International Committee of the Red Cross

Interview by Fiona O'Reilly with Alain Mourey

An impromptu visit to colleagues at the ICRC in Geneva proved warm, friendly and interesting. It left me with the sense that despite its grand location in the middle of beautiful Geneva, though somewhat isolated from its operations, the organisation was anything but removed from the victims it is mandated to protect.

There is a buzz of energy and commitment within the working offices of ICRC ... of people just back from 'mission' or about to go... and a sense of extensive experience in the field of international disaster relief and assistance. The dynamism, casual dress and smoke filled canteen creates an atmosphere much like any major operational NGO.

However ICRC is not like any NGO as its head of relief operations Geoff Loane explained. 'ICRC differs from other NGOs principally in terms of mandate. While we are committed to relief assistance this is in the context of the protection of disaster affected victims - in other words we are protection rather than assistance-driven'.

Alain Mourey, ICRC's Nutritionist at HQ, has decades of experience in emergency work. He joined ICRC after graduating from the MSc course in Human Nutrition at the London School of Hygiene and Tropical Medicine in 1982. Alain has played a significant role in developing and shaping ICRC's nutrition and assistance policies over the past 19 years.

Family packets distribution to Tchetchen refugees in Grozny, 1995

My first question to Alain had to be why ICRC, in contrast to almost every other humanitarian agency, invoked and persisted in using the QUAC stick (based on a combination of height and mid upper arm circumference) to identify and treat malnutrition in communities. Alain explained how this came about. Having completed research on anthropometric indicators in a hospital in Geneva he tested out some of his findings in a therapeutic feeding programme in Huambo, Angola in the early 1980s. In this emergency Alain admitted children to the TFP centre with severe malnutrition based on clinical criteria 'I picked out children who were undoubtedly severely malnourished who could benefit from what we had to offer'. Alain also took height, weight and MUAC measurements of every child and discovered that if he had admitted on the basis of weight for height measurements virtually none of the children would have been admitted. This and other similar experience's in Uganda, Cambodia, Thailand and Ethiopia convinced Alain that using the QUAC stick was not only quicker in surveys and rapid appraisals but also identified the right children for treatment. Weight for height, he points out, is problematic because weight can be confounded by medical conditions such as worm load, inflammation, bowel contents and water retention. In Ethiopia there was a better correlation between weight for height and QUAC stick measurements in low land areas where there was no infection or worm load.

Alain was keen to broaden the scope of our discussion and pointed out that anthropometry is only one tool which may or may not be used in the assessment of the nutritional situation of a population. 'In some cases the situation is patchy with wide variations in nutritional status so antropometry is not helpful while in others everyone is affected and it's crazy to target, for example in Burundi everyone is in need.'

Alain explained how ICRC had been forced by the scale and complexity of relief operations of the early 1980s to refine its conceptual approach to interventions on the basis of health problems that civilian populations are likely to face in conflict. Alain described the conceptual approach used by ICRC known as the "Health Pyramid" as more 'a matter of common sense' than anything else. It sets priorities for intervention so as to reduce as quickly and effectively as possible the risks of morbidity and mortality faced by the victims of armed conflict. Access to food and water is given precedence and health services take second place.

Looking back over the last two decades Alain identified areas where he felt the emergency nutrition sector has advanced and highlighted areas of stagnation or regression. Unafraid of being controversial, Alain is critical of the Sphere project. He sees the project as contributing to the continuing fragmentation of nutrition into separate and specialised fields. This is underpinned by the way the Sphere project separated Nutrition and Food aid (soon to become Food Security) as two subjects in the SPHERE handbook. This Alain feels is dangerous and has already had repercussions in the field. He says 'Agencies are specialising so much in narrow focused responses like therapeutic feeding that they are beginning to lose sight of the economic and food security context in which malnutrition occurs and therefore respond inappropriately. For example, NGOs are sometimes unable to step in and fill food gaps when for whatever reason WFP cannot implement a general distribution programme because the NGOs say they cannot do General rations.' 'In this type of situation an isolated therapeutic feeding programme can have little impact' Alain exclaimed in dismay.

On the positive side he believes that the nutrition sector has become increasingly professional. For example, Alain strongly supports the development of food economy tools and analytical approaches which have helped field workers understand the context of malnutrition and devise responses accordingly. Furthermore, proponents of this approach, e.g. SCF FSAU, have been able to document approaches for others to use. Also the explosion of technology has meant easier dissemination of advances. Improved communications has also facilitated the coming together of nutrition personnel through various networks.' Notable amongst positive developments has been work by Prof. Mike Golden on type 1 and type 2 nutrients and the development of F100 for the treatment of severe malnutrition.

Alain highlighted a recent important policy development in ICRC. In the early nineties the ICRC adopted a resolution aimed at protecting victims against famine¹. This was an important move for advocacy purposes but also operationally as humanitarian workers had to concentrate more on the impoverishment process - which leads to the levels of malnutrition and destitution associated with famines. In order to detect impoverishment, methodologies that describe and monitor people's economic behaviour have to be used. The realisation that famines are economic disasters, which bring about social disruption before becoming health disasters led to profound changes in research as well as field work. In particular it became clear that coping mechanisms that people use in the face of crisis were one of the most important factors to take into account when deciding on the timing and content of humanitarian relief. Sooner or later coping means surviving at the cost of impoverishment and increased vulnerability. As long as impoverishment means using reserves put aside as a buffer against hardship it is a normal phenomenon. However, when coping involves losing essential assets - in particular, means of production - it becomes extremely dangerous and has to be stopped as soon as possible. For ICRC the decision to provide humanitarian assistance should come at this point. Eventually the realisation took hold that food is not the only resource people need to secure in order to survive. This was particularly evident in the Soviet Union and former Yugoslavia where ICRC's experience demonstrated the necessity of examining people's economic circumstances in war as well as their access to food. This experience eventually led to the establishment in 1998 of the ICRC's Economic Security Unit.

On leaving the ICRC I realised that my preconceptions about the agency may have needed some revision. The ICRC is not always known for a readiness to share information and experiences with other agencies in the field, I once heard their acronym interpreted as - I Couldn't Really Comment. This however was not my impression as Alain seemed eager to talk and share experiences until the very last minute of our meeting before rushing off for his nest mission... to Angola.

¹Resolution no. 13