The meaning and measurement of acute malnutrition in emergencies: a primer for decision-makers

International agencies have been using malnutrition prevalences to confirm humanitarian emergencies for more than four decades, with many early examples from the international response to the Nigerian civil war in Biafra in the 1960s to the famine across the Sahel in the 1970s. These early surveys were powerful tools for some of the first major media campaigns in the West publicising the severity and scale of a nutritional crisis, and were used to reinforce shocking images of hunger, starvation and death. The prevalence of acute malnutrition is now one of the most widely used indicators of the severity of humanitarian crises throughout the world, and is endorsed by a wide array of UN organisations, donors, national governments and international agencies.

Despite this, the use of malnutrition to diagnose a humanitarian crisis and prescribe an appropriate response is not without problems. Often, rates of malnutrition do not match the wider international analysis of the situation. For example, in southern Africa in 2002 two years of drought and widespread harvest failure caused acute food insecurity and a regional food crisis followed, but there was apparently no widespread malnutrition and mortality.

A further problem is that rates of malnutrition on their own do not mean very much, unless the underlying causes of malnutrition are understood: i.e. whether the cause is related to food, health or social and behavioural factors, or a combination of all three. Nutrition survey reports frequently lack this type of analysis, which has led to disputes between food agencies and health agencies, for example in Darfur where WFP and UNICEF could not agree on why rates of malnutrition remained persistently high in some camps. This obviously has implications for subsequent response strategies. .

Despite the widespread use of malnutrition data to indicate crises, there remains a dearth of publications which explain and present in simple terms the ins and outs of nutrition surveys for decision-makers. Most programme officers who have to make decisions about the merits and importance of multiple nutrition surveys rarely have access to technical support, and therefore must make up their own minds whether the findings can be trusted, and what the implications are in terms of threats to lives and well-being, and in terms of practical response options. This type of understanding is now expected of all humanitarian professionals, whether they are trained nutritionists or not.

The broad aim of the paper is therefore to help decision-makers understand, use and interpret nutritional information and analysis, by reviewing in non-technical language how nutrition data is collected, analysed and interpreted.

The importance of nutrition surveys and the data they generate in emergencies cannot be underestimated. There has always been a steady interest in, and donor support for, emergency nutrition surveys, but donors do not always respond according to need.

The recent humanitarian reform agenda, which aims to make the humanitarian system more accountable, has led to a surge in interest in acute malnutrition as an indicator of humanitarian crisis. WHO and UNICEF, as UN cluster leads in health and nutrition, have put forward a proposal for a ‘Humanitarian Health and Nutrition Tracking Service’ to help track humanitarian outcomes and performance on request from the Inter-Agency Standing Committee. This is not only a technical challenge, but also an institutional one, as it is often institutional constraints that hamper the implementation of, and response to, nutrition surveys. Thus, a further objective of this paper is to link the technical issues with a more pragmatic understanding of the institutional constraints to collecting and using information.

The paper’s target audience comprises principally the users of nutritional data, who include the wide array of decision-makers in stakeholder institutions. These decision-makers include programme and project managers, humanitarian officers or managers, technical programme or policy advisers and consultants, and early warning and other information analysts, including experts in evaluation and monitoring. Many epidemiologists and nutritionists lack humanitarian experience or training, and this paper will be relevant to them too. Increasingly, academic institutions are including humanitarian studies within their curricula, and this paper will also hopefully provide a primer for the humanitarian professionals of tomorrow.