History of Food and Nutrition in Emergency Relief

Transcription

1 History of Food and Nutrition in Emergency Relief Foods Provided through U.S. Government Emergency Food Aid Programs: Policies and Customs Governing Their Formulation, Selection and Distribution 1,2 Thomas J. Marchione 3 Bureau for Humanitarian Response, U.S. Agency for International Development, Washington, DC ABSTRACT This report describes the food commodities that are used in U.S. emergency food aid programs and outlines issues in their distribution, selection and formulation that may limit their ability to meet the nutrition needs of recipients. Issues are being raised at this time because the U.S. Congress plans to renew the authorizing legislation by the end of The author summarizes quantity and quality problems with food aid contributions and the difficulties experienced with the coordination of food aid with related needs of disaster victims. He identifies the foods supplied for emergency feeding by the U.S. Government and the World Food Program, and describes the limited applications of nutrition science to the formulation of the processed foods provided through U.S. food programs. The core of the report outlines the dominant nonnutritional priorities, stemming from the linkages to U.S. agricultural supply markets, U.S. commercial food interests, food aid pledging customs and difficulties in U.S. Government humanitarian response coordination. The presentation concludes with a review of issues, emphasizing the need for further studies, and some suggestions for shaping future food aid programs and policy with a strengthened capacity for protecting and promoting the nutritional status of disaster victims. J. Nutr. 132: 2104S 2111S, KEY WORDS: emergency food aid food rations food aid commodities Human nutrition is nowhere more critically important than in those situations where the normal channels of food access have been disrupted or cut off because of natural or man-made disasters. A fair amount of inferential evidence exists to show that in the second part of the 20th century U.S. food assistance has probably saved the lives of millions people [see (1)], although food assistance in emergencies is widely alleged to be not as effective as it could be. Experienced field nutritionists and some limited field research point to serious nutritional and health problems in emergency victims because of food shortages, untimely food delivery and inappropriate types of food being supplied. The U.S. Government, as the largest provider of food aid, carries a special responsibility to explore the extent to which these problems exist; if its policies and practices may be contributing to them, it must make the necessary remedies. Reports of field-level problems Reported difficulties with emergency food aid fall roughly into three categories: 1) the quantity of rations provided; 2) the quality of rations, particularly their micronutrient content 1 Presented as part of the workshop History of Food and Nutrition in Emergency Relief given at the Experimental Biology 2001 Meeting in Orlando, FL on April 3, This workshop was sponsored by the American Society for Nutritional Sciences. Guest editor for the workshop publication was Samuel G. Kahn, U.S. Agency for International Development, Washington, DC. 2 This presentation represents the views of the author and in no way represents the official position of the United States Government. 3 tmarchione@usaid.gov. and the appropriateness of foods in the ration; and 3) the coordination of food aid programming with the health and personal care components required to protect the nutrition of people affected by emergencies. Problems with ration quantities. After decades of inadequate ration provision, minimum international standards were set for average daily energy needs of disaster victims [2100 kcal/person/d; see (1,2)]. Serious health consequences have been observed where dietary energy supplies have fallen short of this standard. For instance, in the Horn of Africa in the 1990s, the UN Agency Committee on Coordination/Sub- Committee on Nutrition (ACC/SCN) analyses reveal that rations providing under 1500 kcal/person/d (a standard employed by some donors at the time) were associated with much higher crude mortality rates than those providing over 2000 kcal/person/d (4,5). In complex emergencies, such as those in the Horn, shortages of food rations often result from the inherent risks of relief operations, national sovereignty constraints and diversions of rations for political and military purposes. Nonetheless, authors strongly suggest that specific food aid policies and practices of donors and their partners carry some of the responsibility for shortages (5). Among the problems are shortfalls in meeting international food aid appeals, planning amounts too close to minimum food requirements and logistic gaps in the arrival of food aid shipments. These problems are traced to donor assistance policies requiring that food aid must be procured from its domestic market for each specific emergency rather than advance funding of contingency accounts, such as the World Food Program s (WFP) /02 $ American Society for Nutritional Sciences. 2104S

2 EMERGENCY FOOD AID 2105S immediate response (cash) account (IRA) or international emergency food reserve (IEFR). 4 All these problems are magnified in the instances of rapid-onset emergencies that require large quantities of food in a short period of time from a variety of donors. Problems of ration quality. Providing a diverse diet, with culturally appropriate foods that are rich in micronutrients, is a persistent food aid quality problem reported in emergencies. Classic dietary deficiencies in emergency victims, such as scurvy, night blindness and pellagra, have been well documented in refugee situations in the late 1980s (6), and continue to some degree in refugee feeding programs with serious consequences for health and growth in many food aid dependent populations (5). A related difficulty is that micronutrient-rich food aid commodities, such as the U.S. blended food corn soy blend (CSB), have been limited to supplementary and targeted feeding programs and not provided in sufficient quantities for general feeding. When they are provided, the micronutrient levels in them have been unreliable until quite recently because of the lack of quality control standards (7). Micronutrient problems have also been related to poor ration planning and wrong assumptions about the capacity of the recipients to provision themselves. Donated food is particularly singled out when refugees, largely dependent on food aid, exhibit micronutrient deficiencies after many months in camp settings (5). Problems of coordinating food aid with health, care, and livelihood needs. The isolation of the food aid supply from other inputs needed for good nutrition is a well-recognized problem. Food is too often the overwhelming and reflexive initial response to all disasters, whether food is or is not the most appropriate response to the problems being faced by the disaster victim, who may be in more need of water, medicine or shelter. Once programs are in operation, there may be little understanding of other human needs critical to nutrition and livelihood. Oversupply should be avoided because of the possibility of unintended diversion for military or commercial purposes, although concerns about oversupply can be exaggerated. Common misunderstandings include the following: overly strict opposition to the sale of ration commodities by recipients, severe reactions to overregistration in refugee camps and inflated expectations of self-sufficiency of food aid recipient communities (5). This thinking fails to recognize that in emergencies food aid becomes a valuable part of the coping strategies of disaster victims, allowing them to barter for local foods or other goods necessary for their families survival (8). Food aid can be used to buy fresh and nutritious local foods from local markets or, in contrast, good-quality food aid might be traded for fuel or other survival necessities, degrading an otherwise nutritious ration, but for good reason. When gaps in food supplies occur, recipient households may be forced to sell assets, sacrificing their long-term livelihood and nutritional well-being for the sake of short-term food needs, and these assets can be permanently lost when donors are reluctant to replace shortfalls retrospectively once the shortage period is past (9). Foods supplied by the United States for emergency assistance The current U.S. international food assistance programs began after World War II in an environment of U.S. agricultural surpluses and the looming Cold War challenge to win over emerging nations (10). Two specific programs started during that period continue to provide much of the world s emergency food aid: Title II of Public Law 480 of 1954 (P.L.480), administered by the U.S. Agency for International Development (USAID), commonly known as the Food for Peace Program; and Section 416(b) of the Agricultural Act of 1949, administered by the U.S. Department of Agriculture (USDA). Despite the declining global contribution of food aid to overall development assistance, and the declining overall budget of the U.S. for foreign assistance, the United States continues to be the largest donor of both emergency and nonemergency food aid. In 1999 global food aid shipments were 13.3 million metric tons, whereas food aid shipped from the United States was 8.3 million metric tons. The WFP managed 3.2 million metric tons, but nearly half of that was food aid pledged to WFP by the U.S. Government and purchased from U.S. producers. Emergency food aid shipments have grown markedly since the end of the Cold War because of the proliferation of civil conflicts and internal wars, whereas other forms of food aid have markedly declined. Since the later 1980s, the WFP budget for emergency food aid rose from 30% of all its assistance to approximately 66% (11), although the P.L.480 Title II program has remained constant at approximately 2 million metric tons, valued at $800 million to $1 billion a year. The expenditures for emergency P.L.480 Title II had risen from approximately 47 to 54% of the total dollar budget, purchasing a tonnage ranging from 780,000 to one million metric tons at a cost of $ million annually, whereas the balance of the budget was mandated for use in nonemergency, development contexts. In contrast, over the same period the USAID government-to-government food aid program dropped from nearly $300 million annually to $116 million and was virtually zero in 2001 (12). Although the P.L.480 Title II program procures its food with an annual congressional appropriation, the quantity of emergency food aid available through the Section 416 authority is totally dependent on U.S. agricultural surpluses. For instance, after a period of abundant surpluses during the 1980s, subsidies to U.S. farmers dropped and Section 416 assistance fell to zero. This happened just as emergency crises were proliferating in the mid-1990s. Surpluses did not revive until 1999 when food commodity prices were plunging and President Clinton, by means of a presidential initiative, reintroduced price supports. As a result, Section 416 assistance soared to 5.2 million metric tons at a cost of $740 million, much for emergency relief (13). When one excludes assistance that was provided for economic crises rather than natural or man-made disasters (e.g., countries in the former Soviet Union), Section 416 emergency food aid climbed to 2.8 million metric tons in 1999 and total U.S. emergency food aid was approximately 3.7 million metric tons. In 1999 most of this food was provided for emergencies in Africa and Asia. There were 16 foods provided by the United States for foreign emergencies in fiscal These foods reflect abundant U.S. cereal and soy production that have dominated food aid programs for 50 y including the fortified and blended foods that were introduced in USDA customarily classifies food aid into five categories: 1) wheat and wheat products (five commodities), 2) feed grains 5 (six commodities), 3) pulses 4 There is also evidence that food assistance standards in European emergencies are higher than those for emergencies in African countries. There are also foreign policy influences beyond the scope of this report. 5 Their category refers to the fact that these foods are commonly used for feed in the United States, although much is also used for human consumption

3 2106S SUPPLEMENT TABLE 1 U.S. emergency food aid distributed in fiscal year 1999 Food aid commodity P.L. 480 Title II Section 4161 Total Metric tons (MT) Wheat 51,700 2,374,620 2,126,320 Wheat flour 50, , ,880 Rice 167, ,470 Bulgur wheat 34,740 66, ,033 Corn 98,620 98,620 Corn soya blend 97,050 97,050 Vegetable oil 69,281 69,281 Sorgum 66,150 66,150 Beans 58,195 58,195 Soy-fortified cornmeal 31,270 31,270 Cornmeal 31,270 31,270 Peas 27,920 27,920 Lentils 19,580 19,580 Soy-fortified sorghum 4,490 4,490 Wheat soya blend High energy biscuits Total, MT 809,216 2,784,938 3,594,154 1 Excludes Russia and assistance to other countries of the former Soviet Union. (three commodities), 4) vegetable oil and 5) other (in this instance, rice) (Table 1). Because the United States is the most generous donor of food aid globally and is the largest contributor to the World Food Program, the cross section of foods provided worldwide closely reflects U.S. donations (see Table 2). The foods more frequently provided in emergency situations are unprocessed grains, although processed foods are critical for meeting micronutrient needs and helping in situations where local processing capability is absent. Processed foods distributed in substantial quantities were wheat flour, bulgur wheat, cornmeal, vegetable oil (usually from soy beans) and various forms of soy-fortified cereals and cereal blends. The widespread use of soy protein in U.S. food aid commodities reflects the thinking about protein calorie deficiency in the 1950s and 1960s, when these fortified foods were designed and introduced. All these processed grains are fortified with micronutrients. At a minimum, the micronutrient fortification for all the processed grains consists of elemental iron and B vitamins, a package of nutrients identified 40 y ago for enrichment of U.S. wheat flour, plus vitamin A (required to be a minimum level of 8800 IU per pound or 1900 IU per 100 g). 6 Of particular interest are foods especially designed for young children, the blended foods, corn soya blend (CSB) and wheat soya blend (WSB). These are the richest sources of micronutrients of particular importance in emergency feeding programs, although not specifically designed for them (see Table 3). The micronutrient premixes (3% by weight) consist of 17 minerals and vitamins important to the growth and health of young children and other physiologically vulnerable groups, such as pregnant and lactating women. (e.g., corn). The U.S. food aid program does not export foods in this category for animal feed but for human consumption. 6 The nutritional composition of these foods can be found in the USAID Commodity Reference Guide at TABLE 2 Foods supplied by the World Food Program in 1999 (all programs) Commodity Total, MT Cereals 2,535,557 Blended foods 182,097 Dairy products 14,332 Meat and fish 14,418 Oil and fat 128,286 Other (pulses, etc.) 273,384 Total 3,248,074 The application of nutrition science to U.S. food aid commodities In fact, the best illustration of the use of nutritional science to food aid commodities is in the blended foods developed for feeding young children. The U.S. Department of Agriculture and USAID developed these foods with assistance from the National Institutes of Health (14). When introduced in 1966, the blended foods contained nonfat dry milk and were corn soy milk (CSM) and wheat soy milk (WSM). These were intended to complement the supply and acceptance of dry milk as a protein source, which was widely distributed and a common U.S. agricultural surplus. The nutrient profile of these blends was designed for the needs of growing children, em- TABLE 3 Nutritional characteristics of wheat soy blend and corn soy blend per 100 g of dry product1 Wheat soy blend2 Amount Corn soy blend3 Amount Protein 21.5 g Protein 17.2 g Energy kcal Energy kcal Lipid 5.9 g Lipid 6.9 g Vitamin A 2323 IU Vitamin A IU Thiamin (B1) 0.54 mg Thiamin (B1) 0.53 mg Riboflavin (B2) 0.50 mg Riboflavin (B2) 0.48 mg Niacin 8.19 mg Niacin 6.23 mg B mg B mg B g B g Folate 275 g Folate 300 g Pantothenic acid 3.7 mg Pantothenic acid 3.4 mg Vitamin C 40 mg Vitamin C 40 mg Vitamin D 198 IU Vitamin D 198 IU Vitamin E 8.7 mg Vitamin E 8.7 mg Calcium 842 mg Calcium 831 mg Zinc 5.5 mg Zinc 5.0 mg Iron mg Iron mg Magnesium mg Magnesium mg Phosphorus 294 mg Phosphorus 206 mg Iodine g Iodine 56.9 g 1 Adapted from USAID Commodity Reference Guide, 1999 at www. info.usaid.gov/hum_response/crg (accessed on July 7, 2001). 2 Key ingredients (in descending order): 53% bulgur flour; 20% wheat protein concentrate; 20% soy flour, defatted; 4% soybean oil, stabilized; 3% vitamins and minerals added as premixes. 3 Key ingredients (in descending order): 69.5% cornmeal, processed and gelatinized; 21.8% soy flour, defatted and toasted; 5.5% soybean oil, refined, deodorized and stabilized; 3.0% vitamins and minerals added as premixes mg added as pyridoxine HCl mg added as pyridoxine HCl.

4 EMERGENCY FOOD AID 2107S phasizing the need for a large proportion of protein in the diet, a prevalent view of child nutritional deficiency at that time. As milk surpluses became exhausted in the later 1980s, milk was dropped from the blends, which were replaced by CSB and WSB with a similar nutrient profile. In 2001 nonfat dry milk surpluses have reemerged with expansion of the USDA pricesupport programs and abundant milk surpluses. In 2001 the P.L.480 and Section 416 programs have begun to reintroduce CSM and WSM and other uses of nonfat dry milk. Since the protein-fortified and blended foods were introduced, formulation and fortification of processed foods have been changed infrequently and only slightly to reflect new scientific knowledge. Most have been in response to the discovery of the broader child survival and health significance of vitamin A deficiency. In 1988 vitamin A levels were nearly doubled in all processed cereal foods. In 1998 magnesium was added, zinc levels were significantly increased and vitamin B-12 was decreased in the two blended foods (15). Vitamin A was introduced into refined vegetable oil in 1998 (16). Furthermore, manufacturing standards have not been rigorous. Unlike the products made for the U.S. commercial market, U.S. commercial food suppliers to the P.L.480 program were not required by USAID or USDA which procures P.L.480 foods for USAID to meet product standards until 1999, one-third of a century after blended products were introduced. USAID-sponsored research, conducted in cooperation with the USDA, eventually led to the establishment of micronutrient standards and a product monitoring program as part of the USDA Total Quality Systems Audit (TQSA) program; enforcement began in February 2000 (17). 7 Other than these steps, little work has been done over the past three and a half decades to incorporate scientific and technical knowledge into the development of new and improved products for food aid. There has been limited incorporation of new technical knowledge about efficient production processes, nutrient absorbability and responses to the special requirements and diets of disaster victims [see recent recommendations from the conference, Enhancing Refugee Diets (18)], for instance, the need for more stable micronutrients, supplying foods requiring less cooking time, tailoring fortification to local needs and the like. In general, the formulation and variety of foods provided is more dependent on U.S. agricultural food supply policy and food supplier interests. In summary, many of the distribution and nutrition issues surrounding emergency food aid are the outgrowth of U.S. Government policy and legislation, to which we now turn. Issues of emergency food aid policy and programming It is timely to reexamine the issues surrounding U.S. food aid, which is part of the international trade section of the U.S. farm legislation that will be renewed by the end of The emergency purposes of P.L 480 Title II food aid are to provide U.S. agricultural commodities 1) to address famine or other urgent and extraordinary relief requirements; 2) to combat malnutrition, especially in children and mothers; and 3) to carry out feeding programs (see Article XV: Agricultural Trade in Public Law , the Food, Agriculture and Conservation, and Trade Act of 1990). In the 1990 P.L.480 legislation, the U.S. Government mandated the current policy to...use [our] abundant agricultural productivity to promote the foreign policy of the United States by enhancing the food security of the developing world through the use of agricultural commodities...under this Act. This represented a substantial refocusing away from the international trade development emphasis that dominated U.S. food aid policy in the post-wwii period, but the trade development purpose has not been eliminated and the stricture to purchase foods exclusively from U.S. sources was maintained. This is related to several issues influencing the selection and distribution of U.S. emergency food aid. Delays and gaps in shipment resulting from the need to procure foods from U.S. suppliers. Delays and pipeline breaks in delivery of foods from U.S. suppliers to distant emergency sites have been a common problem faced by USAID programmers. For example, private voluntary organizations are told by USAID s Office of Food for Peace to allow a 4- to 5-mo lead time before shipments can be expected to reach the field, although shorter delivery times are possible for WFP-sponsored programs. In the case of rapid-onset emergencies, diversions of foods in the pipeline for development purposes can substantially shorten this lead time. Delays have also been offset in the last few years by more prepositioning of food aid stocks at U.S. ports (19). Furthermore, when emergency foods are needed immediately, USAID can purchase from foreign sources and deliver small quantities of foods for a short time with cash resource provided to its Office of Foreign Disaster Assistance. Uncertainties because of the overall availability of foods depend on U.S. agricultural surplus policies. Section 416(b) of the Agricultural Act of 1949 provides for overseas donations of surplus commodities owned by the Commodity Credit Corporation (CCC). The CCC is the U.S. Government purchaser of farm commodities, which supports farm prices and supplies U.S. Government food distribution programs at home and abroad. Surplus commodities acquired by the CCC as a result of price support operations may be made available under Section 416(b) if these surplus commodities cannot be sold or otherwise disposed of without disruption of price-support programs or sold at competitive world prices. Clearly, the Section 416(b) program is not designed to subordinate U.S. domestic agricultural policy to the emergency nutrition uses in the choices of commodities. Eligible commodities include dairy products, rice, feed grains and products, oilseeds and other commodities acquired by the CCC through price support operations. Commodities may not be made available in amounts that will reduce amounts traditionally used for domestic feeding programs. On the other hand, food aid under P.L.480 is better coordinated to emergency demand. Appropriated dollars will buy marginally less tonnage in years when agricultural prices are high and vice versa; however, when unanticipated emergency demand is great and especially if the emergency has a high political profile (i.e., CNN effect ), it is possible to borrow from other legislative authorities, such as Title I P.L.480, receive supplemental Congressional appropriations and draw from emergency commodity reserves. 8 7 The USDA uses vitamin A assays to ensure that 80% of the added micronutrients are present at the specified levels in the finished product. In the case of the blended foods, where a separate mineral premix is used, iron assays must also demonstrate that at least 100% of the specified levels of all added minerals are present in the finished product. 8 In practically all instances, the laws governing P.L.480 food aid procurement and distribution are subject to not withstanding provisions that allow the Secretary of Agriculture, the USAID Administrator, to waive all legal mandates, with Congressional concurrence, to meet urgent humanitarian requirements. However, in practice, program managers work hard to avoid waivers of the normal provisions of the law.

5 2108S SUPPLEMENT P.L.480 again has more flexibility in choice of commodity. For P.L.480, no agricultural commodity is made available if its disposition would reduce the domestic supply below domestic requirements and provide adequate carryover, unless the Secretary of Agriculture determines that some part of the supply should be used for urgent humanitarian purposes. The availability of surpluses also affects the quality of formulated food aid commodities. For instance, as pointed out previously, the availability of dry milk powder drives the formulation of the blended foods CSB or CSM and WSB or WSM, as well as their instantized forms (Instant, Corn Soy Blend/Milk and Instant Wheat Soy Blend/Milk), not the need for high quality protein in the formulation. Distortions in foods developed and supplied because of U.S. commercial food and shipping interests. Domestic food commodity interests along with nongovernmental organizations are a formidable constituency supporting the continuation of a substantial U.S. global food aid commitment. However, in the current policy environment, the pursuit of selfinterest by U.S. producers and food processors, the ingredient industries, shippers and other interests represents a major influence on the commodities and conduct of the program. Not only do lobbies for these groups actively shape appropriations and authorization bills, they are also involved in program operations on a day-to-day basis. Agricultural producers promote their foods for use in specific situations and are quick to intervene if their commercial markets are threatened. Processors seek to increase the value-added (processed) foods included in food aid shipments, and mineral and vitamin manufacturers want more additives included in processed products (20). Influences have increased since 1996 when, under pressure from agricultural lobbies, the P.L.480 food aid consultative group where P.L.480 Title II program guidance is debated and shaped was expanded to include representatives from commodity groups such as the U.S. Dry Bean Council, the Potato Board, the North American Millers Association and the Food Additives Council. It is not uncommon for producers of specific foods to seek to extend their markets by approaching their congressional representatives or otherwise influencing the food aid procurement process. Rarely does the food aid program and its partners research and define food needs and seek private sector support in procuring a new food aid commodity. Ironically, because of the domestic purchase requirement, P.L.480 appropriations must not be used to purchase special emergency foods produced in other countries, such as high energy therapeutic milk or high energy biscuits (although limited quantities are purchased by USAID s Office of Foreign Disaster Assistance). Two legal requirements are especially illustrative of commercial interests that influence the programs, the valueadded mandate and the Cargo Preference Act. 1. Value-added mandate. Under Title II, nonemergency, the P.L.480 law mandates that 75% of all foods shipped are to be value-added, that is, they must be processed, fortified or bagged. This is a provision, originally supported by USAID and the private voluntary organizations, that is now supported and defended by the interests of U.S. food processors and packaging interests. The list of commonly used value-added commodities is determined internally at the highest levels of USDA and USAID, with little or no consultation with nutritionists. At present, the blended foods, refined vegetable oil, but not unrefined vegetable oil, powdered milk and formula milk, and many other processed or bagged cereals or legumes are on the list (Table 4). Although this mandate explicitly does not apply to emergency food aid, it has a bearing on the TABLE 4 Processed and fortified cereal grains: commonly used value-added commodities1,2 Bulgur Corn, bagged Cornmeal Corn soy blend Instant corn soy milk Corn soy milk Sorghum, bagged Nonfat dried milk Rice, bagged Rice, bulk with BNT3 Soy fortified bulgur Soy fortified rolled oats Soy fortified sorghum grits Vegetable oil 4 L Wheat flour Wheat soy blend Beans, pinto Peas, green Vegetable oil 20 L Peas, yellow Butter Cheese Wheat soy milk Lentils Beans, red Fortified non-fat dried milk Butter oil 55-gal drum Corn, bulk with BNT Wheat hard durum, bagged Wheat soft red winter, bagged Wheat northern spring dark, bagged Wheat hard red winter, bagged Wheat soft white, bagged Wheat hard durum with BNT Wheat soft red winter with BNT Wheat hard red winter with BNT Wheat soft white with BNT Beans, navy Corn soy masa flour Beans, black Beans, Great Northern Beans, pink Beans, kidney Peas, green split Peas, yellow split Potato flakes Infant formula Whole dry milk 1 USAID, Office of Food for Peace 2002 Guidance. 2 Determined to be processed, fortified, or bagged. 3 BNT, bags, needles, and twine. commodity mix in emergencies, because donors and field agencies are accustomed to requesting them, know how to handle them and U.S. suppliers are likely to have them available. To shorten the supply delays for rapid-onset emergencies, limited quantities of the commonly used commodities are being stockpiled or prepositioned at U.S. ports. Field agencies can request any commodity and, if approved by program authorities (e.g., yams), USDA would procure it for shipment by USAID under Title II (provided it was not explicitly excluded because of U.S. domestic needs). However, in practice this would probably involve longer delays if it was not one of the commonly used value-added or bulk commodities. Adequate manufacturing capacity and supplies might not exist. Costs, availability, packaging, handling, and shelf-life issues would be under greater scrutiny because of the limited experience the programs have with such foods. Food aid programmers claim to be always responsive to field requests; however, field agencies faced with longer waits for the preferred foods are likely to chose the less-preferred commodity. It seems that if the processed and fortified foods were supplied on the basis of nutritional and food needs, the valueadded mandate would apply to emergency food aid. Emergency feeding recipients have difficulty preparing unprocessed grains and have a greater need of a complete diet from food aid, including micronutrient fortificants. Fortified commodities may also be less likely to be shipped because either requesting governments or inexperienced requesting agencies may view emergency nutrition problems strictly in terms of calorie supply. Larger numbers of persons can meet basic energy needs with a commodity such as wheat or corn at approximately $150/metric ton than can be satisfied with corn soya blend at $350/metric ton or higher. Moreover, because of the orientation of the program toward domestic food processing and value-added commodities, little interest can be generated in policy circles to process and fortify

6 EMERGENCY FOOD AID 2109S foods near emergency food distribution sites overseas or to export vitamin premix under food aid budgetary authority. 2. The Cargo Preference Act. Another constituent for the food aid programs is U.S. shippers. Under the Merchant Marine Act of 1936, as amended, 75% of all food aid must be shipped under U.S. flag carriers, a generous subsidy to the U.S. Merchant Marine. Regulations do provide exceptions to minimize the effect on timeliness. The requirement can be waived if no ships are readily available and long transit times to rapid-onset emergencies must be avoided, and occasionally emergency shipments are delayed because of disputes surrounding the interpretation of this law. However, every effort is made to satisfy this requirement over the course of each year, at great expense to the program (21). Shipping costs on U.S. bottoms are often 20 50% above foreign-flag carriers. This reason partially explains why shipping, internal transport, and handing costs for food aid programs can in many countries cost about the same as the commodity supplied to an emergency food aid operation. It is important to note that for P.L.480 Title II emergencies, this estimate is $60 million in excess charges a year, over 10% of the cost for shipping, internal transport, and commodity purchases for all emergency food, which is over 30 times greater than all the funding for technical assistance for the food aid program. Failure of coordination of donor emergency food aid pledges. Clearly the quantity of food aid supplied by the U.S. Government is not fully coordinated to the global requirement for emergency food aid because of its linkage to U.S. agricultural policy. However, the key source of difficulty in delivery to emergency sites may be the failure of international coordination of emergency food aid appeals. The United States rarely programs or pledges sufficient resources to supply all the needs in any one emergency. Consequently, the total quantity and qualitative mix of foods supplied are made up of food provided from European bilateral or multilateral sources, Canadian, or other donors. When delays in fulfilling commitments occur by any of the parties in a burden-sharing arrangement, implementing agencies are faced with a situation in which they must borrow or stretch the available commodity until commitments are filled. Recipients in such situations may be forced to dig deep into scarce tangible assets to fill their food needs. Multilateral pledges to international reserves by the United States and other donors are currently too little to prevent this problem from occurring all too frequently, especially with the decline in European food aid donations in recent years. Coordination of food and nonfood support for nutrition In 1999 the emergency P.L.480 program provided food directly to over 14 million individuals, largely targeted to vulnerable age groups, usually women and young children, in 30 countries. In 1999 the largest recipient countries were Ethiopia, Honduras, North Korea, Sudan, Indonesia, the Balkans and Bangladesh, for victims of natural disasters, continuing military conflicts or severe economic crises facing poor countries. The Title II emergency program holds itself accountable to improve or maintain the nutritional status of emergency food aid recipients in most of these situations, and USAID encourages its field partners to monitor crude mortality and nutritional status as key indicators of its performance, but has yet to receive data fully demonstrating its impact. Whereas food aid programming seems straightforward, U.S. food aid is provided in emergency situations, typically through different implementing agencies, based on specific emergency proposals from private voluntary organizations, as part of international emergency appeals or included in the biannual pledge for prolonged refugee and rehabilitation operations to the World Food Program. U.S. emergency food aid programs usually involve three or more field agencies, each managing the distribution of three or more commodities for the same country. For instance, the Ethiopia program in 1999 involved distribution of vegetable oil, wheat, and lentils by one nongovernmental organization; oil, corn and corn soya blend (CSB) by another; and beans, vegetable oil, CSB, and rice by the World Food Program (12). (With the resurgence of the USDA Section 416 program, another layer of coordination has been added to many emergency programs.) These illustrations only partially represent the degree of organizational complexity in emergency response; they do not account for the many other governmental, nongovernmental and intergovernmental institutions that would be involved in a large-scale emergency response. In addition to the coordination of USDA, USAID, and WFP, operations usually include the USAID Office of Foreign Disaster Assistance (OFDA); the Department of Defense; the U.S. Department of State; Bureau for Population, Refugees, and Migration; and counterpart elements of the European Union and other donor country bureaucracies. Coordination with agencies such as the UN High Commission for Refugees, UNICEF, WHO, The Office of the Coordinator for Humanitarian Affairs (OCHA), and U.S. nongovernmental organizations are also often involved. Food program isolation and poor coordination with nonfood inputs needed for nutrition support. An issue of major importance for nutritionists is that, although food aid is often the major part of an emergency response, it cannot protect or promote nutritional well-being in isolation from disease prevention and family care of disaster victims. The best-executed food program will fail if water, sanitation, health care services, personal security, and household integrity are undermined. Unfortunately, the present structure of U.S. humanitarian response militates against close coordination of these needed inputs. USAID food and nonfood responses are separated under separate legislative authorities and appropriations. The P.L.480 law governs food aid, whereas nonfood inputs to emergencies are governed by the Foreign Assistance Act through the International Disaster Assistance account and other sources of dollar funding managed by other parts of USAID and the Department of State. Administrative support for refugee camp operations are supported by the Department of State, whereas OFDA provides short-term health, shelter, water, and even limited quantities of foods. However, these operations in the same emergency response are often not fully coordinated and exist on separate tracks. In short, providing a reliable supply of all the inputs needed to support the nutritional status of a refugee or drought victim is among the most complex of administrative tasks. Conclusions and policy proposals Over the past half century, U.S. Government food aid has played a critical role in the nutrition and survival of millions of international disaster victims. The U.S. Government continues to be the largest donor of food aid in emergencies, reaching at least 14 million recipients in 1999 under the P.L.480 program alone. Yet, informed nutritionists make credible claims that food aid is not as effective as it should be in protecting the nutritional well-being of disaster victims. Knowledgeable observers link these problems to the unreliable quantity of food supplied, the low quality of the food supplied and the lack of full recognition and coordination of food aid with other needs of people. However, the paucity of nutrition

7 2110S SUPPLEMENT research prevents us from knowing whether these are general or isolated problems and to what extent they can be remedied by donor policies and practices. An important task before us is to support a full review of the linkages of emergency nutrition conditions with food supply problems. We do know the U.S. Government has made limited use of nutrition science in formulating, selecting and distributing food aid commodities. Technical support to emergency food aid programs for all purposes is very paltry relative to the commodity budget: around $1 of technical assistance for every $1000 of food provided. Nonnutritional priorities stemming from U.S. food aid policies and customs have been the dominant influences on formulation, selection and distribution of food. Although further research is needed to establish whether the nutrition of disaster victims is systematically being compromised by our policies, we might start our inquiry by sorting through the issues and options for policy change along the following lines. 1. Delays and gaps in shipments resulting from the need to procure foods from U.S. suppliers. The length of time from the receipt of emergency food proposals to delivery of food aid to the recipient can be as much as 4 5 mo, and further delays and gaps are not uncommon. Could mechanisms now available to shorten lead-time be strengthened, such as the following: 1) more prepositioning of food aid stocks at U.S. or foreign ports, 2) using of a portion of the emergency food aid budget to purchase foods from local sources near emergency events or 3) bolstering the undesignated cash budget of the Office of Foreign Disaster Assistance? (The latter two steps would also provide more acceptable local foods to disaster victims.) A feasibility study of these options above would review the experience of the WFP immediate response account (a cash reserve), which is commonly used for local purchases. For instance, how readily availability and costly are appropriate foods near an emergency event and what happens to the cost of foods in these markets in the event of unanticipated emergency demand? What is the typical response time using these mechanisms? 2. Supply uncertainties because of the overall availability of foods depend on U.S. agricultural surplus policies. If reliance on food surpluses was reduced, could a regular humanitarian budget appropriation be generated to meet worldwide emergency food aid contingencies? European donors have increasingly broadened food assistance budget lines to include support for food security in cash or kind and direct donations of food have declined since 1996 (22). How well has this policy been working? Could the next round of talks on world trade be approached with a proposition that a proportion of food surpluses could be marketed internationally, on the condition that the cash resources generated must be contributed to a multilateral reserve for emergencies? The seller might be required to donate the full world market price to the fund, encouraging sellers to obtain the best possible price and minimizing impact on the market. This way, if the food is not required for a specific emergency need, funds could be reserved for a time when food was needed. Although this might depress the price for some foods in times of surplus, it would elevate their price when funds were used to supply an emergency in times of global food scarcity. Perhaps this system would be an acceptable risk for the markets while protecting emergency victims. 3. Distortions in foods developed and supplied because of U.S. commercial food, labor and shipping interests. If food aid were uncoupled from domestic purchase requirements, would food aid programs lose an important technical ally in identifying new food aid commodities? Or could the public private partnership be elevated to a higher plane so private industry would serve the public interest in improving and developing commodities truly needed in emergencies without regard to the export assistance the program provides? If the latter, the value-added list of foods could be reconsidered and expanded in terms of recipient cultural preferences and nutrition requirements rather than domestic food and ingredient company interests. Would freedom to purchase on the world market only lead the United States to become hostage to the commercial food interests in other countries that seek a larger share of the emergency food aid market, or would a healthy competition in supplying appropriate emergency foods be generated? Can the budget be increased for operational research and nutrition studies to identify the best foods for disaster victims in a variety of natural and complex emergencies in different ecological and cultural areas of the world? Without more funding for independent assessments and technical assistance in food and nutrition, any future food aid program will be forced into a largely reactive posture toward commercial food producers rather than an active position in the development and identification of food most appropriate for the nutritional needs of disaster victims. Could support for fortification and processing near areas prone to emergencies receive legislative support? If so, how would quality control capacity be built in so the quality and safety of foods produced in such facilities can be ensured? What has the experience of WFP been in this regard, and could the United States or U.S. food processors assist in such projects? Because most of the countries with severe food insecurity and nutrition problems are agricultural countries, the export of value-added know how by wealthy countries is a major development and poverty-reduction strategy. Food aid could play a major role in such a strategy if combined with the former. With the opening of free trade and investment as part of the globalization of world economies, why would the U.S. Foreign Assistance Act or the Farm Bill hinder such uses of food aid? Because of the poor audit results, the USAID Inspector General has already called for reform of the Cargo Preference Requirement. Perhaps it should be eliminated entirely. If the requirement to ship food aid in U.S. carriers was eliminated, would the overall P.L.480 budget be decreased accordingly because Congress will need the funds to provide the maritime subsidy in another way? Or will there be sufficient commitment to emergency food aid to unlink the two and maintain the budget. This could result in significant additional funds for emergency programs while concomitantly removing a cumbersome layer of complication from the administration of food aid shipments. 4. Gaps in food supplied because of failure of coordination of donor emergency food aid pledges. Internationally, how might the global pledging system be changed to improve coordination? Could the WFP cash reserve accounts for emergencies be strengthened specifically to manage coordination issues? Could the UN Office of the Coordinator of Humanitarian Affairs or some other multilateral body be strengthened to take a more forceful role in coordination of receipts as well as coordination of appeals? Bilaterally, the experience of food aid program coordination could be studied by examining instances in which a single donor takes the lead to isolate the effect of poor donor coordination on food distribution. One could look at instances where the United States was a major supplier of food aid, or try a pilot program where a single donor takes responsibility for providing the food aid to see whether better coordination could be demonstrated.

8 EMERGENCY FOOD AID 2111S 5. Food program isolation and poor coordination with nonfood inputs needed for nutrition support. Internationally, could a UN interagency organization such as the UN Sub- Committee on Nutrition propose how food and nonfood inputs should be managed in emergencies? The U.S. Government should consider the costs and benefits of joining portions of the P.L.480 and IDA (International Development Account) budgets, technical assistance and administrative structures, using the best nutritional support skills of the different parts. Clearly if greater flexibility in emergency response budgets for food and nonfood inputs was allowed, coordination would improve. Many of the issues identified by field nutritionists and in the preceding analysis of U.S. policies are linked to the fact that U.S. food aid must be procured from U.S. domestic markets as an element in U.S. domestic agricultural policy. Consequently, the range of commodities supplied is determined by what is abundantly produced in the United States as well as the strength of domestic U.S. constituencies influencing the programs. Restricted procurement also eliminates global competition among suppliers to develop and supply special foods needed for emergencies at the lowest possible cost. These restrictions also work against needed international coordination and rapid response. One might argue, therefore, that simply to unlink the programs from this requirement would free up the programs to satisfy the nutritional needs of recipients, eliminating many cumbersome and expensive policies and program practices. However, such a step could lose an influential part of the constituency for the food aid program. Congressional support for the program would rapidly diminish along with the budget for Title II food aid. A replacement may not be impossible, but would have to be carefully thought through. It could be that in the field of foreign assistance, food aid in disasters is the one area that might be built on a nutrition or humanitarian imperative with support from U.S. nongovernmental organizations and an informed U.S. public. However, although emergency food aid might find a willing constituency, it is certainly less possible to delink nonemergency, development uses of food aid from commercial and domestic agricultural policy, which has less support among Americans than does humanitarian assistance. The risk is that an attempt to radically reform U.S. emergency food aid for the sole purpose of providing the best nutrition to disaster victims might lead to less humanitarian assistance, less overall food aid or both. Nevertheless, the effort is a worthy one, for if the policies and customs discussed in this report constrain the mode and mix of commodities distributed in emergencies, the programs and the commodities could be reinvented with a nutrition imperative uppermost in mind. In such a scenario, the United States would lead the world toward a more effective and compassionate tool for relieving human suffering, fitting the highest aspirations of the new millennium. LITERATURE CITED 1. McClelland, D. G. (2000) Complex Humanitarian Emergencies and USAID s Response. USAID Program and Operations Assessment Report no. 27. Center for Development Information and Evaluation, U.S. Agency for International Development, Washington, DC. 2. Committee on International Nutrition, Institute of Medicine, National Academy of Sciences. (1995) Estimated Mean Per Capita Energy Requirements for Planning Emergency Food Aid. National Academies Press, Washington, DC. 3. WFP/UNHCR. (1999) Guidelines for Estimating Food and Nutritional Needs in Emergencies. World Food Program, Rome, Italy/United Nations High Commission for Refugees, Geneva, Switzerland. 4. ACC/SCN. (1994) Update on the Nutrition Situation. Agency Committee on Coordination/Sub-Committee on Nutrition, Geneva, Switzerland. 5. Shoham, J., O Reilly, F. & Wallace, J. (2000) Humanitarian crisis and conflict: food assistance and nutritional security issues. In: Food Aid and Human Security (Clay, E. & Stokke, O., eds.). Frank Cass, London, UK. 6. Toole, M. J. (1994) Preventing Micronutrient Deficiency Diseases. In: University of Nairobi (1995). Report of a Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa. Machakos, Kenya, December 5 7, Marchione, T. J. (2000) Title II food aid and the nutrition of children in Latin America and the Caribbean. Food Nutr. Bull Reed, B. & Habicht, J.-P. (1998) Sales of food aid as a sign of distress, not excess. Lancet 351: Payne, L. (1997) Impact of food delays on refugees. Field Exchange Marchione, T. J. (1996) The right to food in the post-cold War era. Food Policy WFP. (2001) Online Statistical Reports. World Food Program, Rome, Italy. 12. U.S. Agency for International Development/Food for Peace Information System. (1999) FY 1999 Approved Budget Summary Report, December 28. Office of Food for Peace, Washington, DC. 13. U.S. Department of Agriculture. (2000) Online reports of Section 416: Accessed June 30, Senti, F. R. (1972) Guidelines of the nutrient composition of processed foods. Cereal Science Today, 17 June. 15. Combs, G. F. et al. (1994) Micronutrient Fortification and Enrichment of P.L.480 Commodities: Recommendations for Improvement. USAID Opportunities for Micronutrient Interventions (OMNI) Project. U.S. Agency for International Development, Washington, DC. 16. Sharing Untied States Technology to Aid in the Improvement of Nutrition (SUSTAIN). (1999) The Micronutrient Assessment Project, Final Report. SUS- TAIN Project, U.S. Agency for International Development, Washington, DC. 17. USAID. (1999) Enhancing the Quality of Blended Food Aid Commodities. Internal memorandum. Office of Program, Planning, and Evaluation, Bureau for Humanitarian Response, U.S. Agency for International Development, Washington, DC. 18. Food Aid Management (FAM)/Food and Nutrition Technical Assistance Project (FANTA)/SUSTAIN Project. (1999) Enhancing Refugee Diets: Proceedings of the USAID-funded workshop. U.S. Agency for International Development, Washington, DC. 19. USAID. (2000) Annual Food Assistance Report U.S. Agency for International Development, Washington, DC. 20. Committee on International Nutrition, Institute of Medicine, National Academy of Sciences. (1997) Vitamin C Fortification of Food Aid Commodities. National Academies Press, Washington, DC. 21. USAID. (2001) Audit of USAID s Cargo Preference Reimbursements under Section 901b of the Merchant Marine Act of Office of the Inspector General, U.S. Agency for International Development, Washington, DC. 22. Clay, E. & Stokke, O. (2000) The changing role of food aid and finance for food. In: Food Aid and Human Security (Clay, E. & Stokke, O., eds.). Frank Cass, London, UK.