1/10,000/day
Wasting* >3% but <10%
Stunting 20-40% (<-2SD HAZ), increasing
Acute food and livelihood crisis CMR 0.5-1/10,000/day
U5MR 1-2/10,000/day
Wasting* 10-15% (>-2SD WHZ), > than
usual, increasing
Humanitarian emergency CMR <1-5/10,000/day, >2x baseline
rate, increasing
U5MR >2-10/10,000/day
Wasting* >15% (>-2SD WHZ), > than
usual, increasing
Famine/Humanitarian catastrophe CMR >2/10,000/day (e.g., 6,000/1,000,000/
30 days)
Wasting* >30%

* And/or oedema
Note: CMR = Crude Mortality Rate, ODI = Overseas Development Institute, FSNAU/FAO = Food Security and Nutrition Assessment Unit (for Somalia)/Food and
Agriculture Organization of the United Nations

16
New scale to be released in 2011 which will include revised malnutrition and mortality thresholds, www.ipcinfo.org

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Table 2: IPC Strategic Response Framework

Strategic Response Framework
General Emphasis of Objectives: (1) mitigate immediate, (2) support
Phase Classification Strategic Response livelihoods, And (3) address underlying causes
1 Generally Investment in livelihood production Strategic assistance to pockets of food insecure
Food Secure system, trade, and distribution systems; groups Investment in food and economic
enabling development; addressing production systems Enable development of
issues of equity and sustainability livelihood systems based on principles of
sustainability, justice, and equity Prevent
emergence of structural hindrances to food
security Advocacy
2 Chronically Provision of safety nets; risk reduction Design and implement strategies to increase
Food Insecure interventions; livelihood support; stability, resistance and resilience of livelihood
addressing structural hindrances systems, thus reducing risk Provision of ‘safety
nets’ to high risk groups Interventions for
optimal and sustainable use of livelihood assets
Create contingency plan Redress structural
hindrances to food security Close monitoring of
relevant outcome and process indicators
Advocacy
3 Acute Food and Urgent interventions to increase food Support livelihoods and protect vulnerable
Livelihood Crisis access/availability to minimum groups Strategic and complimentary
standards and prevent destructions of interventions to immediately † food access/
livelihood assets availability AND support livelihoods Selected
provision of complimentary sectoral support
(e.g., water, shelter, sanitation, health etc.)
Strategic interventions at community to national
levels to create, stabilize, rehabilitate, or protect
priority livelihood assets Create or implement
contingency plan Close monitoring of relevant
outcome and process indicators Use ‘crisis as
opportunity’ to redress underlying structural
causes Advocacy
4 Humanitarian Urgent interventions to prevent severe Urgent protection of vulnerable groups
Emergency malnutrition, starvation, and irreversible Urgently † food access through complimentary
asset stripping by increasing food interventions Selected provision of
access/availability and other basic complimentary sectoral support (e.g., water,
needs to minimum standards shelter, sanitation, health, etc.) Protection
against complete livelihood asset loss and/or
advocacy for access Close monitoring of
relevant outcome and process indicators
Use ‘crisis as opportunity’ to redress underlying
structural causes Advocacy
5 Famine/ Critically urgent protection of human Critically urgent protection of human lives and
Humanitarian lives through comprehensive vulnerable groups Comprehensive assistance
Catastrophe assistance of basic needs (e.g. food, with basic needs (e.g. food, water, health, shelter,
water, health, shelter, etc.) etc.) Immediate policy/legal revisions where
necessary Negotiations with varied political-
economic interests Use ‘crisis as opportunity’ to
redness underlying structural causes Advocacy

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Where do nutrition emergencies occur? Table 3: Countries with wasting levels of 10 per cent or
above (from State of the World’s Children, UNICEF 2011)
Historically, the largest famines (in terms of excess mortality)
have occurred in Asia. Annex 4 lists the famines recorded Country Prevalence (%)
during the twentieth century that collectively resulted in more
than 70 million deaths. The largest famine occurred in China Bangladesh 17
between 1958 and 1962 and resulted in an estimated 30 Burkina Faso 11
million deaths. More recently, the Democratic People’s
Republic of Korea has reportedly experienced widespread Central Africa Republic 12
famine with reports of up to 3.5 million deaths (1990s). In both Democratic Republic of the Congo 10
cases, the root cause of famine was government policies that
led to massive food shortages. The secretive nature of both Djibouti 17
governments prevented reports of famine from getting out Eritrea 15
and thus the international response was limited.
Ethiopia 12
Over the years, Africa has suffered more frequent famines and Haiti 10
nutritional crises but fewer deaths (due to lower population
density of vulnerable populations in Africa vs. Asia)17. However, India 20
up to 1 million famine deaths occurred in Ethiopia during the Indonesia 14
1983 to 1985 drought. Famines continue to be reported in
Maldives 13
different parts of the world although the term is much debated
and for political reasons used very cautiously. Mali 15
Morocco 10
Nutritional crises are currently more commonly reported given
the political weight of the word ‘famine’ and the varying Myanmar 11
definitions of the word. For example, using the Howe and
Nepal 13
Devereux classification, the situation in Niger in 2004/5
characterised by large scale food shortages, high levels of acute Niger 12
malnutrition and mortality would be classified as a ‘famine’.
Nigeria 11
However, the international community referred to the situation
as a ‘food crisis’, possibly due to pressure from the government. Pakistan 14
Therefore, while not broadly categorised as ‘famines’, there are Sao Tome and Principe 11
several recent nutritional crises that have occurred with sign-
ificant levels of acute malnutrition, mortality and widespread Sierra Leone 10
suffering including the 1998 crisis in South Sudan (Bahr-al- Somalia 13
Gazal), Malawi in 2002, as well as that of Niger in 2004/5.
Sri Lanka 15
In addition to the declared nutrition crises, the distribution of Sudan 16
acute malnutrition by country suggests that most nutritional
emergencies are chronic and ‘invisible’. Globally, out of 132 Syria 10
countries with data, 23 countries have levels of wasting above Timor Leste 25
10%18. Table 3 lists the countries with a national prevalence
of acute malnutrition of 10 per cent or more. Based on these Yemen 15
prevalences, according to the WHO decision-tree (Annex 3), Source: United Nations Children’s Fund, The State of the World’s Children, 2011.
selective feeding programmes should be introduced in all of Note1: Wasting refers to % < -2SD weight for height, WHO Child Growth
these countries. Standards (2006)
Note 2: Egypt and the Philippines are not included in this list as they have
The average level of wasting in South Asia is 17 per cent com- national wasting prevalences below 10%. They are included in Table 4
as they have a large number of wasted children, even with national
pared to 10 per cent in sub-Saharan Africa19, suggesting that prevalences below 10%
South Asia is in a constant state of ùacute food and livelihood
crisisû requiring emergency nutrition interventions.

17
Devereux, S. Famine in the 20th Century, IDS Working Paper 105, 2000. http://www.staffs.ac.uk/schools/sciences/geography/dlearn/ma_folder/FAS07/FAS07/
downloads/devereux.pdf
18
State of the World’s Children, UNICEF 2011.
19
Tracking progress on child and maternal nutrition: A survival and development priority. UNICEF 2009

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Table 4: 10 Countries that account for 60% of the global wasting burden

Wasting

Moderate and severe Severe

Numbers Prevalence Numbers Prevalence

Country (thousands) (%) (thousands) (%)

India 25, 075 20 8,105 6

Nigeria 3,478 14 1,751 7

Pakistan 3,376 14 1,403 6

Bangladesh 2, 908 17 485 3

Indonesia 2,841 14 1,295 6

Ethiopia 1,625 12 573 4

Democratic Republic of the Congo 1,183 10 509 4

Sudan 945 16 403 7

Egypt 680 7 302 3

Philippines 642 6 171 2

While 23 countries have levels of wasting that warrant inter- • Inadequate household food security
vention, just 10 countries account for 60% of the burden of
• Inadequate care
wasting in the world20, outlined in Table 4 above.
• Inadequate services and unhealthy environment

What are the causes of undernutrition? In practice there is significant overlap in the three groups of
Maternal and child undernutrition is estimated to cause 3.5 underlying causes.
million deaths annually21. Complex and chronic emergencies
and natural disasters increase the risk of undernutrition and All three clusters of underlying causes of undernutrition are
mortality in a population. subject to seasonal variation. For example, access to food typi-
cally reduces prior to the harvest when workload is also high
The UNICEF conceptual framework is a useful tool to help un- (for agricultural producers), or prior to the rains when workload
derstand the many factors that impact on nutrition status. It finding water and pasture is high (for pastoralists).
identifies three levels of causality: immediate, underlying and
basic which can all be disrupted during emergencies. The third level of factors contributing to undernutrition ope-
rate at the basic level. This refers to the resources available
The immediate causes of undernutrition are a lack of dietary (human, structural, financial) and how they are used (the
intake, or disease. This can be caused by consuming too few political, legal and cultural factors).
nutrients or an infection which can increase requirements and
prevent the body from absorbing the nutrients consumed. Political, legal and cultural factors may defeat the best efforts
of households to attain good nutrition. These include the
Whether or not an individual gets enough food to eat or degree to which the rights of women and girls are protected
whether s/he is at risk of infection is mainly the result of factors by law and custom; the political and economic system that
operating at the household and community level such as: determines how income and assets are distributed; and the
ideologies and policies that govern the social sectors.

20
Tracking progress on child and maternal nutrition: A survival and development priority. UNICEF 2009
21
Black et. al, Lancet Nutrition Series, 2008.

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Box 3: The UNICEF conceptual framework for undernutrition

Malnutrition, disability,
MANIFESTATIONS
morbidity and death

Inadequate diet Disease IMMEDIATE CAUSES

Inadequate household Inadequate services and

Inadequate care UNDERLYING CAUSES
food security unhealthy environment

Lack of capital: financial, human,

physical, social and natural

BASIC CAUSES

Social, economic
and political context

The link between health and nutrition What are the causes of
As the conceptual framework demonstrates, there is a close
relationship between undernutrition and illness and the
nutrition emergencies?
interplay between the two tends to create a vicious cycle. Emergency situations characterised by high levels of acute
Where a child is undernourished, immunity to infection is com- malnutrition are usually the result of severe shortages of food
promised, thus the child may fall ill and then undernutrition combined with disease epidemics. Vulnerability to nutrition
worsens, leading to further reduction in resistance to illness. emergencies is also dependent on a variety of factors including
Children who enter this undernutrition – infection cycle can the underlying health and nutrition situation, poverty and the
quickly fall into a potentially fatal spiral, as the severity and risk of shocks (natural disasters, economic) to the population.
duration of illnesses increases one condition and this feeds Some populations are more vulnerable than others due to their
off the other. specific contexts.

Additionally, the health and nutritional status of pregnant

women will significantly impact the health, well-being and
nutritional status of their infants. For more information on the
links between health and nutrition in emergencies, see Module
8 on Health Assessment and the Link with Nutrition and
Module 15 on Health Interventions.

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Vulnerability to nutrition emergencies At an individual level, the vulnerability of individuals with HIV
and/or AIDS may be increased in an emergency as care and
Underlying health and nutrition situation support services as well as medical supplies can be disrupted.
The existing health and nutrition situation greatly affects how See more on HIV under the Cross cutting interventions section
vulnerable a population is to a nutritional emergency. For later in this module as well as Module 18 on HIV and Aids and
example the health and nutrition situation in Haiti was poor Nutrition.
before the earthquake in 2010, there was nationally high
stunting (29%) in children under-five, and rates of exclusive Poverty and urban pressures
breastfeeding were 41%22 though many estimated this was The world is rapidly urbanising with the majority of the
much lower at 20-30%. An estimated 5% of the under five world’s population now living in urban areas. This demographic
population was acutely malnourished, of whom 0.8% suffered transition has created complex urban landscapes with dispro-
from SAM23. In addition, nutrition surveys carried out in the portionately large slums that concentrate vulnerabilities to
capitol, Port au Prince reported high levels of food insecurity, natural disasters.
lack of access to health services, limited services to treat SAM
and poor water quality. The population was very vulnerable Urbanisation is a result of rapid natural increase in population,
to any shock and much less resilient to the health and nutrition rural urban migration and displacements. It is estimated that
challenges brought on as a result of the earthquake including more than half of the Sub-Saharan African population will live
increased diseases (cholera outbreaks), disruptions to existing in urban areas within two decades. Short of drastic action, the
food supply, disruption to infant feeding practices and limited world slum population will probably grow by six million each
access to clean water and sanitation. year (or another 61 million people) to a total of 889 million by
202026.
The situation in Haiti after the 2010 earthquake offers a stark
contrast to the earthquake and tsunami in Japan in 2011. The Urban areas and slums are characterised by shortage of
initial response in both focused on life-saving medical support, adequate shelter resulting in overcrowding, inadequate and
often through visiting medical teams to ad-hoc camps of insufficient drinking water, substandard sanitation facilities and
displaced people (Haiti) and designated evacuation centres infrastructure, exposure to urban pollution and hazardous
(Japan). However in Japan, the underlying health and materials, lack of affordable and adequate land and frequent
nutritional status of the population was good, as was access food shortages. These factors can adversely affect nutrition
to health services. There was an effective infrastructure, policies status at the immediate and underlying causal level.
and resources for emergency response. As such, there has been
no known news coverage of large scale health and nutrition In general, children under five years of age in urban areas are
deterioration beyond that related to radiation. less underweight and stunted than children in rural areas.
However data from slum areas in Bangladesh and Indonesia
Human immunodeficiency virus (HIV) show the prevalence of underweight, stunting and wasting
The prevalence of HIV and AIDs in a country can also increase were higher in the slum areas than in the rural or urban (total)
the vulnerability of a population to nutritional emergencies. population27.
HIV and AIDS are having a marked effect on food security, par-
ticularly in already poor countries. Labour shortages, know- Rapid and unplanned urban growth has a range of humani-
ledge loss, and loss of formal and informal institutional capacity tarian consequences. Urban crises are likely to occur more fre-
caused by HIV and AIDS have had an adverse impact on large- quently and with varying degrees of magnitude and scope.
scale commercial agriculture. Although there is limited Many urban authorities are not sufficiently prepared to
evidence of a clear association between the prevalence of manage such crises. Cities affected by poor governance,
malnutrition and HIV and AIDS at a population level, popula- political conflicts and limited disaster management capacity,
tions with high levels of HIV and AIDs are very susceptible to will increasingly experience humanitarian crises calling for an
nutrition emergencies. For example, in Malawi between 30 and external response as witnessed in recent crisis in Zimbabwe,
50% of all children with SAM in Nutrition Rehabilitation Units Sudan, Somalia, DRC, Pakistan and Haiti28.
have been documented as havingHIV24, 25.

22
Demographic and Health Surveys 2005-2008
23
Demographic and Health Surveys 2005-2008
24
Bunn et al. Features associated with underlying HIV infection in severe acute childhood malnutrition: a cross-sectional study. Malawi medical journal, September 2009.
25
Impact of HIV/AIDS on Malnutrition in Malawi, Thurstens, S and M Corbett. Field Exchange, May 2005.
26
73rd IASC Working Group Meeting, March 2010
27
http://www.fao.org/ag/agn/nutrition/urban_assessment_en.stm
28
Humanitarian consequences of urbanisation, 73rd IASC Working Group Meeting, March 2009.

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Natural disasters reported 1900-2009

550

500

450

400
Number of disasters reported

350

300

EM-DAT created (1988)

250

200

150
CRED created and OFDA
began compiling (1973)
100
ODDA created (1964)

50

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2009

EM-DAT: The OFDA/CRED International Disaster Database – www.emdat.be – Université Catholique de Louvain, Brussels – Belgium

The fluctuation in food prices in 2008 and again in 2011 has While there is some controversy over the potential impact of
increased the vulnerability of millions of households to poverty climate change in the coming years, many believe that it will
and economic crisis. This is a particular problem for low income not only increase the number and frequency of natural dis-
households that are net purchasers of food. Urban populations asters but that it will also increase the risk of hunger and under-
are often dependent on the market for accessing food and nutrition due to changes in the pattern of climate-related
therefore with a rise in price of basic food commodities, a poor extreme events such as heat waves, droughts, storms, heavy
urban household can easily slip into crisis. precipitation and floods. It is predicted that there will be an
increased risk to disasters and vulnerable communities and
Climate change households will suffer serious setbacks in terms of food and
Reported natural disasters have increased in number over the nutrition security. One current example of this is the drought
past century from under 100 annual natural disasters reported in Somalia and the wider Horn of Africa (2011), caused by a La
before 1975 to over 450 in 2000 (See graph)29. Niña phenomenon. The World Meteorological Organization
states that the 2011 La Niña phenomenon is the strongest in
The increase in the number of disasters can be attributed partly a century30.
to an increase in better reporting over time, though is also a
result of growing population, increased urbanisation, building
in more risk prone areas, and climate change.

29
Examining linkages between Disaster Risk Reduction and Livelihoods, Feinstein International Famine Center. February 2011.
30
The 2011 La Niña phenomenon is the same which caused flooding in Australia and South East Asia in 2010

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Climate change negatively affects food availability (reducing While the number of geophysical disasters, such as volcanoes
production) and access (increasing prices and decreasing and earthquakes, has remained fairly steady, the number of
purchasing power). These factors lead to increased food hydro-meteorological disasters such as droughts, windstorms
insecurity particularly for poor households, and can also and floods has more than doubled since 1996. Due to climate
increase the risk of micronutrient deficiencies due to the change, the number of extreme events such as droughts,
substitution behaviour, whereby poor households switch to floods and heat waves will increase (see section on Climate
cheaper less nutritious foods due to price increases Climate Change above).
change also negatively affects nutrition through its impacts
on health. Climate disruptions decrease quality and availability Conflict
of water, disrupt sanitation systems, and increase the risk of Conflict, especially internal conflict, is a major trigger for nutri-
infectious diseases which eventually increase the nutrient tion emergencies. The majority of internal conflicts have
needs of an individual31. occurred in Africa (Sudan; Democratic Republic of Congo,
Niger, Somalia, Cote d’Ivoire) and in Asia (Pakistan, Afghanistan,
There is growing awareness that climate vulnerability analysis Uzbekistan, and Nepal). Growing conflict in the Middle East is
should be incorporated systematically into policy and institu- arising in response to food price increases and economic
tional frameworks for disaster preparedness and response. policies.

Triggers for nutrition emergencies Conflict and war cause nutrition emergencies in different ways
Where there is underlying vulnerability, sudden events such than that of natural disasters. The very tactics of war are often
as natural disasters, conflict or economic shocks can trigger a designed to block people’s normal ways of accessing food and
nutrition emergency. health services while conflict often destroys infrastructure to
support health, food production and marketing. While there
Natural disasters are many examples of how conflict has impacted mortality
Natural disasters include floods, hurricanes, cyclones, volcanic and acute malnutrition including the Democratic Republic
eruptions and drought. Floods are the most damaging of of Congo (early 2000s), Somalia (1990s-2000s), Box 4 details
natural disasters, particularly in Asia. Floods can cause sudden the way in which conflict in West Darfur, Sudan resulted in in-
destruction of crops and livestock, and sever people’s links creased mortality and acute malnutrition.
with markets. Health systems can be disrupted and health risks
can increase. However if managed properly, floods can also Political crises and economic shocks
be beneficial and increase the cultivation area for off season A significant underlying factor in the cause of nutrition
cropping – though this requires investment and polices by emergencies is the nature of a political regime. Political systems
governments. that have either disintegrated altogether (as in Somalia) or are
undemocratic (as in the Democratic People’s Republic of Korea)
Drought is a natural, cyclical event that usually develops slowly, are the most vulnerable to nutrition emergencies. In these
gradually worsening if left unchecked. Destitution, starvation situations, individual vulnerability is often related to social or
and death may arise from a drought situation in the absence political status. For example, Afghan women, who under
of appropriate response and support mechanisms. Drought Taliban rule were socially, politically and economically
may result in reduced food production, loss of livestock and marginalised, were particularly vulnerable. Furthermore, they
increased food prices, thus resulting in a shortage of overall were found to be at greater risk of malnutrition than their
food availability as well as a reduction in normal food sources children in various nutritional surveys conducted during 2000
for some groups. Lack of water for human consumption re- and 2001.
duces hygiene and thus increases the risk of disease.
Political systems and related economic strategies have caused
Earthquakes can kill large numbers of people in one fell swoop some of the worst food and nutrition crises in history. For
and can have a devastating impact on livelihoods and food example, in the ‘Great Chinese Famine’ of 1958 to 1962, the
security. In rural areas earthquakes can destroy crops, food food crisis was the direct result of political and economic
reserves, assets and roads, all of which can impact adversely policies: enforced collectivisation of agriculture, obligatory
on food production and food security. In urban areas earth- procurement of grain and an intensive industrialisation pro-
quakes can destroy small businesses and shops, impacting a gramme. A famine in Ukraine between 1932 and 1934 killed
household’s purchasing power and ultimately decreasing food between 5 million and 8 million people and was again caused
security. Earthquakes can also destroy health facilities, water by deliberate political and economic policies. Greater detail
and sanitation systems. on the Soviet famine is provided below in Box 5.

31
Climate change and nutrition security: Message to the UNFCCC negotiators. 16th United Nations Conference of the Parties (COP16), Cancun, November 29th-
December 10th, 2010.

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Box 4: Conflict and mortality in West Darfur, 2004

Conflict in West Darfur, Sudan began in 2003 following an offensive movement of two rebel groups towards the
Government of Sudan. The ensuing anti-rebel offensive led by pro-government Janjaweed militia and Sudanese army
units, resulted in the displacement of more than one million people within Darfur itself, and the flight of about 188,000
to neighbouring Chad up until August 2004.
Médecins Sans Frontiers, one of the first international aid agencies to obtain authorization to work in the area, conducted
a retrospective mortality survey in 2004. Until this survey there had been no systematically gathered epidemiological
evidence of mortality.
The survey found that prior to arrival at displacement sites, mortality rates (expressed as deaths per 10,000 per day),
were between 5.9 (95% CI 2.2-14.9) and 9.5 (6.4-14.0) in 4 towns and camps surveyed. Violence caused 68%-93% of these
deaths. People who were killed were mostly adult men, but also women and children. Most households fled because of
direct attacks on their villages. In camps, mortality rates fell but remained above the emergency benchmark, with a peak
of 5.6/10,000 per day. The report documented the exceptional nature of the conflict due to the overwhelming contribution
of violence to mortality, resulting in crude mortality rates that were actually higher than mortality rates among children
younger than 5 years.

Source: Deportere E, et al (2004): Violence and mortality in West Darfur, Sudan (2003-4): epidemiological evidence from four surveys. The Lancet, vol 364, October 9th,
2004, pp 1315-1320 as reported in Field Exchange Issue 24, March 2005.

Box 5: The Soviet famine: 1932-1934

In 1929, Stalin launched a campaign for ‘collectivisation’. Wages were abolished and workers were instead paid as a share
of the collective’s output. Peasants violently resisted and Stalin responded by declaring all collective land state property
and anyone guilty of destroying them was to be severely punished. Agricultural production fell by 40 per cent and
famine ensued.
Despite the massive scale of the famine, a deliberate conspiracy of silence was enforced and doctors were forbidden to
disclose on death certificates that the deceased had starved to death. Figures on the number of people who died
during the famine in Ukraine are difficult to accurately determine. Estimates vary between 5 million and 8 million, equi-
valent to between 10 to 25 per cent of the entire population of the Ukraine.
The Ukrainian famine finally ended in 1934 when Stalin ordered a stop to the forced seizure of grain and allowed each
household to have a small plot of land on which to grow vegetables and raise a cow, a pig and up to 10 sheep.

Source: Watson, Fiona, ‘One hundred years of famine – a pause for reflection’, Field Exchange, No. 8, November 1999.

There are several examples of recent food and nutrition crises isations including WFP. The agencies still present deliver
that have been caused by political and economic mismanage- services under very difficult circumstances and ‘remote imple-
ment including Somalia. Somalia has been in a crisis state for mentation’ through national staff and local implementing
20 years32 during which time there has been no central govern- partners is increasingly the norm. However, the lack of access
ment protracted civil war and a large part of the country has to this region has significantly increased the vulnerability of
suffered from a humanitarian crisis. The humanitarian com- the population to nutritional crisis. As of 2011, following a
munity has provided significant support over the years though severe drought and economic crisis forcing cereal prices over
the situation remains precarious. Humanitarian organisations 200% of average; this area is in the most critical nutrition situa-
face severe constraints including regular interference in their tion within the country. It is classified as ‘very critical’ on the
operations by armed groups. In 2010, this interference nutrition scale33 which is characterised by levels of acute mal-
escalated in south central Somalia to the outright banning by nutrition above 20% GAM34.
the militia group, Al Shabaab, of eight humanitarian organ-

32
Since 1991 (CAP 2011)
33
OCHA Nutrition Situation, January – June 2011
34
FSNAU Nutrition Technical Series Report, Post Deyr 10/11, February 2011 and Nutrition Update March – April 2011

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Box 6: Participatory study of impact of the global crises on the poor35

A study was conducted in February 2009 to examine the impacts and responses to the food, fuel and financial crises in
poor rural and urban communities in Bangladesh, Indonesia, Kenya, Jamaica and Zambia.
The global financial crises hit when the shock of the high food and fuel prices still reverberated. People had not yet
recovered from the peak of the food and fuel prices, many prices remained high and fluctuation created uncertainty.
The study showed that livelihood adaption had been swift, but into low-yield or dangerous activities. Eating less frequently,
and less diverse and nutrient rich diets was reported. Education for children appeared to be on the decline as children
were being withdrawn from school and entering work and there were a growing number of children and young girls
selling sex.
Community based support was largely inadequate and government programmes were largely insufficient. Stress levels
in households were increasing and there were indications domestic violence was increasing. Petty crime, drug and
alcohol abuse were also on the increase.

Food price volatility oil prices which drive up the cost of agricultural essentials like
Global food price fluctuations and increases have caused fertiliser and transport and overall underinvestment in the agri-
increased vulnerabilities to nutrition emergencies in the past cultural sector. The outlook, according to the World Bank is for
few years. Global food prices began to rise in 2005, and volatile prices through 2015.
compounded with the global economic and fuel crises in 2008,
has caused increased levels of poverty, food insecurity and Those most affected by the food price crisis include countries
resulting undernutrition36. The impact of the global food and who are net importers and households with low incomes who
economic crises on the poor is outlined below in Box 6. are net food buyers. The poorest and most vulnerable suffer
most, with the higher prices taking an exponentially greater
The global food crisis continues due to a variety of reasons amount of their already limited resources and forcing them to
including reduced agriculture production (extreme drought consume fewer nutritious foods and reduce access to basic
or floods as in Australia, Pakistan and Russia), export restrictions services such as health and education. Box 7 below summa-
and panic buying, increased demand for both biofuels (which rises the results from a study on the impact the global food
takes land away from food production) and for food (especially crisis is having (particularly on children).
meat), financial causes (depreciation of the dollar), increased

Box 7: The global food crisis impact on children

In November 2008, Save the Children UK examined how the global food crisis affected different sectors of a rural
community in northern Bangladesh. It was evident the rise in global food prices had a damaging impact on the nutrition
situation of the poorest households in these communities. After food prices reached their peak in 2008, between 32%
and 50% of households had a lower disposable income. The percentage of households that were unable to afford a diet
that met their energy requirements doubled. The poorest families were even less able to afford a diet that provided the
necessary quantity and quality for good health and nutrition. Children from the poorest households received fewer
meals per day, had less diverse diets and were less likely to receive nutritious foods. To cope with the rise in rice prices
damaging strategies were adopted such as sending children to work, selling assets, and eating less.
Global increases in staple food prices not only threaten the food security of millions but the economic recovery and
social stability of developing countries as recently demonstrated by the protests in Egypt, Haiti, Jordan, Mozambique,
Tunisia and Yemen.

Source: How the Global Food Crisis is hurting children: The impact of the food price hike on a rural community in Northern Bangladesh, Save the Children UK, April 2009.

35
Field Exchange, Issue 37, November 2009
36
Hungry for Change, Save the Children UK, 2009.

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Who are most nutritiona lly vulnera ble Geographical vulnerability

In some emergencies, populations who live in certain geo-
in emergencies? graphical areas are at particular nutritional risk. For example,
The population groups most nutritionally vulnerable in those living in rural drought- or flood-prone areas are likely to
emergencies can be categorised according to their: be less food and nutritionally secure. Certain livelihoods can
become unsustainable as natural resources become scarce.
• Physiological vulnerability
Families who live in front-line areas during a war or in areas of
• Geographical vulnerability conflict, or in densely populated urban areas (slums) are also
vulnerable.
• Political vulnerability
• Socio-economic vulnerability Political vulnerability
• Internal displacement and refugee status As mentioned above, political factors have been the cause of
some of the worst famines and nutrition crisis in history and
Physiological vulnerability groups who suffer from political persecution can be nutrition-
ally vulnerable.
Individuals are physiologically vulnerable for two reasons.
Firstly, nutrient requirements increase at certain ages. For
Socio-economic vulnerability
example, young children who are growing and developing
quickly and pregnant and lactating women who require more The poorest households are often some of the most vulnerable
nutrients to feed a baby are all physiologically vulnerable. Also, to disasters often struggling the most to cope with shocks. As
reduced appetite and ability to eat can cause vulnerability. detailed under economic shocks above, the impact of the food,
Older people, the disabled and people living with chronic fuel and economic crisis in 2008 and again in 2011 is a good
illness such as HIV and AIDS may all suffer from a reduction in example. With fewer resources, the poor in several countries
appetite, difficulties in chewing and difficulties in accessing have resorted to eating less frequently, consuming a less
food, all of which makes them vulnerable (see Module 3 on diverse and nutrient rich diet and engaging in riskier livelihood
Understanding Malnutrition for more in-depth descriptions strategies.
about physiological vulnerability).
Internal displacement and refugee status
The elderly and the disabled are also often reliant solely on Both natural- and conflict-related disasters can lead to popu-
others for fulfilling their basic needs such as food, water, lation migration and displacement. Displaced populations can
medical support and care. In emergency situations their pre- be particularly vulnerable to nutrition emergencies. Currently,
existing support structures, resources and coping mechanisms there are approximately 16 million refugees and 26 million in-
may be inaccessible or destroyed. The 2010 earthquake in Haiti ternally displaced persons (IDPs) worldwide37. The number of
displaced over 200,000 people over the age of 60, many of whom IDPs is much higher than the number of refugees, partly
found shelter in camps with the help of family, friends and because it includes those who have fled their homes as a result
humanitarian workers. Blindness in the elderly population in Haiti of any type of emergency, not just those who have fled per-
is highly prevalent, limiting mobility to access food, water and secution.
medicines. The vulnerability of elderly to dehydration and
undernutrition is compounded by the fact that aging reduced the Refugees and IDPs who flee with little or no resources are at
body’s resilience. risk of food insecurity, as they may be completely cut off from
their normal food sources, social structures and coping mecha-
Gender also plays a role in a person’s physical vulnerability. nisms. Refugees often end up in inhospitable and isolated parts
Women/girls and men/boys face different risks in relation to of the country, such as Northern Kenya and Eastern Chad. Their
deterioration of their nutritional status in emergency contexts. situation also depends on the size of the refugee or IDP popu-
These different vulnerabilities are related both to their differing lation, whether they are living in large overcrowded camps, in
nutritional requirements and to socio-cultural factors related small groups or with host families, whether they have access
to gender. For example in emergency situations where food is to land and income earning opportunities, and on the food
in short supply, women and girls may be more likely to reduce security of the host country and population themselves.
their food intake as a coping strategy in favour of other house-
hold members. This can contribute to undernutrition among Many of the countries hosting refugees suffer from chronic
women and girls. Furthermore because of social traditions men food insecurity, chronic poverty, conflict and political and
and boys may be favoured and fed better than women and economic insecurity. For example, Eastern Chad where millions
girls in some societies. of Darfur refugees from Sudan have fled is chronically food

37
UNHCR Annual Report, 2009.

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Box 8: Inadequate general rations associated with persistent angular stomatitis in refugees in Bangladesh: 2003

Since 1978, refugees from Northern Rakhine State, Myanmar, have been living in camps in the Cox’s Bazar area of Bang-
ladesh. Nutrition survey data was compiled in 2003 and showed that angular stomatitis, a clinical sign of ariboflavinosis,
had been prevalent in children (6-59 months) since at least 1997.
Analysis of the general ration received during 2002 and the first half of 2003 contained an average of only 33% of the
population requirement for riboflavin.
Micronutrient powders and other specialised food supplementation products have been piloted in these camps to
increase access to multiple micronutrients. (See module 14 for more information on interventions for micronutrient
malnutrition.)

Source: Report on Nutrition Survey and an Investigation of the Underlying Causes Of Malnutrition. Camps for Myanmar Refugees from Northern Rakhine State Cox’s
Bazar, Bangladesh, August 2003. UNHCR

insecure with persistent conflict. Conflict is escalating in Yemen mental potential. It can have a major impact on work output
currently due to economic insecurity – resulting in the return and national economic development39. Furthermore, small
of many Somali refugees to return to Somalia. Populations mothers have small babies who are more likely to be sick and
hosting refugees and IDPs are often increasingly vulnerable die. Stunting therefore is becoming an increasingly important
to nutrition crises for the above reasons and they typically measure of nutritional wellbeing in chronic emergencies and
receive less attention from the international community is included as one of the variables in analysing the level of
because they have not crossed an international border. food and nutrition insecurity in the Integrated Phase
Classification system (see Module 20 for more information)40.
What types of ma lnutrition occur There are several chronic emergency situations characterised
in emergencies? by high levels of stunting. In Mae La Camp in Tak province on
the northern border between Thailand and Burma where over
The most common nutritional problems in emergencies are
40,000 Burmese refugees live, the prevalence of stunting in
acute malnutrition (wasting and/or nutritional oedema)
children under 5 years is 34% while the prevalence is 16% in
especially in young children, micronutrient deficiencies and
the host community41. Additionally, in Somalia the prevalence
in some situations chronic malnutrition (stunting). Table 5
of stunting is as high as 30% in the south-central, compared
provides a brief overview of these. (More detailed descriptions
to between 15 and 25% in other regions42 highlighting the
of types of malnutrition can be found in Module 3 on Under-
chronic emergency state of the south-central region.
standing malnutrition and on Module 4, Micronutrient malnu-
trition.) Micronutrient deficiencies are often found in emergency-
affected populations. Although micronutrients are needed in
Of concern in emergencies is the increased risk of moderate
small amounts, a diverse diet is needed to obtain these
and severe acute malnutrition because acute malnutrition
required amounts. During emergencies, diets often lack
is strongly associated with death. Children suffering from SAM
essential micronutrients and deficiencies subsequently arise.
are 9 times more likely to die than a healthy child38. Children
Populations that are entirely dependent on a general food
under the age of five are particularly vulnerable to developing
ration are often at risk of micronutrient deficiency disease
acute malnutrition during emergencies and are frequently the
outbreaks, such as that described in Box 8 above.
first group in a community to show signs of malnutrition du-
ring times of hardship. In certain situations of food and nutrition crises, populations
resort to the consumption of certain toxic wild foods (unknow-
In many long-term emergencies, however, the prevalence of
ingly) or harvest crops too early in order to avoid starvation.
acute malnutrition may be relatively low while the rates of
This has occasionally resulted in outbreaks of various condi-
other forms of malnutrition, such as stunting are high. Stun-
tions, which have been resolved when alternative food sources
ting inhibits a child from reaching his or her full physical and
became available.

38
Lancet Nutrition Series, 2008.
39
Tracking Progress on Child and Maternal Nutrition, UNICEF 2009.
40
While difficult to address in a short-term emergency response it needs to be highlighted as a problem and a response integrated into transitional, recovery and
long term health and nutrition planning and policy.
41
Banjong O et al (2003). Dietary assessment of refugees living in camps: A case study of Mae La Camp, Thailand. Food and Nutrition Bulletin, vol. 24, no 4, pp 360-367
from Field Exchange Issue 22, 2004.
42
Somalia National Micronutrient Study, ICL 2009.

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Table 5: Types of undernutrition

Acute malnutrition Description

Marasmus (or wasting) Marasmus is a form of acute malnutrition that can be moderate or severe. Marasmus is
usually the result of inadequate food intake, illness, poor feeding practices or a
combination of these. Marasmic individuals are wasted, characterised as very thin, often
with flaccid skin, hanging in loose folds to give an ùold manûs appearance’. Marasmic
individuals may be alert but irritable.
Kwashiorkor Kwashiorkor is a form of severe acute malnutrition. It is characterised by clinical signs
(or nutritional oedema) including nutritional or bi-lateral pitting oedema which is swelling on both sides of the
body due to water retention) beginning in the feet and lower legs which can spread
upwards to other parts of the body. Other signs include cracked and peeling skin,
changes in hair colour (lightening) and texture, and lethargy.
Marasmic-kwashiorkor Marasmic-kwashiorkor is a severe form of acute malnutrition and occurs when an
individual shows clinical signs of both marasmus and kwashiorkor.
Chronic malnutrition
Stunting Stunting is a form of chronic malnutrition that arises when individuals are too short for
their age. It occurs in the first 2 to 3 years of life.
Underweight Underweight individuals are too light for their age (maybe short or thin or both).
Micronutrient deficiencies
Iron deficiency (anaemia) Lack of iron eventually results in iron-deficiency anaemia. Typical signs are: paleness,
tiredness, headaches and breathlessness.
Vitamin A deficiency Lack of vitamin A results in xeropthalmia. The signs in order of presentation are: night
(xeropthalmia) blindness, Bitots spots (dryness and foamy accumulations on the inner eyelids), corneal
xerosis (dullness or clouding of the cornea), keratomalacia (softening and ulceration of
the cornea), permanent blindness.
Iodine deficiency Iodine deficiency causes a range of abnormalities including goitre (swelling of the
(goitre and cretinism) thyroid gland in the neck) and cretinism (mental and physical disability).
Vitamin C deficiency Vitamin C deficiency results in scurvy. Typical signs are: swollen and bleeding gums,
(scurvy) minute haemorrhages (bleeding), brittle hair, slow healing of wounds.
Niacin deficiency Niacin deficiency results in pellagra, which affects the skin, gastro-intestinal tract and
(pellagra) nervous systems. For this reason, it is sometimes called the 3Ds: dermatitis, diarrhoea
and dementia. Dermatitis is the most distinctive feature causing redness and itching on
areas of the skin exposed to sunlight.
Thiamin deficiency Thiamin deficiency results in beriberi of which there are eight clinically
(beriberi) recognizable syndromes.
Riboflavin deficiency Riboflavin deficiency leads to ariboflavinosis, a deficiency disease characterised by
angular stomatitis that affects the corners of the mouth, which can become split or
cracked. Cheilosis, scaling and cracking of the surface of the lips may be seen. Glossitis,
inflammation or swelling of the tongue is also sometimes reported.

For example, in 2004 in eastern and central Kenya, an outbreak extended to other regions and aflotoxin screening of maize
of aflotoxin poisoning was documented due to widespread was increased43.
aflatoxin contamination of locally grown maize, which oc-
curred during storage of the maize under damp conditions. Table 5 provides a brief overview of the different types of un-
The government of Kenya provided replacement maize to the dernutrition often found in emergencies; see Module 3
affected population once the cause of the poisoning was (Understanding Malnutrition) and Module 4 (Micronutrient
recognised, surveillance for aflotoxin poisoning of humans was Malnutrition) for more detail.

43
Morbidity and Mortality Weekly Review (MMWR) by the Centers for Disease Control (CDC), September 3, 2004/53(34); 790-793.

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Response to nutrition emergencies is necessary to develop an appropriate response. Analysis of

data on the affected population and area increases our
Nutrition response includes both assessment (and analysis) understanding of the extent and causes of the undernutrition.
followed by intervention. Primary data can be collected through different types of
assessments. Additionally, it is important to review available
Nutrition assessment existing data on the population. Table 6 highlights the diffe-
rent types of nutrition assessments and data collection
An understanding of the context of the emergency situation methods common in an emergency.

Table 6: Types of nutrition assessment

Type of assessment Objectives Data collection methods

Rapid nutrition • To verify the existence or threat of • Direct observations of population

assessment a nutrition emergency and environment
• To estimate the number of • Interviews with key informants
people affected • Review of records from available feeding
• To establish immediate needs centres and/or health facilities
• To identify local resources available • Nutritional screening
and external resources needed
• To provide initial screening for
inclusion in a selective
feeding programme
Anthropometric • To establish the prevalence • Surveys of under-fives (sometimes women
nutrition surveys of malnutrition or adults)
• To identify likely causes
of malnutrition
Nutrition surveillance • To identify trends in nutrition status • Repeated surveys
• Growth monitoring
• Sentinel site surveillance

Rapid assessments are useful to quickly establish if there is a Anthropometric household rapid assessment can also be
major nutrition problem or not and to identify immediate undertaken. In this case, as it is often not possible to draw a
needs. Rapid assessments are frequently multi-agency and random sample representative of the population surveyed, the
multi-sectoral in order to have a broad analysis of risks, needs findings must be used cautiously. The measurement of the
and priorities and to make recommendations to ensure all the mid-upper arm circumference (MUAC) is often used in these
health and nutrition needs of an emergency-affected popu- circumstances as it can be done quickly and requires very little
lation are met. equipment (only a measuring tape).

Commonly, information relating to nutrition is gathered from Rapid assessments are frequently multi-agency (involving sev-
key informants as part of a broader emergency needs rapid eral agencies) and multi-sectoral (involving several technical
assessment. For example, informants may be asked whether sectors) in order to have a broad analysis of risks, needs and
malnutrition has become more common and whether any priorities and to make recommendations to ensure all the
children are displaying signs of kwashiorkor or micronutrient health and nutrition needs of an emergency-affected popula-
deficiencies. Informants may be asked about changes in tion are met. An initiative to improve the effectiveness of rapid
dietary habits such as reduction in food quantity, quality and assessments has resulted in a multi-cluster initial rapid assess-
reduced frequency of meals. Consumption of unusual wild ment (IRA) tool44. This was developed by the nutrition, health
foods is also frequently a sign that nutrition is becoming com- and WASH (water, sanitation and hygiene) clusters in 200745.
promised. Direct observations of population and environment The tool includes guidelines, a standard data collection form,
can also be used as well as review of records from available an associated aide memoire for field teams, and a data entry
feeding centres and/or health facilities. and analysis template and software. The tool is available on
the cluster websites.

44
For details see the nutrition cluster website , http://oneresponse.info/GlobalClusters/Nutrition/Pages/default.aspx
45
The ùCluster approachû is one of the outcomes of the Humanitarian Reform, led by the Inter-Agency Standing Committee with the aim of improving coordination and
the quality of humanitarian action. For details see http://www.onerespons.org.

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A new inter-sectoral tool to include other sector such as Non-anthropometric data

education and protection is currently being developed by the It is crucial to analyse non-anthropometric data along with
Needs Assessment Task Force (NATF) of the IASC, called the anthropometric data to understand the severity and context
MIRNA – (multiple indicator rapid needs assessment) and of the situation and to identify factors likely to be associated
should be rolled out late 2011. with malnutrition. However it is not recommended that many
additional data are added to the survey as it might undermine
Anthropometric nutrition surveys involve the collection of the quality of the whole survey due to surveyors and respon-
anthropometric information which is used to establish the dents fatigue.
prevalence of acute malnutrition in a population. In addition,
underweight and stunting can be estimated, keeping in mind There are no standard methods for collecting information on
that the uncertainties about the age will undermine the the determinants of malnutrition either in terms of what to
accuracy of those results in some populations. collect or how to collect it. Different agencies tend to use their
own data collection forms and collect different types of infor-
Other data can be collected in addition to anthropometry but mation.
it is not recommended that many additional data are added
to the survey as it might undermine the quality of the whole The most common tools used to assess the determinants of
survey due to surveyors and respondents fatigue. Moreover, malnutrition include:
information on food security or public health might be
• Secondary information – collation of existing
available from secondary data or might be collected more
information from various sources such as government
efficiently using other types of assessment methodologies.
departments or international agencies working in
the area
Surveys are cross-sectional (one-off ) and provide a ‘snap-shot’,
e.g., the information collected reflects the situation for a • Questionnaires – a set of questions that may be
particular point in time. When repeated surveys of the same qualitative or quantitative; often filled in by the survey
population are conducted, trends can be established. Most of field workers who take a sample of mothers (of children
the time, it is not possible to measure everyone in the area who are being anthropometrically measured) or
surveyed so a representative sample of the population will be households heads from the geographical area of interest
selected who will then be measured to determine the
• Key informant interviews – individual interviews
prevalence of acute malnutrition in the population.
possibly with local leaders or government
representatives encouraging informants to articulate
Survey populations
their own opinions and concerns
In many countries young children are the most nutritionally
vulnerable and act as a proxy for the nutritional status of the • Focus group interviews – Possibly with small groups of
entire population. Since the children aged 6-59 months are local people such as village women or farmers
routinely measured in nutrition surveys, they serve as a prin- • Direct observation – Observations of the environment
cipal group for which comparisons could be drawn among such as sources of drinking water, sanitation systems,
populations measured at different times and places. quality of housing, and health facilities and services

Younger or older children, adults and the elderly are assessed • Seasonal calendars – Calendars developed to
less frequently but may be included where there is reason to illustrate the seasonal variation of factors affecting
believe that they are nutritionally vulnerable. For example, the nutritional status
elderly were found to be nutritionally vulnerable during the
Bosnian crisis of the early 1990s and after the Haiti earthquake A recent attempt to standardize nutrition assessments in
in 2010 while the focus in Kosovo 2000 was on infants under emergencies is the SMART initiative, see Box 9.
six months of age.
Additionally, a nutrition assessment checklist has been deve-
The nutritional status of women, usually mothers or carers, is loped by the Centre for Research on the Epidemiology of Dis-
sometimes assessed in nutrition surveys. Women who care asters (CRED) which provides useful standard guidance on
for young children are often nutritionally vulnerable, especially assessments (http://www.cedat.be/completeness_checklist).
as they are most likely to be pregnant or lactating. (For more
information on Individual and Population Assessment, please For more information on anthropometric nutrition surveys, see
see Modules 7 and 8.) Module 7 on measuring malnutrition: population assessment.

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Box 9: SMART initiative

The Standardized Monitoring and Assessment of Relief and Transitions (SMART) Initiative, is one effort seeking to ensure
that reliable and consistent data are available in humanitarian emergencies. SMART has identified three types of data
(mortality, nutritional status and food security) as critical and has developed a computer-based system, SMART
Methodology Version 1, to improve and standardize survey data collection and dissemination.
The SMART Methodology draws from core elements of several methodologies and current best practices in assessing
nutritional status, mortality rate, and food security. It is iterative, with continuous upgrading that will be informed by
research and best practices. In Version 1, the food security component is considered a “work in progress.” For more
information and to download the free software, visit http://www.smartmethodology.org/.

Nutritional surveillance and information systems Nutrition responses

Nutrition surveillance refers to a continuous process and
A wide variety of response options exist for the different phases
focuses on monitoring trends in the nutrition situation over
of food and nutrition crises. Table 7 lists a range of common
time rather than providing one-time estimates of absolute
responses options. The table has been divided into responses
levels of malnutrition.
that aim to prevent undernutrition, such as improving the
water supply and sanitation situation to prevent epidemics of
Nutrition surveillance or nutrition information systems collect,
disease, and those with the objective of treating acute malnu-
analyse, interpret and report on information about the nutri-
trition, such as therapeutic care. More detail on the various
tional status of populations and are used to inform appropriate
response options is provided below in the table, detailed
response strategies. Nutrition surveillance can, and should,
information can be found in Modules 11 to 19.
incorporate many sources of information (anthro-pometric,
food security, nutritional, health) in order to maximise its use-
fulness and integration. Interventions detailed
The objectives of a nutrition surveillance system depend on Food aid
the context. In general there are four principle objectives: to Food aid has traditionally been the dominant form of response
inform programme design, programme management and to nutrition-related problems in emergencies. However donors
evaluation, policy making and crisis management. and humanitarian agencies are increasingly using the term
food assistance as an alternative to food aid in response to the
Data from existing surveillance systems is very useful in changing landscape of global food insecurity and recognition
emergencies and should be analysed to inform situation that a broadened approach to food insecurity could improve
analysis and develop appropriate response strategies. If there the efficiency of the response. Additionally, at the global level,
is no form of nutrition surveillance in an emergency situation, the IASC has formed a Global Food Security cluster to coor-
careful consideration should be taken in developing a system. dinate food related interventions and increase access to food,
A strong nutrition surveillance system requires multiple thus expanding beyond food aid.
stakeholder commitment and long term funding and support.
While systems can be established quickly, it is crucial to identify In general, food aid still dominates in emergency response
objectives and stakeholder and develop stakeholder support though increasingly food assistance is broadening to include
and funding from the outset. cash transfers, food vouchers, and agricultural and livestock
support.
More details on nutrition surveillance and nutrition information
systems can be found in Module 10, Nutrition information and Global humanitarian expenditure by sector for 2010 is shown
surveillance systems. in Table 8. By far, the largest expenditure for a specific sector
was on food.

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Table 7: Typical response options for nutritional emergencies

Intervention Objectives Description Limitations

Response options aimed at preventing undernutrition

General food • To meet immediate and General food distribution (GFD) is the Food aid needs to
distribution medium term food needs term used for food rations that are be linked with other
and restore and protect given out to selected households interventions that
the livelihoods of affected by an emergency. The food address underlying
vulnerable and ration consists of a number of items causes of undernu-
marginalised groups. (the minimum three are cereal, pulses trition to have
• To improve the access to and oil, but items such as salt, sugar, maximum impact.
food for IDPs and fresh vegetables, fortified blended
returnees in a specific area flours, canned meat or fish can
• To support the improved be added).
nutrition and health status
of children, pregnant and The general ration is normally delivered
lactating women, people as a package of dry items.
living with HIV/AIDS and
other vulnerable groups Food aid can be a form of livelihood
• To help to improve the support either when provided through
health and nutritional a general food distribution, which
status of mothers prevents people from selling assets to
and children buy food and other essential
commodities, or as a food-for-work
programme, which creates community
assets that promote livelihoods
providing wages in the form of food.

Livelihood support
• Income and • To protect the sale of Cash transfer interventions include Cash programmes
employment assets or the recovery cash distribution, cash for work, and can only be
of assets micro-finance. In theory, cash grants implemented if food
• To provide a means for are quicker and can be applied on a is available locally or
accessing basic needs larger scale in acute emergencies than where food markets
other forms of cash transfer. are functioning.
There is a need for
more evaluation of
cash programming
to refine
understanding of
the impact on food
security, nutrition,
markets, social
relations
and security.
• Production • To protect livelihoods by Production support includes crop
support preventing the sale of production, livestock interventions and
assets or assisting the fishing support.
recovery of lost assets
Crop production support is commonly
comprised of seeds and tool
distribution and or seed fairs – markets
organized so that affected households
can access seed through exchange
of vouchers.

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Table 7: Typical response options for nutritional emergencies (continued)

Intervention Objectives Description Limitations

Livestock interventions include

livestock off-take, fodder distribution,
veterinary care, repairing boreholes
and other water sources and
destocking (providing livestock owners
a value to animals that would
otherwise die). Emergency animal
health and vaccination campaigns
are important
• Market support • To ensure that people’s Market support interventions can take An understanding
access to basic goods many forms: cash and voucher of the key markets
is maintained programmes, programmes that that affect the
maintain food prices in markets (e.g., livelihoods of poor
through the provision of subsidised people is critical in
foods); and programmes to ensure developing
producers to access markets. appropriate market
access
interventions. It is
still unclear whether
these market and
production oriented
interventions can be
scaled up
sufficiently and
rapidly in an acute
emergency to meet
the needs of large
numbers of people.

Emergency school • To reduce short-term Typical school feeding programs Studies have shown
feeding hunger of children distribute food to schools for on-site that the link
attending school (wet) feeding. Some programs provide between the
• To improve attendance, a ration to the households as well, to provision of school
enrolment and encourage school attendance and lunch or breakfast
concentration participation in the program. School and improved
• To contribute to feeding can be started quickly if the growth is weak.
household food security school is well established and able to They have also
prepare the food. School feeding shown that the
supports the psychosocial benefits and effect of school
social cohesion that school provides for meals on cognitive
children who have experienced a crisis. performance is
inconsistent46.

46
School feeding position paper, Save UK, 2001.

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Table 7: Typical response options for nutritional emergencies (continued)

Intervention Objectives Description Limitations

Children who do
not attend school
do not benefit from
the programme. In
some cases, children
benefiting from the
program may
receive less food
from home (i.e.,
the “substitution
effect”).

Blanket • To prevent deterioration Emergency blanket supplementary The decision to

Supplementary in the nutritional status of feeding programmes (SFPs) target a open a blanket or
feeding at-risk groups in food supplement to all members of a targeted
a population specified at-risk group, regardless of supplementary
• To reduce the prevalence their nutritional status. Blanket SFPs are feeding programme
of MAM in children under often implemented when general food should be based on
five thereby reducing the distribution for the household has yet a thorough analysis
risk of mortality and to be established or is inadequate for of the situation,
morbidity (illness) the level of food security in the including past and
population. The supplementary ration current levels of
is meant to be additional to, and not a acute malnutrition,
substitute for, the general ration. underlying causes,
public health
priorities and
available human,
material and
financial resources.

Infant and young • To promote early initiation Priority interventions include The nature and
child feeding of breastfeeding breastfeeding protection and support, impact of IYCF
support in newborns. minimising the risks of artificial feeding interventions is
• To protect and support and enabling appropriate and safe influenced by the
exclusive breastfeeding for complementary feeding. prevailing IYCF
the first six months of life practices in the
• To enable timely, Multi-sectoral engagement is essential, population: sub-
appropriate and safe in particular reproductive health child optimal IYCF
complementary feeding protection and health services. practices make
from 6 months to 2 years Advocacy with and links to WASH, response more
of age and beyond shelter and food security interventions difficult and the
• To manage artificial are needed to priortise the needs of situation more risky
feeding at individual and pregnant and lactating women, and for infants and
population levels families with children under 2 years. young children.
• To integrate skilled Emergency
breastfeeding Mothers, families, communities and preparedness is
• To uphold the provisions health workers should be reassured of crucial.
of the Operational the resilience of breastfeeding.
Guidance on IFE and
The Code47 in all Frontline emergency staff are prepared
emergencies as a to deal with cases they may encounter
minimum requirement. requiring urgent assistance around IYCF.

47
The International Code of Marketing of Breastmilk Substitutes was adopted in 1981 by the World Health Assembly and calls upon breastmilk substitute
manufacturers and distributors not to provide free or low-cost supplies to any part of the health care system.

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Table 7: Typical response options for nutritional emergencies (continued)

Intervention Objectives Description Limitations

Safe ‘corners’ or spaces for mothers and IYCF protection and

infants should offer services such as support requires
one-to-one counselling, enable cross-sectoral
mother-to-mother support, and involvement that
provide information on allied services. can be difficult to
make happen.
Where artificial feeding is indicated,
mothers and caregivers need assured Management of
access to adequate amounts of an artifical feeding in
appropriate breastmilk substitute for as emergencies is
long as they need and the associated challenging,
essential supports (water, fuel, storage resource intensive
facilities, growth monitoring, medical and carries risks.
care, time).

Milk and milk products should not be

included in untargeted distributions.

Donations of BMS, milk products,

bottles and teats should not be sought
or accepted in emergencies. Code
violations should be reported to WHO
and UNICEF (see Operational Guidance
on IFE for contacts).

Health support • To ensure people have Nutrition-related health

access to services that interventions include:
prevent, diagnose and • Provision of essential health services
manage communicable • Provision of adequate and safe water
diseases supplies and sanitation
• To ensure that all children • Prevention of overcrowding in
aged 6 months to 15 years refugee and displaced camps
have immunity against • Immunization
measles • De-worming
• To ensure people have • Prevention and management of
access to free communicable diseases (e.g. hygiene
reproductive health promotion, diagnosis and case
services including clean management and outbreak
and safe deliveries detection, investigation and
response for key communicable
diseases such as HIV, pneumonia,
diarrhoea, measles etc.)

Micronutrient • To reduce micronutrient There are a variety of interventions that Excessive intakes of
interventions malnutrition support improved micronutrient micronutrients can
• To prevent epidemics nutrition in emergencies including the be harmful. It is
of micronutrient inclusion of nutrient-rich commodities important that
deficiency diseases in food aid rations, provision of fresh strategies for
food items that are complementary to reducing micro-
a general ration, provision of nutrient malnu-
micronutrient-fortified foods (e.g. trition ensure that
Blended foods), distribution of food intakes remain
supplementation products for home within recom-
fortification mended levels.

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Table 7: Typical response options for nutritional emergencies (continued)

Intervention Objectives Description Limitations

Responses aimed at treating undernutrition

Therapeutic care • To treat and reduce the Severely acutely malnourished children
prevalence of severe without medical complications are
acute malnutrition and treated in the community with RUTF
prevent mortality and provided regular medical checks.
Those with medical complications
receive specialized medical care at
inpatient health facilities and are
provided with F75, F-100 and/or RUTF
for nutritional treatment.
Skilled support for breastfeeding and
infant feeding should be integrated
into therapeutic care programmes.

Targeted • To treat moderate Targeted SFPs provide nutritional Targeted SFPs

Supplementary acute malnutrition support to individuals with moderate should always be
feeding acute malnutrition. The ration is meant implemented when
to be additional to, and not a substitute there is sufficient
for, the general ration or the food supply or an
household’s own food. adequate general
Skilled support for breastfeeding and ration.
infant feeding should be integrated The most
into targeted supplementary feeding appropriate food
programmes. commodity should
be selected based
on available
evidence.
Programme design
should be based on
the context and
reviewed frequently
to ensure positive
outcomes.

Treatment of • To treat micronutrient Usually an oral supplement tablet or Appropriate

micronutrient deficiency diseases capsule. A relatively new and effective supplements should
deficiency diseases approach involves using micronutrient be made available
powders (eg Sprinkles) that can be as part of an
added to normal food to increase essential drugs
micronutrient intake. package. Effective
treatment should
always be
accompanied by
the development of
a prevention
strategy.

Much of the emergency food aid goes to Africa. For example, per cent of emergency food aid to sub-Saharan Africa and 20
in 2009, the World Food Programme (WFP), who delivers per cent to Asia.48
almost 70 per cent of the world’s emergency food aid, sent 65

48
World Food Programme, Annual Report 2009, WFP, 2010.

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Table 8: Global humanitarian expenditure by sector (2010) camp situations has increasingly been given to the affected
community themselves.
Sector % of global
humanitarian A general food ration consists of a number of items, the
expenditure minimum three being cereals, pulses and oil. Items such as
salt, sugar, fresh vegetables, canned meat or fish can be added.
Sector not yet specified* 31.6 Fortified blended foods (FBFs) are also often included in a
Food** 27.8 general food ration for some or all individuals in a household.
FBFs are processed mixtures of cereals and other ingredients
Coordination and support services 9.5 (e.g., pulses, dried skimmed milk, and possibly sugar and/or
Health 8.6 some kind of vegetable oil) that have been milled, blended,
fortified with micronutrients and pre-cooked. FBFs provide an
Shelter and non-food items 4.7
additional source of micronutrients to the ration. Examples of
Water and sanitation 3.9 blended foods are Corn Soy Blend (CSB), UNIMIX and Wheat
Soy Blend (WSB).
Economic recovery and infrastructure 3.7
Agriculture 2.9 The traditional composition of CSB and UNIMIX have recently
been reformulated by UNICEF and WFP to meet additional
Protection/human rights/rule of law 2.4
energy density and micronutrient needs of some population
Education 2.2 subgroups, see Box 10.
Multi-sector 1.4
A full ration, targeted to populations entirely dependent on
Mine action 1.2 the ration and who have no access to other foods, provides
Total 99.9 on average 2100 kcals of energy per person per day (Sphere
minimum standard). This figure may be adjusted depending
Source: OCHA, 2010. on the demographic profile of the population, ambient tem-
* “Sector not yet specified” contains unearmarked or loosely earmarked peratures, physical activity level of recipients and access to
contributions that the recipient has not yet applied to specific projects
and sectors.
alternative food sources.
** Nutrition interventions are often included under food, though can also
be found in Health and Agriculture In addition to ensuring adequate quantity of the ration, it is
important to ensure nutritional quality in a food ration. WFP
However, the allocation of emergency food aid is not based and UNHCR have developed a spread sheet application (Nut-
solely on the levels of wasting in a given country but on a val) for planning, calculating and monitoring the nutritional
range of other factors. For example, between 2000 and 2004, value of the general food rations. Nutval (www.nutval.net) has
emergency food aid went principally to just six countries: been designed to make the jobs easier for those involved in
Ethiopia, Sudan, Afghanistan, Angola, Iraq and the Democratic planning food rations. It aims to ensure nutritionally adequate
People’s Republic of Korea. Some of these countries were rations to minimize public health problems such as micro-
obviously prioritised for political reasons; supporting the nutrient deficiencies.
assertion that often “food aid allocations…have traditionally
served primarily domestic agricultural interests and…foreign A general food ration is normally delivered as a package of
policy objectives”.49 dry items. Targeting of dry rations should consider the most
appropriate way to ensure vulnerable groups including
Food aid is an important element of emergency response. women, child headed households, and the elderly can access
However to maximise impact on undernutrition, it needs distributions, and ensure relevant security provisions are
to be linked with other interventions addressing underly- provided. If a programme is providing food to heads of house-
ing causes. hold, consideration should be given to female heads of house-
holds, polygamous households and child headed households.
General food distribution (GFD)
In specific circumstances when people do not have the means
Food aid can be delivered in several forms. The most common
to cook for themselves or where insecurity would put reci-
form is through GFD, where a group of select food commo-
pients of take-home rations at risk, a large scale cooked food
dities are given out to vulnerable households affected by an
distribution (often called ‘wet feeding’) may be appropriate
emergency. Over the past decade, the responsibility for
until such a time as the entire population can be assisted in
targeting and distributing emergency general rations in non-
the form of take-home GFD rations.

49
Morris, Saul S., Bruce Cogill, Ricardo Uauy, ‘Maternal and Child Undernutrition Series: Effective international action against undernutrition: why has it proven
so difficult and what can be done to accelerate progress?’, The Lancet, 371 (9612), 16 February 2008.

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Box 10: Reformulation of CSB

Corn Soy Blend Plus (CSB +/++) is a reformulation of the original CSB to meet the additional energy density and micronutrient
needs of some population subgroups. CSB+ is a product for children two years of age and older, adolescents, pregnant/
lactating women, adults and other vulnerable groups such as those with chronic illnesses. It is a mixture of cereals, soy
beans, sugar and a vitamin/mineral mix. CSB++ is a more digestible form of CSB intended for children 6-23 months. In
addition to the above-mentioned components it includes dried skim milk and oil in its formulation and has a higher
nutritional value with 410kcal, 16 per cent protein, 9 per cent fat and a vitamin and mineral complex. Both of these new
CSBs contain an improved micronutrient formulation. As of early 2010 WFP has replaced all FBF’s in GFDs with the
improved CSB+/++. CSB++ can also be used in treatment as well as prevention programs.

Source: Module 11

Distributing cooked food can be advantageous because it can Income and employment
guarantee access to food for the politically vulnerable, reduce An increasing number of agencies are supporting and
the risk of food rations being “taxed” for safe passage, and implementing cash transfer interventions in a variety of
addresses problems of lack of fuel, utensils, and/or water. emergency contexts. Cash distributions are often more cost-
However, distributing cooked food is resource intensive and efficient when compared to food aid and can also be faster to
encourages population concentrations, which may increase implement. Furthermore, cash can be easily invested in liveli-
the risk of physical attack, spread of diseases and/or military hoods. There is also some evidence to suggest that cash trans-
recruitment. Such programmes should only be considered as fers can improve the status of women and marginalized
a short-term measure to be phased out when people have groups.
the necessary resources to prepare food at home and/or when
security permits. It is generally accepted that cash is appropriate when food
and essential non-food items are available and markets are
See Module 11 for a detailed description of general food ra- functioning, when there are reasonable assurances that the
tions, ration design, food commodities and targeting. intervention does not raise security concerns for staff or
recipients and when there is little potential for price distortion
Livelihood support (e.g., inflation) within the local market.
There are a large variety of livelihood support interventions
that can be implemented in emergencies. These can be A number of agencies are gaining experience in implementing
divided up into four broad groups: food aid, income and cash interventions (cash grants and cash for work). These
employment, production support and market support. interventions have certain advantages over delivery of food
aid. They can be more rapidly implemented, require less
Food aid can be a form of livelihood support either when logistical support and allow participants to choose how to
provided through a general food distribution, or as a food-for- meet their immediate needs. There is a need for more evaluation
work programme, which creates community assets that of cash programming to refine understanding of the impact on
promote livelihoods providing wages in the form of food. food security, nutrition, markets, social relations and security. For
more information see Module 16.
Food for work
Food for work (FFW) and food for asset creation are program- Production support
mes where households receive a general ration in exchange Production support includes crop production, livestock and
for work. Such schemes are often implemented to discourage fishing support. These can take a variety of forms, depending
dependency on food aid and also to create assets such as on the stage and type of emergency and the livelihoods
roads, schools or irrigation systems. FFW is also seen as a way affected.
of ensuring that only the needy receive assistance. It is
important that FFW programmes ensure women as well as Livestock interventions include livestock off-take, fodder
men are targeted but that programmes do not prevent distribution, veterinary care, and repairing boreholes and other
women from having the time to care for their infant and water sources. Other interventions include subsidies for
children. transport to market or initiatives to improve access to pasture
in neighbouring regions or countries. Restocking is carried out
Establishing sizeable programmes in a short space of time can during the recovery or rehabilitation stage of an emergency.
be difficult, requiring significant management resources. A
disadvantage of these kinds of programmes is that a house-
hold without a physically active member is not able to parti-
cipate.

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Market transport subsidies may be possible for animals still in acute emergency to meet the needs of large numbers of
a fair condition early in an emergency. Purchase for slaughter people. Implementing agencies are currently piloting interven-
can be started after the end of any market transport subsidy. tions and assessing capacities and outcomes.
Purchase for slaughter targets the animals still in good
condition. A significant ‘unknown’ with regard to livelihood interventions
in emergencies is whether the same level of resources can
Destocking (also referred to as livestock off-take) involves and will be made available by donors on an equivalent scale
buying (or exchanging) livestock for immediate slaughter with to that which has historically been made available for food aid
the meat distributed dry or fresh. The main aim of destocking programming. See Module 16 for a more detailed discussion.
is to provide a value to animals that would otherwise die.
Destocking has become one of the most widely used emer- Emergency school feeding
gency interventions in pastoralist areas. Destocking can be run Emergency school feeding programmes provide a food
alongside a veterinary or feed supplement programme, where supplement for children attending school. The aim of most
the money from livestock sales can be used to buy veterinary programmes is to keep children in school, address short term
drugs or fodder for the remaining stock. hunger and/or increase food security of the household.

Emergency animal health and vaccination campaigns are There are a variety of types of food supplements and/or meals
important because of increased risk of exposure to disease in that are provided as part of a school feeding programme from
some emergencies. fortified biscuits to meals of rice and dahl. Some programmes
provide a take-home ration to the child to increase attendance.
Restocking is a method of asset building aimed at families who
have recently lost most of their stock. In food insecure envi- Parents and communities may be required to contribute food
ronments, beneficiaries may need to be supported with addi- or non-food items. The food provided to children through the
tional food or cash so that they do not have to sell their herds programme is not always intended to be a significant part of
to meet basic needs. For more information see Module 16. the child’s daily energy needs. In food insecure areas, it is inten-
ded as an ùadded extraû to the child’s home diet. The amount
Market support provided to school-aged children is therefore intended to
Markets play a crucial role in supplying goods and services to provide approximately one third of the child’s daily energy
ensure survival and to protect livelihoods. Prior to, during and requirements (from 550-700 kcal).
after a crisis, disaster affected populations depend on markets
for employment and income. Emergency school feeding has advantages and limitations. It
can offer a rapid way of distributing food in an emergency-
Organisations are increasingly realising that optimising affected community if the infrastructure is largely in place.
opportunities for assisting disaster affected communities need Programmes also increase the likelihood that children will
to consider market function. An analysis of markets is needed continue to attend school. However, in many emergency affec-
in order to ensure sustainable support to livelihoods of disaster ted areas the poorest households may not be able to send
affected populations. The aim of market support programmes their children to school or to allow their continued attendance
in emergencies is generally to ensure that people’s access to where children are required to undertake key household acti-
basic goods is maintained. vities. Children receiving a food supplement or meal at school
might not be provided food at home. Additionally, studies have
Market support interventions can take many forms: cash and shown that the link between the provision of school lunch or
voucher programmes, programmes that support market breakfast and improved growth is weak and that the effect of
infrastructure and the maintenance of food prices in markets school meals on cognitive performance is inconsistent50.
(e.g., through the provision of subsidised foods); as well as
ensuring producers to access markets. Gaining a sound under- Infant and young child feeding
standing of the key markets that affect the livelihoods of poor Infant and young child feeding (IYCF) encompasses inter-
people is a critical first step in developing appropriate market ventions to protect and support the nutritional, care and
access interventions. Simple market analysis tool are available development needs of infants and young children. It is parti-
which can assist in determining whether an increase in cularly important to support optimal IYCF during emergencies
demand for basic goods, created by cash distributions, can be because of the higher risk of disease in young children as a
met through the market. result of population displacement, overcrowding, food insecu-
rity, poor water and sanitation and an overburdened health
It is still unclear whether these market and production oriented care system. Non-breastfed infants and infants that are partially
interventions can be scaled up sufficiently and rapidly in an artificially fed are especially at risk.

50
School feeding position paper, Save UK, 2001.

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Priority IYCF interventions include breastfeeding protection new cases of disease, improving the nutritional status of the
and support, minimising the risks of artificial feeding and population and offering vaccination (for measles and menin-
enabling appropriate and safe complementary feeding. Special gitis).
attention should be paid to feeding pregnant and lactating
mothers in order to encourage them to breastfeed successfully It is important to ensure health services are designed with the
and to maintain their nutritional status. Skilled support for different needs of women and men in mind – ensure access
breastfeeding should be provided to those requiring it (e.g. to quality services for all; develop targeted services for hard to
mothers of newborn infants, malnourished mothers and/or reach populations as needed; ensure gender balance among
infants, HIV-affected mothers who are breastfeeding). Mothers health providers where needed so that all community mem-
and caregivers who artificially feed their infants must be bers are reached (e.g. in Purdah communities women and girls
supported to do so in the safest possible manner and with cannot be easily treated by male health attendants).
the commitment to sustain this support for as long as the
infant needs it. Implementation of essential services should be carried out in
a way that supports and strengthens the health system and
Basic, multi-sectoral interventions are needed to create a does not undermine it or its future development. Health and
protective and supportive environment for IYCF. Support to nutrition programming should be integrated or well-coordi-
meet basic household needs – food, WASH, shelter, health – nated and focus on the key priority proven effective inter-
should to be prioritised for pregnant and breastfeeding ventions that will have high impact on the main causes of
women and mothers with children under 2 years. excess morbidity and mortality. See Module 15 for more details.

Key policy guidance documents to inform emergency Supplementary feeding

programming include the Operational Guidance on IFE51 and There are two types of supplementary feeding programmes
the International Code of Marketing of Breastmilk Substitutes (SFPs) in emergencies: blanket and targeted. Blanket SFPs aim
(BMS) and subsequent relevant World Health Assembly (WHA) to prevent deterioration in the nutritional status of at-risk
resolutions (collectively known as the Code). Sphere 2011 groups in a population or to reduce the prevalence of MAM in
includes two IYCF standards. children under five thereby reducing the risk of mortality and
morbidity (illness). Targeted SFPs aim to rehabilitate (or treat)
Additionally, the management of acute malnutrition in infants individuals with MAM.
(MAMI) has been the subject of review and a recent report
provides information on the management of acutely The decision to open a blanket or targeted SFP should be
malnourished infants under six months of age (infants <6m) based on a thorough analysis of the situation, including past
in emergency programmes and suggested ways forward to and current rates of malnutrition, underlying causes of malnu-
improve practice52. trition, public health priorities, and available human, material
and financial resources. Current recommendations are to con-
For more details on IYCF in emergencies, see Module 17. sider overall trends in GAM and SAM and context rather than
waiting until a certain threshold has been reached, by which
Health interventions it could be too late to implement an effective response.
There are strong linkages between health and nutrition status
and programming. A number of priority health interventions Blanket SFPs are often set up at the onset of an emergency
will significantly impact the nutritional status of the population, when the GFD systems is being established and/or rates of
additionally; many nutrition interventions (prevention, acute malnutrition are high (e.g., more than 15 per cent), or
promotion and treatment) are conducted through the health an increase in rates of malnutrition is anticipated due to
care system. seasonally induced food insecurity, epidemics, or in case of
micronutrient deficiency disease outbreaks.
In emergencies, with displaced, overcrowded populations and
often a break down in health services, infectious diseases Based on current evidence it is recommended that targeted
become more prevalent. Risks of epidemics of diarrhoea, SFPs should be implemented when there are large numbers
measles, dysentery, malaria and meningitis are elevated. The of malnourished individuals (some guidelines stipulate a cut-
most important way of stopping these epidemics is by off of 15% GAM). Targeted SFPs should ideally be run in con-
improving sanitary conditions through ensuring proper water junction with a GFD. For long term sustainability and as part
supplies, personal and food hygiene and sanitation, avoiding of the Integrated Management of Acute Malnutrition these
overcrowding, providing vector control (such as mosquito nets types of interventions should be integrated within existing
and residual spraying) and essential health services to treat health structures.

51
Endorsed in the World Health Assembly Resolution 43,23 (2010)
52
For more information, visit http://www.ennonline.net/research/mami

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Box 11: Lack of evidence-base for emergency supplementary feeding programmes

Supplementary feeding programmes (SFPs) have been a major part of emergency nutrition response in most of the
large-scale emergencies over the last 50 years. However, evidence that they are effective is limited. A study of 82 program-
mes implemented between 2002 and 2005 concluded that: “the data collected by agencies on coverage and prevalence of
malnutrition do not demonstrate any impact of emergency SFPs at population level. Indeed, a significant number of nutrition
surveys showed a decline in nutritional status following a period of implementation of the SFP”. Furthermore, less than 40 per
cent of programmes reviewed met Sphere performance targets.

Source: Navarro-Colorado, Carlos et al. ‘A Retrospective Study of Emergency Supplementary Feeding Programmes’, Emergency Nutrition Network and Save the
Children United Kingdom, June 2007.

There are a wide range of commodities currently in use to treat Therapeutic care
MAM. They generally fall into two categories: dry rations/ Severe acute malnutrition is a complex medical condition that
premixes (such as fortified blended foods like Corn Soy Blend needs specialised care to save a patient’s life. Therapeutic care
(CSB)) or ready- to- use foods (RUF). Dry rations/premixes require programmes aim to save the lives of individuals with SAM.
some additional preparation in the home, while RUFs can be
eaten directly from the package without any additional pre- Therapeutic care programmes are often initiated in emer-
paration. While numerous trials are on-going, there is no clear gencies when population malnutrition and mortality rates
evidence about whether RUFs have more impact than dry reach specific levels taking into account contextual factors,
rations/premixes or are more cost effective for the treatment underlying health situation and services as well as available
of MAM. resources and, increasingly, are continuing beyond an emer-
gency to become part of routine health service delivery in
Powdered milk-also known as dry skim milk (DSM), non-fat dry many countries.
milk (NFDM) or dry whole milk-should never be distributed
alone in a take-home ration as part of a SFP or (other interven- Therapeutic care has evolved in recent years from an approach
tion). The risk of dilution and germ contamination are very high based solely on inpatient care to an integrated strategy in which
and the milk could be used as a breast milk substitute. those with SAM and medical complications are treated in
Powdered milk can be added to fortified blended foods (FBFs) hospitals and those with no medical complications are treated
before distribution but not when FBFs are pre-mixed with oil, at community level. This community based approach has been
unless the client is directed to use the FBF within two weeks made possible through the development of Ready-to- Use
to avoid spoilage.53 Neither RUFs nor blended food rations are Therapeutic foods (RUTFs) which can be consumed by the
appropriate for use with infants under 6 months of age54. patient at home, see Box 12 below. The evidence base for
RUTF is very strong.
It should be noted that a global review in 2005 highlighted
the lack of effectiveness of targeted SFPs, see Box 11. A variety This community-based approach is commonly referred to as
of different approaches (and food based products) for Community Management of Acute Malnutrition (CMAM). Key
addressing MAM are currently being field tested and there is components of this approach include inpatient care (for
ongoing work into alternative strategies. complicated cases of SAM and infants with SAM under 6
months), outpatient care (for uncomplicated cases), commu-
If a SFP is to be implemented, the most appropriate food com- nity mobilisation and active case finding. Evidence for the
modity should be selected based on available evidence and CMAM approach using RUTF is very strong.
the programme design should be based on the context and
reviewed frequently to ensure good coverage, good recovery Therapeutic care should be integrated into routine primary
and low default55. It should also be linked to other health and health systems in post and non-emergency situations.
nutrition interventions in emergencies to ensure a full range Emergency therapeutic care programmes should build on
of health and nutrition support to targeted individuals. what capacity exists with an aim to improve capacity through
the emergency for long term management of SAM.
For more information on target groups, admission and dis-
charge criteria, monitoring and evaluation and food commo- It is recognized that there is need for more documentation
dities for SFPs, see Module 12. and analysis of the experiences of integration in different
contexts. See Module 13 for more details.

53
FANTA (2008). Training guide for community-based management of acute malnutrition (CMAM). Washington DC. FANTA.
54
ENN (2002) Operational Guidance on Infant Feeding in Emergencies 5.1.5 Module 2. London: ENN.
55
See Sphere indicators for programme performance in Sphere Handbook, 2011 or in Module 12.

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Box 12: What are RUTFs?

Ready –to-use Therapeutic Foods, or RUTF, are soft or crushable foods that can be consumed directly from the packet by
children from the age of six months. RUTF formulation is specifically for the dietary treatment of SAM before the onset of
medical complications or when these are under control after stabilisation.
RUTF has a nutrient composition based on the F100 liquid/milk diet which has been recommended since 1999 by WHO
for the recovery phase in the management of SAM. It is produced by replacing part of the dried skim milk used in the
F100 formula with peanut butter. Studies have shown that it is at least as well accepted by children as F100; that it is
effective for rehabilitating severely malnourished children, and that it promotes faster weight gain than F100. RUTF
nutrition composition has been developed based on metabolic and clinical research and its formulation allows rapid
growth and recovery of children with severe acute malnutrition.
RUTF can only be given to children aged six months or above. Infants less than 6 months do not have the reflexes to
swallow solid foods and also have a metabolism which needs higher water intakes than older infants.

Treatment of micronutrient deficiency diseases pose an additional burden on strained emergency services.
Micronutrient deficiency diseases require urgent medical The ability of mothers and other carers living with HIV to
treatment. This usually takes the form of oral supplement provide optimal nutrition and care for their children may be
tablets or capsules. A relatively new approach involves using affected and subsequently affect the nutritional status of those
micronutrient powders that can be added to the normal food children. The lack of awareness and prevention programs,
to increase micronutrient intake. These have been shown to disrupted families, and gender based violence may increase
be effective for the treatment of iron deficiency anaemia. spread of HIV through the community. Eight critical HIV/AIDS
and nutrition related activities in emergencies have been
In some situations the prevalence of a micronutrient deficiency identified as follows.
disease may be so high that blanket treatment of a population
is justified. However, if this is done, the possibility of excessive Eight critical HIV/AIDS and nutrition-related activities
intake for those who are not suffering from deficiency must in emergencies
be taken into account.
1. Integration of HIV into all aspects of emergency care -
prevention, education, health, basic services, planning
Recognition and treatment of these diseases has the potential
and management
to greatly reduce the burden of morbidity and mortality in a
population. Appropriate diagnosis and treatment of cases 2. Targeted food support
should always be accompanied by the development of a pre-
3. Maternal and infant health and feeding
vention strategy. (See Module 14 for more detail.)
4. Treatment and care of HIV (and TB)

Cross cutting issues for emergency 5. Treatment of severe malnutrition

nutrition response 6. Support networks, including livelihood support and
home based care
HIV
Humanitarian crises, which are often linked to displacement, 7. Food hygiene, sanitation, water, shelter
food insecurity and poverty, increase vulnerability to HIV and 8. Protection
negatively affect the lives of people living with HIV. Pre-
emergency HIV services may be disrupted and people may Gender
no longer have access to services for care, support and Gender mainstreaming of a nutrition project means ensuring
prevention. HIV infection causes poor immunity and increased the distinct needs and realities of women, girls, men and boys
metabolic demands. are reflected throughout the project. Gender equality in pro-
gramming aims to ensure the different nutrition needs of all
In emergencies there is often reduced access to nutritious are understood and to ensure that they all have equal access
foods, health services, and sanitation. Pre-emergency HIV ser- to and benefit from relevant interventions.
vices such as antiretroviral treatments, home based care pro-
grams, nutritional support programs, and palliative care Key activities to ensure gender equality in nutrition program-
programs may be disrupted. The health status of people living ming include56:
with HIV can deteriorate rapidly under these conditions and
56
Adapted from IASC Gender Handbook, 2006. http://www.humanitarianreform.org/Default.aspx?tabid=656

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• Design nutrition interventions in accordance with requires a collaborative and coordinated response by various
food culture and nutritional needs of all national and international actors with diverse mandates,
community members. expertise and experience58, 59.
• Ensure meaningful participation of women and men
The Sphere handbook (2011) outlines four basic Protection
in decision making and programme design,
Principles that should inform all humanitarian action:
implementation, monitoring and training.
1. Avoid exposing people to further harm as a result of
• Monitor access to services by different population
your actions
groups to ensure adequate access.
2. Ensure people’s access to impartial assistance –
Evaluations of humanitarian effectiveness show gender equa- in proportion to need and without discrimination
lity results are weak, although there is a universal acceptance
3. Protect people from physical and psychological harm
that humanitarian assistance must meet the distinct needs of
arising from violence and coercion
women, girls, boys and men to generate positive and sustain-
able outcomes. 4. Assist people to claim their rights, access available
remedies and recover from the effects of abuse.
As a result, the IASC sub-working group on Gender has deve-
loped a Gender Marker which is a tool that codes, on a 0-2 The Global Protection Cluster, chaired by UN High Commis-
scale, whether or not a humanitarian project is designed well sioner for Refugees (UNHCR), is in the process of developing
enough to ensure that women/girls and men/boys will benefit guidance and tools on protection for use at the country level60.
equally from it or that it will advance gender equality in another
way. If the project has the potential to contribute to gender Environment
equality, the marker predicts whether the results are likely to The Sphere handbook (2011) defines the environment as ‘…
be limited or significant. The marker can be used by project the physical, chemical and biological elements and processes
design teams to assess and strengthen the gender equality that affect disaster-affected and local populations’ lives and
potential of projects. livelihoods’. As such, it provides the natural resources that
sustain individuals and contributes to quality of life. It needs
As of 2010, all humanitarian appeals and funding mechanisms protection and management if essential functions are to be
are expected to use the marker to code and improve the maintained.
gender dimensions of projects. At the country level, Nutrition
Cluster country teams will designate a gender code for each Given the impact of climate change over the past few years
project, they will also evaluate and monitor projects to ensure and the projected increase in dramatic climatic events, often
positive gender outcomes. At the global level, the Gender occurring in vulnerable areas, all actors in emergency response
Marker is being integrated into the training of Humanitarian should consider the environment in their analysis, planning,
Coordinators and cluster leads as well as in the guidance notes and implementation to ensure that their activities do not
for the Consolidated Appeals Process (CAP) and Central negatively impact it. The Sphere minimum standards provide
Emergency Response Fund (CERF) proposals. guidance on how to address the need to prevent over-
exploitation, pollution and degradation of environmental
A key component of the Gender Marker for nutrition program- conditions. They also highlight mechanisms to reduce risk and
mes is that all programme data must be disaggregated by sex vulnerability61.
or it is unlikely to receive humanitarian funding through the
CAP, CERF or pooled funding57. Disaster risk reduction
In the context of humanitarian emergencies, focus is usually
Protection placed on the initial humanitarian and emergency response.
Protection is concerned with the safety, dignity and rights of However, the importance and value of disaster risk reduction
people affected by disaster or armed conflict. Protection covers (DRR) programming is increasingly being recognized. A DRR
a wide range of activities that are aimed at ensuring respect approach suggests that a comprehensive view of risk and vul-
for the rights of all individuals, regardless of their age, gender nerability are necessary elements in preventing, reducing and
or social, ethnic, national, religious or other background. This mitigating the negative impacts of shocks on lives and liveli-
hoods.
57
All information and documents related to the Gender Marker is available on the OCHA website and
http://oneresponse.info/crosscutting/gender/Pages/The%20IASC%20Gender%20Marker.aspx
58
Sphere handbook, 2011.
59
Global protection cluster overview, http://oneresponse.info/GlobalClusters/Protection/Pages/default.aspx
60
For more information on protection or the Global Protection Cluster contact, [email protected] or
visit http://oneresponse.info/GlobalClusters/Protection/Pages/default.aspx.
61
Sphere handbook, 2011.

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Given the broad definition of DRR, organisations have adopted Working with the community
a variety of approaches to addressing it through development All emergency related programming needs to work with the
programming, hazard and risk analysis, risk management, and support of the community. Disaster-affected people possess
natural resource management. and acquire skills, knowledge and capacities to cope with, res-
pond to and recover from disasters. The local population is
While there is increased understanding of the need to focus usually the first to react in a disaster and even early in a res-
more attention on mitigating risks to disasters, there is a lack ponse some degree of participation is always feasible. Explicit
of standardisation of definitions, tools, methodologies and as- efforts to listen to, consult and engage people at an early stage
sessments associated with DRR. Additionally there is propor- will increase quality and community management later in the
tionally much more limited funding for DRR than that for programme67.
response (most bi-lateral donors earmark only 5-10% of their
annual humanitarian budget to DRR)62. Increased standardisa- Active participation in humanitarian response is an essential
tion, funding and programming for DRR activities could assist foundation of people’s right to life with dignity affirmed in the
agencies and communities to develop initiatives and Code of Conduct for the International Red Cross and Red Cres-
strengthen systems to limit the damage of future disasters. cent Movement and Non-Governmental Organisations (NGOs)
in Disaster Relief68.
Early recovery
Early recovery is an approach to emergency response that This is reflected in the Sphere Common Standard 1: people’s
applies development principles of sustainability and local capacity and strategies to survive are integral to the design
ownership to the delivery of humanitarian assistance as early and approach of the humanitarian response and agencies
as possible. Recovery is about building back better and should act to progressively increase the disaster affected peo-
creating safer and more resilient communities63, 64. ple’s decision making power and ownership of programmes
during the course of a response.
Early recovery is most achievable when principles are main-
streamed in the planning and implementation of the emer- For more on working with the community in nutrition emer-
gency phase and carried forward in transition and recovery gencies, see Module 19.
strategies. Increased integration of early recover principles in
emergency response could strengthen existing systems and Linking interventions and sectors
communities and facilitate local ownership, capacity deve- To effectively address undernutrition, all underlying causes
lopment and partnerships. must be addressed. For an emergency nutrition intervention
to have maximum impact, they need to be linked to each other
Challenges to the early recovery concept relate to the com- as well as to that of other sectors. For example, the treatment
plexities of coordination between relief and development act- of acute malnutrition should include relevant WASH and health
ors, donors and funding budget lines. Additionally, early recov- activities. Similarly, IYCF is now recommended to be system-
ery interventions require more effective, rapid and flexible fi- atically included in CMAM activities.
nancing that that often offered under development funding65.
Capacity development69 in Nutrition in Emergencies
The Early Recovery cluster, led by the UN High Commissioner In many countries, national capacity for response to nutrition
for Refugees (UNHCR), has developed a variety of resources, emergencies is sorely limited. Reasons for limited capacity in
guidelines and tools for the analysis, assessment, and program- nutrition in emergencies include70:
ming within an Early Recovery framework66. For more informa-
• The lack of well-funded in-country training facilities
tion visit the Early Recovery page on the following website:
for nutrition
www.humanitarianreform.org.
• The focus of many international agencies on in-house
capacity building, bypassing government

62
Examining linkages between Disaster Risk Reduction and Livelihoods, Literature Review, Feinstein International Centre, Tufts University, 2010.
63
Early Recovery FAQ’s, Early Recovery Cluster, 2008.
64
Early Recovery: UNICEF Policy brief
65
Early Recovery: UNICEF Policy brief
66
Early Recovery Key Things to Know, Early Recovery Cluster, 2009.
67
Sphere handbook, 2011.
68
Sphere handbook, 2011.
69
Capacity development’ is an on-going process that needs to be embedded within organisations to be maintained. In contrast, ‘capacity building’ implies that there is
an end point – i.e. capacity having been built
70
Capacity Development for Enhancing Nutrition in Emergencies- Stakeholder Report, NutritionWorks, June 2007.

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Box 13: Role of government and UN in coordinating emergency response

A. Led by the national authority through established structures.

In countries with repeated emergencies, governments may have special departments for coordinating emergency
nutrition preparedness and response. For example, in 2000, with the support of UNICEF and WFP, an Emergency Nutrition
Co-ordination Unit (ENCU) was established in Ethiopia as part of the Disaster Prevention and Preparedness Commission
(DPPC). The primary role of the ENCU is facilitate the use of good quality nutrition and nutrition-related information to
enable the rational use of food aid and other resources in emergency affected areas. The ENCU continues to lead and
coordinate emergency nutrition response throughout the country.
B. Operation in the absence of a national authority
When there is no recognised government or authority, humanitarian agencies often come together and work under a
common framework. Humanitarian response in Somalia was initially supported by the Addis Ababa Declaration in 1993
which created the Somalia Aid Co-ordination Body (SACB) with the aim of facilitating the development of a common
approach to the allocation of resources available for Somalia. The SACB consisted of donors, UN agencies, NGOs as well
as multilateral and regional institutions and organisations. Coordination has since been taken over by the Cluster Approach
(detailed below).
C. Co-leading by government and external partners
There are also examples where neither of the above hold true – such as the case of the USA-led coordination of the
humanitarian response to the Haiti earthquake in January 2010. Within 10 days of the earthquake, agreements were
made between the Haitian president and the US Secretary of State, as well as between the UN and the US Government
which paved the way for a strong US role in the Haiti response.
Under these agreements, the US was ‘to assist as needed in augmenting security in support of the Government and
people of Haiti and the United Nations, international partners and organisations on the ground.’ A US Joint Task Force
Haiti (JTH) was deployed to support the humanitarian response, and the US military force operated under autonomous
US command.

Source: Module 2 The Humanitarian System

• The high level of staff turnover particularly among Works have all developed training initiatives to improve capa-
government employees due to poor incentives city at the national level. It is recognised that capacity deve-
lopment needs to be institutionalised in order to be sustained.
• The lack of career structures/incentives within
government to remain in the nutrition sector.
• Lengthy periods between emergencies whereby Coordination of nutrition in emergencies
national institutional memory and capacity is eroded Ensuring that there is an enabling environment for coordina-
tion is particularly important given the increase in the number
Building capacity as part of the emergency nutrition response of organisations working in the humanitarian sector and in
is recommended to ensure that that national staff gains nutrition-related areas during emergencies in recent decades.
knowledge, skills and hands-on experience which they can
use throughout recovery efforts, in development and in future Ultimate responsibility for the provision (and coordination) of
emergency situations. relief rests with the authority controlling the territory affected
by the disaster, be it a national government or occupying
Currently there are a growing number of initiatives aimed at power. This is a fundamental principle of humanitarian action,
developing capacity in the sector. Capacity development for yet one that can be challenging to adequately address in prac-
nutrition is a focus of the Global Nutrition Cluster and several tice. There is the additional risk that poorly planned and poorly
tools such as the Harmonised Training Package (HTP)71 have coordinated humanitarian action can undermine this respon-
been developed as a mechanism to improve training and sibility, in particular during early stages of response. Never-
ultimately help develop capacity. Additionally agencies such theless, this responsibility of the authority controlling the
as UNICEF, ACF, Concern Worldwide, and Save the Children, as affected territory needs to be recognised at all times, even in
well as institutions such as Institute of Child Health and Deve- situations where that responsibility has been delegated, or
lopment, the Emergency Nutrition Network and Nutrition- assumed, by other actors.

71
The entire HTP is hosted on the UN sub-Committee for Nutrition (SCN) website and has been developed by NutritionWorks in collaboration with the Emergency
Nutrition Network (ENN). http://www.unscn.org/en/gnc_htp/.

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Where the government cannot or will not undertake this At the country level, the cluster approach aims to ensure a
responsibility, then the UN has a responsibility to intervene. A more coherent and effective response, supported by the
Humanitarian Coordinator (HC) is then designated by the designated CLA, by mobilising agencies to respond strategi-
United Nations to lead and coordinate humanitarian efforts. cally across all relevant sectors. While coordination is relevant
The HC is responsible for coordination amongst a variety of in both emergency and non-emergency contexts, the cluster
actors including UN agencies, NGOs, civil society organisations approach has one additional aspect, which is that the CLA is
and components of the Red Cross/Red Crescent movement to act as the “Provider of Last Resort.” In other words, if the CLA
that commit to participate in coordination arrangements has the resources to do so, and the affected population are
accessible, the CLA is responsible to step in and fill the gaps in
Examples of the varying role of the national government in humanitarian response if no other option is available. In cases
emergency response are found below in Box 13. where insecurity or limited funds are the key barriers to fulfilling
the role of provider of last resort, the CLA is responsible for
Mechanisms for coordination advocacy to address these barriers.
To ensure that assistance is delivered in a cohesive and effective
manner, various coordination mechanisms, frameworks and Within the CLA, individuals or teams are designated to fulfil
structures have been established at global and country levels72. the cluster coordination role. While they are employed by the
The UN Office for Coordination of Humanitarian Affairs (OCHA) CLA, their role is to represent the best interests of the cluster
is responsible for bringing together humanitarian actors to as a whole. Currently, there is a Global Nutrition Cluster (GNC)
ensure a coherent response to emergencies. Coordination Team based in UNICEF NY and Geneva. It is res-
ponsible for coordination of the GNC, a network of individuals
In 2005, an independent review of identified significant gaps and agencies at global level, and increasingly to providing
in humanitarian response. In response to the review, and as support to county level implementation. The GNC focuses in
part of a process to improve the response and coordination in six strategic areas, namely coordination, advocacy and resource
humanitarian emergencies, the United Nations Inter-agency mobilisation; policy, standards and guidelines; capacity
Standing Committee (IASC) initiated the Cluster Approach for development; preparedness; assessment, information and
emergency response. The Cluster Approach is intended to monitoring; and best practices and lessons learned.
strengthen predictability, response capacity, coordination and
accountability through defining partnerships and account- At country level, individual nutrition cluster coordinators (and
ability in key sectors of humanitarian response. in some cases cluster coordination teams) work with national
and international partners in a number of areas. This includes
The Cluster Approach operates at two levels. At the global level, establishment and maintenance of cluster coordination
the aim is to strengthen system-wide preparedness and mechanisms, assessments; developing response strategies to
technical capacity to respond to humanitarian emergencies address agreed upon priorities; ensuring standards are in place
by designating Cluster Lead Agencies (CLAs), and in some as well as capacity to meet them; information and knowledge
instances co-chair CLAs, for specific technical areas. Eleven management around nutrition response, and resource
global clusters have been identified: Health, Nutrition, Water mobilisation and advocacy.
and Sanitation, Food Security and Agriculture73, Shelter, Educa-
tion, Camp Management, Protection, Early Recovery, Logistics Despite the various initiatives, adequate coordination remains
and Telecommunications. UNICEF is the CLA for the Nutrition a challenge in many emergency settings. See Module 2 for a
Cluster. In addition, CLAs for cross cutting issues such as Early more detailed discussion.
Recovery, Age, Gender, the Environment and HIV/AIDS have
also been defined. By designating global CLAs for technical
areas and cross cutting issues, it is possible to ensure predi- Standards, monitoring and evaluation,
ctable leadership and accountability in the main technical and accounta bility
areas of humanitarian response, in particular in terms of pro-
Over the past decade, it has been recognised that there is a
moting global guidance and capacity development within and
need to develop standards and improve monitoring and
between clusters
evaluation in humanitarian emergencies. Additionally, new
initiatives have been developed to help ensure accountability.

72
For further details, see Module 2.
73
Officially created in 2011

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There are several types of standards for humanitarian response. There is also a trend towards conducting real time evaluations
meant to provide quick and practical feedback in ‘real time’ in
Legal standards based on International Human Rights Law the early stages of an emergency to strengthen the response75.
(IHRL) and International Humanitarian Law includes the right
of all human beings to adequate food and to be free from Accountability has many dimensions and many definitions.
hunger74. The right to food is not a right to be fed, but primarily The term ‘accountability web’ has been used to describe the
the right to feed oneself in dignity. The right to food requires multi-stakeholder and multi-directional accountabilities of
States to provide an enabling environment in which people humanitarian organisations – to their board of trustees as well
can use their full potential to produce or procure adequate as to their donors, charity law, their partners and the people
food for themselves and their families. In addition, IHL stipu- on whom their work is focused – disaster-affected persons.
lates that the starvation of civilians as a method of combat is Agencies have recognised the need to be accountable to their
prohibited – both in international and non-international armed donors and to their agency mission statement or principles,
conflicts. and have put in place systems to do so. These accountabilities
continue to dominate agency practices. In contrast, there is
The Sphere standards are largely recognised as the universal currently no incentive, or obligation, to be accountable to
technical standards for humanitarian response. There are 18 affected communities, other than a voluntary commitment
minimum standards in food security and nutrition (highlighted to do so. Several initiatives including the Humanitarian Ac-
at the beginning of this document). These are qualitative, countability Partnership (HAP) have emerged to fill these gaps.
neutral, statements that are meant to be universal, specifying In particular, the HAP offers guidance, technical support, advice
the minimum levels to be attained in humanitarian response. and inspection services so as to strengthen organisations’
They are complemented by key indicators, and guidance on accountability to affected persons.
approaches also highlighting dilemmas, controversies or gaps
in current knowledge. Sphere also emphasises the process of Although much has been done on the development of stand-
engagement through its Minimum Standards in Core Areas ards, monitoring and evaluation frameworks, and account-
which should be incorporated alongside the technical ability in humanitarian emergencies, challenges remain.
standards of each chapter. Standards and monitoring procedures for new types of
interventions have yet to be defined (e.g. cash programming).
Guidelines for the monitoring and evaluation of each of the There are also concerns that in some contexts, existing stand-
main nutrition related interventions in emergencies have been ards are not achievable or even appropriate. Impact evalua-
strengthened due to the development of these technical tions are still rarely conducted in nutrition emergencies. And,
standards. These can be found within the other modules of the evidence of accountability in nutrition is a work in progress.
the HTP. See also module 20 on Monitoring and Evaluation. See Modules 20 and 21 for more discussion on monitoring
and evaluation as well as standards and accountability
It is recognised that key areas to evaluate in emergency (respectively).
nutrition interventions include:
• Effectiveness: (achieving objectives – doing the thing Recent Developments and on-going
right, including cost-effectiveness)
cha llenges in nutrition in emergencies
• Efficiency: (doing it right, with as few resources as
possible; effort, time, money, people, material) Recent developments
• Relevance/Appropriateness (doing the right thing in Over the last 40 years, there have been many advances in key
the right way at the right time) areas of nutrition in emergencies, even if efforts to further
improve standards and practices are needed.
• Impact (doing the right thing, changing the situation
more profoundly and in the longer-term) • Standardisation of assessments
• Coverage (the extent to which the interventions reach Nutrition assessments are now far more rigorous than in the
the intended target population-linked to effectiveness past. In particular, nutrition surveys to establish the prevalence
(level) of malnutrition in emergency-affected populations are
There is a trend to try and combine evaluations of organisations now widely carried out. Internationally agreed upon standard
with different mandates to obtain a fuller picture of the overall guidance exists for design, implementation, analysis and pre-
operating context and causal relationships between interven- sentation of nutrition survey results.
tion areas.

74
International covenant on economic, social and cultural rights, 1976. http://www2.ohchr.org/english/law/cescr.htm
75
Real time evaluations are carried out 8 to 12 weeks after the onset of the emergency and the results are usually processed within one month of data collection.

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• Early warning systems that can be provided as part of a general ration or targeted to
Many early warning systems (EWS) have been set up at national particularly vulnerable groups has helped to reduce
and regional levels. These have become increasingly sophis- micronutrient deficiencies. Micronutrient supplementation (for
ticated and no longer rely solely on food production informa- example, with vitamin A) has also become an important part
tion. EWS now incorporate information on access to food as of emergency nutrition response.
well as availability, e.g., markets and coping strategies. Systems • Infant and Young Child Feeding (IYCF) in
which have been operating for a number of years in crisis- emergencies
prone countries have built up baseline information and an
Significant policy guidance has been developed to support
understanding of trends so that alerts to pending emergencies
IYCF in emergencies. Documents to support emergency
are produced in a timelier manner.
programming include the Operational Guidance on Infant and
• Standardization of ration scales Young Child Feeding in Emergencies77, the International Code
The United Nations revised ration scales in 1997 to better re- of Marketing of Breastmilk Substitutes (BMS) and subsequent
flect nutrition requirements. It is currently recommended that relevant World Health Assembly (WHA) resolutions (collectively
a full ration provide on average 2100 kcal/person/day76 (an known as the Code). Additionally, Sphere 2011 includes two
increase from the previous 1900 kcal). IYCF standards.
• Improvement in nutritional quality of fortified • Expansion of interventions to address
blended flours (FBFs) undernutrition in emergencies
WFP and UNICEF have revised the composition of traditional The range of interventions to prevent and address malnutrition
corn-soy blend (CSB) based on nutritional requirements. CSB+ has expanded. In addition to more traditional food aid
and CSB++ are the resulting new formulations developed to distribution and selective feeding programmes, food security
meet the additional energy density and micronutrient needs and livelihood support interventions, including cash distri-
of some population subgroups. As of early 2010 WFP has re- bution, are now common. It is recognised that well-designed
placed all FBF’s in general food distributions with the improved non-food interventions have greater capacity to protect and
CSB+/++. promote livelihoods in the longer term than food aid alone.
• Targeting of food rations • Coordination and increase of agencies involved
Systems for targeting food aid have been refined with an There has been a significant expansion in the number of
increasing emphasis on community-based involvement to organisations working in nutrition-related areas during
determine targeting criteria. Systems to monitor the success emergencies. Coordination has therefore become a priority.
level of targeting have been established. Where these ap- The Office for the Coordination of Humanitarian Affairs (OCHA)
proaches work, resources are conserved and communities are was created in 2005 to coordinate United Nations agencies.
empowered. Additionally the United Nations Inter-agency Standing Com-
mittee (IASC) initiated a cluster approach to facilitate the
• Therapeutic care in the community coordination and improve response in emergencies.
Therapeutic feeding programmes have been revolutionised
• Lesson-learning
by the development of RUTF. Children with SAM without
complications can now be treated in the community with Evaluations and reviews of lessons learned are now much more
RUTF and regular medical visits. This has led to far greater frequently carried out in an effort to avoid the repetition of
programme coverage and has reduced crowding in centres mistakes. Dissemination of experience has also increased
where the risk of cross infection is high. through a number of initiatives such as the GNC, publications
such as Field Exchange78 and those produced as part of the
• Micronutrient nutrition Humanitarian Practice Network (HPN)79 and the Active Learn-
The importance of micronutrients (vitamins and minerals) for ing Network for Accountability (ALNAP).80 In addition, opera-
health and growth has been proven. While there is no one tional research during emergencies has increased aiming
single approach to preventing micronutrient malnutrition in to provide a greater evidence base for future emergency
all emergency contexts, the development of new products response.
such as blended foods and multiple micronutrient powders

76
The management of nutrition in major emergencies, WHO (2000) and Sphere handbook, 2011. The International Committee for the Red Cross suggests 2400 kcal.
77
Endorsed in the World Health Assembly Resolution 43,23 (2010)
78
Field Exchange is a magazine containing field articles, research and news pieces for those working in emergency nutrition and food security.
For details see www.ennonline.net.
79
HPN publications are written by and for practitioners. HPN produces three types of specialist publications for the humanitarian community: Humanitarian Exchange
Magazine, HPN Network Papers, Good Practice Reviews. For details see www.odihpn.org.
80
ALNAP was established in 1997, following the multi-agency evaluation of the Rwanda genocide. It is a collective response by the humanitarian sector, dedicated to
improving humanitarian performance through increased learning and accountability. For details see www.alnap.org/about.

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On-going challenges in nutrition In addition, the private sector has taken an increased role in
in emergencies the development, promotion and marketing of various food
based products. Several agencies are embarking on public-
While there have been important advances in the area of private arrangements (with Pepsico, Campbells, etc) for food
nutrition in emergencies over the last 40 years, a number of based product development and use.
major challenges remain. These are mainly operational and
result from the political and institutional factors that have a Rigorous research and documentation is required to build the
major influence on the outcomes of response to emergencies. evidence base on the effectiveness and feasibility of these
They include: products. Additionally, guidance for the production, marketing
• Lack of commonly agreed classification system for and distribution of food based products (like that of the Code
nutritional crises of Breastmilk substitutes) is urgently required to provide a
framework and guidance for the food industry.
• Proliferation of food based products for the treatment of
moderate acute malnutrition Limited evidence for an effective model to treat MAM
• Limited evidence for an effective model to treat MAM Various actors within the global nutrition community have
developed pilot programmes to test the feasibility and
• Challenges in implementation of the Operational effectiveness of different models as well as different products
Guidance on IYCF in emergencies to treat MAM. At the same time, many agencies have deve-
loped decision trees for programming with new food based
Constraints to the operating environment
products including UNHCR, UNICEF, and WFP; however all are
• Inadequate skills and expertise in nutrition in different.
emergencies at national level
As yet, there is no evidence for an effective, cost-effective
• Linking relief, recovery and development efforts
approach to treat MAM. Additional research and ultimately
• Linking nutrition interventions with each other and with normative guidance for programmes is necessary.
other sectors
Challenges in implementation of the Operational Guidance
Lack of commonly used classification system for on IYCF in emergencies
nutrition crises
While the IPC is gaining support in a number of countries and It is crucial to protect and support the nutrition, care, health
with a number of agencies, there is no agreed upon framework and development needs of infants and young children in
for analysis and classification of nutrition crises situations. emergencies due to their higher risk of disease. Significant
Therefore it is impossible to compare the scale of an advances have been made in awareness and in the deve-
emergency in one area to that of another. Furthermore, areas lopment of policy guidance, standards and training materials
with high rates of malnutrition are not necessarily recognized for IYCF in emergencies. However there remains a gap and
as nutrition emergencies and may not receive emergency demand for development of programmatic guidance on IYCF
international aid. An estimated 10 children die every minute assessment and programming design in emergencies at scale,
from undernutrition, most of whom live in Asian countries to enable practitioners to meet the provisions of the
where levels do not result in an emergency being declared. Operational Guidance on Infant Feeding in Emergencies. There
is also often limited experience and capacity to address IYCF
Proliferation of food based products for the treatment in emergencies, poor emergency preparedness and in some
of acute malnutrition contexts, Code violations.
Significant evidence exists for the effectiveness of treatment
Constraints of the operational environment
of SAM with RUTF. Based on this evidence, the UN issued a
Joint Statement on the Community Management of Acute Many emergencies occur in extremely hostile and difficult
Malnutrition in 2009. The success of outpatient programming contexts. Relief operations are therefore hampered by threats
to treat SAM using RUTF has spawned a proliferation of to security, lack of access, transportation problems, lack of
products available on the market to treat MAM and prevent infrastructure and other obstacles outside the control of aid
undernutrition, though to date there is limited (or no) evidence workers. There are cases where malnutrition rates have soared
on the effectiveness of most of these products though research and it has been very difficult to address the problems purely
is ongoing and decision making trees to help guide decision because of insurmountable logistical and access problems. For
making on the products that can be used, are being developed example access to populations in South-eastern Somalia is
by many agencies and the GNC. limited due to political issues and continued conflict resulting
in a very precarious nutrition situation. Additionally, popula-
tions in Libya and Ivory Coast have been cut off from interna-
tional support due to internal conflict.

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The Humanitarian Response Index 2010 documented a lack Linking relief, recovery and development efforts
of access as one of the main constraints to humanitarian res- While agencies are embracing Disaster Risk Reduction and
ponse, reporting that donor governments do not still support Early Recovery more and more, proportionally there is much
protection of civilian efforts adequately to ensure protection limited work on prevention, preparedness and linking human-
needs of populations are met.81 itarian relief, recovery and development programmes. This is
vital in order to prevent and minimise human suffering when
Inadequate skills and expertise in nutrition in all scenarios suggest increased humanitarian needs83.
emergencies at national level
National capacity for responding to nutrition emergencies Common frameworks, guidelines, tools, funding and evidence
differs across countries and while some have built significant of impact are all required to make this more of a reality.
capacity such as Ethiopia, most others have very limited capa-
city. While some agencies have developed significant capacity Linking nutrition interventions with each other,
development activities and many resources have been and other sectors
developed, to realise capacity development in the long term, Given the multi-causality of undernutrition, nutrition interven-
efforts must be sustained, integrated into national develop- tions in emergencies need to be integrated with other sectoral
ment processes, build national commitment and be supported responses for maximum impact. Clean water and sanitation,
by long term funding82. food security and health care are all necessary to combat acute
malnutrition in emergencies, in recovery and in development
contexts. Without ensuring a range of multi-sectoral interven-
tions to address the underlying causes in each situation, many
stand-alone nutrition interventions will have limited impact.

81
DARA is an independent organization committed to improving the quality and effectiveness of aid for vulnerable populations suffering from conflict, disasters and
climate change. http://daraint.org/humanitarian-response-index/humanitarian-response-index-2010/key-findings/
82
Capacity Development for Nutrition in Emergencies: Beginning to synthesise experiences and insights, Gostelow 2007.
83
Humanitarian Response Index, 2010.

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Annex 1: Definitions of emergency

“An unforeseen and often sudden event that causes great damage, destruction and human suffering” (Centre for Research on the
Epidemiology of Disasters, 2007)

“Urgent situations in which there is clear evidence that an event or series of events has occurred which causes human suffering or
imminently threatens human lives or livelihoods and which the government concerned has not the means to remedy; and it is a
demonstrably abnormal event or series of events which produces dislocation in the life of a community on an exceptional scale” (World
Food Programme, Consolidated Framework of WFP Policies, Policy Issues Agenda item 4, 2007)

“A state in which normal procedures are suspended and extraordinary measures are taken in order to avert the impact of
a hazard on the community” (World Health Organization, Emergency and Humanitarian Action, 2005.)

“Any situation where there is an exceptional and widespread threat to life, health and basic subsistence, which is beyond the coping
capacity of individuals and the community” (Oxfam Humanitarian Policy, 2003.)

Complex emergency
“A humanitarian crisis in a country, region or society where there is a total or considerable breakdown of authority resulting from
internal or external conflict” (Inter-Agency Standing Committee, FAO field programme circular 2/96 (annex), 1994.)

“Relatively acute situations affecting large civilian populations, usually involving a combination of war or civil strife, food shortages,
and population displacement, resulting in significant excess mortality” (Burkholder, B. T., Toole, M. J., ‘Evolution of complex disasters’,
The Lancet, 346 (8981), 14 October 1995.)

“chronic, multi-causal disasters: political factors are however primary in determining their intensity” (Macrae, J., ‘Aid under fire: redefining
relief and development assistance in unstable situations’, Wilton Park (UK), 7-9 April 1995.)

HTP, Version 2, 2011 43

44
Annex 2: Nutrition-related standards and benchmarks used to gauge the severity of an emergency and the
response requirements
Source: Darcy, James and Charles-Antoine Hofmann, ‘According to Need? Needs Assessment and Decision-Making in the Humanitarian Sector’, Humanitarian Policy Group Report 15, Humanitarian Policy Group, September 2003.
MODULE 1

HTP, Version 2, 2011

ODI Classification of levels and types of food security 2003
TECHNICAL NOTES

Mortality and
Level malnutrition indicator Food security indicators Responses

Chronic (or periodic) CMR 0.2-1/10,000/day Production: Poor yields leading to pre-harvest Typical indicated responses: Longer-
food insecurity ‘hungry season’; low prices for cash crops, etc. term strategies: support to livelihoods,
Access to food limited, often Wasting 2.3-10% Income and employment: high unemployment and food security, existing public health
seasonally, and diet inadequate for low wages leading to poverty. Dependence on system; social safety nets
good health. High prevalence of Stunting >40% casual labour and the informal economy, etc. Information systems required: early
chronic malnutrition (stunting) and Markets: price instability of staple foods and other warning systems; health and nutrition
likely to be some seasonal increase key commodities; shortages of key commodities and surveillance
in mortality, morbidity and acute foods (often seasonal); lack of market integration
malnutrition (wasting) Assets: low asset base; high reciprocity (e.g.,
dependence on loans, kinship/family ties, seasonal
labour).
Coping strategies: adaptive or insurance strategies
periodically employed (e.g., changes in cropping
patterns; sale of non-productive assets; borrowing
small loans; seasonal labour migration; collection of
wild foods, etc.)
Introduction to nutrition in emergencies
 ODI Classification of levels and types of food security 2003 (continued)

Mortality and
Level malnutrition indicator Food security indicators Responses

Acute food crisis A crisis of food CMR 0.2-2/10,000/day Production: precipitating events such as drought or Typical indicated responses:
access generally precipitated by war lead to loss of crops and/or livestock; dramatic Emergency responses and ‘stepping
a shock but may be compounded Wasting 2.3-10% decline in overall food availability up’ of longer-term strategies; targeted
by longer-term vulnerabilities Income and employment: loss of jobs; fall in wages; general ration; possibly targeted
(e.g., poverty, HIV/AIDS, etc.). or increased dependence on the informal economy supplementary and therapeutic
National capacity (or will) to Markets: dramatic rises in price of food and other feeding; increased health care
espond exceeded e.g., lack of increases in wasting basic items provision; targeted agricultural
strategic food reserves). CMR and rates (e.g., doubling Coping strategies: normal coping mechanisms start production inputs; livelihood and
wasting levels remain normal over a few months) to break down under stress. Increase in unsustainable food security support information
initially but rise as a crisis persists. crisis strategies (e.g., changes in consumption systems required: early-warning
patterns; disposal of key productive assets) systems (food availability and prices);
health and nutrition surveillance;
Introduction to nutrition in emergencies

multisectoral assessments (including

household food security, livelihoods,
health and nutrition status, access to
water and sanitation); mortality and
nutrition surveys

Extended food crisis A long-term CMR 1-2/10,000/day Production: low crop and livestock production over Typical indicated responses: Longer-
crisis of food access often long time period term strategies together with some
associated with poverty, Wasting 15-30% Income and employment: poverty and destitution emergency responses; strengthening
lack of investment, erosion of high; high unemployment; low wages; high civil organisations (especially of
livelihoods and political dependence on welfare and low return activities marginalized groups); sustainable
marginalization. Wasting levels (e.g., petty trading). livelihood support; targeted general
remain chronically high and Markets: prices of food and other basic items ration; supplementary and
fluctuate depending on season and unaffordable for the poor therapeutic feeding
level of humanitarian aid Coping strategies: unsustainable crisis strategies Information systems required: health
(if provided). relied upon during specific seasons and nutrition surveillance;
multisectoral assessments (including
household food security, livelihoods,
health and nutrition status, access to
water and sanitation); mortality and
nutrition surveys
TECHNICAL NOTES

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MODULE 1

45
46
ODI Classification of levels and types of food security 2003 (continued)

Mortality and
Level malnutrition indicator Food security indicators Responses
MODULE 1

HTP, Version 2, 2011

Famine A food crisis that results in CMR >2/10,000/day Characterised by catastrophic lack of access to food, Typical indicated responses: Major
major excess mortality and very including market collapse; mass destitution; social and immediate emergency response.
high levels of severe acute Wasting > 25% breakdown; breakdown of formal and informal Blanket general ration distribution;
TECHNICAL NOTES

malnutrition (both children social systems extensive supplementary and

and adults) or Coping strategies: coping and crisis strategies therapeutic feeding; health service
exhausted or extreme survival strategies (e.g., support
dramatic increases in distress migration, high-risk activities) Information system required: health
wasting rates (e.g., trebling and nutrition surveillance; repeated
over a few months) multisectoral assessments; repeated
mortality and nutrition surveys
Introduction to nutrition in emergencies
 Howe and Devereux famine magnitude scale 2004
Source: Howe, Paul. and Stephen Devereux, ‘Famine intensity and magnitude scales: A proposal for an instrumental definition of famine’, Disasters, 28(4), 23 November 2004.

Phase designation ‘Lives’: malnutrition and mortality indicators ‘Livelihoods’: food security descriptors

Food security conditions CMR <0.2/10,000/day and Social system is cohesive; prices are stable; negligible adoption of
Wasting <2.3% coping strategies.

Food insecurity conditions CMR ≥ 0.2 but <0.5/10,000/day and/or Social system remains cohesive; price instability, and seasonal
Wasting ≥2.3 but <10% shortage of key items; reversible ‘adaptive strategies’ are employed.

Food crisis conditions CMR ≥ .5 but <1/10,000/day and/or Social system significantly stressed but remains largely cohesive;
Wasting ≥10 but <20% and/or prevalence of oedema dramatic rise in price of food and other basic items; adaptive
mechanisms start to fail; increase in irreversible coping strategies.

Famine conditions CMR ≥1 but <5/10,000/day and/or Clear signs of social breakdown appear; markets begin to close
Wasting ≥20% but <40% and/or prevalence of oedema Or collapse; coping strategies are exhausted and survival strategies
are adopted; affected population identify food as the dominant
Introduction to nutrition in emergencies

problem in the onset of the crisis.

Severe famine conditions CMR ≥5 but <15/10,000/day and/or Widespread social breakdown; markets are closed or inaccessible
Wasting ≥ 40% and/or prevalence of oedema to affected population; survival strategies are widespread; affected
population identify food as the dominant problem in the onset of
this crisis.

Extreme famine conditions CMR ≥15/10,000/day Complete social breakdown; widespread mortality; affected
population identify food as the dominant problem in the onset of
the crisis.
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FAO/FSNAU integrated food security and humanitarian phase classification reference table
Source: Food and Agriculture Organization, Food Security and Nutrition Analysis Unit – Somalia. Integrated Food Security and Humanitarian Phase Classification: Technical Manual Version I. Technical Series Report No. IV, FAO,
Nairobi, 11 May 200684.

Phase classification Key reference outcomes (current or imminent outcomes Strategic response framework (mitigate immediate outcomes,
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on lives and livelihoods; based on convergence of evidence) support livelihoods, and address underlying/structural causes)

Generally food secure Crude mortality rate <0.5/10,000/day Strategic assistance to pockets of food insecure groups
TECHNICAL NOTES

Acute malnutrition <3% (w/h < -2 z-scores) Investment in food and economic production systems
Stunting <20% (w/age <-2 z-scores) Enable development of livelihood systems based on principles of
Food access/availability usually adequate (>2,100 kcal sustainability, justice and equity.
ppp day); stable Prevent emergence of structural hindrances to food security
Dietary diversity consistent quality and quantity Advocacy
of diversity
Water access/availability usually adequate (> 15 litres
ppp day); stable
Hazards moderate to low probability and vulnerability
Civil security prevailing and structural peace
Livelihood assets generally sustainable utilization
(of 5 capitals)

Chronically food insecure Crude mortality rate <0.5/10,000/day; Design and implement strategies to increase stability, resistance
U5MR<1/10,000/day and resilience of livelihood systems, thus reducing risk.
Acute malnutrition >3% but <10% (w/h <-2 z-score); Provision of ùsafety netsû to high risk groups
usual range; stable Interventions for optimal and sustainable use of livelihood assets
Stunting >20% (w/age <-2 z-scores) Create contingency plan.
Food access/availability borderline adequate (2,100 kcal Redress structural hindrances to food security.
ppp day); unstable Close monitoring of relevant outcome and process indicators
Dietary diversity chronic dietary diversity deficit Advocacy
Water Access/Availability borderline adequate (15 litres
ppp day)
Hazards recurrent, with high livelihood vulnerability
Civil security unstable; disruptive tension
Coping ‘insurance strategies’
Livelihood assets stressed and unsustainable utilization
(of 5 capitals)

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Introduction to nutrition in emergencies
 Acute food and livelihood crisis Crude mortality rate 0.5-1/10,000/day; Support livelihoods and protect vulnerable groups
U5MR 1-2/10,000/dy Strategic and complimentary interventions to immediately
food
Acute malnutrition 10-15% (w/h <-2 z-score); > than access/availability AND support livelihoods
usual; increasing Selected provision of complimentary sectoral support
Disease epidemic; increasing (e.g., water, shelter, sanitation, health, etc.)
Food access/availability lack of entitlement (2,100 kcal Strategic interventions at community to national levels to create,
ppp day) stabilize, rehabilitate or protect priority livelihood assets
Dietary diversity acute dietary diversity deficit Create or implement contingency plan.
Water access/availability 7.5-15 litres ppp day; Close monitoring of relevant outcome and process indicators
accessed via asset stripping Use ‘crisis as opportunity’ to redress underlying structural causes.
Destitution/displacement emerging; diffuse Advocacy
Civil security limited spread, low intensity conflict
Coping ‘crisis strategies’; CSI > than reference; increasing
Livelihood assets accelerated and critical depletion or
loss of access
Introduction to nutrition in emergencies

Humanitarian emergency Crude mortality rate 1-2/10,000/day, >2 x reference rate, Urgent protection of vulnerable groups
increasing; U5MR >2/10,000/day Urgently
food access through complimentary interventions.
Acute malnutrition >15% (w/h <-2 z-score); > than Selected provision of complimentary sectoral support
usual; increasing (e.g., water, shelter, sanitation, health, etc.)
Disease pandemic Protection against complete livelihood asset loss and/or
Food access/availability severe entitlement gap; advocacy for access
unable to meet 2,100 kcal ppp day Close monitoring of relevant outcome and process indicators
Dietary Diversity regularly 2-3 or fewer main food Use ‘crisis as opportunity’ to redress underlying structural causes.
groups consumed Advocacy
Water access/availability < 7.5 litres ppp day
(human usage only)
Destitution/displacement concentrated; increasing
Civil security widespread, high intensity conflict
Coping ‘distress strategies’; CSI significantly >
than reference
Livelihood assets near complete and irreversible
depletion or loss of access
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Famine/Humanitarian Crude mortality rate >2/10,000/day Critically urgent protection of human lives and vulnerable groups
catastrophe (e.g., 6,000/1,000,000/30 days) Comprehensive assistance with basic needs
Acute malnutrition >30% (w/h <-2 z-score) (e.g., food, water, shelter, sanitation, health, etc.)
Disease pandemic Immediate policy/legal revisions where necessary
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Food access/availability extreme entitlement gap; Negotiations with varied political-economic interests
much below 2,100 kcal ppp day Use ‘crisis as opportunity’ to redress underlying structural causes.
Water access/availability <4 litres ppp day Advocacy
TECHNICAL NOTES

(human usage only)

Destitution/displacement large scale; concentrated
Civil security widespread, high intensity conflict
Livelihood assets effectively complete loss; collapse

United Nations thresholds for malnutrition (2004)

Source: The Management of Nutrition in Major Emergencies (IFRC, UNHCR, WFP, WHO)

Prevalence of global acute

malnutrition (<80% below
Interpretation median/or <-2 Z scores) Mean weight-for-height Z score

Acceptable <5% >-0.4

Poor 5-9% -0.4 to 0.69

Serious 10-14% -07 to 0.99

Critical >15% <-1.00

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TECHNICAL NOTES

Annex 3: WHO decision tree for implementation of selective feeding programmes

Source: World Health Organization, The Management of Nutrition in Major Emergencies, WHO, Geneva, 2000.

Finding Action required

Food availability at household level below Unsatisfactory situation:

2,100 kcal per person per day • Improve general rations until local food availability and
access can be made adequate.

Malnutrition rate 15% or more Serious situation:

or • General rations (unless situation is limited to vulnerable
10-14% with aggravating factors groups); plus
• Supplementary feeding generalized for all members of
vulnerable groups especially children and pregnant and
lactating women
• Therapeutic feeding programme for severely malnourished
individuals

Malnutrition rate 10-14% Risky situation:

or • No general rations; but
5-9% with aggravating factors • Supplementary feeding targeted at individuals identified as
malnourished in vulnerable groups
• Therapeutic feeding programme for severely
malnourished individuals

Malnutrition rate under 10% with no Acceptable situation:

aggravating factors • No need for population interventions
• Attention for malnourished individuals through regular
community services

Note: This chart is for guidance only and should be adapted to local circumstances.
The malnutrition rate is defined as the percentage of the child population (6 months to 5 years) who are below either the reference median weight-for-height -
2SD or 80 per cent of reference weight-for-height.
Aggravating factors:
• General food ration below the mean energy requirement
• Crude mortality rate more than 1 per 10 000 per day
• Epidemic of measles of whooping cough (pertussis)
• High incidence of respiratory or diarrhoeal diseases

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TECHNICAL NOTES

Annex 4: Famines of the twentieth century

Source: Devereux, 2002.

Location Date Causal trigger Excess mortality

Nigeria (Hausaland) 1903-06 Drought 5,000

Tanzania (South) 1906-07 Conflict 37,500
West Africa (Sahel) 1913-14 Drought 125,000
Tanzania (Central) 1917-19 Drought and conflict 30,000
China (Gansu, Shaanxi) 1920-21 Drought 500,000
Soviet Union 1921-22 Drought and conflict 9,000,000
China (northwest) 1927 Natural disasters 3,000,000-6,000,000
China (Hunan) 1929 Drought and conflict 2,000,000
Soviet Union (Ukraine) 1932-34 Government policy 7,000,000-8,000,000
China (Henan) 1943 Conflict 5,000,000
India (Bengal) 1943 Conflict (fear of Japanese invasion) 2,100,000-3,000,000
Rwanda 1943-44 Conflict and drought 300,000
Holland (Dutch Hunger) 1944-45 Conflict (Nazi blockade) 10,000
Soviet Union 1946-47 Drought and government policy 2,000,000
Ethiopia (Tigray) 1957-58 Drought and locusts 100,000-397,000
China 1958-62 Government policy 30,000,000-33,000,000
Ethiopia (Wollo) 1966 Drought 45,000-60,000
Nigeria (Biafra) 1968-70 Conflict (war of independence) 1,000,000
West Africa (Sahel) 1969-74 Drought 101,000
India (Maharashra) 1972-73 Drought 130,000
Ethiopia (Wollo and Tigray) 1972-75 Drought 200,000-500,000
Somalia 1974-75 Drought and government policy 20,000
Bangladesh 1974-75 Flood and market failure 1,500,000
Cambodia 1979 Conflict 1,500,000-2,000,000
Uganda (Karamoja) 1980-81 Conflict and drought 30,000
Mozambique 1982-85 Conflict and drought 100,000
Ethiopia 1983-85 Conflict and drought 590,000-1,000,000
Sudan (Darfur, Kordofan) 1984-85 Drought 250,000
Sudan (south) 1988 Conflict 250,000
Somalia 1991-93 Conflict and drought 300,000-500,000
Democratic People’s 1995-1999 Government policy and floods 2,800,000-3,500,000
Republic of Korea
Sudan (Bahr el Ghazal) 1998 Conflict and drought 70,000

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