Nutrition outcomes have been associated primarily with the availability of food and the presence of infection which influences intake, absorption and utilisation of food. Figure 4 depicts the linkages of social factors and nutritional status, underlining the role of care in nutrition. Care interventions involve efforts to maintain physical, intellectual and cognitive development. Psychosocial care relates to the direct traumatic effect on a child's emotional development from the loss of personal security, as well as broader issues relating to a child's wider social needs (Longhurst & Tomkins, 1995).

Care affects nutritional status in three ways: through feeding practices such as breast-feeding and the preparation of nutritious foods for weaned infants and others in the household; through health and hygiene practices both within the family and within the community; and through support to the mother, both by the family and by the community, so that she has sufficient time to care for the child.

Armed conflict seriously constrain the care system in the household and the community. Families seek the best way to cope and often tend to emphasize protection of livelihoods. This may have negative implications for child care and welfare. With income diversification and longer searches for water, food, and work, the amount of time devoted to children will decrease. Distress and destitution activities may include migration by entire family units, members of families, prostitution by both women and the female children and, in extreme cases, selling off and abandonment of children (Longhurst & Tomkins, 1995 and Human Rights Watch/Africa, 1995). Care interventions are not only a family matter, actions taken by governments and other bodies at international, national and regional levels can affect care in the household and the nutritional status of family members including children.

Care of infants and children under five years of age:

Care is vital for the nutritional well-being of the young child. Care-giving behaviours include breast-feeding, diagnosing illnesses, determining when a child is ready for complementary feeding (weaning), stimulating language and other cognitive capacities, and providing emotional support (Longhurst & Tomkins, 1995). Armed conflicts interfere with all of these aspects of care.

Breast- and infant feeding during conflicts and emergencies:

A consensus has been reached that under optimal conditions, breast-milk alone can provide all the nutritional requirements of the infant for the first four to six months of life. Thereafter, complementary feeding is required in order to meet the infant's increasing energy and nutrient needs. However, in emergency situations such as conflict there is some confusion over the "management" of breast-feeding and the conditions causing mothers either to maintain or to stop breast-feeding (Kelly, 1993 and Almedom, 1994)

During conflicts, a series of constraints to breast- and infant feeding can be mentioned that endanger the nutritional status of the child (Almedom, 1994). Displacement of the mother or the entire household might lead to both exhaustion and hunger in the mother, thus impairing breast-feeding. Violence and/or trauma suffered by both mothers and infants and the sociocultural response to them can cause impairment in breast-feeding, for example, in the case of rape. In many cultures, knowledge about breast-feeding is passed on from generation to generation through mothers and grandmothers, traditional birth attendants and mothers-in-law. This kind of knowledge transfer can be lost, especially when families are broken up or when people flee and become refugees or are displaced (Box 11).

A general lack of nutrition knowledge with regard to feeding of the young infant has been highlighted in Mozambique today. The Ministry of Health in Mozambique has observed a large gap between what they recommend through their Provincial Health Directorate and the practices which are observed. The ministry indicates that the lack of transfer of health and nutrition knowledge can be largely attributed to the war. Young couples returning to the country who grew up in refugee camps do not know how to prepare any foods other than those distributed in the general ration: maize, beans and oil. They are not familiar with traditional foods or feeding practices, for instance, foods used during weaning.

Village life is still completely disrupted in many areas. The generation-to-generation transfer of knowledge within communities and families is often disrupted, as many families have lost one or two generations of family members. The elderly, who often remained behind in their home areas when others fled, have lost their relatives and have no social ties with the returnees.
The problem is knowledge transfer: who will teach the young returnees how to cultivate and prepare food, and what are the traditional habits? One solution that has been proposed is to encourage the elderly to teach the young, but it has yet to be clarified whether this will be acceptable to either group (De Winter, personal communication 1995).

As a result of conflict conditions, mothers may have to take up completely different roles in the household with a different daily routine. This may interfere with breast-feeding, for example, when the family splits up, or the mother is forced to spend long hours to get food, water and fuel. Lack of nutritional and other support for suckling which stimulates the affectionate relationship between mother and child can interfere with breast-feeding. Disorganized or inappropriate interventions, as can occur with milk distribution (infant formula or dried skimmed milk), may detract further from successful breast-feeding.

Response of relief agencies:

Although the feeding of babies and children is a very important issue in relief work, many agencies are ill-equipped to deal with this matter. Examining different situations, it was found that systematic studies on infant feeding practices in emergency as well as non-emergency situations are scanty. However, breast-feeding is an activity that should be protected, promoted and supported. Recent research findings show that it is even more important to focus on the process of weaning, because it is during the weaning period that infant mortality peaks (Almedom, 1994).

In general, agencies with responsibility for child health need to understand the underlying issues in infant feeding, in order to avoid the very real dangers associated with indiscriminate use of breast-milk substitutes and other unhelpful practices during disasters. Practical guidelines need to be developed and put into practice, focusing on how to protect and support breast-feeding during emergencies in communities. This is especially true in situations where it is no longer the norm to breast-feed. Guidelines are needed on ways to assist artificially fed infants without exposing them to the dramatically increased risks associated with artificial feeding under disaster conditions (Annex 5) (Kelly, 1993).

Care for the school-age child and the minor:

The conventional definition of children is rarely considered sufficient in armed conflict either by the international community or by the parties to the conflict (some of whom are signatories to the Geneva Convention on the Rights of the Child). In practice, definitions of children within conflict frequently appear to revolve around the physiological vulnerability of children under five years of age and to ignore older children, particularly those between the ages of ten to eighteen years.

Very little work has been done on the role of the child within different communities and how this changes with age. The role of the child in a community influences both the status of the child and the child's potential physiological, social, economic and political vulnerability, all of which may negatively affect their nutritional status at any age. The impact of malnutrition on both the physical and mental development of children of all ages not only affects the individual child but can have serious implications for the future development of a country.

The school-age child in conflict situations is likely to be less vulnerable to malnutrition in physiological terms than young children. However, in terms of inadequate care and psychosocial trauma, school age children might run greater risks than younger children. Due to the constraints a household may face, time allocated to care for the school age child can diminish greatly, especially in comparison with younger children. School age children might have to contribute to household survival, looking for food and employment. Often school age children have to abandon school and friends when the family decides to flee from the war zone. These children will be vulnerable to shocks from lack of supervision, discipline and nurturing, and they are prone to undertake actions such as prostitution, theft and robbery (Longhurst & Tomkins, 1995). Boys risk being recruited into the military, whilst girls may face gender related violence such as rape. School age children, being more mobile and susceptible than the younger ones, run more risk of witnessing or being exposed to violence, they may be harmed or disabled. Children from the age of six upwards are more likely to be separated from the family, especially when fleeing from active warfare. Disabled children, in conflict situations, are especially at risk of becoming malnourished because of a combination of poverty, ignorance and lack of appropriate care capacities, and the fact that disabled children require more care than healthy children (Miles & Medi, 1994). In addition, many children may be orphaned, or deliberately abandoned and placed in orphanages by their parents who can no longer take care of them, in order to increase their access to food.

Care and nutritional status of adults:

The presence of adults is essential if sufficient care is to be provided to children. Adults not only provide care but help children to place themselves within the culture of the society. Care of or assistance to other family members, who are essential for the well-being of children, is frequently neglected in the earlier stages of relief interventions. For example, in 1992 by the time relief reached Baidoa, Somalia, a large proportion of the young Somali children had already died and mortality rates were reported to be higher among adults than among children (Collins, 1993). An adult therapeutic feeding programme was established in October 1992, when more than 70 percent of reported deaths were adults. The first 650 adults admitted had an average Body Mass Index (BMI) of 13 and some had BMIs of 10 upon admission (Annex 2).
Mortality in adults has serious repercussions for children. They are left orphaned and without the family support and environment essential for their care. Parents are the economic and social resource of children. Lack of support to families - and an overemphasis on the child alone - has meant that all too often children have been sent to local orphanages in order to be ensured of food and care, as well as to increase the resources remaining for the rest of the family members. Whilst orphanages may have adequate access to food, the care provided in orphanages for children cannot be compared to the care that a child receives within the family.

Women:

Protecting the nutritional status of females is important for women as individuals and as mothers. The nutritional status of women before and during pregnancy, and during lactation is important. Better nourished mothers give birth to infants with higher birth weights and they have better nourished children. In conflict situations, ensuring adequate maternal nutrition may be difficult to accomplish due to the economic and social constraints on the household. Mothers are often the first to reduce their food intake in order to increase the amount of food for other family members, especially children. Thus, mothers jeopardize their own nutritional status to cope with the shortages (IFPRI, 1995).

In conflict situations, the number of female headed households often increases as men leave home and become involved in the warfare, or are injured, disabled or killed. As the head of the household, the woman then has the multiple task of providing all the care, searching for food and generating income, which seriously impairs her ability to care for her children. She is likely to take up a different role in the household, resulting in a change in time allocation to household tasks and care practices. Often women have reduced access to employment and income, either because of lack of training or because of their socio-cultural status. This may lead to reduced access to food. In addition, women might have less access to shelter.

Women run the risk of increased exposure to gender-specific war crimes, such as rape and sexual abuse, which often have long-term traumatic consequences. This also reduces their caring capacity. The emotional impact of the loss of fathers and husbands results in lasting pain in both children and women.

Elderly:

The nutritional and social vulnerability of the elderly has received little attention in relief assistance, especially in African emergency and conflict situations. Life expectancy is still low in many African countries, for example, it is 47 years in Somalia compared to 72 years in Yugoslavia (UNICEF, 1996). In eastern Europe, the proportion of elderly people in the population is considerably higher than in Africa. Nutrition surveillance data from eastern Europe (former Yugoslavia, Russia, Armenia) show that the elderly are often at a greater risk of becoming malnourished than other population groups (Vespa & Watson, 1995). Undernutrition in the elderly, in particular those over the age of 60 years, is more often a result of the combination of sickness, cold and stress, and the inability to prepare food than an absolute lack of food.

There are physiological and psychological reasons for the increased vulnerability to malnutrition among the elderly. Dietary energy requirements may be increased by the cold temperatures during the winter due to lack of heating, or the increased physical exertion required for collecting fuel, water, and food rations. Elderly people may have an impaired ability to prepare meals especially in difficult circumstances due to age-related disabilities, such as problems with vision and manual dexterity. They may suffer from chronic diseases which are aggravated by the conflict. Also, violence, separation from families, and the breakdown of formal and informal support systems causes a lack of physical care and support. Depressive illnesses are leading to an increased vulnerability among the elderly as well (Ibid).

Usually resources are limited and relief assistance is targeted to young children, pregnant and lactating women who are regarded as the most vulnerable members of the society. However, recent findings suggest that this focus may be too limited and does not always lead to the most appropriate relief response (e.g. Bosnia). This has relevance to children as the elderly are important family members. They often provide additional care for children as well as support and knowledge to the mother. The loss of the elderly people has a significant impact on community knowledge both during and after conflict.