Insights from social-ecological systems thinking for understanding and preventing famine.

The risk of famine is rising in many countries today. Bold changes to famine information and response systems are urgently needed to improve capacities to prevent famine. To this end, the paper identifies six insights from social-ecological systems (SES) thinking for understanding and preventing famine. It argues that a state of famine emerges from human-environment interdependencies, complex causality, and non-linear system dynamics, shaped by history and context. The likelihood of famine can be reduced by strengthening resilience to the diverse stresses and shocks that drive destitution, food insecurity, undernutrition, morbidity, and mortality. SES thinking offers new opportunities to understand the dynamics of famine, diagnose lesser-known drivers, pinpoint new metrics, ascertain leverage points for intervention, and develop conceptual frameworks to inform policy. SES concepts and methods could also support the development of practical analytical tools to guide decisionmakers on how, where, and when to intervene most effectively and efficiently to strengthen resilience to the drivers of famine.

Measuring anthropometric indicators through nutrition surveillance in humanitarian settings: options, issues, and ways forward.

The technical discourse on nutrition surveillance started decades ago, and the first technical guidelines were proposed in mid-1970s. In spite of this long history, little evidence and consensus exists on the best methods for conducting nutrition surveillance, and on the validity of data produced by these approaches. Multiple nutrition surveillance systems exist in humanitarian settings; however, the validity and usefulness of data produced by these systems are often questionable. In this paper, we outline and define five major methodological approaches to collecting child anthropometric data through surveillance: repeated surveys, community-based sentinel sites, mass screenings, admission data from feeding centers, and data from health clinics. We discuss outstanding methodological and practical challenges with direct implications for quality, validity, and interpretability of collected data and highlight comparative advantages and disadvantages of different methods. We also propose ways forward to building a better evidence base by documenting the strengths and limitations of different approaches, with the eventual goal of achieving consensus on the best ways to collect anthropometric data through surveillance.

Impact of drought and HIV on child nutrition in Eastern and Southern Africa.

BACKGROUND: Intermittent food insecurity due to drought and the effects of HIV/AIDS affect child nutritional status in sub-Saharan Africa. In Southern Africa in 2001-3 drought and HIV were previously shown to interact to cause substantial deterioration in child nutrition. With additional data available from Southern and Eastern Africa, the size of the effects of drought and HIV on child underweight up to 2006 were estimated. OBJECTIVE: To determine short- and long-term trends in child malnutrition in Eastern and Southern Africa and how these are affected by drought and HIV. METHODS: A secondary epidemiologic analysis was conducted of area-level data derived from national surveys, generally from the mid-1990s to the mid-2000s. Data from countries in the Horn of Africa (Ethiopia, Kenya, and Uganda) and Southern Africa (Lesotho, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe) were compiled from available survey results. Secondary data were obtained on weight-for-age for preschool children, HIV prevalence data were derived from antenatal clinic surveillance, and food security data were obtained from United Nations sources (Food and Agriculture Organization, International Labour Office, and others). RESULTS: Overall trends in child nutrition are improving as national averages; the improvement is slowed but not stopped by the effects of intermittent droughts. In Southern Africa, the prevalence rates of underweight showed signs of recovery from the 2001-03 crisis. As expected, food production and price indicators were related (although weakly) to changes in malnutrition prevalence; the association was strongest between changes in food production and price indicators and changes in malnutrition prevalence in the following year. Areas of higher HIV prevalence had better nutrition (in both country groups), but this counterintuitive association is removed after controlling for socioeconomic status. In low-HIV areas in Eastern Africa, nutrition deteriorates during drought, with prevalence rates of underweight 5 to 12 percentage points higher than in nondrought periods; less difference was seen in high-HIV areas, in contrast to Southern Africa, where drought and HIV together interact to produce higher prevalence rates of underweight. CONCLUSIONS: Despite severe intermittent droughts and the HIV/AIDS epidemic (now declining but still with very high prevalence rates), underlying trends in child underweight are improving when drought is absent: resilience may be better than feared. Preventing effects of drought and HIV could release potential for improvement and, when supported by national nutrition programs, help to accelerate the rates of improvement, now generally averaging around 0.3 percentage points per year, to those needed to meet Millennium Development Goals (0.4 to 0.9 percentage points per year).

Fluctuations in wasting in vulnerable child populations in the Greater Horn of Africa.

BACKGROUND: Malnutrition in preschool children, usually measured as wasting, is widely used to assess possible needs for emergency humanitarian interventions in areas vulnerable to drought, displacement, and related causes of food insecurity. The extent of fluctuations in wasting by season, year-to-year, and differential effects by livelihood group, need to be better established as a basis for interpretation together with ways of presenting large numbers of survey results to facilitate interpretation. OBJECTIVE: To estimate levels of and fluctuations in wasting prevalences in children from surveys conducted in arid and semiarid areas of the Greater Horn of Africa according to livelihood (pastoral, agricultural, mixed, migrant), season or month, and year from 2000 to 2006. METHODS: Results from around 900 area-level nutrition surveys (typical sample size, about 900 children) were compiled and analyzed. These surveys were carried out largely by nongovernmental organizations, coordinated by UNICEF, in vulnerable areas of Eritrea, Ethiopia, Kenya, Somalia, Southern Sudan, and Uganda. Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data were used for comparison. Data were taken from measurements of children 0 to 5 years of age (or less than 110 cm in height). RESULTS: Among pastoral child populations, the average prevalence of wasting (< -2 SD weight-for-height) was about 17%, 6-7 percentage points higher than the rates among agricultural populations or populations with mixed livelihoods. Fluctuations in wasting were greater among pastoralists during years of drought, with prevalences rising to 25% or higher; prevalences among agricultural populations seldom exceeded 15%. This difference may be related to very different growth patterns (assessed from DHS and UNICEF/MICS surveys), whereby pastoral children typically grow up thinner but taller than children of agriculturalists. Wasting peaks are seen in the first half of the year, usually during the dry or hunger season. In average years, the seasonal increase is about 5 percentage points. Internally displaced people and urban migrants have somewhat higher prevalence rates of wasting. Year-to-year differences are the largest, loosely correlated with drought at the national level but subject to local variations. CONCLUSIONS: Tracking changes in wasting prevalence over time at the area level--e.g., with time-series graphical presentations--facilitates interpretation of survey results obtained at any given time. Roughly, wasting prevalences exceeding 25% in pastoralists and 15% in agriculturalists (taking account of timing) indicate unusual malnutrition levels. Different populations should be judged by population-specific criteria, and invariant prevalence cutoff points avoided; interpretation rules are suggested. Survey estimates of wasting, when seen in the context of historical values and viewed as specific to different livelihood groups, can provide useful timely warning of the need for intervention to mitigate developing nutritional crises.

Identifying priorities for emergency intervention from child wasting and mortality estimates in vulnerable areas of the Horn of Africa.

BACKGROUND: The relation between anthropometric measures and mortality risk in different populations can provide a basis for deciding how malnutrition prevalences should be interpreted. OBJECTIVE: To assess criteria for deciding on needs for emergency interventions in the Horn of Africa based on associations between child wasting and mortality from 2000 to 2005. METHODS: Data were analyzed on child global acute malnutrition (GAM) prevalences and mortality estimates from about 900 area-level nutrition surveys from Ethiopia, Kenya, Somalia, Sudan, and Uganda; data on drought, floods, and food insecurity were added for Kenya (Rift Valley) and Ethiopia, from Food and Agriculture Organization (FAO) reports at the time. RESULTS: Higher rates of GAM were associated with increased mortality of children under 5 years of age (U5MR), more strongly among populations with pastoral livelihoods than with agricultural livelihoods. In all groups spikes of GAM and U5MR corresponded with drought (and floods). Different GAM cutoff points are needed for different populations. For example, to identify 75% of U5MRs above 2/10,000/day, the GAM cutoff point ranged from 20% GAM in the Rift Valley (Kenya) to 8% in Oromia or SNNPR (Ethiopia). CONCLUSIONS: Survey results should be displayed as time series within geographic areas. Variable GAM cutoff points should be used, depending on livelihood or location. For example, a GAM cutoff point of 15% may be appropriate for pastoral groups and 10% for agricultural livelihood groups. This gives a basis for reexamining the guidelines currently used for interpreting wasting (or GAM) prevalences in terms of implications for intervention.

AIDS, drought, and child malnutrition in southern Africa.

OBJECTIVE: To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. DESIGN: Epidemiological analysis of sub-national and national surveys with related data. SETTING: Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. SUBJECTS: Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. RESULTS: Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. CONCLUSIONS: First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.