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If you have to starve to death, better to do it in a war-torn country

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Jean-Hervé Bradol
Jean-Hervé
Bradol

Medical doctor, specialized in tropical medicine, emergency medicine and epidemiology. In 1989 he went on mission with Médecins sans Frontières for the first time, and undertook long-term missions in Uganda, Somalia and Thailand. He returned to the Paris headquarters in 1994 as a programs director. Between 1996 and 1998, he served as the director of communications, and later as director of operations until May 2000 when he was elected president of the French section of Médecins sans Frontières. He was re-elected in May 2003 and in May 2006. From 2000 to 2008, he was a member of the International Council of MSF and a member of the Board of MSF USA. He is the co-editor of "Medical innovations in humanitarian situations" (MSF, 2009) and Humanitarian Aid, Genocide and Mass Killings: Médecins Sans Frontiéres, The Rwandan Experience, 1982–97 (Manchester University Press, 2017).

For the past several months, news about food shortages and famines affecting large segments of the East African population have been fueling donation appeals from major public and private aid organizations. Low rainfall and - in Somalia's case - recent stirrings in the 20-year-old civil war explain how a bad situation has suddenly become catastrophic. A precipitous drop in many families' purchasing power in recent years, owing in large part to skyrocketing food costs, has created a situation in which any short-term disequilibrium - due to climate or security conditions, for example - is apt to turn into a disaster that can last a year or even more. In this regard, what is happening in central and southern Somalia is an extreme example of a wider phenomenon. Throughout the region, millions of people lack the purchasing power to buy what they need, though the markets are well-stocked. The markets in Somalia are functioning, too, despite the war, and people are dying of hunger not far from warehouses filled with food they can't afford.

While the media broadcast, ad nauseum, images and accounts of the suffering endured by the people of central and southern Somalia and epidemiological surveys confirm the severity of the situation, bringing help to Somali children is no simple matter. The armed opposition fears that a food distribution operation within its territory by foreign organizations could be used to weaken it. After all, the safety of food aid convoys was the main rationale behind international military intervention in 1992. Today, international troops engaged in military operations against the armed opposition are already involved in food distribution, and are asking for several thousand more men. Food aid lies at the heart of political and military issues, and a massive emergency deployment would mean a major, rapid shift in power relationships. In reality, the political and military conditions necessary to the success of operations that donors are being asked to fund do not currently exist.

How childhood malnutrition is being managed in neighboring countries - where unlike Somalia, relief operations aren't hindered by armed conflict - also raises some awkward questions. Some of these countries have populations ten times larger than Somalia. Take Ethiopia, for example. According to UNICEF, in the 2000s, Ethiopia and Somalia had the same percentages of moderately and severely underweight children - meaning that in absolute terms, there are ten times as many undernourished children in Ethiopia.

Who is it that is dying of hunger? Young children. What could prevent their deaths, in the short term? Powdered milk-, sugar- and oil-based food supplements. Why isn't this being given to undernourished children before they reach a critical state? For two reasons. The first is a professional standard that pits prevention of undernutrition (promoting breastfeeding and certain dietary habits, and adding micronutrients to basic foodstuffs) against treatment (distributing dietary supplements to children for nutritional rehabilitation). The second is simply economic feasibility; the dietary supplements needed for nutritional rehabilitation of undernourished children now cost two to three euros a kilo. At that price, neither families nor public health institutions have the budget to treat the millions of infants each year found to have height or weight growth delays at medical visits. That's why infants diagnosed with undernutrition usually return home untreated. Indeed, international and national recommendations require that a child be at the most advanced stage - severe marasmus or Kwashiorkor - before he is given an appropriate dietary supplement.

There are a few exceptions to this, however. The distribution of free food is considered justified in war and natural disaster situations. In these cases, infants may be treated before they reach the most severe stage of undernutrition. Outside of these humanitarian emergencies, children usually do not get food aid. So unlike Somali children, Ethiopian children - unless they've reached end-stage malnutrition - don't get any help, despite the absence of any conflict preventing aid organizations from reaching them.

We should point out that two hundred years ago, people everywhere around the globe faced the same scourge. Since then, things have gotten better in the four out of every five countries that have managed to make food that specifically meets the needs of fast-growing young children available to families. In the thirty or so countries where deadly pockets of childhood undernutrition continue to be a fact of life, however, the situation can only persist. Aside from treating a few cases of severe marasmus, neither public health institutions nor families can afford nutritional rehabilitation for infants. After thirty years of trying, it's clear that neither preventive measures nor economic development efforts in these countries can by themselves compensate for the market's lack of affordable, infant-appropriate dietary supplements.

Since the 1970s, not a single transnational public health effort has been able to thrive under initial market conditions - whether it be immunization, contraception, the use of national essential drugs lists or drugs for AIDS. The creation of transnational public health-specific economic sectors has been possible only through differential pricing based on the income level of the countries in question. To do this, private economic operators reluctantly agreed to make a few exceptions to a single world price, while the States agreed to fund the now less-expensive effort. Without a comparable development in the area of infant feeding, we are condemned to watch children disappear year after year from the deadly combination of undernutrition and infection. The current exacerbation in climate- and economy-related malnutrition should finally convince us that it's time to take action to ensure that dietary supplements are more available, and administered sooner, to deal with the most deadly form of malnutrition - infant undernutrition. Should a Tobin tax ever be established, funding this type of public health project would be an excellent use of the money.

To cite this content :
Jean-Hervé Bradol, If you have to starve to death, better to do it in a war-torn country, 12 September 2011, URL : https://www.msf-crash.org/en/blog/war-and-humanitarianism/if-you-have-starve-death-better-do-it-war-torn-country

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