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Judit Katona-Apte is a Senior Humanitarian Affairs Officer in the Department of Humanitarian Affairs and a Senior Programme Advisor for the World Food Programme in New York.Abstract
Emergency nutrition is a specialization for strengthening the training and research capacities of developing countries to meet nutritional needs during natural and man-made disasters. Efforts are being made to prevent famines, especially those arising from natural disasters. However, there will be less food available in the future, although new emergency situations are developing constantly and lasting longer. It is important to train nutritionists, administrators, policy and decision makers, and others to be able to prioritize food needs and make the best use of available resources. Methodologies, techniques, expertise, and even theoretical frameworks that can be used in training programmes must be developed and strengthened. The paper discusses four areas where expertise in nutrition is weak and could be strengthened through short courses, workshops, and internships: assessment methodologies, monitoring and evaluation, conflict and post-conflict situations, and advocacy.
Institutional capacity-building and training must also include meeting the nutritional needs of populations during disasters. This requires competence in a new specialization, emergency nutrition. Emergency is a relative term: rather than referring to a specific set of conditions, an emergency may be defined as any serious disruption of the functioning of a society that exceeds the ability of an affected people to cope solely by means of its own resources.
There are more than 50 million people in the world who are affected by war or civil conflict and countless others who are affected by floods, droughts, hurricanes, and other natural disasters. A large number of these people depend on external assistance for at least a part of the duration of their displacement. Governments, (national, local, and bilateral), non-governmental organizations, international government organizations, and the United Nations all provide nutritional support to these populations at one time or another. However, without the benefit of appropriately trained nutritional experts, this support is often poorly provided.
Efforts are being made to prevent famines, especially those that result from natural disasters. During the drought in South Africa in the early 1990s, for instance, deaths from famine were averted by a massive shipment of food into the region. At times of conflict, such as the tragedy in the Great Lakes region of Africa, in Somalia, or in the former Yugoslavia, food has been provided to keep populations from starvation.
However, the donor agencies should not become complacent about their ability to provide assistance during emergencies. It is predicted that there will be less food available for such purposes in the future, even though new emergency situations are constantly developing and tend to last longer. These factors present a growing challenge to relief delivery services to provide services both cost-effectively and efficiently. To meet this challenge, it will be necessary to create a critical mass of nutritional experts - administrators, doctors, and others - who are able to assess and prioritize food needs and to make decisions about the best use of available resources. In order to equip nutritionists with the knowledge and skills required to carry out such responsibilities, it is necessary to identify, develop, and strengthen methodologies, techniques, expertise, and even theoretical frameworks that can be used in training programmes.
The first step in positioning ourselves to meet these challenges is to improve existing human resource capacity by initiating specific training opportunities for those already involved in the administration of emergency nutrition services, i.e., policy makers, technical experts, and fieldworkers. Policy and decision makers must be among those targeted for training, because without their informed support, nutritional experts may not be included in emergency teams. It is essential that members of emergency nutrition teams be trained in the skills necessary to define objectives, reach consensus, and carry out effective advocacy.
There are four subject areas in which a working body of emergency nutrition expertise should be developed, which could easily be transmitted through short courses, workshops, and internships: (1) assessment methodologies, (2) monitoring and evaluation, (3) conflict and post-conflict situations, and (4) advocacy. This is not to imply that these are the only areas where nutrition expertise is needed. Programme design and project management, for example, are not addressed here. For the sake of brevity, however, only the above-mentioned subjects will be discussed here.
Nor do I wish to imply that the core of professionals needs to be competent in all of these areas, although this would be ideal. Not every emergency requires the same specific expertise. Rather, individuals who work in the field of emergency nutrition should be aware of the importance of each of these perspectives. If individuals could be trained to become proficient in any of these aspects, this would be a step in the right direction.
During emergencies populations that are dependent on external assistance usually receive food aid. Delivery of appropriate rations is difficult for a variety of reasons (logistics, resource shortages, etc.). Designing those rations in terms of quantities and types of food aid commodities, however, is a task that falls within the domain of nutritionists. There has to be justification for initiating and phasing down food assistance. However, there are currently no training programmes in the methods of assessment for food aid needs or for estimating the levels of food security.
Nutritional requirements, although acknowledged to exist, are not often considered important enough to warrant seeking specific technical input in times of emergency. The number of qualified experts working for United Nations agencies and non-governmental organizations in the area of emergency nutrition is very small. Yet the nutritional well-being of populations during emergencies depends on valid assessments of their food needs and dependence on external food assistance. Such assessments are usually carried out by national governments, United Nations agencies, and non-governmental organizations. These activities, however, do not make use of existing dietary assessment theories, methods, guidelines, or short- or long-term training courses.
The same situation is true of methods for establishing the degree of food security, an indicator for determining when food aid could be phased out. Currently there are no reliable methods or guidelines for these assessments. It is important that these be established, because the availability of food resources is diminishing in comparison to the need for them. Energy experts should be involved in such assessments, but in order to be effective they need to be trained how to design and initiate surveys, analyse the data, and make implementable recommendations.
Monitoring and evaluation
After emergency programmes are implemented, they must be carefully monitored and then evaluated. Emergency nutrition is applied nutrition; we are interested in monitoring the process and the outcome of nutritional intervention as well as the impact on the target population.
In emergencies very large quantities of food commodities are shipped, stored, and distributed. Although it is possible to track the food to distribution points, it is much more difficult to know what happens to the food after it is dispensed: who gets what and how much. It is essential, therefore, to monitor every stage in the movement of food commodities and nutritional outcomes.
Food monitors are often placed in refugee camps to help authorities to be certain that the distributed goods actually reach their targeted destinations. Monitors need to acquire the skills to fulfill the following responsibilities, among others: (1) checking transport and distribution records and other aspects of the food distribution process, (2) determining household-level food availability and consumption, (3) identifying essential inputs for food security interventions, (4) tracking changes in the nutritional status of the population, and (5) identifying those at risk for malnutrition and persuading them to seek assistance. All of these tasks are most efficiently accomplished by persons familiar with the population. Thus, training programmes to improve local capacity (including members of the affected populations) are urgently recommended.
The quantity and type of external food assistance depend on donor perceptions of need and impact. It is important, therefore, to document that training and research programmes, along with proper interventions, do result in reduced malnutrition rates or that they are, at least, successful in the prevention of further deterioration of nutritional status, if that is the objective. Otherwise, future donor response to nutritional needs will decline.
Potential roles for nutritionists in preparedness and post-conflict peace-building
There are important ethical, conceptual, and policy issues to be clarified in the work of nutritionists, who must be able to translate humanitarian principles into actions appropriate to the needs of the victims. One of the dangers of working in emergency nutrition is a tendency to focus on the immediate needs of the victims - perhaps because so much bureaucracy stands between those entitled to receive assistance and its actual delivery. To do this properly requires support of food as a human right and opposition to the use of food as a weapon.
Nutritionists should be on the forefront of negotiations that affect the availability of food to populations during emergencies. They should be trained in methods of improving disaster preparedness, the early warning indicators of impending crises (such as deterioration of the food supply), the art of negotiating for the safe passage of food (as in Sudan and Bosnia), finding resources for victims of natural disaster (such as are currently needed for North Korea), and designing exemption programmes for government-imposed sanctions. Each of these areas of activity requires special skills - including diplomatic and political adeptness - which are not currently included in nutrition training programmes.
During post-conflict peace-building and reconstruction activities, the objectives are to sustain safe and productive livelihoods as well as lives. This requires a long-term perspective, the opposite of the perspective of emergency relief, which is perceived as temporary. Thus, policy makers and planners may not regard nutrition as a priority in their post-crisis endeavours; after all, the immediate danger of death from starvation has passed. However, the inclusion of nutritional considerations in the design of development programmes is important, as the recovering population is still vulnerable and may not be able to cope with the next crisis.
Nutritionists should be active participants in all stages of planning to ensure that government programmes are created that will assess and correct deficiencies and that safety nets are provided for groups vulnerable to malnutrition. It is highly desirable to train nutritionists to communicate and interact effectively with policy makers and planners in order to make convincing arguments for including nutritional concerns in a countrys strategy. In this way they could share the common goal of safeguarding the welfare of the population and improving the quality of life during reconstruction.
It is essential to promote, support, and advance the cause of nutrition if nutrition programmes and considerations are to move forward. When nutrition is not perceived as a priority, it does not receive the prominence necessary to get the job accomplished. This may be because nutritionists do not know how to sell their discipline. Excellent technical capacity and expertise are not enough.
The communication gap between nutritionists and policy makers must be closed. Policy makers require easily understood and implementable recommendations. Nutritionists must be able to prepare documents that also serve advocacy purposes. It is also important that nutritionists be able to convince decision makers that there are structural uncertainties that cannot be solved by simple technical recommendations and that require more extensive input.
Training programmes must, therefore, not only stress technical report-writing skills, but should explore the methods to accomplish the objectives of advocacy. Such skills would eventually help to create a policy environment conducive to incorporating nutrition in a countrys planning strategies.
There is little appropriate training available in the management of emergency nutrition. This deficiency can be met by including additional courses in existing advanced programmes or by creating special courses in universities and institutes. In some areas, such as Africa, because of the frequency of their emergencies and the necessity for capacity-building in preparedness, emergency nutrition programmes should be developed that would strengthen local institutions and train local persons. There is a special need to build up the nutritional capacity of these non-governmental organizations, because such organizations are on the spot and deal with emergencies as they arise. Recipient country governments are the appropriate organizations to carry out the necessary assessments, monitoring, and evaluations, as they have the advantage of being on site and of knowing the local languages, customs, and conditions.
A quick and easy way to improve the level of expertise and communication skills in emergency nutrition would be to develop course modules designed for different sorts of professionals, e.g., policy makers, technical experts, and food monitors. These modules would be used in workshops and/or training courses in a variety of settings. These should then be followed by the establishment of more elaborate and expensive training opportunities, which would offer field and other on-site experience. It is most important to establish emergency nutrition as a specialized field and to provide opportunities for specific training in this area.