04.16.17

Hunger, Health, and Compassion – and Our Responsibility

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Famine has already been declared in parts of South Sudan, and threatens Somalia, Yemen, and Nigeria. Map courtesy of Al Jazeera.

This piece was written by Eric Friedman and Lawrence Gostin. It is an extended version of Prof. Gostin’s JAMA Forum posting from April 12, 2017.

The contrast must have been enough to send a shiver down the spine of the global humanitarian and human rights communities. Even as headlines warned of 20 million people in Africa and the Mideast facing starvation, the Trump Administration was proposing steep cuts in foreign assistance.

While the drastic cuts are likely not come to pass, as Senate Majority Leader Mitch McConnell has made clear, American values of compassion and caring are being eroded. Secretary of State Rex Tillerson warned other countries to provide a larger share of assistance, suggesting a U.S. retreat. Perhaps in a sign of what is to come, in the first quarter of 2017 US contributions to humanitarian appeals decreased by one-third from the level for 2016 (from 30% in 2016 to 15% in 2017 as of the end of March 2017, since increasing to 20%). And even small cuts to humanitarian assistance are more than the world’s most desperate people can afford, with UN humanitarian appeals already routinely underfunded.

The consequences of less funding would likely be measured in untold thousands, perhaps hundreds of thousands, of avoidable deaths. There is another path, though: an international community that uses a public health crisis to mobilize political will and sustainable funding. Rather than weakening the United Nations, the United States should help enhance its capacities. The United Nations needs a major influx of funds for food, clean water, and other humanitarian relief, and for protecting its staff and supply lines when delivering aid within conflict zones.

A hunger crisis of historic proportions

The current hunger crisis encompasses South Sudan, Yemen, Somalia, and northeastern Nigeria, all experiencing severe droughts. Yet the disaster’s primary drivers are armed conflicts and outright war. Health risks extend well beyond starvation, with waterborne illness such as cholera, a major threat. This is the largest humanitarian crisis since the United Nations came into existence.

The origins of the hunger and the obstacles to relief assume their own dynamic in each country, though the basic storyline is shared: ineffective, unaccountable, or malevolent political leadership, violence and conflict, and a dearth of humanitarian funding turning droughts and rain that does not fall into the catastrophes now unfolding.

The United Nations has officially declared a famine only for certain northern parts of South Sudan, with 100,000 people experiencing famine, and 5.5 million South Sudanese expected to urgently need food aid by the summer. The declaration of famine has a precise tragic meaning: “at least 20 percent of households in an area face extreme food shortages with a limited ability to cope; acute malnutrition rates exceed 30 percent; and the death rate exceeds two persons per day per 10,000 persons.”

South Sudan also stands out for the government’s direct responsibility for widespread hunger. In a conflict that has assumed pernicious ethnic dimensions following the collapse of a 2015 peace agreement, government troops have prevented aid from reaching rebel-controlled areas. The United States has accused the government of “deliberate starvation tactics,” both blocking aid and raising fees for foreign aid workers to $10,000 each. Government forces have also directly targeted civilians, “waging war ruthlessly against their own people.” The rebels, too, have committed atrocities and obstructed aid. At least 79 aid workers have been killed since fighting began in December 2013.

Yemen has the most people at risk from hunger – 17 million, including 8.2 million deemed food insecure and in need of aid. Among them are 2.2 million acutely malnourished children and 1 million acutely malnourished adults. Civil war has raged since 2015, with a Saudi Arabia-led coalition (supported by the United States) targeting the agricultural sector and food-bearing trucks and other civilian infrastructure, and imposing a blockade. The blockade is destroying the economy, with food prices skyrocketing beyond people’s reach. Rebel forces, too, have obstructed food aid. In addition, 14 million people have no access to health services.

In Somalia, the effects of a severe drought are worsened by an ongoing struggle against al-Shabaab, now in its second decade, as 3 million people face starvation. The last famine that Somalis experienced (2011-2012) cost nearly 260,000 people their lives. The militant Islamic insurgency, which still holds sway in the countryside, bans Western aid agencies. Cholera has taken hold in displaced persons camps and beyond, with a cholera vaccination campaign now underway.

Hunger in northeast Nigeria is wrapped up with the Boko Haram insurgency. An estimated 5 million Nigerians are at risk of famine, as insufficient funding and dangerous conditions prevent delivering food aid – or even accurately accessing how many need it. Insecurity is fueling the food crisis, as farmers have been forced to abandon their farms, and the disruption of food production and markets is putting food beyond people’s economic reach.

And so in Africa and the Middle East, at least 20 million people face severe hunger, with the risk of starvation, heightened susceptibility to illness, and long-term health and development consequences of malnutrition. Even children with severe acute malnutrition who survive, for example, are likely to experience developmental disabilities. As wells, rivers, and other sources of relatively safe drinking water dry up, people must turn to unsafe drinking water – the alternative is no water at all – even, in South Sudan, “barely chewable lotus plants and worm-infested swamp water.” The lack of clean water, and resulting diseases, such as cholera in Somalia, may be the biggest killer. The health effects of a famine may extend “years, if not decades” beyond the immediate crisis, as people sell off their assets to afford food, and then, without their productive assets, persist in a state of food insecurity.

The United Nations required $4.4 billion by the end of March for these four crises, but as the month drew to a close, it had received only about one-tenth that level. A massive and immediate infusion of funding is required.

Realities of US foreign assistance

Secretary Tillerson’s claim that the US provides a major share of disaster assistance is true, but disingenuous. The United States may have been the largest contributor to the World Food Programme in 2016, providing 34% of contributions. But with the food agency falling more than $2 billion short of the $8.6 billion it required, and U.S. contributions representing less than one-quarter (24%) of the need, the United States suddenly look far less generous. Worse, the U.S. share of 30% of overall UN humanitarian funding last year, beyond food assistance alone, was only 20% of what needed. And even the large share of what countries actually contribute represents the United States coming up short. The U.S. gross national income (GNI), a standard economic measure, is 36% of high-income countries’ overall GNI. The Secretary is right that other countries do need to step up, but so does the United States.

U.S. humanitarian assistance should also be seen in the context of overall development assistance, where relative to the size of the American economy, the United States falls far short of most wealthy countries. The major donor nations contributed an average of 0.30% of their GNI to official development assistance in 2015. Nineteen countries provided more than the 0.17% of GNI that the United States contributed, a level that was about four times less the long-standing 0.7% UN target. And that was before threatened cuts.

Secretary Tillerson’s assertion also plays dangerously into the perception among Americans that our foreign assistance is far more generous than it is. The public consistently believes about one-quarter of the budget goes to foreign assistance; in reality, less than 1% does.

New strategies for humanitarian financing

Looking longer-term, how to prevent this perniciously predictable litany of vastly underfunded humanitarian emergencies? The United Nations took a significant step back in 2005, establishing a Central Emergency Response Fund (CERF), a standing fund that serves as an existing pool of funds for UN agencies to draw upon to help meet funding requirements of the world’s most neglected crises and for rapid responses, to “jump-start activities in sudden-onset emergencies,” and to address emergencies where “the situation suddenly deteriorates.” The UN General Assembly, in establishing the fund, set a goal of $450 million; the fund has been largely successful in raising these resources.

This was never going to enough, however. Oxfam was calling for a billion dollar fund when the United Nations established the CERF. Since 2005, the total annual UN humanitarian appeal has soared from about $6 billion that year to more than $21 billion in 2017. The 2005 appeal fell nearly $2 billion short. The shortfall for last year’s appeal – the CERF notwithstanding – neared $8 billion.

The General Assembly has the authority to establish assessments for UN members for “expenses of the Organization,” as laid out in Article 17(2) of the UN Charter. The General Assembly already sets assessments for peacekeeping. Why not also for the world body’s role in stemming humanitarian emergencies, another central function of the United Nations?

Since 2001, the peacekeeping assessments have been based on the assessments of the regular budget, adjusted to have premium (higher) contributions by Security Council members and discounted (lower) assessments for other UN members, linked to per capita gross national income. Assessments for humanitarian appeals could follow a similar model, with regular budget assessments as a starting point, and perhaps a premium for a defined set of wealthiest nations (based on income alone, or tracking members of the Organisation of Economic Cooperation and Development’s Development Co-operation Directorate, typically viewed as members of the international assistance donor community).

Given the frequent link between hunger and other humanitarian disasters and conflict, another fund or initiative is surely in order, one focused on conflict prevention, with the longer-term, less headline-grabbing work of building community trust and resilience, promoting non-violent conflict resolutions and fair resource allocation, and other such approaches.

Gaining the political will for stable, sufficient funding for emergency response and conflict prevention will be difficult. In 2015, the World Health Organization established a Contingency Fund for Emergencies, following the Ebola epidemic, with a modest target of $100 million. Yet well over a year later, through March 2017, it had received only $38 million.

All of this would be too late for people facing immediate need in South Sudan, Somalia, Yemen, and Nigeria. For now, the international community must use standard practices to meet funding needs. The UN Secretary-General should urgently convene a donor conference to address the hunger crisis, or a member state could take the lead, as the Netherlands did in response to the Trump Administration resurrection and expansion of the Global Gag Rule, prohibiting U.S. health assistance to organizations that provide abortion services or counseling.

Towards political resolutions

Beyond this, the conflict dimensions of these crises remain fundamental. The roots – and solutions – of the hunger in all four countries are ultimately political, requiring political solutions. Some immediate steps are possible. In Yemen, for example, the United States should step up pressure on Saudi Arabia, including by suspending all arms sales to and military cooperation with Saudi Arabia, a major American munitions purchaser.

Meanwhile, the UN Security Council strengthened the mandate of the UN peacekeeping mission in South Sudan last December, instructing the UN force “to use all means necessary to” protect and deter violence against civilians, including gender-based and sexual violence, and to enable “the rapid, safe and unhindered access of relief personnel to all those in need in South Sudan.” Yet this has not stopped the government’s war on civilians. The Security Council will need to continually assess cooperation and further empower the UN force to carry out its mandate, while member states ensure sufficient troops and equipment. More political pressure is needed, from an arms embargo – which failed to win Security Council support last December, with Russia leading the opposition – to referring South Sudan for investigation by the Prosecutor of the International Criminal Court. The Security Council and international community need to consider more forceful, and even controversial, possibilities, from a willingness to engage combatants that are obstructing the delivery of humanitarian aid to a dramatic proposal for temporary UN and African Union stewardship of South Sudan.

Leadership from below

Even as more creative, forceful, and engaged leadership is needed, the world’s most powerful country is pulling back. Some of the world’s most desperate people will continue to suffer unthinkable trauma, and more will lose their lives. In the absence of political leadership, health and humanitarian advocates will have to press elected officials to act, insisting that they not be blind to the atrocities and human cost of what is occurring, and contributing to humanitarian organizations. Civil society cannot compensate for missing billions or a shortage of political will by those holding the levers of power, but it can raise its voice – and each of us can raise our voice – on behalf of millions of people who are now mostly alone, helping some to survive.

You can help. Among the many organizations seeking donations to help fill the immense funding – or might we say, humanity – gap are the World Food Programme (South Sudan-specific appeal), UNICEF, the International Rescue Committee, Oxfam, Mercy Corps, and Save the Children.

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