Ethiopia 2003: towards a broader public nutrition approach

Twenty years on from one of the most severe famines ever witnessed in Ethiopia, the prospect of hunger, starvation and death threatened ever-increasing numbers of people in 2003. Experience of famine response in Ethiopia since the mid-1980s has led to a ‘food first’ bias, which fails to take account of the broader risks and vulnerabilities associated with famine. Current policy and programming gaps require significant institutional change and major capacity development if progress is to be achieved.

The ‘food first’ culture

The ‘food first’ culture of humanitarian assistance is reflected in the almost continuous flow of emergency food aid to Ethiopia since 1965. This has been linked with more-or-less continuous nutritional assessment and surveillance, which has explicitly advocated for a food aid response to increasing levels of acute malnutrition. The 1989 Ethiopian nutrition guidelines state that a food aid response is necessary when the prevalence of acute malnutrition (wasting and nutritional oedema) rises above 10%. While this level of acute malnutrition is clearly unacceptable, this policy fails to recognise the impracticality and long-term implications of such a recommendation. First, the 2000 demographic health survey reported that the prevalence of acute malnutrition in rural areas was 11.1%, suggesting national coverage of rural areas with food assistance. Second, there is little or no room for analysis of the actual underlying causes of malnutrition, linked with the social and care environment, access to health care and the health environment, as well as food security. This means that there is a risk of failing to identify those situations where people are dying, but not necessarily from lack of food. Figure 1, which shows the results of nutrition surveys from late 2002, indicates that this is indeed happening in parts of Ethiopia.

The disaster response in 2002–2003

The main needs assessment in Ethiopia was the multi-agency post-harvest assessment, which took place in November 2002. This determined the number of people requiring food assistance at district level, and the duration of assistance for 2003. In keeping with previous years, the focus was on food security and associated food aid needs. Around 20 teams participated, with approximately 80 assessors from over 15 agencies, including the government’s Disaster Prevention and Preparedness Commission (DPPC), the World Food Programme (WFP) and other UN agencies, donors, NGOs and regional authorities. The assessment was complemented by the annual FAO/WFP Crop and Food Supply Assessment Mission, which focused on crop production and food supply and demand.

Shortly after the assessments, in December 2002, Prime Minister Meles Zenawi launched a joint appeal with the UN for emergency assistance; Ethiopia, he said, could face a disaster worse than 1984. The appeal estimated that upwards of 11 million people were in need of relief food, and an additional three million needed close monitoring. A multi-agency reassessment of emergency food took place in April 2003, and figures were revised upwards, to 12.6m. Although this surpassed all previous emergency appeals in Ethiopia it was met in its entirety.

Early warning and needs assessments

The process of prioritising areas for relief is a combination of technical assessment and analysis and negotiation. Woredas are categorised as ‘moderately’, ‘severely’ or ‘very severely’ affected. In addition, WFP singles out those districts where the proportion of the population in need is greater than 50% of the total, and where baseline chronic food insecurity is four or five, on a scale of 1–5. In the light of ongoing early-warning data, such as market prices, migration and nutritional status, the list is updated as required, which means that assigned categories of priority may change from month to month.

In February 2003, the Emergency Nutrition Coordination Unit (ENCU), part of the DPPC, adopted a new decision-making tool for the geographic targeting of supplementary feeding. This was based on the presence of indicators including the prevalence of acute malnutrition. While this may work to a degree, it has two major pitfalls. First, it risks failing to identify the real cause of malnutrition, so children continue to suffer despite an apparently adequate response; second, it fails to recognise other responses to moderate malnutrition, which are likely to be more effective and appropriate than targeted supplementary feeding.

Nutrition survey data has long been used in Ethiopia in relation to famine prevention, and for targeting assistance in a systematic way. Currently, the DPPC mainly uses nutrition status data for verifying nutrition-related problems (which are known already to exist), and for pressing the international community for an emergency response.

Overall, the analysis of nutrition in emergencies in Ethiopia has improved substantially in terms of quantitative estimates of acute malnutrition, but this has not always been matched by an improvement in the more qualitative analysis of underlying causes.

Ration scales

Emergency food assistance in Ethiopia currently consists of three programming strategies:

• General distribution of a general ration for all affected people.
• Blanket feeding of a complementary ration for specific at-risk groups.
• Targeted supplementary feeding for moderately malnourished children.

In practice, the general ration for all drought-affected people was reduced from an agreed 500g of whole-grain cereals per person per day to approximately 400g. This reduction was a result of food aid shortages rather than any strategic review of nutritional composition.

The 1989 DPPC ration reflects the internationally agreed planning figure for energy, which at that time was 1,900kcal per person per day. Since then, the planning figure for energy has increased to 2,100kcal, but this has not been reflected in ration scales in Ethiopia. A major problem is the lack of a public or transparent process of reviewing and establishing ration scales. As a result, in mid-2003, there was widespread confusion and misinformation about what the scales should be. For example, the US-funded Joint Emergency Operations Plan partners, which included six NGOs , assumed a general ration of 15kg of cereals, 0.5kg of oil and 1.5kg of CSB. This is more-or-less the 1989 ration, and fails to recognise changes brought in by the DPPC and WFP.

Notwithstanding the planned ration, the actual rations that people receive are different again. In Tigray, for example, committees decide who is entitled to receive rations. This usually results in only two people from each household receiving food, thereby diluting rations even further. Rations are further reduced by the need to sell a proportion to pay for transport from the woreda centre back to the village, or to buy essential goods. The sale price is typically less than the usual market value, because market prices fall as a result of sales of relief grain on the day of distribution. In Somali Region, the system of registration and targeting is less structured – everyone who turns up for a distribution receives a share, which means that ration sizes change depending on the total number of people present.

In mid-2003, a joint NGO advocacy initiative called for an increase in the general food ration and the provision of blended food for all drought victims to prevent the ‘slow starvation’ associated with the regular ration. The need for widespread emergency food assistance is not in question, but it must be only one part of a carefully planned and comprehensive national disaster response strategy. In 2003, good nutrition was equated with 12.5kg of cereal grain for more than 10m people. It does not take a nutritionist to work out that this ‘one size fits all’ approach to emergency relief is likely to fail to reduce preventable morbidity and mortality, and that a wider range of food security and public health strategies is required. Of equal concern is how the short-term solution of emergency food aid affects longer-term recovery: how, for example, is it linked to or even exacerbating destitution?

A focus on nutritional risk provides a much broader understanding of nutritional problems, which in turn requires a broad-based response that is not limited to food aid. For this to be achieved, the entire range of nutritional concerns in emergencies must be adequately addressed at all levels, including national policies. Because no single organisational body, including the ENCU, has either the capacity or the authority to coordinate, facilitate and strengthen all emergency-related nutrition activities, these tasks must be subdivided between relevant ministries and departments. All should nonetheless fall within the wider overall nutrition strategy for Ethiopia. These ideas were widely endorsed by a participatory review of the Ethiopia emergency at a workshop hosted by Unicef in November 2003.

Conclusions

Thirty years of humanitarian practice in Ethiopia have generated the widely held view that famine is the outcome of a failure in the food supply, resulting in malnutrition and mortality which could be addressed by better and more efficient food distribution. This ‘food first’ approach has become an institution deeply embedded within the Ethiopian humanitarian enterprise, with its own rules, principles and advocates. Last year was no exception, with a continued heavy emphasis on food aid assessment and appeals. Although these problems are widely recognised, a significant shift in the ‘food first’ bias seems unlikely given the importance of the institution of food aid globally, and the power it affords a wide range of stakeholders within Ethiopia. It is therefore imperative that its use is better monitored and evaluated, while more appropriate approaches to addressing food insecurity and supporting livelihoods are actively pursued. Concerted efforts are needed on all sides, not only to improve the quality and flexibility of food aid programming, but also to move forward with a more comprehensive approach to addressing humanitarian needs, as encapsulated by public nutrition within the broader context of protecting livelihoods.

Helen Young is Associate Professor at the Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Her email address is: Helen.Young@tufts.edu.

References and further reading

This article is based on work undertaken during a Tufts study into nutrition and livelihoods in Ethiopia. See Sue Lautze et al., Risk and Vulnerability in Ethiopia: Learning from the Past, Responding to the Present, Preparing for the Future (Boston, MA: Feinstein International Famine Center, Tufts University and Inter-University Initiative on Humanitarian Studies and Field Practice, 2003).

See also:

Nutritional Guidelines for Food Relief Rations (Addis Ababa: Relief and Rehabilitation Commission, 1989).

Ethiopia Demographic Health Survey 2000 (Addis Ababa and Calverton, MD: Central Statistical Authority and ORC Macro, 2001).

Starving Slowly (Addis Ababa: Save the Children UK, 2003).

D. L. Pelletier et al., ‘The Food-First Bias and Nutrition Policy: Lessons from Ethiopia’, Food Policy, vol. 20, no. 4, 1995.