74306 How to Protect and Promote the Nutrition of Mothers and Children Purpose of the toolkit in Latin America and the Caribbean “Improving nutrition for pregnant women and children under two is one of the smartest investments we, or anyone, can make.� Hillary Clinton - United States Secretary of State, September 2011 -i- Table of Contents Foreword iii Acknowledgments iv List of Acronyms v Executive Summary 1 Objective of the Toolkit 3 Rationale for the Toolkit 4 Methodology for Development of the Toolkit 7 Introduction 10 The Importance of the “First 1,000 Days of Life� 10 Crises and Emergencies in Latin America and the Caribbean 11 The Nutrition of Mothers and Children in Times of Crisis and Emergency 13 Laying the Foundation to Protect and Promote the Nutrition of Mothers and Children in Times of Stability, Crisis, and Emergency 14 - ii - Foreword In recent years, the region of Latin America and the Caribbean (LAC) has been hit recur- rently by a range of crises, including social and economic upheavals, periods of major food- price volatility, and devastating natural disasters. Too often the poorest, least-educated, and indigenous groups live in a constant state of crisis, which prevents them from breaking out of poverty and contributing productively to society. While making significant socioeco- nomic strides over the past few decades, LAC remains one of the most unequal regions in the world, and eradication of undernutrition in the region is still an unfinished agenda. A plethora of evidence demonstrates that crises and emergencies take a toll on the nutri- tional status of the most vulnerable, especially mothers and children. Failure to address the nutritional needs of mothers and children as part of crisis management results in human suffering and vast missed opportunities for developing every person’s potential. The mal- nutrition that ensues has significant negative, permanent impacts on human development, the quality of the workforce, and the economic productivity of individuals and society. It follows that policy makers need to know what actions they should take to promote and protect the nutrition of the population in crises and emergencies. This toolkit is the first of its kind to provide information on promoting and protecting the nutritional status of mothers and children in crises and emergencies. We hope that coun- tries will find it useful to strengthen both their crisis response and human development policies and programs. We invite you to provide feedback on the toolkit and look forward to a more in-depth exchange of ideas and experience with countries on how to eradicate malnutrition in the region. Keith Hansen Joana Godinho Director – Human Development Sector Manager-Health, Nutrition & Population - iii - Acknowledgments This document was produced by a team led by Marie Detailed peer reviewer comments were provided by Chantal Messier and composed of Christine Macdon- Ilka Esquivel (UNICEF), Israel Rios (World Food Pro- ald, Susan Shulman and Jennifer Bernal. Substantial gram) as well as Benedicte Leroy de la Brière, Leslie contributions were also provided by Evelyn Rodri- Elder and Michel Matera from the World Bank. guez, Marcia Griffith, Tom Schaetzel and Geraldine Beneitez. Isadora Nouel provided resourceful assis- Worthy comments and precious additional inputs tance throughout the production of the Toolkit. have been provided by the following colleagues: Ruslan Yemtsov, Harold Alderman, Claudia Rokx, Lucy The authors are grateful to Keith Hansen, Director of Bassett, Alessandra Marini and Barbara Coello from the Human Development Department, Joana Godin- the World Bank as well as Mohamed AG Ayoya and ho, Sector Manager for Health Nutrition and Popula- Enrique Paz from UNICEF. tion and Margaret Grosh, Lead Economist in the Latin America and Caribbean Region as well as Hideki Mori, The report was skillfully edited by Judith Navarro. Program Manager for the Rapid Social Response Trust The design was elaborated by Jorham Moya. Fund and Ludmilla Butenko, Country Manager for the World Bank Country Office in Panama, for their stra- This work was supported by a grant from the Rapid tegic support and judicious guidance in producing Social Response Trust Fund and the Human Develop- this Toolkit. ment Department of the Latin America and the Ca- ribbean Region and the Panama Country Office of the The authors would like to thank each and every one World Bank. The Rapid Social Response (RSR) Pro- of the more than 130 people from the 12 countries gram is a multi-donor endeavor to help the world’s who participated in the consultation process that led poorest countries to build effective social protection to the development of this toolkit for their kind col- and labor systems that safeguard poor and vulner- laboration and their willingness to generously share able people against severe shocks and crises. RSR information. They would also like to thank all the col- has been generously supported by the Russian Fed- leagues from the World Bank, including Sector Lead- eration, Norway, the United Kingdom, and Australia. ers and Country Offices who have assisted with the organization of this extensive consultation process. - iv - List of Acronyms AFAS Acceptable, feasible, affordable, sustain- LBW Low birth weight (<2,500 g) able LNS Lipid-based nutrient supplement ARI Acute respiratory infection MAM Moderate acute malnutrition ART Antiretroviral therapy MDG Millennium development goal ARV Antiretroviral MIYCN Maternal, infant, and young child nutrition BMI Body mass index MNP Micronutrient powder CGP Community growth promoter MOA Ministry of Agriculture CHW Community health worker MOH Ministry of Health CMAM Community-based management of acute MUAC Mid-upper arm circumference malnutrition NIE Nutrition in emergencies COMBI Communication for behavioral impact NGO Nongovernmental organization eLENA WHO’s e-Library of Evidence for Nutrition OCHA United Nations Office for Coordination of Actions Humanitarian Affairs ENN Energy Nutrition Network ORS Oral rehydration salts (or solution) EWARN Early warning and response PLWHA People living with HIV/AIDS FAO United Nations Food and Agriculture PMTCT Prevention of mother-to-child transmis- Organization sion FEWSNET Famine Early Warning Systems Network PMNCH Partnership for Maternal, Newborn, and GDP Gross domestic product Child Health GIEWS Global information early warning system P4P Purchase for Progress program GMP Growth monitoring and promotion RNI Recommended nutrient intake GNI Gross national income RUIF Ready-to-use infant formula HIV/AIDS Human immunodeficiency virus/acquired RUSF Ready-to-use supplementary food immune deficiency syndrome RUTF Ready-to-use therapeutic food HAZ Height-for-age Z score SAM Severe acute malnutrition HTP Harmonized training package SMART Standardized monitoring and assessment IBFAN/GIFA International Baby Food Action Network/ of relief and transitions Geneva Infant Feeding Association SUN Scale up nutrition IBRD International Bank for Reconstruction and U5MR Under 5 mortality rate Development UNHCR United Nations High Commissioner for ICRC International Committee of the Red Cross Refugees IDA Iron-deficiency anemia UNICEF United Nations Children’s Fund IDA International Development Association USI Universal salt iodization IDD Iodine-deficiency disorder VAD Vitamin A deficiency IDP Internally displaced person WASH Water, sanitation, and hygiene IFA Iron-folic acid WAZ Weight-for-age Z score IFE Infant feeding in emergency WB World Bank IMR Infant mortality rate WEDC Water, Engineering, and Development IOM Institute of Medicine, National Academy Center of Sciences, United States WFP World Food Program IVM Integrated vector management WHZ Weight-for-height Z score IYCF Infant and young child feeding WHO World Health Organization LAC Latin America and the Caribbean -v- Executive Summary Latin America and the Caribbean is one of the most assessment tool to evaluate countries’ readiness to vulnerable regions in the world to major crises and protect the nutritional status of the most vulnerable emergencies. The resultant economic and human as compared to international recommendations re- costs can set back countries’ development for years. garding key nutrition actions. These crises and emergencies take a toll on the nu- tritional status of the most vulnerable, especially The toolkit comprises three main components: pol- poor mothers and children. The poorest often live in icy guidance for priority nutrition interventions and a constant state of crisis as they are confronted with cross-cutting approaches; a country benchmarking; recurring financial, environmental, and social shocks. and case studies. The methodology used to produce The malnutrition that ensues leads to irreversible this toolkit was based on internationally validated negative impacts and generates high human, social, scientific evidence and extensive consultations with and economic costs that contribute to perpetuating countries. Development of the policy guidance en- poverty. tailed a rigorous review and synthesis of interna- tional policy guidelines as well as programmatic and The rationale for this toolkit derives from three main technical documents. principles: 1) the sound economic sense of investing in nutrition in the first 1,000 days of life; 2) the need That approach resulted in an inventory of 13 major to help countries faced with transitioning from stable programmatic categories: six “priority nutrition in- times into and out of crisis to prevent potential irre- terventions� and seven “cross-cutting approaches� versible damage to human capital and; 3) the imper- that are necessary for the successful application of ative to build the resilience of the most vulnerable to the nutrition interventions. The policy guidance on shocks and to protect livelihoods. priority nutrition interventions cover assuring ma- ternal, infant, and young child nutrition; promoting The aim of this toolkit is to inform changes in coun- healthy growth and healthy motherhood; preventing tries’ policies and practices and to guide their at- and treating micronutrient deficiencies and infectious tempts to deal with persistently high prevalence diseases; and ensuring food security. The cross-cut- rates of malnutrition among their poorest, least edu- ting approaches cover targeting; multisectoral co- cated, and indigenous populations. In a single-source ordination; policy making and planning; emergen- compilation, it offers clear guidance on cost-efficient cy communication; human resources and training; interventions to assist countries in safeguarding the water, sanitation, and hygiene; and monitoring and nutritional status of mothers and children during evaluation. times of stability, crisis, and emergency. The benchmarking exercise included 12 countries The value added of this toolkit is that it is the first to from the Latin American and Caribbean region: Dom- underscore the importance of protecting and promot- inica, Grenada, St. Lucia, St. Vincent, Haiti, Hon- ing nutrition of mothers and children during times of duras, Nicaragua, El Salvador, Guatemala, Panama, crisis. It addresses the existing policy and informa- Bolivia, and Colombia. They were selected on the tion gaps by providing direction on how countries can basis of a number of criteria, such as poverty, mal- protect and promote nutrition when faced with tran- nutrition levels, susceptibility to natural catastro- sitioning in and out of a crisis, by focusing especially phes, and vulnerability to crises. Elaboration of the on the unique window of opportunity represented by country benchmarking stemmed from discussion with the first 1,000 days of life. Moreover, it offers an some 130 key informants from governments, devel- -1- preliminary version opment agencies, and civil society organizations. The The last part of the toolkit offers a series of case information was analyzed with a view to identifying studies that illustrate ways in which countries have trends, strengths, and weaknesses in each of the implemented some of the recommended interven- countries and sub-regionally. tions. The results of the benchmarking exercise reveal that As its design is simple and comprehensive, the tool- most crisis-response policies and programs in the re- kit is intended for non-specialists in nutrition such gion overlook the needs of mothers and young chil- as policy makers, program managers, crisis-response dren. They are either poorly targeted or not priori- personnel as well as by health and nutrition profes- tized, or the interventions used are not appropriate sionals. It can also be easily adapted and replicated to protect and promote the nutrition of these groups. beyond Latin America and the Caribbean to be used Countries either have not set up the appropriate pro- in other regions of the world. grams in stable times or do not seize the opportunity of existing programs to expand coverage in times of Governments and their development partners are crisis and emergency. This situation results in im- thus encouraged to use this toolkit to review, adapt, portant inefficiencies and service-delivery gaps. It and update current policies and programs according also appears that, in comparison to countries in Latin to their specific contexts to ensure that the nutrition- America, those in the Caribbean are less prepared al status of mothers and children is adequately taken and equipped. All countries need to reinforce the into account at all times. They should establish a solid promotion and protection of breastfeeding. Also of foundation during stable times by mainstreaming nu- concern are weak monitoring systems and rare sys- trition in their development programs, scale up and tematic evaluations of the crisis response, a situation intensify those programs in times of crisis, and ad- that impairs timely and informed decision making. dress immediate nutrition needs during emergencies. A number of countries would benefit from updating In addition, to more efficiently use their resources, their nutrition policies and adapting the food and they should seek closer collaboration across sectors water rations given in emergencies to the specific such as crisis response, health, nutrition, agriculture, nutritional needs of pregnant and lactating women water and sanitation, and social protection. Doing so and children under 2 years of age. Some examples should contribute to protecting the human capital of include the prevention of micronutrient deficiencies the most vulnerable, promoting the economic devel- during emergencies with micronutrient powders; opment of countries, and interrupting the intergen- treatment of acute malnutrition, notably with provi- erational cycle of poverty. sion of ready-to-use foods; and efficient treatment of diarrhea through the combined use of oral rehydra- tion solution and zinc. preliminary version -2- Objective of the Toolkit This toolkit aims to improve the resilience of the 1,000 days of life. Moreover, it offers an assessment most vulnerable in times of intensified nutritional tool to evaluate countries’ readiness to protect nu- needs, most notably pregnant and lactating moth- tritional status and build the resilience of the most ers as well as children under two years of age. Its vulnerable in the face of shocks. principal objective is to offer countries, when faced with the transition from stable times into and out of This toolkit has been crafted so that it can be readily crisis, clear guidance on how to safeguard the nu- used by non-nutrition specialists. It is intended for tritional status of mothers and children during times policy makers, development program managers, cri- of stability, crisis, and emergency. The principal ob- sis and disaster-response personnel, aid workers as jective of this toolkit is to offer clear guidance, in a well as health and nutrition professionals. single-source compilation, that will assist countries in safeguarding the nutritional status of mothers and The full set of interventions proposed in this toolkit children during times of stability, crisis, and emer- seeks to protect the human capital of the most vul- gency. It aims to inform changes in countries’ poli- nerable groups in society, contribute to the economic cies and practices and to guide their attempts to deal development of countries, and interrupt the inter- with persistently high prevalence rates of malnutri- generational cycle of poverty that can be brought tion among their poorest, least educated, and indig- about by malnutrition. Toward that end, the infor- enous populations. It provides policy and decision mation is presented through three main components: makers - charged with planning and implementing policy guidance for priority nutrition interventions crisis-response systems - comprehensive and interna- and cross-cutting approaches; a country benchmark- tionally validated information on how to protect the ing; and case studies. nutritional status of mothers and children in the first -3- preliminary version Rationale for the Toolkit The rationale for this toolkit is founded on three main principles: 1. the sound economic sense of investing in nutrition in the first 1,000 days of life; 2. the need to help countries faced with transitioning from stable times into and out of crisis to prevent potentially irreversible damage to human capital; and 3. the imperative to build the resilience of the most vulnerable to shocks to break the cycle of poverty. The profitability of investing in maternal and child nutrition. The most recent Copenhagen Consensus (2012) ranked a bundled set of nutrition interventions in the first 1,000 days of life—among them, micronutrients and infant and young child feeding—first out of 30 investment options. Considering the benefits that it offers for education and health, this bundled set of interventions was estimated to return $30 for every $1 spent, even in very poor countries (1)*. Malnutrition in the early years of life can have catastrophic short- and long-term human and economic consequences for both individuals and society as a whole. A largely preventable cause of over one-third of all child deaths (2), malnutrition decreases children’s ability to resist infection and disease. Those who suffer malnutrition in their early years fail to fully develop their physical and cognitive potential, have trouble in school, and as adults have an increased risk of non-communicable diseases and tend not to be as productive as those who were well nourished during infancy (3). Various forms of malnutrition reduce the intelligence-quotient metric by 5-25 points (4). Productivity losses as a result of malnutri- tion have been estimated to exceed 10% of an individual’s lifetime earnings and to be responsible for at least a 2-3% drop in the GDP of countries whose populations are significantly affected by undernutrition (5). Thus, ensuring good nutrition for mothers and children, rather than simply being an expression of com- passionate welfare, makes economic sense and represents a sound investment in a country’s economy, because it reduces health care costs, contributes to a better educated workforce, increases workers’ incomes, and boosts national productivity. * All references are located in a separate book named Glossary, References, and Annexes preliminary version -4- Figure 1. Short- and long-term consequences of child malnutrition for individuals and society Reduced     GDP   Reduced   workers'   Increased   mortality   revenues   CHILD   MALNUTRITION     Reduced   Increased     schooling   illness     Reduced     cogni?ve   development   -5- preliminary version The dearth of information on how to safeguard the nutritional status of moth- ers and children in unstable times. Scant literature is available on how to address, during times of crisis, the particular nutritional needs of new mothers and young children, although several programs— the 1,000 Days Initiative, Scaling Up Nu- trition, and UNICEF’s Renewed Efforts Against Childhood Hunger (REACH)—have highlighted this critical window of opportunity. WHO has established cutoffs to define crisis and emergency levels for individual nutritional issues, but does not recommend a combination of indicators for defining a multi-dimensional nutritional crisis or emergency. FAO has devised an Integrated Food Security Phase Classification scheme that provides an example of level/stage definitions that focus on outcomes and match responses with defined classes; the scheme relies on a broad range of outcome measures—crude mortality rate, wast- ing, stunting, disease, food access/availability, dietary diversity, water access/availability, destitution/ displacement, civil security, hazards, coping, structural conditions, and livelihood assets—and specifies strategic responses for each classification level of food insecurity. Individual countries can thus create their own sets of indicators, but they should achieve consensus in their identification of situations for which specific interventions are appropriate. At present, little is known on how well countries in Latin America and the Caribbean are performing in effectively implementing internationally recommended nutrition actions. Shortcomings in countries’ responses to promote and protect the nutrition of mothers and children, particularly in times of crisis. While several countries in the region did scale up their responses during recent crises –e.g., school feeding, cash transfers, labor market mechanisms, and the easing of trade barriers on food or grain im- ports to help the population better cope with the effects of those crises—little is known about whether or how these measures protected the nutritional status of pregnant and lactating women and children under 2 years of age. In addition, food policy interventions in Latin America and the Caribbean often fail to pay attention to preventing the loss of human capital that can result from emergencies and cri- ses, especially among children. Given the recurring shocks and crises that countries in Latin America and the Caribbean are facing, it is important to guide decision makers in countries with respect to the most profitable investment of their limited national resources in both stable and unstable times. In that regard, protecting mothers and young children from malnutrition should be an indisputable priority. In order to achieve this, countries need to build solid programs in health, food and nutrition security as well as social protection, which then can rapidly be expanded in times of crisis and emergencies to protect the poor and those at risk of falling into poverty. Adaptability and replicability of this toolkit. This toolkit should have widespread usefulness in regions beyond Latin America and the Caribbean. It can readily be adapted and applied by countries in regions throughout the world, given the internation- al sources used to conduct the research from which it stems, the analysis and findings with regard to priority interventions and cross-cutting approaches, the inventory of best practices and international recommendations, the benchmarking methodology, and the lessons learned from country case studies. preliminary version -6- Methodology for Development of the Toolkit Policy Guidance: Priority Nutrition Interventions and Cross-cutting Approaches The purpose of this section is to identify and de- trition interventions� are six interventions— assuring scribe evidence-based interventions that promote nu- maternal, infant, and young child nutrition; promot- trition and related positive health outcomes during ing healthy growth; preventing and treating micro- the first 1,000 days of life in crises and emergencies. nutrient deficiencies; preventing and treating infec- The guidance resulted from a review and synthesis tious diseases; promoting healthy motherhood; and of validated international scientific and technical lit- ensuring food security. Under the group “cross-cut- erature on protecting the nutrition of mothers and ting approaches� are seven approaches—targeting; children during the first 1,000 days of life in crises and multisectoral coordination; policy making and plan- emergencies. It included documents, publications, ning; emergency communication; human resources and resources from United Nations agencies as well and training; water, sanitation, and hygiene; moni- as from reputable international and nongovernmen- toring and evaluation. The guidance section provides tal agencies such as the International Red Cross, the international recommendations and best practices for Micronutrient Initiative, and the Emergency Nutrition each of those 13 categories, with examples of country Network. Searches included online databases such experiences collected during the benchmarking exer- as WHO’s e-Library of Evidence for Nutrition Actions cise as well as suggested additional readings. (eLENA). Consultations were also conducted with ex- perts and international-development partners such as Countries should customize application of these in- UNICEF, WFP, PAHO, and the World Bank. Guidance terventions to fit their specific contexts and circum- documents published by various United Nations agen- stances. Moreover, this toolkit suggests that interven- cies were emphasized, given their thorough processes tions be considered in three general types of settings: of reviewing evidence, consulting with experts, and stable times, crises, and emergencies. As shown in publishing recommendations. Figure 2, longer-term interventions build resilience to shocks as part of disaster-risk management and sus- That review and synthesis resulted in the identifica- tainable development efforts (e.g., agricultural pol- tion of 13 major programmatic categories in two main icies to diversify local food production and enhance groups: (1) “priority nutrition interventions� that are dietary diversity). Some interventions may be more substantively related to the protection and promotion relevant or applicable after a crisis has occurred or a of nutritional status during the first 1,000 days; and (2) disaster has struck (e.g., distribution of food rations). “cross-cutting approaches� that are complementary And some interventions are relevant in both emergen- and necessary for the successful planning, implemen- cy and more stable contexts (e.g., ensuring consump- tation, monitoring and evaluation, and sustainability tion of iodized salt). of those interventions. Under the group “priority nu- -7- preliminary version Figure2. Applicability of interventions in stable, crisis, and emergency settings STABLE CRISIS EMERGENCY Development - Interventions Interventions oriented, applicable in to address structural both settings, immediate Interventions scaled up needs Long-term Short-term RESPONSE Building resilience Responding to immediate needs preliminary version -8- Country Benchmarking The country benchmarking section presents the re- tionnaires; and face-to-face, in-depth interviews. sults of an extensive consultation exercise that com- For the online survey, two questionnaires were sent pared existing country policies and practices to the to pre-identified key informants in the 12 countries: international recommendations regarding each prior- one for senior managers of government institutions ity nutrition intervention and cross-cutting approach responsible for programs regarding health and nutri- presented in the policy guidance. Its findings as to tion and/or crisis and emergency planning; the oth- existing national policies and practices pointed up er for respondents from country-level development both strengths and areas for improvement. That in- partners such as United Nations agencies, interna- formation was analyzed with a view to identifying tional and national NGOs, as well as civil society or- trends within Latin America and the Caribbean and ganizations working on nutrition or emergency relief its subregions. (see Annex 1)3. A total of 57 responses was received: Bolivia (n=5), Colombia (n=4), Grenada (n=2), Guate- Latin American and Caribbean countries included in mala (n=17), Haiti (n=2), Honduras (n=12), Nicaragua the benchmarking exercise were selected on the ba- (n=2), Panama (n=1), El Salvador (n=10), and St. Lu- sis of several criteria: poverty levels1, malnutrition cia (n=2). prevalence, susceptibility to natural catastrophes, and increase in vulnerability as a result of recent fi- The information collected through the online ques- nancial crises and high food-price volatility. Countries tionnaires was complemented by in-depth face-to- meeting those criteria were then contacted to deter- face interviews with in-country decision makers to mine their willingness to participate in the bench- ensure complete and precise data. In May-June marking exercise. As a result, 12 countries in Latin 2012, five trained interviewers traveled to the se- America and the Caribbean were included: in the Ca- lected countries and conducted a total of 130 inter- ribbean—Dominica, Grenada, St. Lucia, St. Vincent, views with key government and nongovernmental and Haiti; in Central America—Honduras, Nicaragua, personnel involved in nutrition and emergency man- El Salvador, Guatemala, and Panama; and in South agement (see Annex 2)4. Interviewees were asked America—Bolivia and Colombia2. about the presence of a national policy or norms and the strengths and areas for improvement relative to Data collection for the benchmarking activity used each priority intervention and cross-cutting approach two methodologies: online, semi-structured ques- identified in the policy guidance methodology. Case Studies The case study section presents examples of how were elaborated by a range of international experts countries recently faced with a crisis or emergency and program managers based on field data and docu- have implemented various nutrition interventions de- mented experience of selected countries whose pop- scribed in the policy guidance section. These studies ulations have lived through volatile times. 1 All selected countries with the exception of Colombia, El Salvador, Guatemala, and Panama are members of the International Development Associa- tion (IDA) of the World Bank, with membership based on a country’s relative poverty, defined as GNI per capita below the established threshold of US$1,175 in fiscal year 2012. IDA also supports some countries, including several small islands, which are above the operational cut-off but lack the creditworthiness needed to borrow from the International Bank for Reconstruction and Development (IBRD). 2 Dominica, Grenada, St. Lucia, St. Vincent, and Honduras are net food-importing countries (NFIDC), which makes them more vulnerable to food-price volatility. 3 Annexe 1 is located in a separate book named Glossary, References, and Annexes. 4 Annexe 2 is located in a separate book named Glossary, References, and Annexes. -9- preliminary version Introduction The Importance of the “First 1,000 Days of Life� The first 1,000 days of life, represented by the period lead to the period of greatest growth faltering. As from conception until 2 years of age, are commonly shown in Figure 3, this is especially the case for chil- referred to as the critical “window of opportunity� dren who are born with a low weight and children for child growth and development. As such, failure aged 6-24 months. to provide adequate nutrition during this period can Figure 3. The first 1,000 days of life: the “window of opportunity� for address- ing undernutrition Weight for age Z-score (NCHS) Most of the damage during this period is irreversible Age (months) Source: Adapted from (6). During this period, numerous causes can result in time —a situation that is aggravated in crises and child undernutrition including, among others, inad- emergencies—failure to intervene with the aim of equate food intake, diarrhea, respiratory infections, helping the very young among vulnerable populations measles, and malaria. In addition, when access to can have severe and irreversible consequences. food and health services is compromised during this preliminary version - 10 - Crises and Emergencies in Latin America and the Caribbean Latin America and the Caribbean is one of the most gion experienced economic growth in recent years, vulnerable regions in the world to crises and emer- that growth has not always directly translated into gencies. These range from devastating natural di- improvements in indicators of health, food security, sasters, economic shocks, recurrent social upheavals, and nutrition, especially amongst the poorest, least and food-price fluctuations to complex humanitari- educated, and the indigenous population. In view of an crises stemming from the aforementioned factors that, many of the most vulnerable in Latin America as well as political instability, food insecurity, and and the Caribbean live in a state of constant crisis. rapid urbanization. Though most countries in the re- Natural disasters In many countries in the region, the effects of eco- Honduras and Guatemala, resulting in some 10,000 nomic shocks, rising and fluctuating food prices, cli- deaths, the disappearance of almost as many people mate change, environmental degradation, pressure (7), and agricultural losses estimated at more than on natural resources, inappropriate land tenure sys- US$2.3 million (8). In 2010 the earthquake in Hai- tems, and insufficient investment in agriculture have ti obliterated much of that country’s infrastructure, resulted in greater exposure to risk, notably from killed approximately 220,000 persons, injured anoth- natural disasters. Approximately one-third of the er 300,000, and left 1 million people homeless. In region’s population is exposed to sudden-onset di- 2011, natural disasters in the region were responsible sasters such as hurricanes, floods, landslides, earth- for US$22 billion in economic losses and some 2,000 quakes, and volcanic eruptions, as well as gradu- deaths; that year the most significant weather-relat- al-onset events such as droughts. From 1991 to 2010, ed event was a tropical depression (“12-E�), which three of the five countries in the world most affected caused massive flooding that affected an estimated by natural disasters—both in terms of fatalities and 2.6 million people in six countries (Guatemala, El Sal- economic losses—were in Latin America and the Ca- vador, Honduras, Nicaragua, Costa Rica, and Mexico), ribbean (Honduras, Nicaragua, and Haiti) (2). In 1998 caused 117 deaths, and resulted in US$2 billion in Hurricane Mitch affected almost 2 million people in losses (9). - 11 - preliminary version Economic crisis and food-price volatility In addition to natural disasters, the region was also Higher food prices push people into poverty, decreas- hit by the 2008 global economic crisis. Though over- ing their available income and eroding their purchas- all, Latin America and the Caribbean absorbed the ing power, which in turn can force them to reduce the shock better than expected, the situation was not quantity and quality of foods they consume, cut back uniform across every country, and the negative im- on health and education services, sell productive as- pact on countries in the Caribbean was particularly sets, migrate to find better-paying jobs, and adopt severe. An estimated 180 million people in the region risky behaviors. Since the poor spend a larger share continue to dwell in poverty. of their income on food, high food prices further ag- gravate their limited access to food, which can neg- The effects of the economic crisis were compounded atively impact the nutritional and health status of a by rising food prices. Between March 2006 and March population’s most vulnerable groups, notably mothers 2008 the international food-price index nearly dou- and young children (10). The urban poor are particu- bled in nominal terms, and food-price inflation in- larly susceptible to food insecurity, as—because they creased across the entire region. Food-price volatility do not grow their own food—they must rely on income continued in late 2010 and early 2011, and in 2012 to purchase it; loss of revenue or sharp increases in countries remain vulnerable to food-price fluctua- food prices can significantly compromise their ability tions triggered by droughts in the United States and to procure nutritious food; in addition, they may be elsewhere. more isolated and have less access to supportive so- cial networks. Social instability Despite a marked trend in the region over the past decade towards stronger democratic governments and significant economic progress, crime-related crime-related violence is common in many areas (11). Colombia, having suffered an internal armed conflict for more than 40 years, has the second largest num- ber of internally displaced people of any country in the world (the first being Sudan) (12), and Honduras and El Salvador have the highest homicide rates (13). preliminary version - 12 - The Nutrition of Mothers and Children in Times of Crisis and Emergency Poor households tend to react to crisis by lowering their well-nourished counterparts (17). Malnourished spending on items that build human capital—such as children who survive tend to experience increased education, health, and food—contributing to future susceptibility to infection, stunted growth, micronu- vulnerability (14,15). Women frequently become the trient deficiencies, and impaired cognitive develop- “shock absorbers� for the family, taking less food in ment—all of which can have life-long repercussions order to protect their children’s diets (15), thereby that include impeding their productivity as adults compromising their own nutritional status and, if they (18). Children with signs of malnutrition at 3 years are pregnant, potentially harming their children. of age are also predisposed to neurocognitive defi- cits, which can lead to antisocial behavior through- These coping mechanisms have severe repercussions out childhood and adolescence (19). for the nutritional status of mothers and children. In Latin America and the Caribbean, it is estimated that Crises can also influence negatively the quality of 7.2 million children under 5 years of age are chron- the food people purchase, thereby affecting the ically malnourished, while anemia affects almost 38 prevalence of both under- and overnutrition. During million women and 22.5 million young children. Young times of economic hardship, poor families reduce the children 6-24 months of age are most susceptible to quantity of food they consume or replace high-value, chronic undernutrition, and more than two-thirds of nutritious foods with cheaper, lower-quality alter- this age group suffers from anemia (16). The direct natives, such as foods with refined sugars and fats. causes of child undernutrition, mainly inadequate Increasingly, evidence points to early undernutrition consumption of food and various infectious diseas- as a risk factor for adult obesity. While stunting is es, are similar in stable times and during crises and often a result of poverty, obesity is not necessari- emergencies. However, their increased prevalence ly the prerogative of the rich: in many countries, a during unstable times—especially when coupled with considerable proportion of the urban poor and the crisis-associated conditions such as rapid increase of less educated is overweight. It is increasingly the food insecurity, economic instability, and social dis- case in the region that significant numbers of women ruption—can significantly undermine the nutritional and children in the region suffer from both undernu- status of mothers and young children, particularly trition (often in the form of micronutrient deficien- that of the poorest among them. cies or stunting) and overnutrition. Three of the four countries in the world with the highest percentage of Young children can rapidly develop acute malnutri- overweight mothers and malnourished children living tion—characterized by low weight for height—as a in the same household are in Latin America: Guate- result of a recent shock, such as an illness, lack of mala (13%), Bolivia (11%), and Nicaragua (10%) (20). adequate food, or social change. Children with mod- If left unchecked, this double burden of malnutrition erate and severe acute malnutrition are, respective- will result in high human and economic costs to the ly, more than three and nine times as likely to die as region. - 13 - preliminary version Laying the Foundation to Protect and Promote the Nutrition of Mothers and Children in Times of Stability, Crisis, and Emergency Stable, crisis, and emergency situations can be seen mechanisms to deal with the situation. The need as representing a continuum: at one end lies the sta- to recur to these coping mechanisms can eventually ble situation during which a developmental, struc- undermine the well-being of the poorest in society, tural foundation and adequate social resiliency can triggering possibly irreversible human and social con- be built that will enable a population to deal with sequences. eventual economic, health, and nutrition shocks. At the other end lies the emergency situation, which Countries’ policies should aim to build a solid foun- requires an immediate, focused rescue response. In dation during stable times through a combination of between these two extremes is the crisis situation, balanced income growth strategy and investment in which can be precipitated by a shock. Crisis situa- more direct interventions in health and nutrition. tions are not as acute as emergencies, but can result Policy makers also need to be prepared to be able in sufficiently precarious conditions that heighten in- to strengthen, scale up, and intensify these inter- dividuals’ vulnerability. A prolonged crisis gradually ventions during times of crisis—periods which may erodes the economic, social, health, and nutritional aggravate vulnerability and trigger poverty. And, in status of households, forcing them to adopt coping times of emergency, they need to be able to swiftly Figure 4. Nature of the response in stable, crisis, and emergency situations preliminary version - 14 - respond to the needs, and procure the basic neces- Establishing a strong base of quality nutritional sup- sities, of children in the first 1,000 days of life, who port services, with wide coverage, in times of stabil- otherwise might suffer long-term consequences due ity creates an infrastructure for expanding services to privation, even for a relatively short time. Figure in times of crisis, while reducing vulnerability and in- 4 depicts how the proposed interventions are part of creasing resilience in the face of shocks (21). a comprehensive response system depending on the situation. Sound, comprehensive health, nutrition, education, and social policies during stable times can influence It is important to remember that the various “situ- the possibilities and conditions of entry into the la- ations� described above are interdependent. During bor market, affecting a country’s ability to cope with a stable situation, a foundation can be created and technological and economic change (22). For exam- strengthened for unstable times. For example, a coun- ple, safety nets can enhance resilience by moderating try that aims to build resilience through a program for the effects of shocks, expanding their countercyclical preventing micronutrient deficiencies can offer vari- response when a shock-induced crisis reduces eco- ous means for households to meet their micronutrient nomic activity, food availability, and institutional sup- requirements (e.g., micronutrient supplements, for- ports. Rapid scale-up of response to crisis is difficult, tified foods, diverse diets). In a crisis situation, one however, without an existing infrastructure to sustain or more of these means may become inaccessible to it, so design and creation of safety net programs in some households (a diverse and nutritious diet, for in- times of stability are essential for timely response stance, may become unaffordable or unavailable). If, to meet needs during a crisis (23). Furthermore, the however, the foundation has been laid with a sound countercyclical nature of crisis management requires program that enables resilience, the remaining means governments to expand services at a time when rev- of micronutrient intake (supplements or fortified enues are decreasing. In order to support a “surge� foods) can compensate. To meet crisis-level needs, response during a crisis, when revenues and spend- existing programs have to expand in order to protect ing decrease, governments must act during times of an increasing number of vulnerable households (e.g., stability to create set-aside or “rainy-day� resources increased numbers of households receiving micronu- reserved for this purpose (24). trient supplements). Emergency responses go beyond those of a crisis and focus only on the most efficient Meeting a population’s needs in crises and emer- means of preserving lives (in the example given, mi- gencies requires close collaboration across time, cronutrient supplementation), but they benefit from situations, and sectors—notably, nutrition, health, the ramping up that occurs during a crisis. education, water and sanitation, social protection, agriculture, food security, as well as with crisis- and Independent of economic considerations, house- emergency-response personnel. Such collaboration holds maintaining adequate nutritional status better will not only enable countries to break the cycle of withstand shocks. In order to build the resilience of poverty, giving the next generation a strong base for a mothers and children who are regularly exposed to bright and productive future, but it will also contrib- shocks, it is important to strengthen the conditions ute to accelerating economic development. that contribute to their good health and nutrition. - 15 - preliminary version - 17 - preliminary version