hunger matters 2013

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H

MBuilding tHeFoundations

For goodnutrition

2013An Action Against Hunger | ACF International publication

Foreword byArchbishop Desmond Tutu


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Never beore has the world had such abundant resourcmoney, knowledge and ood. And yet hunger continuesravage the lives o millions o people. The great injusticthe youngest children, the most vulnerable and innocenhuman beings, continue to go hungry through no ault

own, simply because they do not have access to vital nuwhere and when they are needed.

Their parents have only the best intentions or them andbest they can. However they are orced to watch as thechildren grow weak rom hunger and become malnour surely there is no greater pain or a parent than that.

We all know a little about eeling hungry. We all eel pahunger at some point or another, sometimes on a dailysometimes less oten. But too many children in this worwith hunger constantly, and endure it until their bodies so malnourished that their lives are put at risk. In act, amalnutrition can become so normal that entire commusimply learn to accept it, believing it to be inevitable.

The acceptance o child acute malnutrition as a act o one o the most shocking realities o the condition; espwhen it is truly possible to make access to adequate nuthe rule and not the exception.

Action Against Hunger is a remarkable organisation wsta o energetic, enthusiastic and deeply committed pewho are determined to make a dierence to those whohave access to ood, good nutrition, health services, clewater and good sanitation.

Making children the ocus o their work and mission, AAgainst Hunger tackles undernutrition by providing diresupport to children and their amilies, including those w

aced with a lie o grinding poverty or who are the victconicts or natural disasters. They also help governmencannot provide this essential support themselves.

By putting themselves in the shoes o the people they ahelping whose lives are endangered by undernutrition,Against Hunger demonstrates that compassion is centrhumanitarian action. They are taking determined and daction to end one o the major injustices o all times: bedenied access to good nutrition.

I would like to commend Action Against Hunger on this publication and on the rest o the essential work that thearound the world. I also welcome this opportunity to expsupport and urge you to do the same.

ahbhp dm Mp t

Foreword

This page: Prahlad Ramesh, who is recovering rom severeacute malnutrition, is bathed by his mother Rekha in Madhya

Pradesh, India (Credit: ACF India, courtesy o Sanjit Das).

Front cover: A woman carries her crops home through the rainin South Kivu Province in the Democratic Republic o Congo

(Credit: ACF DRC, courtesy o Jana Asenbrennerova).


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4Hunger Matters. Building the Foundations or Good Nutrition

o m is to save livesby eliminating hunger throughthe prevention, detection andtreatment o malnutrition,especially during and ateremergency situations o conict,war and natural disaster. Fromcrisis to sustainability, we tacklethe underlying causes omalnutrition and its eects.By integrating our programmeswith local and national systems

we urther ensure thatshort-term interventionsbecome long-term solutions.

It is my pleasure to once again introduce Hunger Matters, Action Against Hunger | ACFInternationals agship annual publication. Whether you are a supporter, partner,employee or under, the articles in this issue will give you a taste o the sheer diversity osupport ACF provides to thousands o vulnerable communities in its mission to achievea world without hunger.

The theme this year is Access to Good Nutrition.

Access is the common actor across the world hunger map. The world has enough oodor no one to go hungry many simply cannot access it. Access becomes all the morecomplex when parents or carers are striving to ensure their children grow up wellnourished. Supporting amilies to provide their children with the essential elements ogood nutrition is the cornerstone o ACFs eorts. Without an understanding o whatthese elements are, no progress can be made.

This years issue o Hunger Matters explores the most critical o these elements anddemonstrates how ACFs programmes empower communities to overcome the barriersstanding in their way. To grow and develop in the frst ew years o their lives, childrenmust eat an adequate diet o nutritious ood; provided by parents or carers whounderstand their needs in an environment where health services, good sanitation and

clean water are accessible and aordable.

Access to these basic needs is inuenced by actors in a amilys immediate and widerenvironment (see the conceptual ramework on page 10). In late 2011, Typhoon Washidestroyed many homes and health care acilities in the coastal city o Iligan in thePhilippines leaving carers with nowhere to saely raise their children. During the 2012ood crisis in West Arica, increased staple crop prices and reduced harvests orcedmany poor amilies to scale back on the regularity o meals.

ACF assesses each situation where rates o undernutrition are or have the potentialto be dangerously high and tailors its support to meet the needs o those aected.By understanding that undernutrition has multidimensional causes, ACF deliversmultisectoral, holistic responses which are integrated with existing governance bodiesin order to ensure the longevity o their impacts.

Sometimes social and political actors exacerbate the immediate causes oundernutrition. Few countries ofcially recognise the human right to ood. ACF helpsthose that dont, like Paraguay, to enshrine the right to ood in national law and enablecitizens to hold their government to account when their children go hungry.

With its extensive experience and expertise, ACF provides long-term technical supportacross health, nutrition, ood security, water and sanitation sectors. Where needed italso continues to provide assistance directly to communities during emergencies.

The pathway to good nutrition is clearly marked. Acute and chronic malnutrition areconditions that no child need suer rom. We hope that this publication makes it clearthat children do not slip into the grip o undernutrition just through lack o ood. Endingundernutrition requires action to improve access to the complete range o actors that

ensure good nutrition all essential in their own right. We encourage you to join us onour journey to end all orms o undernutrition.

d MzChairman, International Chairmans CouncilAction Against Hunger | ACF International

welcoMe

H MAction Against Hunger |ACF International 2013

Managing Editor:Mariana Merelo Lobo

External Editor: Charlie Peverett(weareneo.com)

Designer: Neo

ACF UK Production Team:Hugh Lort-Phillips, Claire

Blackburn and Rachel Robson

Contributors: Ben Allen, LyzielAmpo, Habiba Bishar, CcileBizouerne, Kristine Calleja, HlneDeret, Jainil Didaraly, Louise FinanMaureen Gallagher, BronwenGillespie, Amador Gomez, ElenaGonzalez, Jean Michel Grand,Saul Guerrero, Samuel HauensteinSwan, Anne-Dominique Israel,Christine Kahmann, Matt Kletzing,

Anas Lafte, Jean Lapegue, InigoLasa, Karl Lellouche, Hajir MaalimSandra Mutuma, Martin Parreno,

Alvaro Pascual, James Phelan,Silke Pietzsch, Jennier Stevenson,

Morwenna Sullivan and Bapu VaitlaPublishing Headquarters:

Action Against Hunger UKFirst Floor, Rear Premises161-163 Greenwich High RoadLondon SE10 8JA

T: +44 (0)20 8293 6190

F: +44 (0)20 8858 8372

[email protected]

Registered UK charity number:1047501

ACF UKs social media:Facebook: Action Against

Hunger UKTwitter: @ACF_UK


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6 Global Hunger

8 Root cause: a holistic approachto tackling undernutritionTe actors behind good nutrition and how ACF

identies beneciaries and prioritises its support.10 The pathwa to good nutrition

A visualisation o ACFs ConceptualFramework or Nutrition.

12 Access denied: The struggle o armersin the occupied Palestinian territorFarmers earning a living in the occupiedPalestinian territory ace many barriers Louise Finan explains what ACF is doingto help them.

15 A da in the lie: diaro an ACF feldworkerLyziel Ampo describes what she and her

team do every day to support communitiesin the Philippines.

16 Tipping the balance: theSahel ood crisis in 2012An overview o the ood and nutrition crisis inthe West Arican Sahel in 2012 and its impactor one landless arming amily in Niger.

Contents

21 32

21 Care practices in Iligan CitHow ACFs work has helped parentsto care or their children in the wake oyphoon Washi.

24 Mental health and child care practicesOutlining the care practices that areessential in the rst ew years o a childslie, and how ACF supports carers toprovide them.

26 Strengthening health sstemsHealth system strengthening constitutesmuch o ACFs work in developmentcontexts Dr Sandra Mutuma explainswhy it is done and the impact it has hadin Nigeria.

29 Out in the WASH: Taking actionon water, sanitation and hgiene

Why clean water and good sanitation areessential i children are to grow up reerom undernutrition.

32 Considering cultures: Grasplocal traditions to fght hungBronwen Gillespie explores the cactors driving consistently high o anaemia in the Peruvian Ande

36 Gender mattersA lack o access to decision-makiby women can perpetuate high ro undernutrition, as MorwennaSullivan explains.

39 Hunger and citizenship:The Right to Food in todasBapu Vaitla argues that a world hunger is only possible i all counrecognise access to ood as a hum

42 Last word: Making the airwawith nutrition

Te Executive Director o ACF iargues that ending child undernushould be a priority or world lea


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FRENCH

GUIANA

URUGUAY

VENEZUELA

BRAZIL

BOLIVIA

COLOMBIA

PA

RA

GU

A

Y

ECUA

D

O

R

EL SALVADOR

A

S

U

R

I

N

M

E

G

U

YAN

A

C U B A

GUATEMALA

JAMAICA

HAITIDOMINICANREPUBLIC

NICARAGUA

COSTA RICA

PANAMA

HONDURAS

BELIZE

GREENLAND

gloBal HungerDespite progress in the last ew years, hunger continues toretain its grip on many around the world. Te ood crisisin West Arica exposed some o the worlds most vulnerablecommunities to additional hardship in their already perilouslives. Natural disasters and volatile ood prices let millionsaround the world unable to provide nutritious and regularmeals or their amilies, while conicts orced many toabandon their homes, communities and livelihoods.

In all o these cases, children were deprived o their essentialnutritional needs leading to the onset o undernutrition a condition that at best permanently stunts physical andmental development, and at worst takes young lives.

Across the world, Action Against Hungers (ACF) eldprogrammes help communities to address undernutritionand prevent hunger or uture generations.

This map is portrayed through the Peters Projection. The Peters Projection shows the true area o land masses as opposed to the moretraditional Mercator projection which infates the sizes o regions according to their distance rom the equator.

Source: 2012 Global Hunger Index, published by the International Food Policy Research Institute, Concern Worldwide and Welthungerhile.

Extremely alarming

Global Hunger Index 2012 by Severity

Alarming

Moderate

Low

No data

Industrialised country

Serious

The WesT AfricAn sAheErratic weather patterns in 201and 2012 meant poor harvest

leading to ood shortages an

inated prices or an estimate18 million people. This slowburning crisis let over one millio

children at risk o death rosevere acute malnutrition. Coniin northern Mali displaced almohal a million people, more tha

300,000 internally and ov170,000 to reugee camps neighbouring countries suc

as Mauritania. Many ed winothing, leaving their belonging

and livestock behind. ACFs teamraced to the aid o thousands

displaced Malians and are workinto treat and prevent outbreaks

undernutrition triggered by th

ood cris

hAiTiStill reeling rom 2010s earthquake,Haiti was struck by disaster again in2012 when Hurricane Sandy broughtmassive ooding to the island. Thestorm damaged or destroyed morethan 27,000 homes and paralysed

roads, hospitals and schools. Thenumber o cholera cases jumped inthe atermath meaning more thanhal a million people have nowcontracted cholera in Haiti since2010. ACFs teams have beensupporting communities in Haiti orover three decades and continue toprovide amilies with the support theyneed to build a better uture. In2012, more than 190,000 peoplebenefted rom their water, sanitationand hygiene programmes.



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MOLDOVA

QATAR

SRI LANKA

ZAMBIA

ACIRFAHTUOS

LESOTHO

NAMIBIA

ANAWSTOB

ZIMBABWE

ANGOLA

TANZANIA

KENYA

GABON

COMOROS

SWAZILAND

DEMOCRATICREPUBLIC OF

CONGO

M

A

L

A

W

I

M

A

D

A

G

A

S

CA

R

C

O

N

G

O

BURUNDI

RWANDA

ETHIOPIA

DJIBOUTI

ERITREA

NIGERIA

CHADNIGER

MAURITANIA

ALGERIA LIBYAEGYPT

CTEDIVOIRE

GUINEA

NORTHSUDAN

SOUTHSUDAN

RA LEONE

SAU

M O R O CCOT

U

N

I

S

I

A

ISRAEL

SAUDI

JORDAN

TURKEY

IRAQ

SYRIA

ESTONIA

LATVIA

LITHUANIA

BELARUS

SLOVAKIA UKRAINE

ROMANIA

BOSNIA-

HERZ.

SLOVENIA

CROATIA

MACEDONIAALBANIA

BULGARIA

ARABIA

SERBIA

OMAN

CYPRUS

LEBANON

YEMEN

GEORGIA

IRAN

UZBEKISTAN

TURKMENISTAN

AFGHANISTAN

INDIA

CHINA

BHUTAN

MYANMAR

THAILAND

CAMBODIA

MALAYSIA

INDONESIA

TIMOR-LESTE

PAPUA

NEW GUINEA

N. KOREA

RUSSIAN FEDERATION

EQUATORIAL GUINEA

BAHRAIN

KYRGYZSTAN REPUBLIC

TAJIKISTAN

KAZAKHSTAN

MO

ZAMBIQUE

CENTRALAFRICANREPUBLIC

GHANA

TOGO

B

ENIN

BURKINAFASO

MALI

CAMEROON

UGANDA

PAKISTAN

BANGLADESH

LAOS

VIETNAM

EGAL

OCCUPIEDPALESTINIAN

TERRITORY

PHILIPPINES

SINGAPORE

BRUNEI

AZERBAIJAN

ARMENIAAZER.

KUWAIT

NEPAL

MONGOLIA

SOM

ALIA

actionagainsthung

cenTrAl AfricAn republicClashes between rebels andgovernment orces ared up in

January 2013, limiting communitiesaccess to public services andpreventing humanitarian agenciesrom reaching those most in needo help. As a result, 30% o thepopulation o the Central AricanRepublic are now unable to covertheir ood needs and amilies arestruggling to access markets. ACFspriorities in the country are to gainaccess to vulnerable communities,treat children suering rom acutemalnutrition and provide amilieswith the means to access ood.

philippinesTyphoon Bopha devastatedPhilippines at the end o 20Over 6.2 million people weaected, with more than 1,killed and 850,000 let hom

With so many houses destrand so much agricultural larendered unusable, ACFs have been helping amilies

rebuild their lives, ocusingshelter, ood, agriculture, wand sanitation. Thanks to Awork, more than 90,000 pgained access to clean watthe worst aected areas o Philippines in 2012 alone.

YemenYemen is the poorest couin the Middle East and wascarcity, high ood prices,instability and conict hait the 11th most ood insecountry in the world. Fiveindividuals are severely oinsecure and the lives o

250,000 children are thrby severe acute malnutrit

ACF is working to help thmost at risk and get to thcauses o Yemens high rundernutrition.

DemocrATic

republic of congoSince early 2012 ethnic tensionshave led to renewed violence inthe east and north-east o thecountry, resulting in more than 2.2million people being orced romtheir homes. Rates o sexual andgender-based violence are highwith security issues and poor accessto communities making it hardto deliver humanitarian support.Despite these obstacles ACF hasstepped up supply o lie-savingaid and therapeutic care or over42,000 children across the country.


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I you live without enough ood, the eects ondaily lie are proound but its oten otherissues, with broader implications than just accessto ood, that lie behind the problem. o ghtundernutrition in communities, we need tounderstand those root causes. Sandra Mutuma,Senior Nutrition Advisor at Action Against

Hunger in the UK, explains how.

root

causea holistic approach totackling undernutrition



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Sometimes the caregiver simply caord the necessary resources. Tcould be due to chronic poverty,

ood prices or unequal distributiomoney at household level.

Physical access to those resourcebe the problem, made impossiblconict, distance to markets or sibecause they do not exist.

The caregiver might not know homaintain good nutrition in their cdue to a lack o education (particor women) or inherited cultural bOr they may know that their childtreatment or undernutrition but bunaware o relevant services avathem in their area. Social barrieras discrimination or cultural praccan also be signifcant.

a hm pbm hm

Hunger and undernutrition are ninevitable. They are human-madthereore can be human-solvedo action is a violation o the righmillions o children the world ove

While hunger can be solved by p

ood or the ability to grow ood, undernutrition demands a moresophisticated set o responses rooa real grasp o what creates the por dierent communities. To ovewe must understand it.

See ACFs Conceptual Framework or Nuon pages 10 & 11.

in adulthood. Where it is widespread,productivity may suer on a nationalscale. Research suggests that developingcountries can lose as much as 3% o theirGross Domestic Product because o poorproductivity caused by undernutrition.

Its impacts can also be invisible untilmiddle age or later in lie. Those whowere undernourished when they wereyoung are more at risk rom heart

disease and cancer later in lie.

Mothers with stunted growth are muchmore likely to give birth to undernourishedchildren and suer more complicationsduring pregnancy and delivery. Successivegenerations may experience the sameeects which by virtue o beingcontinuous may not seem abnormal.

Compounded by the inaction ogovernments that ail to see the truelong-term impacts o undernutrition,this apparent normality o stunted growth

in a population undermines the abilityo the people aected by it to recognisethe problem, let alone make the choiceto fght it.

c

All o the underlying actors in ACFsConceptual Framework or Nutrition(pages 10 & 11) need to be present and consistently accessible or achild to grow and develop to their ullpotential. Its when those caring orchildren are unable to access one ormore o the immediate actors that ACF

steps in.

Traditionally ACF has provided supportduring humanitarian emergencies.However, as the organisation has grownACFs mandate has evolved to includeaddressing the underlying actors oundernutrition as well, to assure morelong-term and sustainable solutions touture emergencies.

This includes helping vulnerablecommunities bolster their reserves oood and money, both beore and ater

the most difcult periods.

df h pbm

At this point, i we are to intervenesuccessully, its crucial that we understandthe reasons why a caregiver cannot accessthe basic actors needed to provide theirchildren with adequate nourishment.

The damage caused by undernutritionacross the world is hard to overstate. In2009, 8.1 million children died beoretheir fth birthday. Estimates vary, butbetween 35% and 56% o these deathswould have been associated withundernutrition.

Undernutrition is a condition thatresults rom insufcient ood intake,repeated inectious diseases and poor

care practices; oten due to economic,political and socio-cultural actors.For many living with the condition it issomething that will have been with themsince beore they were born and manymothers will pass it on to their children.

Good nutrition is important throughoutchildhood, but especially in the frstthousand days o lie rom the timea woman becomes pregnant until herchilds second birthday. During thistime, the childs body is going throughits most critical phase o development.

Breasteeding is particularly important,especially in the frst six months aterbirth, as the mothers milk boosts theirchilds weak immune deences.

Children are, pound or pound, moreintensive users o energy than adults,but their capacity to store it is lower asthey have smaller organs. They thereorerequire more requent meals duringchildhood, which is why in periods ostress and ood shortage children are thefrst to be aected by undernutrition.

Without consistently good nutrition duringthese early years a childs body is less ableto develop and is less likely to reach itsull growth potential. This has a prooundimpact on the rest o their lie, with someeects more obvious than others.

Mp

Severe weight loss or wasting is aamiliar symptom o acute malnutritionand can be combined with the swellingo the body as a result o oedema.Stunted growth is a clear impact ochronic malnutrition, where the bodynever achieves its ull potential heightand weight. In other cases blindness canoccur due to defciency o Vitamin A inthe diet.

A hidden eect o undernutrition is thatit can impair mental development too,rendering individuals less productive


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Louise Finan, Advocacy and Communications Coordinator in the oPt.

On his small arm in Gaza, Hussein

Lawalha once grew cucumbers in rowso greenhouses or proftable export, ashis amily had done or 40 years beorehim. Six years ago, everything changedwith the beginning o the blockade othe Gaza Strip. Now his greenhouseswindows lie broken as a consequence othe regions conict, and even i he couldaord to fx them, Hussein would not beallowed to sell his produce outside Gaza.

Lie has totally changed, says Hussein,who is in his early 50s. We only eatthe cheaper ood now lentils, some

vegetables and on rare occasions meator fsh. Ive been trying to make moneyselling other armers produce in localmarkets here. I dont even know howmuch income Ive lost.

Its a similar story or 30 year old HaniQdaih. Hani and his wie have twochildren and also provide or his motherand two sisters. He took over the runningo his amilys arm when his ather dieda ew years ago. He owns two dunumso land (one dunum is roughly 1,000square metres) suitable or cultivating

vegetables such as tomatoes, lettuceand onions. However, most o his land islocated within 200 metres o the securitybarrier that orms the border betweenGaza and Israel and thus he is bannedrom using it. He now has access to justhal a dunum, and his income has morethan halved as a result.

I was growing enough vegetables

here to provide me and my amily witharound 1,500 NIS [equivalent to aboutUS$400] per month. What I grow nowand earn rom work programmesprovided by aid agencies only generatesaround 500 NIS [US$135] per month.Also I have to be careul with what Iplant as now the water is too salty ora lot o crops and they will die.

The blockade has been enorced by theIsraeli military since 2007, ollowing thevictory o Hamas over its political rivals inthe Gaza Strip. The blockade has virtually

stopped Palestinian armers in Gaza romselling their crops. Exports have droppedrom 4,769 truckloads between Januaryand May o 2007 to just 132 truckloadsin the same period in 2012.

During this time armers in Gaza havesteadily lost access to their land, whileobtaining water or irrigation hasbecome almost impossible in manyplaces, with 90% o wells containingsaline water that is unft or agriculture.

Conict across the occupied Palestinian

territory (oPt) is compounding theinsecurities o communities, causingsocio-economic conditions to stagnateor deteriorate. An estimated 1.3 millionPalestinians now live without adequateaccess to ood some 44% o thepopulation in the Gaza Strip and 27% o allPalestinian households throughout the oPt.

The struggle of farmers in theoccupied Palestinian territory

Access

Denied

OCCUPIED PALESTINIAN TERRITORY


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Two boys help plant grazodder or local herders ihills above Az Zuwdein, H


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ACF is working with herders in theWest Bank to support and improvetheir income, enhancing their resilienceagainst orced displacement rom theirland. Demonstration arms have beenestablished to promote alternative activitsuch as cheese-making and animalhusbandry programmes. ACF also helpsherders to improve productivity and

reduce production costs by supportingherding cooperatives to purchase in bulkand to process, store and sell improvedodder at competitive prices.

This is the second year Ive been involvein the animal husbandry project, andits really increased my ock, saysKhadraIssa Taha Tarayrah, a emalearmer in Bani Naim, in the Hebron HillOur last season saw the birth o 10 lamand I now have 30 sheep. We keep themhere in the yard and I eed them hay andsilage. Its going well so ar, and I make

cheese rom the sheeps milk, which weeat in the house.

exporTs from gAzA hAve

DroppeD from 4,769

TruckloADs beTWeen JAnuArY

AnD mAY of 2007 To JusT 132

TruckloADs in The sAme perio

in 2012

In Gaza, ACF runs a pilot project to reusgrey water (water that has already been

used in the household) or crop irrigationThis brings substantial savings to armerswho normally have to purchase water atinated rates. At the same time, educatiois provided on the types o plants thatare tolerant to the lower-quality wateravailable in Gaza.

At a community level, small-scale solutioto the obstacles aced by armers andherders in Gaza and the West Bankcan be ound, but the wider situation isunsustainable. Unless there is an end tothe Gaza blockade, Palestinian armers

in Gaza will never be able to grow andexport a sufcient quantity o crops tosustain themselves and their amilies. Anin the West Bank, specifcally Area C, thelack o access to permits or communitieto build essential inrastructure andrestrictions on land and water use willcontinue to undermine livelihoods.

We cant move with our herd like weused to and its now very difcult tomaintain the same number o animals,says Hassan Hamdeen, 31, a herderin a small village outside Jerusalem.We are Bedouins and herding animalshas always been our way o lie, butit is getting very difcult. There is asettlement around us and we are notallowed to go near the land its on withour animals. We now have to buy odderor the herds, but its very expensive sothe number o animals we can aord tokeep is always going down.

d

In Area C o the West Bank thelandlocked Palestinian territory whereIsrael retains ull control over bothsecurity and civil administration communities are unable to access waternetworks without permits. These aretough to obtain, and over 60,000 peopleliving in Area C are not connected to awater network at all, leaving them relianton rainwater and water trucked into thearea by private vendors and agencieslike Action Against Hunger (ACF) duringthe dry season. For those Palestiniancommunities who are connected,

supplies can be inrequent and deliveron average 50 litres per person per day,as opposed to an average o 300 litresprovided to Israeli settlements.

In addition, herders ace restrictionsin accessing the land they traditionallyused or grazing their animals. The wallseparating the West Bank rom Israel inaddition to checkpoints, settlements, andclosed military zones crisscross much othe West Bank, leaving herders with littleoption but to overgraze small parcelso land and run the risk o degrading

the soil. A quarter o all land in theWest Bank has already been declared aclosed military area, where Palestinianresidents are eectively denied all rightsto exercise their livelihoods. IllegalIsraeli settlements and their continuedexpansion contribute to an ever greaterloss o Palestinian land.

Find out more about our work in the oPt:www.actionagainsthunger.org.uk/opt

Credit:ACFoPt,courtesyofMarcoBottelli

Cre

dit:ACFoPt,courtesyofAnnePaq

Above: Mousa Muhammad Ibrahim Abu Arram and his amily in ront o their house, which wasdemolished hours beore. Ad Deir, South Hebron Hills

Above: Hani Qdaih has erected a smallgreenhouse to grow tomatoes but needsmore investment and space to grow enoughto sell at market.


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Waking at fve each morning gives me time to meditate,exercise and eat a breakast o rice, omelette, ruit and coee.At eight I start work at our ofce, which is in the city o Bislig,by checking my work plan and updating any paperwork.

The climate here is jokingly described as wet or very wet as itrains all year. At least three times a week I go to the local areasknown as barangays which are located in the rolling terrainalong the coast o Surigao del Sur province. The barangaysare only accessible with our-wheel-drive vehicles or on oot or,in some cases, only by canoe. My frst port o call is always thelocal government ofce as we need municipal and barangaypermission to implement our activities.

As part o Action Against Hungers (ACF) emergency responseproject my team addresses the immediate and liesavingneeds o the most vulnerable populations aected by TyphoonPablo, which passed through the region last December. As theFood Security and Livelihoods Supervisor, I assess the ood

availability and shelter o communities in the region, andcoordinate the distribution o ood kits, non-ood items andshelter repair kits.

Fishing is the main income source in the region, but it meansthat communities build their homes perilously close to thehigh tide mark, where they are vulnerable to extreme weather.

Lyziel l. Ampo has worked as a Food Security and Livelihoodsechnical Supervisor or Action Against Hunger or nearlyour years. Based in her home country o the Philippines, she iscurrently assisting with the emergency response to yphoon Pabloin Surigao del Sur, a province in the south o the Philippines.

Profle

A day in the lie:diary o an ACF Field Worker

actionagainsthunge

In December 2012, the typhoons high winds and heavrainall resulted in tidal surges and landslides aectingthan 7,000 amilies (nearly 40,000 people) in Surigao Sur. There had been plans to relocate homes and armvulnerable to typhoons, but fnancial limitations had prthe government rom implementing them.

At lunchtime I eat with the communities: I particularly ethe seaood ound in the coastal areas. Walking arounvillages and talking to dierent people gives me a gooopportunity to assess the situation. As a member o theindigenous Manobo tribe I understand the communitieculture and working with them allows me to understandchallenges rom their perspective.

ACFs projects aim to support arming by advising armeand teaching them sustainable alternatives to practices sslash and burn, which involves clearing orests or armdecreasing orest land in the highlands and increasing th

o landslides in the lowlands. Farming small parcels o lacomposting waste vegetation or ertiliser can yield the savolume o crops over smaller areas, serving the dual puincreasing ood security while ensuring ecological sustain

When we are in the barangays, the weather can change and we are careul not to get stuck overnight. We leave intime to return to the ofce by fve. My colleagues and I odinner together in the evenings. We usually eat seaood avegetables. I then occasionally do the hula-hoop or exer

Finding lasting solutions to the challenges aced in thebarangays will not be easy. Because o the poor state oroads, links with markets and government agencies to

armers needs are poor and need to be enhanced, andgovernment units should invest more to protect commurom the impact o natural disasters.

The sense o ulflment I get rom working to make peoplebetter is a great reward. Every time someone approaches thanks me or what I have done I eel happy, and that is mthan enough to make my day. In the uture I want to stay in humanitarian work and continue to make a dierence.

Lyziel talks with community members ollowinga distribution o home repair kits.

Credit:ACFPhilippines


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tpp

h bTe Sahel ood crisis in 2012Millions o amilies in the semi-arid regions o the Sahel live in aconstant state o hardship, as witnessed bySamuel Hauenstein Swan,Senior Policy and Research Advisor at Action Against Hunger (ACF),

when he met Zara and her amily in the West Arican Sahel.



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Credit:ACFNiger,courtesyofS

amuelHauensteinSwan


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The response delivered immediate,lie-saving support to many o the mostdesperate amilies, enabling them tosurvive until the next harvest in late2012. At the same time, ACF helped tobuild the capacity o poor households toproduce or buy ood, helping to preventa dangerous deterioration in their oodand nutrition situation.

By analysing satellite images o the

semi-arid regions and monitoring thequantities o vegetation, ACF was ableto warn donors and other humanitarianorganisations about areas with potentiapasture and water shortages in late2011 and so trigger distribution oanimal odder and water. Using localradio stations, ACF also warnedlivestock herders in the aected regionsabout the availability o odder andchanges to livestock prices, enablingthem to congregate in locations whereemergency odder was available or togo to markets where they could sell theilivestock or the most.

Much progress has been made sincethe Horn o Arica crisis. The emergencyresponse in the Sahel was switer, bettercoordinated and more timely. However,while the crisis is ofcially over andrains have improved harvests andpastures, millions o amilies like Zarasremain critically vulnerable in 2013, stilstruggling to recover rom the multipleshocks o previous years.

More investment is needed rom West

Arican governments, external donorsand agencies to help amilies build theicapacity to survive uture shocks. All toorequently attention is diverted awayrom an area immediately ater a crisis.Programmes linking nutrition, healthand water and sanitation can preventamilies rom resorting to harmul copinstrategies. For example, by continuing tosupport health systems that treat acutemalnutrition while providing seasonalwork programmes and training on wateretention techniques. Communities can

thereore strengthen their resilience andbuild up their resources beore or atershocks, enabling amilies like Zarasto atten the peaks o crises driven byactors outside their control.

Read more about the impact o ood price rises:www.actionagainsthunger.org.uk/oodprices

lv h

The poor harvest experienced by Zaraand others orced many amilies to buyood rom markets. This increase indemand caused the price o staple crops

to rocket. Compounded by a rise in priceson international markets and a lack otransparency around available stock innational reserves, the price o crops suchas corn rose by up to 80 per cent. Forthe estimated 10 million households inthe region who, like Zara, are extremelypoor and spend up to 80 per cent o theirincome on ood, these spiralling oodprices meant access to ood became amuch bigger issue than sheer availability.Food price volatility is a global problem,but with unequal local impacts.

This dangerous situation came to a headless than two years ater the regionsdevastating 2009-2010 ood crisis.While Sahelian amilies might have beenable to weather a one-o shock to theirlivelihood, they were still in the process orecovering and rebuilding their householdassets when conditions took another turnor the worse in 2012.

Trapped in this cycle o deprivationand hardship, mothers like Zara arebarely able to access the basics theyneed to keep their children alive, suchas resh water and nutritious ood,meaning they are unlikely to grow anddevelop to their ull potential. All toooten, they ace stark choices such aschoosing between spending time fndingood and taking their ill children to thehealth centre. Even a relatively smallchange in her circumstances, such as aminor injury, can result in a prooundimpact on her own health and that oher children.

l vm v

Humanitarian organisations and

donors provided a swit responseto the deteriorating conditions in theSahel in 2012. Early warning systems,notably absent rom the Horn o Aricaa year earlier, raised the alarm asearly as October 2011. This prompteddonors to initiate a large-scaleemergency response across the regionin early 2012.

Credit:ACFNiger,courtesyofSamuelHauensteinSwan


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When yphoon Washi swept through Iligan City in thePhilippines in December 2011, homes and communityhealth acilities were destroyed, making it tough or manyparents to care or their children.Martin Parreno, Heaand Nutrition Coordinator or Action Against Hunger

(ACF) in the Philippines, describes how ACF responded.

CAREPRACTICES INILIGAN CITy

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Typhoon Washi, in December 2011,was one o the strongest tropicalcyclones ever to hit the city. In itswake it let widespread destruction homes were destroyed, large areaso the city ooded, electricity supplieswere disrupted and drinking water

contaminated. Hospitals and healthcentres were also aected and becameinaccessible to many in need.

Health indicators were already lowdue to poor healthcare services.Immunisation coverage o childrenwas inadequate and statistics wereparticularly concerning or pregnantand nursing mothers just 45% receivedappropriate care rom trained staduring their pregnancies and only 37%breasted their children up to theirsecond birthday.

Caregivers were particularly aected bythe typhoon: limited space in transitioncamps or mothers meant they could notbond with their babies, health centresand other structures where caregiverslearnt about child care were destroyedand the emotional stress in the atermatho the typhoon reduced the mental

capacity o caregivers. I no additionalcare had been provided or mothersand children at this stage, the city wouldhave witnessed an inevitable rise in rateso child undernutrition.

impm , hh

p hIn the atermath o Typhoon Washi,ACF pioneered emergency carepractices programmes in mother-babyriendly tents in transition camps.The programmes have since beenrolled out in local health centres as thecommunities have recovered. Caregiverscan receive support and inormationabout caring or their children rompsychosocial workers, while healthworkers address their nutritional needs.As well as providing a space to treat

acutely malnourished children, theprogrammes also enable health workersto monitor the links between the variouscauses o undernutrition. Even in thechaotic atermath o the typhoon,the programmes have prompted asignifcant increase in mothers seekinghealth advice, prenatal services andimmunisations or their children.

Josephine Restauro, a young mothero three, survived the typhoon and hasfrst-hand experience o the benefts othe programme. By joining the carepractices programme, I realised thatsome o my old belies were preventingme rom providing the best care or my

child, she says. For instance, I used tobelieve that it was taboo or a pregnantwoman to wear black or bathe onTuesdays and Fridays. I also now knowthe importance and meaning o exclusivebreasteeding and have shared thisknowledge with ellow mothers.

Josephine and her husband volunteer atthe health centres to pass on what theyhave learnt to others and to demonstratethe correct way to bathe and massagebabies. Workshops, group discussionsand hands-on activities, like art therapy

and baby massage, teach carers the valuo interacting with their children, givingthem the skills and knowledge to osterhealthy growth and development. Whatmakes ACFs programmes stand out romother care practices programmes is theemphasis on all potential carers o thechild participating, not just the parents.

TYphoon WAshi lefTWiDespreAD DesTrucTion homes Were DesTroYeD,elecTriciTY suppliesDisrupTeD AnD DrinkingWATer conTAminATeD


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Melissa, a mother o two, describes howthe ocus group discussions inormedher o the importance o immunising herchildren against preventable diseases.A lack o money or transportation and aheavy workload usually mean that unlessher children are very ill, she cant takethem to health centres or vaccinationsor health checks. The care practicessessions made her realise that investingher time and money in regular check-

ups or her children is a lot cheaper thantreating them when they are sick.

Teenage pregnancy was also becomingwidespread in the atermath o theemergency. Most teenagers who allpregnant hide it rom their parents anddo not receive advice on how to care orthemselves during pregnancy. As such inmany cases their baby does not developproperly. The mother-baby riendly tentsprovide a location or young mothers toshare their concerns with health workers,and to seek reuge i necessary.

Acfs cAre prAcTicesprogrAmme hAsbeen insTrumenTAl inproviDing knoWleDge AnDsupporT To fAmiliesDuring TurbulenT Times

Credit:ACFPhilippines,courtesyofM

imiMaitem

translatin

Food andHealtHcareinto goodnutrition

Care practices are the behaviouand practices provided by carerthat ensure children receive the (including exclusive breasteedinor the frst six months), healthcastimulation and emotional supp

needed or growth and develop

Rates o undernutrition in Iligan have remained high despite thegovernment previously undertaka range o programmes to tacklthe other underlying causes oundernutrition, such as a lack oaccess to nutritious ood and a henvironment. Health authorities thereore concluded the consistehigh rates are due to a lack o cpractices.

ACFs programmes thereore oon care practices and includethe ollowing activities: care owomen, advice on breasteedingand complementary eeding, oopreparation, psychosocial careo children, hygiene and homehealthcare.

i p h v

Ensuring sustainability meanstranserring skills and knowledge tolocal sta and providing materialsor use in uture training sessions.Where possible ACF sta involve localhealth proessionals and volunteers intraining sessions to oster partnershipsand educate more people about the

importance o good care practices.

With the support o the localgovernment, ACFs approach to carepractices is being promoted throughall health centres. Since July 2012,training programmes have beenrolled out across the six barangays(districts) o the city. From now on,when parents take their children tohealth centres or vaccinations orpregnant women go or check-ups,there will be dedicated spaces or themto learn about and improve their care

practices. The results o this careullycoordinated eort have been verypromising so ar. At one health centre,the number o pregnant or breasteedingmothers visiting the programme roserom 930 to nearly 1,200 in the monthollowing its introduction.

Along with other aid agencies in thecountry, ACF has also contributedto the development o the Philippinegovernments Emergency NutritionProgramme toolkit or the use ohealth workers. While the toolkit is not

yet fnalised, learnings rom ACFsresponse to Typhoon Bopha in late 2012have contributed to its development.Like Typhoon Washi, ACFs immediateresponse to Typhoon Bopha includedestablishing emergency care practicesprogrammes to provide privacy andadvice to mothers and athers withyoung children who had lost everything.

ACF has the potential to transormthe way amilies meet the essentialneeds o their children but the successand sustainability o this programme

will depend on the commitment oall involved rom parents andhealthcare workers to local authoritiesand national government.

Learn more about care practicesand ACFs work in the Philippines:www.actionagainsthunger.org.uk/carepractices andwww.actionagainsthunger.org.uk/philippines


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Weak health systems in low and middle-income countries can be aleading cause o child undernutrition. Action Against Hunger (ACF)

works with ministries o health and local health authorities to bolster theircapacity to address the condition. One way is to work with governmentsto help them integrate the Community-based Management o AcuteMalnutrition (CMAM) approach, which can help correct and preventthe long-term impact o severe acute malnutrition on a community.

Strengthening

health systems


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National healthcare systems that havebeen weakened by civil wars, naturaldisasters or political instability are otenboth the cause o undernutrition andthe reason why it persists. In countrieswith weak health systems child mortality,illness and undernutrition are common.Political leaders in these countries needto make a frm commitment to buildinghealth systems that are strong enough toprevent and treat diseases and maintainthe lielong good health o all men,women and children indiscriminately.This includes addressing the causes andeects o undernutrition.

Many national governments are startingto work with international agencies,donors and the private sector to increasethe ability o their health systems todeliver better outcomes. In countries withhigh rates o acute malnutrition, ACFuses the six building blocks o the WorldHealth Organisations Framework orAction (see box on page 28) as a guideto support and strengthen a countryshealth system.

Strengthening a health system is acomplex process requiring long-termcommitment. Signifcant improvementsin the overall health o the populationmay not be seen or several years,but will beneft the whole communityor generations to come. As with alldevelopment initiatives the process mustbe tailored to the individual community.A programme that sees success inone location will not necessarily suitanother and there is every chance thatinitial activity will need to be tested andredesigned beore any benefts begin totake eect.

cmm-b pph

The Community-based Management oAcute Malnutrition (CMAM) approachpromotes the treatment o acutemalnutrition within communities and thehome. It helps malnourished childrenaccess the treatment they need, withoutthe need or their parents or carers to

make long trips to hospitals.

As the name suggests, CMAM mustbe managed within the community.Health centres will still be neededto treat children with severe acutemalnutrition (SAM), but volunteers romthe community (known as CommunityHealth Workers) can provide essential

support. The CMAM approach meansthat tens o thousands o acutelymalnourished children can receive thetreatment they need at home or withintheir community beore their conditionbecomes critical.

In 21 o its missions around the world,ACF works to strengthen health systemsby promoting and integrating the CMAMapproach. Crucially, this means that the

improved health system will have thecapacity to continue the work whenACF leaves the country or region.

M p n

Nigeria has, ater India, the secondhighest number o acutely malnourishedchildren in the world. It is particularlywidespread in northern Nigeria wherean estimated 800,000 young children(European Commission, 2010) suerrom SAM the most deadly orm o

hunger. Throughout 2012, ACF workedwith the local health authorities o YobeState in northern Nigeria, to integrateaspects o the CMAM approach into itshealth services.

sTrengThening A heAlTh

sYsTem is A complex process

requiring long-Term

commiTmenT

Beore ACF arrived in Yobe State, the

knowledge and skills to diagnose andtreat SAM in children were limited tospecially trained nurses and doctorsin regional hospitals. ACF ocused ontraining individuals and groups whowere in the best position to tackle acutemalnutrition in the predominantly ruralcommunities. This included trainingministry o health and local healthauthority employees to identiy and treatthe condition, and helping communityhealth workers, volunteers and keyindividuals such as village chies,traditional healers and hairdressers

oten the hub o inormation sharingamongst women in communities toidentiy SAM and reer children ortreatment. On ACFs recommendation,local health authorities organised streettheatre sessions in markets and eatureson radio shows to educate the generalpublic about what acute malnutrition isand why it is so harmul to children.

wHat isa HealtHsysteM?

A health system includes all theorganisations, institutions andresources whose primary purpois to improve the health o the lopopulation. A good health systeshould make tangible improvemto peoples lives every day.

For example, a mother who givechildren Vitamin A and dewormtablets twice a year to prevent lithreatening illness is benefting

a health system. The same is truamily accessing clean water at maintained village water pump by a government-sponsored sanproject, or a child with severe acmalnutrition who receives readyto-use therapeutic ood, nutritiocounselling and regular check-uan aordable or ree clinic.


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have escalated in recent times, thesecurity risk to ACF sta has thereorebeen reduced.

a f p h p

ACFs work in northern Nigeria is anexample o how strengthening healthsystems, rom state to community level,can provide local communities withlong-lasting, sustainable access tothe prevention and treatment o acutemalnutrition. Its experiences in YobeState also show that health systemscannot simply be defned as a governingbody, proessional health workers and

the hospitals or health centres thatdeliver health care. They also includethe community members themselves.

The process o strengthening Nigeriashealth system to deliver a key eature othe CMAM approach is still in its inancybut the impacts o the changes initiatedby ACF are already evident. It can takeyears to see the positive, long lastingimpacts o successul interventions.However, ollowing many years oexperience in dierent countries, ACFhas learned how to meet the immediate

needs o aected communities whilstat the same time building the countrysability to tackle the problem on its ownand to make progress in eradicatingacute malnutrition or good.

ACFs support was not limited totraining and raising awareness. Italso helped mainstream the CMAMapproach in local health services bystrengthening other health systembuilding blocks. For example, it assistedwith the logistics o supplying essentialmaterials and therapeutic oods toremote communities, supported datacollection and analysis, and advisedhealth authority managing bodies onleadership and governance.

The benefts o ACFs work to integratethe CMAM approach into Yobes healthsystem are clear. In 2011, beore ACFstarted to support the health system,around 11,000 children receivedtreatment or acute malnutrition. In 2012,the frst ull year o the programme, thisgrew to 23,000 and, with more childrencoming to health centres, immunisationagainst preventable diseases increased.The integration o CMAM also boostedthe reputation o the health acilitiesand the credibility o health workerswithin the community. Health workersare now thanked by community leadersor the work that they do to tackle acute

malnutrition, instilling in them a senseo pride.

As local health authorities andcommunities in remote areas learnedhow to tackle the condition without theneed or direct support, ACF was ablegradually to close feld ofces. In aregion where civil insecurity and unrest

six BuildingBlocks For aFunctioningHealtHsysteM

The World Health OrganisationsFramework or Action identifessix components.

1. sv v

The provision o eective, sae, qualityhealth interventions to those whoneed them with minimum waste oresources in hospitals, health centres,pharmacies, operating theatres andcommunity-based groups

2. spp m p,v ppph

3. Hh

Sufcient personnel at all levels romnurses, doctors and nutritionists toporters and ambulance drivers who areevenly distributed to provide efcient,air and responsive health care

4. Hh f

5. Hh m m

The production, analysis, disseminationand use o reliable and timelyinormation on the local populations

health, health system perormanceand health status

6. lhp v

Ensures that strategic policyrameworks exist and are combinedwith eective oversight, coalition-building between key stakeholders,regulation, attention to system designand accountability

Credit:ACFDRC,CourtesyofRLeeney

Listen to Saul Guerrero, ACF UKs Head oechnical Development, talk more aboutintegrating CMAM into health systems:www.actionagainsthunger.org.uk/cmamaudio


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Karl Lellouche & Dr. JeanLapegue are water, sanitation andhygiene (WASH) advisors based in

Action Against Hungers Paris ofce.In this interview they explain whyaccess to clean water is essential orchildhood nutrition.

aking action on water, sanitation and hygiene

o hwasH


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H b h b wasH ?

It is a massive problem, and it is growing. Across the globea staggering 2.5 billion people do not have access to basicsanitation and 783 million have no access to clean water(UNICEF & WHO, 2012). Around 3.5 million people dierom waterborne diseases every year.

Children are at most risk: diarrhoea kills 1.2 million children

under fve each year, 80% o whom are aged two or less, andtogether with cholera it kills more children than Aids, malariaand measles combined.

Waterborne parasitic inections also aect two billion people;they are not always deadly, but reduce nutritional intake, anddamage overall health and cognitive capacity. Treating themuses a signifcant proportion o health budgets.

H , h h hh?

Clean and abundant water, good sanitation and appropriatehygiene are key to maintaining a healthy environment,especially or a child. Without access to basic sanitation andclean water or drinking, cooking and cleaning, children aremore likely to suer rom diseases such as diarrhoea andparasitic inections.

Diarrhoea reduces the bodys capacity to absorb nutrients,diminishes appetite and increases dehydration, leading toundernutrition. This weakens the immune system and makesthe body more vulnerable to inections. Parasitic inectionssuch as intestinal worms and malaria, caused by inadequatesanitation and hygiene, can lead to anaemia and impedephysical and cognitive development, which can ollow a childinto adulthood.

Credit:AC

FDRC,courtesyofJanaAsenbrennerova



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Collecting water uses valuable resources both time andmoney. Those without access to a clean water source may needto buy it rom vendors, leaving less money or ood, essentialmedicines or hygiene products, like soap. Time spent collectingwater takes time away rom other activities, such as education,which can have a lielong eect on a childs wellbeing andeconomic status. It can also put them at risk or examplewomen and girls are oten assaulted while collecting waterar rom their dwellings.

i pb h , ,

h p ?Water, sanitation and hygiene are interdependent and shouldnot be separated in any programme tackling water-relateddisease. Diseases like diarrhoea spread through contaminateddrinking water or ood, or direct or indirect contact withaeces, either via vectors in the environment (such as ies) orinterpersonal contamination (the hands and clothes o others).Drinking water needs to be protected rom human and animalwaste with eective sanitation; and good hygiene practices withclean water avoid recontamination.

A sae WASH environment is particularly important orbreasteeding mothers, reducing the unnecessary strain o

collecting water, helping to avoid illness and acilitating positivecare and hygiene practices, such as bathing babies.

a h p acF wasH pmm?

Two main actors inuence ACFs decision to initiate WASHprogrammes in communities.

In the atermath o natural disasters or when amilies eeconict, the quantity and quality o water tends to be low andthe sanitary environment poor, increasing the risk o epidemicsand water-related disease. To prevent health crises ACFbuilds emergency latrines, provides hygiene kits or amiliesand delivers clean water directly to communities via trucks or

temporary water bladders.

In rehabilitation (post-emergency) and non-emergency contexts,WASH programmes are implemented alongside nutritionprogrammes to support the treatment o undernutrition andprevent inections. This involves longer-term measures toimprove clean water supply and sanitation, including buildinglatrines, installing water pumps and improving drainage, with astrong emphasis on the communities themselves taking controlo the ownership and maintenance o these acilities. Teamsalso promote important hygiene awareness-raising to amiliesand children at schools, in health centres or at home, especiallythrough community health workers.

In its eorts to provide communities with sustainable access toclean water and adequate sanitation, ACF also promotes theright to water and sanitation at national level. The right to waterand sanitation was ormally recognised as an internationalhuman right in 2010. ACF encourages governments to ormallyenshrine the right in national law and provides them with thenecessary guidance to do so. In this way communities can holdtheir government to account when they ail to provide a cleansupply o water and adequate sanitation.

actionagainsthunge

impm wasH mm

Increasingly, ACF and other international organisations recognising the need to implement nutrition and WASHprogrammes together.

In Mali, UNICEF has estimated that almost 210,000 chsuered rom severe acute malnutrition in 2012 and thao these cases were linked to diarrhoea and other waterdiseases. As such they have started to implement WASHactivities alongside nutrition interventions. First they identhose most at risk, usually mothers with severely malnouchildren, and reer them to health centres with their chilor treatment. When the mothers arrive at the health ceUNICEF sta treat their children and give each o them hygiene kit with instructions on their use. The kits contaisoap, water purifcation tablets, jerry cans to store watea bucket with a cover. Such simple equipment enables pto puriy water at home and practice basic hygiene, sucwashing hands. At health centres, amilies are also ableaccess clean water, hand-washing points and clean toile

Families are then visited once a month to ensure that thwater is being properly stored and treated.

These measures go a long way to ensuring that the bespossible WASH conditions are in place so that one o thprominent underlying causes o undernutrition can be aACF is piloting an integrated programme like this one, as a WASH in Nut programme, in its Niger mission.

Learn more about our WASH programmes: www.actionagainsthunger.o


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PERU

c

Drawing on Action Against Hungers experience in the Peruvian Andes,

Bronwen Gillespie explores the importance o considering cultural

actors in the ght against hunger and presents some key conceptsgoverning ACFs approach to tackling anaemia in children in the region.

Grasping local traditions to fght hunger

Credit:ACFPeru



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Credit:ACFPakistan,courtesyofNSobecki



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Women are the cornerstone o anutrition. Preventing childhoodundernutrition starts with them.It is usually women mothers,grandmothers, daughters and au who take the lead in caring orchildren and who produce, prepand distribute ood to the wholeamily. Despite this, in many couwomen have little inuence on h

the amily income is spent and laaccess to proessional advice on to care or children. This is why Aocuses on empowering women actively participate in eorts to taundernutrition.

F mpm

ACFs experiences indicate that ware more likely to make best usethe limited resources their househave. In Bangladesh women usemore productively and wisely thapreerring to spend it on schoolinnutritious oods. The evidence is strong or agriculture, with emaarmers more likely to take on nearming techniques than men, anlikely to employ unnecessary lab

In northern Uganda, ACF suppoeconomic empowerment o womreduction o gender-based violenby promoting gender equality wiawareness-raising sessions and tFemale entrepreneurship is encothrough cash grants, training in

and management skills and acceloans. As a result, participants haenjoyed better income and agricproduction and many have set uand other micro-enterprises.

Women in the region are now abaccess social services and healthmore readily than beore. With rfnancial pressures, ewer couplenow fghting and decision-makinincreasingly shared between cou

F

Compelling evidence rom a randeveloping countries proves thateducation makes the single greacontribution to bringing down rachild undernutrition (Smith and H2002). However in many societiewomen do not even have accessbasic education.

Morwenna Sullivan, Senior Food Security Advisor or

Action Against Hunger (ACF) in London, explains thevital role women play in building a world ree romhunger and how ACFs programmes empower emalecarers to access the skills and knowledge they need togive their children a healthy start in lie.

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gm P

Farzana works as a CommunityMobiliser in Sindh Province,Pakistan. She visits villages to identiyundernourished children and reer

them to treatment centres, and sheraises awareness o undernutritionamong carers o children.

As a woman, Farzana is not allowedto share the back seat o a car witha man and so inventive methodsare needed or her to travel aroundthe district. When she works awayrom home or a number o days,ACF arranges transport andaccommodation or both her anda male relative.

In some cases the same customs canwork to her beneft. Unlike her malecolleagues, Farzana can visit homesand acilitate group sessions inside thevillages. To conduct the same activities,Amir, a male Community Mobiliser, hasto stop at the village entrance and askthe men to bring mothers and childrento him. In some cases, he isnt evenable to speak directly to the women.

While these considerations do notmake ACFs work impossible, theydo increase programme costs. To

address the barriers preventing womenrom travelling independently to takechildren to treatment sites, or romattending Farzanas awareness-raisingsessions, ACF engages with the Imam,the religious leader in the district,to explain its activities and how theybeneft the community. Simple actionssuch as this can do much to improvethe eectiveness and impact o ACFswork in Pakistan.

Deeply entrenched cultural belies candetermine what children are given to

eat and drink and oten increase therisk o undernutrition. In Aghanistan,it is common or women to eed theirbabies tea beore they are six monthsold but i made with contaminatedwater this can lead to diarrhoea, a causeo undernutrition. In South Sudan, acommon belie is that i a mother whois breasteeding becomes pregnant, herbreast milk becomes polluted and willmake the inant ill. She may thereorestop breasteeding early, putting herchild at risk.

For mothers o children suering romacute malnutrition, ACF organisestraining sessions on health and child-eeding practices. Women are taughtessential skills to improve nutritionat home, ranging rom cookerydemonstrations using local oods, towork in vegetable gardens where theylearn how to grow ruit and vegetablesand store and process the oodsaely. These sessions give women theindependence they need to manage thenutrition and health o their amilies.

n , hACF has recently started nutritiontreatment programmes in Yemenwhere 58% o children are estimatedto be chronically malnourished thesecond highest rate in the world aterAghanistan. Customs and culturalpractices in some parts o Yemen governwhat women can and cannot do. ACF is

thereore working with communities andauthorities in the country to tackle childundernutrition in the most appropriate,and culturally sensitive, ways.

In many cases women are not allowed toleave their home without their husband ora male relative. So i a child is sueringrom acute malnutrition, they must beaccompanied to ACFs TherapeuticFeeding Centre by both parents. This can

mean a signifcant cost as the householdloses a days income. It also means thatmothers who stay at home are unlikelyto hear about nearby eeding centres.Similar traditional practices exist in theSindh province o Pakistan, limiting themovements o mothers and ACF emalesta members (see case study).

To reach as many children as possible,ACFs mission in Yemen thereore needsto careully consider how to implementprogrammes in a way that respectstraditional practices. One solution is

or health workers employed by ACFto make house-to-house visits to raiseawareness about undernutrition amongsthousebound women and to reer anyacutely malnourished children they fndto the eeding centres.

th

ACFs experiences show that the activeinvolvement o women in education,income-generating activities and themanagement o household incomeconsistently contributes to lower rateso undernutrition, and ultimately tostronger development o nations.O course, to achieve this, it is notenough to engage with women alone.Men too must be part o the discussions,to build the trust and understandingacross communities that is needed tomake a lasting positive impact.

All ACFs missions work hard toappreciate the gender dynamics othe communities they work with. Withthis crucial knowledge they are in abetter position to design programmesthat empower and educate women,equipping them with the necessary skillsto care or their growing children, detectthe early signs o undernutrition andhave the confdence to act to protecttheir childrens health.

Credit:ACFPakistan,courtesyofJFriedman

Find out why investing in small-holderarmers, especially women, matters:www.actionagainsthunger.org.uk/womenarmers


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For centuries weve known that hungers causes, and solutions,are overwhelmingly within human control. More recently,its the relationship between the citizen and the state that hasbecome the ocus or those campaigning to create a world reerom hunger, as Food Security Expert Bapu Vaitlaexplains.

In 1632, in the atermath o oneEnglands last great ood emergethe Archbishop o Canterbury, WLaud, grimly noted that last yeaamin was made by man and noGod (Walter and Wrightson 197Laud was speaking o grain hoalocal merchants that resulted in d

amilies not being able to accessaordable ood, but his condemcould have been broader. He coalso pointed to unaccountable pofcials ailing to provide ood reto the inequality in land ownershorced small armers to live tenubetween meagre harvests; to theo legal avenues by which poor could argue or the simple justicesurviving a bad harvest.

Nearly our centuries on, the geoo hunger has changed Europe

not known peacetime amine sinFinnish catastrophe o the late 18 but the political nature o its cahas not. From market manipulatto apathetic bureaucrats to wealtinequality; all continue to persist todays landscape o undernutritin the developing world. Marketsand states continue to work primCr

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as

The Right to Food in todays world

Hunger

citizenship

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or those strong enough to inuencetheir unctioning, and the rest o thepopulation oten reaps little o the gainso economic and technological change.Even those amilies lucky enough to beassisted by aid organisations remain,ultimately, in a powerless position. Gitsare accepted, but the threat o the nextharvest ailure hovers, and uture welarcontinues to depend on the choices othe powerul.

In contrast, where amine andundernutrition have been deeated inthe world, a recognition o citizenship,rather than simply that o benefciary orconsumer, has played the central role.Rights-holders have demanded that theielected executives and legislators makegovernment and markets work or themand sought legal redress when theirgrievances went unheard.

The human right to ood is graduallygaining credence in both international

orums and in domestic courts. Theroots o its international recognition liein the Universal Declaration o HumanRights o 1948, which mentions the righto ood in Article 25. This documentinspired the International Covenant onEconomic, Social and Cultural Rights(ICESCR), which was brought into orcein 1976 and makes specifc reerenceto the right to adequate ood. To date160 countries have signed and ratifedthe ICESCR. In recent years, substantivesteps have been taken to assist countrieto realise the obligations o this andother treaties, including the appointmenby the United Nations o a SpecialRapporteur on the Right to Food and theintroduction by the Food and AgricultureOrganisation o guidelines to protect theright to ood.

At national level, treaties can be enorceby the government in a number odierent ways. In some countries, treatietake on the status o national law oncethey have been ratifed by the countrysparliament or equivalent body. In others

ramework legislation needs to bedevised in line with the obligations o thetreaty. An example o this is in Paraguay,whose experience is discussed in the boxon the let.

The strongest orm o domestic legalprotection is, o course, constitutional.Eight countries Bolivia, Brazil, Ecuador

ParaguayIn 2007, with the support o theSpanish government, Action AgainstHunger (ACF) began supportingpublic institutions and civil societyorganisations in Paraguay to develop alaw or Sovereignty, Food Security, andNutrition. Together with a ParaguayanNGO and the National Congress,ACF organised a public hearing togather inormation on what the country

had achieved in pursuit o the right toood. It then went on to run a serieso workshops to drat the frst versiono the law, which was introduced todecision makers at lobbying events andmeetings. The ormal proposal waspresented to President Fernando Lugo,who requested that it be reviewed by theMinistry o Agriculture and Livestock.

Further workshops, organised by theTechnical Secretariat o the President,were attended by representativeso public institutions and armersorganisations rom across the country.These resulted in the developmento another consensus version o theproposal, which was again deliveredto President Lugo. The inclusion oarmers organisations in the process odrawing up policies and plans relating

to ood security and nutrition hasbeen one o the major achievementso the project. Since President Lugospresidency came to an end in June2012, the establishment o the lawhas been on standby, waiting or theapproval process to recommence whenthe new government comes into placeater the April 2013 elections.

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actionagainsthunge

long-term commitment, internationalorganisations can transmit inormationabout best practices rom othercountries, help to build technicaland advocacy capacity, and assistin procuring international resourcesand political support or home-growngroups. Action Against Hunger (ACF) isundergoing a transormative phase in

its own development by promoting andsupporting the implementation o theright to ood in some o the countrieswhere it is present, such as in Paraguay,as described in the box on page 40.

What underpins ACFs approach is itsbelie that ood and nutrition securityare public goods to which all citizensare entitled. Its actions include raisingawareness o the right to ood with localcivil society groups and supporting theiradvocacy eorts to lobby governments.It also supports governments directly to

devise appropriate regulations aroundood security, nutrition and water andsanitation, providing practical advice onthe changes needed to ensure that theircitizens beneft rom the right to ood.

As governments and markets acrossthe world become more credible to allclasses o society as citizens acquiregreater aith in the institutions theyhave created legal norms become anincreasingly powerul way to compelsocial change, especially when the willo policymakers has ailed. The right

to ood is becoming as real and asundamental as the political rights wehave long held dear, and in the decadesto come will guide the fght againsthunger in our world.

india

With the support o the judiciarysociety in India has spearheadeeort to create ormal legal proo the right to ood. Civil societyled reorm frst gained momentuin 2001, when a severe droughthe northwestern state o Rajasth

leading to deaths rom starvatioMeanwhile, ood grain stocks heby the central government wereexpanding greatly, reaching som50 million metric tons by 2002. civil society organisation called Peoples Union or Civil Liberties(PUCL) fled public interest litigawith Indias Supreme Court, assthat the Indian government hadlegal responsibility to release thestocks to the hungry. In particulaadvocates reerenced obligationArticle 21 o the countrys Const

which guarantees the right to litheir arguments were urther boby directive principles within theConstitution that commit the staimprove nutrition.

Over ten years later, a fnal decison the case has not yet been reaBut since the original writ the octhe litigation has broadened. Thejoined with a host o other organto create the Right to Food CampThe Supreme Court released aset o Interim Orders directing th

state to improve the operation oongoing ood and nutrition-relatprogrammes. Special Commissiowere appointed by the court to mwhether administrative authoritiein compliance with the Interim Oand to hear and respond to grievrom citizens. The Supreme Courhas in eect begun the process otransorming ood and nutrition into legal entitlements and has ca ramework or transparency.

Learn more about the Right to Food in an interviewwith Amador Gomez, ACF Spains echnicalDirector: www.actionagainsthunger.org.uk/rt

Guyana, Kenya, South Arica, Nepal,and Nicaragua explicitly include theright to ood as a separate, stand-alone right in their constitution. Othersrecognise the right to ood as anobjective o the state. India alls withinthis category, and the work o civilsociety movements in leveraging judicialauthority to compel ood and nutritionpolicy there is summarised in the boxon the right.

The wide variety o emerging nationalright to ood legislative rameworksteaches us that no one policy blueprintwill end hunger and undernutrition.Dierent countries have dierentneeds. Some ocus on maternal andchild health, others on smallholderagriculture, and still others on socialprotection or poor households.However, some broad patternsregarding the underlying politicalcircumstances in which such changesare taking place can be identifed.

A climate o reorm is necessary, inwhich ofcials are either challenged byopponents wielding the language ohuman rights to describe grievances,or use such language themselves tooer solutions to prevailing inequalities.A strong and independent judiciary,especially at the constitutional courtlevel, is necessary. Perhaps mostimportantly, powerul and mobilisedcivil society organisations are critical.Civil society groups need to be willingto engage all branches o governmentand to devise strategies that combinepressure on policymakers with a visiono electoral rewards or those who wouldsupport the right to ood. In Brazil,or example, the unyielding inuenceo pro-poor social movements andnon-governmental organisations hasslowly but permanently pushed theissues o poverty, inequality and hungerto the centre o the political stage. Theresult, made maniest especially inthe last decade, was the creation o awide range o policies spanning many

dierent sectors which set out to addressthe root causes o undernutrition.

International non-governmentalorganisations also play a key role insupporting domestic social movementsto protect the right to ood. While localcivil society groups oten have theadvantage o contextual knowledge and

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Q. Youve worked for ACF for over two decades. What motivatesyou?A. From my experiences o working in Burma, Tajikistan,Bosnia, Malawi and Zimbabwe I have time and again seenthe hidden, devastating physiological impact hunger has onchildren. Acutely malnourished children are extremely weak.The frst thing you notice when entering a treatment centre ishow still and quiet they are.

The eects o undernutrition are irreversible. I childrendont develop as they should in the frst critical 1000 days otheir lie they will not grow into healthy adults. This severelyimpacts their ability to raise a amily and provide or theirown children. Thereore addressing undernutrition is not onlya moral imperative, it is an investment in the uture economyand prosperity o a country.

The good news is that we know how to treat acutemalnutrition. Plenty o evidence, built up by ACF and itspartners over past decades, proves this. The challengeis to improve access to the treatment and prevention oundernutrition to the millions who desperately need it. Inyears to come, uture generations will look back and wonderhow we could have ailed to act. ACF is determined to endundernutrition once and or all.

Undernutrition is a problem which many fail to grasp. How canwe address this? The lack o understanding in poorer countrieso what undernutrition is, and the impact it has, is one o thereasons why it persists. Many amilies need to be taught howto recognise it and what to do about it. Basic advice on howto prevent the condition can be liesaving. The governmentso these countries also need to acknowledge the problem anddevelop comprehensive plans to address it. Beyond the words,there should be actions.

In countries like the UK, the stream o images o starvingchildren in destitute communities has led to public atigue. Itsnot that people dont care people just eel powerless. Theywonder i previous work to fght hunger has ailed and lose trustin the work that aid organisations do. In response we show oursupporters the positive impact o our work and the amilies wehave helped. There are plenty o successes in the global eort

to eliminate hunger which we need to shout about. However Idont think we should stop inorming people about the harshreality o acute hunger. We dont want to create a veil odecency to hide the atrocities that continue to happen.

What must be done to reach all malnourished children? Nationalgovernments, international donors and institutions, NGOs andcommunities need to have the motivation and, critically, mustcommit to ending undernutrition. Without commitments andstrong accountability, eorts to end undernutrition will go nourther than good intentions and pledges.

The UNs Scaling Up Nutrition Movement has generated muchneeded momentum to tackle undernutrition at the internationalevel, by ostering international collaboration betweencountries, UN organisations, civil society and the private sectoWhether this translates into concrete actions that improve thesituation in households and communities remains to be seen.The momentum is there, but we need unding and commitmento put words into action.

Sustained, long-term unding must thereore be dedicated toimproving nutrition and delivered to the communities that needit most. Around $11.8 billion is needed every year on top owhat is currently being spent to address the immediate causes oundernutrition in the most vulnerable areas o the world. HoweveACFs recent Aid or Nutrition report series ound that between2005 and 2009 less than one per cent o this amount wasdelivered annually. I the necessary unding was divided across alcountries and multilateral organisations, each would be making arelatively small contribution. Combined, these contributions wouldsave the lives o hundreds o thousands o children.

Finally, and perhaps most importantly, pregnant and lactatingwomen and children under fve must be at the core o anypolicy, strategy and plan o action. It is they who will participatin and beneft rom these investments directly. Concrete actionat community level are central to maximising the impact othese investments and to achieving universal coverage or thetreatment o malnourished children.

Jean-Michel Grand, Executive Director o Action AgainstHunger (ACF) in the United Kingdom, explains why action onundernutrition must become a priority or international leaders.

Last word

Making the airwaveswith nutrition

Read Jean Michels ull interview: www.actionagainsthunger.org.uk/jmginterview



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a a H | acF i

Action Against Hungers vision is o a world without hunger. A world in whichall children and adults have sufcient ood and water, equitable access to theresources that sustain lie, and are able to attain these with dignity.

acF-ukFirst Floor, Rear Premises161-163 Greenwich High RoadLondon, SE10 8JAT: +44 (0) 208 293 6190www.actionagainsthunger.org.ukReg. Charity no: 1047501

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4 rue Niepce75662 Paris Cedex 14T: +33 (0) 14335 8888www.actioncontrelaaim.org

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