Special Report

Ending Deaths from Famine -- The Opportunity in Somalia

Robert W. Kates

N Engl J Med 1993; 328:1055-1057April 8, 1993

Article

As we witnessed the starvation, disease, and dying in Somalia, it was surely difficult to remember that Somalia was the site of the greatest triumph of 20th-century international public health. There, in October 1977, Ali Maow Maalin, a 23-year-old cook in the town of Merca, was identified as having “the world's last endemic case of smallpox”1. Now, more than 15 years later, Somalia may again prove to be a turning point in the much longer and larger human struggle to end deaths from famine. To understand that opportunity amid all the pain and suffering requires a sense of that long struggle, an assessment of the trends in cause, prevalence, and prevention of modern famines, and the specific challenges of undertaking humanitarian action in the midst of armed conflict.

Food shortage and subsequent starvation are what is popularly conceived of as famine: an absolute shortage of food within a bounded area, usually caused by the failure or destruction of crops or by wartime sieges or blockades. But studies of major modern famines -- in the Soviet Union in 1932 through 1934, Bengal, India, in 1943, China in 1958 through 1961, and Ethiopia in 1972 through 1973 and 1984 through 1986 -- indicate that widespread hunger and starvation can occur even when food is available if large numbers of people lose their capacity to produce, purchase, exchange, or receive food2. Thus, a sudden increase in food prices, a drop in laborers' incomes, or a change in government policy can create hunger for millions even in the absence of the more familiar causes of food shortage: droughts, floods, pests, or armed conflict.

Famine is as old as humanity. Its occurrence is inferred from paleoforensic data in the Harris lines of long bones and in the Wilson bands of teeth3. It is recorded in the 4000-year-old lamentation for the Mesopotamian city of Ur after one of the earliest Iranian-Iraqi wars: “In all its streets, where they were wont to promenade, dead bodies were lying about; Ur -- its weak and strong perished by hunger”4. It is displayed on the stelae all around the Roman empire that laud the generosity of the wealthy politician who supplied grain in the region's great moment of need5., and it is carefully documented in the “last great subsistence crisis in the Western world,”6 which hit Europe and North America in 1816.

The 1816 crisis was also a turning point in the struggle to end deaths due to famine. The year was known in New England as “the year without summer,” when wet, cold weather throughout North America and Western Europe was triggered by the dust veil that followed the eruption of Mount Tambora in Indonesia. Crop and harvest failures combined with the unsettled economic conditions in post-Napoleonic Europe led to widespread food crises. But in this case, unlike the frequent famines of the previous century, European states and cities organized to prevent famine deaths by raising funds and importing food from Russia and the Baltic states. The new commitment not to accept deaths due to famine as inevitable was seen everywhere in Europe except two areas, Ireland and Transylvania, each still beyond the pale of the dominant empires of Great Britain and Austro-Hungary. This commitment would again fail the Irish in 1847 and particular populations in the two world wars of this century, but overall it would hold in Europe and then be gradually extended to other parts of the world. To this day, the 19th-century famine codes serve as a basic framework for the highly successful programs of famine prevention and relief in India7.

Famine, while frequent in history, is never ordinary. Food is the most basic of human needs, and mechanisms to cope with periodic food shortage are features of the earliest social systems. For the mechanisms of famine prevention to fail, multiple stresses, such as the “year without summer” coinciding with an economic depression, are almost always required. Over time, the natural causes of famine -- drought, flood, pests, and disease that lead to crop failure and animal death -- have become relatively less important. Social causes of famine have become correspondingly more important as the nature of food procurement has changed from simple access to natural resources and the help of kinfolk to a complex set of productive resources, exchanges, and gifts., and throughout time, famine created in the course of war has persisted, even as the scale and technology of warfare have changed.

Food sources now include the entire globe instead of the area bounded by the earlier limits of a day's walk, a hunting trip, or a seasonal migration. This enlargement of scale, however, so important to the reduction of scarcity, renders some areas marginal and courts catastrophe when errors in food-system management occur. Big food systems can make big mistakes. Thus, the worst famine of the 20th century, the Chinese famine of 1959 through 1961, in which between 15 million and 30 million people died, was rooted primarily in state policies connected with the ill-fated “great leap forward” that devastated the Chinese food-producing system while ignoring the warning signs of increasing stress8.

Famine is the only form of hunger that one is likely to see on television. The power and immediacy of the medium creates a sense of widespread and increasing vulnerability. Yet the numbers affected by famine -- now 15 million to 35 million at risk -- are relatively small. Other less acute forms of hunger, however, are much more common. The recent International Conference on Nutrition estimated that 780 million people in developing countries lack access to enough food to meet their basic daily needs for health, growth, and light activity (an average daily caloric requirement of 1.54 times the basal metabolic rate)9. In addition, one child in six in the world is born underweight, and almost two in five children are underweight by the age of five10. Some 2 billion people, mostly women and children, are deficient in one or more of the three major micronutrients: iron, iodine, and vitamin A11.

The total population residing in countries where episodes of famine have been reported in The New York Times can serve to indicate the population at risk. Figure 1Figure 1The Average Total Population of the Countries Where Famine Was Reported in The New York Times from 1950 through 1991. shows such a measure from 1950 through 199112. By this measure, the trend in famines since the end of World War II is clearly downward, reflecting a lessening of the prevalence of famine and a major shift in the incidence of famine from populous Asia to less-populated Africa. The total population in countries with reported famine peaked in the period from 1957 through 1963 at a yearly average of almost 788 million, then declined to a yearly average of 264 million in 1978 through 1984. This decline continued over the next seven years (from 1985 through 1991), when the combined population of famine-plagued countries averaged 141 million., and it declined further in 1992, when famine was reported only in Somalia and Sudan, which have a combined population of 35 million.

Four years ago, an ad hoc international group meeting in Bellagio, Italy, found that it was theoretically possible to halve hunger in this decade by building on the successful efforts that were currently under way13. Four specific goals were adopted: to eliminate deaths from famine; to end hunger in half the poorest households; to cut malnutrition in half among mothers and children; and to eradicate iodine and vitamin A deficiencies14. The optimism that underlay these commitments, even in the midst of disaster, was based on the long-term downward trend in the size of the populations affected by famine and the knowledge that most of the elements required to prevent famine were already in place.

The effort to cope with drought, flood, war, and famine in the 1980s led to major improvements in the global emergency-food-aid system. Early-warning systems, dispersed emergency stocks, continuing commitment on the part of donors, and improved logistical and distributional capability either now exist or can readily be brought into being13. An important international early-warning system coordinated by the United Nations Food and Agriculture Organization was established in 1975, and several regional systems are in operation as well. Some 2 to 4 million metric tons of emergency food aid have been distributed annually in recent years. With the continuing commitment of donors, it should be possible to place emergency stocks near where they may be most useful and to deliver them when and where needed.

In all of the countries that have reported famine so far in the 1990s -- Angola, Ethiopia, Liberia, Mozambique, Somalia, and Sudan -- armed conflict has been a major cause. Indeed, “food wars” -- conflicts in which a principal feature has been the destruction or interdiction of civilian food supplies or of resources to produce food -- became a consistent feature of the Cold War years15. For example, in 1989, there were 19 such food wars16. In the 1990s, armed conflict became the dominant cause of famine worldwide.

Thus, the key obstacle to eliminating deaths due to famine remains the destruction or interdiction of civilian food supplies in zones of armed conflict. The rudiments of the international protection of civilians' right to food exist in the form of the Universal Declaration of Human Rights, the International Covenant on Economic, Social, and Cultural Rights, and most specifically, the 1977 protocols to the Geneva Conventions of 1949 that prohibit starvation of civilians as a means of combat. Ad hoc humanitarian efforts to deliver food to civilian populations in conflict-torn Mozambique and southern Sudan had some success in staving off mass starvation. But the efforts broke down with the eruption into armed conflict after the Cold War of political, ethnic, religious, and even clan-based rivalries. Old and new conflicts threaten civilian food supplies in Afghanistan, Angola, Azerbaijan, Bosnia-Hercegovina, Croatia, the Kurdish regions of Turkey, Iran and Iraq, Liberia, Mozambique, Somalia, and Sudan.

The current efforts in Somalia follow in the path of the “corridors of tranquillity” established in southern Sudan (routes successfully negotiated with the help of strong international pressure to provide cross-border relief within that zone of conflict17) and the opening of the port of Massawa in the Eritrean-Ethiopian conflict. Another precedent was the direct use of force by the Allied Coalition to ensure a protected Kurdish enclave in Iraq18. These efforts paved the way for the military force led by the United States that has provided the necessary space for humanitarian relief operations in Somalia.

If the operations in Somalia are to be a turning point in the long struggle against famine, they must lead to the development of rules of humanitarian intervention. The reluctance of some to intervene in Somalia and of many to undertake similar operations in Bosnia arises partly from the sense that the United States and the world are now on a slippery slope. Many Americans are concerned that intervention will bring, at worst, other Lebanons and Vietnams or, at best, continued tasks and moral fatigue for the United States in its role as the would-be world policeman. For the world, intervention conjures up fears that the now lone superpower will interfere in the affairs of other nations wherever its imperial designs or concerns raised by CNN's television coverage take it. Thus, while there is a pressing need to move along the process of humanitarian intervention if we are to realize the promise of ending deaths from famine, there is also a need to take the process beyond the media-mediated moral claims that require both public exposure and enormous death tolls to bring forth action. (A beginning can be found in the Providence Principles on Humanitarian Action in Armed Conflict, which identify the primacy of life-threatening suffering wherever it may occur and assert that assistance should be appropriate to local needs and given in a nonpartisan and open manner19.) Most important, and most controversially, when humanitarianism and sovereignty clash, a new understanding of sovereign rights must be developed that defers to urgent humanitarian needs. Stated simply, no nation has the right to starve its own or other people.

Beyond such emerging principles, there is a need for a new system of humanitarian assistance, a graduated response that uses armed intervention only as a last resort. Such a system would require the various United Nations agencies, the International Committee of the Red Cross, the regional intergovernmental groups, and the international and national nongovernmental organizations to be prepared for a range of appropriate responses to the humanitarian needs of civilian populations in conflict, including protection by armed forces and preventive enforcement of the peace.

Our intervention in Somalia takes us into the truly unknown territory of world order and disorder, of conflicts of principles and claims of compassion, and the reach and overreach of power. If we are not to be overwhelmed by the difficulty of traveling into the unknown, it is useful to recall the true length and nature of the journey.

Source Information

Address reprint requests to Dr. Kates at P.O. Box 8075, Trenton, ME 04605.

References

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Citing Articles (1)

Citing Articles

1. 1

   Oliver E. Owen, Karl J. Smalley, Robert L. Jungas. 2011. Starvation. .
   CrossRef