1. Introduction to Nutrition in Emergencies
This session is approximately 30 minutes
Module 01

2. Learning Objectives Know where most nutrition emergencies occur
Understand what causes nutrition emergencies
Know which groups are most nutritionally vulnerable in an emergency
Be aware of the different types of malnutrition that arise in emergencies
Be aware of the range of emergency nutrition responses and when they are appropriate
Have a better understanding of the operational challenges in Nutrition in Emergencies

3. What is an emergency?
Various definitions exist such as: Any situation where there is an exceptional and widespread threat to life, health and basic subsistence, which is beyond the coping capacity of individuals and the community” (Oxfam Humanitarian Policy, 2003.)
‘Complex emergency’ refers to a major humanitarian crisis of a multi-causal nature, essentially from internal or external conflict and which requires an international response that extends beyond the mandate or capacity of any single agency
Distinction between loud and silent emergencies stresses the fact that there is often a serious disconnect between need and response
Loud emergencies: catastrophic events such as natural disaster or war. Receive considerable international publicity and massive humanitarian response (of varying degrees of adequacy)
Silent emergencies: protracted and receive limited international attention and insufficient humanitarian response.
Give handout on various definitions of emergencies from module 01

4. What types of Emergencies are common in country x?
Use name of country where NiE training is taking place

5. What types of Emergencies are common in country x?
Complex – conflict-related
Droughts
Floods (often with landslides)
Earthquakes
Famine
Provide a list of the common emergencies that occur in that country

6. What is an emergency? (2)
Emergencies cover a wide variety of different scenarios. They differ in terms of:
Length (short-term, chronic)
Cause (natural, conflict-related {‘complex’}, economic-political)
Impact (destruction of infrastructure, agricultural, health and social systems)
Affected groups (internally displaced persons, refugees, stable populations)
Humanitarian response (large-scale response, no response at all)

7. What is Malnutrition?
Ask the participants to say what the type of malnutrition each image represents as the images fly in one by one

8. What is a nutrition emergency
Many classification systems exist, which agree on the definition of the situation through progressive stages, the most severe being labeled “famine”
Most systems combine CMR and wasting for classifying the situation, as this 1995 UN SCN threshold system:
Classification system
Level
Mortality and malnutrition indicator
UN SCN thresholds 1995
Alert
CMR 1/10,000/day
U5MR 2/10,000/day
Wasting 5–8%
Severe
CMR 2/10,000/day
U5MR 4/10,000/day
Wasting >10%
CMR – Crude mortality rate

9. Integrated Phase Classification system (IPC)
Most recent classification system to be developed
Builds significantly on other systems
Aims to develop a common scale for food security classification comparable across countries
Facilitates identification of priorities for intervention before situation becomes catastrophic
Includes a much wider variety of non-nutrition indicators such as disease, access to water and conflict

10. Summary of IPC food crises and famine classification system with thresholds
FSNAU/FAO integrated food security phase classification (IPC), 2007
Generally food secure
CMR < 0.5/10,000 /day
Wasting* < 3% (<-2SD WHZ)
Stunting < 20% (<-2SD HAZ)
Moderately/Borderline Food Insecure
CMR < 0.5/10,000/day
U5MR < 1/10,000/day
Wasting* > 3% but <10%
Stunting % (<-2SD HAZ), increasing
Acute food and livelihood crisis
CMR /10,000/day
U5MR 1-2/10,000/day
Wasting* 10-15% (>-2SD WHZ), > than usual, increasing
Humanitarian emergency
CMR <1-5 / 10,000/day, >2x baseline rate, increasing
U5MR > 2-10/10,000/day
Wasting* > 15% (>-2SD WHZ), > than usual, increasing
Famine/Humanitarian catastrophe
CMR >2/10,000/day (e.g., 6,000/1,000,000 /30 days)
Wasting* >30%
Give handout on IPC classification from module 01

11. Where do Nutrition Emergencies occur?
The largest famines in terms of excess deaths have occurred in Asia
China ( ) killed 30 million people
Democratic People’s Republic of Korea (1990s) killed up to 3.5 million people
Root cause for both famines was government policies that led to massive food shortages
Africa has suffered more frequent famines but with fewer deaths (lower population density)
Ethiopia ( ) famine due to drought killed 1 million people
Famines in the the twentieth century killed more than 70 million people
Is there currently an ongoing famine, if yes where?

12. Where do Nutrition Emergencies occur? (2)
% of infants with low birthweight
% of under–fives (2003 –2009) suffering from:
underweight (NCHS/WHO)
underweight (WHO)
wasting (WHO)
stunting (WHO)
moderate & severe
severe
SUMMARY INDICATORS
2005–2009
Africa 13 24 20 6 9 40
Sub-Saharan Africa 14 27 22 7 42
Eastern and Southern Africa 25 21 44
West and Central Africa 28 23 8 10
Middle East and North Africa 5 31
Asia 18 17 35
South Asia 47 15 19 48
East Asia and Pacific 11 –
Latin America and Caribbean 4 2
CEE/CIS 1 3 16
Industrialized countries
Developing countries 26 12 34
Least developed countries 33
World
Discuss only the region where the country receiving training is, to put the their situation in context. For example, for Chad focus on West and Central Africa

13. Where do Nutrition Emergencies occur? (3)
% of under–fives (2003 –2009) suffering from wasting (WHO, moderate & severe)
Timor-Leste 25
Somalia 13
India 20
Central African Republic 12
Bangladesh 17
Ethiopia
Djibouti
Niger
Sudan 16
Burkina Faso 11
Eritrea 15
Myanmar
Mali
Nigeria
Sri Lanka
Sao Tome and Principe
Yemen
Democratic Republic of the Congo 10
Indonesia 14
Haiti
Pakistan
Morocco
Maldives
Sierra Leone
Nepal
Syrian Arab Republic
This table needs updating whenever new information becomes available

14. Vulnerability to Nutrition Emergencies?
Existing health and nutrition situation greatly affects how vulnerable a population is to a nutritional emergency
HIV and AIDS increases food insecurity, poverty, and even has negative effects on labour force and agriculture at large scale
Poverty and urban pressure overcrowding, inadequate drinking water, substandard sanitation facilities and infrastructure, exposure to urban pollution and hazardous materials, landlessness, and frequent food shortages
Climate change may have an increasing impact leading to more frequent famines in the future

15. Triggers for Nutrition Emergencies
Natural disasters affect food availability and access, disrupt health systems, destroy WASH systems
Conflict can lead to Nutrition Emergencies in many ways due to lack of access to food, health, WASH, etc.
Political crises and economic shocks contribute to Nutrition Emergencies through discrimination of ethnic groups or inadequate political decisions (China famine in the late 50s)
Global food prices fluctuations have caused increased levels of poverty, food insecurity and resulting undernutrition

16. Who are the most vulnerable in emergencies?
Physiological vulnerability: children less than 5, older people, people affected by chronic diseases, gender
Geographical vulnerability: flood or drought-prone areas, conflict front lines
Political vulnerability: discrimination, persecution
Internal displacement and refugee status: 26 million IDPs, 16 million refugees at the end of 2010 (minus the Arab spring displacements).

17. What types of malnutrition occur in emergencies?
The major concern in emergencies is the increased risk of moderate and severe acute malnutrition because acute malnutrition is strongly associated with death
In many long-term emergencies levels of other forms of malnutrition (stunting and underweight) are often high
Stunting inhibits a child from reaching his or her full physical and mental potential
Can have a major impact on work output and national development
Is becoming an increasingly important measure of nutritional wellbeing in some emergencies
Micronutrient deficiencies are common in emergencies, particularly in affected people dependent on food rations

18. Nutrition assessments in emergencies
Aims at establishing the prevalence of malnutrition in emergency-affected populations using internationally agreed upon standard methods
Anthropometric information and various indicators are collected for identifying direct, underlying and basic causes of malnutrition
Will be covered in modules 6 & 7

19. Internationally used emergency thresholds Based on NCHS reference
Acute Malnutrition level
Nutrition classification
<5%
Situation is acceptable
5 - 9%
Situation is of concern
10 – 14%
Situation is serious
≥ 15%
Situation is critical
Aggravating Factors:
Inadequate general food ration
CMR > 1/10,000/day
Epidemic of measles or whooping cough
High incidence of respiratory or diarrhoeal diseases

20. Nutrition Responses
A wide variety of response options exist for the different phases of food and nutrition crises
See Handout for detailed list
Working with the community All emergency related programming needs to work with the support of the community
Disaster-affected people possess and acquire skills, knowledge and capacities to cope with, respond to and recover from disasters
Local population is usually the first to react in a disaster and even early in a response some degree of participation is always feasible
Explicit efforts to listen to, consult and engage people at an early stage will increase quality and community management later in the programme
 ”Active participation in humanitarian response is an essential foundation of people’s right to life with dignity”
Code of Conduct for the International Red Cross and Red Crescent Movement; Sphere handbook, 2011.

21. Challenges in Nutrition in Emergencies
Lack of impartiality in responding to nutrition emergencies: response does not match needs at global level
Political and media focus often followed by higher rates of response
Most undernourished children are in “non emergency” countries
Dominance of food aid: represents the most funded domain of all humanitarian interventions. Changing slowly
Constraints of the operational environment: access to the populations in need is often difficult for many reasons such as weak infrastructure, insecurity

22. Challenges in Nutrition in Emergencies (2)
HIV and AIDS and Nutrition: stigma, discrimination and lack of international guidelines remain common challenges for humanitarian workers
Lack of an evidence base for interventions: only a few interventions are based on clear evidence
Lack of skills and expertise in Nutrition in Emergencies: national capacity is often missing in many countries affected by nutrition emergencies.

23. Key Messages
Protecting the nutritional status of vulnerable groups affected by emergencies is essential to prevent acute malnutrition, disease and death.
Several systems exist for the classification of food and nutrition crisis; the IPC system is one example which has been adopted by several agencies and governments to analyse and design responses to food insecurity
Nutrition emergencies are primarily caused by severe shortages of food combined with disease epidemics though underlying factors such as poor care and feeding practices, and insufficient access to health care and an unsafe environment all contribute
While Asia and Africa have suffered significant famines over the past 100 years, food and nutrition crises continue and many countries on both continents have baseline levels of acute malnutrition that indicate emergency response interventions are required

24. Key messages (2)
Acute malnutrition is a major concern during emergencies, but chronic malnutrition and micronutrient deficiencies are also issues in certain emergency affected populations. A range of nutrition interventions are typically implemented in an emergency, both to prevent and treat acute malnutrition as well as support livelihoods
Existing challenges in the area of Nutrition in Emergencies include:
Lack of commonly agreed classification system for nutritional crises
Limited evidence for an effective model to treat moderate acute malnutrition
Constraints to the operating environment
Inadequate skills and expertise in nutrition in emergencies at national level
Linking relief, recovery and development efforts
Linking nutrition interventions with each other and with other sectors