Part 1:

Guidelines for ICRC activities on behalf of persons

deprived of their freedom in the event of nutrition
problems

A. Mourey/ N.Roggo Septembre 2010

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1. Introduction ....................................................................................................................................... 4
2. Definitions .......................................................................................................................................... 5
3. The bases and general objectives of ICRC action on behalf of persons deprived of their
freedom ..................................................................................................................................................... 5
4. The ICRC’s guiding principles, criteria for intervention and modes of action ...................... 6
5. Operational directives ...................................................................................................................... 8
5.1 Full, professional evaluation of the situation ....................................................................................... 8
5.2 Intervention strategy ............................................................................................................................. 9
5.3 Planning .............................................................................................................................................. 10
5.4 Implementation................................................................................................................................... 10
5.5 Monitoring .......................................................................................................................................... 10
5.6 Review and evaluation ....................................................................................................................... 10
6. Intervention strategy in nutrition ............................................................................................... 10
7. Substitution-type interventions in nutrition ............................................................................. 12
7.1 Factors to take into consideration....................................................................................................... 12
7.1.1 The urgency of the situation .............................................................................................. 12
Health risks: ............................................................................................................ 13
Rate of deterioration .............................................................................................. 13
Expected duration of causes .................................................................................. 14
Origin of the problem’s causes .............................................................................. 14
The degree of suffering being endured ................................................................. 14
7.1.2 Scope of needs ........................................................................................................... 14
7.1.3 The causes ................................................................................................................. 15
7.2 Timing of the intervention.................................................................................................................. 15
7.2.1 Expected emergencies .............................................................................................. 15
7.2.2 Existing emergencies ................................................................................................ 16
A. Uniform situations (general malnutrition throughout the place of
detention) ................................................................................................................ 16
In this situation the problem concerns all detainees. .......................................... 16
B. Heterogeneous situations (malnutrition affects particular parts of the
prison or certain detainees) .................................................................................. 16
In this case the problem especially affects detainees who are victims of
discrimination or who are very vulnerable. ......................................................... 16
7.3 Types of activities .............................................................................................................................. 17
7.4 Disengagement criteria and follow-up ............................................................................................... 17
8. Conclusions ....................................................................................................................................... 18
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SUMMARY
GUIDE TO NUTRITION IN PLACES OF DETENTION

Introduction
In the course of their visits to persons deprived of their freedom ICRC delegates often notice nutrition problems.
To date these have been met in a wide range of ways, depending on the context, since the ICRC had not issued
any recommendations in this respect.

The objective of the present document is to fill this gap by defining decision-making guidelines which in
particular cover instances when the ICRC acts in place of the authorities (substitution). The present Guidelines
are intended for all staff and management of the ICRC involved in activities of this nature, both in the field and at
headquarters, and aims to make it easier to initiate nutrition programmes in places of detention.

The ICRC’s approach

When the material conditions of detention are such that the life or health of detainees is at risk, the ICRC should
not merely substitute itself for the authorities and carry out their responsibilities but also be guided by the
principle of humanity. That means accepting that in emergency situations, and faced with existing or expected
serious health problems, the ICRC on its own can provide assistance to detainees. The defining criteria are the
actual needs and that the ICRC should be able to prevent and alleviate suffering, its action not being subordinate
to “political” considerations.

Interventions to address nutrition problems in a place of detention pursue two objectives:

- to preserve the life and health of detainees;

- to ensure that the authorities meet their obligations in the long term.
To meet these objectives the ICRC makes use of a combination of five different modes of action, which fall into
two different categories: dialogue, with a view to persuading, mobilizing or denouncing, and the provision of
services, by which vital services are provided directly by the ICRC instead of the authorities (substitution),
and/or appropriate support is given that will enable the authorities to meet their obligations in the long term.

In combining these approaches a balance has to be struck between, on the one hand, saving the lives and
preserving the health and dignity of the detainees and, on the other hand, ensuring that the authorities meet
their obligations. This being said, dialogue should always precede, or at least take place in parallel with, the
provision of services. In the event of an existing or expected emergency, and if dialogue is not sufficiently
effective, it becomes necessary to take action in the place of the authorities. The more urgent the situation, the
less time can be spent on discussions with the authorities.

Entering and exiting “substitution mode”

When it acts in place of the authorities the ICRC seeks as much to prevent emergency situations as to put an end
to them. The goal of ICRC activities is always to enable the authorities themselves to meet their obligations as
soon as possible.
The decision to substitute for the authorities must be based on specific, measurable and verifiable elements
defining the emergency (risk to health, rate of deterioration, anticipated duration of causes), the scale of the
needs and the causes of the problem. Substitution activities vary widely and, depending on the situation, may
range from the distribution of meals to human resource capacity building.
Once substitution has reached its objectives the ICRC defines its follow-up in accordance with the risk of
deterioration: as a rule, it will disengage and hand over the responsibility for the relevant activities to the
authorities, yet remain ready to return to action if dialogue with the authorities do not have the desired effect,
and without waiting for the lives and health of detainees to again be at risk.
The discontinuation of substitution activities is likewise based on concrete, measurable and verifiable elements,
such as acceptable levels of malnutrition or mortality.
The importance of a rigorous approach and of regular follow-up on the basis of defined parameters
As with any project, the quality and success of the action depend on a full, professional assessment of the
situation, definition of an intervention strategy, and planning, implementation and rigorous follow-up of the
parameters defined, coupled with regular evaluation and reviews.
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1. Introduction
When the ICRC visits persons deprived of their freedom it has to meet an ever wider spectrum of
needs. For instance, delegates are frequently faced with problems related to nutrition. So far, the
ways in which the organization responded to such situations varied widely and were sometimes
frankly contradictory, for the following reasons:
▪ No practical recommendations on nutrition have been issued to help those in charge of the
delegation to take decisions in this respect;
▪ Each context tends to be very different from the next;
▪ Creating and transmitting an “institutional memory” is difficult;
▪ The ICRC tends to hesitate to initiate nutrition assistance programmes in places of detention,
for the following reasons:
o Embarking on programmes of this kind is considered counterproductive to
representations made to encourage the authorities to meet their obligations;
o Where the ICRC is familiar with the context and can expect persuasion and delivery of
services to be of limited effectiveness and unlikely to last in the longer term, it knows
that it will also be difficult to disengage;
o Negotiating the dilemma between dialogue and direct action requires striking a
balance between, on the one hand, saving lives to respect the principle of humanity
and, on the other hand, encouraging the authorities to meet their obligations and
persuading them to ensure that, in the long term, all detainees enjoy minimum living
conditions.
o Depending on the number of places of detention and detainees to be assisted, the
ICRC’s commitment may have to be substantial if the action is to be effective.

As a result, the ICRC has in the past adopted many different approaches, depending on the
interpretation given by the delegation to the ICRC’s role, and the modes of action used.
Example 1.
Faced with an increased mortality risk due to a beriberi epidemic, the delegates in the field decided to
intervene immediately, arguing that when the ICRC was in a position to stop the detainees it visits
from dying, there was no reason not to do so unless it decided not to visit them at all. This action was
criticized by some members of the organization’s management, who considered it hasty and to cast
doubt on the delegation’s strategy on assistance to detainees and places of detention. It should be
noted that without the assistance, many detainees would have died.

Objective of the document:

The objective of this document is to define a set of guidelines applicable irrespective of
circumstances, in cases of severe existing or expected nutritional problems. It is intended for all
ICRC management and staff involved in carrying out an action, both at headquarters and in the field,
to help them decide whether a nutrition programme should be implemented in places of detention
visited by the ICRC. It therefore concerns primarily the decision whether or not the ICRC should
take the place of the authorities1, - a question that is particularly difficult to resolve in contexts of
this kind. The objective of this document is not to make the organization’s actions subject to rigid
procedures but to guide its activities using an analytical process that is designed to arrive at the best
solution for the victims. The present document thus begins by presenting a contingency concept
addressing the most delicate and difficult aspects of decision-taking, and then moves on to suggested
practical solutions.

1
These can be either government or de facto authorities.
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2. Definitions
Nutrition problem:
This refers to any problem that is primarily or partly related to nutrition and which endanger, or may
endanger, the life and health of individuals or groups of detainees. The problem may either be an
existing one or be expected to occur, that is to say, the indicators at the ICRC’s disposal suggest that
the situation is highly likely to deteriorate to the point of endangering the life and health of detainees
in the short term, thus making it an emergency situation as defined in item 7.1.1 below.
ICRC nutritional intervention:
Any measure taken by the ICRC to address a nutrition problem affecting all or part of a prison
population, using the options made available by the different modes of action.
Relief activity:
Any activity by which the ICRC partly or entirely takes the place of the authorities (substitution) and
delivers direct aid (examples include therapeutic feeding programmes, or supplies of food and the
materials needed to store, prepare and distribute it).

3. The bases and general objectives of ICRC action on behalf of persons

deprived of their freedom
The bases for intervention are determined by the contexts in which the ICRC carries out, or wishes to
carry out, its protection activities. Depending on the nature of the context, the ICRC intervenes on
behalf of the victims of armed conflict and other situations of internal violence on the basis of
applicable law and the mandate conferred upon it by the international community, in particular
through the Statutes of the Movement.
The objective of ICRC activities in places of detention is that of preventing and/or stopping
disappearances, torture and mistreatment, ensuring respect for judicial guarantees and conditions of
detention which comply with international standards, and to allowing family links to be restored2.
It is important to reiterate that the ICRC’s main objective when granted access to places of detention
is to ensure that the integrity and dignity of detainees are respected. It is concerned with the
conditions and well-being of detainees and with the way places of detention are run (prison
management), to the extent that this will improve the situation of persons held there. It should also
be recalled that improving the conditions of detention consists not only of getting individuals out of
emergency situations or preventing them from ending up in one, but also of making sure that they are
correctly taken care of by the authorities for the full duration of their detention. This has important
consequences for the ICRC’s intervention strategy.3
Interventions for nutrition problems thus have two objectives:
- preserving the life and health of detainees
- encouraging the authorities to assume their responsibilities in the long term.
To reach this objective the ICRC uses a combination of five different modes of action, which fall into
two different categories: dialogue to raise awareness of responsibilities through persuasion,
mobilization or denunciation, and delivery of services, by which vital services are provided directly
by the ICRC instead of the authorities (substitution), and/or appropriate support to build the
authorities’ capacity to meet their obligations in the long term.

2
See AESCHLIMANN, Alain, "Protection of detainees: ICRC action behind bars", in International Review of the
Red Cross, Vol. 87, No. 857, March 2005.
3
See the ICRC’s Protection Policy.
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4. The ICRC’s guiding principles, criteria for intervention and modes of

action
Under international law all States have an obligation to ensure the health and general well-being of
persons deprived of their freedom. In situations of armed conflict, all the parties to the hostilities are
bound by this obligation. When faced with material conditions of detention which threaten the health
or lives of detainees, the ICRC must not simply substitute itself for the authorities by assuming their
responsibilities to detainees. It may carry out relief activities only in an emergency (existing or
expected) and if the authorities are unable to meet their responsibilities in the short term. Raising the
authorities’ awareness of their responsibilities is the key to prevention.
A further guiding principle is the principle of humanity, which is considered «… the soul and spirit
of the Red Cross and Red Crescent” 4. According to this principle, every effort should be made to
prevent and alleviate human suffering in all circumstances, and to strive to defend human life, health
and dignity. Giving effect to this principle lies at the very heart of protection in the widest sense.
Applying this principle means accepting that, in the event of an existing or expected emergency
situation in which lives are at risk, the ICRC by itself can assist detainees.

Example 2
In 1994, having realized that it was ethically unacceptable for the ICRC to visit political detainees in
good health while disregarding ordinary detainees starving to death in the very same prison, and
subsequent to the adoption of policy document 4, the ICRC, on the basis of the principle of humanity,
took direct action in Zairian prisons by distributing meals to the most severely malnourished
detainees. However, from the outset it looked for solutions by which the authorities would be
encouraged to meet their obligations and reliable partners could be found to help them meet the
overwhelming material needs. Regarding actual food assistance, this entailed strengthening the role
and resources of the churches which had a long history of being present in prisons, and discussing
budget problems with donors and embassies with a view to finding a long-term solution.

When the ICRC decides to visit places of detention in a given context, either by virtue of its
mandate (international conflict) or by making use of its right of initiative, the defining criteria for
assistance actions are objectively determinable, existing or expected needs5 and the ICRC’s ability
to alleviate suffering owing to its special position based on the principles of humanity, impartiality,
independence and neutrality.
This means that, outside of any operational constraints that may objectively limit its scope for action
(lack of financial and/or human resources, insecurity, problems with perception, …), the ICRC’s
response cannot not be conditional upon “political” considerations which, in two situations of
identical needs, would lead it to do more in one context than in another.

4
HAUG, Hans, Humanity for All – the International Red Cross and Red Crescent Movement,
Berne/Stuttgart/Vienne, Institut Henry Dunant/Éditions Paul Haupt, 1993, pp. 448-454.
5
Guidelines on expected needs are discussed in more detail under item 7.2.1. below.
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Therefore, in the light of policy document 46 and bearing in mind that the ICRC is guided by reasoned
compassion with the situation of the victims, the decision to provide assistance in an emergency
situation in principle should never be governed by criteria such as:
- Progress in negotiations pertaining to other areas of the ICRC’s work: the organization must
never “benefit” from an emergency situation by making an action subject to conditions such as,
for example, obtaining satisfaction in any other matters it might be negotiating with the
authorities: examples include visits to categories of detainees to which the ICRC has not been
granted access, access to closed regions, or measures taken to address other forms of abuse.

- The authorities’ failure to respond to ICRC representations: any results obtained or expected to
be obtained in the short or medium term in respect of activities carried out using other modes
of action (most commonly persuasion and/or mobilization) may not enter into the decision as
to whether assistance should be provided. The victims may not be taken hostage by an attempt
to try and incite the authorities to respond to bilateral approaches and/or representations
made by the ICRC to third parties. However, this last aspect can in some instances be taken into
consideration when deciding on the timing or duration of an intervention;

- The ICRC’s level of commitment in other areas of activity, such as assistance to displaced
people, should not prevent it from intervening on behalf of persons deprived of their freedom;

- The type and legal qualification of the situation: since this aspect will normally already have
been taken into consideration when the initial decision to intervene in a given context was
made, there is no reason to re-examine it if visits to places of detention have revealed urgent
needs;

- The prospects for disengagement: the fact that at the moment when assistance is needed it is
not clear when exactly the ICRC will be able to end its action, and that there should be no
timetable for disengagement, may not prevent the organization from taking action.
If needs are urgent in a given context the delegation concerned must rigorously analyse its
decision to intervene and its chosen operating mode and present a precise, written argument
in support of its decision. The selected approach must be coherent7 at the level of both the
organization and the geographical region, and be approved by the Department of Operations.
Whether it is judged appropriate to provide assistance will depend on this analysis and a number of
context-related elements:
- The quality of the dialogue with the authorities and their willingness to meet their obligations
towards persons deprived of their freedom: even in the presence of urgent needs the ICRC
may decide not to intervene if assistance would not result in effective improvements in the
conditions of detention, be counterproductive, for example by endangering the lives of some
categories of detainees, bringing about more violations and abuse (disappearances, torture,
corruption) and increasing repression, or if the assistance might be used to coercive ends.

- The scope of the needs, the geographical area concerned, and logistical constraints: the ICRC’s
operational capacities are finite and sometimes choices have to be made between several
priorities, depending on the resources available; however, the ICRC has a duty to strive to
obtain the resources it requires in order to meet all needs;

- Instability: the ICRC may decide not to intervene if an assistance programme would be
disrupted by an environment in constant flux.

6
“Internal violence: Action taken by the ICRC in response to humanitarian problems in non-international armed
conflicts or situations of internal violence, or which occur in other situations and require its intervention”,
DOCT/4 – 1992/1.
7
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5. Operational directives
The quality and success of the ICRC’s response to problems related to conditions of detention are
determined by compliance with the following steps: evaluation / definition of a strategy / planning /
implementation / follow-up / review. For every operation, each point has to be the object of
consultation between senior management and representatives of Protection and Assistance and
decisions must be supported by all of the staff members involved. Management is responsible for
taking the decision and seeing the programme through to completion. Protection is in charge of
ensuring that the action is appropriate to places of detention, of combining the modes of action and of
the overall follow-up of the intervention. Assistance is responsible for implementing activities to
improve the nutritional status of the detainees.

5.1 Full, professional evaluation of the situation

An intervention can be carried out correctly only if it is based on the most comprehensive possible
analysis and understanding of the problems, their causes and their context. How the ICRC responds to
a situation of general malnutrition will depend on whether it is due to a lack of interest on the part of
the authorities, a shortage of means, the recent influx of large numbers of detainees, or a tuberculosis
epidemic. The response to a set of symptoms will depend at least as much on the causes as on the
severity of the problems and their likely development. Therefore, neither the intervention strategy
nor the intervention itself can be decided upon without in-depth knowledge of the problems and
their causes. It is thus crucial that the situation be evaluated by a multidisciplinary interactive team.
Problems related to conditions of detention are generally the result of structural shortcomings in the
judicial system. They may originate at any one of three levels, and failings at any one of these levels
have an impact on the next one:
a) Government/de facto authorities:
▪ the government does not allocate, or does not have at its disposal, the resources needed
for the humane, efficient management of detention and imprisonment;
▪ resource mobilization is insufficient;
▪ the administration of justice system itself is insufficient, which causes or aggravates
problems in places of detention;
▪ …
b) Prison administration:
▪ the available resources are poorly managed;
▪ …
c) Place of detention:
▪ the materials and infrastructure are inadequate;
▪ services are insufficient or inappropriate;
▪ the available resources are poorly managed ;
▪ the social climate encourages discrimination;
▪ detainees are mistreated;
▪ survival mechanisms are inexistent or insufficient8;
▪ …

The above shortcomings may be the result of a variety of factors:

➢ a lack of political will (either desire to do harm or negligence)
➢ a lack of resources
➢ incompetence / ignorance
➢ corruption
➢ inappropriate or inadequate management mechanisms
➢ lack of cohesion within the system
➢ etc. …

8
However, it is important to bear in mind that the existence of survival mechanisms does not release the
authorities from their obligations, and that the very presence of such mechanism is evidence of the authorities’
failure to assume their responsibilities.
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The objective of the evaluation is to establish which failures are at the origin of the nutrition problem
or might be able to cause one, and at what level they are occurring. Next, the measures that might be
taken to address each one of the identified failures must be defined, the causes of the failures being
an essential factor influencing the choice of mode of action.

5.2 Intervention strategy

Experience has shown that usually nutrition problems are a consequence of failures in more than one
area and that these failures often have more than one cause. Therefore, a combination of modes of
action – persuasion, mobilization, denunciation, substitution, support – is absolutely essential
to tackle the causes of the problems and to achieve the objectives of the intervention (see
above).
Example 3
In 2004, the ICRC mission in Madagascar proposed a plan of action covering places of detention for a
period of three years (2005-2007) and combining the modes of action persuasion, substitution and
support, especially with regard to food supplies. The proposals centered on an evaluation of
detainees’ nutritional status and presentation of a corresponding report to the authorities, ad hoc
material assistance and the rehabilitation of prison camps (fields).
Strategies tend to change as interventions proceed and comprise three different phases: entry,
consolidation, and exit. Entry and disengagement strategies are contained in the initial plans and are
drawn up with the participation of all parties concerned. Entry and disengagement strategies are
both based on a combination of modes of action, the move towards disengagement being dictated by
the relative effects they are having. The impact of persuasion, mobilization and support must be as
effective as possible to permit a phasing out of first substitution and then support.
The objective of the entry strategy is to improve conditions of detention as quickly as possible, mainly
using substitution, while continuing with persuasion and evaluating the options presented by support
and, if necessary, denunciation. The aim of the exit strategy is to raise the authorities’ awareness of
their responsibilities and to give them the means they need to meet their obligations. This means that
at a certain point substitution is ended and the emphasis shifted to other modes of action, depending
on the cause of the nutrition problem and the possibilities of finding a structural solution to them, so
as eventually also to be able to end support.
Exit strategies should be transparent and adjustable as necessary. The fact that there is no concrete
time frame for disengagement from an intervention should not automatically call into question
whether it should be started at all9. However, it is important at all time to investigate possibilities for
disengagement which harm neither the detainees nor efforts made to raise the authorities’ awareness
of their responsibilities and help them carry out their duties.

Example 4

In 1994, the vast number of arrests and deplorable conditions of detention in Rwanda prompted the
ICRC to intervene on a massive scale in substitution mode, while seeking to persuade the authorities
to meet their obligations. As time went by the relationship between the ICRC and the authorities
became more structured and, even as the major assistance programme was continued, efforts also
shifted to mobilization and support. As a result, after 12 years of action the ICRC was finally able to
end its food assistance.

9
However, this factor may be taken into consideration when deciding on the size of the intervention.
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5.3 Planning
An action plan should be drawn up which should be as detailed as possible and include all the actions
envisaged by the ICRC to address the problems it has identified. This is best achieved by blending the
different available modes of action and making sure the necessary human resources are available
both at headquarters and in the field.
Planning must comply with the methodology defined during the ICRC planning process (planning for
results). Planning should not be carried out once year but be subject to review every time there is a
change in the defining parameters. As far as possible, needs should be evaluated beforehand, bearing
in mind how the situation is likely to develop, general and specific objectives should be defined, and
an emergency intervention plan should be put into place. However, adhering to plans does not mean
refraining from carrying out emergency actions if needs arise unexpectedly.
To reach the objective defined above it is likely that an intervention will last longer than a year.
Therefore, the resources required for the full duration of the proposed intervention must be planned
for and explicitly defined, even if the intervention continues for several budget periods. In addition,
interventions should be based on the project cycle model and their structure should follow a logical
framework10.

5.4 Implementation
The ICRC must have at its disposal the skills and means needed for the rapid and efficient
implementation of the main activities of the intervention.
It is important to involve the relevant authorities as much as possible, by jointly deciding who carries
out which tasks and by formally defining mutual commitments.
When the activities are carried out in partnership with other actors (public or private sector) or with
components of the Movement, these arrangements should be the subject of an agreement.

5.5 Monitoring
A system for monitoring the situation and the results of the programme is set up from the start of the
intervention to ensure that progress made is systematically and continuously monitored on the basis
of selected indicators (specified in the logical framework). This follow-up system allows for timely,
appropriate decision-taking.

5.6 Review and evaluation

Monitoring is completed by reviews and evaluation with the aim of learning lessons that will help
with the writing of policies and their practical implementation.

6. Intervention strategy in nutrition

The analysis described in item 5.1 above enables the ICRC to define and adapt its intervention
strategy, which essentially consists of a combination of the different modes of action at its
disposal and the way they are implemented. It is important to point out that no one mode of action
ranks higher than another, and that they are not mutually exclusive. On the contrary, even though the
revised policy document 1511 recalls that persuasion remains the ICRC’s preferred modus operandi,
the strategy’s effectiveness lies in the combined, simultaneous use of several, or all, modes of action
12.

10
The relevant tools are described in the database: “Ecosec reference manual”; see GVALNBD1.
11
“Action by the ICRC in the Event of Violations of International Humanitarian Law or other Fundamental
Rules protecting Persons in Situations of Violence”, DOCT/15 – 2005/10
12
See OP/PROT, “Les modes d’action ou l’adaptation des réponses aux besoins” in La protection des personnes
privées de liberté dans les situations de violence interne: cadre de reference et construction d’une stratégie
d’action, chapter 5, July 1999.(ok to leave the french version)
 11
Faced with an existing or expected nutrition problem, the choice of modes of action will depend on
the following parameters:
▪ urgency, which itself is essentially determined by the risk to health, the speed at which
detainees’ health is deteriorating, the expected duration of the causes, the origin of the causes
(before or during detention), and the suffering endured;
▪ the scope of the problem (number of detainees affected by it, number of places of detention
concerned, etc.);
▪ the willingness and capacity of the authorities to address the problem;
▪ the means at the authorities’ disposal to address the problem;
▪ the effective involvement of other actors and/or the possibility of mobilizing third parties to
solve or help solve the problem.

These parameters will be defined as part of the initial appraisal.

Depending on the urgency of the situation, the attitude of the authorities, the means at their disposal
and the possibility of mobilizing third parties a balance has to be found between the two objectives of
the intervention: a) saving lives and preserving the health and dignity of the detainees (this objective
fits with the principle of humanity), and b) persuading the authorities to meet their obligations(that
is to say, to respect international humanitarian law and human rights and ensure satisfactory
conditions of detention in the long term). Therefore, it is necessary to weigh up the urgent need to
save the lives and protect the health and dignity of detainees, which often calls for direct, immediate
assistance, against the need to empower the authorities and to find long-term solutions, which
generally requires numerous representations and long-term support to the authorities.
Delivering aid on the one hand and making representations on the other may appear contradictory:
indeed, it is possible for direct aid to have the effect of discouraging the authorities from meeting
their obligations and to frustrate the ICRC’s efforts at persuasion if they lack political will. This
seeming contradiction can put the ICRC in a dilemma: should it immediately intervene with a relief
operation to reduce mortality and morbidity, or should it stand firm and push the authorities into a
situation where they have no choice but to acknowledge their responsibilities, by insisting on their
obligations before starting relief aid, at the risk of potentially dramatic consequences for the life and
health of some detainees? Practical experience has shown that there is no easy answer to this
question. The interests of the victims have priority and the sometimes very real risk of discouraging
the authorities from meeting their obligations must be counteracted with even more vigorous
representations.

The ICRC’s intervention strategy is based on the following elements:

▪ Dialogue (depending on the options, persuasion, mobilization and, if necessary denunciation)
must always precede, or at least take place in parallel with, the delivery of aid, irrespective of the
seriousness of the situation;
▪ The more serious the situation, the less time can be spent on dialogue to push the authorities or
other actors into action; however this does not mean stopping contacts altogether;
▪ In the presence of an existing or expected emergency situation (morbidity associated with a risk
of mortality), either representations show immediate results – in which case the intervention is
considered a success – or they do not have sufficient effect (owing to a lack of means, skills or
willingness on the part of the parties concerned), in which case substitution becomes necessary;
however, representations will continue and the possibility of changing to the ‘support’ mode of
action is evaluated;
▪ When a relief operation has been necessary and has reached its objective of, if possible in the
long-term, restoring the nutritional status of detainees to levels at which their life and health are
no longer at risk, the continuation of the ICRC’s presence depends on a variety of factors: the
success of confidential bilateral discussion and possibly the mobilization of third parties; the
 12
measures taken by the authorities to prevent emergency situations from recurring; and the risk of
future deteriorations in the nutritional status and health of the detainees;
▪ In principle, relief operations should be stopped as soon as they have reached their objective, it
being a priority to hand over responsibility to the authorities and prompting them to meet their
obligations while offering any support that is feasible and relevant. It may be necessary to resume
a relief operation if the representations made and support provided do not have the desired
results, without waiting for the situation again to deteriorate to a point where the lives and health
of the detainees are in danger.
▪ This having been said, the ICRC clearly cannot risk subjecting the health of detainees to a yo-yo
effect. Therefore, if the dialogue with, and support offered to, the authorities do not have the
hoped-for effect in the time available, direct aid programmes sometimes have to be continued for
several years. In that event, the situation should be re-examined regularly and analysed in terms
of changes in needs, results obtained through dialogue and, possibly, the structural support
provided, the attitude of the authorities and the objective constraints under which they are
operating, etc. …
▪ The ICRC may end up having to terminate a relief operation before having reached its nutritional
objectives. This decision will have to be motivated in writing by the delegation and if it does not
involve the suspension of all activities in the context, will have to followed by a redoubling of
representations (especially mobilization and, possibly, public denunciation).
This pragmatic approach, which has already been put into practice on several occasions (in Uganda,
Rwanda, Guinea, Madagascar, Haiti and Côte d’Ivoire), is probably the one that yields the best results.
Under this strategy the delivery of relief is triggered by an existing or expected health emergency,
using the ‘substitution’ and ‘support’ modes of action. Therefore, every time there is an emergency or
indicators point to a potential health problem, staff members trained in nutrition and structural
support for prison systems should take part in the definition of the strategy and intervention
programme, define the parameters for follow-up of the nutrition situation, and accompany the
implementation of the relevant activities.

7. Substitution-type interventions in nutrition

7.1 Factors to take into consideration

The decision to start or end a relief operation aimed at addressing a nutrition problem depends on
several factors, all of which must be examined if an informed decision is to be made.

7.1.1 The urgency of the situation

Emergencies are classified according to:

- the scope or severity of the humanitarian needs (famine, epidemics, etc.);
- the fact that the events having caused the humanitarian needs are recent;
- the level of response by the authorities and other parties with obligations, and the capacity of
institutions and regulatory mechanisms to meet essential needs.
In this regard, the question arises as to what exactly constitutes a nutritional emergency.13 In fact, this
term simply refers to a situation in which it is necessary to act fast to keep victims alive, alleviate
their suffering and prevent the late effects of dietary deficiencies from adversely affecting their
future:

13
See MOUREY, Alain, Nutrition manual for humanitarian action, Geneva, International Committee of the Red
Cross, 2004, pp. 336-339.
 13
▪ not having enough to eat leads to weight loss and possible specific deficiencies;
▪ weight loss and specific deficiencies cause functional problems in the body;
▪ functional impairments leave malnourished individuals physiologically and psychologically
vulnerable;
▪ being physiologically vulnerable predisposes to infectious disease and anorexia;
▪ infectious diseases and anorexia trigger a vicious circle in which malnutrition and infection
mutually reinforce each other;
▪ malnutrition and serious infections can lead to death.
The question thus arises when the ICRC should intervene by providing direct food assistance, and to
whom, knowing that persons in good condition today may fall ill the next day. The answer depends
on a number of factors: the actual risk to health, the rate of deterioration, the duration of the causes,
the physical origin of the main cause (inside or outside the prison), and the suffering being endured.
These factors in turn depend on other information, which must be obtained during the initial
appraisal:

Health risks:
▪ These are risks resulting from malfunctioning structures and services (upstream), whether
for structural or economic reasons. Examples include:
o a poorly functioning food supply system and insufficient access to food;
o inadequate water and housing hygiene;
o an inadequate health system;
o an insufficient budget and/or corruption.
▪ Physiological risks related to the nutritional status (upstream) and manifesting themselves
through three types of symptoms aggravated if they coexist and/or in the presence of
concomitant disease:
o weight loss to a BMI (body mass index)14 below 18.5, which is associated with
impaired functional capacities, or to below 16, which indicates severe malnutrition
(marasmus) and is associated with a significantly increased risk of death;
o bilateral oedema of the legs, which most frequently indicates severe malnutrition
(kwashiorkor15) but can also be the result of beriberi, poor posture or lack of
movement;
o specific vitamin or mineral deficiencies with clinical signs; beriberi, pellagra and
scurvy (all potentially fatal), vitamin A deficiency which affects resistance to
infections and vision; iron deficiency, which reduces the capacity to work; and other
deficiencies affecting the body’s functional capacities.

Rate of deterioration
This depends primarily on:
▪ Nutritional status and health at the time of the evaluation;
▪ The amount of available nutrients (protein, carbohydrates, lipids, vitamins and minerals)
16;

14
BMI = weight (kg) / height2
15
Together with marasmus and (stunted growth), kwashiorkor is one of the three forms of severe malnutrition. It
is also often the most severe of these, and the most difficult to treat.
16
Even if all other nutrients are available in adequate amounts, a shortage of thiamine (vitamin B 1) can rapidly
result in fatal beriberi epidemics among individuals which, in all other respects, can appear to be perfectly well.
 14
▪ Physical stress as a result of cold (for example, a lightly-clothed man weighing 65 kg and
not carrying out any physical activity, at ambient air temperatures of 15°C and no air
currents has to spend 750 kcal a day just to maintain his body temperature – a 45%
increase in his basal metabolic rate);
▪ Water and housing hygiene, which influence the risk of infectious disease;
▪ Access to health care, which affects the course of disease.

Expected duration of causes

An analysis of the causes of nutritional deficiencies reveals whether they are temporary or lasting. If
malnutrition and disease are the result of temporary problems or deficiencies and likely to be
resolved naturally or by measures taken by the authorities, the determining factor is how fast the
problem can be expected to be solved. In that event, the choice is either to do nothing and wait for the
situation to improve by itself, or to intervene even more quickly to bridge the gap and the support the
authorities in their efforts.
Conversely, some indicators suggest that the causes of malnutrition and diseases are long-term, that
the situation is highly likely to become critical to health – and thus an emergency – and that there is
no hope of the authorities acting quickly (for whatever reason). If this is the case it is preferable to act
fast to eliminate or reduce suffering and to avoid having to mount an assistance programme that will
only increase in size and complexity as the situation deteriorates.

Origin of the problem’s causes

If the existing or expected problem originates in the place of detention, all of the above applies.
However, if the problem was caused by events preceding the detainees’ arrival in the place of
detention it may not be necessary to act, or only by providing temporary support, depending on the
means being mobilized and the authorities’ willingness to rapidly solve a problem related exclusively
to the transfer of detainees to a different place of detention.

The degree of suffering being endured

The degree of suffering caused by malnutrition depends on:
▪ discrimination;
▪ the level of solidarity among detainees;
▪ the behaviour of wardens and their superiors ;
▪ the amount of space available to each detainee;
▪ the prison facilities;
▪ the quality and availability of health care.
Not all of these aspects are objectively quantifiable and thus the decision to deliver direct aid to a
place of detention will to some extent always remain a subjective one17. The final decision should be
taken by experienced professionals in the field.

7.1.2 Scope of needs

Urgency is defined not only by the severity of the humanitarian needs but also their scope. In this
respect the following WHO recommendations may be useful:
➢ 5-9% of individuals have a BMI < 18.5 = slight prevalence (alarm signal, monitoring needed);
➢ 10-19% of individuals have a BMI < 18.5 = low prevalence (unsatisfactory situation);
➢ 20-39% of individuals have a BMI < 18.5 = moderate prevalence (serious situation);

17If specialist advice is not available on site it is always possible to consult specialists working for
Protection and Assistance in Geneva or in the field.
 15
➢ 39% of individuals have a BMI < 18.5 = severe prevalence (critical situation).
Regarding oedema, the significance of prevalence rates differs depending on whether the oedema is
due to kwashiorkor, which indicates severe malnutrition requiring rapid intervention, or o beriberi,
in which case immediate measures must be taken.
An analysis of prevalence rates also has to take into consideration their representativeness. The
above emergency criteria are valid only if the conditions of detention in the prison are homogeneous
and if the detainee population is too. The significance of a 9% prevalence of a BMI < 18.5 will vary,
depending on whether the detainees concerned are uniformly spread throughout the prison or all in
the same cell: in the latter instance, the prevalence rate would be >39%, signaling a specific problem
in that particular cell which has to be analysed and treated as a matter of urgency. Therefore, a mean
BMI for an entire prison must be treated with the same caution as a prevalence rate below a given
threshold.
These recommendations notwithstanding, it is important to remember that in emergency situations it
is not the number of individuals concerned that determines whether or not action should be taken.
The numbers only give an idea of the scope of the problem, the feasibility of action and the necessary
resources. In fact, what puts certain individuals at risk might be more a problem of discrimination,
illness, or personal vulnerability (such as separation from family) than one of general access to food
in the prison. Such individuals, even if few in number, are in special need of protection by the ICRC.
The above two observations indicate the limits of evaluating emergencies on the basis of the scope of
needs alone.

7.1.3 The causes

Although the direct cause of malnutrition is always an insufficient intake of food and/or an illness, it
is very important to understand the underlying causes before deciding whether to take action. If
detainees are malnourished because they are suffering from tuberculosis, the approach to the
problem and any action taken will vary, depending on whether the underlying cause is negligence on
the part of the authorities or a lack of resources to supply the prison with food. The same reasoning
applies to problems resulting from discrimination towards certain categories of detainees as opposed
to problems affecting all the detainees. Moreover, if the cause of the nutrition problem is inadequate
access to food and the population outside the prison likewise suffers from it, it is important to make
sure that the general population is also assisted.

Example 5
In Uganda the ICRC was faced with a situation characterized by all the factors listed above: a complete
breakdown in structures and services, severe malnutrition rates of more than 40% (BMI < 16 and
kwashiorkor), widespread specific deficiencies, rapid deterioration of the situation owing to highly
insufficient and unbalanced nutrition, catastrophic water hygiene and access to water, and a complete
absence of health care. There was no hope of improvement since the causes of the situation were
situated both in the place of detention and upstream of them, starting at the time of arrest. Although
the ICRC had been aware of the gradual deterioration in the situation, it was prompted to intervene
by mortality rates of epidemic proportions. The modes of action were a combination of dialogue and
direct assistance.

7.2 Timing of the intervention

7.2.1 Expected emergencies

Provided the necessary resources are available, it is preferable not to wait with preventive nutritional
assistance until individuals are at serious risk. On the other hand, it must be virtually certain that the
situation will deteriorate and that it will do so rapidly (in a matter of weeks).
This can be ascertained by:
 16
▪ Carrying out an in-depth analysis of access to food in prisons, taking into account the following
elements:
o the food supply system and prison regulations;
o visits from family members ;
o income and the possibility of buying food in or outside the place of detention;
o health conditions and water and housing hygiene ;
o the conviction that dialogue will be ineffective, because of a shortage of means and lack of
will;
o possibilities and constraints;
o knowledge of the detainees’ history;
o where applicable, previous actions by the ICRC.

7.2.2 Existing emergencies

Proceeding from the concept of emergency as defined above, the delivery of direct assistance is
subject to specific conditions.

A. Uniform situations (general malnutrition throughout the place of detention)

In this situation the problem concerns all detainees.

If dialogue alone cannot, in the time available, avoid levels of morbidity that will eventually put
detainees’ lives at risk, it is unacceptable to wait for detainees to die before taking measures.
Therefore, action should be taken as soon as:
➢ 30% of detainees in a prison have a BMI lower than 18.5; or
➢ 5% of detainees have a BMI lower than 16; or
➢ 10 % of detainees present with kwashiorkor; or
➢ 5% of detainees present with clinical signs of wet beriberi; or
➢ 10% of detainees present with clinical signs of scurvy or pellagra; or
➢ 30% of detainees present with signs of specific deficiencies other than those mentioned above.

It goes without saying that the specifics of the intervention will depend on each particular case (a
kwashiorkor problem will not be dealt with in the same way as a problem related to specific
deficiencies or to a BMI lower than 18.5 or 16). It is further obvious that, outside the above types of
cases, any detainee who is at significant risk of dying must be attended to if at all possible, in keeping
with the principle of humanity.

B. Heterogeneous situations (malnutrition affects particular parts of the prison or certain

detainees)

In this case the problem especially affects detainees who are victims of discrimination or who are
very vulnerable.
If dialogue alone cannot, in the time available, avoid levels of morbidity that will eventually put these
detainees’ lives at risk, the ICRC should not wait before taking measures.
Action should be taken as soon as such individuals present with:
➢ Severe malnutrition (BMI < 16 or kwashiorkor); or
➢ Clinical signs of fatal specific deficiencies (beriberi, scurvy and pellagra).
 17

7.3 Types of activities

Depending on the causes, the consequences and the urgency of the response, the substitution
activities best suited to the situation must be chosen. Examples include the following:
➢ Strengthening food chain logistics (for instance by ensuring that food products arrive in
regions that are difficult to reach);
➢ Improving infrastructure (premises, ovens, cooking utensils, cleaning, waste disposal,
evacuation of waste water and smoke, trays for carrying food);
➢ Purchasing food (this concerns those food items which are most difficult to find, such as
iodized salt and pulses, or expensive items, in situations where financial resources are clearly
lacking);
➢ Providing materials and services (maintenance and cleaning supplies, pallets for storage,
organizing kitchens and preparation of meals);
➢ Supplying meals;
➢ Providing medical care (for example, treating beriberi);
➢ Strengthening human resources (the regular presence of an experienced delegate with
precise terms of reference can be useful in addressing certain shortcomings and training
existing prison staff, especially in monitoring the nutritional situation through BMI records,
detecting micronutrient deficiencies, and handling crisis situations (measures to take). It
should be noted that the presence of an experienced delegate is particularly important in
view of the difficulty of controlling food use in prisons.
These activities have to be carried out by skilled staff. The importance of logistics should not be
overlooked18.

7.4 Disengagement criteria and follow-up

In both the uniform and heterogeneous situations described above the following criteria have to be
satisfied before the ICRC will end a substitution nutrition intervention

➢ Severe malnutrition is under control (no more cases with a BMI < 16 and no more kwashiorkor); and
➢ Fatal specific deficiencies are under control (no more cases presenting with clinical signs of fatal deficiencies
and
➢ Dialogue has had the desired effect: the authorities or reliable partners are ready to take over (which does no
mean that dialogue should be discontinued).

Once physiological problems have been brought under control by direct aid supplied by the ICRC, it
may nevertheless be necessary to resume relief operations if dialogue does not show any results, no
long-term measures are taken or no reliable partners can be found. In that event, the criteria outlined
above continue to apply. However, reproducing this cycle several times should be avoided: if it is
already clear that there is no hope of dialogue yielding results in the near future, assistance should be
continued until there is a change in the authorities’ attitude and/or in the resources they are willing
to make available, as was the case in Rwanda in the 1990s.
In this scenario, the ICRC has several options:

18Technical references for work in the field are set out in the Manual Health in detention and the
Ecosec guidelines for places of detention, which are in the process of being finalized.
 18
▪ If food supplies in the prison are borderline insufficient such that only the health of vulnerable
individuals is at significant risk it is possible – assuming that doing so is feasible (risk of achieving
the opposite effect, problems managing the programme) – to target all detainees with a BMI <
18.5 and to phase them out of the programme once their nutritional status has approximately
reached that of the other detainees, their BMI has remained above 18.5 for at least three weeks
and they are considered to have good chances of maintaining it. What makes this solution
satisfactory is that it achieves the following:
o It does enough without doing too much;
o It supports the most vulnerable detainees and reduces their health risks;
o It does not prolong an assistance programme beyond the point where it is no longer
strictly necessary;
o It keeps the “yo-yo effect” to a minimum.
However, implementation is cumbersome, requires constant monitoring and substantial human
resources. It also involves targeting individual detainees, which is never easy in a place of detention,
as those who are selected may be victims of discrimination and their situation might be aggravated if
they enjoy privileges the other detainees are deprived of. In addition, given the monotony of the food
served in places of detention, some detainees might be tempted to lose weight in order to have access
to more attractive meals. Targeting malnourished detainees can also be detrimental to mechanisms of
solidarity.

▪ If food supplies are generally insufficient, all detainees should be fed without any attempts at
singling out the worst cases. This is involves less work and is less complex. However, this
approach encourages the laxity of the authorities and harms persuasion and mobilization efforts.
In both cases, one option is to take action as soon as more than 10% of detainees present with a BMI
< 18.5, as this does not detract from the ICRC’s message that its assistance is temporary. Although it
does require careful monitoring of detainees’ nutritional status it also minimizes the “yo-yo effect”.

8. Conclusions
As demonstrated above, needs are central to the ICRC’s activities in the field of nutrition. An in-depth
analysis of the urgency of these needs and their structural causes determines the nature of the ICRC’s
response.
This response will consist of a programme combining all available modes of action in a way designed
to maximize impact.
Regarding the question of substitution, that is taking action in the place off the authorities, the ICRC
endeavours as much to prevent emergency situations as to end them. Its activities are always part of
a wider objective: enabling the authorities to meet their obligations in the shortest possible time.