Famine Flashcards
Describing or defining famine
Using crude mortality ratios (CMR: Rubin 2014)
1 attributable death/ 10,000/ d = famine
5 attributable death/ 10,000/ d = severe famine
15 attributable death/ 10,000/ d = extreme famine
Using a multi-layered diagnostic tool - IPC (this will be discussed in the seminar)
Causes of famine
- Famines can be man-made or natural but are ALWAYS social phenomena
-> Natural disasters occur relatively frequently but do not always result in famine
-> Natural famines are often connected to climatic change or natural disaster - flood, drought, cyclones etc. - Oversimplified and crude
-However, it is almost impossible for natural famines to exist outside of man-made famines. FAMINE, by it’s very nature, is a social phenomenon and the impact of famine will always depend upon how a society is organised.
- In natural famines - the ‘natural’ phenomenon is usually only one event amongst others such as war, social or political unrest, livelihood disturbance etc.
The ‘Food Availability Decline’ thesis:
will there be enough food everyone? This theory relies on natural disaster being the cause of unequivocal famine. Economically speaking:
food availability = total production + imports - exports
Tackling famine
requires that livelihoods are created and protected - usually through public action.
The ‘Entitlement Approach’
Pioneered by Amartya Sen (1981), Nobel Laureate (economics)
It identifies Endowments and Entitlements which give access to livelihoods and food
Endowments
- Owned assets or personal capacities
- Can establish entitlements, which in turn give command over food
- owned land, labour power, produce that can be sold are all endowments.
Entitlements
- Relationships established by trade, production or sale of labour power
- Direct: food is gained through production (reliant on endowments - land, seeds, tools)
- Exchange: selling one’s own labour power to buy food (reliant on endowments - labour power)
- Trade: selling produce to buy food (which is reliant on endowments - produce - which requires e.g. land, tools, seed, labour power)
Social context of famine
what can be done to help?
Sen’s pioneering economic approach to famine & starvation underpins the modern paradigm
Democracy & free-press are widely acknowledged preventers of famine
->Initially highlighted by Sen
Haan et al. describe these as:
“…critical institutions for establishing a social contract for famine prevention between citizens and the state.” (2012, p77)
“Famine is a catastrophic disruption of the social, economic, and institutional systems that provide for food production, distribution, and consumption. Contemporary famines stem less from crop failure than from the political and financial failures of governments to prevent famine and respond effectively” (Cohen 2017, p657)
Nutritional consequences of famine
Truswell (2012)
- Children stop growing
- Children and adults lose weight
- Starvation causes people to suffer:
hypothermia
weakness
hunger
loss of subcutaneous fat
muscle wastage
↓ pulse
↓ BP
abdominal distension
diarrhoea
infection - pneumonia, TB, typhus
Wasting
(Filteau & Akik 2017)
- Held to indicate recent energy insufficiency (due to poor nutrition and/ or infection)
->Contrary to stunting
->Prone to oversimplification (this terminology is generally deemed confusing)
->Recent severe wasting SAM; ‘clinical wasting’ or ‘baggy pants’
~10% = African children
~14.5% = S. Asian children
~1.2% = European children
WastingUnderstanding Growth Charts
This is a weight for age growth chart for use from birth.
Infants are measured preferably at monthly intervals – especially early on in life.
This chart is a unisex chart which shows the 3rd centile for girls and the median for boys.
The 3rd centile marks the point at which weight is considered healthy for only around 3% of individuals. The median is the 50th centile – the point at which weight is considered healthy for around 50% of individuals.
Growth charts are an easy and useful way of monitoring undernourished children. They can clearly show catch-up growth and growth failure.
In the developing world, however, ageing a child can be much more difficult than it seems. With large families, no central birth register and often no calendars, parents rarely know the exact age of a child.
It is useful to create a local events calendar which may help when ageing children. A local events calendar consists of the exact dates of recent news worthy events in the local area. E.g. newpapers may record the dates of earthquakes, droughts, heatwaves, crop failures, building of new wells etc. You can then ask the parent, was the child born soon after the earthquake last year? etc. and try to age the child from that.
WastingUsing Growth Charts
The first chart shows a child whose growth has faultered around 6 moths of age. This could be due to infection - especially as children often become more active around this time. Sever undernourishment has ensued but by 15 months of age the child has shown a good deal of catch-up growth. The growth line, however, continues below the 3rd centile.
The second chart shows a child who has had a similar onset of undernutrition. In this case, however, the is very poor catch-up growth and the growth failure continues. This child continues to be severely at risk.
Severe Acute Malnutrition (SAM)
(Filteau & Akik 2017, UNICEF 2015)
- Extreme wasting or oedema (kwashiorkor)
~16 mill. children <5y affected by SAM
~2/3 in Asia & 1/3 in Africa
- Major cause of death in children <5y
- 9x more likely to die than well-nourished children
- SAM cases ↑dramatically in emergencies
- Majority of cases occur in DCs not affected by emergencies
- Chronic poverty, lack of education, poor hygiene, limited access to food, poor diets
- Lack of sustainable development
Oedematous SAM (kwashiorkor)
(Truswell 2012, Cohen 2017)
what does it cause to the body…
- Incompletely understood but poor prognosis
Death: due to the severity of the problem, due to relapse, due to late admission to hospital…
Illness: general misery, pain, expense to the family, opportunistic infections…
Diarrhoea: opportunistic infections often cause diarrhoea which in turn leads to even worse dehydration. Diarrhoea can be either acute, persistent or chronic – the last two tend to be due to general malnutrition – which alters the gut lining.
Dehydration: partly due to diarrhoea. Requires urgent treatment – ORT. In kwashiorkor – dehydration causes diminished oedema – the oedema will return upon rehydration.
Infections: Most severely malnourished children have an infection – can be difficult to diagnosed because the PEM may mask some of the classic symptoms.
Hypoglycaemia: Low blood sugar can cause brain damage or death if left untreated.
Hypothermia: develops surprisingly easily. Hypothermia occurs when the body’s temperature drops below 35.5°C. Hypothermia is a very common cause of death in malnourished children.
Anorexia: loss of appetite – common in kwashiorkor or marasmic-kwashiorkor.
Anaemia: caused by iron deficiency or folate deficiency. May also be the result of hookworm or malaria – iron should not be given until the child begins to recover due to its free radical properties.
- prolific ROS production + poor antioxidant status
- disruption of cell membrane permeability (mvt. of K & Na)
- water leaks into extracellular space
- May also involve alterations in microbiome & complications of systemic inflammation
- Relatively rare in Asia now but is still common in African hospitals
Kwashiorkor
Acute condition – may, over the course of a few days become incredibly ill.
Oedematous – classic sign of kwashiorkor – due to retention of sodium and body fluid.
May not show reductive adaptations – stunting/wasting
Low potassium, high sodium - due to the leakiness of cell membranes.
Fatty liver – TAGs accumulate in the liver
Free radical damage – is thought to be partially responsible for many of the feature of kwashiorkor.
Long term consequencesof famine
(Dercon & Porta 2014)
(Ampaabeng & Tan 2013)
Case-study: ‘Live-Aid’ 1984 N. Ethiopia
- Severe drought after frequent severe rainfall failure plus conflict
- Exacerbated by politically driven delays in food aid provision
- Up to 1mill. deaths
Effect of household-level drought shock in children on anthropometrics 20y on
- In utero <36mo at peak of nutritional shock
- 12-36mo at time 5cm shorter 20y with a poss. 5% _ income in adulthood
- May be more likely to be ill in adulthood
Case-study: 1983-4 Ghana
- Effect of childhood famine on adult cognitive development 20y on
- 0<2y Vs. 3<8y at height of food shortages (1984)
- 0-2y at time had impaired adult cognitive development
- on average ~6% lower IQ score
- test performance equates to ~two-fifths to a half year loss of schooling
- 3<8y at time unaffected
How to respond to humanitarian crisis?
UNICEF 2015b
short term = prevent and reduce immediate excess morbidity undernutrition and mortality
long term = development solutions that help build the resilience of communities by protecting and supporting people’s long-term health, nutrition and overall livelihoods
Initial response to famine
crisis
(Bahwere 2006)
- Children 6m - 5y prioritised in food emergencies (WHO guidance)
- more susceptible to malnutrition (higher requirements relative to weight)
- ↑ exposure to infection
- excl. breastfed children <6m are less affected by malnutrition & infection
General Food Rations
- Given to EVERYONE in a population
- Where there is no other source of food, must cover total nutritional requirements (Truswell 2012)
-> E.g. sorghum, wheat or rice + oil + beans or lentils
-> Milk powder for children
-> Clean water - Where this is staple foods only it’s called ‘basic ration’
Complementary Rations
E.g. Lactating mothers
Must complement:
- the general/ basic ration
E.g. herbs, spices, coffee, tea, sugar, oils
- May also include
HEB (high-energy biscuits - BP100) micronutrient enriched 30% fat,14% protein energy (Duggan 2012)
‘Sprinkles’ or ‘Mix Me’
vitamins & iron, zinc, iodine & selenium(Truswell 2012)
Make general rations more nutritionally suitable & diet more palatable
Priorities around famine
Access to adequate diet/general ration
Access to clean water
Immunisation against measles
Vitamin A supplementation if appropriate
Therapeutic Feeding
Can run contrary to the goal of PHC for all
Resource heavy, expensive & highly selective
Relatively low priority even in life-threatening emergency situations
designed for specific, usually nutritional, therapeutic purposes as a form of dietary supplement
Harmful Consequences of Simple Food Distribution
Draws people away from their usual lives & creates unrealistic expectations
Changing attitudes & hinders grassroots development
Depresses local food prices affecting livelihoods
May produce conflict in wider communities or with development agency/authoritarian role
Potential for political manipulation
how to build Resilient populations
Traditional vegetables; managed and wild (Muller and Almedom, 2008)
‘Pocket’ gardening schemes = distribution of fast growing seeds – esp GLVs.
Establishment of markets = to sell local produce – importance of fresh produce.
Herbs & Spices: relieve monotony of staple dependent diets, contains many vitamins and minerals – contribute to a traditional diet.
Lactating mothers: should receive augmented rations.
Supplementary Feeding Programme
Rations given to vulnerable
Wet Feeding
Distributed centrally (controlled consumption)
Opportunities for education/progress monitoring
Dry Feeding
Distributed weekly (convenient/fewer centres required)
May not reach those who require them intact
SFPs aim to provide an extra 500kcal/day
May provide simple medicines
Do not tackle underlying causes of malnutrition
OTP: Ready-to-use Therapeutic Foods (RUTF)
Locally available
High-energy, micronutrient enhanced paste
peanut butter, milk powder, vegetable oil, sugar, vitamin mix & mineral mix
Not full proof product as it could upset the peanut market elsewhere – isn’t widely used
To treat children <5y with SAM
No cooking or prep required
Long shelf-life
Safe
E.g. Plumpy’nut
Typical course for 1 child est. to cost $22-$55 (Duggan 2012)
In 2007, UNICEF expenditure on RUTF was reported to be $18 million (Duggan 2012)
Local manufacture is key to driving down price
Community Theraputic Care principles(Bahwere et al 2006)
Max. coverage & access
Designed to achieve greatest possible coverage by improving accessibility. Aims to reach entire SAM population.
Timeliness
Aims to begin case-finding & treatment before malnutrition prevalence escalates & complications arise.
Appropriate care
Simple, effective outpatient care for those who can be treated at home & clinical care for those who need it.
Care for as long as needed
Improved access allows patients to stay in the programme until recovered. Capacity building & integration ensures treatment remains available as long as AM is present in the population.
Fully evolved CTC system(Bahwere et al 2006)
give priority to overarching humanitarian principles
ensure rapid response for those in immediate need
quickest, most effective means to establish immediate life-saving components, regardless of issues of longer-term sustainability
SUN (Scaling-up Nutrition)
(SUN 2016)
multiple…
Multiple stakeholders
Multiple sectors
Multiple levels
Currently 57 countries
Interventions (UNICEF 2015b)
Launched in 2010
nutrition specific + sensitive
what do they aim to tackle
who are they mainly aimed at?
‘Nutrition-specific’
Aim to ↓ stunting, micronutrient deficiencies & wasting as well as the risk of OW & obesity.
Largely focus on ♀, esp. pregnant & lactating ♀, & 0-2y olds in the most disadvantaged populations
‘Nutrition-sensitive’
Aim to address underlying determinants of undernutrition & future OW & obesity
May serve as platforms for nutrition-specific interventions
Larger focus on preg. And lactating women + first 1000 days children
Reaching the SUN movements strategic objectives
1) expand and sustain an enabling political event
2)prioritise and institutionalise effective actions that contribute towards good nutrition
3)Implement effective actions aligned with common results
4) effectively use, and sig increase, financial resources for nutrition
The future
“At what point does the international community set aside any (tragically) lingering financial or political hindrances to ratchet up its response in scale, comprehensiveness, and urgency?”
(Haan et al. 2012, p75)
In the light that famines are argued to always have a ‘man-made’ component, there is the question of accountability which as yet has not been answered
(Haan et al. 2012; see also Rubin 2014)
Note the difference:
famine as a consequence of commission
deliberately causing food insecurity as an act of war
e.g. in Somalia where key aid agencies were banned [WFP] or ejected [Save the Children etc.]
Prohibited under international humanitarian law
famine as a consequence of omission (failing to prevent famine)
