Hunger Watch Report 2007-08: The Justice of Eating

Hunger Watch Report 2007–08 The Justice of Eating – the Struggle for Food and Dignity in Recent Humanitarian Crises Edited by

Samuel Hauenstein Swan and Bapu Vaitla Foreword by

Dr Stephen Devereux

Pluto

P

Press

LONDON • ANN ARBOR, MI

in association with

Action Against Hunger

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First published 2007 by Pluto Press 345 Archway Road, London N6 5AA and 839 Greene Street, Ann Arbor, MI 48106 www.plutobooks.com Copyright © Action Against Hunger 2007 The right of the individual contributors to be identified as the author of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Hardback ISBN-13 978 0 7453 2747 1 ISBN-10 0 7453 2747 8 Paperback ISBN-13 978 0 7453 2746 4 ISBN-10 0 7453 2746 X Library of Congress Cataloging in Publication Data applied for

This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. 10

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Contents

About Action Against Hunger Acknowledgements Foreword by Stephen Devereux Preface by Richard Cockett 1 Introduction: A Life Worth Living Report Summary 2 The Burden of Survival: Inside the Pain of Darfur’s Livelihood War A War of Poverty and Politics, not Ethnicity We Were No Longer Welcome: Stories from Darfur’s Livelihood War Refugee Camps, or Urban Slums? The Lives of Darfur’s Displaced Protecting the Right to Food in Darfur: Shortand Long-Term Solutions 3 Free Markets, Imprisoned People: Niger and the Dangers of Deregulation Market Forces and Malnutrition Market Emergencies are not Inevitable: Options to Reverse the Tide

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16 19 20 23 28

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4 Portraits of a Pandemic: Families on the Abyss in Zambia and Malawi The Cross-Impacts of HIV, Malnutrition and Poverty Protecting the Health of HIV-Positive Children The Dangers of Discrimination The Importance of Water Access in the Fight Against Malnutrition

49 54 58 60 63

5 The Meanings of Dignity: Quiet Tragedies and Indomitable Spirits in Ethiopia

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6 Postscript: Conscience and Power

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Notes and References Notes on Contributors Index

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About Action Against Hunger

Registered charity number 1047501

Hunger, famine, HIV/AIDS, global warming, genocide for political or religious gains – these are issues that grab news headlines and our attention every day. In a world of plenty, close to 1 billion people still do not have access to enough food to eat. This is an affront to human dignity and raises the question ‘Is there any justice left in the world?’ I am afraid not. The image of a young mother cradling her malnourished child whose beautiful but accusing eyes stare straight in to one’s soul haunts me. Who should we hold responsible? The so-called civilised populations of the developed world? Politicians? It is a difficult question to answer, but I do know that you and I through Action Against Hunger can make a difference and touch the lives of many, many people. We can work together and give those in need not only food as immediate relief, but sustainable, long-term assistance that will help them to build a better future. The Carluccio’s organisation is actively supporting Action Against Hunger and I hope that you too will join us. My vii

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personal proposal: Give up on your favourite treat or dessert once in a while and make a contribution to the fight against hunger. You will be happy knowing that your effort will bring a smile to the face of a deprived child. Thank you for your help. Commendatore Antonio Carluccio, OBE

ACTION AGAINST HUNGER For over 25 years, Action Against Hunger has been at the forefront of the fight against hunger and malnutrition worldwide. Its vocation is to save lives, especially those of malnourished children, and to work with vulnerable populations to preserve and restore their livelihoods with dignity. Action Against Hunger’s activities include the diagnosis, treatment and prevention of malnutrition, as well as food security, water and sanitation and basic health programmes. An international, non-political, non-religious and non-profit-making organisation, Action Against Hunger helps more than 4.2 million people in 43 countries worldwide. In 2005, Action Against Hunger launched Hunger Watch, its research and advocacy department. For the past year, Hunger Watch has looked at the causes of, responsibilities for and responses to current food crises. Over the course of this project, the Hunger Watch team has examined transversal factors such as conflict, market instability and HIV/AIDS and analysed their linkages to acute hunger. Hunger Watch has visited households affected by malnutrition to collect first-hand testimonies and engage in discussions pertaining to the experience of living with hunger. Hunger Watch has also

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set up a comprehensive Nutritional Geodatabase as a tool for comparing the extent and severity of nutritional crises across the globe. The department’s findings are presented in this publication.

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Acknowledgements

This report would not have been possible without the help of many people. Foremost, we would like to thank the families from Sudan, Niger, Zambia, Malawi and Ethiopia who allowed us to use their words and images for the testimonies compiled in this report, particularly Asha Suleiman, Awa Abdallah and Hawa from Sudan; Harouna Zaroumai and Zeinou Issafou from Niger; Beauty Ziko and Ivy Mwansa from Zambia; Aragash and Shunkay Yutata, Yohannes and Abarash Niammey, Werekey and Bekelur Dika, Obeshet Gussesa, Dotora and Asada Fenoga, Asfew Gelecha and Aleku Makonnen from Ethiopia; and the many others who have chosen to remain anonymous. We hope that this report proves to be of benefit to these families and their communities. Claire de Menezes would specifically like to thank Jennifer Organ, Children in Distress (CINDI), the Malawian organisation REACH, Pamela Fergusson, Nynke Nutma and the Ministry of Health and Population in Malawi. Raj Rana would like to thank the Action Against Hunger team in Nyala, as well as all the beneficiaries in the surrounding camps for talking openly on questions that evoked such painful memories. Paul Rees-Thomas would like to thank Tewodros Eshetu and the Action Against Hunger team in Addis Ababa. The editors would like to acknowledge their debt to the many individuals inside and outside of Action Against x

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Hunger who provided editorial and other valuable assistance in the creation of the report: Christine Kahmann, Natalie Duck, Suan Khaffaf, Chris Jones, Angelina Lawrence, Henri Leturque, Mariana Lobo Merelo, Inma Manas Hueto, Josh Colston, Menaka Raman, Shona Kriss, Milair Ryalls, Christina Torres-Eve, Milo Douglas, Emanuela Ferrari, Eliza Anyangwe, Monika Vrsanska, Alan Martin, Harry Ingram, Alison Hauenstein Swan, Julia Cohen, Tree Kilpatrick and many others. Finally, special thanks to Antonio Carluccio, Richard Cockett and Stephen Devereux for their contributions.

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Foreword Stephen Devereux

Hunger is undignified. Hunger is injustice. Only by talking with people who suffer hunger do these harsh truths become real. The Hunger Watch Report 2007–08 combines analysis of the causes of hunger in several African countries with personal testimonies from families who face hunger, or the threat of hunger, on a daily basis. This book presents a powerful indictment of the local institutions, national governments, international agencies and policies that allow hunger to persist in the contemporary world. Hunger is often analysed as a technical problem, as ‘chronic’ or ‘transitory’ ‘food insecurity’ that requires ‘consumption smoothing’ or ‘safety net’ programmes to minimise malnutrition statistics. It is humbling to be reminded that hunger has a human face, that every day millions of people are forced to make heartbreaking choices about who in their family eats and who does not. This report examines the indignity and injustice of hunger in Ethiopia, Malawi, Niger, Sudan and Zambia. It concludes that the right to food is a matter of social justice and human dignity. Who could possibly disagree? There have been some successes in tackling hunger in recent decades, and these should be recognised and applauded. Famine has apparently been eradicated from South Asia, and trends in poverty and food insecurity are positive in most parts of the world. Civil society and non-governmental xii

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organisations have contributed to realising the right to food and forcing this issue up domestic and global policy agendas. The Millennium Development Goals (MDGs) are concentrating minds and mobilising public resources around the reduction of poverty and hunger. But in much of sub-Saharan Africa the trends are moving too slowly or even in the wrong direction and, far from being eradicated, food crises are now occurring in countries that were not historically famine-prone (Malawi, Zambia) or where famine was thought to have been successfully eradicated (Niger). In the Horn of Africa (Ethiopia, Sudan), vulnerability to hunger and famine is as deep and persistent as ever. All five countries featured in this report have suffered major food crises within the past ten years. Yet four of the five are multi-party democracies. Amartya Sen, the Nobel Prize-winning development thinker and famine theorist, famously argued that no substantial famine has ever occurred in a democratic country, no matter how poor. Democracy implies accountability and a ‘social contract’ between states and citizens, which is built and enforced by campaigning opposition parties and the critical scrutiny of a free press. Democracy also gives citizens the right to vote a government out of power if it fails to protect them against gross violations of basic human rights, such as the right to food. Of course, these are very young democracies that have yet to be consolidated. The democratic transitions in Ethiopia, Malawi, Niger and Zambia all occurred during the 1990s. The institutions of democracy are weak and the state’s ability to respond effectively to poverty and hunger is severely constrained. In all four countries, the responsibility for preventing famine and hunger has become shared between national governments (who are accountable to local

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citizens but lack capacity to respond to their needs) and the international community (who have the response capacity but are unaccountable to local citizens). This diffusion of accountability has left millions of Africans more vulnerable to hunger, not less. The failure of the transition to democracy in Ethiopia, Malawi, Niger and Zambia to ensure the right to food for all, as documented in this report, is not an argument against democratisation as a desirable process. On the contrary, it is an argument for a deepening of democratic accountability, not only by national governments but also by international actors. In countries with immature political institutions and weak state capacity, the international community must be held accountable for the policies it advocates – at the very least, responsibility must be shared. Many policies that were imposed on reluctant African governments by donors through aid conditionalities have proved detrimental rather than beneficial in terms of their impacts on hunger. One example is the structural adjustment reforms that aimed to reduce state interventionism in the agricultural sector and promote the role of private sector alternatives. Agricultural seasonality is a defining characteristic of rural livelihoods in Africa, and a direct cause of hunger. Reliance on a single harvest as their main source of food and income results in annual ‘hunger gaps’ that force poor farming families to consume their next harvest prematurely – as Aleku Makonnen from southern Ethiopia explains in the introduction to this report. African governments were well aware of seasonality, and implemented various measures to ameliorate its worst consequences, including grain reserve management and food price subsidies. Parastatals were mandated to buy grain after harvest and sell it back onto

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local markets six to eight months later at cost price, to stabilise food supplies and prices. By legislating a minimum ‘floor’ price for producers and a maximum ‘ceiling’ price for consumers, governments provided incentives for farmers but kept food prices affordable for the poor. But these public interventions in agricultural markets contradicted the neo-liberal principles of ‘Washington consensus’ thinking, which dismissed institutions like parastatals and grain reserves as inefficient and corrupt, and policies like price subsidies as unaffordable and undermining of private sector development in poor countries. So parastatals and grain reserves were scaled down, abolished or run on a commercial basis, and subsidies were phased out. The intention was to provide incentives for private traders to step in and provide ‘market-oriented food security’. When traders failed to do so, this paved the way for what this report labels a ‘market emergency’ in Niger, a phrase which also accurately describes the catastrophic market failures that preceded the recent food crises in Malawi. It is time to reconsider these failed policies, and to move towards a more balanced partnership between government, private sector and civil society actors in providing food security and freedom from hunger. Ethiopia, Malawi, Niger and Zambia are highly dependent on international donors, with close to half of their annual budgets funded by ‘development partners’. These governments have done everything asked of them by the international community, from economic liberalisation to public sector reform to political transformation. Nonetheless, appeals for emergency assistance by Ethiopia in 1999/2000, Malawi in 2001/02 and Niger in 2004/05 were ignored until it was too late. Instead, in Malawi the

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International Monetary Fund (IMF) advised the government of Malawi to sell the Strategic Grain Reserve, and in Niger the government was required to impose a 19 per cent tax hike on staple foods in early 2005, as an IMF conditionality for budget support. Only after protest marches in the capital, Niamey, in which demonstrators carried signs reading ‘We’re hungry, help us’, were these starvation taxes revoked. Fundamental questions must be raised about the nature of democracy in such highly aid dependent contexts with such interventionist donors. If the international community stands accused of intervening inappropriately in terms of the policy advice it gave in Niger and Malawi, it stands accused of intervening inadequately in the case of Sudan. In Darfur, where food is a weapon in a ‘livelihood war’, hunger is closely associated with violent death – people who venture out of internally displaced person (IDP) camps in search of food, risk being shot and killed. Stopping this conflict is a prerequisite to stopping the hunger, saving lives and restoring dignity. Yet the international community appears disinterested and unwilling to act decisively to stop the terror. This failure amounts to a dereliction of global moral responsibility, and highlights the stark fact that although the technical capacity to prevent hunger and food crises now exists, political will is lacking, and sometimes flowing in the wrong direction. In Darfur there appears to be more political interest internationally in condemning than intervening. Hunger is a silent violence, a largely invisible violation of human dignity and social justice. Hunger can and should be tackled: not just halved, as the MDGs aim to do by 2015, but eradicated as a crime against our common humanity. As this report so powerfully reminds us, the persistence of hunger is an indignity to us all.

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Preface: Hunger and Famine

FACE TO FACE WITH HUNGER As with many people in the rich world, confronted with the televised images of famine and malnutrition from around the globe in the comfort of my own home, I have often been forced to think about the problems of hunger. Indeed, as a person who grew up with Live Aid in the mid 1980s, it has become almost impossible to avoid doing so. And I might even have given some money over the years to help. But I can also say that I only finally understood the reality of hunger and malnutrition when I visited northern Ghana last year. I had gone there to do a story for The Economist on Africa and the Millennium Development Goals. I was taken to a village north of the city of Tamale, one of the poorest regions of Ghana, to look at a new school-enrolment project. The teachers were proud that they had managed to persuade so many girls to come to the school – a perennial problem throughout Africa. So I asked to speak to some of the pupils and we sat down under a tree to chat. But for the naïve Westerner, there seemed to be something wrong. The children were introduced to me as being 17, 18 or even 19 years old. The children I saw in front of me seemed, physically, to be barely into their teens – more like ten or eleven. And, as we struggled to talk, they seemed to be younger even than that lower estimate. It only dawned on me later, and it was confirmed by the local health workers, that what I was seeing first-hand was xvii

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in part due to the physical and developmental effects of chronic malnutrition; life-chances ruined by the physical scarring of a dreadful diet and a lack of food from birth. However hard these children had tried at school, it would be very difficult for them to overcome the legacy of hunger that they have endured for their entire lives, particularly in the early years when cognitive development is at its most crucial. Of course, there was much else to reflect on in Tamale; malaria and other diseases, diarrhoea, AIDS, grinding poverty, to name but some. But it was the way that hunger and malnutrition could so corrode a child’s ability to break out off his family’s cycle of poverty and dependency that really struck home at me. Famine is an appalling tragedy – but the silent killer of malnutrition is just as bad. So I welcome this volume of essays on how to tackle these two worldwide problems and hope that they may contribute, even in a small way, to the eradication of these twin scourges in the future. Richard Cockett, Africa Editor, The Economist

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1 Introduction: A Life Worth Living

Figure 1.1 Traditional coffee serving set, Ethiopia. Copyright © Paul Rees-Thomas.

Despite all the struggles of his life, Aleku Makonnen smiles easily. The fading light of early evening glances off our weary clipboards and tape recorders; Mr Aleku will be the last of some 50 in-depth interviews we have conducted so far this 1

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week in the Sidama area of southern Ethiopia, and we are ready to be done for the day. But being greeted with a warm grin and a steaming cup of Sidamo coffee can do wonders for the spirits of a research team. Soon we are all gathered around the old avocado tree in front of Mr Aleku’s woodand-earth hut, laughing along with our host at stories from decades past, stories of impossibly stubborn donkeys and even more stubborn government officials. Mr Aleku has lived a long time, and there is much to tell. It is dark before we remember that Oh, yes, we have work to do, and, not without a few grumbles, pull out pencils and surveys. We are here to study the causes of hunger in Mr Aleku’s village, and we have many questions: ‘How much land and livestock do you own? How much do you expect to earn from your maize harvest? Did your family have enough to eat this past year?’ Mr Aleku answers each question patiently. He owns a quarter-hectare and one cow; he sold his other cow to pay for his son’s funeral last year. He expects to sell very little maize this autumn; he harvested most of it two months ago before it was completely dry, so that his family could eat the crop in its ‘green’ (but edible) form during the lean season when food supplies were low. One of our researchers, stifling a yawn in the darkness, interrupts the elderly man to ask, ‘Did you know, Mr. Aleku, that if you allow the maize to mature and dry instead of harvesting it green, you will have almost twice the yield available to eat?’ At this, Mr Aleku looks at the researcher and chews a bit of sugarcane, thoughtfully. ‘My friend, that is a wonderful idea’, Mr Aleku says, pausing for dramatic effect. ‘Next year I will wait until I’m dead to eat my maize. I’ll ask my wife to open my mouth and toss in some kernels before they bury me – but I’ll make sure she feeds me twice

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as much as normal.’ For a moment, there is only awkward, embarrassed silence. Then suddenly Mr Aleku howls with laughter, we join in, and suddenly we understand why it is that the old man has been so patient and good-natured with us for the past hour. When one understands struggle, one understands easy smiles. When one understands the meaning of a son dead from malaria, and the meaning of very little to eat for half of the year, then one understands the value of a good cup of coffee, laughing at silly questions, and a peaceful darkness. Life alone is not enough: it must be a life worth living, worth fighting for: a life of dignity and joy. Despite all the struggles of his life, Aleku Makonnen smiles easily. *

*

*

A life of dignity, for all people: this is the hope that lies at the heart of this report. It is true that governments and other participants in ‘development’ often balk at such elusive concepts as dignity. But in the final analysis, building wells to provide safe water, brokering peace agreements and treating malnourished children all share the same basic goal: to protect the possibility of self-respect, of pride in one’s life. It is an indignity to be constantly sick from pathogens in water; it is an even greater indignity to be brutalised by men with guns; and it is perhaps the greatest indignity of all to watch helplessly as your child dies slowly of hunger. In any good thing the world has accomplished in the furthering of human development, we find at the core a victory of dignity. The basic set of freedoms that we call ‘human rights’ are, collectively, the minimum conditions necessary for the

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realisation of dignity. The right to health care, the right to education, the right to free expression – indeed, the entire litany of hopes expressed nearly 60 years ago in the Universal Declaration of Human Rights – all comprise inseparable and interdependent aspects of dignity (see Figure 1.2).1

Right to Life Freedom from Torture and Right to a Fair Trial

Freedoms of Thought, Belief, and Expression

Right to Food

Right to Work

Human Dignity

Right to Housing and Clothing

Freedom from Discrimination

Right to Education

Right to Health Care

Figure 1.2 Human rights and dignity.

As an organisation whose mission is the prevention and treatment of malnutrition, Action Against Hunger is concerned chiefly with one often overlooked aspect of dignity: the right to food. Unlike many of the rights portrayed in Figure 1.2 – for example, the prohibition of torture or

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freedom of expression – the right to be free from hunger has remained largely outside the shelter of public outrage, except during massive famine events such as the Ethiopian catastrophe of 1984. Almost 1 billion people in the world are still chronically hungry, lacking the means to obtain enough food to satisfy their daily nutritional needs. Every year, tens of millions of these – the vast majority of whom are very young children – are pushed by conflict, unstable economies, illness and other shocks into the dangerous condition of acute malnutrition (see Box 1.1). In a world of abundance, why does hunger, and especially acute malnutrition, continue to exist? Or, put another way, what prevents the right to food from becoming a political priority? The primary problem is perhaps one of emotional comprehension. The human heart intuitively understands the horror of premature death – death from war, death from

Box 1.1 What is acute malnutrition? Throughout this report, we refer to the condition of acute malnutrition. A person is said to be ‘acutely malnourished’ if he or she exhibits the condition of wasting: very low body weight as compared to height. Wasting usually results from illness or extreme reductions in food intake. The seriousness of malnutrition in an area is often represented by the statistic of global acute malnutrition (GAM): the percentage of people in a population who fall below a critical weight-forheight threshold. This measurement is most commonly made for children under the age of five. A GAM rate of 15 per cent – that is, 15 malnourished children in every 100 in a population – is considered by Action Against Hunger as grounds for emergency nutritional intervention.

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When a person is dangerously wasted – that is, his or her weight has dropped to such an extremely low point that, without treatment, death within weeks is possible – he or she is termed ‘severely acutely malnourished’ (the corresponding statistic is severe acute malnutrition, or SAM). Death among severely acutely malnourished people often results from associated illnesses such as pneumonia, sepsis (overwhelming blood infection), dehydration or shock. Even for those who receive treatment and survive, severe acute malnutrition has many long-term negative effects, including impaired cognitive and physical development. Action Against Hunger considers emergency intervention to be necessary when the SAM rate in a population has reached 2 per cent.

Figure 1.3 A child suffering from wasting, Malange, Angola, 1999. Copyright © Samuel Hauenstein Swan.

famine. When the lives of innocent people are threatened, many of us react with instinctive compassion. Yet perhaps the brutality of living with hunger, day in and day out, is harder to grasp, to visualise and feel. Thus our first goal in writing this report is to illustrate that hunger is indeed woven

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through with a violence of the highest order, a violence that can be as painful as the most barbaric torture or as mind-numbing as the most severe repression. We make this argument throughout the report, using not only statistics and observer accounts but also the words and emotions of people themselves who have been caught in the midst of recent food emergencies, particularly in Sudan, Niger, Zambia, Malawi and Ethiopia. In addition to providing a clearer look at the violence of hunger, these personal testimonies also show the remarkable courage demonstrated by families in their struggle for food and dignity.

Figure 1.4 Mr Aleku Makonnen, from the community of Bokaso, in the Sidama zone of Ethiopia’s southern region. Copyright © Bapu Vaitla.

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Another obstacle hindering political response to hunger is the perception that the causes of malnutrition are too complex and broad to be addressed effectively. Thus the second objective of this report is to unravel the causal complexities of hunger, to show that the rise and persistence of malnutrition can in fact be understood and analysed rigorously – and that with such understanding, effective response is indeed possible. We especially highlight the fact that too often abstract forces like ‘disease’ or ‘volatile markets’ are blamed for causing hunger, which obscures the fact that human decisions – and, in some cases, the decision of human beings not to act in the face of clear evidence of insults against dignity – underlie these phenomena. If the right to food is to be considered as important as the other human rights depicted in Figure 1.2, then we must take the steps necessary to enforce it, much as we have begun to prosecute the crime of genocide. The process of enforcement must include a careful, systematic identification of the human decisions that lead to the right being violated. Hunger is not inevitable; it is not a predestined product of history. It is rather a breaking of the law of human society – an oftenbroken law, it is true, but a broken law nonetheless. The existence of hunger is, simply put, a lack of justice. Thus the intention of this report is to examine the costs and the causes of malnutrition, particularly in those places of the world that have suffered the most in recent years. We believe that if hunger were seen in the true fullness of its violence, and if solutions were rigorously comprehended – in other words, if each of us deepened our empathy and our understanding – then the fight for food and dignity could indeed be won, throughout the world.

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REPORT SUMMARY Chapters 2, 3 and 4 of this report focus on recent food crises in Sudan, Niger, Zambia and Malawi. We analyse how malnutrition in these crises has been driven by various factors: conflict and the destruction of livelihoods in the case of Sudan, unstable markets in Niger, and the HIV/AIDS pandemic in Malawi and Zambia. Chapter 5 is comprised of in-depth testimonies from households residing in the coffee highlands of south-western Ethiopia, one of the areas of the world at greatest risk of future malnutrition crisis. In that chapter, families tell us in their own words the daily experience of their struggle for food and dignity. Chapter 2, ‘The Burden of Survival: Inside the Pain of Darfur’s Livelihood War’, looks at what are currently the most famous killing fields in the world: the Darfur region of western Sudan. A full three years after United Nations officials termed Darfur ‘one of the world’s worst humanitarian crises’,2 the emergency continues. To date, the war has killed between 200,000 and 400,000 people, and displaced over 2 million from their homes.3 Thus far, the international community’s responses – mainly humanitarian assistance to refugee and internally displaced person (IDP) camps4 and the limited deployment of peacekeeping forces – have been inadequate to protect the right of Darfur’s people to food and dignity. The popular characterisation of the war in Darfur as an ‘ethnic’ conflict between ‘black African’ and ‘Arab’ populations obscures a more complex reality. We argue that a different understanding of the Darfur situation – not as an ‘ethnic conflict’ but rather as a war over food and livelihoods5 – would compel a more durable and effective

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Figure 1.5 Locations of hunger crises profiled in this report.

assistance response. The military tactics that have been used in the conflict are indicative of what could be termed a ‘livelihood war’, where essential resources become targets – for example, fields and orchards burned and grain stocks destroyed. Eventually, civilians are forced by intimidation

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and assault to become refugees and IDPs, and thus sacrifice their livelihoods entirely. If we see the crisis in this way, responses would be driven not by the objective of only ‘restoration of peace’, but rather by the necessarily larger and more ambitious ‘restoration of livelihoods’. Our analysis in Chapter 2 centres on the words of families affected by the war. They speak not only of the violence that forced them to leave their communities and livelihoods, but also of their struggles in the IDP camps, which are increasingly coming to resemble urban slums. We assert that uncompromising international action needs to be taken to stop the armed conflict and sustain a genuine peace negotiation process, and thus eventually allow families to return to their homes, lands and economies. In the short term, however, diverse types of livelihood and other assistance are needed in the camps themselves – not just food aid, but also cash transfer programmes, guaranteed access to safe water and quality health services, and education and information systems. Sustaining IDP camps as semi-permanent settlements may be an unpalatable prospect to many, but in the absence of security and stability, we argue that there is no other short-term option if the protection of dignity of the Darfuri people is indeed the objective. Chapter 3, ‘Free Markets, Imprisoned People: Niger and the Dangers of Deregulation’, examines the Niger food crisis of 2005, in which close to a quarter of a million children under the age of five were treated for acute malnutrition in one of the largest relief interventions in history. The Niger emergency was often described as ‘unforeseeable’, as it was popularly believed to have been caused by locust invasion and drought in the preceding year. These natural factors, however,

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were merely the final trigger in a process of deepening vulnerability that had been occurring for decades. We assert in Chapter 3 that this vulnerability is due largely to misguided economic policy. As an overall thrust towards economic liberalisation during the 1980s and 1990s, Niger’s government, in concert with other West African countries and Northern donors,6 implemented policies which led to deregulation of food markets and reduction of subsidies to small farmers and livestock herders (‘pastoralists’). As a consequence, poor families in Niger are exposed to extremely volatile food prices and income flows. The 2005 Niger crisis mainly resulted from families not having enough money to afford the food on the market, and is thus emblematic of a new type of hunger emerging in the world: the ‘market emergency’, a hunger driven by the adverse effects of reliance on unstable and unregulated markets. Despite the longterm potential of liberalisation to spur economic growth and reduce poverty, we assert that such policies can have dangerous short-term effects on the ability of families to meet their food needs, especially when applied in the context of weak economies and political instability. Yet there are solutions. Intentional protection of key domestic sectors in the face of global competition has underwritten human development throughout the history of most Northern countries, and similar policies are essential for the development of Southern countries like Niger. In addition, regionally coordinated market regulation of key commodities is needed to mitigate the price spikes and drops that are so devastating to poor families; the freedom to eat must take precedence over excessively ‘free’ markets. ‘Safety net’ employment programmes, which have proven effective in other developing nations, should be implemented to increase

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household incomes during the annual lean season, when food stocks are declining and prices are high. In summary, the end of hunger in Niger is a question of good economic and development policy, supported by the willingness of rich countries to provide meaningful levels of assistance and create a fairer international trade system. Chapter 4, ‘Portraits of a Pandemic: Families on the Abyss in Zambia and Malawi’, then looks at the greatest public health tragedy in modern history: HIV/AIDS in southern Africa. In 2006 alone, about 1 million people in the region are estimated to have died from the virus. Over the past two decades, that number is likely to have been greater than 10 million.7 If the fulfilment of the Universal Declaration of Human Rights is indeed a universal responsibility, then the failure to adequately fund public health systems, and particularly HIV prevention and treatment programmes, in southern Africa must be seen as one of the most serious violations of human rights that has taken place in the world over the last quarter-century. The impact of the pandemic on the right to food is particularly heartbreaking; the livelihood economies of the poor in southern Africa are disintegrating under the force of the virus. In Chapter 4, drawing upon Action Against Hunger’s technical experience of treating malnourished children in Malawi and Zambia, we chronicle how the virus infects every aspect of the daily struggle for food and dignity in these countries. In addition to the impact of the virus on the right to food, we also highlight two other issues relating to HIV. The first deals with how stigma and discrimination affect the ability of families to receive health care services. There is a common perception among health care providers that HIV-positive children – especially those who are also severely malnourished

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– are ‘lost causes’, and that investing in their care is a poor use of scarce resources. The result has been discrimination in providing the medical treatment which HIV-affected families so desperately need, and indeed to which they have a right. Through detailing our research in Chapter 4, we assert that with adequate access to treatment and livelihood support for their families, children affected by both severe malnutrition and HIV can indeed lead healthy lives. The final topic of Chapter 4 addresses the ability of HIVaffected families to obtain safe water. Water-borne illnesses such as cholera, dysentery and typhoid are responsible for a great deal of sickness and death in the world, and are among the leading causes of child malnutrition. The cross-impacts between HIV infection and poor access to safe water are worrying, and we examine these links in detail through a case study of households in the Copperbelt region of Zambia. Chapter 5, ‘The Meanings of Dignity: Quiet Tragedies and Indomitable Spirits in Ethiopia’, is comprised of testimonies from families living in the coffee lands of south-western Ethiopia, an area at great risk of nutritional crisis. While the words of people affected by hunger are highlighted throughout this report, in Chapter 5 the stories of households are presented in a more complete form. In order to present a more detailed, contextualised portrait, we restrict our geographical focus to two communities in the south-western Ethiopian region, where Action Against Hunger has worked for several years. The testimonies illustrate vividly that hunger is about much more than simply lacking enough food to fill the stomach; it also can mean illness, debt and grief. Yet within the stories in Chapter 5 there is also great courage. Despite the difficulties that these families face, they strive tirelessly to lead lives

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of dignity, trying in innumerable ways to obtain the things they need and value: food, medicine, clothes, shelter and education. Chapter 5 is both a troubling illustration of the brutality of hunger and a testament to the resourcefulness and strength of families living on the edge of crisis. In the concluding chapter, ‘Postscript: Conscience and Power’, we note that the international community has indeed succeeded in helping to reduce mortality in the developing world over the past few decades, especially during famines. But survival, by itself, is not the ultimate goal: human dignity is. We argue that the success in responding to famine came about as a result of moral commitment by political leaders and private citizens all over the world, a commitment underpinned by good policy and considerable financial assistance. The end of hunger is likewise possible, but it must be backed by an expansion of conscience. We must fight for dignity as uncompromisingly as we have fought for the right to survive potential famine.

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2 The Burden of Survival: Inside the Pain of Darfur’s Livelihood War

In the past year, the Darfur conflict in western Sudan has become something of an international cause célèbre, with increasing numbers of politicians and movie stars voicing their outrage at the continuing crisis, which thus far has claimed the lives of between 200,000 and 400,000 people and displaced over 2 million more.1 Yet, in the well-intentioned attempt to ‘sell’ the urgency of the situation to the general public, the suffering has often been simplified. What flickers on our television screens is an uncomplicated picture of ‘just another age-old ethnic conflict’: genocidal ‘Arab’ militias terrorising ‘black African’ villages, murdering and raping the innocent. Similarly, the objective of the international community in Darfur has been reduced to one word – ‘security’. Our job, we tell ourselves, is to protect human life until a more durable peace can be built in the region. Pain, however, rarely has such uncomplicated borders, and Darfur is no exception. In this chapter, we assert that the crisis in Darfur needs to be understood not just as a threat to human life, but rather as a threat to the full set of human rights that surround dignity, and especially the right to food. 16

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Figure 2.1 The Darfur crisis in Sudan. Source: CIA Factbook.

The cost of the war should be calculated not only by the loss of lives, but also by the loss of community, the loss of work, the loss of homes and the resulting rise of hunger. In fact, far from being another ‘ethnic conflict’, we argue that the Darfur crisis is at its core a ‘livelihood war’: the struggle

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among various groups to procure enough land, water and livestock resources to survive in a context of accelerating environmental degradation.2 Of course, not every place in the world where people compete for limited resources explodes into massive humanitarian crisis, and an analysis of larger political agendas is essential in understanding the destruction of Darfur.3 Yet the lens of ‘livelihood war’ does compel the international community to have a larger objective in Darfur: not simply the restoration of security and protection of life, but also the restoration of livelihoods. This is admittedly a far more complex goal, and one that requires longer-term commitment and investment, but the imperative of human dignity demands just such a widening of ambition. In this chapter, in addition to examining Darfur’s livelihood war, we also look at a relatively less publicised face of the crisis: life inside the internally displaced person (IDP) camps that surround the urban centres of the region. These camps are now, and will be into the indefinite future, the home of hundreds of thousands of families who have been forced to abandon their villages as a result of the violence. Primarily through the words of people currently living in the camps, we illustrate how survivors of the conflict struggle to obtain food, to stay healthy and to lead a life of dignity. Although the public perception may be that refugee and IDP areas are havens of safety, uncertainties in food distribution, lack of police security, and insufficient water and health services are leading to high rates of malnutrition in the camps. We conclude by asserting that if acute malnutrition in Darfur is to be reduced in the short term, a wider raft of livelihoods development interventions is needed within the camps themselves.

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A WAR OF POVERTY AND POLITICS, NOT ETHNICITY Portraying Darfur’s story as a fight between ‘Arabs’ and ‘black Africans’ is misleading at best. While quasi-distinct ethnic communities do indeed exist within the region, the boundaries demarcating these groups have historically been fluid, useful for defining economic and social relationships but not as markers of inevitable fault lines of violence.4 Three factors changed Darfur from a largely peaceful mosaic of coexisting communities to the increasingly polarised place it is today: political manipulation by outside parties, environmental degradation and the proliferation of arms. Darfur’s history is one of political neglect and subjugation to the agendas of governments and other powerful actors. The region, one of the most landlocked on the African continent, was largely ignored in the wider development of Sudan, both during British colonial rule and after independence. Even today, public services in Darfur lag far behind other areas of Sudan. During the past few decades, this neglect has been exacerbated by the use of Darfur as a proxy battlefield for war between the governments of Sudan, Libya and Chad. All of these countries, for various reasons of their own,5 advanced the hardening of ethnic identity within Darfur. One can argue that the boundaries of ethnic enmity that seem to be gaining credence today in the region are primarily a result of the actions of these outside interests. The severe droughts of the 1970s and 1980s,6 which occurred concurrently with the proxy wars, also played a role in identity formation. The relationship between farmers and pastoralists – the two major livelihood groupings in Darfur – was traditionally mutually beneficial: cattle would be allowed to graze on fallow tracts of cropland, and in the process

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of grazing apply manure and increase soil fertility for the next crop. As environmental conditions began to deteriorate, however, these livelihood groups began to compete for everscarcer land and water resources. The final major factor unravelling Darfur’s social fabric was the increasing amount of arms proliferation in the mid to late 1980s, an indirect result of the proxy wars being fought in the region. As Flint and de Waal note, ‘in 1990, a Kalashnikov could be bought for $40 in a Darfur market’.7 Traditionally, tensions between communities would be resolved through a complex system of negotiation involving village leaders (‘Sheikhs’), nomadic chiefs and the state. With the increasing militarisation of the region, the arbitration system broke down. Propelled by all these factors, the livelihood war came to a head in the 1990s. Offensives from an increasingly bold rebel movement, driven by grievances against the Sudanese government’s neglect and marginalisation of the region, pushed central authorities in Khartoum to launch counteroffensives of their own. Alongside the counter-offensive, bandit militias began to organise in opposition to the rebel groups. The resulting terror inflicted by the militias has destabilised the region, pushed an already fragile economy over the edge into crisis and created serious fissures between groups in the region.

WE WERE NO LONGER WELCOME: STORIES FROM DARFUR’S LIVELIHOOD WAR Asha Suleiman’s Story My name is Asha Suleiman. I am a grandmother: with my four adult children and their families, we had been moving non-stop for a year

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before coming to this camp [Al Salam camp, outside the city of Nyala, the capital of South Darfur]. In our village, we were small farmers; we managed to survive by eating our crops and buying some food with the little cash we made selling what we did not eat. In the beginning, things were peaceful, but tensions with the pastoral tribes rose over time. Things worsened last year, when our family lost its entire crop because the tribes deliberately grazed their cattle on our farmland. It was at that point that we realised we were no longer welcome. But instead of trying to retaliate, we chose to move to another village. We planted some crops there too, but they were also lost to the violence. We became tired, exhausted of all the fighting. We had nowhere to turn to, nowhere to demand justice and our right to grow our food. We finally decided to leave our land and come to Al Salam camp. All but three families in our village fled with us. They were all facing the same problems and had nowhere to go.

Awa Abdallah’s Story My name is Awa Abdallah. I now live in Otash IDP camp [near the city of Nyala] with my children. Life has been difficult since the war started. At first, it was just rumours of fighting, of villages being burned and people being killed. We were scared and did less farming, so that if they attacked our fields there would be less chance of us being caught there. But this meant that our harvests became smaller, and we never had enough food to fill us up. Then one day, last October, the militia came to the village, in the early morning. They locked all the villagers in the schoolhouse, burned our homes and grain, and killed our chickens and goats. We gathered what possessions we had left and travelled two days by truck to reach this camp. My smallest child, Mubarak, almost died during the journey – I couldn’t breastfeed him in the crush of people inside the truck. I had to hold him above my head to keep him from suffocating and so he wasn’t able to be fed. Since we’ve moved here to the camp, we’ve had only bad news from the village. They say everything has been burned. The fields, the shops, the school, our wells have all been destroyed.

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Not all families have the ability to organise transport in the manner of Awa Abdallah. Those with savings can hire a truck with others, gather up what assets they are able to save, and move their families to a refugee or IDP camp. However, many poorer families without the money to hire transport must simply stay in their villages and bear the brunt of the conflict, or walk for weeks to try to reach safety. Anonymous’ Story The attack on the village happened early in the morning. The bandits and soldiers arrived suddenly and started shooting. My sister tried to look for her husband but couldn’t find him. She held on to her three children, carrying the smallest one on her back and pulling the other two by the hand. She was also three months pregnant. When she started running towards the mountains, one of her sons she was holding by the hand was shot and died immediately, but she kept running, knowing that to stop would mean death for all of them. After a few minutes she heard another gunshot, and realised that her child, the one she had been carrying on her back, was dead. My sister does not speak any more, since that day.

Fields on fire; a family losing the only home they ever knew; the death of a baby carried on his mother’s back – the faces of tragedy in Darfur’s livelihood war are innumerable. The statistics we listed at the beginning of this chapter are staggering: between 200,000 and 400,000 Darfuri civilians have lost their lives, and 2.1 million have been forced to leave their homes. Yet these numbers are only grasped in their full importance if we understand that each of them represents a story of great sadness, stories like the ones recounted above. Below, we follow families to the displacement camps and ask why, in the face of what is popularly thought to be massive

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international response, hunger and malnutrition still persist within these camps.

REFUGEE CAMPS, OR URBAN SLUMS? THE LIVES OF DARFUR’S DISPLACED The town of Nyala, in South Darfur, is surrounded by seven major camps for internally displaced persons. One of these, Kalma, is one of the biggest displacement camps in the world, home to 92,000 people. This population lives on about 7.5 square kilometres of land, making Kalma one of the most crowded places on earth. Despite its size, however, this camp town possesses only the most basic formal economy, and little administrative structure exists to represent the needs and concerns of its inhabitants.

Figure 2.2 Food distribution in an IDP camp outside Nyala. Copyright © ACF.

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The stories of people living in these camps clearly demonstrate that although families here are generally less exposed to direct violence, life remains very difficult. There is little work available and external assistance is insufficient. A recent Action Against Hunger assessment in the camps around Nyala found that IDPs identified the lack of food as their biggest single concern. Malnutrition rates continue to fluctuate greatly, and remain very high in some of the camps, as Figures 2.3 and 2.4 show. 25

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Figure 2.3 Level of global acute malnutrition (GAM) among IDPs and residents in Nyala city and surroundings, South Darfur state, Sudan, 2004–06. Sources: Action Contre la Faim; UN Standing Committee on Nutrition, Nutrition Information in Crisis Situations (NICS) Survey Results Database; Centre for the Research on the Epidemiology of Disasters (CRED) Complex Emergency Database.

Hawa’s Story My name is Hawa. I am 23 years old and the mother of triplets. Their names are Bahar, Baharia and Badur, and they are only 42 days old.

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I am a widow from my first husband, and I don’t know where my second husband, the father of my children, is. I fled my village six months ago to escape the violence. I first came to Nyala city to stay with family, but after some weeks they couldn’t afford to support me any longer. I had to leave them and come to the Kalma camp, where I had other relatives. But there I wasn’t allowed to register to receive food assistance, so I moved on to Otash camp, where I hoped to get a ration card for a monthly ration of cereals, pulses, vegetable oil, salt and sugar. After a long time, I still had not received a ration card. I lost a lot of weight and was unable to provide milk for the triplets. I was then admitted to the feeding centre to be treated for malnutrition, along with the children. After two weeks in the centre my physical condition improved and now the triplets feed completely on my breast milk; I 3.5 3 2.5 2 1.5 1 0.5 0 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07 Kalma IDPs

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Figure 2.4 Level of severe acute malnutrition (SAM) among IDPs and residents in Nyala city and surroundings, South Darfur state, Sudan, 2004–06. Sources: Action Contre la Faim; UN Standing Committee on Nutrition, Nutrition Information in Crisis Situations (NICS) Survey Results Database; Centre for the Research on the Epidemiology of Disasters (CRED) Complex Emergency Database.

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will be finishing the treatment next week. But I am not sure what to do next – keep trying to get a ration card in the Otash camp, or rather return to my relatives in the Kalma camp. But even in Kalma no one has any space for us; the only accommodation we will be able to find is under the palm leaf where I gave birth to my triplets. I don’t know. I can’t dwell on the choice: it is a decision for next week.

The camps are populated almost entirely by former agricultural households who have been forced to become quasi-urban residents. With little land, farming is not possible, and for many families no other sources of income are available. As mentioned in the account below, inadequate amounts of humanitarian assistance force some families to engage in high-risk practices to ensure their survival. To improve this situation, humanitarian agencies will need to expand livelihoods development and cash transfer interventions,8 as we discuss later in this chapter. Anonymous’ Story The food in the camps [distributed by relief agencies] is not enough. If we eat normally, the monthly food ration we receive will not last more than 15 days. So we have to ‘stretch’ the food by eating less and cutting back on the number of meals. Sometimes we go outside the camp to collect firewood to sell or to gather wild roots for eating. But going out into the forests and fields is very dangerous for us women – there are bandits and men with guns and many women have been assaulted. But we have little choice. If the men go instead, they will be killed.

The challenges of living in the camps are not only economic in nature, but also psychological. An Action Against Hunger assessment of the needs of recently arrived women in Otash camp in November 2006, carried out in collaboration with

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Cooperative Housing Foundation, found that many were struggling to adapt to their new environment. They had very little knowledge about how to create social networks in an IDP camp, where they are living amongst unknown people. Many also lacked money, assets or family support. These difficulties would manifest themselves in symptoms of psychological distress, high levels of anxiety and difficulties in caring adequately for their children.9 The problem is exacerbated when the women are victims of assault, as has occurred frequently in the camps. The residents of many IDP and refugee camps are essentially living in urban slum-type conditions, with all of the associated problems. Like slums, the camps were not designed with a permanent and reliable service infrastructure – water supply and sanitation systems, health care services, education facilities, police security, and so on. Some services are being provided in a transitional manner by a patchwork of humanitarian organisations, each taking responsibility for a limited zone of need; for example, managing drinking water for one sector of one camp. However, given the funding constraints and the number of refugees and IDPs involved, the challenges of addressing all the many needs of the entire displaced population are formidable. Expanding services within the refugee and IDP camps to cover longer-term needs is controversial. Already, as the displaced population grows, life has become more difficult for people residing in the cities surrounding the camps. Rent and the cost of living have increased. Increasingly, the tightening economy is forcing residents themselves to seek assistance. Yet pushing displaced people to return to their home communities is not a feasible option, given the ongoing violence. Humanitarian agencies are thus caught in a bind

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between the impossibility of supporting returns, on the one hand, and contributing to an unsustainable urbanisation of the camps, on the other. Yet the basic truth of the situation is that the most immediate cause of malnutrition within the camps is not conflict, but rather the lack of economic opportunities and social services. If the objective is indeed protection of the right to food, the current ‘humanitarian/emergency response’ being applied does not fit the types of problems that IDPs face after four years of displacement. As we discuss below, solutions focused on livelihoods development are needed to decrease malnutrition in the camps.

PROTECTING THE RIGHT TO FOOD IN DARFUR: SHORT- AND LONG-TERM SOLUTIONS The solution to malnutrition in Darfur is often portrayed in the simplest terms: stop the war, and you will stop hunger. Yet peace does not seem imminent, and the twin goals of protecting people’s lives and helping to rebuild their livelihoods cannot be thought of as sequential, but rather must occur simultaneously. Malnutrition rates in the refugee and IDP camps remain high, and we cannot wait for the end of the conflict to address the current serious violation of the right to food. The short-term solution to combat malnutrition within the refugee and IDP camps is to develop transitional livelihoods development and cash transfer projects. Action Against Hunger and other organisations are designing various interventions of this type within the IDP camps surrounding Nyala town in South Darfur. For example, after finding that the cost of milling grain was the second-highest expense

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of families in the camps (after food purchase), one Action Against Hunger project distributed milling vouchers to 6,000 families; the vouchers cover half of the milling cost and allow households to spend money on food and other essential needs. Another project provided fuel-efficient cooking stoves and solar cookers to approximately 500 families. These cookers lessen the time-cost of obtaining firewood, and, even more

Figure 2.5 A child obtaining water in an IDP camp outside Nyala. Copyright © ACF.

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importantly, reduce the very real risk of assault faced by those who leave the camps to collect the firewood. A third project identified camps where some families have safe access to agricultural land, and provided seeds and tools to prospective farmers. As market costs of seeds and tools are often very high, families have been unable to start planting, and the provision of these inputs can help to kick-start food production once again. Other organisations have implemented similar livelihoods and cash transfer projects in the camps. Again, however, the total coverage of these projects is limited, as compared to need. The funding available for livelihoods development initiatives has been sparse, and indeed it was only recently that most humanitarian organisations themselves began to redefine the crisis not as an acute emergency, but rather as a chronic problem without a rapid solution. As the Darfur war enters its fifth year, the international community is slowly beginning to understand that protecting the right to food means rebuilding the shattered livelihood economies of the Darfuri people. Ultimately, however, Darfuris in the camps want to return home; and, apart from the population in the camps, some 2 million other people living in rural areas of the region are still affected by the conflict. To enable IDPs and refugees to return home, and to implement livelihoods development projects in war-affected areas, the international community must take a tough stance in ensuring peace in the region – and, simultaneously, in supporting a genuine peace process that includes all relevant parties and addresses the root causes of the conflict. Many factors have thus far prevented Northern governments from taking such a tough stance, including an unwillingness to finance an expanded and strengthened

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United Nations peacekeeping operation, as well as a concern that confrontation over Darfur will derail the concurrent peace process between the Sudanese government and other rebel groups in the south of the country. Yet without a more resolute position, millions of Darfuris will be forced to languish in camps, and millions more will continue to live in fear of marauding militia groups. As globally concerned citizens, the following are what we must demand from our leaders to end the tragedy of Darfur: • increased funding to expand the humanitarian and livelihoods development response to the refugees and IDPs living in camps, recognising the very urban nature of the problems they face; • continued political pressure promoting a meaningful and inclusive peace negotiation process that addresses the underlying causes of the Darfur conflict; and, • the deployment of an appropriately sized and equipped peacekeeping force – agreed upon by all parties to the conflict – in order to ensure the rights of civilians under international law.10 Darfur is still seen by global leaders as peripheral to the interests of most people in the world, and indeed that is why the region has been allowed to burn for over four years. But an end to the violence is possible; it requires only that the citizens of the world insist that the dignity of all people, including the Darfuri people, is in fact our greatest interest.

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3 Free Markets, Imprisoned People: Niger and the Dangers of Deregulation

Between January and October 2005, an estimated 230,000 children in Niger were treated for acute malnutrition;1 60,000 of these were severely acutely malnourished.2 The size of the relief intervention, one of the largest in history, illustrates the seriousness of a crisis that only belatedly made world headlines. The 2005 emergency in Niger exposed to full view an increasingly common feature of hunger in Africa: the role of market forces in destabilising the livelihoods of poor families and enabling the rise of malnutrition. In this chapter, we examine this phenomenon of ‘market-induced food emergency’. We argue that the volatility of food prices, unfair international trade policies and the underlying environment of economic liberalisation were the primary causal factors that two years ago led to nearly a quarter of a million children in Niger being deprived of their right to food and health. The chapter concludes by discussing the policies needed to successfully mitigate the adverse impact of market forces on 32

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Areas affected most strongly by the 2005 crisis, Niger. Source: CIA Factbook.

livelihoods and generally reverse the deadly acceleration of poverty and hunger in the country. The 2005 food crisis was initially blamed on locust invasion and drought. But regional West African cereal production that year – the combined total of Niger and the neighbouring countries with which it trades – was around 11.5 million tonnes, actually a slight increase over the average of the previous five years.3 For Niger alone, the country hardest hit by the emergency, cereal production at the end of 2004 was only 7.5 per cent below the national food requirement.4 However, this modest drop in production and food availability took place in circumstances that should have already been considered as a nutritional emergency prior to 2005. The Sahel, where Niger is located, is the region

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Figure 3.2 A mother and her child being treated for acute malnutrition in a therapeutic feeding centre, Niger. Copyright © Susana Vera.

of the world most affected by food shortages. Global acute malnutrition affects between 10 per cent and 20 per cent of all children under the age of five at any given time. In addition to this high ‘background’ level of malnutrition, Niger is subject to further dramatic increases of malnutrition during

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the annual lean season, the period during which households have depleted their food stocks from the previous harvest and are awaiting the new harvest. High rates of malnutrition also directly contribute to the death of children: more than one out of four children in Niger does not live to reach the age of five.5 Yet there is no war or civil strife to blame for hunger in Niger; it is instead extreme poverty that underlies these statistics. In both the 2005 and the 2006 United Nations Human Development Index, Niger was ranked as the poorest country in the world.6 It is thus important to bear in mind that Niger is a country in which millions of rural poor live permanently on a knife-edge. In such conditions, livelihoods are extremely fragile and it does not take much for an already fragile situation to become disastrous. This is in fact what happened in 2005.

MARKET FORCES AND MALNUTRITION Price Volatility on Cereal Markets Cereal markets in the Sahel are marked by strong seasonal variations. Prices often increase sharply in the lean season, as household stocks from the previous harvest begin to run out and demand outstrips supply. 2004–05 was an especially difficult year for poor families: the price of 1 kg of millet, the main staple food, more than doubled during the 2005 lean season, and even tripled in some parts of the country.7 In July 2005, a farmer in Niger paid more for 1 kg of millet at the local market than a European or an American consumer paid for 1 kg of rice in the supermarket – and 63 per cent of Niger’s population lives on less than $1 a day. As Figure

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3.3 shows (for Maradi, one of the areas in Niger hardest hit by malnutrition), the price increase was closely tracked by a rise in malnutrition. 35

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Figure 3.3 Millet prices versus admissions for malnutrition in the Maradi treatment centres of Médecins Sans Frontières (MSF) Source: MSF-France, Humanitarian Exchange, vol. 33, March 2006: 21.

In addition to the high in-year seasonal variations, annual averages of cereal prices have been steadily rising for the past 15 years. Prices in 2000–04 have doubled compared to the average a decade prior.8 This increase follows a similar international trend, largely driven by increasing demand for grains in emerging markets like China and India, as well as the growing use of cereal crops for biofuels.9 In theory, high cereal prices are not necessarily bad for those that grow these crops, as many of Niger’s farmers do; higher prices can mean greater income. Unfortunately, it is mostly grain traders that actually profit from the price hikes, as many

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small farmers are forced to sell their crops immediately after harvest in order to repay debts and finance other essential expenses. This is also the period when prices are low, as the market is saturated with cereals. Thus net revenues from crop sales are minimal, and the same households may then need to purchase food in the lean season, when prices are high. Harouna Zaroumai’s Story

Figure 3.4 Mr Harouna Zaroumai, from the community of Djibile, Niger. Copyright © ACF.

I am 68 years old, and a farmer. I have a field that I cultivate with my grandchildren, but the production is poor, and the harvest only lasts us a few months. In order to be able to purchase enough food, sometimes I have to send my grandchildren away to work, and sometimes we have to sell our animals, when we have some available to sell. Sometimes

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we are able to eat only two meals a day, depending on how much food we have left from our last harvest. After the rainy season we sell part of our millet harvest, some of our sorghum, and all of our sesame, beans and groundnuts to pay off our debts. But, like most of the people here, we run out of food in the period between the two harvests, and have to buy food back from the market. But the prices are higher during the lean season – we buy millet, sorghum and beans from the same merchant we sold it to after the harvest, but the price is always much higher than what we sold it for. The farmer always loses but I don’t have any choice because I need to spend money immediately after the harvest, to pay off debts as well as to buy clothes and pay my taxes.

Zeinou Issafou’s Story I lost my husband two years ago and now I live alone with my children. My husband was sick for a long time; I was at his bedside and visited several healers, health centres and hospitals, but eventually he gave up his soul. After his death we had nothing: we had sold everything in the search for a cure for his illness. The problem is that most of the children are still very young. The oldest are not yet able to look after themselves so they all come home to eat. My main sources of food are our fields, but they produce a poor harvest because of the recent lack of rain. On the local market I sell our crops, especially beans, to the traders, but usually I have to buy them back a few months later at very high prices. But we have no choice about selling after the harvest, as we have to pay debts and buy clothes for the children before they go back to school. I used to sell prepared meals of rice and beans, but a lot of women were doing the same thing, and so the price dropped. It put me in a difficult position because I often bought the ingredients on credit and then when the price dropped I was in debt. Now I only sell millet paste on market day. But it is hard work – crushing millet is often a half-day’s work. It makes me tired and I don’t have the time to do the other things I need to do. It would be easier if we had a mill to crush the millet for us, but the only windmill

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in the village broke down a year ago, and after many attempts the owner has been unable to repair it, so all of the work has to be done by hand.

Agricultural Trade: A Source of Both Income and Vulnerability Close to 80 per cent of the Sahelian population is involved in some form of agriculture. Subsistence farming is widespread in the region, but few households are entirely self-sufficient. Most families must sell a portion of their agricultural commodities to raise the cash for essential non-food expenditures such as clothing, health care and schooling, as well as to diversify their diet beyond what they grow themselves. This reliance on markets, however, makes households vulnerable to price instability. The form and extent of this vulnerability varies according to the specificities of people’s livelihoods – what types of crops they grow, their sources of off-farm income, and so on. Livestock production – not only of cattle, but also of camels, sheep and goats – is also a major activity in Niger. Pastoral communities sell part of their production in Sahelian cities, but most is exported to coastal countries, especially Nigeria. Pastoral livelihoods are also very sensitive to the volatility of food prices, as pastoralists usually grow limited amounts of cereals and depend largely on the income produced by livestock sales to purchase grains from the market. High cereal prices thus mean the degradation of the ‘terms of trade’ for pastoral populations. For example, in Niger’s pastoral zone of Dakoro, cereal prices were more than 45 per cent higher in 2005 than they were the year before, while the price of a cow was only 40 per cent of what it was in 2004.10 As a result, a household had to sell five cows to get the same amount of cereal that one cow would have purchased in the

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previous year; this is equivalent to an incredible 80 per cent drop in income.11

Figure 3.5

Niger, August 2005.

Copyright © Susana Vera.

The inability to produce or purchase adequate amounts of food forces families to utilise other strategies to satisfy their nutritional needs. As Figure 3.6 shows, these strategies, or ‘coping mechanisms’, become progressively more irreversible and harmful as the food crisis deepens. Hunger in Niger is commonly described as arising from ‘unavoidable’ circumstances, such as weather hazards or world market trends. As we argue below, however, hunger is in fact a direct consequence of policy choices made in the Sahel and around the world. Liberalisation of Agricultural Trade Many Sahelian farming households specialise in cash crops such as cotton, cowpeas or vegetables geared towards

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Generalised progression of coping mechanisms during food crises.

regional or international markets. Cash crops can provide substantial income but require farmers to devote land away from subsistence crops, consequently pushing families to turn to markets for their own food supply. Prices for cash crops generally do not vary as much as cereal prices in the course of the agricultural year; thus, while incomes for cash crop producers may be stable, rapidly increasing food expenses can push families into hunger. To protect both producers and consumers from price volatility, in the 1960s and 1970s most countries in the Sahelian region created governmental agencies that were responsible for the regulation of national cereal markets and provision of support to farmers. These institutions bought cereals from farmers, stored the purchases as national grain reserves, and released them to the market in the case of a bad harvest. They also organised the redistribution of food from

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surplus to deficit areas of the country. The overall goal was national self-sufficiency in food production. Over the past 20 years, however, national cereal market regulation has been rolled back as part of the regional drive towards economic liberalisation. Free trade agreements, under the auspices of economic partnerships such as the Economic Community of West African States (ECOWAS) and the Union Economique et Monétaire Ouest Africaine (UEMOA; Economic and Monetary Union of West Africa), have promoted the creation of a regional common market based on freedom of movement for people, goods, services and capital. In pursuing this open market, Sahelian countries abandoned the idea of national food self-sufficiency in the belief that regional and international trade would be a more effective method of ensuring an adequate food supply. In theory, under the free trade regime, countries would specialise in the production of exportable products in which they enjoy some comparative advantage; for example, livestock or cotton. The export earnings from these products would then fund the import of the products each country needed, but did not produce in sufficient quantity. For instance, Niger would hypothetically export cattle, vegetables or cowpeas to the large urban centres of Nigeria; these exports would then provide the resources needed to import cereals from Nigeria or from elsewhere. This regional economic integration has indeed progressed, and today Sahelian countries can no longer be considered distinct national markets. This has had a direct impact on food availability in any given country, as supply is no longer determined by domestic production but rather by aggregate regional production and trade flows. The problem, however, is that the common markets have proven to be extremely

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volatile, due to annual variations in regional food production, unstable exchange rates, conflicts, differences in the relative economic power of trade partners, and inconsistent government policies. As a result, food availability at country level is becoming increasingly uncertain from year to year. Furthermore, since the withdrawal of state regulation, regional agricultural trade (and therefore national food supply of individual Sahelian countries) has become largely dominated by private traders – a situation that becomes problematic when traders engage in speculative behaviour and hoarding, as occurred during the 2005 crisis. Logically, traders seek to maximise their profits by purchasing cereals when prices are low and waiting for higher prices to release their stocks, but this type of speculation prices poor families out of the market. In addition, the private sector essentially controls the general orientation of cereal flows within countries and the region.12 During the 2005 crisis, grain exports out of Niger were partially driven by strong demand and greater purchasing power in coastal West African countries.13 Meanwhile, Niger itself, with its relatively weak purchasing power, was the loser in the game of open trade. Niger also suffered during the 2005 crisis from the decisions of its large southern neighbour, Nigeria. The larger country feared its own cereal production deficit, and so prevented the export of its own agricultural goods back over the border to Niger. As a result, food supply within Niger dropped and prices rose to an unaffordable level for many families within the country. Nigeria’s decision to protect its own people is understandable, but the situation was once again due to poorly regulated markets and poorly coordinated policies.

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Unfortunately, the 2005 experience is likely to be repeated in the future. While the implementation of free trade regimes in West Africa is based on the model of the European Union in the 1960s and 1970s (insofar as they are an attempt to strengthen the regional market and promote higher agricultural productivity), the agreements have failed to achieve the same success. Part of the problem is that West African countries have thus far been largely unable to design a common agricultural policy and to set adequate trade rules for agricultural commodities. Another serious issue is that revenues from West African crops on global markets have been low, due in great part to an inequitable trade environment enforced by rich countries. The example of cotton is a good illustration of this inequitable trade environment. Cotton is a particularly important cash crop in West Africa; some 8 million farmers in the region currently grow cotton as one of their primary sources of income.14 The regional specialisation in cotton, however, has led to what has been called the ‘cotton crisis’. After years of increasing reliance on the crop, a drop in international prices since the mid 1990s has severely impacted farmers’ incomes and livelihoods. Adjusted for inflation, prices are now lower than at any time since the 1930s.15 This downward trend is partially due to the high level of subsidies provided to cotton producers in the US, which allow American cotton to be sold on international markets at far below its cost of production.16 In 2005 alone, the US provided its cotton farmers with nearly $5 billion in subsidies,17 several times greater than the United States development agency’s budget for all of Africa.18 Sahelian producers simply cannot compete with this level of support.

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MARKET EMERGENCIES ARE NOT INEVITABLE: OPTIONS TO REVERSE THE TIDE The grim picture we have painted above is not inescapable, however. The measures necessary to address the effects of price volatility, reverse the erosion of assets and build household resilience to market shocks are known and possible. Sound policies and initiatives at national, regional and international levels can eventually lead to the durable eradication of hunger in the Sahel. Below, we review what some of these actions would look like. Enhancing Cereal Banks and the ‘Warrantage’ System Cereal banks and the ‘warrantage’ system are potential alternatives to the regulatory role that public institutions used to play in Sahelian countries. Cereal banks buy grain from farmers at harvest time, when prices are low. The food is stored until the lean season arrives. The food is then sold below market prices to enable poor families to buy the food, but with enough of a margin to cover management costs and future purchases. Meanwhile, the ‘warrantage’ system, initiated in 1999 in Niger on a small scale, performs a similar function, but is operated by farmers’ cooperative groups themselves. The farmers sell the crop to the cooperative at harvest time; the crop is then kept in storage and sold on the open market a few months later, when prices are higher. Farmers then acquire the additional revenue obtained by the higher price. The net effect is to provide the earnings the farmers would have received had they been able to wait to sell the crop at higher market prices later in the season.

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The effectiveness of these instruments has to date been uneven in the Sahel, particularly due to the fact that cereal banks and cooperative organisations often lack the capital necessary to make large purchases at harvest time. If this weakness were overcome through government or international assistance, in the form of either grants or zero-interest loans to cereal banks and cooperatives, then poor households could be shielded from the dangers of price volatility. Implementing Sound Agricultural and Trade Policies The Common Agricultural Policy (CAP) was instrumental in making the European continent a prominent exporter of agricultural commodities after the Second World War. The CAP combined support to farmers with regulation of production and markets. In fact, no rich country in history has ever been able to develop its agricultural economy without market regulation, including protective barriers and policies preferential to domestic producers. A major objective of the West African trade partnerships is the creation of a similar common market, based on the elimination of all trade barriers between member states, the adoption of a common external tariff, and common trade policy vis-à-vis third-party countries. Yet, 30 years after this agreement was signed, West Africa still has not applied a common agricultural policy that could protect farmers and promote growth in the regional agricultural system. The common external customs tariff (CCT) adopted in 2006 by ECOWAS gives little protection to farmers; none of its import duties go beyond 20 per cent – as compared to Japan, which taxes imported rice at 500 per cent, and Nigeria, which taxes 100 per cent. Surprisingly, and despite strong pressure from local farmer organisations, the West African heads of state

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have decided not to use protective options offered by current World Trade Organisation (WTO) regulations on customs tariffs and special treatment measures available for ‘Least Developed Countries’. In fact, the measures taken by West African states in 2006 surpass the liberalisation requirements stated by the WTO and the International Monetary Fund.19 The poorest countries in the world, where hundreds of thousands die every year because of poverty-related malnutrition, need a specific trade regime allowing the protection of local farmers from cheap food imports and favouring rural development. Regulation of cereal markets, to ensure that price volatility is controlled and food actually reaches the poor, must become a critical priority for the West African regional institutions. Food security cannot be left in the hands of market forces. Markets respond to demand, not to needs; without regulation, they can be said to ‘work’ only for those who have the resources to participate competitively. Sahelian countries also need a commitment from Northern donor governments to create a fair economic playing field. The example of US export subsidies on cotton illustrates how far we are from that ideal. The frank reality is that international development assistance, with all of its noble claims of helping to eradicate poverty, is ineffective in the face of such an inequitable trade system. Finally, beyond simply relief and development projects, international organisations should engage to a greater extent in the growth of an active local civil society. In Niger, some farmer groups are already involved at the local level in risk reduction interventions such as cereal banks and warrantage systems, and also at the national and regional level in influencing the design of the regional agricultural common policy. Supporting these groups, and bringing more like them

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into the policy-making process, is vital to defending the rights of the poor to live in dignity and freedom from hunger. *

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Nowhere in the world is the new market-driven form of hunger as apparent as it has been recently in Niger. We are witnessing what some have termed the ‘postmodern’ food crisis, where hunger is caused not by inevitable forces but rather by an overconfidence in liberal ideology, as well as by the agendas of powerful actors – both Northern governments and local trader elites. The removal of measures to protect weak economic actors, the rise of trader oligopolies and the fickle ‘give with one hand, take with the other’ policies of Northern countries all contributed to hundreds of thousands of Niger’s children being pushed into acute malnutrition in 2005. A repeat of this crisis can be avoided, but only if the right to food of Sahelian people is genuinely prioritised over ideological and political interests.

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4 Portraits of a Pandemic: Families on the Abyss in Zambia and Malawi

In a small community in the Copperbelt of Zambia, six children lose their mother after a long and demanding illness. Their father had died the previous year, and so all six children are left in the care of their mother’s sister, Mary, and her husband. Two years after the children move into their new home, however, Mary’s husband also dies whilst she is six months pregnant. Mary is now caring for a home of 18 people. Mary is HIV-positive, and some of her own younger children are also probably infected. As in most parts of subSaharan Africa, without treatment there is a 50 per cent chance that the infected children will die before they are three years old, and a 90 per cent chance that they will die before they reach age nine.1 Mary understands this. She is also aware that without access to medication and a healthy balanced diet, she is very likely to develop AIDS herself in the near future. Yet Mary cannot afford the drugs and food that would save the lives of her children and extend her own life. When Mary is gone, her eldest son will take over responsibility of the whole family. With fewer wage-earners, buying 49

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food and medicine for the family will be even more difficult, and the possibility that the children will become seriously malnourished or ill is very high. Mary and the children around her continuously live on an abyss of illness and death. As heartbreaking as their story is, it is not a unique one in the countries of southern Africa.

Figure 4.1

Political map of Zambia.

Source: CIA Factbook.

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Figure 4.2 Political map of Malawi. Source: CIA Factbook.

In Malawi and Zambia, the countries we focus on in this chapter, around 15 per cent – or more than one in every seven – of the young adult population is HIV-positive. Women are particularly affected by the virus; in neighbouring Zimbabwe, female life expectancy has dropped an astonishing 30 years

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in the last decade, with latest estimates predicting the average Zimbabwean women to die at around 34 years of age. Children are not spared the effects of the virus, either. HIV can be transmitted from women to children during pregnancy, delivery or breastfeeding. Even for those babies lucky enough to escape infection, the consequences of a sick or deceased mother are serious. In Malawi and Zambia alone, there are more than 1 million children who, like Mary’s nieces and nephews, have been orphaned by AIDS.2 In this chapter, we look at the impacts of HIV on households like Mary’s, specifically in Malawi and Zambia, two of the epidemic-stricken countries in which Action Against Hunger works. Summarising the results of clinical and field research conducted in the past year, we examine the effect of the virus on health, nutrition, livelihoods and access to safe water. We argue that only a multifaceted approach addressing a wide range of needs will ultimately succeed in protecting the right of HIV-affected families to food and dignity. *

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Although Action Against Hunger has worked for several decades in diverse types of hunger emergencies, we observed a new pattern of malnutrition emerging during the southern Africa food crisis of 2001/02. It was not only the sheer numbers of malnourished children in need of therapeutic feeding that drew our attention, but also the many children who were simultaneously suffering from serious illnesses, with more complications than are usually seen. On closer analysis, we noted three additional issues. The first was that, on admission to the feeding centre, the children were far more severely malnourished than one would expect, given that they were coming from a bad but not catastrophic food

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deficit situation in their homes. The second issue was that some children were dying even in far advanced stages of treatment, when recovery should have been almost certain. Finally, upon release from the feeding centre, many children quickly relapsed into malnutrition. In short, a great number of children were simply not responding to procedures that had long proven effective for the treatment and care of severe acute malnutrition.

Figure 4.3 A mother and child in the Nutritional Rehabilitation Unit, Kamuzu Central Hospital, Lilongwe, Malawi. Copyright © Roger Grasas.

The key factor behind the illness and mortality patterns was HIV; many of the children were infected with the virus. Sickness among HIV-positive people is common, as the virus directly attacks the body’s immune system. Pathogens in the body that had been previously harmless become increasingly active in the face of a weak immune system, often resulting in

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life-threatening illnesses. Many of these HIV-related infections are transmitted and exacerbated through the conditions of poverty: unsafe water, poor housing and lack of resources for good hygienic practices. These are also many of the same factors associated with malnutrition. Over the past few years, Action Against Hunger has conducted clinical and field research in the countries of Malawi and Zambia, with three major objectives in mind: first, to look at the interactions of poverty, illness, and nutrition in families affected by the pandemic; second, to determine how we could improve our treatment of HIV-positive malnourished children; and third, to look at other key topics – for example, health care discrimination or inability to access safe water – that are strongly related to both malnutrition and HIV. This chapter outlines the key findings of our work.

THE CROSS-IMPACTS OF HIV, MALNUTRITION AND POVERTY In the absence of treatment, the majority of those infected with HIV in southern Africa will also suffer from malnutrition at some stage of their lives; the two aggravate each other, and both are related to poverty. A good diet can strengthen the immune system of an HIV-infected person and protect the body from debilitating illnesses. For this reason, people living with HIV/AIDS are recommended to increase their calorie intake by 10 per cent, even in the absence of clinical symptoms of the virus. For those who do show symptoms, the recommendation is a 20–100 per cent increase in calories, depending on age.3 For most HIV-affected families in Malawi and Zambia, however, almost exactly the opposite occurs: food intake

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drops in the face of HIV/AIDS (see Figure 4.4). Inability to afford or access medical care leads to a decline in health, which in turn reduces work capacity. Wage labour and work on home farms become more difficult, and thus income and food production fall. The income loss comes at a time of rising expenses for health care and possibly the hiring of labour to assist with either farm work or child care. The additional expenses force the family to reduce their purchase of food to an even greater extent. With less food, those who are HIV-positive become even more ill, and perhaps die, as the household begins a downward spiral into extreme poverty. Often the family is forced to turn to dangerous or illegal forms of wage-earning to afford basic needs. The stories

Figure 4.4 The downward spiral of HIV, malnutrition and poverty. Copyright ©ACF.

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below illustrate the struggles of two Zambian families living with both HIV and hunger. Beauty Ziko’s story (Chipata community, Zambia) I used to go to the richer areas in the community to plait women’s hair. It was a good job; I could earn a bit of money doing this. But I began to feel so ashamed doing this work – people would ask me lots of questions about my health, commenting on how I had become thin. So I stay at home instead. Many people around me gossip about my condition, but I try not to pay any attention. Since leaving the hair-plaiting work, I have started selling kachasu [an illegal local type of homemade liquor] because I don’t have anything else to do to earn a living. It is better than begging, at least; when I sell kachasu I make a small profit which I use to buy food for my children – it’s enough to get vegetables, charcoal and maize meal. One time, though, the police came and took me to the police station for selling the liquor. I was ordered to pay a fine and they poured away my two containers of alcohol, which I’d just bought on credit. I’m now in serious debt to the person I had bought the liquor from; it would be good to stop selling this stuff, but if I stop now, what will happen to me? My children will be hungry and I will never have adequate capital to start another business. If I did have capital there are lots of legal businesses I could do. I could sell sardines or go to Chikwepe [a nearby market town] to buy and sell vegetables and sweet potatoes. I’d rather sell these things than sell my own possessions, like I’ve done in the past. If I was stronger I could even sweep people’s houses, wash and iron their clothes or something like that. But I am so weak now that it’s better to sell things, to stay seated.

Ivy Mwansa’s story (Zamtam community, Zambia) I lost both my parents: my father around Christmas time in 1995 and my mother about four years later. Now I try to provide for my younger brothers and sisters; when times are good, we eat once a day. CINDI

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[Children in Distress, a local Zambian organisation supporting children orphaned by AIDS, and a partner of Action Against Hunger] gives us maize meal once a month. We try to stretch out this ration to make it last as long as possible. I cook pumpkin or sweet potato leaves to go with it, because we don’t have vegetables. If we don’t receive food from CINDI, or if I can’t get out of the house to find work, we sometimes have to go three days without eating. If the neighbours notice that we don’t have food, they invite us to eat with them, but because there are also lots of people in their family, I tell only my younger brothers and sisters to go over there. On nights when the family has to go to bed without a meal, my brother and I wake up the next morning and go looking for work on a ‘piece rate’ basis. But this is not the best arrangement, as sometimes in the past we were cheated – we worked and then didn’t get paid for our work. So instead my brother has started going to the bush to trap small animals; he leaves on a Friday to set the snares and returns on Saturday to check what he’s caught. If he has done well he sells the catch and buys small packets of maize meal with the money. Once when times were very hard, I sold two of my skirts and made enough money to buy us a daily meal of maize for a month. When we’re in a really difficult position, we go to the nearby community maize mill and pick up the maize meal residues that are left on the floor. We’re not the only ones in Zamtam that do this, so sometimes there’s nothing left to get. What we manage to find we sieve to remove the dirt, but even then it’s not good for cooking, and often causes diarrhoea in the children. Getting sick is another problem. My younger brother is asthmatic but I haven’t got any medicine to give him. When my parents were alive, they used to take him to hospital, and sometimes they were able to buy and keep drugs in the house. The doctors say his condition is serious and if he feels sick or gets a fever we should rush him to the hospital. But from the time that my parents died, this has been difficult to do. It is only God that keeps him alive.

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PROTECTING THE HEALTH OF HIV-POSITIVE CHILDREN Our clinical research, conducted over the last three years in the Lilongwe area of Malawi, showed that children with severe malnutrition do indeed have a higher prevalence of HIV than the community as a whole. As described above, these children are caught in a downward spiral of ever-worsening health, as poor diet leads to opportunistic illnesses attacking a weakened immune system. Treatment for HIV – known as anti-retroviral therapy, or ART – has proven to be effective in arresting this decline. At the time of the research, however, lack of resources prevented all but a small fraction of HIV-positive children in Malawi from obtaining free medication. Without access to ART, one-third of the malnourished HIV-positive children in the therapeutic feeding centres we examined in our study died. This mortality rate was three times higher than for HIV-negative malnourished children. In Northern countries, the HIV-positive children would have received treatment and survived. With the help of international donors, the Malawian government is currently expanding ART coverage in the country. Increased resources for ART programmes will lead directly and unequivocally to saved lives: children who are HIV-positive may take longer to recover from malnutrition and illness than those who are HIV-negative, but with proper treatment they can make a full recovery. The key need is to diagnose these children as early as possible before their condition deteriorates into severe malnutrition and the complications of illness that lead so often to death. Early diagnosis should then be complemented with dietary supplementation, prophylactic antibiotics and, when it becomes

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Figure 4.5 Patients in the Nutritional Rehabilitation Unit, Kamuzu Central Hospital, Lilongwe, Malawi. Copyright © Roger Grasas.

necessary, ART to maintain the children’s nutritional and immune status. We recently conducted detailed follow-up interviews with 35 families in Malawi that had children admitted to therapeutic feeding centres in Lilongwe for treatment of acute malnutrition. About half of the children we followed up in our interviews were HIV-positive. As part of their initial treatment, these children were referred to HIV services, and nearly all of them are now on ART. We found that none of the children we surveyed had relapsed into malnutrition, and the group generally reported a decline in illness in the past year. Our small sample of families shows that HIV-positive children, with proper care, can indeed lead healthy lives. In the case of our field programmes in Malawi, the increasing numbers of children accessing HIV services is

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extremely encouraging. A major concern, however, remains: in the process of HIV counselling and testing, it is made clear to mothers that a positive HIV result for the child indicates that there is a strong chance that she herself is positive. Despite the willingness of many mothers and caregivers to acknowledge the HIV-positive status of their children and seek treatment, many are reluctant to accept that they themselves are infected and must attend to their own health needs. The issue of caregivers ignoring their own HIV-positive status is a danger not only to the mother herself, but also to the child: poor maternal health will negatively impact child care and feeding practices, as well as the child’s psycho-social development.4 While it appears that the children in the families we interviewed are currently doing well, deterioration in the health status of mothers will rapidly lead to serious difficulties for the child as well. In the worst-case scenario, as in Mary’s and Ivy’s stories above, the children will become orphans. In summary, if the objective is to keep HIV-positive children healthy – and with political commitment and adequate resources, this is an achievable goal – then interventions must be holistic, considering nutrition as well as health, adults as well as children. More programmes are needed to specifically address malnutrition linked to HIV/AIDS, and diagnosis and treatment of the virus must happen in a timely manner. Again, early intervention is the key to reducing mortality.

THE DANGERS OF DISCRIMINATION The availability of health services by themselves, however, is not enough. Health care providers must also offer services in a manner that is non-discriminatory and guards against

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stigmatisation of the HIV-positive patient. There is some evidence from past studies that people living with HIV/ AIDS are often treated unfairly in health clinic settings. To explore this topic, Action Against Hunger, in partnership with the local Malawian organisation REACH, conducted a small study to explore how discrimination and stigma on the basis of perceived HIV status among severely malnourished children affects interactions between health staff, mothers and the children themselves. Direct observation of health worker behaviour confirmed some of our concerns. Some doctors and nurses were seen to avoid engaging with severely malnourished children they perceived to be HIV-positive. Interviews with health workers showed that this discriminatory behaviour was largely due to the fact that they simply did not believe the children would survive their illness. The doctors and nurses preferred to devote their scarce resources5 – to patients they saw as having a viable chance of recovery. Given the severe time and money constraints of Malawi’s health care system, such an attitude is understandable – but mistaken. As we found in our followup interviews with families of HIV-positive children who had been severely malnourished, appropriate treatment and care can lead to a full recovery. The critical step is an increase in health care resources, as well as change in attitude: to accept not only that these children are able to lead normal, healthy lives, but also that they have an inviolable right to do so. Discrimination against HIV-positive and severely malnourished children has heavy consequences for the mothers and caregivers as well. Negative and judgemental attitudes from doctors and nurses – who are held in esteem as ‘experts’ and ‘healers’ – generate a great deal of anxiety and fear among HIV-positive people. Many of the mothers we

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Figure 4.6 A man waits for the result of his HIV test in the community of Malembo, Malawi. Copyright © Susana Vera.

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spoke to reported that the degrading manner in which they were treated played a part in their decision to discontinue medical care. Given that there are already many other factors that prevent caregivers from accessing health care services for their children – for example, the real and perceived costs of medication, the costs of missing work (especially around harvest time), and the problems of leaving other children unattended at home – the added issue of discrimination is a serious one. Even among the households we interviewed that are utilising ART, we found that few are accessing important complementary HIV services, despite the fact that many other such services are available. It appears that the combination of stigma and discrimination, financial constraints and other issues is leading to families pursuing only the minimum set of services and treatment they perceive as essential. Unfortunately, failure to access complementary services such as nutritional supplements, child care and psycho-social counselling can often undermine the gains of ART treatment.

THE IMPORTANCE OF WATER ACCESS IN THE FIGHT AGAINST MALNUTRITION In the Kitwe area of Zambia’s Copperbelt, over a quarter of the adult population is HIV-positive. The pandemic has led to great economic difficulty for many households, and Action Against Hunger is working with our local partner organisation CINDI to develop livelihood projects to increase income. One of the projects helps families create small vegetable gardens that can be an important source of immune system-strengthening micronutrients. One of the critical elements to successful home gardening in this area,

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however, is access to water for irrigation. As we examined this issue in more detail, we began to realise that many families affected by HIV were facing great difficulties in obtaining water, not only for irrigation but also for domestic use. To better understand how to respond to these problems, Action Against Hunger conducted a small study in December 2006 examining the water needs of HIV-affected households. The lessons we learned from our research are summarised in the paragraphs below. We found that the simple physical distance of households to a water point is a key concern, particularly in families that have only one parent available to care for the children. The problem is made worse if the parent is HIV-positive and ill. Water collection is always an arduous task, but if one is sick or lethargic, the work is almost impossible. It is difficult for friends and neighbours to constantly assist HIV-positive households in obtaining water, as it is a labour-intensive and time-consuming undertaking. This is especially true in the many rural communities where pumps do not work and wells are seasonally dry; families must find alternative sources, such as buying the water or going to the local river and carrying the water back to their homes. Another issue is that people living with HIV/AIDS are advised to drink greater quantities of water, especially when on medication or suffering from diarrhoea or fever. In addition, more water is needed for personal hygiene and cleanliness of the home environment, to reduce the risk of contracting infection. This is especially the case when family members are afflicted with diarrhoea. The quality of water is another source of worry, especially if households must obtain their water from the river or other unprotected sources. Chlorine tablets can purify the water

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to a limited extent, but many households cannot afford this option. Boiling water is an adequate alternative, but this requires money or extra time spent collecting firewood, which can be a physically demanding task. We found that few families are able to purchase chlorine tablets or boil water on a consistent basis. Overall, we noted that the families that had the greatest difficulty in obtaining water were those who had lost the primary caregivers to illness or death, especially households headed by grandmothers or children. What might be a simple inconvenience to most families – for example, if community water points are broken or the price of chlorine tablets high – will be a severe problem for such extremely vulnerable households. In areas where HIV has robbed many families of their adult members, the maintenance of safe water points becomes a critical measure in fighting the pandemic. Finally, we noted one other issue that is frequently glossed over in speaking of water access: the specific needs of women and children, who are often the family members responsible for collecting water. In private interviews, many women told us that water points or latrines placed in secluded or unlit areas put them at risk of assault and rape. In areas where HIV prevalence is extremely high, sexual assault can be tantamount to a death sentence. For this reason, careful thought into security considerations – for example, providing lighting or placing water points in safer locations – is necessary when planning the creation of water facilities. Children also have particular needs, especially related to the ease of water access: facilities located far away, or which require great physical effort to obtain the water, will decrease supply in households where children are the only family members healthy enough to acquire water. All members of a community, especially

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those often ignored in decision-making processes, must have a voice in resolving questions of shared water access – type of water point, location, security, affordability, maintenance, and so on. The findings from our study highlight the fact that HIV-positive households have particularly pressing needs regarding access to water. The construction and maintenance of easily accessible safe water sources is of great importance in protecting the dignity of these households. While access to safe water is a serious problem in many areas of the developing world, the heightened vulnerability of HIVpositive individuals makes safe water provision an even more critical issue. For families affected by HIV, safe water may not be just a question of occasional sickness; it may indeed be a question of life and death. *

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The past decade, and especially the past few years, has witnessed important advances in the fight against the HIV/ AIDS pandemic. With the increasing amount of funding available from sources like the William J. Clinton Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria, public health systems are slowly improving, and evidence of the impact of this improvement is clear. But the struggle against the virus is not just a question of public health, and that indeed is the most important lesson we can draw from our body of research in Malawi and Zambia: the right to health care means little if it is not accompanied by protection of other human rights, including the right to food and the right to safe water. Once again, the component parts of human dignity are seen to be intimately connected

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and inseparable: if any one aspect is not valued, then the whole is violated. The central message of this chapter is that the whole of dignity can indeed be protected, with enough resources and political commitment. Despite the dire initial state of the children in our studies – severely malnourished, HIV-positive, with strongly comprised immune systems – we found that with access to ART, food and safe water, they are able to lead healthy, creative lives. And what is true for the Malawian and Zambian children in this chapter can be true for any child in the world.

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5 The Meanings of Dignity: Quiet Tragedies and Indomitable Spirits in Ethiopia

Figure 5.1 A man transporting firewood, in the community of Bokaso. Copyright © Paul Rees-Thomas.

Bokaso and Moto are two villages in the Sidama coffee lands of south-western Ethiopia, an area where Action Against Hunger has established food, water and nutrition programmes. 68

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This region is steadily becoming more food-insecure, as low coffee prices, increasing soil erosion, small landholding size and lack of off-farm employment opportunities all continue to break down household resilience. Recurrent droughts during the 1990s forced many families to sell off their productive assets, especially their livestock. The coffee price crash at the end of the decade, coupled with continuing drought conditions, was a crippling blow to the hundreds of thousands of households in this area who depend on coffee as the primary source of income. The humanitarian crisis of 2003, in which millions of people in the area required emergency food assistance, revealed this region to be one of the most fragile areas in Ethiopia. Despite relatively favourable harvests and slowly increasing global coffee prices in the last several years, severe acute malnutrition rates in various parts of the region remain at distressing levels, especially during the lean season. If a repeat of past crises is to be avoided, it is critically important that policy-makers and citizens all over the world hear the stories of families here. In this chapter, we present a few of those stories, particularly from households who have had children treated recently for severe acute malnutrition at Action Against Hunger’s therapeutic feeding centres. Taken as a whole, the set of testimonies below make a strong case for the international community to expand the boundaries of conscience and engage proactively and decisively with the daily violence of hunger. Incredible sacrifice runs throughout these stories; they portray not only the cost of deprivation, but also how courageous the pursuit of dignity truly is. One often hears, as an argument against foreign aid, the facile view that ‘people in poor countries need to fight for their development like

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the people of Northern countries have historically fought for theirs’. We hope that the accounts below demonstrate definitively that people are indeed fighting, with considerable strength and intelligence. Aragash and Shunkay Yutata’s Story Aragash: I’ve lived in this village, Bokaso, for my whole life. My father was born here too. This is my wife, Shunkay, and these are my three children, Ondalay, Shufaory and Shebrow. They are six, four and two years old. We’ve also lost three other children, they all became sick from hunger – it’s been five years since the last one left us. My father died a few years ago and left me and my brothers about one-half timad1 [an eighth of a hectare] of land each. This is not enough land to provide enough food or income for my family, so I have an arrangement with another farmer. I tend some of his land, and I keep some of the produce from that plot of land as well, especially the enset.2 My brothers and I would like to help each other more than we do, but we are all in a similar difficult position – in the end, we are unable to support each other much. The last five years have been hard. We used to have two goats and three sheep, but had to sell them all to buy food during the lean season – we received between about 100–200 birr3 [approximately £6–12] for each one. Even with the other plot of land I manage, we need to be constantly looking for off-farm work to feed the children. Lately I’ve found some work helping to build houses and mending walls and fences. When I can find that kind of work, I get paid about three to four birr a day [17–23p]. There are times, though, when I can’t find extra work like this for a month at a time. During the dry season, work is usually more available – this is also the harvest time, so there’s more money in the village for people to hire workers. But during the rainy season, which is also the hunger period in the few months before the harvest, finding work is difficult. In the past few years we have had to cut down our enset plants before they were mature to make it through the lean season.

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Figure 5.2 Preparing the earth for planting, in the community of Bokaso. Copyright © Paul Rees-Thomas.

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Shunkay: I grew up in the neighbouring district. I helped my mother sell vegetables in the local market and by the side of the road when I was a teenager. This was before I was married. Neither Aragash nor I were able to go to school growing up. Like Aragash, I try to find work in other people’s farms, mostly helping with the enset crops – it’s a lot of work to process the plant, so often people need help.4 I take the children with me when I work. Once in a while I will also find work in our neighbours’ houses, making food and doing domestic chores. For this job I am usually paid in the lower-quality kocho5 that’s harvested. Sometimes I am paid in cash – I made about 15 birr [85p] in the last three weeks doing this kind of work. The children have all had bouts of diarrhoea recently. I took them to the health centre and received some tablets, free of charge. The youngest one was treated for being sick from hunger last year. We try to give the children milk, but we haven’t been able to afford it the last few months – we only buy milk for them when they’re sick. Otherwise they mostly eat just the kocho, with us. Also, because the youngest was admitted to the malnutrition treatment programme, we have been receiving some grain from the government.

Yohannes and Abarash Niammey’s Story Yohannes: We own about a one-half timad of land, and rent another timad from a neighbour. We also live in this neighbour’s house for the moment. Our own house was damaged in a storm about six months ago, and I have been sick since then and unable to fix it. It is difficult to be sick right now – the crops need to be tended. We have planted enset, coffee and maize. Last year’s coffee harvest was small, about 100 kilogrammes, and I sold it for about 100 birr [£6].6 I used part of the money to buy one piece of clothing for each of the four kids – either a shirt or trousers – and I bought some trousers for myself. When I am feeling strong enough, I farm other people’s land for about three to four birr a day [17–23p]. I usually use this money to buy kocho or vegetables from the market. We don’t have enough to

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Arabash Niammey processing the enset crop. Copyright © Paul Rees-Thomas.

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buy milk for the children, but we do buy some when they are sick, to make them stronger. We usually have enough tea or coffee for the mornings, and try to add sugar when we can afford it. Things would be easier if we had livestock. My neighbour has goats, and they not only give his family milk, but they can also be sold if the next year is very hard and the family needs to buy food. We had to sell our cows and goats about five years ago to pay for medication, and now we have no livestock. Abarash: I moved here nine years ago to marry Yohannes. We have four children; two have been sick with malnutrition in the past three years, and we took them to be treated. The youngest, Yontoura – he is two years old – went for treatment last year and recovered fully. It has been difficult for the children. Both Yontoura and his eight-year-old brother Hashamou have had diarrhoea and worms in the past week. We went to the health centre and received some oral rehydration medicine for the diarrhoea. The other two children, Facardo and Adanou, have been complaining of abdominal pains for the past few days. I would like to take them to the health centre, but we can’t afford more medication right now. I work on other peoples’ farms, processing enset. I earned about ten birr [57p] last week doing this, although the wages always change – it depends on whether the person is generous, and also if it’s been a good year for them. I also try to make some money selling vegetables. I walk to a market in the highlands, where the vegetables are better quality because they receive more rainfall there, and bring as many as I can carry on my back to sell in the local market in this village. I make three to five birr [17–30p] profit doing this. When I’m working away from home, I leave the children with the neighbours, or trust the older children to take care of the younger ones. The older kids will also do household chores or work on our plot of land. Just like our parents couldn’t afford to send us to school, we can’t afford to send our children either.

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Werekey and Bekelur Dika’s Story

Figure 5.4

Mr Werekey Dika harvesting from his fields. Copyright © Paul Rees-Thomas.

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Werekey: I am 25 years old. Bekelur and I have two children, aged one and five; their names are Balachu and Alemu. We have about one-half timad of land, which we received from my father when we were married. I plant what my father planted – mostly enset – but I would like to plant more coffee trees in the future; I have a few now, but not many. Enset is a reliable crop for food, and we can also feed the animals with the leaves of the plant, but coffee brings in cash for when we need to purchase clothes and other household things, as well as for medical bills. We harvest the coffee from October to January and store the beans inside our home. The warmth from cooking helps to dry the beans out before selling. We bought two female goats a few weeks ago, from the money we saved after selling the coffee. The goats give about one cup of milk a day, which we boil and give to the children. I’m going to fatten the goats up to sell, and try to breed more from the older female I purchased. Here in Sidama it used to be the common practice that, if you didn’t have a male animal to impregnate your female, your neighbour would lend you a male. But now this is changing somewhat, as times get harder for people. I may need to pay to borrow a male for impregnating the female goat I bought, if I can’t find anyone within my close family who’s able to lend me their male. I try to find off-farm work whenever I can, ploughing, weeding, clearing plots, or doing maintenance and repair jobs. It brings in about three birr [17p] a day, but I was only able to find work two days last week. I used to travel very far to find this kind of work, but now that I am a father I try to stay close to home. Bekelur and I have been sick a lot lately. She has had abdominal cramps and diarrhoea in the past week, and hasn’t been able to travel far to find work. My stomach gets upset frequently; I’ve been vomiting too, and don’t have much of an appetite. But the kids are healthy again, mostly – just a little cough now and then, and some skin problems. I can’t remember being hungry and sick like this when I was growing up. My family wasn’t so badly off, and we had milk whenever we needed it. Since I’ve started my own family, it’s been a struggle.

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Obeshet Gussesa’s Story

Figure 5.5 A schoolchild with books, at a community school in Bokaso. Copyright © Paul Rees-Thomas.

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I am a teacher here at the Bokaso village primary school. The school conditions here are not easy for the children. There are sometimes as many as 50 children in one class. We don’t have enough desks and many have to sit on the floor. But even though our school is overcrowded, probably half the children in the area are not attending school at all. The usual starting age for primary school should be five years old, but some of the students in the first grade are nine, ten, even eleven years old. Their families can’t afford the school expenses at an earlier age, and the kids have to wait. It’s the high registration fees that keep many families from sending their kids to school, but we teachers have little choice about setting the fees. The school suffers from a lack of money to conduct proper classes even for the kids we do have. Many of the children are from the highlands and the trip to the school can take up to three hours each way. A lot of the kids tell me early in the morning that they are hungry, and the teachers will sometimes give a few birr to the children they know are really struggling. When they are hungry it’s easy to see that the kids are irritable, lack concentration, fall asleep in class, and are generally unable to follow the lessons. Usually about one out of every ten kids drops out of the school in a given year. But in bad years more drop out around the beginning of the lean season in April, when families can’t afford the cost of even the basic school supplies. More children fall sick during this time too and stop attending classes. Also, some of the older children have to leave during the lean season to help their parents work. The teachers try to follow up on those who’ve dropped out, to try and understand why the family is having difficulties, and to see if there’s any way to get the child back to school. Often, we feel like we’re social workers as much as teachers.

Dotora and Asada Fenoga’s Story Dotora: We own about one timad of land here in Moto village. Mostly we depend on coffee for our income; I made about 160 birr last year [£5.70] selling the coffee to the local cooperative. The cooperative

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Measuring coffee beans for sale, Bokaso market. Copyright © Paul Rees-Thomas.

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gives a higher price than the private traders. We also have some bananas that we sell. We try to keep them on the tree as long as possible, because they don’t store for very long. We do try to keep some bananas for the kids to eat, but usually we need the money more than the fruit. I used to be a coffee trader a few years back. Over the years, I had slowly been able to build up my livestock, and then I sold them to get the capital to start my coffee trading business. I would move between markets, trying to buy at a low price and sell wherever the price was highest. A few years ago, though, the prices dropped a great deal7 and I lost almost all my savings. I would like very much to go back to those days and try trading coffee again, but I can’t imagine how I could ever save enough to break back into the market. It’s possible to get credit from the richer families in the community, but only at very high interest, usually 100 per cent. It’s not really possible to negotiate a lower interest rate, but sometimes you can ask for an extension on payback. I have an outstanding debt of about 50 birr [£2.85] right now. I wouldn’t hesitate to take more if some health emergency came up; it’s the only way. A lot of households borrow money. Most of the larger loans are for building houses. To purchase wood, mud and bamboo of good enough quality to build a house, you need around 800 birr [£45]. Sometimes families have difficulty paying back the loans, and then the committee of village leaders steps in and tries to mediate. They are usually pretty fair; I only remember one time when the committee forced a household to sell their assets to pay back the loan. Asada: I’ve been sick for a few months, with stomach cramps and aching bones all the time. My husband Dotora has had to do most of the housework since I’ve been feeling this way. I’m not sure what it is that’s making me ill. Every time I go the clinic to buy medicine, we have to sell something to afford the cost. We had to sell a chicken for the last visit. Sometimes when there is nothing to sell, Dotora has to borrow money to pay for my medicine. When I was feeling better, I would look for work on other people’s land. I would make two birr

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Figure 5.7 Mr Dotora Fenoga, preparing the earth for planting. Copyright © Paul Rees-Thomas.

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[11p] for the half-day’s work and use the money to buy some flour or milk for the children. We are still able to eat three meals a day usually, but how much we eat varies from day to day. In the last few days, we have had kocho for breakfast, lunch and dinner, but last night I was able to add some vegetables to the dinner. This morning we had coffee, which we aren’t always able to have. The last time we had meat was Christmas, about four months ago. The church took contributions from any family who could afford to pay, bought an animal to slaughter, and then held a feast for the whole community. Christmas and Easter are usually the only times of the year we’ll have meat.

Asfew Gelecha’s Story I live with my three sons, between the ages of nine and fifteen. It is a hard time for us. My wife died suddenly only three weeks ago. I think it was heart failure; she died less than an hour after she told us that she was feeling fever symptoms. We had been building a new house, with the help of our neighbours and relatives. They would work with us during the day, and my wife and I would give them kocho to eat in the evening. The stock of kocho that my wife made is now finished. I hope that my relatives will help me provide more kocho to my neighbours; the house is not finished yet, and if you ask someone to work you should provide food. We have had a lot of health problems over the years. One rainy season four years ago, the entire family contracted malaria; it took years before I felt completely recovered. My wife and sons were unable to get out of bed for months. If it had not been for the support of friends and family, I don’t know how we would have made it through. I had to borrow 300 birr [£17] to buy the malaria medicine, and then had to pay back twice as much. It took me three years to pay it back completely. Last year, my youngest son got malaria again, and went to both the local and district health centres to get treatment. He lost a lot of weight and that’s why he was treated for malnutrition. Things have been so hard in the past few years that I sent my second son to live with my mother-in-law. This has helped him a lot, since

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Figure 5.8 Commonly used agricultural tools in the coffee areas of Sidama. Copyright © Paul Rees-Thomas.

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she’s better off. I’m proud of him: he’s currently in school, in the sixth grade. My youngest son has started school, but he failed the class and will repeat again next year. My eldest son was going to school too but dropped out to help me work on farms and transporting goods from time to time. The recent coffee harvest was a good one, in comparison to the year before. I made about 250 birr [£14] this year, about two and a half times what I’d made the year before. But I only kept 50 birr of this amount, as I had to pay about 200 birr in debts to the local moneylender. I bought clothes for the family with the 50 birr I had left. Fortunately, the enset harvest was also a good one, and my wife processed about 100 kilogrammes of kocho from the crop. This is what we have been sharing with the neighbours helping us on the house, but as I said, the stock of kocho is now almost finished.

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The stories above come from just two communities in one region of Ethiopia. While this geographical focus is narrow indeed, the accounts in this chapter embody themes that are common in this report: the great costs of hunger, and the constant striving of families for dignity. The testimonies in this chapter beg the question: ‘What can we do to support families like those of Bokaso and Moto?’ In Ethiopia, progress is being made. The Ethiopian government, in partnership with a wide range of donors from Northern countries, recently launched a five-year £1.5 billion food security initiative. In 2007, this programme was seeking to provide benefits, mostly through public sector employment projects, to nearly 9 million Ethiopians. The benefits have been planned to be disbursed during the lean season, and thus should assist in reducing malnutrition.

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At first glance, the £1.5 billion figure looks impressive. Yet when one looks closer, it is clear that such a financial commitment only scratches the surface of what is needed. An estimated 30–35 million Ethiopians live below the national poverty line (the amount of money a family needs to meet essential food and non-food needs), struggling to meet the challenges of volatile markets, ever-decreasing rainfall and a still-unstable democracy. The benefits of the food security initiative manage to reach only perhaps a third of those living under the poverty line. The £1.5 billion figure is further diluted by its five-year duration, which means that the actual amount of benefits given to each household is quite low: wages for work in the government labour programme are about six birr a day (34p), with a maximum of 30 working days per year. Research conducted by Action Against Hunger last year in the Sidama area has shown that, whilst households do indeed benefit from the new food security programmes, the vast majority of people still fall well short of meeting their food needs. When faced with such criticisms, donor agencies often reply that little money is available in foreign aid budgets to increase funding for programmes such as Ethiopia’s food security initiative. Yet the issue is more one of political priorities. In the case of the US, both the Hurricane Katrina reconstruction and the Iraq war are examples of responses that demanded hundreds of billions of dollars of funding for which no money had previously been budgeted. Yet when they became political priorities, the government found the money. The fight against malnutrition is no different: the money can be generated, if the political will to do so exists. The daily cost inflicted by hunger on millions of families across the world is easily on the scale of Hurricane Katrina

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or the Iraq war, and, in a just world, more resources would be devoted to protecting the right to food of families like those of Bokaso and Moto. But it is not a yet a just world. It remains to us, the citizens of both Northern and Southern countries, to work in our lives to make it so, to awaken our leaders to the reality of hunger’s hidden violence.

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6 Postscript: Conscience and Power

Figure 6.1 Children in class at a Bokaso school. Copyright © Paul Rees-Thomas.

Ethiopia is a country whose name remains indelibly connected with 20-year-old images of dust-filled starvation: the great famine of 1984, which killed close to 1 million people. For 87

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those Ethiopian families who lost sons, daughters, fathers and mothers in 1984, it is no consolation that the devastation was largely responsible for awakening the conscience of the Northern public to the horror of famine. But Ethiopia has not had a disaster of remotely the same magnitude in the two decades since, and while the lion’s share of the credit for this success must be given to the ideas and efforts of the Ethiopians themselves, the increased public pressure on Northern governments to guarantee that famine does not occur again also played an important role.1 The donor countries responded to this pressure by raising levels of international assistance. The humanitarian and development initiatives that have been implemented with this increased assistance have undeniably been influential in lowering death rates in Ethiopia. Ethiopia is not unique; similar stories could be told for many places around the world. Despite the frequently heard contention that ‘foreign aid has had little positive impact’, the opposite is clearly true. Despite the inefficiencies, despite the losses to corrupt bureaucrats, hundreds of thousands of lives have been saved with intelligent and timely aid, and the world community should be proud of its accomplishments. But, as we have insisted throughout this report, ‘freedom from abnormal mortality’ is a far cry from ‘dignity’. What lower mortality implies is survival, in the strictest biological sense of the word; not a quality life, not a life full of joy and possibility. The world’s future must be defined in terms far broader than not-death; life as little more than a sum of constant and extreme pain is no cause for celebration. We argue instead that the challenge is just beginning, and an important opportunity lies before us, an opportunity to expand once more the boundaries of conscience: to see dignity, not

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survival alone, as a feasible goal. As an organisation working to end hunger, we urge the beginning of this expansion of conscience by demanding the right to food with the same passion that we have learned to demand the right to survive famine conditions. The Universal Declaration of Human Rights, and every human rights covenant since, can yet stand for more than a utopian dream. With a combination of increased foreign assistance, financial investment, and trade policies preferential to developing countries, the right to food is indeed attainable. Yet it is not the technocratic blueprint for ending hunger that we lack. It is rather that questions of conscience and priorities face the international community: economic hegemony for the rich, or economic opportunity for the poor? Realpolitik in the interests of only the powerful, or human dignity in the interests of everyone? A politically useful chimera of human rights norms, or the justice of eating? *

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Thankfully, finding examples of success in the fight against hunger is not difficult: there are many private individuals, civil society organisations and governments who are indeed working tirelessly to improve the lives of the most vulnerable people. Technical responses are constantly being enhanced: increasing numbers of food security projects are moving away from a narrow focus on food aid to a broader emphasis on protecting livelihoods; more effective water harvesting and storage mechanisms are increasing safe water supply to communities; a better understanding of the connections between HIV and malnutrition is leading to superior medical treatment, and so on. Humanitarian workers and human

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rights activists all over the world are struggling, often at great personal risk, on behalf of those exposed to mental and bodily suffering. The accelerating expansion of popular media, particularly via the internet, is allowing journalists, writers and ‘ordinary’ citizens to tell more and more stories of our global community and its struggles. The courage, sacrifice and fortitude underneath this panoply of compassion and action is remarkable, and worthy of immense praise. Yet, if the complete dignity embodied by the Universal Declaration of Human Rights is the goal, we argue that good ideas and bold, caring hearts are not enough. Our analyses of the crises in Sudan, Niger, Zambia and Malawi share a causal nucleus: an overwhelming imbalance of power between those whose rights are violated and those who are responsible for the violation – whether national governments, local economic elites, or the international community. Power – the kind of real social power that people require to prevent the violation of their right to food – is a zero-sum game: decision-making is either shared, or it is dominated by the stronger party. If people are unable to voice their opposition to political or economic agendas that cause the loss of lives and the collapse of livelihoods, if they are unable to participate in the decision-making process that determine these agendas, it is powerlessness that silences them. But what, then, is power in the context of human development? We define it thus: power is the ability to demand – and receive – enforcement of the full set of basic human rights in the face of any competing interests. This type of power results when the pursuit of dignity is valued, by the international community as a whole, as pre-eminent over other economic, political or cultural agendas. The outcome of such power is the realisation of a radical equality of opportunity:

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the opportunity of each human being to be well-nourished, to have access to the best health and educational services global society can provide, and to be politically free. Each of the crises studied in this report could have been averted and hundreds of thousands of lives saved from death and hunger had such a prioritisation of dignity existed. The above sentences depict an admittedly idealistic picture of the world; or, avoiding the negative connotations of idealism, perhaps we should say instead ‘a picture of the world far different than the present reality’. But if there is one message above all others that we would like to transmit in this report, it is that while choices in the political world are painted in shades of grey, the consequences of those choices are often irreversibly black and white: life, or death; the joy of health, or the violence of hunger. Conceiving of and implementing mechanisms to transfer control over people’s lives from rich and powerful actors to the families themselves is no small goal: above the technical obstacles, voluntarily giving away dominance is not something that human beings do well. The will to justice, however, may yet prove stronger than the will to power, and it is in devotion to that hope that this report is written.

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Figure 6.2 A child from the community of Moto. Copyright © Paul Rees-Thomas.

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1

INTRODUCTION: A LIFE WORTH LIVING

1. United Nations, The Universal Declaration of Human Rights, 1948. Accessed 20 June 2007 from http://www.un.org/Overview/ rights.html. 2. United Nations News Centre, Sudan – Humanitarian Situation One of Worst in the World, 4 May 2004. Accessed 20 June 2007 from http://www.un.org/apps/news/story.asp?NewsID=10615& Cr=sudan&Cr1=. 3. United Nations News Centre, Annan Welcomes Extension of African Union in Darfur, 21 September 2006. Accessed 20 June 2007 from http://www.un.org/apps/news/story.asp?NewsID=19948&Cr=s udan&Cr1=; see Eric Reeves, Quantifying Genocide in Darfur: Current Data for Total Mortality from Violence, Malnutrition, and Disease, 28 April 2006. Accessed 20 June 2007 from http://www. sudanreeves.org/index.php?name=News&file=article&sid=102; United Nations, Office of the UN Deputy Special Representative of the UN Secretary General for Sudan, UN Resident and Humanitarian Co-ordinator, Sudan, Darfur Humanitarian Profile No. 27, 1 April 2007. Accessed 20 June 2007 from http://www. reliefweb.int/rw/RWFiles2007.nsf/FilesByRWDocUnidFilename/ 9F195407A9628CA5492572E9000D04DB-Full_Report. pdf/$File/Full_Report.pdf. 4. Refugees are people who have been forced to flee across international borders. Refugees are under the jurisdiction of international refugee law, and their protection is mandated to the United Nations High Commission for Refugees (UNHCR). Internally displaced persons (IDPs) have also been pushed from their communities – often thousands of miles away from the place of origin – but remain within the borders of their country. IDPs are protected by various bodies of law; principally national law, 93

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human rights law and, if they are in a state undergoing armed conflict, international humanitarian law for the protection of civilians. However, in many cases the state itself is the cause of displacement, and thus is unwilling to assure – or may even actively block – the implementation of these laws. 5. We use the term ‘livelihoods’ in this report in a general sense, to mean ‘the ways by which households attempt to satisfy their basic needs (food, clothes, shelter, and so on)’. Agriculture and livestock-keeping (‘pastoralism’) are two examples of livelihood strategies. 6. In this report, we refer to industrialised countries as ‘Northern’ and developing countries as ‘Southern’. 7. Joint United Nations Programme on HIV/AIDS, HIV Data, 2006. Accessed 20 June 2007 from http://www.unaids.org/en/HIV_data/ default.asp.

2 THE BURDEN OF SURVIVAL: INSIDE THE PAIN OF DARFUR’S LIVELIHOOD WAR 1. See Chapter 1, note 3, above. 2. We do not go into detail in this chapter on the issue of environmental degradation. However, we briefly state here that yearly average rainfall in Darfur decreased precipitously during the 1970s and 1980s, before exhibiting a slight upward trend during the 1990s. Variability of rainfall – large spikes and valleys – is unambiguously increasing. Climate change, caused mainly by greenhouse gas emissions from industrialised countries, appears to be a major factor behind the rainfall trends. Climate change models for the Sahelian region of Africa, in which Darfur lies, differ in their projections for future rainfall quantities but all predict increasing variability. For a discussion of these issues, as well as a list of climate and environment data sources for Darfur, refer to the Tearfund (2007) report, ‘Darfur: Relief in a Vulnerable Environment’, accessible at http://www.tearfund.org/webdocs/ website/Campaigning/Policy%20and%20research/Relief%20in% 20a%20vulnerable%20envirionment%20final.pdf, as well as the

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3.

4. 5. 6. 7. 8.

9.

10.

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United Nations Environmental Programme Report, ‘Post-Conflict Environmental Assessment’, accessible at http://sudanreport.unep. ch/UNEP_Sudan.pdf. See Julie Flint and Alex de Waal, Darfur: A Short History of a Long War. London: Zed Books, 2005; Gerard Prunier, Darfur: The Ambiguous Genocide. Ithaca, NY: Cornell University Books, 2005. Flint and de Waal, Darfur. See ibid., and Prunier, Darfur, for a more detailed overview of Darfur’s history, as well as of the recent conflict. See note 2 above. Flint and de Waal, Darfur. ‘Livelihoods development’ projects seek to increase the income and food-earning power of families; for example, through increasing market access or enhancing agricultural productivity. ‘Cash transfer’ interventions provide more direct assistance to families; for example, in the form of employment programmes, distribution of vouchers that can be redeemed for key goods and services, or even direct cash payments. Action Contre la Faim, Preliminary Results, Nutritional, Anthropometric and Retrospective Mortality Survey, Otash Camp, Nyala, South Darfur, Sudan. January 2007. We wish to stress one important point here about the deployment of a peacekeeping force: any force that includes foreign soldiers must be agreed to by all armed factions involved in the Darfur conflict, as well as by Sudanese civil society. Without such agreement, the civilian population may suffer from a backlash against foreign presence in the region.

3 FREE MARKETS, IMPRISONED PEOPLE: NIGER AND THE DANGERS OF DEREGULATION 1. See Chapter 1, Box 1.1, ‘What is acute malnutrition?’, pp. 5–6. 2. Direct communication from the Centre d’Information Humanitaire, Niamey, October 2005.

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3. Sahel and West Africa Club Secretariat, Food Insecurity in West Africa. Why Now Again? What Has Been Done? What Still Needs To Be Done? July 2005. 4. FAO/WFP Crop and Food Supply Assessment Mission to Niger, Special Report, December 2004. Accessed 20 June 2007 from http://www.fao.org/docrep/007/j3969e/j3969e00.htm. 5. United Nations Children’s Fund, Niger: Update on UNICEF’s Work with Malnourished Children, 31 July 2006. Accessed 20 June 2007 from http://www.unicef.org.uk/press/news_detail. asp?news_id=575. 6. As the United Nations Development Programme website (http:// www.undp.org) states: ‘The human development index (HDI) is a composite index that measures the average achievements in a country in three basic dimensions of human development: a long and healthy life, as measured by life expectancy at birth; knowledge, as measured by the adult literacy rate and the combined gross enrolment ratio for primary, secondary and tertiary schools; and a decent standard of living, as measured by GDP per capita.’ See also United Nations Development Programme, Norway at Top, Niger at Bottom of 2005 Human Development Index, 31 July 2006. Accessed 20 June 2007 from http://content.undp.org/go/ newsroom/human-development-index070905.en. 7. Price data from SIMA-Niger (Agricultural Market Information System). 8. Geert Beekhuis, World Food Programme Report, Niger: Profile of Cereal Markets, August 2005. 9. C. Ford Runge Benjamin Senauer, ‘How Biofuels Could Starve the Poor’, Foreign Affairs, May/June 2007. Accessed 20 June 2007 from http://www.foreignaffairs.org/20070501faessay86305/cford-runge-benjamin-senauer/how-biofuels-could-starve-the-poor. html. 10. Livestock and cereal price volatility are closely linked. When cereal prices are high, pastoralists have to sell more livestock to get the cash they need to purchase cereals. This automatically increases the supply of livestock on local markets, and thus drives livestock prices downward. This pattern was aggravated in 2005 by the impact of locust and drought, which reduced the amount

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11. 12.

13.

14.

15.

16. 17.

18.

19.

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of usable pasture land and pushed pastoralists to sell off part of their herds. See Sahel and West Africa Club Secretariat, Food Insecurity in West Africa. Johny Egg, Franck Galtier and Emmanuel Gregoire, ‘Systèmes d’Information Formels et Informels, la Régulation des Marchés Céréaliers au Sahel’, Cahier Sciences Humaines, 32(4), 1996: 853. Comite Permanent Inter-Etats de Lutte Contre la Secheresse dans le Sahel (CILSS) et al., Sécurité Alimentaire Et Echanges Transfrontaliers Dans la Zone de Kano–Katsina–Maradi K²M, Rapport de Mission Conjoint, July 2006; Famine Early Warning Systems Network (FEWSNET) and United States Agency for International Development (USAID), Niger: An Evidence Base For Understanding the Current Crisis, 28 July 2005. Accessed 20 June 2007 from http://www.fews.net/centers/innerSections. aspx?f=r1&m=1001611&pageID=monthliesDoc. ROPPA and OECD, Initiative Paysanne en Faveur du Developpement de la filière coton en Afrique, March 2004. Accessed 20 June 2007 from http://www.oecd.org/dataoecd/38/45/30748731.pdf. Oxfam International, Cultivating Poverty: The Impact of US Cotton Subsidies on Africa, 2002. Accessed 20 June 2007 from http://www.oxfam.org.uk/what_we_do/issues/trade/downloads/ bp30_cotton.pdf Ibid. Oxfam America, US Must Reform Agricultural Subsidy Program, 1 September 2006. Accessed 20 June 2007 from http://www. oxfamamerica.org/newsandpublications/press_releases/press_ release.2006-09-01.3724151415. USAID, FY2005 USAID Country Allocation Summary, 2005. Accessed 20 June 2007 from http://www.usaid.gov/policy/budget/ cbj2005/pdf/fy2005summtabs4_alloc.pdf. ABC Burkina, West African farmers state their position on the CET (Common External Customs Tariff) adopted by the Heads of State of the ECOWAS on January 12 2006 in Niamey. Accessed May 2006 from http://www.abcburkina.net/english/eng_vu_vu/ abc_182.htm.

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4 PORTRAITS OF A PANDEMIC: FAMILIES ON THE ABYSS IN ZAMBIA AND MALAWI 1. S.S. Abdool Karim and Q. Abdool Karim, HIV/AIDS in South Africa. Cambridge: Cambridge University Press, 2005. 2. United Nations Children’s Fund, State of the World’s Children 2006. Accessed 20 June 2006 from http://www.unicef.org/sowc06/ pdfs/sowc06_fullreport.pdf. 3. World Health Organisation, Nutrition and HIV/AIDS: Report by the Secretariat, EB 116/12, May 2005. 4. Lucy N. Thairu et al., ‘Sociocultural Influences on the Feeding Decisions among HIV-infected Women in Rural Kwa-Zulu Natal, South Africa’, Maternal and Child Health, 1(1), 2005: 2–10. 5. At present, sub-Saharan Africa has just 1–3 per cent of the world’s health workers but some 25 per cent of the global burden of disease. See World Health Organisation, World Health Report 2006, available at http://www.who.int/whr/2006/whr06_en.pdf.

5 THE MEANINGS OF DIGNITY: QUIET TRAGEDIES AND INDOMITABLE SPIRITS IN ETHIOPIA 1. A timad, traditionally considered the amount of land one ox can plough in one day, is the common unit of land measurement in this area of Ethiopia. One timad is roughly equivalent to a quarter of a hectare. 2. Enset, or ‘false banana’, is a starchy tuber crop endemic to this part of Ethiopia. For most poor families in this area, enset comprises the majority of calories in their diet. While inferior in vitamin and mineral content in comparison to other staple crops, the crop is drought-resistant and provides high yields per unit area relative to other crops. Enset usually takes six to eight years to mature, but can be harvested early (at reduced yield) in times of need. However, early harvesting kills the plant. 3. The Ethiopian currency is called the birr. Currently, 18 birr is approximately equivalent to about £1 (9 birr = approximately $1; 12 birr = approximately €1). To adjust for purchasing power

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4.

5. 6.

7.

– that is, to estimate what the Ethiopian currency can purchase in the context of Ethiopian prices (which tend to be much lower than First World prices for most goods, reflecting the lower cost of labour, and so on) – divide the exchange rate by a factor of seven. Thus, while 18 birr is equivalent to £1 on the international markets, in Ethiopia this 18 birr can purchase roughly what £7 could purchase in the UK. All the values given in the text are unadjusted exchange rates. Processing enset is labour-intensive. In addition to utilising the tuber portion of the plant, both the bark and the leaves of the tree are utilised for food and other purposes. Kocho is the name of the starchy paste-like food made from enset. At the time of writing, the retail price of ground Sidamo coffee in a London supermarket was around £8 per kg, or £800 per 100 kg – about 130 times greater than the price for which Yohannes and Abarash Niammey sold their coffee beans last year World coffee prices crashed to a 30-year low in 2002, falling to almost one-third of what they had been five years earlier.

6 1.

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POSTSCRIPT: CONSCIENCE AND POWER

This statement should have two qualifications: ‘the increasing political pressure on Northern governments to prevent such levels of famine-related mortality, in the case of famines perceived to be caused by natural disasters, from occurring again anywhere in the capitalist world’. The Second Congo War of 1998–2003, in which nearly 3 million people are thought to have died from malnutrition-related causes, illustrates the first qualification; the North Korean famine of the mid 1990s, with a body count in the range of 600,000–1,000,000, illustrates the second.

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Notes on Contributors

Richard Cockett works for The Economist. Richard joined The Economist in 1999 as Britain Correspondent and then became Education Editor. In 2002 he became Correspondent for Central America and the Caribbean, based in Mexico City, lately becoming Bureau Chief. In the summer of 2005 Richard returned to London as Africa Editor. Claire de Menezes, the primary writer of the Zambia and Malawi chapter, is the Nutrition/Health advisor for Action Against HungerUK. She also works as a paediatric nurse, and was trained at the Great Ormond Street Hospital for Sick Children in London in 1990. Claire specialised in paediatric infectious diseases and HIV in London, and began working with the ACF International Network in 2001. She has worked on nutrition and health programmes in Sudan, Malawi and Zimbabwe and contributed to the overall HIV/AIDS strategy for Action Against Hunger. Stephen Devereux is a Research Fellow at the Institute of Development Studies, University of Sussex, and a Director of the Centre for Social Protection. Stephen works on food security, famine and social protection issues, mainly in Africa. His books include Food Security in Sub-Saharan Africa (edited), Theories of Famine and The New Famines: Why Famines Persist in an Era of Globalisation. Among other topics, his research has included a study of destitution among farmers in highland Ethiopia and a study of livelihood vulnerability among pastoralists in Somali Region, Ethiopia. Samuel Hauenstein Swan, co-editor of the report, is the head of the Hunger Watch department at Action Against Hunger-UK. He has been working for humanitarian organisations since 1994. Samuel has worked in a dozen countries on four continents affected by social, economic and political instability, researching health and human rights issues in conflict-ridden contexts. Samuel’s research interests deal primarily 100

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with community development during the transition from war to peace, especially the interaction of humanitarian assistance with local entrepreneurial structures. Frederic Mousseau, the primary writer and researcher of the Niger chapter, has been working for the past 15 years with different international organisations, including Action Against Hunger/Action Contre la Faim, Médecins Sans Frontières (MSF), the Oakland Institute and Oxfam. Frederic’s work has involved the direct design and oversight of food security interventions as well as programme evaluations in more than 20 countries. He has conducted and published a number of studies and reviews related to responses to food crises, aid and development policies and institutions. Raj Rana, the primary researcher of the Sudan chapter, is a consultant and researcher with a decade of experience working in armed conflict, complex humanitarian emergencies and disaster management. His field postings have included experience as a peacekeeper while a serving Canadian Army Officer in Bosnia-Herzegovina (1993–94), and eight years with the International Committee of the Red Cross (ICRC) in Afghanistan, the Democratic Republic of the Congo, the Russian Federation/Chechnya, Darfur and Iraq. His current research interests include the link between state-building and state-failing, humanitarian protection and the responsibility to protect. Paul Rees-Thomas, the primary writer and researcher of the Ethiopia chapter, is a nutritionist who has worked in emergency and transitional contexts in 13 countries (mostly central and eastern Africa) since 1995. He spent seven years with Action Against Hunger working on rapid assessment, causal analysis and nutritional surveys in eastern Europe, the former Soviet Union and the Horn of Africa, as well as in the Paris headquarters. Since then he has worked for MSF, the British Red Cross and Concern Worldwide, where he focused on the application of community-based therapeutic feeding. He now works as a health advisor for Merlin on the expansion of nutrition programming within primary health care services. Bapu Vaitla, co-editor of the report, is a researcher in the Hunger Watch department at Action Against Hunger-UK. Bapu currently works

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on the assessment and prioritisation of the needs of malnutritionaffected populations in countries where Action Against Hunger is active. He has conducted research and worked in Ethiopia, India and Chile on various food security, public health and agricultural development projects.

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Index Compiled by Sue Carlton

Abdallah, Awa 21–2 Action Against Hunger 4 assessment of IDP camps 24, 26–7 emergency intervention 5, 6 and food security programmes 85 HIV/AIDS research 52, 54 health workers and discrimination 61 water needs of affected households 64 interventions in IDP camps 28–9 livelihood projects 63 nutrition programmes 68–9 anti-retroviral therapy (ART) 58–9, 63, 67 Bokaso 7, 68–9, 70–2, 77–8, 79, 87 cash crops 40–1, 44 cash transfer interventions 11, 26, 28, 30 cereals 33 cereal banks 45–6, 47 market regulation 41–2, 47 prices 35–9, 45–6 speculation 43 see also maize

Chad, and Darfur crisis 19 children access to water 65 education 4, 11, 27, 74, 77–8, 84, 91 HIV/AIDS 13–14, 49, 52, 53–4, 58–60, 63 malnutrition 13–14, 32, 34–5, 48, 52–4, 61, 69, 72, 74 chlorine tablets 64–5 cholera 14 CINDI (Children in Distress) 56–7, 63 civil society 47–8, 89 coffee 72, 76, 78–80 agricultural tools 83 prices 69, 80 cognitive development, impairment of 6 Common Agricultural Policy (CAP) 46 common external customs tariff (CCT) 46 common markets 42–3, 46 compassion 6, 90 cooking stoves 29 Cooperative Housing Foundation 27 cooperatives 78–80 coping mechanisms 40, 41 cotton 40, 42, 44, 47 103

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Darfur conflict 9–11, 16–18 causal factors 19 costs of war 17 livelihood war 9–11, 17–18, 20–2 droughts 19–20 environmental degradation 19, 20 ethnic identity 19–20 internally displaced person (IDP) camps 11, 18, 23–31 peace process 30–1 protecting right to food 28–31 de Waal, A. 20 debt 14, 37, 38, 56, 80, 82, 84 dehydration 6 diarrhoea 57, 64, 72, 74, 76 dignity 3–4, 6, 9, 11, 15, 16, 18, 31, 66–7, 84, 88–9, 90–1 Dika, Werekey and Bekelur 75–6 droughts 11, 19–20, 33, 69 dysentery 14 Economic Community of West African States (ECOWAS) 42, 46 economic liberalisation 12, 32, 40–4, 47, 48 see also markets education 4, 11, 27, 74, 77–8, 84, 91 enset 70, 72, 73, 74, 76, 84 Ethiopia 2, 7, 9, 10, 68–86, 87–8 famine (1984) 5, 87–8 food security initiative 84–5

AAH 02 index Sec1:104

foreign aid 85, 88 humanitarian crisis 2003 69 poverty 85 testimonies from 14–15, 70–84 Fenoga, Dotora and Asada 78–82 firewood, collecting 26, 29–30, 68, 69 Flint, J. 20 food right to 8, 13, 16, 28–31, 32, 66, 90 self-sufficiency 42 foreign aid/assistance 9, 11, 15, 26, 46, 47, 69, 85, 88, 89 free expression, right to 4 free trade agreements 42–4, 46 Gelecha, Asfew 82–4 global acute malnutrition (GAM) 5, 24, 34 Global Fund to Fight AIDS, Tuberculosis and Malaria 66 Gussesa, Obeshet 77–8 Hawa (refugee) 24–6 health care, right to 4, 32, 66 health services HIV/AIDS patients 13–14, 60–3 in IDP camps 11 HIV/AIDS 9, 13–14, 49–67 access to treatment 49, 55, 58–60, 63

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Index

105

HIV/AIDS continued anti-retroviral therapy (ART) 58–9, 63, 67 children 13–14, 49, 52, 53–4, 58–60, 63 discrimination 13–14, 60–3 and malnutrition 54–60, 61, 89 orphans 52, 56–7, 60 and poverty 55–7 and sexual assault 65 water needs 14, 63–6 women 51–2, 60 home gardening 63–4 human rights 3–4, 66, 89, 90 see also food, right to; Universal Declaration of Human Rights humanitarian assistance see foreign aid/assistance hunger causal complexities of 8 emotional comprehension of 5–7, 90 eradication of 45–8 violence of 6, 15, 86, 91 see also malnutrition Hurricane Katrina 85

impact on surrounding cities 27 Kalma camp 23, 26 malnutrition 24, 28 Otash camp 21, 25–6 provision of seeds and tools 30 psychological problems 26–7 role of humanitarian agencies 27–8 Al Salam camp 21 internally displaced persons (IDPs) 11, 16 reaching camps 22 return of 30 International Monetary Fund 47 Iraq war 85 Issafou, Zeinou 38–9

information systems 11 internally displaced person (IDP) camps 11, 23–31 cash transfer interventions 11, 26, 28, 30 conditions 18, 27 food production 30 food rations 26

maize 56, 57, 72 harvesting early 2–3 Makonnen, Aleku 1–3, 7 Malange, Angola 6 malaria 3, 82 Malawi 7, 9, 10 HIV/AIDS 9, 13–14, 51, 52, 54–5, 58–60, 61, 67

AAH 02 index Sec1:105

justice 8, 86, 91 Kalma camp 23, 26 Kitwe 63–4 kocho 72, 82, 84 Libya, and Darfur crisis 19 Lilongwe 58, 59 livelihood development projects 28–30, 31, 89 locust invasion 11, 33

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malnutrition 5–6, 34–5 and access to water 63–6 children 13–14, 32, 34–5, 48, 52–4, 61, 69, 72, 74 and HIV/AIDS 54–60, 61, 89 in internally displaced person (IDP) camps 24, 28 long-term effects 6 and market forces 32–3, 35–44, 47, 48 understanding causes of 8 see also hunger Maradi 36 markets and malnutrition 32–3, 35–44, 47, 48 regulation 12, 41–2, 47 unstable 9, 12 see also economic liberalisation milk 72, 74, 76 millet 38–9 prices 35, 36 milling vouchers 29 mortality, reducing 15, 60, 88–9 mothers, HIV/AIDS 60 Moto 68–9, 78, 92 Mwansa, Ivy 55–6 Niammey, Yohannes and Abarash 72–4 Niger 7, 9, 10, 32–48 agricultural trade 39–40 cereal banks 45–6, 47 cereal prices 35–9, 36 cereal production 33 civil society 47

AAH 02 index Sec1:106

economic liberalisation 12, 32, 40–4, 48 food crisis (2005) 11–13, 32–3, 35, 43–4, 48 livestock production 39–40 malnutrition 34–5, 36 poverty 35 warrantage system 45–6, 47 see also Sahel Nigeria 43, 46 Nyala, IDP camps around 23–6 opportunity, equality of 90–2 Otash camp 21, 25–6 peacekeeping forces 9, 31 physical development, impairment of 6 pneumonia 6 power 90–2 REACH (Malawi) 61 refugee camps see internally displaced person (IDP) camps refugees see internally displaced persons (IDPs) safe water, right to 66 safety net employment programmes 12–13 Sahel 33–4 agricultural trade 39–44 eradication of hunger 45–8 national food self-sufficiency 42 see also Niger

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Index

Al Salam camp 21 sepsis 6 severe acute malnutrition (SAM) 6, 53, 69 shock 6 Sidama 2, 7, 68, 76, 83, 85 solar cookers 29 subsistence farming 39, 41 Sudan 7, 9, 10 government and Darfur crisis 19, 20 see also Darfur Suleiman, Asha 20–1 survival 15, 88–9

107

warrantage system 45–6, 47 wasting 5–6 water access to 11, 14, 63–6, 89 quality 64–5 West Africa, common agricultural policy 44, 46, 47 William J. Clinton Foundation 66 women access to water 65 HIV/AIDS 51–2, 60 World Trade Organisation (WTO) 47

typhoid 14 Union Economique et Monétaire Ouest Africaine (UEMOA) 42 United Nations 9 Human Development Index 35 peacekeeping operation 31 Universal Declaration of Human Rights 4, 13, 89, 90

AAH 02 index Sec1:107

Yutata, Aragash and Shunkay 70–2 Zambia 7, 9, 10 HIV/AIDS 13–14, 49–50, 51, 52, 54–5, 63, 67 Zaroumai, Harouna 37–8 Ziko, Beauty 56 Zimbabwe 51–2

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