Nutrition intervention in crisis some worrying practices

by Alain Mourey

Alain Mourey is ICRC's HQ nutritionist. He joined ICRC after graduating from the MSc course in Human Nutrition at the London School of Hygiene and Tropical Medicine in 1982. Since then he has played a significant role in developing and shaping ICRC's nutrition and assistance policies over the past 20 years.

During recent field work (notably in Burundi), I came across certain worrying practices in the emergency nutrition sector. Throughout my 22 years of experience in the field of nutrition, I have tended to take a broad view of the subject. This approach does not sit comfortably with the impression I have today, in that nutrition is viewed by many as a 'narrow' discipline and this in turn leads to questionable practices in the field. As Field Exchange offers a medium to voice field level experience, I would like to share mine here, as well as my worries, in the hope of getting some feed-back from other practitioners.

The concept of nutrition

Gasenyi, Kayanza province. Preparing for a food distribution.

Nutrition is not a well defined science. Some have argued that the issues and problems nutrition addresses 'range from the ribosome to the combined harvester' (Rivers, 1979). Others have made the case that the responsibility and challenge for nutritionists today is to actively link the biological and social sciences, and to reduce the fragmentation which exists between the two disciplines (Waterlow, 1981). These views serve to underline the broad view of nutrition that it is possible to take. However, in the world of humanitarian interventions, there seems to be an increasing tendency to conceptualise nutrition as a sector that deals only with the measurement of nutritional status and treatment of moderate and severe malnutrition. These activities appear to be increasingly divorced from wider food security analysis and general food distributions.

Specialisation in nutrition: does it make sense?

The fragmentation of nutrition activities probably partly results from the specialisation of humanitarian organisations into those that assess nutritional status and set up feeding centres, and those that implement food security analysis and general food distributions (usually as implementing partners of the WFP). The fragmentation and distinctions are not always this clear cut, but recently in Burundi such distinctions were all too clear to see. The confinement of nutrition into very specific activities may partly stem from textbooks on nutrition dealing with crisis. The MSF guidelines, as well as the recent WHO manual on nutritional emergencies, restrict nutrition largely to nutritional assessment and treatment of malnutrition. They devote little attention to methods of assessing whether a population can feed itself properly. On a practical level, the specialisation of organisations may make sense. However, in my opinion, this phenomenon undermines a 'global understanding' of what is going on and creates coordination difficulties at field level. A global understanding is necessary because I do believe that there is a fundamental link between nutritional status and food security assessment, as well as between general food distribution and feeding programmes aimed at tackling moderate and severe malnutrition.

Nutrition: an inclusive definition

My view of nutrition is that it involves different activities in the broad field of what is, unfortunately today, called "food and nutrition" - as if these two terms were different enough to be two different entities. I have tried for many years to come up with a definition of nutrition, which encompasses all components of what I perceive nutrition to be. It was only when I started to write a book on nutrition that I really had to settle on a definition which made sense of my understanding of the subject. Obviously, the definition I eventually chose had to be broad. It is this. Nutrition, as a science, studies the exchange of matter and energy between living organisms and their environment. In practice, it deals with the following:

• the nutritional needs arising from the thermodynamic reactions which characterise life, and the necessity to accommodate these reactions in a defined structure (the body) which needs to be built up and maintained;
• the feeding process which aims at meeting nutritional needs through three main steps:

1. obtaining food (essentially geared by economic determinism)
2. the consumption of food (where socio-cultural determinism is most important)
3. the biological utilisation of food (essentially geared by physiological determinism);

• nutritional status which is the outcome of the feeding process;
• nutritional crisis resulting from inadequate or inappropriate feeding process;
• interventions aimed at restoring adequate /appropriate feeding processes.

Encouraging a holistic approach

If we accept this all-encompassing definition of nutrition, we can see that assessment of nutritional status, assessment of food security (or food economy) as well as food consumption, and distribution of food through any means (general food distributions, supplementary feeding, therapeutic feeding), are activities that all fit into the field of nutrition. I would hope that any person purporting to be a nutritionist and working for a humanitarian organisation would be capable (if not expert) in carrying out any of the activities described above. This would mean we would no longer see professional cards of 'Mrs/Mr So and So, Nutritionist and Food Security Analyst'. 'Nutritionist' would be good enough. Today, unfortunately, the false dichotomy between food security analysts and nutritionists is harming the latter, as they find themselves 'straight-jacketed' into implementing an endless round of what are often inappropriate anthropometric surveys and supplementary feeding programmes. This tendency has probably been reinforced by the Sphere project, which aims to establish minimum standards for humanitarian response. The standards have, for obscure reasons, separate chapters on nutrition and food aid and in my view, do not provide sufficient warning about the limited utility and in some cases 'abusive' practice of supplementary feeding in times of food crisis. This fragmentation of nutrition is not only detrimental to the profession of nutrition but also to the victims of crisis. The lack of a broad definition and understanding of nutrition determines that no one has the mandate or responsibility for examining nutritional problems as a whole. It also makes for problems of co-ordination at field level.

Supplementary feeding programmes (SFP): recurring limitations

Irrational targeting?

The distribution of complementary rations (usually in the form of wet feeding) is commonly referred to as supplementary feeding programmes (SFP). In the mid-eighties, the League of the Red Cross and Red Crescent Societies (which later became the IFRC) had some painful experiences with its food relief operation in the Sahel (IDS, 1986). The programme evaluation highlighted the pointlessness of distributing complementary rations in feeding centres in the absence of an adequate general ration. The conceptual and operational inadequacy of SFP in times of food crisis and famine has been discussed and reviewed many times (Godfrey, 1986; Briend, 1995; Curdy, 1995; Shoham, 1995). The main difficulty with SFPs is that they are supposed to supplement the basic food ration that the family has access to, either by its own means and / or through the food that is provided by humanitarian assistance in a general food distribution. However, if the basic food ration is sufficient, there is no need to give a supplement, unless it is intended to help beneficiaries recover from moderate malnutrition. If the basic food ration is marginally insufficient, one has to question whether it is sensible to target children who have a smaller energy requirement per day than adults, especially during the lean period where the physical workload of adults can be considerable. If the basic ration is quite inadequate, is it acceptable to give a small amount of food to children, whether for home feeding or in a feeding centre? If consumed at home, it may well be shared by the whole family in amounts that are only a small proportion of overall household need. If eaten in a feeding centre, it will probably be the only meal the child is going to eat. Furthermore, in situations of grossly inadequate basic rations, where the criteria for admission into the SFP is moderate malnutrition, we may well see children being deliberately starved in order for desperate households to obtain access to at least some food. All these difficulties can engender a lot of frustration amongst the beneficiary population and those who have to implement the programme.

A reflex response?

Despite these well-known problems, SFPs continue to flourish in times of crisis, with the apparent blessing of everybody. Why is it, that while there is consensus amongst so many nutritionists that SFPs have to be considered carefully when used to respond to nutrition crisis, implementation of these programmes is almost a reflex action for many agencies? Certainly, SFPs are much easier to implement, cheaper and better for fund-raising purposes than general food distributions. However they cannot serve any useful purpose if they are employed as a relatively cheap substitute for an inadequate or absent general food distribution.

Personal experiences in Burundi

My recent experiences in Burundi have consolidated my worst fears about the lack of coherence in the nutrition profession and the folly of mindlessly implementing SFPs. SFPs in Burundi had been in operation for a number of years and had evolved into a kind of safety net programme during the non-crisis period until 2000. Up until this time they may have served a useful purpose. However, when information started to emerge that the rate of admissions in the centres had increased above normal (up to an alarming level taking into account the seasonal patterns), there was at first not much practical reaction. This was largely because there was nobody with a mandate to investigate what was going on and to take a global over-view of the nutrition situation. The nutrition coordination meetings at Bujumbura level were limited to focusing on the nutrition centres and to issues of food supply for these centres. However, nobody was systematically looking at the access to food. This would have been the only way to detect the evolving crisis early enough, which was largely due to erratic climatic conditions during the previous two years. In the field, things were a little bit different. The staff running the supplementary feeding centres were well aware that the situation was deteriorating because the beneficiaries were quite clear about the nature of the problem, and the nutritional status of the children at the centres did not improve anymore (and in many cases started to decline sharply). This was simply because there was insufficient food at home. Therefore either the take away supplementary ration was shared by the whole family or those entitled to a meal at the centre (on-site feeding) would not receive enough food at home. The rate of re-admission also increased sharply, the centres became over-crowded and the food supply could not keep pace with the influx. Frustration amongst feeding centre staff was high and the 'beneficiaries' became quite desperate. Eventually, the humanitarian agencies reacted. A proper nutrition surveillance system, owned and used by all the agencies, would probably have helped relevant actors to understand much earlier that a general food distribution was necessary. However, the specialisation of agencies and the compartmentalisation of activities did not allow for this. Such problems are extremely worrying and must be taken seriously by the nutrition community.

Adequate basic ration: A prerequisite to feeding programmes

For the past 18 years the ICRC have chosen to avoid SFPs and to focus resources and capacity on first making sure that the general food distribution is adequate. In most circumstances this will allow for recovery from moderate malnutrition. If adequate access to a basic food ration is provided, then therapeutic feeding centres can be considered for the treatment of severe malnutrition. Obviously, a key difference between the ICRC and other agencies is that the ICRC implements general food distributions and can therefore safeguard against food scarcity induced malnutrition. Other agencies may not have such control and choice. However, if agencies 'choose' to tackle malnutrition in a curative way then they have a responsibility to understand what the root causes are and the measures necessary to tackle the causes or to mitigate their effect.

Adequate understanding: A prerequisite to interventions

This type of understanding can only come through a nutrition survey, which examines the way people get access to food. Agencies also have the responsibility to advocate for appropriate measures to be taken where they are aware of inappropriate or inadequate action. This means that despite the specialisation of their activities, they must have a broad conceptual understanding of nutrition, which encompasses all the steps of the feeding process and all the factors influencing those steps. With such an understanding it is also more likely that establishment of SFPs would be considered more carefully. In fact their very existence in crisis could be used to point to the inadequacy of the humanitarian intervention.

Please send reactions to this article to the ENN (address on back) email: fiona@ennonline.net For further information contact: Alain Mourey at amourey@icrc.org