Famine looms in Yemen, Nigeria, South Sudan and Somalia. The horrible, medieval fate of starving to death is once again a 21st-century reality. But what does the word famine actually mean and how do aid workers treat it?
For aid workers, famine is the extreme end of a long spectrum of what is know as food security – jargon for the level of physical and economic access a group of people have to adequate nutrition. A country should, ideally, be Food Secure. The next place on the spectrum is Food Insecure: these are countries where access to food is limited: people can’t buy enough food, or grow it, or the local markets can’t supply what’s needed. If this gets worse and worse again, if markets collapse, if people – especially children – start dying, then the country moves into Food Crisis.
Only then, if the situation is not controlled or responded to, following months of crisis and suffering, is the fifth and final stage is reached - the terrible state of famine. It is, of course, an emotive word. But for aid worker, it is also a highly technical one. It has taken years of discussion but now the WFP and others have a standardised definition.
There are three key conditions that have to be met. First, at least 20% of households must be facing extreme food shortages with limited ability to cope. In other words, one in five people flatly don’t have enough to eat (below 2,100 calories per day) on an ongoing basis.
Second, death rates must exceed two per 10,000 people per day. This means that twice as many people are dying daily as normal.
And third, the prevalence of serious malnutrition (which is measured using the slightly confusing term Global Acute Malnutrition, the nutritional status of the entire population of the country/area in question) must exceed 30%.
In practice that means that one in three – usually children – are exhibiting the life-threatening symptoms of malnutrition’s most acute clinical manifestation, severe acute malnutrition.
What this means in reality is that the body is collapsing. “You’ve dismantled a lot of your metabolic processes: liver, heart, kidney function are all compromised. Your immune system also breaks down. Ultimately you lose appetite and at that late stage, treatment is really hard. Even in hospitals, mortality used to be 20-30%,” says nutritionist Steve Collins, director at NGO Valid Nutrition.
To get to this state takes time. And this is the thing about famine. Most humanitarian crises – earthquakes, typhoons – happen overnight. Famine, by contrast, starts slowly. A failed harvest, an armed insurgency, a people on the move. Households economising on luxuries like milk and meat, then staples. “You don’t suddenly get malnutrition and die,” says Collins. “You spiral slowly into death.”
Famine is a slow moving, inexorable kind of a crisis. The country will already have passed through the other stages, which are severe enough. “A global acute malnutrition (GAM) rate above 10% is a problem,” says Arif Husain, chief economist at the World Food Programme. “GAM above 15% is already an emergency.” Long before famine is officially declared, he says, “bad things have already happened. Large numbers of people will already have died and the situation spiralled out of control.”
This is why aid workers call famine the F word: it stands for failure. A slow-growing crisis is easy to see coming. Famine is preventable. “Our job is about reacting long before the famine,” says Husain. “We try our utmost not to get there.”
So how do aid agencies prevent famine? Well, first of all they watch at-risk groups carefully. The closest eye is on children: the canary in the food security coal mine. Children, especially those under five, burn far more energy per kilo of body weight than adults and have small stomachs so need to eat more often. So they show signs of malnutrition before adults. Faced with inadequate nutrition, babies start crying more. Children become listless, and stop playing. With compromised immune systems, they fall ill more often.
Aid agencies track everything from market costs to adult mortality. Recent years have seen great investment in famine tracking systems, the best known of which is the Famine Early Systems Warning Network (Fewsnet), which tracks famine indicators globally.
Bodies like Fewsnet are the product of long, bitter experience. In Ethiopia in the 1980s medical aid workers began systematically trying to measure famine, mostly by treating and collecting data around children.
The tools, however, were clumsy. Collins remembers depending on complicated height/weight ratios for diagnosis, which required both the capacity to weigh and to measure, and access to printed tables. Others have used cruder, improvised methods. One nurse says she used to get children to play football and the quicker they stopped playing, the worse the situation.
Then a new, simpler method began to be widely accepted: the middle arm test. Today, aid workers just slip a colour-coded armband halfway between the elbow and the shoulder and pull it tight. If the circumference is less than 11.5cm in a child under five, the band will meet at the point where it turns red and the child is diagnosed with SAM. The test has revolutionised diagnosis, not least because it is not literacy or numeracy dependent and can be used by mothers, health visitors and community carers. A standardised version of the armband was issued by WHO and Unicef in 2009.
So who decides when a food crisis becomes a famine? Technically, governments. It’s their job to tell their populations and the world. But in some cases, governments don’t have the capacity to do this so the UN steps in – this is what happened in Somalia in 2011, the last time famine was formally declared. And quite often governments don’t like declaring famine because it represents failure. That’s what happened in Niger in 2005.
When it comes to response, a lot has changed since the images of lines or starving people in Ethiopia in the 1980s. Large-scale food distributions still happen, often well before a famine is declared, but mostly gone are the grand shipments from the west, which in practice often cost a fortune to ship, took months to arrive and could have a catastrophic effect on fragile local markets.
Today, 25% of WFP’s projects use cash-based vouchers that enable families to buy what they need locally and the trend is expected to accelerate. While food distributions will always have a role because sometimes local markets cease to function, cash distributions help to sustain local markets and give families choice over what to buy.
The clinical treatment for severe malnutrition has also changed dramatically. Generic versions of a therapeutic food called Plumpy Nut (a kind of turbocharged peanut butter) that was invented in France in 1996 now make up the bulk of ready-to-use therapeutic foods (RUTF) used globally. And anywhere peanuts grow, locals can make a homemade version. One of the best things about RUTF is that it can easily be administered by mothers at home, meaning no inpatient stays, no family division and no need for elaborate clinical facilities.
But the profound problem of convincing donors to provide enough funding for early interventions remains a huge problem. “When you look at what prompts donors, it’s often when pictures of starvation appear on screens and that’s too late. There’s always a lag. There’s little kudos in preventing a famine,” says Collins. “The fact that it’s still happening is a total disgrace.”