Preface

This manual is intended to help health, nutrition, and other professionals involved in the management of major emergencies with a nutritional component, whether at local, national, or international level. By improving understanding among the health professionals and intersectoral personnel who are collectively responsible for ensuring adequate nutrition in emergency-affected populations, the manual should promote coordinated and effective action.

All major emergencies, by definition, threaten human life and public health. They often result in food shortages, impair or jeopardize the nutritional status of a community, and cause excess mortality in all age groups. Nutrition is therefore a key public health concern in emergency management. Accordingly, this manual deals with the following topics: initial nutritional assessments; identifying the risk or presence of various forms of malnutrition; calculating food needs and, where necessary, ensuring generalized or selective food distribution; treating malnutrition and preventing the occurrence of nutritional deficiencies; monitoring the nutritional status and the food availability in households; and preventing and controlling nutrition-related and food-borne communicable diseases.

The occurrence of both natural and man-made emergencies has risen dramatically in recent years, with a parallel growth in the numbers of stricken communities, refugees, and internally displaced persons. The International Conference on Nutrition, convened by FAO and WHO in 1992, devoted much time to the nutrition of refugees, and displaced and war-affected populations - "the world's most malnourished nation". The World Declaration and Plan of Action for Nutrition,¹ signed by 159 ministerial representatives and the then European Economic Community, urged governments to provide sustainable assistance to these people and to ensure their nutritional well-being. Part 6 of the World Plan of Action (Caring for the socio-economically deprived and nutritionally vulnerable) states in Article 37:

"Among refugees and displaced populations, high rates of malnutrition and micronutrient deficiencies associated with high rates of mortality continue to occur. The magnitude of the problem has grown over the last decade. Increased political commitment to and accountability for the protection and promotion of the nutritional well-being of refugees, displaced populations, those under occupation, prisoners of war and other affected groups are urgently required in accordance with international humanitarian law. Governments, in collaboration with the international community, should:

(a) Provide sustainable assistance to refugees and displaced persons and work to monitor their nutritional well-being, giving high priority to the control of diseases and to the prevention of malnutrition and outbreaks of micronutrient deficiency disease. Wherever feasible such assistance should encourage their ability to support themselves rather than increase their dependence on external assistance. The food provided should be nutritionally adequate and safe.

(b) Identify, within civilian populations situated in zones of conflict, refugee and displaced populations and groups needing special care including the disabled, the elderly, children, mothers and other nutritionally vulnerable groups in order to provide for their special needs."

¹ World Declaration and Plan of Action for Nutrition, Rome, December 1992. Geneva, World Health Organization, 1992 (unpublished document ICN/92/2).

In response to the World Declaration, almost all countries have developed, or are developing, a national plan of action for nutrition, which should include action for preparedness and capacity-building for management of nutrition in emergencies.

While awareness of the risk and burden of malnutrition in emergency situations has grown, there have also been many advances in knowledge in the fields of nutrition, of emergency preparedness and response, and of the interrelations between disasters and development, and consequent improvements in practice. This manual deals primarily with the nutritional aspects of emergency relief, but it also reflects these new approaches to management, preparedness, prevention, and rehabilitation. This new knowledge has already been put to extensive use in various emergency situations, such as the severe crop failures in southern Africa in the early 1990s; thanks to better management of generalized food distribution and other supportive health measures there were very few surplus deaths and no widespread severe undernutrition.

It is important that nutrition-related interventions be viewed and undertaken as an integral part of a comprehensive approach to emergency management in affected areas. This also implies the inclusion of nutrition in overall emergency preparedness. It is a regrettable fact that, up to now, much of the action in emergency situations has been taken by external agencies, often by-passing national nutritional institutions. This is attributable partly to lack of adequate national resources but also to inadequate preparedness. The 1978 WHO monograph The management of nutritional emergencies in large populations, together with the World Declaration and Plan of Action, provided valuable inspiration and background material for the present manual. This manual, and the learning modules and human resource development programmes to be derived from it, should help to reinforce national capacities and enable national authorities, institutions, and nutrition programmes in particular, to ensure adequate management of nutrition in emergencies. The guidelines should be equally valuable to any organizations cooperating with the government in the management of an emergency.

One important lesson drawn from the experiences since publication of the 1978 monograph is that emergency management is a multisectoral and institutional venture: it cannot be the domain only of the national or local government or of military authorities. Ministries and departments of local government, health, agriculture, environment, welfare, finance, trade, transport, communications, and public works need to plan and work together for emergency prevention, preparedness and response, and rehabilitation.

A second lesson has been that disasters do not occur in a vacuum: they originate from disturbances of the physical, social, or economic milieu, and they can have long-term consequences for nutrition and development itself. Malnutrition may be the primary feature of an emergency, as in drought or flood with subsequent famine, or may be its painful consequence, as in war, mass displacement, or economic disaster. Either way, nutritional considerations are an inescapable element of any major emergency. Particular understanding and efforts are essential to ensure adequate nutrition both in the relief phase and during the subsequent rehabilitation and development phases.

Drought is often the proximate cause of food shortage. However, it is rarely the sole, or even the basic, cause. Emergency preparedness must deal with the deeper causes and, when needed, with the chain of results following food shortage. The consequences of cyclic ("normal") decreases in rainfall may be exacerbated by poor management of land and environment, demographic pressures, inadequate or inappropriate farming technologies, and poor infrastructure, leading to periodic food shortages. Economic constraints at the local, national, and international (trade) levels can all aggravate a marginal food situation. The poorest countries often have inadequate services and safety nets to cope with severe recurrent or periodic stress. Loss of production, however, does not only produce food shortages. Employment and purchasing power are also lost, trade and marketing systems break down, and prices increase dramatically; thus poor urban people are affected, as well as farming populations. Shortage of water may cause the death of livestock, increase the risk of diarrhoeal disease, and even affect the productivity of local industries and the production of energy. Soil structure, vegetation, and wildlife can all be seriously and even irreversibly affected.

Survival strategies at family and community level often include selling basic assets, migration, and disruption of households. Parents are likely to be too busy to take their children regularly to health clinics unless the clinics are nearby. Such widespread poverty, bringing physical, mental, social, and economic hardship, will accentuate vulnerability to nutritional deficiencies. The environment and socioeconomic fabric of an entire country or region can suffer a prolonged set-back.

This brief analysis highlights the need to develop emergency preparedness and management capacities, and so reduce the vulnerability of the population and mitigate the consequences of the crisis. Preparedness is crucial to the community's survival and continuing development.

It is beyond the scope of this book to deal in detail with food security, emergency preparedness, and rehabilitation. The initial rapid-assessment phase - when famine or risk of famine is suspected - is dealt with in another WHO manual, Rapid health assessment protocols for emergencies (1999). Rapid health assessment is likely to be the first and immediate action required in an existing emergency situation, and may or may not involve nutrition specialists. The multisectoral and interdisciplinary (health) process for emergency preparedness is dealt with in the WHO publication Community emergency preparedness: a manual for managers and policy-makers (1999). Only the broad lines of approach to management in the rehabilitation and development phases are given in this manual, mainly in Chapter 7.

A third lesson learned since the 1978 monograph is that ensuring adequate nutrition in emergencies compels a holistic and proactive approach, which implies more than food distribution and protection of health. Intersectoral and comprehensive action is called for in the areas of environment, population, economic and human development, land and water management, food production and trade, services, human rights, governance, empowerment, and growth of the civil society. The health sector has a precise role to play in all these areas, providing education, advocacy, and technical expertise to ensure vulnerability reduction and preparedness for appropriate nutrition-related relief, treatment and prevention of malnutrition, and ultimately promotion of nutrition in the context of broader health, community rehabilitation, and development policy.

For emergency relief to be effective, preparedness is vital. A country with a strong preparedness system will be ready to respond to emergencies effectively and efficiently, allowing the normal development processes to be resumed as rapidly as possible. Effective handling of an emergency requires countries to establish mechanisms that can provide early warning of impending difficulty and deal proactively with the needs (rather than simply rely on external agencies to provide relief activities and food). This manual identifies the basic nutritional needs and hazards of an emergency situation and the national programmes required to safeguard the nutrition of the population.

If governments do not take these steps in advance it will prove near-impossible to break the vicious cycle of poverty, undernutrition, and underdevelopment at any level of society. Ecosystems will be increasingly degraded, mass movements of people will continue. The demand for short-term relief will continue to grow, fostering dependency and a stop-gap approach to a crisis that has deep-rooted, but preventable, causes.

Experience gained since publication of the 1978 monograph has also shown that the primary responsibility for disaster/emergency management must rest with national governments, in a framework of decentralization. For policies and plans to be effective, the authority and resources for their implementation should be decentralized to sub-national levels. International, bilateral, and nongovernmental organizations and the private sector should complement and support the national goals and mechanisms of emergency preparedness and management. When disaster strikes and relief is needed, these groups should accept coordination by the national authorities. Where the government is not in control, external agencies for emergency relief coordination may take temporary responsibility for essential operations, but all special humanitarian assistance programmes should respect the primary need for building or rebuilding national capacities for managing both the relief phase and the transition to rehabilitation and development phases.

A final lesson is that communities and families themselves have often developed some coping strategies, particularly if they have been involved previously in emergencies. The goal of emergency preparedness and response is essentially to enhance this self-help capacity, as well as to ensure all the support necessary to enable each community to manage the health, food, and nutrition situation adequately.

As regards nutrition, this approach offers a particular challenge. Very often countries have a national nutrition unit and programme, but lack nutrition personnel at district and lower levels. General health, agriculture, and administrative personnel therefore need reinforcement of their technical knowledge and skills if they are to respond appropriately and meet the nutritional needs. Human resource development programmes at all levels are thus crucial in most emergency-prone countries and should be given the highest priority for immediate action. It is also important to inculcate and facilitate the habit of working together across sectoral boundaries.

In brief, nutrition is a key component of emergency preparedness and response. Hunger and starvation have immediate health, humanitarian, and political dimensions. In an emergency, a ministry of health will be called on to respond to daily queries about the affected populations and their needs, to dissipate rumours, to mobilize support, and to undertake powerful advocacy. Ideally, the ministry should be aware of, and be able to coordinate and facilitate, the work of all concerned with nutrition in emergencies, including international partners.

The nutrition section of a health ministry, in close coordination with the section responsible for interdisciplinary emergency management, should have the capacity and structure of a highly organized technical and managerial unit, able to carry out functions such as those listed in the box on the following page.

Since the essential purpose of this manual is to help build national capacity for managing emergencies, and this implies human resource development within the country, Annex 9 of this manual provides a framework for a human resource development programme for the management of nutrition in emergencies, in the form of appropriate general, intermediate and specific objectives. These would have to be adapted to the national circumstances and would then become the basis for defining the content of a training course, most of the material for which is covered in this manual.