Famine

Hunger, starvation, and famine have existed throughout all of history. The Joseph story in the Bible narrates the concept of planning for lean years three millennia ago. During recent decades, the most common emergencies affecting the health of large populations in developing countries have involved famine and forced migrations. Since the early 1960s, most emergencies involving refugees and displaced persons have taken place in less developed countries where local resources have been insufficient for providing prompt and adequate assistance. The international community's response to the health needs of these populations has been at times inappropriate, relying on teams of foreign medical personnel with little or no training.

One way of describing the evolution of disasters is in terms of a "trigger event" leading to "primary effects" and "secondary effects" on vulnerable groups in the population (2). In the case of a rapid-onset natural disaster like an earthquake, the primary effects, deaths and injuries, may be high, but there are few secondary effects. In the case of slow-onset natural disasters like drought and manmade disasters, like war and civil strife, the secondary effects (i.e., decreased food availability, environmental damage, and population displacement) may lead to a higher delayed death toll than that of the initial event. Although population displacement may result from a number of different types of disasters -- manmade and natural -- the two most common recent trigger events have been food deficits and war. In many parts of the world where food shortages have become common, war and civil strife are major causative factors. Consequently, war, food deficits, famine, and population displacement have been inextricably linked risk factors for increased mortality in certain large populations in Africa, Asia, Latin America, and the Middle East.

Famine is defined as "a condition of populations in which a substantial increase in deaths is associated with inadequate food consumption". Famine does not necessarily arise solely from problems of food production. Natural disasters (e.g., drought or crop infestations) may act as triggers, but lack of sufficient food for consumption may be due to economic collapse and loss of purchasing power in some sections of the population, (i.e., the Indian famine of 1972). In early 1992, efforts to assess the impact of sudden economic changes in the republics of the former Soviet Union focused on income and food price indicators. In Russia, elderly pensioners were identified as a vulnerable group among whom the income-to-food cost ratio was estimated to be 1:2 in mid-January. Other causes of famine have included disruption of food production and marketing by armed conflict (i.e., Biafra in 1968, Sudan in 1988, and Somalia in 1991) and widespread civil disturbances (i.e., Zaire in 1991).

Famines are often assessed and reported in terms of cases, rates, or degrees of malnutrition, or numbers of deaths from malnutrition. These parameters have been classified as "trailing" indicators and are not useful for early famine detection and the initiation of prevention or mitigation measures. More important in the early detection of famine are "leading" and "intermediate" indicators that reflect changes in the economic, social, and environmental factors that influence the evolution of food shortages and famine.

The most direct and obvious results of famine are severe undernutrition and death. While longitudinal studies have demonstrated that undernourished persons -- particularly children -- are at higher risk of mortality, the immediate cause of death is usually a communicable disease. Malnutrition causes an increased case-fatality ratio (CFR) in the most common childhood communicable diseases (i.e., measles, diarrheal disease, malaria, and acute respiratory infections (ARIs)). Those at highest risk of mortality during nonfamine times -- namely, the poor, the elderly, women, and young children -- are the same groups most at risk for the morbidity and mortality caused by famine. In addition, the movement of populations into crowded and unsanitary camps, the violence associated with forced migrations, and the negative psychological effects of fear, uncertainty, and dependency contribute to the health problems experienced by displaced persons.

Famine is usually caused by the amplification of a pre-existing condition characterized by widespread poverty, intractable debt, underemployment, and high malnutrition prevalence. Under these conditions, a large percentage of the population may routinely experience starvation. When additional burdens related to the production or availability of food arise, generalized starvation occurs rapidly. In recent years, frequent crop failures in Ethiopia, Somalia, Sudan, and the Sahelian countries of Africa have been attributed to progressive deterioration of the environment, including deforestation, desertification, and poor agricultural practices.

Famine in the absence of violence has generated few of the world's refugees. Populations experiencing famine may or may not displace themselves in order to improve food availability. Initially, male family members may migrate to cities or neighboring countries to seek employment. During a full-scale famine, whole families and villages may flee to other regions or countries in a desperate search for food. In most of the major population displacements of recent decades, however, people have been forced to flee because of fear for their physical security caused by war or civil strife.

The deficiency of food in Continental Europe at the end of 1918 was due much more to failure in production than to the lack of imports. The labour of men and animals was taken from the fields, artificial fertilizers were scarce, reduced crops led to destruction of animals and to further impoverishment of the soil through lack of manure. For the whole Continent cereal production was reduced by one-third; the reduction in livestock varied from 14% in France to over 70% in West Poland, and carcass weights were reduced even more on account of the leanness of the animals. In Germany milk production was only one-third of the pre-war level. The total imports by the official relief systems, which ended in September, 1919, were less than in a corresponding period before the war, and did not make good the deficit in the wheat harvest alone.

The power to allow or deny foodstuffs to occupied countries according to their value in the war effort was a most valuable weapon in Germany's hands for the rations allowed in 1942 in different parts of Europe. It was estimated that the average normal consumer on the Continent was receiving 1,400 calories a day, which meant a deficit of 600 talories. The deficiency varied from a consumption- of under 1,000 calories in Greece, Poland, and Spain to a consumption of almost completely adequate amounts in Germany. Slaughter of at least 10,000,000 cattle had led to a deficiency of meat, milk, cheese, and butter. Compared with a pre-war level of 3,000 calories the rations in Bohemia- and Moravia provided 1,800 calories, in Norway 1,200, Denmark 1,400, Holland 1,800, Belgium 1,000, France 1,000, Serbia 1,200, Croatia 900, Greece 500; in Eastern Poland the Poles received 700 calories and Jews only 400, while in Western Poland the ration was about 1,000 calories. There was severe deprivation in occupied Russia. For the rest of Europe 1,000 to 1,500 calories could be taken as typical, with a tendency for malnutrition to be worse in towns. The number of calories required would vary from 900 for a child under 1 year to 4,200 for an adult male engaged in heavy work.