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1 Médecins Sans Frontières / Doctors Without Borders (MSF) UK
Famine and Feast Life on the margins: the inequality of food and nutrition security RESPONSE AND MANAGEMENT: FOOD AID AND ASSISTANCE PowerPoint presentation by Médecins Sans Frontières / Doctors Without Borders (MSF) UK Schools Team: Mary Doherty and Severa von Wentzel March 2014

2 International Response and Management:

3 Management of food security and supply
Management of food security and supply, an age-old topic, became very topical in the 2000s because of: Economic concerns following food price shocks of Environmental concerns such as climate change, soil degradation and water Health, particularly growing malnutrition including obesity epidemic and related non-communicable diseases Concerns with resilience of food supply; for instance, in the UK after the lorry strike that brought the country to 5 days from shortages Note for teachers: Another slide which would benefit from discussion Source: “Food Security and Sustainability: One Can’t Make an Omelette Without Cracking Some Eggs”

4 Actors in the international response
International food aid and assistance is driven in large part by: Donors and international institutions UN institutions such as World Food Program NGOs (non-governmental organisation) actors are independent of national governments such as MSF, World Vision, CARE and Catholic Relief Service World bank Formed at Bretton Woods in 1944,its remit is to support developing countries. IMF Formed at Bretton Woods in 1944, it is in charge of stabilising currencies and supporting weak economies Further Info Critical view on the actors, politics and economics of Food Aid: Greeley et al Effect of mass supplementation URBAN SETTING RESPONSE Teacher resource slides: Humanitarian Principles

5 Rome-based agencies After the global food price hikes, there was a call to increase the coordination of the Rome-based agencies and the focus on improving the link between food assistance and food security. Rome-based agencies is a short-hand for three United Nations’ agencies based in Rome: World Food Programme (WFP): Largest humanitarian organisation in the world that handles most of the multi-lateral (involving more than 2 donors) food aid Food and Agriculture Organization (FAO): International Fund for Agricultural Development (IFAD): Source:

6 Donors US – biggest donor, around 50% since 1980
EU and its member states Canada Japan Non-DAC donors such as Kuwait, Saudi Arabia and United Arab Emerites becoming more significant. China and South Korea started making substantial provisions of in-kind food aid largely directed at North Korea in the 1990s. Source:

7 DAC and non-DAC donors The Organisation for Economic Co-Operation and Development’s (OECD) Development Assistance Committee (DAC) serves as a discussion forum on issues surrounding aid, poverty reduction and development. Member states marked in yellow. Image:

8 Focus of food aid and assistance
The focus is still largely on addressing undernutrition, not the double burden of malnutrition. Food aid represents the majority of humanitarian appeals. Constantly shifting contexts and needs in emergency and transitional settings and growing funding requirements. Further info CAFOD Aid Factsheet Humanitarian Policy Group Food aid and food assistance in emergency and transitional contexts: a review of current thinking – shift to food assistance and trends Case study success stories Nutrition report UN childhood nutrition report on 11 countries with success in their childhood feeding programmes On “The future of food aid” Source: Levine and Chastre et al “Missing the Point” HPG report

9 Types of food aid (1) Food aid and assistance: The terms and definitions used around food aid and food assistance are not very clear and changing - clarity needs to be greater. The have changed, in particular, to allow for the inclusion of the provision of cash for food-related purposes. The use of cash-based transfers and vouchers has increased. Programme Food Aid is almost always made up of in-kind direct transfers (see next slide) and makes up the majority of US food aid. Relief, or Emergency Food Aid Usually free food distribution during emergency situations as a result of natural or man-made disasters. Not necessarily short-term, as countries can suffer chronic food insecurity for long periods. It may include food, water, tents, clothing or rescue and medical teams. Project Food Aid This is food aid delivered as part of a specific project related to promoting agricultural or economic development, nutrition and food security, such as food for work and school feeding programmes. Relief aid and project food aid are usually distributed by the World Food Programme (WFP), Non-governmental organizations (NGOs), and occasionally by government institutions. Development aid: Given to benefit the people and economy of a country, money is given to a wide range or programmes and projects such as infrastructure and education. Note to teachers: a useful slide, if you can, provide students with a paper copy to annotate as you discuss Source:

10 Types of food aid (2) In-kind aid: Food grown in the donor country is distributed or sold abroad. Usually it is a government to government transfer, where the recipient countries purchases the food with money borrowed at lower than market interest rates. Local and regional procurement: Purchases in and around the countries that need it. Tied aid: Money that comes with strings - a requirement to spend it a certain way or to follow a particular policy. What is monetization of food aid? Untied aid: No spending or policy proviso attached to money given. SAPs (Structural adjustment programmes) Implemented by the IMF, aid or loans given if a country followed SAPs. Aimed at boosting development and reducing corruption, they were criticised for benefiting rich countries and corporations. Multilateral aid: Given by multiple donors to a specific country, it may be collected by an UN organisation or an NGO Bilateral aid: Given by one country directly to another. Most non-DAC donors provide assistance bilaterally from government to government assistance, but there is a paucity of information on this. Source:

11 Aid strategies Short-term actions and supply-led strategies prevail over long-term policies as most political attention is short-term. The wide spectrum of strategies includes: Fairer trade Reduced debt servicing Reduced subsidies to richer economies Less tied aid More community involvement Appropriate technology Infrastructure building Action for students: Discuss in pairs and make notes in your folder about what each of the different strategies above entails refer to concrete examples and highlight the desired outcomes. Identify the strategies which are long term, short term Watch the Fairfood international clip “A Fair Future for food chain workers: Read the CAFOD Factsheet on Debt and explain debt servicing Note for teachers: You may want to discuss the importance of global strategies in the management of food supply and security to overcome the short term strategies of individual countries. Teacher resource slide: TEACH A (WO)MAN To FARM

12 Food aid and assistance trends
Shift away from in-kind food aid to many new response options and more flexible donor resources such as local and regional procurement away from aid sourced internally in a donor country (except for USA). “People need different kinds of aid in different situations. If food is not available in a flooded area, actual food supplies are the answer. In the case of chronic shortages, experts suggest cash or vouchers, integrated into a broader social protection system, might be the answer.” More emergency and less programme and project aid. They can help build the basis for long-term food security and can be particularly important in countries in protracted crisis. An emergency response is not designed to be sustainable, but rather to keep people alive. Major efforts to improve food security analysis, early warning, response analysis However, there “remains little in the way of an evidence base about what works best under what circumstances.” and little on recipient preference Growing focus on nutrition programming and on the nutritional outcomes of food assistance and linking of food assistance to nutritional outcomes. Growing scientific and political consensus on the need to focus on children under two. Source: Note for teachers: It will be helpful to students’ understanding to discuss the difference between food aid and food assistance Teacher resource slide: Donor Commitment Index AND HANCI Index

13 Graph: http://www. odi. org. uk/sites/odi. org

14 Advantages and disadvantages of aid
Note for teachers: A useful summary slide Teacher resource slide: Problems with food aid Source:

15 Ways of minimising negative effects of food aid
“Depression of food prices in local markets, affecting local livelihoods: Buy food for distribution from local markets. Intercommunity conflict when food aid is targeted; friction between the agency and the community: Involve communities in the selection of targeting methods and other aspects of food distribution. Hijacking of food for political purposes (e.g. feeding armies): Use a food commodity that only the most needy will find desirable. Households outside the immediate area leave their homes in order to be close to sources of aid: Spread information about targeting criteria before aid distribution starts. Change of attitudes and creation of unrealistic expectations; hindrance of traditional coping strategies: Limit to the absolute minimum the time that free food aid is distributed, and replace it with other forms of aid if necessary. Friction between refugees or IDPs and local populations: Make sure that local leaders are informed at all stages about the aid, and include the most vulnerable of the host population in assistance interventions. The market becomes flooded with food aid commodities, prices tumble and the food loses its economic value: Target food aid as much as possible. Reduced demand for local farmers' produce: Choose commodities that will not compete directly with local production, or else purchase commodities in local markets.” (Source: Note to teachers: This and the preceding slides would benefit from discussion.

16 Multi-sectoral approach
“Malnutrition is often misunderstood by policymakers as simply a ‘lack of food’ problem. It is not. Rather, it is a complex multidimensional and intergenerational problem and needs a multi-sectoral as well as direct and specific interventions.” ( /0 ) As malnutrition and its causes are complex, a multi-stake holder and multi-sectoral approach underpinned with better governance is required. Such an approach can meet multiple objectives such as nutrition, gender equality and sustainability. Most current policy responses focus on supply side (producing more), but given global numbers of hungry this is not working on its own. Consumerism and markets need to be accompanied by policies that help rebalance power. Source:

17 Challenges to coordinated response
International management is increasingly needed to ensure food supply and security. A multi-sectoral approach includes interventions in food systems, public health and education and needs to create an enabling environment through broader interventions and direct nutrition-specific ones. Action is urgent for both types of interventions. Challenges are to To sustain global commitment To boost country-level commitment To translate commitment into action To boost improvements in nutritional status and livelihoods Source:

18 Linkages in the food security architecture can be further improved.
Note for teachers: This slide will need to be discussed and unravelled Source:

19 Governance: coordination and coherence
In an effective, timely and comprehensive mechanism for governing and coordinating food and nutrition security and sustainability, including food aid, key stakeholders could: Address complex and interrelated issues and deeper underlying determinants such as the quality of governance and institutions as well as issues relating to peace and security. Fragile states have special needs. Garner high-level support and political partnerships as a foundation for an “whole of society” approach with “ownership” led by the governments, but including civil society, parliaments and the private sector. Country-owned strategies may not be possible in fragile states, so other actors must assume a more activist role based on interim strategies. Build a mechanism for “policy coherence”, timely policy co-ordination through government-wide attention to unintended negative consequences on nutrition of donor and recipient countries’ policies and interventions; for example, subsidies for biofuels and food exports. Source:

20 International consensus
Initiatives such the UN REACH and the Millennium Development Goals have been followed by the L’Aquila initiative and New Alliance for Food Security and Nutrition and US Feed the Future, "1,000 days" campaign and “Scaling Up Nutrition” (SUN). The Committee on Food Security, UN High Level Task Force, New Food Security Cluster and Food Assistance Convention have been active. These are developed by government, academic, research institution, civil society, private company, development agency, UN organisations and the World Bank specialists and bring together countries suffering high levels of malnutrition with major international food donors. Further info: “Aid policy: New mechanism to boost food security” Source: MSF “Food Aid System continues to fail malnourished children” “UN REACH (Renewed Effort Against Child Hunger and Undernutrition): Established in 2008 by the Food and Agricultural Organisation (FAO), the United Nations Children’s Fund (UNICEF), the World Food Programme (WFP), and the World Health Organization (WHO) to assists governments of countries with a high burden of child and maternal undernutrition to accelerate the scale-up of food and nutrition actions. The International Fund for Agricultural Development (IFAD) joined REACH later on with an advisory role. REACH operates at country level as a facilitating mechanism in the coordination of UN and other partners support to national nutrition scale-up plans.” (Sun movmement website glossary) The Scaling Up Nutrition framework was launched at the April 2010 meetings of the World Bank and IMF

21 Millennium Development Goals
In Sub-Saharan African countries levels of malnutrition are declining very slowly, remain very high or are growing, while there are have been large declines across Asia, Latin America and the Caribbean. First Millennium Development Goal: reduce by half the proportion of people who suffer from hunger between 1990 and 2015. ( Based on the latest FAO undernourishment estimates, this can be met if appropriate actions are taken to reverse the slow down since 2007/2008. Further info: Save the children, Ending poverty in our generation. MDG, Food and Agriculture: agriculture/56-mdg-food-and-agriculture Farming is key to Africa’s prosperity (supporting women farmers) Source: Note for teachers: This slide is include to remind students of the Millennium Development Goals “At the Millennium Summit in September 2000 the largest gathering of world leaders in history adopted the UN Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets, with a deadline of 2015, that have become known as the Millennium Development Goals. The Millennium Development Goals (MDGs) are quantified targets for addressing extreme poverty in its many dimensions-income poverty, hunger, disease, lack of adequate shelter, and exclusion-while promoting gender equality, education, and environmental sustainability. They are also basic human rights-the rights of each person on the planet to health, education, shelter, and security.”(Sun Movement website glossary) Teacher resource slide: MDG 1 Progress AND Progress Toward MDGs

22 MDGs: sustainability and gender
“We have learned from the experience of the MDGs. There have been huge successes, but also gaps. I believe the new goals need specific targets on hunger and nutrition. I believe we need a strong emphasis on agriculture, and in particular climate-sensitive agriculture. I believe we need a stronger, more specific approach on the rights of women and girls.” - Irish Minister for Foreign Affairs and Trade Eamon Gilmore MDGs: sustainability and gender Environmental sustainability and gender equality are key to meeting Millennium Development Goals. “Conserving the agricultural resource base and livelihood security of the poor can be mutually supportive in three ways. First, secure resources and adequate livelihoods lead to good husbandry and sustainable management. Second, they ease rural-to-urban migration, stimulate agricultural production from resources that otherwise would be underused, and reduce the need for food to be produced elsewhere. Third, by combating poverty, they help to slow population growth.” (UN Documents, Our Common Future - Note for teachers: Discuss with students whether they believe we need new MDGs specifically on hunger and nutrition and if so to use the slide on the MDGs and suggest the goals for hunger and nutrition Image MDGs: Source:

23 L’Aquila Rome principles
The report on the 2009 G8 Summit in L’Aquila, Italy recognised the “the combined effect of long standing under investment in agriculture and food security, price trends and the economic crisis have led to increased hunger and poverty in developing countries, jeopardizing the progress achieved so far in meeting the Millennium Development Goals.” (Joint Statement) Leaders launched the L’Aquila Food Security Initiative (AFSI), which follows the five Rome principles on sustainable food security. It call on donors to draw up and implement development plans that respond to the needs of developing countries and ensure that all actors are cooperate in their work to achieve sustainable outcomes: Rome principles: 1. Country Ownership; 2. Strategic coordination; 3. Comprehensive approach; 4. Multilateral support and improvement; 5: Sustained financial commitment Other core commitments: gender, environmental sustainability, transparency Source:

24 Global initiatives L’Aquila
The G-8 group of powerful nations made a L’Aquila commitment signed by over 20 countries in 2009 in Italy to "take urgent action to eradicate hunger from the world." It set out to invest $22 billion in agriculture over three years based on the Rome Principles. This reversed two decades of aid policies that neglected developing country agriculture to invest in country-led programmes. Instead of renewing the L’Aquila 2009, which was up in May 2012, the New Alliance for Food Security and Nutrition and US Feed the Future and was rolled out. Video and article on food security policy and trade: (16:45 min) International Food Policy research Institute (IFPRI) Global Food policy Report 2012 Teacher resource slide: L’Aquila pledges, Copenhagen Consensus

25 New Alliance for Food Security and Nutrition
“At the G-8 Summit hosted by President Obama at Camp David, African heads of state, corporate leaders and G-8 members pledged to partner through the New Alliance and, working with the African Union and Grow Africa, lift 50 million people out of poverty in sub-Saharan Africa by 2022.”( The New Alliance for Food Security and Nutrition private-sector-led affords a lot more power to partnerships with the private sector, multinationals like Monsanto and Yara. Conditions imposed by donors give foreign firms greater access to Africa's markets. Source: Image: Note for teachers: You will want to discuss with students the pros and cons of these private-sector led partnerships

26 World Health Assembly 2012 Resolution:
Supporting global impact Together, countries and supporting stakeholders are collectively working to reach the global targets set out by the World Health Assembly 2012 Resolution: 40% reduction of the global number of children under 5 who are stunted Target 1: Target 2: 50% reduction of anemia in women of reproductive age Further info: Slideshow on SUN Framework. Target 3: 30% reduction of low birth weight Target 4: Increase exclusive breastfeeding rates in the first 6 months up to at least 50% Four strategic objectives as priorities for the Movement to the end of 2015: 1) The creation of an enabling political environment, with strong in- country leadership, and a shared space (multi-stakeholder platforms) where stakeholders align their activities and take joint responsibility for scaling upnutrition; 2) The establishment of best practice for scaling up proven interventions, including the adoption of effective laws and policies; 3) The alignment of actions around high quality and well-costed country plans, with an agreed results frameworks and mutual accountability; 4) An increase in resources, directed towards coherent, aligned approaches Target 5: No increase in childhood overweight Target 6: Reducing and maintaining childhood wasting to less than 5%

27 Specific Actions for Nutrition Nutrition-Sensitive Strategies
Nutrition-sensitive strategies increase the impact of specific actions for nutrition Specific Actions for Nutrition Nutrition-Sensitive Strategies Agriculture: Making nutritious food more accessible to everyone, and supporting small farms as a source of income for women and families Clean Water & Sanitation: Improving access to reduce infection and disease Education & Employment: Making sure children have the nutrition needed to learn and earn a decent income as adults Health Care: Access to services that enable women & children to be healthy Support for Resilience: Establishing a stronger, healthier population and sustained prosperity to better endure emergencies and conflicts Feeding Practices & Behaviors: Encouraging exclusive breastfeeding up to 6 months of age and continued breastfeeding together with appropriate and nutritious food up to 2 years of age and beyond Fortification of foods: Enabling access to nutrients through incorporating them into foods Micronutrient supplementation: Direct provision of extra nutrients Treatment of acute malnutrition: Enabling persons with moderate and severe malnutrition to access effective treatment Source:

28 International agencies
Action for students: Discuss in a group of four, elaborating on your answers: Why is it necessary for international agencies to be increasingly involved in ensuring food security? What makes an approach purely evidence-based* as opposed to practice- or opinion-based? What evidence matters (e.g., best evidence such as RCT* versus best available evidence)? How do you get it? Why is there a classic policy problem of gap between evidence and policy? 3. What makes an approach sustainable? Are there situations that call for an approach that is not sustaianable? Why does cost-effectiveness matter? Randomised-control trial: specific type of experiment that is the gold standard for a clinical trial More on evidenced based versus opinion based policy making:

29 FOOD AID and Assistance Nutritional emergencies

30 Nexus of strategies and scales (1)
There are no one-size fit all scaling up nutrition programmes. The risks and vulnerabilities of a particular context need to be assessed in order to devise policies and implement interventions. Adequate food and nutrition policies are essential to guarantee the effectiveness of programmes and ensure sustainability. The link between national and district, municipal and community policies is crucial. The combination of interventions needs to be put in place in a number of scales. Apart from nutrition intervention, others may focus on addressing inequities and strengthening legal commitments and health systems, for example. Note for teachers: A useful summary slide which would benefit from discussion, encourage students to annotate the information in the light of the discussion

31 Nexus of strategies and scales (2)
Successful ones addressing the particular vulnerabilities and needs have secured: Political commitment, Evidence-based national policies and programmes Trained and skilled community workers cooperating with communities Effective communication and advocacy Integrated service delivery across multiple sec

32 What works in nutritional emergencies
“Proven solutions exist that can end the preventable child deaths and damage caused by malnutrition. Investing in improved nutrition during the critical 1,000 day window can: Save more than 1 million lives each year; Boost a country’s GDP by as much as 11% annually; Build self-sufficiency--well-nourished children are more likely to continue their education, have higher IQs, and earn up to 46% more over their lifetimes; Significantly reduce the human and economic burden of infectious diseases such as malaria and HIV/AIDS, and chronic diseases such as diabetes; and Help end hunger and break the cycle of poverty.” Source: 1000 “Nutrition – An Investment in Growth”

33 What does not Factors behind low effectiveness of interventions can include: Inadequate targeting; Lack of coordination and integration of interventions; Distributed foods not appropriate in terms of nutritional and micronutrient content; Weak education component.


35 Afar, Ethiopia – Nutritional intervention
“When I see this child I feel very happy because the grandmother and the rest of the community thought she was going to die, but we saved her life and she is still alive,” says Nabiyu Ayalew, MSF’s outreach nurse. Further info:

36 Nutrition interventions are cost-effective
“Evidence shows that nutrition interventions are some of the most cost effective of any development intervention, saving lives and investing in the future potential of children. Scaling up coverage of a minimum package of direct nutrition interventions, identified by the Lancet medical journal in 2008, could prevent a quarter of child deaths and lower the prevalence of stunting —a condition limiting physical and cognitive development caused by chronic malnutrition—by a third.” Enough Food If Campaign “G8 Summit Briefing” Action for students: Watch “MSF Campaign for Effective Treatment” on therapeutic foods and their use in Niger, Sahel

37 Strategies in classic emergencies
Quality Coverage NUTRITION Acutely Malnourished therapeutic At risk blanket General population general distribution FOOD AID

38 Food aid in crisis situations
Teacher resource slide: Ways of minimising negative effects of food aid AND Types of feeding programmes Source:

39 Proven interventions (Lancet) to reduce child mortality, improve nutrition outcomes and protect human capital Behaviour change interventions usually delivered on-on-one at the community through community nutrition programmes and such level, Including: Promotion of breastfeeding Appropriate complementary feeding practices (but not provision of food) Proper hygiene notably hand washing (Mason et al. 2006). Micronutrient and deworming interventions that provide a range of supplements for: Children under the age of five (periodic vitamin A supplements, therapeutic zinc supplements to manage diarrhoea, multiple micronutrient powders, and deworming drugs) Pregnant women (iron-folic acid supplements, as well as iodized oil capsules where iodized salt is not available) General population(iron fortification of staple foods and salt iodization). Complementary and therapeutic feeding interventions that provide: micronutrient-fortified and/or -enhanced complementary foods to prevent and treat moderate malnutrition among children 6–23 months of age community-based management of severe acute malnutrition among children under five years of age. Note to teachers: You may need to explain to students what the Lancet is and to discuss the reliability/bias of this document Source: Nutrition programmes as an investment and Source on Lancet study:

40 Core interventions for pregnant women
Source: 1000 Preventing maternal and child malnutrition

41 Core interventions for children under two
Teacher resource slides: Timeline Source: 1000 Preventing maternal and child malnutrition


43 Timeline Pregnancy and first 6 months From 6 to 24 months
Source: 1000 Preventing maternal and child malnutrition

44 Yet, current spending focuses on treatment.
Prevention is much better than treatment – not to get sick in the first place. Preventative measures such as cash transfers and supplementary feeding are far more cost efficient than treating a malnourished child and the loss inherent in its curtailed future. Yet, current spending focuses on treatment.

45 Feeding Programmes Source:

46 Types of feeding programmes: General food distribution
General food distribution (GFD) is typically used in large-scale emergencies, where there is an acute food shortage and / or food prices hikes. GFD is usually not targeted. Examples: GFD in Haiti after the earthquake in 2010 GFD in typhoon affected areas in the Phillippines In such an acute onset emergency, high energy biscuits are used. General food distributions can become part of a country’s anti-poverty programme in which case they are targeted to the poorest segments of the population. Examples of ‘targeted’ GFD: US SNAP programme Brazil’s Fome Zero Source:

47 Blanket feeding PlumpyDoz is used for blanket feeding.
Blanket feeding This is deployed normally during a severe food crisis and also targets specific populations, normally extending non-discriminatory feeding programmes for pregnant mothers, under-5 children, elderly, and the sick, whether they are facing malnourishment or not. Often in conjunction with general food distribution, blanket feeding can also exist independently. It targets the members of a population who are at the highest risk of malnutrition (pregnant and breast feeding women, children under 5, elderly, chronically ill) with foods that are designed to meet their specific nutritional needs. PlumpyDoz is used for blanket feeding. Further Info: Alertnet “Milk in the Sahel; making a real impact on malnutrition”


49 Supplementary feeding programme
Supplementary feeding program (SFP) When malnutrition rates extend over 15 percent and populations still need assistance to fill gaps and in treating specific target groups, NGOs will provide SFPs during the day to provide warm meals, appropriate nutrients, and special foods for various parts of the affected population. It provides supplemental foods to members of the population who exhibit moderate levels of malnutrition (defined by low middle arm circumference or low weight for height) and are at risk for developing severe malnutrition. Most SFP target pregnant and lactating women and children under 5 with energy dense fortified foods. PlumpySup is used for SFP.

50 This child is eating something called ‘plumpy nut’ (ready-to-use food) which is a special food supplement that tastes similar to peanut butter. It helps children to put on weight while also receiving the correct nutritional balance. MSF uses ready-to-use food (RUF) to help prevent and to treat malnutrition in all kinds of settings. This child in Ethiopia is eating a special food supplement rich in vitamins to help him gain weight. © Juan Carlos Tomasi / MSF [Ethiopia] 2008

51 Therapeutic feeding programme
Therapeutic feeding program (TFP) TFPs are established to treat severely malnourished people, and to provide immediate relief to those of an emergency-affected population in danger of dying because of lack of food. Ideally, TFPs are 24-hour stations. In emergency settings, though, staff and supply limitations will often prevent 24-hour operation.” ( The vast majority of TFPs are run in regions where food availability is not the predominant concern (e.g., Niger, Burkina Faso, Ethiopia, Democratic Republic of Congo). TFPs are established in in out-patient clinics and in-patient hospitals areas where childhood malnutrition is endemic due to a high burden of infectious disease combined with poor diets that fail to meet young children’s specific nutritional needs. TFPs may also be set up in emergency-affected populations where there is a background level of endemic malnutrition that will get worse or where there is reason to believe that the number of severely malnourished children will increase. Ready to use foods (RUTF) are used in TFPs. Note to teachers: These slides may be too much detail for some courses- if you use the slides do make sure studens can clearly define the different programmes etc

52 Therapeutic ready-to-use food
Commercialised therapeutic RUF typically takes the form of a peanut/milk-based paste with all nutrients essential to treat severe acute malnutrition. It comes in individually wrapped airtight foil packets that are resistant to bacterial infection and easy to distribute. The product has a long shelf life, making it easy to store, transport and to use in hot climates as an efficient way to provide milk to children under three.

53 Note to teachers: “MUAC has an added advantage of operational simplicity and good mortality predictive power.... MUAC is almost as useful as most other pairs of measurements, such as height and weight. The value of upper arm measurement is derived mainly from the fact that circumference changes very little during the age of 1-5 year(s), and that a single cut-off value (12.5 or 13.0 cm) can be used for children aged less than 5 years to divide those with severe malnutrition from others” (Source: Gener Malnutrition among children in a remote area of Bangladesh

54 MUAC The nutritional status of a child is checked by using the MUAC (Middle-Upper-Arm Circumference) bracelet at an MSF therapeutic feeding centre. The indicator gives rough estimates of protein (muscle) and energy (subcutaneous fat stores) that correlate with changes in body weight in malnourished children.

55 Image: Harvaar Karlsen

56 Image: Stefan Pleger

57 Nutritional intervention UK AND US
Note to teachers: These may be very useful case studies

58 ‘Food stamps’ in the UK Food stamps were last issued during the Second World War to address food insecurity. Right: a woman is handed food stamps in office in Elephant and Castle in south London in 1944 Top right corner: a shopkeeper cuts out a coupon in a shop in 1940 Images: AP Photo Action for students: What are some of the issues raised against moving to payment cards? What are the issues with Foodbanks? Read the BBC article “Numbers relying on food banks triple in a year ” Watch the clip on UK Foodbanks and explain how these help address food insecurity.

59 Foodbanks in the UK

60 UK vouchers: HealthyStart
Programmes such as Healthystart (UK) or WIC (USA) address the problem of nutrition security by providing a limited number of highly nutritious foods, dairy, fruits, vegetables, fish, fortified foods for children. They intend to target the population subgroups most at risk of malnutrition such as pregnant and breast feeding women and young children. Risk of malnutrition has increased with the economic downturn and the rise in food prices in the UK. Action for students: Read about Healthystart vouchers the Guardian’s “Food vouchers to provide emergency help but prevent spending on alcohol” 2. MSN News 'Food stamps' to be issued in the UK: Q&A Source:

61 Double standard: Nutrient-dense at Home and Substandard abroad

62 “The United States is sending food overseas to children that it would not feed to its own citizens. This double standard needs to end.” STARVED FOR ATTENTION

63 US on the edge of poverty
“People have a lot of misimpressions about hunger in America. People think it’s associated with homelessness when, in fact, it is working poor families, it’s kids, it’s the disabled.” - Maura Daly, a Feeding America spokeswoman Action for students: View Video on food stamps in the US by Center on Budget and Policy Priorities: off the charts (Warning: video contains some graphic images of the effects of malnutrition and hunger on children) 2. Look at the slide show “On the Edge of Poverty, at the Center of a Debate on Food Stamps” 3. Read the article with a partner and argue for or against the programme being scaled down. Image: SNAP Hotline

64 US Food insecurity trends
Note to teachers: You may find it useful to refer back to the aftermath of the price hikes in the presentation STRESS FACTORS ON AGRI-BUSINESS to set the context for the worsening food insecurity in the United States. Graph: The Atlantic, Republicans Try to Cut Food Stamps as 15% of U.S. Households Face Hunger

65 Food stamps in the United States of America
Fourteen and half per cent of US population faces chronic hunger according to the US Department of Agriculture’s latest survey. 48 million people, nearly one in 7 people in America receive food stamps at a cost of $72 billion. SNAP - Supplemental Nutritional Assistance program is the official name of food stamps. WIC - The Special Supplemental Nutrition Program for Women, Infants, and Children EBT – Electronic Benefits Transfer cards which resemble debit cards, so can be a more discreet way to use food vouchers. Note to teachers: The US could serve as a good example to illustrate how the rewards from economic growth are increasingly monopolised by the super rich, while the living standards for the majority are stagnating. SNAP image: On SNAP, WIC and EBT Image: Government Issued debit card Image: We accept EBT Latest agricultural survey

66 SNAP K Images:

67 The U.S. Standard and a double Standard
Action for students: Starved for attention The US standard and a Double standard – Part I on WIC in US. Food Prescription Programme. ( million on nutrient-dense foods. Part II “Gift of the American People” - corn soy bean meal. What is MSF calling for? Starved for Attention: What is MSF calling for? Critical view of US food aid - Horn of Africa, Against Corn Soy Blend, Conflict in Kenya and Somalia MSF Why do we have to wait for a nutritional crisis Teacher resource slide: Double standard


69 Food aid or dumping? Food aid (in-kind commodities rather than cash), has been misused to dump surplus production and promote donor country exports. Food aid for commercial purposes and national political interests can distort international trade and be destructive to the recipients country’s food security and economic development. It can hurt poor farmers in LDCs by pushing them to become importers for food products that could be locally grown. Action for students: Why is food aid a trade issue? Why can food dumping (e.g., during the cold war) help donors more than recipients? Read “Food Aid or Hidden dumping?” Note for teachers: The adverse side effects can be substantial. Image:

70 Double standard, but changes for the better
Many countries successfully address malnutrition at home with strategies that target the most vulnerable and make sure they have access to nutrient-dense foods, but send CSB abroad. In the interventions in nutritional emergencies, MSF, World Food Programme and other key food players use supplementary foods that meet the nutritional needs of children as the cornerstone. It has been established that most food aid today does not provide appropriate nutrition to young children, and yet the global food aid system largely continues to provide substandard foods to millions of malnourished children every year Source: MSF “Food Aid System continues to fail malnourished children”

71 Double standard “There is not enough emphasis on the types of foods included in aid deliveries, in other words, the quality of food. Most current food aid programs for developing countries rely almost exclusively on fortified cereals made of corn and soy blend (CSB), which may relieve a young child’s hunger, but do not provide proper nourishment. The US is the world’s largest food aid donor. It produces and ships hundreds of thousands of tons of CSB and other fortified blended flours for use in nutrition programs throughout the developing world, even though these foods are recognized as nutritionally substandard for infants and young children. CSB and other flours are not promoted in the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition safety net program in the US, which provides vouchers to low-income young mothers for the purchase of nutritious foods like milk, fruits, eggs, etc… The United States is sending food overseas to children [food with little nutritional value ] that it would not feed to its own citizens. This double standard needs to end.” (Starved for attention,

72 Problems with food aid Action for students:
In pairs, discuss US food in light of the points below. Research US policy and food aid today. Are there any changes? “It is a donor-driven system It promotes domestic interests of donor countries It is a foreign policy tool International institutions are driven by exporters Development is not necessarily the objective” (

73 RIGHT TO FOOD: Case Study India

74 Right to food: India Food Security Bill
Establishing food as a legal right, the scheme plans to subsidise food for two-thirds of the Indian population. It aims to provide grain to 800 million poor people every month. Source: WSJ “Food Bill – Contours of debate” Hindustan Times “Sonia's ambitious food bill wins LS vote; UPA gets its 'game-changer‘”

75 India’s Food Security Note to teachers: Students could harvest the rich data in this slide Source:

76 Right to Food and India The right to food, to increase food security is not a new idea and appears in many international treaties. It is accepted as a framework for global action. Article 25 of the Universal Declaration of Human Rights, which all United Nations member states adopted in 1948, lists the right to food among a state’s obligation: "Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food." India has one of the worst track records in terms of childhood malnutrition, chronic hunger and deprivation in the world, which are even higher than countries with lower economic development. In the Indian Constitution, Article 21 of the Indian Constitution about a fundamental right to life and personal liberty provides the right to food, as repeatedly interpreted by the Supreme Court. Article 47 holds the Indian state accountable to raise the standard of nutrition of its people. Note to Teachers: Other human rights and other treaties that enshrine the right to food are: The Universal Declaration on the Eradication of Hunger and Malnutrition (1974) The Rome Declaration on World Food Security (1996) The Plan of Action of the World Food Summit (1996) The Declaration of the Rights of the Child (1959) The Declaration on the Protection of Women and Children in Emergency and Armed Conflicts (1974) The World Employment Conference (1976) The World Food Programme (1977) The Declaration of Principles of the World Conference on Agrarian Reform and Rural Development (1979) The Codex Alimentarius Commission of the Code of Ethics for International Trade (1979) The International Conference on Nutrition (ICN) World Declaration on Nutrition (1992)

77 India India has implemented some of the biggest food security schemes in the world during the post-independence decades. Photo: Angel Navarrete The programmes broadly fall into four categories: “Entitlement feeding (Integrated Child Development Services [ICDS], Mid-Day Meal Scheme [MDMS]) Food subsidy programmes (targeted Public Distribution System [PDS] including Antyodaya and Annapurna Yojana) Employment programmes (National Rural Employment Guarantee Act [NREGA], Sampoorna Grameen Rozgar Yojana, National Food for Work Programme, Rashtriya Sam Vikas Yojana) Social security programmes (National Maternity Benefit Scheme, National Old Age Pension Scheme and National Family Benefit Scheme).” Biraj Patnaik, “The Right to Food”

78 Food Security Programmes
While preventing large-scale famines such as Bengal 1943, the programmes “have been unable to substantively address the problem of chronic hunger.  This is not only because of gaps in implementation, but also because...they do not provide for sustainable and lasting livelihood options.... Concerted efforts have been lacking,(except in a few states ,for example, West Bengal,) to undertake land reforms, give communities rights over natural resources, and address the structural causes of poverty caste and gender discrimination have also been major contributing factors. On the contrary, the last two decades have witnessed: an unprecedented alienation of indigenous people and other marginalised communities from their land and other natural resources; displacement due to industrial projects and large dams in rural areas; and fundamental changes in the nature of poverty with unbridled urbanisation and the disenfranchisement of large sections of urban populations. global pressures on the Indian economy and the pursuit of deflationary, neo-liberal policies by successive governments from the early 1990s have abetted in this pauperisation of millions of Indians.” Note for teachers: A very useful slide which would benefit from discussion Biraj Patnaik, “The Right to Food”

79 India Right to Food Action for students: Write a brief report to explain India’s right to food campaign and increasing political will over the last 10 years to address key issues (e.g., access) and objectives. Include lessons India can learn from other countries’ political commitment and convergence. Biraj Patnaik, Principal Advisor Commissioner to India's Supreme Court MSF Starved for Attention 2008 Preliminary Address Article on “How to tackle India’s Hunger” 2. Right to food campaign: Notable judicial activism - FAO on work in Brazil, Guatemala, India, Mozambique and Uganda 3. Clip on the Bihar school lunch poisoning in What are the risks and what are the controls which should be in place to provide food on this scale?

80 Bihar, India Medecins Sans Frontieres is addressing India's unique nutrition issues through mobile clinics, ambulatory therapeutic feeding centres (ATFC’s) and a special emergency clinic to reduce the morbidity and mortality due to severe acute malnutrition (SAM). Photo: Stephanie Sinclair

81 Bihar State, India Action for students: Watch the Starved for Attention clip on malnutrition in Bihar State, India. Discuss why has the status quo existed for many generations. Bihar is one of the poorest states in India and there are high levels of malnutrition in children aged between six months and five years. In Darbhanga district, MSF operates an inpatient therapeutic feeding centre for children in a critical condition, and several outpatient centres, where those with severe malnutrition come for weekly medical check-ups and receive therapeutic food. Note for teachers: Discuss with students how to extract information from the slides in this section to construct a case study Teacher resource slides: Right to Food India Food security bill AND India food security Photo: François Saint-Sauveur

82 India Action for students: Read the articles or research your own on the right to food debate in India to identify and record the objectives and issues (e.g., corruption) with the bill. “Food rights and welfare squeezes: how do we free people from hunger?” ”Is India’s food security bill the magic pill?” “In Business – Can India Afford the Food Security Bill?” “India cabinet approves food security bill March 2013” “India upper house passes cheap food plan” Hindustan Times “Sonia's ambitious food bill wins LS vote; UPA gets its 'game-changer‘”

83 Teacher resource slides

84 K Bangladesh case study.
MDG 1: 50% reduction in undernourishment achieved and likely same for underweight; MDG 4 (child mortality) achieved. MDG 5 (maternal health) on track to achieve (SUN 2011) K

85 Progress towards MDGs MDGs cannot be reached without paying urgent attention to nutrition and its determinants. Graph: Progress towards meeting the MDG target across regions

86 L’Aquila pledges According to the ONE organisation report on accountability of donors to the l’Aquila pledges, only 22% have been met. And most are not on track to meet them within their pledge period. Source:

87 Note for teachers: Helpful to discuss.

88 Source:

89 Actors in international response
Player + motive Role in sustaining life of the margins Examples Individuals e.g. Farmers Survival/ profit Direct producers of food Communities harbour stores of valuable local knowledge, coping strategies and innovation Their co-operation is critical to ensure environmental sustainability Fair Trade, substance farming, organic farming Government Stability Funding for agricultural research and development (R & D) Creating political and economic conditions creating stability of food supply Response during times of crisis. Often techno centric large scale projects e.g. China’s Great Green Wall, or UK overseas aid projects TNCs Profit Research and investment into new farming methods and technologies Resource exploitation and trade in cash crops, fertilizers and farm machinery for profit GM Golden Rice Agro-biotech corporations such as Monsanto (subsidiary of Pharmacia), Syngenta (merger between AstraZeneca and Novartis), Aventis, Dupont and Dow. NGOs and Foundations -Philanthropic Community level support for farmers in the developing world Education, training and skills providers Many promote social equity, for instance female empowerment Practical Action ,Water Aid Emergency aid eg Medecins Sans Frontieres The International Alliance Against Hunger Research Organisations Academic Scientific research on new species and systems Education and skills training of farmers The development of HYVs by IRRI AGRAs work on a ‘Green Revolution of Africa’ IGOs Eg UNEP & FAO Promote international co-operation Implementation of global actions such as MDGs Monitoring and research to identify problems and seek solutions Development assistance and aid to the developing world World Bank’s Global Response Food Programme 1994 UN Convention on Desertification Watchdog pressure groups Environment Research and information gathering and Lobbying of agencies World Resources Institute USA Coalition Food SUSTAIN Source: Edexcel Student Guide Unit 4, Option 3; Note to teachers: This is a useful summary slide which would benefit from full discussion with the students.

90 MSF: Contact us or find out more
Visit our website: About MSF: us: Find us on facebook: Follow us on Twitter: Follow us on You tube: The MSF movement was awarded the 1999 Nobel Peace Prize.  Contents

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