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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Hunger, Health, and Compassion

The juxtaposition of headlines must have sent shivers down the spines 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 unprecedented cuts in foreign assistance.

Lawrence Gostin, JD

(Image: Georgetown University Law Center)

While the drastic cuts may not come to pass, US values of compassion are being eroded. Secretary of State Rex Tillerson warned other countries to provide a larger share of assistance. Perhaps signaling what is to come, in the first quarter of 2017, US contributions to humanitarian appeals decreased by nearly one-half from the level for 2016. And even small cuts to humanitarian assistance are more than the world’s most desperate people can afford, with United Nations humanitarian appeals already routinely underfunded.

The consequences of less funding would likely be measured in 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 weaken the United Nations, its capacities should be enhanced with 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.

Historic Hunger Crisis

The current hunger crisis, the largest humanitarian crisis in UN history, encompasses South Sudan, Yemen, Somalia, and northeastern Nigeria. All are experiencing severe droughts, yet the disaster’s primary drivers are armed conflicts and outright war. Health risks extend beyond starvation, including waterborne illness such as cholera. The famine’s origins and obstacles to addressing it vary in each country, though the basic storyline is shared: ineffective, unaccountable, or malevolent political leadership; violence and conflict; and a dearth of humanitarian funding.

The United Nations has officially declared a famine only for South Sudan, with 100 000 people experiencing famine and 5.5 million people expected to urgently need food aid by the summer. 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. At least 79 aid workers have been killed since fighting began in December 2013.

Yemen has the most people at risk—17 million, including 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 trucks and other civilian infrastructure. A 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, as 3 million people face starvation. The militant Islamic insurgency still holds sway in the countryside and bans Western aid agencies. Cholera has taken hold in displaced persons camps and beyond; a vaccination campaign is now under way.

Hunger in northeast Nigeria is wrapped up with the Boko Haram insurgency. An estimated 5 million Nigerians are at risk of famine. Farmers have been forced to abandon their farms, and the disruption of food production and markets is putting food beyond people’s economic reach.

At least 20 million people face hunger and the risk of starvation. Heightened susceptibility to illness and long-term health and development consequences of malnutrition are also at issue. Children with severe acute malnutrition, for example, are likely to experience developmental disabilities. The lack of clean water, and resulting diseases, such as cholera, may be the biggest killer. The health effects may extend years beyond the immediate crisis, as people sell off their assets to buy food and then persist in a state of food insecurity.

The United Nations required $4.4 billion by the end of March for these 4 crises, but had received only about one-tenth that level.

Realities of US Assistance

Tillerson’s claim that the United States provides a major share of disaster assistance is true, but disingenuous. In 2016, the World Food Program fell more than $2 billion short of the $8.6 billion it required. Other countries need to step up, but so does the United States.

US disaster assistance, which should also be seen in the context of overall development assistance, falls far short of most wealthy countries. The major donor nations contributed an average of 0.30% of their gross national income (GNI) to official development assistance in 2015. Nineteen countries provided more than the 0.17% of GNI that the United States contributed—a level less than one-fourth the long-standing 0.7% UN target.

Tillerson’s assertion also exacerbates the public’s perception that US foreign assistance is far more generous than it is. The public believes about one-quarter of the budget goes to foreign assistance; in reality, less than 1% does.

New Strategies for Humanitarian Financing

How can the international community avoid this perniciously predictable story of vastly underfunded humanitarian emergencies? The United Nations took a significant step in 2005, establishing the Central Emergency Response Fund (CERF) for UN agencies to “jump-start activities in sudden-onset emergencies,” and to deliver aid when “the situation suddenly deteriorates.” The UN General Assembly set a goal of $450 million annually, which has been largely achieved.

However, this was never going to be enough. Oxfam was calling for a billion dollar fund when the CERF was established. Since 2005, the total annual UN humanitarian appeal has soared from about $6 billion to $21 billion in 2017. The 2005 appeal fell nearly $2 billion short. The shortfall for last year’s appeal neared $8 billion.

The UN General Assembly already sets assessments for UN members for peacekeeping. This model should be replicated for stemming humanitarian emergencies.

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

For now, though, the international community must use standard practices to meet funding needs to address the hunger crisis. The UN Secretary-General should urgently convene a donor conference, or a member state could take the lead, as the Netherlands did in response to the Trump administration’s resurrection and expansion of the “global gag rule,” a policy prohibiting US health assistance to organizations that provide abortion services or counseling.

Leadership From Below

Even as more engaged leadership is needed, the United States is pulling back. Some of the world’s most desperate people will continue to suffer unthinkable trauma. Many 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 acknowledge the atrocities and human cost of what is occurring, and contribute to humanitarian organizations. Civil society cannot compensate for missing billions, but it can raise it is voice on behalf of millions of people who are now mostly alone, helping some to survive.

About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).
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