Marion E. Wright, BSc, MSc, PhD, RN, RM, RHV
Maija Vesala-Husemann, MSc, RN, RHV, QNT
Many disasters that occur throughout the world remain largely under-reported, frequently because they began a number of years ago, and have become "chronic" or "long term." Yet, in their vulnerability, the affected populations are no less deserving of humanitarian aid than those involved in the more acute, sudden disasters that make a major impact in the media. Aid providers need to direct their efforts at enabling populations to build their capacity and decrease their vulnerability, thus enhancing their preparedness for any future disaster. This article considers the importance of paying careful regard to the vulnerability, capacities, and disaster preparedness of people affected by these long-term disasters. Vulnerability, capacity, and disaster preparedness are examined specifically in the context of food shortages and malnutrition, with particular reference to the long-term disaster in the African country of Kenya.
Citation: Wright, M., Vesala-Husemann, M., (September 30, 2006). "Nutrition and Disaster Preparedness: Focusing on Vulnerability, Building Capacities". OJIN: The Online Journal of Issues in Nursing. Vol. 11 No. 3, Manuscript 5.
Key words: capacities, community development, disaster preparedness, Millennium Development Goals, nutrition, vulnerability
Media appeals for financial and other assistance are often supported by photographs and video clips of severely malnourished infants in therapeutic feeding centres. Behind those dramatic images lie the less obvious and cumulative effects of complex and long-lasting hardship.
The World Food Programme (WFP) focuses on the poorest countries and poorest people and aims to emphasise tackling vulnerability in order to achieve sustainable development. The WFP Strategic Plan for 2004-2007 indicates that vulnerability and resilience must be considered "an integral part of rural development strategies so that years of development gains are not lost when there is a crisis." It also contends that "well-designed risk-management investments that enhance vulnerable people’s ability to cope with risks can have important longer-term impacts on productivity and efficiency" (World Food Programme, 2003, p. 6).
Vulnerability and capacity can be viewed from psycho-social and economic perspectives and are not merely physical attributes. Webb & Harinarayan (1999) use the following formula to illustrate that different households deal with hazards in different ways, depending on their coping capacity: V (Vulnerability) = H (Hazards) – C (Coping). This capacity is influenced by factors such as prior experience, access to information, and cultural norms.
Humanitarian aid organisations must take account of potential expertise and contribution from within affected populations...
In a disaster, vulnerability will be influenced by the nature, extent, and time-scale of the disaster and the community’s capacity to cope, that is to "use available resources and abilities to face adverse consequences" (United Nations/International Strategy for Disaster Reduction [UN/ISDR], 2004, definition 7). Addressing vulnerability and capacity (to cope) aims to increase disaster preparedness, that is the measures taken in advance to help ensure effective response to the impact of hazards (UN/ISDR, 2004).
During the last 30 years there has been an increase in the number of complex, humanitarian emergencies, with food insecurity problems compounded by political hostilities. These have led to many developments in emergency public health and have highlighted the importance of the interaction between vulnerability, capacity, and preparedness. Individuals, communities, and countries face various challenges in different ways; some seem well able to cope with adverse situations and overcome them, and others are completely overwhelmed. This suggests that more careful study is needed of the complex interactions among the nature and extent of the disaster itself, the contextual variables within the community, and the individual characteristics of those affected. These interactions are of particular relevance to all who work in the area of disaster relief, including the national and international organisations providing humanitarian assistance.
The Office of the United Nations High Commissioner for Refugees (UNHCR) was established in 1950, and mandated by the United Nations to "lead and coordinate international action for the world-wide protection of refugees and the resolution of refugee problems" (UNHCR, Mission Statement, paragraph 1). In its key role in coordinating the work of many organisations involved in providing assistance to refugees and the governments of host countries, UNHCR provides international standards guiding policy for complex, humanitarian assistance. An example is their Handbook for Planning and Implementing – Development Assistance for Refugees (DAR) Programmes (UNHCR, 2005). Access is also provided to nutrition guidelines such as The Management of Severe Malnutrition (WHO, 1999) and the 1995 Médicins Sans Frontières (MSF) Nutrition Guidelines. Publications also include reports, such as the report entitled, "The State of the World's Refugees 2006" (UNHCR, 2006). UNHCR standards focus more on populations who have had to flee their own countries (externally displaced persons, or refugees). Those who have been displaced within their own country, internally displaced persons (IDPs), will be the focus of this article.
...communities need to be enabled to mobilise as much of their own strengths as possible.
The Sphere Project (so named to convey the sense of universality of this initiative), launched in 1997 by the Red Cross and Red Crescent movement and several non-governmental organisations (NGOs), aims to improve the effectiveness and accountability of humanitarian assistance. Their Humanitarian Charter and Minimum Standards in Disaster Response set standards in several areas including provision of shelter, safe water and sanitation, and food security (The Sphere Project, 2004).
Humanitarian aid organisations must take account of potential expertise and contribution from within affected populations and help offered must be culturally appropriate and acceptable. Otherwise their programmes may be limited in time and effectiveness. An understanding of vulnerability and capacity are fundamental to the argument that communities need to be enabled to mobilise as much of their own strengths as possible. In this way disaster preparedness and community development are inextricably linked. Throughout the world nurses are undertaking important work in disaster relief and community development, and have key roles in helping communities to mobilise expertise to heal themselves. In this article, the need to address underlying vulnerability and build capacity for disaster preparedness will be discussed in the context of chronic food shortages. The food shortage in Kenya will illustrate principles for building capacity which are explained in this article.
Vulnerability, Capacity, and Disaster Preparedness
In this section, the concepts of vulnerability, capacity, and disaster preparedness, and the relationships between them will be reviewed. In addition, the concepts of complex emergency and early warning systems will be discussed. In this context, the basic definitions found in the collection of agreed terminology by the United Nations International Strategy for Disaster Reduction (UN/ISDR, 2004) are helpful. So also are definitions available in the World Health Organization training package on definitions for work in disasters and emergencies (WHO, 2002).
In the disaster reduction context, vulnerability has been defined as "the conditions determined by physical, social, economic, and environmental factors or processes, which increase the susceptibility of a community to the impact of hazards" (UN/ISDR, 2004, definition 42). WHO (2002) defines vulnerability as "the predisposition to suffer damage due to external events" (p.14). Throughout this article the term "vulnerability" will be used rather than "susceptibility," a term meaning "exposure to danger" (WHO, 2002, p.15) which in itself does not imply that disaster will automatically follow.
Recognising and understanding vulnerability in the context of disaster preparedness are fundamental to attempts at appropriate capacity building and long term recovery. Emergency aid, such as general food supplies, delivered by agencies outside the affected community, may be crucial at certain stages of the disaster management process. However, the content of the food rations and the manner of delivery may not always be culturally appropriate or acceptable; and aid cannot, and should not, be provided indefinitely. To enable affected communities to take steps towards self-sufficiency, international and non-governmental aid organisations need to be listening to the local community. Hoffmaster (2006) expressed the thought-provoking contention that our responses tend to focus on what we are doing for the person, rather than on persons and their vulnerability in themselves. This thought is as relevant in relief work as it is in nursing homes, which was the context about which Hoffmaster wrote. Understanding the key vulnerabilities that have contributed to the disaster in the first place should help those who provide assistance to pinpoint why the community is unable to cope and then to try to ensure that those gaps in coping ability are targeted.
It is important to understand the root causes of poor health, for example malnutrition and susceptibility to infection, especially in situations in which there are high rates of childhood mortality. This poor health is caused not simply by food shortages and large increases in population, but also by inequitable food distribution, which may in turn be influenced by social and political structures within countries (Dwyer, 2003). It is not difficult to see how global inequalities in health and also in vulnerability, capacity, and levels of disaster preparedness may result.
Webb & Harinarayan (1999) draw attention to the danger of making generalisations. There may not be a uniform level of vulnerability throughout an entire country, or across a continent. Despite the overall trend for the most vulnerable to be women and young children, this does not mean that all women and children are vulnerable. Nor does it mean that no one in other population groups is vulnerable. Studying trends in vulnerability over time is important as these may vary dynamically through the disaster continuum, from the acute onset where the focus is on rapid response to the rehabilitation period which is more akin to community development.
According to UN/ISDR (2004), preparedness refers to "activities and measures taken in advance to ensure effective response to the impact of hazards" (defintion 29). This includes the use of early warnings and measures to evacuate people from areas that might be affected. The WHO (2002) definition of preparedness is "the measures that ensure the organized mobilization of personnel, funds, equipment and supplies within a safe environment for effective relief" (p.21). However the extent to which vulnerability is addressed by building a community’s capacity is a key factor in determining its disaster preparedness.
Initially the concept of preparedness seems to be clear. As defined by Merriam-Webster OnLine (n.d.), it is "the quality or state of being prepared; especially: a state of adequate preparation in case of war." Depending on how, or in which kind of context, the term "preparedness" is used, however, it is evident that there could be different areas of focus. When the term refers to being prepared for a disaster, the meaning then becomes more specific and, underlying it, is our understanding of the term "disaster."
There are various definitions of disaster. WHO (2002) defines disaster as "an occurrence disrupting the normal conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of the affected community" (p.3). The definition by UN/ISDR (2004) is "a serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community or society to cope using its own resources" (definition 9). The UN/ISDR further explains that a disaster results from "the combination of hazards, conditions of vulnerability, and insufficient capacity or measures to reduce the potential negative consequences of risk" (definition 9). From these definitions the concept of "disaster" can be contrasted with that of "hazard," defined by WHO (2002) as a "natural or human-made event that threatens to adversely affect human life, property or activity to the extent of causing a disaster" (p.11).
The above definitions of disaster include the elements that, according to Perrin (1996, p. 342), are essential in defining disaster:
- the idea of a phenomenon that threatens a population or an environment
- the idea of a vulnerability of the population or system
- the idea of the failure of local resources to cope with the problems created by the phenomenon
Although it is obvious that all these elements have to be taken into account in considering preparedness, it is useful to examine how emphasising one or more specific elements of disaster more than others highlights different aspects of "being prepared." When preparedness is directed towards the threat of a specific phenomenon, like an earthquake, flood, or famine, knowledge gained from experience of comparable situations should be of value. Underlining the concept of vulnerability in disasters enables us to focus on the various questions and challenges for which preparation is needed, such as identifying the vulnerable groups AND the economic, ecological, or environmental vulnerabilities of communities. However, accounts of disaster experiences have also shown how complex the root causes of the vulnerability are, how difficult it is to focus specifically on these causes in acute phases of disasters, and how long it takes to bring about changes.
...earthquake resistant buildings were designed that were largely able to withstand a subsequent earthquake the following year.
According to UN/ISDR (2004), capacity is "a combination of all the strengths and resources available within a community, society or organization that can reduce the level of risk, or the effects of a disaster" (definition 4). This includes physical and human resources as well as leadership and management. WHO (2002) indicates that capacity for emergency management consists of "information, authority, institutions, partnerships" and the "plans, resources and procedures to activate them" (p.19). Enabling communities to increase this capacity is a major concern in the area of disaster preparedness. "Capacity building" is a frequently used term in disaster and nutrition literature. It describes efforts to develop "human skills or societal infrastructures within a community" to "reduce the level of risk," and can also include developing financial, political, and technological resources in the society (UN/ISDR, 2004, definition 5).
The essential meaning of the local capacities of the affected population is evident both in the immediate response to disaster and in the recovery and development processes. The affected community itself possesses knowledge about local needs and capabilities. The role of outside organisations is not to take over unnecessarily but to enable the community, thereby increasing their capacity to take control over their decisions. This may involve provision of resources, information, and training, with a view to building long-term capacity and not just coping with immediate issues. It is illustrated by the following cases described in the 2003 World Disasters Report (International Federation of Red Cross and Red Crescent Societies, 2003a; 2003b), which focused on ethics, particularly in Chapter 2: Building capacity – the ethical dimensions.
Consideration needs to be taken of resources available, and possible conflicts between the priorities of agencies and those of the community.
In India, the best responses found in recent evaluations of disaster mitigation, occurred when outside agencies already had in place, or rapidly set up, strong partnerships with local non-governmental organisations (NGOs). In Peru, the Intermediate Technology Development Group, an international NGO, worked on provision of suitable shelter following the 1990 earthquake. In collaboration with the local population, earthquake resistant buildings were designed that were largely able to withstand a subsequent earthquake the following year. An example of strong local pressure to prevent further mortality from starvation comes from Malawi. In 2002, following failure of international early warning systems to identify nutritional vulnerability due to poor access to food, the Malawi Economic Justice Network (MEJN), a network of church, development, and human rights groups, used local mortality and malnutrition data to highlight the problems. With the help of local media this information was presented to donors and the government until there was acknowledgement that the country was facing famine (International Federation of Red Cross and Red Crescent Societies, 2003a).
Lasting change may take many years to achieve and aid agencies need to be realistic in their objectives. Consideration needs to be taken of resources available, and possible conflicts between the priorities of agencies and those of the community. It is unethical to impose externally designed projects or to commence ambitious plans, only to withdraw while the work is still uncompleted, leaving the community in a worse state than before. It may be preferable to focus on a specific aspect of the immediate causes of vulnerability with a project that has a more realistic chance of being completed. Capacity building needs to be fostered, and the community enabled to progress to a position of greater preparedness for future eventualities. Unless the underlying vulnerability and its relation to disaster preparedness is addressed this process cannot take place.
Complex Humanitarian Emergencies
Increasingly, food insecurity and malnutrition are found in situations where there is political instability, civil conflict, and population displacement. In such situations, there are general safety and food access problems for the community, and delivery of food aid is difficult and dangerous. These situations are referred to as "complex humanitarian emergences," or "complex emergencies." Salama, Spiegel, Talley, & Waldman (2004) describe them as "situations in which mortality among the civilian population substantially increases above the population baseline, either as a result of the direct effects of war or indirectly through increased prevalence of malnutrition and/or transmission of communicable diseases, particularly if the latter result from deliberate political and military policies and strategies (national, subnational or international)" (p.1801).
Most mortality associated with complex emergencies, especially in developing countries, tends to be among infants and children under 5 years. Most of this is due to malnutrition, diarrhoea, and malaria, all preventable conditions (O’Connor, Burkle, & Olness, 2001). The International Rescue Committee has reported that between 1998 and 2000 in the eastern Democratic Republic of Congo, during one of the worst recent complex emergencies in Africa, there were 2.5 million excess deaths. Of these, 14% were due directly to violence. Most of the remainder were caused by malnutrition, diarrhoea, and febrile illnesses, mostly malaria (Roberts, 2001).
According to Salama, Spiegel, Talley, & Waldman (2004), two new areas of work have emerged during the past three decades as a result of complex emergencies. These are public health nutrition and emergency public health. Young, Borrel, Holland, & Salama (2004) have provided a comprehensive overview of the background to, and assessment and management of, nutritional problems following complex emergencies.
Early Warning Systems (EWSs)
Early warning is "provision of timely and effective information, through identified institutions, that allows individuals exposed to a hazard to take action to avoid or reduce their risk and prepare for effective response" (UN/ISDR, 2004, definition 12). The United States Agency for International Development (USAID) Famine Early Warning System provides useful information about food security situations throughout the world. It issues alerts to decision makers, helping in preparedness and response (USAID FEWS NET) www.fews.net/ . Whether national or international, effective EWSs facilitate a specific sequence of events. The hazard is identified, understood, and mapped. Impending events are forecast and monitored, and understandable warnings disseminated to the population and those in authority. Finally, appropriate and timely action is undertaken in response (UN/ISDR, 2004).
Indictors need to help aid organisations gauge the seriousness of impending disaster and decide when best to intervene for maximum effectiveness.
It should be possible to predict all types of disasters using EWSs, by indicating preliminary signs of conflict or indicators of natural disasters, for example earthquakes (Perrin, 1996). In reality most EWS trials have been in the area of drought prediction, possibly due to its slower onset and the large numbers of people potentially affected. Indicators need to help aid organisations gauge the seriousness of the impending disaster and decide when best to intervene for maximum effectiveness. Food security early warning requires indicators that yield information on rainfall, state of crops, market prices, migration of workers, population movement, and changes in nutritional status, and mortality rates (Perrin, 1996).
Possible intervention strategies need to be planned and ready, and must start before any population displacement begins, that is, when the EWS is beginning to indicate the impending crisis. Once migration starts the situation is usually already serious. In addition to food security problems are the problems of maintaining children’s immunisations, managing chronic illnesses, and obtaining obstetric and other health care.
Sometimes EWSs can be ineffective. Crop information may be too general, for example regional satellite information that cannot be accurately applied locally. Resources may be unavailable if governments consider EWSs low on their priority list or refuse to acknowledge the findings of an EWS. There may also be reluctance to authorise intervention programmes on the basis of warnings rather than in response to actual disasters. EWSs have sometimes been ineffective because they have focused on a few very specific indicators. In Niger in west Africa, in 2004/2005, food security EWSs focused on rainfall and food production, with little or no information about malnutrition rates. Yet by summer 2005, it was clear that malnutrition had reached epidemic proportions, with the rate of mortality for children under 5 years at 259 per 1000 live births, being the third highest in the world (Defourny et al., 2006).
Malnutrition and Nutrition-Focused Responses and Preparedness
Nutrition and health are inextricably linked, so the multi-factorial influences on nutrition ultimately affect health. Malnutrition is characterised by dietary inadequacy sufficient to compromise resistance to disease, and is commonly associated with complex emergencies. It normally, but not exclusively, presents as under nutrition, and is a leading cause of mortality. It may be "primary," due to lack of food, or "secondary," associated with diseases that affect ability to eat, digest, and absorb food, and to metabolise nutrients (Golden, 1996).
Poor nutritional status leads to lowered immunity and thus to increased morbidity from infectious diseases such as measles, malaria, or tuberculosis.
The disease/nutrition cycle, which affects infants and young children in particular, is discussed by Bellamy (1997). Poor nutritional status leads to lowered immunity and thus to increased morbidity from infectious diseases such as measles, malaria, or tuberculosis. If further deterioration in nutritional status, through inability to eat and/or malabsorption, is not treated by nutritional intervention and medical care, this cycle continues ultimately leading to death. In complex emergencies an immediate concern is to ascertain the level of malnutrition in the population. As nutritional status in children under 5 years responds rapidly to acute food shortages, high levels of malnutrition in this age group usually indicate acute malnutrition in the overall population.
Affected children present with marasmus (severe wasting), kwashiorkor (where oedema is a key feature), or a combination (marasmic kwashiorkor). As well as "protein energy malnutrition" (PEM), there may be micronutrient deficiencies in the population. These are associated with increased morbidity and mortality, but can usually be treated easily. Vitamin A deficiency is associated with night blindness, ocular damage, and lowered immunity, especially to measles. Iron deficiency anaemia can lead to cognitive impairment in children and, in pregnant women, risk of delivering low birth weight infants. In many developing countries lack of iodine in the soil leads to goitre, stillbirth, miscarriage, and brain damage in children. The body requires adequate stores of micronutrients to prevent deficiency in times of crises such as food shortages or trauma. This is best achieved by providing foods that are rich in nutrients or fortified food. Deficiencies can be also treated using supplements of the micronutrient in the appropriate amount (WHO, 2000).
Guidelines for the identification and management of malnutrition have been published by various international and non-governmental organisations. These include Médicins Sans Frontières (1995), the World Health Organization (WHO, 1999 and WHO, 2000), and UNHCR/UNICEF/WFP/WHO (2003). In addition, food security, nutrition, and food aid are included in the minimum standards set by The Sphere Project (The Sphere Project, 2004). Some of these guidelines are described below as this section addresses the identification of food insecurity and malnutrition, nutritional interventions, community-based therapeutic care, and food security.
Identification of Food Insecurity and Malnutrition
Identification of food insecurity and malnutrition normally commences with a rapid assessment of the general situation (MSF, 1997). Interviews and focus group discussions are carried out with members of the general population, as well as community leaders. This should be followed up by observations, for example of food items people are purchasing or collecting from food relief centres. Together with other local information, such as estimated population size, possible increases in illness and death, and information about water, sanitation, and food crops, it may be possible to gauge if there needs to be a further investigation of the nutritional situation.
Overall nutritional status of a population is normally estimated by surveying (using cluster sampling) children aged 6 to 59 months. Anthropometric measurements and demographic information are obtained. Oedema, especially around the ankles, is an important clinical indicator. The index "weight for height" (WFH) is most commonly used to detect acute malnutrition (wasting) in surveys. It compares weight with the median weight of a sample of children of the same height. To date, United States National Centre for Health Statistics/Centers for Disease Control and Prevention reference tables adopted by the World Health Organization (WHO, 1987) have been used, but recently launched WHO Child Growth Standards provide a new international standard (WHO, 2006). Where large numbers of children have to be screened, mid-upper arm circumference (MUAC) can be used to identify wasting. MUAC measurements <11.0 cm are indicative of severe acute malnutrition and are of value in predicting mortality (The Sphere Project, 2004). WFH less than 70% of the median and/or oedema indicates severe acute malnutrition.
Alternatively Z scores may be used, where the WFH is expressed as the number of standard deviations below the median. Thus a Z score of < -3 and/or oedema indicates severe acute malnutrition (Young, Borrel, Holland, & Salama, 2004). Moderate acute malnutrition is indicated if the WFH is between 70% and 80% of the median, or between -3 and -2 Z scores. The term "global acute malnutrition" (GAM) refers to the total number of children with severe acute malnutrition plus those with moderate acute malnutrition, that is all those with WFH < 80% of median, or < -2 Z scores. WHO has set emergency thresholds, above which nutritional intervention is indicated for the population. A critical situation is reached when over 15% of the children surveyed have global acute malnutrition.
Trends in mortality are important in the interpretation of nutrition data. Crude mortality rate (CMR) is the number of deaths in the population, for example per 1,000 per month, or per 10,000 per day. A doubling of CMR above the baseline indicate a public health emergency (The Sphere Project, 2004).
Delayed growth in both height and weight, "stunting," can be found in situations of chronic malnutrition. In this case, weight for age (WFA) may be a preferred indicator. MUAC has also been used to identify malnourished adolescents, and adults including pregnant women, in need of admission to feeding programmes. A MUAC of <20.7cm indicates severe risk (The Sphere Project, 2004).
...cultural acceptability of the food ration...must be considered.
Nutritional Interventions fall into two main categories: general feeding programmes and selective feeding programmes (WHO, 2000). General feeding programmes, designed to meet the needs of the overall population, should adhere to the minimum standards set by The Sphere Project (2004). They should provide for an average daily energy requirement of 2100 kcals, where the ration is the sole food source. More will be required where malnutrition is present, heavy physical work is being carried out, or at low atmospheric temperatures. Supplies are provided preferably as dry food rations, the basic commodities being cereals, pulses, and vegetable oil, to be prepared at home. As a short term measure, rations may be provided as cooked meals. Factors, such as cultural acceptability of the food ration and the choice of suitable foods, must be considered. There are many challenges in ensuring fair distribution of food aid. Food aid targeting should help identify the most vulnerable areas and households. This requires the use of various indicators, such as health status and food security, in addition to nutritional status (Young, Borrel, Holland, & Salama, 2004).
Selective feeding programmes aim to ensure that individuals in specific vulnerable groups receive adequate nourishment. There are two types: supplementary feeding programmes (SFP) and therapeutic feeding programmes (TFP). The former are concerned with groups such as pregnant and lactating mothers, and moderately malnourished infants and children. They are designed as a "safety net" to prevent further deterioration of nutritional status and reduce mortality. As far as infants are concerned the aim is to encourage breast feeding, if possible.
Therapeutic feeding programmes target the severely malnourished, particularly infants and young children.
For older children and adults, in addition to the general food ration, the SFP supplies an extra 1000-1200 kcal/ person/day (dry rations), or 500-700 kcal/person/day (cooked meal).
Therapeutic feeding programmes target the severely malnourished, particularly infants and young children. These patients are critically ill on admission with high rates of mortality in the first few days. The priority in the acute phase (days 1-2) is treating dehydration, infections, hypoglycaemia, fluid and electrolyte imbalance, and hypothermia. If the infant is being breastfed this should be continued. A starter formula, such as F-75, which is low in protein and sodium and supplying 75 kcal/100ml, should be given in small amounts, initially every 2-3 hours, if necessary through a naso-gastric tube. Once the child’s appetite has returned (usually after 2-7 days), several weeks of rehabilitation follow. F-75 is gradually replaced with F-100 (100 kcal/100 ml) and micronutrient supplements are given, for example vitamin A. The child’s need for social contact, stimulation, and play must not be forgotten. When possible children should be discharged to the care of their own families with weekly monitoring at the feeding centre (WHO, 2000).
Community-Based Therapeutic Care
New methods of therapeutic feeding have led to an increase in community-based therapeutic care (CTC). Ready-to-use therapeutic foods (RUTF), available as energy-dense pastes or biscuits, are resistant to bacterial growth, unlike milk-based liquid products. This has made it easier to care for moderately malnourished children at home (Briend et al., 2005) thus reducing the numbers of children in feeding centres. According to Young, Borrel, Holland, & Salama (2004) this leads to increased access to treatment and possible reduction in cross-infection.
RUTF can also be used in non-emergency situations (Briend et al., 2005). By preventing moderate malnutrition from becoming severe it could play an important role in disaster preparedness. So far most of these foods are imported into the affected area, but there are trials of production of RUTF pastes using locally available grains and legumes, as in Malawi (Collins et al., 2005). Encouraging local initiatives in RUTF production, as well as involving community expertise in CTC implementation, afford opportunities to reduce vulnerability, build community capacity, and increase disaster preparedness.
Addressing Food Security
Nutritional interventions should not result in the community becoming dependent on outside help indefinitely, so rehabilitation is an important component in any programme. Normal food production needs to resume as early as possible. Advice may be required from experts in agriculture and food production, for example with a view to using sustainable methods of food production, or for specific advice to counter soil mineral depletion. The Sphere Project outlines several key indicators designed to ensure that primary food production is protected and supported. It is important that new technologies are only introduced if the "implications for local production systems, cultural practices and environment are understood and accepted by food producers." In addition, inputs and services introduced must not "exacerbate vulnerability" for example by "increasing competition for scarce natural resources or by damaging existing social networks" (The Sphere Project, 2004, p. 124).
Projects involving cash or food in exchange for work can help the community...
Where it has been essential for the affected population to move to a new location, land and resources (tools and seeds) to re-establish food production, and access to markets are necessary. Any host population already living in the new locality must be informed and involved in decision making, and an increase in numbers living in the area may mean that extra services and facilities have to be provided (WHO, 2000).
Projects involving cash or food in exchange for work can help the community, not only financially and nutritionally, but by increasing self-reliance. They can lead to infrastructure improvements, such as the rebuilding of roads and bridges, improvements in irrigation and drainage, tree planting, and building health posts and schools. Disadvantages may include a possible negative impact on the health of children whose mothers are enrolled in food for work schemes (WHO, 2000).
Although it may fit more readily into the fields of agriculture, food production, and economic or social policy, rather than health care or nursing, addressing food security is still relevant here. It represents ways in which communities can address their own vulnerability and build capacity for nutritional preparedness as they are enabled to mobilise their own resources.
The concepts of vulnerability, capacity, and disaster preparedness will be illustrated in the following section. This will be particularly related to nutrition preparedness and reference will be made to malnutrition and chronic food insecurity in the African country of Kenya.
Long-Term Food Insecurity and Malnutrition: A Current Example
Nutrition-related vulnerability, capacity, and disaster-preparedness can be illustrated by a situation that was the focus of media attention in 2005/2006. While many disasters have been acute, many more could be described as "long term" or "silent." That is, they have continued over many years, sometimes fluctuating in severity, but never fully resolved. One such disaster, involving food insecurity and nutritional problems, affects the Horn of Africa, an area in the northeast section of Africa which includes northern Kenya, southern and eastern Ethiopia, and southern Somalia, as well as Djibouti. In this article the particular focus will be Kenya.
Nutritional needs of mothers are unlikely to be met if they cannot first meet those of their children.
In Kenya the estimated number of people most affected by malnutrition is 3.5 million. Yet this is a country of extremes. In quick, general searches for information about Kenya, most information provided describes its tourist attractions, rather than its problems of poverty and malnutrition. Chronic food shortages have been magnified due to drought and poverty, and political and government problems; and the greatest need seems to be in the remote rural areas. A drought EWS was introduced some 10 years ago in Kenya, but lacked resources for an effective response mechanism. Oxfam has requested the government of Kenya and international donors to provide support for a National Drought Management Contingency Fund (Oxfam, 2006).
That children and pregnant women are among the most vulnerable is borne out by recent surveys carried out by UNICEF in Kenya. These revealed high malnutrition rates in children and pregnant mothers especially in pastoralist areas (Bonham Carter, 2006). In the three remote areas surveyed the rates of malnutrition (global acute malnutrition) for children ranged from 18% to 31%, clearly exceeding the 15% emergency threshold considered by WHO to indicate a critical situation. Rates of malnutrition among pregnant women were also high, ranging from 29% to 60%.
It is not difficult to see how the effects of this malnutrition on child health, growth, and development outlined earlier could well be consequences. Also, the nutritional status of the women may well have been compromised through ignoring their own needs to meet those of their children. The levels of malnutrition reported in these rural areas of Kenya indicate an urgent need for general food rations for the whole community. In addition, the women and children would require supplementary feeding programmes to ensure their extra nutrient requirements are met. The severely malnourished need intervention in therapeutic feeding centres.
...outside agencies must consult local knowledge before introducing change.
Longer-term issues in food security affecting capacity and preparedness of the community for future crises need to be addressed. In the article by Cohen (2005), the situation in Kenya illustrates the complexity of these food security issues. "Food security depends principally on three variables: availability of food, access to food and a nutritious diet, and proper use of food to ensure maximal nutrition and hygiene" (p. 775). These variables are influenced by other factors, particularly poverty. In turn, this is influenced by access to pasture, the infrastructure (transportation and communication), population growth, conflict, environmental and climatic factors, and by economic factors (national and international). Other factors include opportunities for appropriate training and job skills and the quality of public health and health care provision (Cohen, 2005).
Over much of rural Kenya, those at greatest risk of food insecurity are pastoralists, who move from place to place in search of suitable pasture for their cattle or goats. There are reports of families going for three to four days each week with no food and being unable to provide milk for their children, due to poverty and/or unproductive dairy animals (Bonham Carter, 2006). Nutritional needs of mothers are unlikely to be met if they cannot first meet those of their children. Settling in one place might seem to offer some sort of solution, but it is essential to consider the cultural and other values underpinning the lifestyle of the community involved. Understanding their perspective and providing appropriate help, such as mobile health care and education, would go some way towards enabling them to maximise their potential. In this way they may be enabled to obtain and also market food from their own dairy sources and become more economically stable.
Some food security capacity building initiatives, including cash for work or food for work projects funded by NGOs, enable communities to build up their assets by working on specific projects. While these may increase the level of preparedness of the community for future food shortages, they need to be appropriate for the local agricultural environment and culture. An unsuccessful project among the Turkana, a pastoralist tribe in north west Kenya, has been described by Cohen (2005). It involved planting a drought-resistant shrub, Prosopis, that unfortunately proved harmful to livestock and humans and compromised security as it provided cover for cattle raiders. This experience illustrates that outside agencies must consult local knowledge before introducing change. Successful cash for work projects will not impose solutions but will enable communities to prioritise and make their own decisions.
Among the Turkana, NGOs have asked vulnerable communities to nominate the most vulnerable members for work programmes, usually people with many dependents, single mothers, and those with no livestock. Projects have included building a water pan to collect and store rain water and erecting fences to prevent cattle raids (Cohen, 2005). Conflict with nearby ethnic groups is a major factor in food insecurity. A local measure to combat this among the Turkana has been establishment of a local peace building group with a key role in negotiating access to land. A market place has been set up to aid the local economy and help reduce poverty, although poor road access is still a problem. Thus there is evidence of community involvement in projects that can help build capacity for nutrition preparedness.
...measures to raise disaster preparedness must go hand in hand with emergency provision.
Challenges certainly exist and need to be addressed, and change may only come about slowly. The intention of cash for work projects is to provide for long-term development by allowing people to build up their assets. However these long-term development needs may be side-tracked and the money used for urgent current food requirements. There needs to be a twin-track approach, providing food aid as well as cash for work (Cohen, 2005), especially in the early stages. This may help to ensure that resources aimed at building capacity are not diverted to emergency provision. Thus measures to raise disaster preparedness must go hand in hand with emergency provision.
Workers on some agricultural projects may find that the main beneficiaries turn out to be the owners of the land they have worked to improve. This can increase financial inequalities and resentment. Working in the programmes may also mean women spend less time looking after their younger children, leaving them in the care of their older children (Leathers & Foster, 2004). This may indicate the need to provide on-site help including facilities where the mother may feed her child. WHO (2000) states that support of breastfeeding and attention to the nutritional needs of under 5 year olds must be included in such programmes.
Educational programmes can also help build capacity, for example by providing knowledge and skills in management, marketing, economic investment, and opportunities to diversify by developing other skills. Education is needed for adults, as well as children, in literacy and health issues. Education for health workers, including nurses and traditional birth attendants, is provided in Kenya by organisations such as Oxfam, preparing them to carry out health promotion, recognise diseases, and refer patients (Cohen, 2005). This should help build capacity, for example through more informed health workers and mothers.
These examples from Kenya illustrate some of the issues that are key to understanding the concepts of vulnerability, capacity, and disaster preparedness related to nutrition.
In trying to raise the level of disaster preparedness, it is important to consider whether the focus should be on preparedness for a specific phenomenon or on vulnerability reduction. To focus on vulnerability means to focus on people and their communities, both their problems, and resources - those that are available as well as those that are lacking.
The aim of the UN Millennium Development Goals, launched in 2000, is to reduce that vulnerability at a global level (www.un.org/millenniumgoals/). The role of the UN in strengthening public health capacities in order to reach the goals is obvious. However Kent (2004) argues that "in terms of refocusing its role, the UN should pay far greater attention to the less-dramatic arena of vulnerability reduction where the real hope for future generations lies" (p. 225). The first of the eight goals is to eradicate extreme poverty and hunger. The strategic plan of the United Nations World Food Programme (WFP) aims to contribute to meeting the Millennium Development Goals through food-assisted interventions. Two out of their five strategic priorities focus on acute crisis situations and saving lives and protecting livelihoods (World Food Programme, 2003).
Recognition of the vulnerabilities and capacities of disaster-affected populations is written into The Sphere Project’s Humanitarian Charter and Minimum Standards in Disaster Response (The Sphere Project, 2004). Even with these standards, achieving the Millennium Development Goals will take a great deal of work and commitment by international, national, and non-governmental organisations, as well as by those who are able to help financially or by giving their time to assist. As United Nations Secretary-General, Kofi Annan, said in relation to the target of reaching them by 2015:
We will have time to reach the Millennium Development Goals – worldwide and in most, or even all, individual countries – but only if we break with business as usual. We cannot win overnight. Success will require sustained action across the entire decade between now and the deadline. It takes time to train the teachers, nurses and engineers; to build the roads, schools and hospitals; to grow the small and large businesses able to create the jobs and income needed. So we must start now. And we must more than double global development assistance over the next few years. Nothing less will help to achieve the goals. (UN Millennium Development Goals).
This is an enormous challenge especially when we remember that, while acute catastrophes and wars make dramatic media headlines, chronic and partly forgotten disasters receive comparatively little attention. Yet they continue to affect the lives of millions. In the disasters discussed in the World Disaster Report for 2000, which had public health as its theme, the preparedness of the affected people or communities was compromised by their enormous vulnerability. As this vulnerability presents itself in various ways in the different phases of disasters it is clear that disaster and development are overlapping and interactive (International Federation of Red Cross and Red Crescent Societies, 2000).
Many problems faced by communities living with long-term disaster, their vulnerability and need for capacity building to improve disaster preparedness, are the same issues and needs that are found in community development situations. They are the issues faced by local populations and the development workers who are trying to facilitate them. These are huge challenges for the people themselves and also for nurses and other health workers who are prepared to listen carefully to those who are suffering these "Silent Disasters" amid a world of plenty.
The transition from receiving relief aid to community development can be difficult.
A key issue in nutrition and disaster preparedness is that development of capacity in vulnerable populations and disaster management must go hand in hand. Food aid and feeding interventions from outside have been vital in disaster management and have made a difference, but these need to be coupled with a development approach. This is true in situations, such as in Kenya, where food insecurity has been of long duration.
The transition from receiving relief aid to community development can be difficult. Agencies may withdraw their personnel and resources, leaving the community with some of the immediate needs met but little reserves to cope long term. On the other hand, the community may become over-dependent on outside help if the agencies remain for too long. Neither approach enables the underlying vulnerability to be addressed, nor capacity and preparedness to develop. This is why the principles of community development and public health approaches to nutrition are essential facets of disaster management.
...knowledge and expertise from several academic and professional disciplines and the local population are needed.
The possibility of future disasters and food shortages cannot be ignored. International early warning systems can certainly raise the level of alertness, but can also have limitations. On the other hand, local data highlighting rising rates of malnutrition can lead to increased efforts directed at prevention or, if necessary, application for food intervention. Ideally, on-going nutrition surveillance should be standard practice in every country so that a deteriorating situation can be identified early. This requires expertise, for example local fieldworkers to carry out data collection, and access to logistical, statistical, and nutritional expertise to analyse and interpret finding. Local skills in numeracy and literacy are required, thus adult as well as child education becomes important in helping to build capacity. Developments in RUTF production have made community-based therapeutic care (CTC) for the moderately malnourished more achievable, and have the potential to prevent severe malnutrition. Another possible benefit to the community is provision of local employment, in the CTC programmes and in the manufacture of RUTF.
The challenges involved in building capacity in vulnerable communities must not be underestimated. A multi-disciplinary approach is needed for effective community involvement. Just as nutrition itself is multi-factorial, so knowledge and expertise from several academic and professional disciplines and the local population are needed. Listening to and respecting the community’s knowledge, experience, views, and expertise, and understanding their specific cultural, social, psychological, economic, and physical needs are all critical forces in building capacity for disaster preparedness in nutrition.
Marion E Wright, BSc, MSc, PhD, RN, RM, RHV
Dr Wright, a lecturer in the Institute of Nursing Research and School of Nursing at the University of Ulster, Northern Ireland, has been teaching nutrition for over 20 years to students in nursing and other programmes. Her students have included many nurses from Malawi, Ghana, and Kenya, from whom she has gained insights into the nutritional problems of their countries. This insight was furthered by several short study periods at the former Tropical Child Health Unit, London, and the opportunity to visit nutrition rehabilitation programmes in Malawi and Ghana. She has coordinated and facilitated an on-line module on Public Health and Nutrition in a European Master’s programme in Disaster Relief Nursing/Healthcare, offered in collaboration with Hämeen ammattikorkeakoulu (HAMK) University of Applied Science, Hämeenlinna, Finland, and the University of Glamorgan, South Wales. Dr. Wright received general nurse education at the Royal Victoria Hospital, Belfast, Northern Ireland, midwifery education at the Western General Hospital, Edinburgh, Scotland, and Health Visitor education in Belfast. Following 12 years in health visiting practice in Northern Ireland, she undertook a full-time post-registration BSc (Hons) degree in Nursing Studies at the New University of Ulster, a Master’s degree in Nutrition at the University of London, England, and a PhD in Nutrition at the University of Ulster. She was awarded a Leverhulme Trust Study Abroad Fellowship in 2000/2001, spending several months in the United States at Kent State University, Ohio, working with Professors Ruth Ludwick, PhD, and Rich Zeller, PhD, on research using the Factorial Survey method to examine nurses’ decision making about nutritional risk in patients.
Maija Vesala-Husemann, MSc, RN, RHV, QNT
Mrs. Maija Vesala-Husemann is a visiting lecturer in the Institute for Nursing and Social Services in Hämeen ammattikorkeakoulu (HAMK) University of Applied Science, where she has taught nursing and health promotion for 20 years to students of nursing and health care. She has also coordinated the health visitor education programme and has held the positions of Head of the Department of Nursing Studies and Vice Principal. She has been an active member of Finnish Non-Government Oranizsations for development co-operation in Tanzania and Uganda, and has had the opportunity of visiting and working for short periods in Uganda. She has undertaken further studies in development issues at the University of Kuopio, Finland. She also facilitates and co-ordinates an on-line module on Public Health and Nutrition in a European Master’s Programme in Disaster Relief Nursing/Health Care, offered in collaboration with HAMK University of Applied Science, Hämeenlinna, Finland and the University of Glamorgan, South Wales.
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© 2006 OJIN: The Online Journal of Issues in Nursing
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