Revised MSF Nutrition Guidelines

by Saskia van der Kam, MSF Holland, Senior Nutritionist

The MSF nutrition guidelines for use in emergencies have recently been revised. The new guideline will be available in January 2001. The main changes to the guidelines occur in the sections on i) analysis of food insecurity situations, ii) the relation between assessment of food insecurity and nutritional interventions, and iii) the treatment of severe malnutrition.Field exchange will highlight these revisions in three consecutive articles. This first article summarises key points in the new section on:

Analysis of a food insecure situation
The new nutrition guidelines adopt an inter-disciplinary approach to assessment and advocates using the UNICEF conceptual framework for analysis so that the assessment focuses on food security, health and care.

The new guidelines define three sequential stages in the transition from food security to famine. These are elaborated below. Every situation is different. The speed with which the stages progress from one to another can vary greatly depending on the nature (or the origin) of the crisis, its context, the range of coping strategies that are adopted, and the aid that is delivered.

Stages of Food insecurity, coping mechanisms¹
Stage of food insecurity process	Coping mechanisms (household level)
Food insecurity	Insurance strategies reversible coping Preserving productive assets Reduced food intake, etc.
Food crisis	Crisis strategies irreversible coping Threatening future livelihood Sale of productive assets, etc.
Famine & death	Distress strategies no coping Starvation and death No more coping mechanisms

People adopt a range of strategies (coping mechanisms) to cope with reduced access to food. In the latter stages of the process, coping mechanisms become exhausted so that the priorities of the individual and community shift towards survival.

Stage 1 - Food insecurity: 'insurance strategies'
During this first stage, the responses developed by the population are reversible and in principle do not damage future productive capacity.

People anticipate problems and adopt insurance strategies planned in advance to minimise the effects of food shortages, enhance productive capacity and preserve their productive assets. People's responses are characterised by diversification of activities, longer work hours and focussing on increasing income and limiting expenditures. The caring capacity for the non-productive members of the community (elderly, children, sick) will be reduced. For example when men migrate to the city for temporary work, women become the head of the household and have more work and therefore less time to care for children. People also reduce their food intake, without this immediately being a threat to health. Therefore an increased level of moderate malnutrition may be seen.

Examples of insurance strategies

Increase resources:

crop diversification for farmers
livestock diversification for pastoral populations, sale of excess livestock, long distance grazing
sale of non productive assets (utensils, jewellery, charcoal, furniture)
labour migration (search for temporary employment in towns)
diversification of informal economic activities
loans
prostitution

Decrease expenditures:

reduction of food intake (reduced meal frequencies and smaller quantities eaten)
change in diet (consumption of wild foods, cheaper foods etc.)
reduction of expenditures on health care (and water purchase)
reduction of social support to the community, (relatives and neighbours)
reduction of time available for care

Stage 2: Food crisis: 'crisis strategies'
The responses in the next stage 'food crisis' are less reversible as households are forced to use strategies that reduce their productive assets and threaten their future livelihoods.

At this stage, the households or individuals are obliged to develop new strategies to meet their food needs. All surpluses have been sold and all potential for increasing resources by diversification of activities have been exhausted. People have to sell goods that are essential for their future livelihoods. Additionally, economising on health and water resources results in a poor health environment which can be made worse by gradual migration of the skilled and educated of the community (nurses, teachers etc.)
In a food crisis, the prevalence of acute global and severe malnutrition as well as mortality rates associated with them, is elevated. An increased risk of mortality in moderately malnourished individuals can be attributed to a deterioration of the health environment, which increases the risk of infections.

Example of crisis strategies for a settled population

Increase resources:

sale of productive assets (tools, seeds, livestock)
massive slaughtering of livestock
mortgaging of farmland or house
sale of farmland, house, sale of land rights, harvest rights,
exchange of livestock for staple food

Breakdown in social structures:

prolonged migration, men do not return from seasonal migration or are enrolled in armies.
further cuts in use of water, firewood and health services
community structures (mutual help systems) collapse
Skilled and educated people (health staff) migrate
decrease of community funds for funerals and weddings
reduction of support to the non-productive members of households (small children, elderly, disabled)
marginalisation of non-productive individuals, (orphans, beggars, etc.)

Stage 3: Famine: distress strategies
Famine is the last stage of this process. In nearly all cases, it is linked to war and conflict. It is characterised by excess mortality and high malnutrition in all the age groups of the population, complete destitution, social breakdown and distress migration as people abandon their homes in search of food. All coping mechanisms have been completely exhausted. The people are dependent on food aid for immediate survival.
Famine situations can result from inadequate relief assistance during the food crisis stage. Relief assistance has been too little, too late, not well targeted, not well organised or co-ordinated and often diverted. This is frequently linked to serious constraints such as high levels of insecurity or lack of political commitment (at international, national or local level).
The combined effects of insufficient food intake and poor health environment are important factors leading to famine and death among moderately and severely malnourished people. In fact, the majority of deaths (in absolute number) occur amongst individuals who are not severely malnourished. One of the main underlying causes of famine mortality is deterioration in the health environment. In addition to an adequate provision of food, access to curative health care, environmental sanitation and shelter can avert many deaths.

Analysis
An assessment should try to locate a deteriorating food and nutrition situation on the continuum of moving from food security to famine.
The table below helps to determine the stage of the process of moving from food insecurity to famine. Each stage will not necessarily show all characteristics, but the table helps to illustrate which stage a situation has reached and in what direction the situation is likely to develop.

Specific characteristics of food insecurity, food crisis and famine
	Food insecurity	Food crisis	Famine
Mortality rate	Normal	Increased or high	Extremely high
Population movements	Seasonal migration	Population displacement +/-	Distress migration
Global malnutrition rate	could be increased	Increased	Extremely high
Mortality related to moderate malnutrition	Low	Elevated	High
Severe malnutrition rate	Low	Moderate or high	High
severe malnutrition in adults	Low	Low/moderate	High
Livelihood changes	Temporary	irreversible	Complete destitution
Selling of capital assets	none or very limited	Important	Exhausted or very limited
Activity diversification	Normal or slightly increased	Increased +++	Exhausted or limited
Reduction of expenditures	Reduced	Reduced +++	No more possibility to reduce.
Food availability	Normal or slightly decreased	Reduced	Rare or none
Food accessibility	Slightly reduced	Reduced	Severely reduced or none
Dependence on food aid	Low	High or moderate	Complete
Reduction in caring practices	Low	Moderate or high	High

Interventions
Locating a situation on the food security/famine continuum helps identify the most appropriate type of intervention.
In a food insecurity situation the focus of interventions should be on preservation of livelihoods to prevent people sliding into food crisis and famine, e.g. food for work. Early warning systems are crucial at this stage. Support can be given to existing health structures to shore up treatment of individual cases of severe malnutrition.
In a food crisis situation it is crucial to prevent further movement along the continuum by ensuring enough food. E.g. general food distribution. As the social caring systems comes under pressure provisions should be made to support special vulnerable groups, e.g. elderly, orphans, under five's in general. Selective feeding programmes like therapeutic feeding centres and supplementary feeding centres can be installed. Health care systems and water resources may also require support.
In a famine situation, the primary goal is to ensure survival, to reduce mortality. The major focus is on general food distributions, supplementary feeding programmes, blanket feeding, and therapeutic feeding and mortality surveillance.

¹ Inspired by H. Young, S. Jaspars. Nutrition Matters. Intermediate Technology publication, London 1995.

In the next issue Field Exchange there will be a further article based on revisions to the MSF guidelines. This article will elaborate further on choice of nutritional strategies and programme designs in relation to context.

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