STUDY ON THE IMPACT OF ARMED CONFLICTS ON THE NUTRITIONAL SITUATION OF CHILDREN
A Report
FOOD AND NUTRITION DIVISION
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“We reaffirm our obligations as nations and as an international community to protect and respect the need for nutritionally adequate food and medical supplies for civilian populations situated in zones of conflict. We reaffirm that in the context of international humanitarian law food must not be used as a tool for political pressure.”
FAO/WHO 1992 World Declaration and Plan of Action for Nutrition, International Conference on Nutrition, (FAO and WHO 1992)
The Food and Nutrition Division of the Food and Agriculture Organization (FAO) would like to thank all those who facilitated this study including the United Nations Children's Fund (UNICEF), New York, the World Health Organization (WHO), Geneva, the Office of the United Nations High Commissioner for Refugees (UNHCR), Geneva, the World Food Programme (WFP) Rome, the FAO country offices for Liberia and Somalia, the UNICEF country offices for Liberia and Somalia, UNICEF Operation Lifeline Sudan (OLS), the Food Security Assessment Unit/WFP Somalia, the WFP country offices for South Sudan and Liberia, Action Africa in Need (AAIN), the Action Internationale Contre la Faim (AICF), the International Committee of the Red Cross (ICRC), Médecins sans Frontières -France (MSF-F), Médecins sans Frontières-Holland (MSF-H), the Norwegian People's Aid (NPA), Oxfam-United Kingdom, the Relief Association Southern Sudan (RASS), Rädda Barnen, Save the Children Fund- United Kingdom (SCF-UK), and the Sudanese Relief and Rehabilitation Association (SRRA).
FAO expresses appreciation to Ms. Jane MacAskill for undertaking the field visits in Liberia and southern Sudan under difficult conditions and preparing the draft report. Special thanks must go to the people of both countries for their patience and time during this study. Thanks must go as well to Ms Danielle de Winter, who collected background information in Mozambique. Finally, financial assistance from UNICEF/the Machel Study is acknowledged.
FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS
Rome, © FAO 1996
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1.1 Background of the study
1.2 Focus of the study
1.3 Methodology
2 IMPACT OF ARMED CONFLICT ON THE NUTRITIONAL SITUATION OF CHILDREN
2.1 Malnutrition in conflict situations
2.2 Causes of malnutrition: a framework for analysis
2.3 Coping in conflict situations
3 HOUSEHOLD FOOD AND NUTRITION SECURITY
3.1 Production
3.2 Access to employment
3.3 Markets
4. INSUFFICIENT HEALTH SERVICES AND UNHEALTHY ENVIRONMENT
4.1 Impaired health services and structures
4.2 Unhealthy environment
5.1 Care of infants and children under five years of age
5.2 Care for the school-age child and the minor
5.3 Care and nutritional status of adults
6 ASSESSMENT OF RELIEF NEEDS AND EMERGENCY RESPONSE
6.1 Assessment needs
6.2 Food relief
6.3 Factors limiting effective responses
8.1 Inadequate household food security
8.2 Impact on health services and health environment
8.3 Impaired caring capacities
8.4 Assessment, responses and impact measurement
9.1 Assessment, monitoring and information needs
9.2 Responses to control and prevent malnutrition in armed conflicts
9.3 Further recommendations
Annexes
Annex 1: Information sheet
Annex 2: Malnutrition in conflict situations
Annex 3: Nutrition status in Mogadishu 1988, 1993, 1995
Annex 4: Results of mid upper arm circumference (MUAC) clinic screening along Nile (in barge)
Annex 5: Proposed guidelines for protection and promotion of breast- and infant feeding during emergencies
Annex 6: The most vulnerable in Bosnia-Herzegovina
Annex 7: Distribution of infant formula: the appropriate response to child malnutrition in Iraq?
Annex 8: Percentage of malnourished children reported to be attending feeding centres distributing cooked food.
List of Tables and Figures
Table 1 Comparison of four countries in conflict
Figure 1 Causes of malnutrition and death
Figure 2 Household food and nutrition security
Figure 3 Insufficient health services and unhealthy environment
Figure 4 Inadequate maternal and child care
List of Boxes
Box 1: Effect of conflict on the population in Liberia
Box 2: Nutritional status data before and during conflict
Box 3: Budget expenditures on war and health
Box 4: Rose's story
Box 5: Mortality and health status among displaced and resident populations of Kabul, Afghanistan
Box 6: The youth in Lafon, south Sudan
Box 7: The impact of conflict on agricultural production in the Juba valley, Somalia
Box 8: The impact of conflict on livestock production in Kongor, southern Sudan
Box 9: Unemployment and access to food in Mogadishu
Box 10: Constraints to marketing in Yambio, southern Sudan
Box 11: Lack of knowledge of infant feeding practices in Mozambique
Box 12: The quality of surveys
Box 13: Selection of appropriate relief food
Box 14: Re-active and preventive programming during conflicts - southern Sudan
BOX 15: Security and relief interventions
1. Context and framework of the study
As part of the United Nations' research programme on the impact of armed conflict on children, the Food and Nutrition Division of the Food and Agriculture Organization carried out this study from September to December 1995. This report on the impact of armed conflict on the nutritional situation of children takes into account the broad causes of malnutrition such as inadequate household food security; poor health care, sanitation and environmental conditions; disruption of family caring practices; socioeconomic and nutritional vulnerability; and, coping strategies employed by the households.
The effects of these factors have been assessed through reviewing the existing literature and discussions with concerned United Nations organizations and non-governmental organizations (NGOs). First-hand information has been gathered through a field visit to two countries, Sudan and Liberia, which are experiencing armed conflict and discussions with some of the affected people. For practical and logistical reasons, it was decided that the study would be limited to Africa and to countries affected by internal conflicts. Reference to other regions and situations are made as required.
It has been estimated that during the conflicts of the past decade approximately 2 million children have been killed, 4 to 5 million became disabled, 12 million were made homeless, more than 1 million were orphaned or separated from their families, and 10 million have been psychologically traumatised.
The study found that the nutritional status of children before the conflict had a significant effect on their status during the conflict. Those countries which had better economic, social and nutritional conditions prior to the conflict had less severe child malnutrition during the conflict.
2. Main causes of malnutrition
It is important to note that in many African countries the nutritional status of children is generally unsatisfactory. Clearly, armed conflicts in Africa can significantly worsen the nutritional status of children and their families and the impact of prolonged conflicts are more serious and devastating.
The factors that cause malnutrition among children during peacetime, i.e. inadequate household food security and poor diet, insufficient health services and poor environment as well as poor maternal and child care practices are all accentuated and exacerbated during armed conflict, leading to a deterioration in the nutritional status of children. Displacement of households and communities, as well as their involvement in actual warfare, creates additional risks for children in terms of availability and access to food and shelter.
2.1 Insufficient household food and nutrition security
Household food security during armed conflict is affected by a decline of agricultural production due to physical insecurity, lack of agricultural inputs and extension services, destruction of infrastructure and markets and loss of farm incomes. Displacement or death of working family members, loss of draught animals, and lack of food to provide adequate energy for work, prevent sufficient land from being planted for food production. All of these factors affect both the quantity and quality of the food which is available to children. In pastoral populations, loss of livestock during armed conflict has a similar nutritional outcome.
When households are in danger of becoming food insecure, they employ various types of coping strategies: they take steps to increase access to alternative sources of food or income by collecting wild foods, looking for credit, selling their labour and reducing consumption. When these are inadequate, they start disposing of non-productive assets and then productive assets, which often leads to destitution.
2.2 Insufficient health services and unhealthy environment
Armed conflict has a fundamental effect on health services and the environment. There is loss of health staff due to their flight, death or conscription by the army. Health care infrastructure, medical supplies, equipment, sanitation and water supplies are destroyed. Finally, there is obstruction of delivery of health services, especially preventive immunization and child care. These are usually superimposed on the family whose food supply is inadequate, reducing resistance to infectious diseases and causing malnutrition.
The destruction of health services and water supplies is exacerbated by population movements. Loss of basic household equipment increases the risk of unhygienic food preparation and water contamination. Loss of mosquito nets and shoes during travel increases the risk of malaria and hookworm infection, and loss of access to fuel wood affects the preparation of food. All of these factors have an adverse effect on the nutritional status of children. Overcrowding in camps leads to rapid spread of disease and further aggravates the condition of children.
2.3 Impaired care capacities
Armed conflicts seriously disrupt the caring capacity of the community and family, especially the mothers. This care is vital for the protection and nutritional wellbeing of children. Mothers tend to have little time to attend to caring activities and they often have to take a different role to protect their family. Breast-feeding is often disrupted and little time is available for the preparation of weaning foods or looking after the health needs of the children. The older children are left to take care of themselves, thus they become more vulnerable to malnutrition and social vices such as violence, theft or prostitution.
Protecting the nutritional status of mothers is essential for protecting the nutritional status of infants and children. In general, healthy adults are needed for providing sufficient care for the children. Clearly, preserving the integrity of the family is crucial for the nutritional welfare of children during armed conflict.
3. Information and response mechanisms
Food relief is the common response wherever there are high rates of malnutrition and acute food shortages. The current methods of assessment of the nutritional situation tend to concentrate on collecting nutritional status and mortality data, mainly to support short term interventions. It is important to have more in-depth information on all aspects of malnutrition and food security, health and care to implement more appropriate responses. The quality of data should be improved and methods of data collection should be standardized for meaningful comparisons of nutrition survey results and assessments of ameliorative actions.
Two types of feeding programmes are commonly established when malnutrition rates are high in conflict situations: therapeutic feeding for severely malnourished children, and supplementary feeding (i.e. distribution of either cooked food or dry rations) for moderately malnourished children. Both have their usefulness and limitations. Whichever method is used, there is a clear need for proper implementation according to precise criteria in order to make such programmes beneficial.
Recently, there has been a move towards utilizing food relief as part of a wider strategy aimed at supporting community and household food security mechanisms, thus creating a long term impact on health and nutrition. Food aid contributes to household food security in several ways: it provides an additional source of food, it contributes to the development of markets, it reduces the displacement of people, it enables the return of displaced persons and lessens intra-tribal tensions and looting.
There is a need for combining efforts both to prevent malnutrition and to restore nutritional status, therefore, preventive and “re-active” planning have been advocated. This approach would maintain a capacity to provide a response to emergencies but at the same time address some of the underlying causes of malnutrition which exist in the society.
To estimate the impact of responses on the nutritional status of children, measuring the number of malnourished children, or morbidity and mortality data at a certain point in time is too limited. It is important to measure the frequency with which a child suffers from repeated episodes of malnutrition, particularly in protracted conflicts. The prolonged nature of most internal conflicts requires a long term developmental approach: all relief measures should link relief, rehabilitation and development objectives and activities. Many of the actions that are required to prevent people from becoming destitute are also fundamental to protecting the nutritional status of children in crisis situations.
4. Main recommendations
Assessment of the nutritional situation in armed conflicts should be designed to clearly bring out programme concerns to assist in the development of better responses to the nutritional needs of children living in these situations. It should identify all important factors that might contribute to malnutrition in an affected area, including an analysis of the food economy of the area, disease trends, and health and sanitary conditions as well as of caring practices. Where possible, information on the situation before the conflict should be obtained.
When identifying the causes of malnutrition, consideration should be given to nutritional outcomes directly resulting from the conflict; those outcomes which may be exacerbated by the conflict; and those which may have contributed to the initiation of the conflict.
Assessments should aim at developing a better understanding of the coping strategies people use in different phases of the conflict. This is essential in designing useful relief interventions and capacity building programmes.
Caring practices should be given more consideration in needs assessments and programme design, including protection and support of breast-feeding and weaning practices. The impact of conflict on women in terms of workload, changes in their role in the household and changes in their status as care providers to the children should be considered more consistently.
The quality of assessments, that is, the quality of data and methods of data collection, should continue to be improved and standardised for meaningful comparisons between sets of data collected by different organizations and at different times. This will allow implementing agencies to ensure that the most appropriate types of interventions are put into place and that impartiality of relief efforts is guaranteed.
In designing programmes in response to malnutrition, the longer term impact of undernutrition on the growth and development of the child as well as acute malnutrition should be considered worthy of an emergency response. The future quality of life of the child, and the impact on the social and economic development of society, should be taken into account as well in designing appropriate responses.
As households are the most important entity to ensure both the survival and nutritional welfare of children during the armed conflicts, programmes to protect, promote and restore the nutritional status of children should be designed to maintain the integrity of the households and to make them economically and socially viable.
Food relief should not be considered in isolation, it should be considered as part of a wider strategy aimed at improving the short, mid and long term prospects for improving the nutritional situation of children and their families.
Supplementary feeding programmes should not stand alone, instead they should be part of a strategy aimed at improving the nutritional status of children both in the short and long term.
In the provision of emergency relief, more emphasis should be given to the rehabilitation of agriculture, livestock and fisheries to enhance local capacities to meet the community's food needs and to improve household food security.
The nutritional problems of lost and orphaned children should be given priority and this should be done in a culturally appropriate fashion as they are the people who are most vulnerable to malnutrition and death.
Programme design should be flexible to take into consideration the impact of constant or recurring insecurity and violence on programme development. Programmes should be designed to take advantage of periods of calm and should improve the capacity of the population to survive periods of crisis. Novel approaches to working in conflict situations need to be constantly developed and refined for each specific situation.
Given the long term nature of the responses which are required in conflict situations, programmes should concentrate on using and strengthening local capacity and skills in all sectors. At all levels of society, local structures through which to work should be identified and there should be considerably more local involvement in decision making processes. More resources for relief assistance should be allocated to the development of local capacity.
Efforts should be made to create and to strengthen national and local capacities to respond adequately to acute emergencies and at the same time address some of the underlying causes of malnutrition among children existing in the society.
There is a general need to develop methods for monitoring the impact of conflict on populations to anticipate, to some extent, the nutritional consequences of different types of conflict for children and to allow rapid identification and implementation of programmes to cater to both their short term and long term nutritional needs.
Measurement of the impact of programmes should shift from purely examining prevailing levels of malnutrition and mortality at specific points in time to monitoring the changes people experience over a longer time frame.
Averting or stopping conflict will do more to help children and to prevent widespread acute malnutrition than any intervention implemented during armed conflict. Therefore, more efforts and resources should be concentrated on conflict resolution, both in countries suffering from armed conflict and in countries affected by internal violence that could eventually lead to armed conflict.
There is a need to identify ways of working in areas which are outside the control of government or where there is no government. Supporting children throughout the conflict should be a priority. State sovereignty should not be invoked to block relief assistance to needy children.
Blockades of food supplies should be internationally banned as this will infringe on the recognised right of the child to adequate food and nutrition.
During armed conflicts, parties involved in the conflict should refrain from the destruction of food crops and agricultural infrastructure in minimize disruption of food supplies and production potential.