Food and Power in Protracted Crisis: How Systems and Institutions Influence Livelihoods,Food Security,and Nutrition

Abstract

This article examines how systems and institutions influence the distribution of resources in society and, as such, affect livelihoods, food security, and nutrition. It draws on research on the political economy of food, and the governance effects of food aid practices, conducted in Sudan and Somalia and on the role of a social approach to nutrition in situations of famine and mass starvation. This article argues first for the importance of examining political structures as basic causes of malnutrition as they influence whether and how institutions function (in relation to land, markets, employment, aid, or justice). Second, this article illustrates how, in situations of crisis, the manipulation of institutions can create power for some and vulnerability to malnutrition in others. Third, it argues that a focus on treatment of malnutrition and behavior (hygiene and feeding practices) has drawn attention away from systems and institutions and feeds into discrimination as a basic cause.

Introduction

Food crisis, famine, and emergencies are increasing worldwide. ^1,2 Many such crises are protracted, with large numbers of people suffering persistently high levels of acute malnutrition. ³ These crisis have persisted despite policy changes in nutrition interventions. In a rerun of the 1970s, the 2008 food crisis stimulated a rebirth of technical approaches to address malnutrition: mostly focused on production and medicalized interventions such as feeding programs. This can be largely linked to an influential series of papers in the Lancet, which reported on a meta-analyses of the causes of malnutrition and “what works” in terms of interventions. They concluded that interventions such as food fortification, vitamin supplements, and nutrition education were effective in addressing malnutrition (later called “nutrition-specific” interventions). ^4,5 These papers also explicitly excluded deprivation and inequity (note 1) from their analysis despite recognizing these as basic causes of malnutrition:

Although addressing general deprivation and inequity would result in substantial reductions in undernutrition and should be a global priority, major reductions in undernutrition can also be made through programmatic health and nutrition interventions. ^{4 (p243)}

This article focusses on these neglected basic or structural causes of malnutrition, in particular, how the nature of systems and institutions can contribute to malnutrition in some population groups. These causes had more prominence in the 1980s and 1990s, including in a social nutrition approach promoted by Pacey and Payne ^7(p10): “which examines those social, environmental, economic and political factors that determine the degree to which people have access to food….” The United Nations Children’s Fund (UNICEF) framework on causes of malnutrition developed in the early 1990s, similarly, has a level of basic political and economic causes which operate at the level of populations, but which nutritionists have rarely examined. ^8,9 Interest in such a socially or politically oriented approach to nutrition has recently been revived; perhaps because of the return of severe famines, ⁸ recognition of persistently high levels of acute malnutrition ³ or crises in food systems due to climate change, ecological crisis, and the industrialization of food products. ¹⁰ Social and human rights movements have also long been advocating for reengaging nutrition with society, drawing attention to the necessity of seeing nutrition as a profoundly political issue, which touches on rights, livelihoods, and health. ^11,12

The analysis presented in this article draws on recent research and policy analysis conducted by the author in Sudan ^13,14 and in Somalia ^15,16 and on the role of social nutrition in famine prevention. ⁸ This article first considers the distribution of resources as a basic cause of malnutrition, how it relates to systems and institutions, and what happens in situations of crisis. This is followed by a focus on Sudan and Somalia, and how in these unequal societies (in terms of distribution of resources) institutions can create power for some and vulnerability to malnutrition in others. Finally, it considers how current dominant ways of assessing and responding to malnutrition fail to consider these basic causes, and even feeds into them, and why.

Unequal Distribution of Resources as a Basic Cause of Malnutrition

It is worth examining briefly the basic causes of malnutrition in frameworks from the 1980s and 1990s as some aspects remain relevant today. In Pacey and Payne’s book on Agricultural Development and Nutrition (1985), they argued that malnutrition has “multiple causes which are closely linked to the conditions of inequality of resources, or poverty, and of social discrimination.”^7(p18) They suggested “a new approach to nutrition that would analyse food systems, the epidemiology of malnutrition, and livelihoods,” to understand how people became malnourished and who they are.”^7(p20) From the 1990s, UNICEF promoted a similar approach. ¹⁷ In their framework, they describe basic causes as related to the unequal distribution of resources in society and go on to discuss a range of social, political, and economic factors that determine what is produced, and how it is distributed and consumed. These factors can also be considered institutions, if defined as the rules of society for the distribution of resources and the interaction between people ¹⁸ or linked to governance in terms of the management of people’s health and well-being. ^19,20 Examples of institutions that UNICEF provides include property relations, labor relations and power structures, the state, legal systems, income and tax policies, land distribution, income and food policies, and historical marginalization. Social institutions may also include extended family, social networks, community institutions (churches or places of worship, local organizations), or schools as well as customary law, for example, around land.

Although nutrition studies rarely examine the role of social institutions beyond the household, there are a few. A study in Yemen and Jamaica showed the importance of social inclusion for good nutrition, ^21(p628) and another one in Niger that women’s income and access to social networks is important to secure nutritional resources. ²² The social dynamics of malnutrition causation are covered more extensively in anthropological food studies: in which issues such as land tenure and access to land, labor relations, changes in farming systems, and power of food corporations are considered as key to food security. ²³

In situations of crisis, the manipulation of resources and issues of marginalization and exclusion are often magnified. Humanitarian crisis or famine hits the poor or politically marginalized hardest as they are often already unrepresented and/or excluded from key institutions or systems of governance. They do not have the political clout to access or claim resources; whether land, food, jobs, aid, or justice, ²⁴ which makes looting, theft, and asset transfer through market manipulation (land, livestock, and labor) by those with power easier. ²⁵ In many crisis situations, key systems and institutions that influence nutrition (eg, land, trade, and aid) do not function for the benefit of citizens but instead maintain or magnify inequalities. In such situations, political systems may be based on patronage, kleptocracy (note 2), and violence; turning governance into a political market place in which transactions or deals to purchase political loyalty dominate laws, institutions, and regulations. ²⁶ Furthermore, without functioning systems of law and justice those already marginalized can be further targeted and exploited. Informal institutions also change: If populations are attacked or coerced into selling assets, families are split through migration of family members or whole families are displaced—disrupting social networks. ²⁷

Political Economy of Food in Sudan and Somalia’s Protracted Crisis

Political and economic institutions related to food can create power for some and vulnerability in others, resulting in high levels of acute malnutrition in vulnerable groups; often linked to their political or ethnic status (as in internal war ethnicity is frequently manipulated for political gains). This section explores these dynamics in Sudan and Somalia, in terms of inequality and marginalization, and for institutions relating to the distribution of food resources, and how these can be linked to the persistently high levels of acute malnutrition.

Malnutrition in Politically Vulnerable Population Groups

Nutrition surveys in Sudan and Somalia have shown some of the highest malnutrition levels ever recorded. ⁸ These countries have also regularly suffered famines and emergency levels of acute malnutrition. ^1,3,13,28 High levels of acute malnutrition are not found everywhere or among everyone, however. Both countries are highly unequal—socially, politically, and geographically. Power and resources—including land, trade, or aid—are concentrated within a central elite, whereas others are unrepresented and excluded from national political and economic institutions. In Sudan, Darfur—its western periphery—consistently has among the highest acute malnutrition prevalences, in particularly North Darfur (note 3). ^{29 -31} Until recently (note 4), populations in central and northern regions have largely experienced better nutrition. In Somalia, those experiencing persistently high prevalence of malnutrition are in the southern and central regions of Bay and Bakool and along the Juba and Shebelle rivers. ^32,33

Inequality, Marginalization, and Crisis

In both countries, the marginalization of particular populations goes back a long time as does the concentration of power within a small elite. In Sudan, colonial strategies created an interconnected political and economic elite, composed of religious and traditional leaders, ministers, and businessmen, mostly from Arab tribes in the country’s riverine heartland. ³⁴ A similar elite has continued to dominate government, more recently consisting of a military–security–industrial complex, with power and development concentrated in the center. This concentration of power was reinforced by food policies such as bread subsidies for urban populations and agricultural subsidies for commercial farmers. ^35,36 Populations in the peripheries lacked political representation but formed a large component of the labor force for commercial farming. ³⁷ Economic mismanagement, corruption, changes in local government, and drought led to famine in the peripheries in the mid-1980s. Food security and famine (including due to conflict between center and periphery) has been common since 1985, 1988, 1991, and 1998. From the 1990s, although Islamists (President Bashir’s regime) initially had ambitious plans for social reform and food self-sufficiency, they ended up governing through patronage and fear—involving the use of impoverished pastoralists as militia in its internal wars. ³⁸ With development aid suspended, humanitarian assistance—in particular food aid—became the main form of aid. ¹³ Key industries, and companies, were taken over by military or security officers. Even in times of rapid economic growth resulting from oil revenue (2005–2011), funds were spent on defense and national security rather than social services. ³⁹ During this same period, Darfur experienced the world’s largest humanitarian crises. After 2011, when South Sudan became independent and oil revenue went down, gold became a more important source of revenue with greater dependence on exploitable rural labor. Furthermore, the Rapid Support Forces (RSF), Bashir’s former militia and—in July 2023—in a violent battle with Sudan’s army (Sudan Armed Forces) (note 5) also secured control over rural production, transport, and trade. ⁴⁰ Sudan’s 2019 popular uprising was not able to dismantle the military–security–commercial complex that controls the country’s resources. Conflict, economic crisis, and political instability have resulted in a major humanitarian crisis, with large-scale violence and displacement in 2023. ⁴¹

Similarly in Somalia, resources have been concentrated within a political and business elite of powerful clans, which has depended on the marginalization and exploitation of certain population groups; in this case those living along the Juba and Shebelle rivers and Bay and Bakool regions in between. This also goes back to colonial times when Italian colonizers established plantations along Somalia’s fertile rivers, turning the original inhabitants into laborers or sharecroppers. ⁴² After independence, political power was concentrated in a small clique of leaders associated with the powerful Daarod clans, who benefited first from state farms and price controls and later from agricultural liberalization (in the 1980s) that facilitated land grabs. ⁴³ Siad Barre’s regime (in the 1970s and 1980s) has been described as a rentier kleptocracy, with governance based on corruption and patronage. When he was ousted in 1991 by a coalition of rebel movements, and the country descended into civil war, a war economy developed of large-scale violent looting and theft from marginalized riverine and inter-riverine populations. ⁴⁴ This population was largely unarmed and suffered Somalia’s most severe famine in 1992. Violence, looting, and displacement continued throughout the 1990s, but at the same time business boomed. Exports of livestock, bananas, and charcoal grew substantially and was dominated by a limited number of large businesses owned by powerful clans. ⁴⁵ Aid contracts, in particular food aid, became the countries’ biggest business and a source of capital and subject to extreme diversion. From the 2000s, Somalia has had some form of government—but control by a political-business elite dependent on manipulating aid and other external financing remains. Within the current political system, which is dependent on buying political loyalty, there is little incentive for institutions to be accountable to citizens. ⁴⁶ Aid continued to be a key resource, in response to displacement (2008–2010) and famine (2011) and food crisis (2017). From 2012 development aid, diaspora and business investment increased but met with a similar fate within the political marketplace. ⁴⁷ The rise of Al-Shabaab, an Islamist movement that took control of much of southern and central Somalia in 2006, further maintained the vulnerability of weaker clans despite their initial policies to defend them. Its designation as a terrorist movement in 2008 halted U.S. aid in their areas, and in 2010, Al-Shabaab also banned Western food aid and organizations. With aid largely going to government-controlled towns, people moved, their aid was taxed, and their labor exploited. ¹⁵

Trade, Land, and Aid as Key Institutions

Institutions linked to trade, land, and aid have been a key part of the predatory political economies of Sudan and Somalia. Since the 1990s, many companies in Sudan, especially those involved in food, have been owned by or closely linked to government, including the military and security sector. ⁴⁸ This includes companies involved in the import of wheat (the basis of the urban bread subsidy), milling, commercial farms, and transport, who receive preferential exchange rates and tax exemption. ^49,50 This keeps profits within a small elite. It also enables hoarding and speculation to influence food prices—common during earlier famines (see study by Keen ⁵¹ ) and which can partly explain why the price of staple food (and fuel) was high during the transitional government (2019–2021): with added political incentives to undermine transition to democracy and retain military power. ¹⁴ The potential loss of control of key companies and resources under a civilian government contributed to the October 2021 coup and again to the April 2023 eruption of violence between the RSF and the Sudan Armed Forces. For already vulnerable and marginalized people, high food prices means they have to sell land and livestock and seek labor under unfavorable conditions, leading to food insecurity and famine but also to benefits for those who can buy livestock, land, and labor at low prices. ^51,52 Aid has become part of these dynamics, being diverted to government (and its supporters) or soldiers, and restricted to maintain high food prices—as part of counterinsurgency but also for profit. During the 1980s and 1990s, contractors maximized their profit by using cheap transport options and prioritizing more accessible areas. Little food aid reached intended beneficiaries during the famines of the 1980s and 1990s. ^{53 -59} In 2004 to 2005, the large quantities of food aid for the Darfur crisis actually reached conflict-affected populations but also led to a massive expansion of 3 Khartoum-based companies who are now multinationals. ⁶⁰ Local procurement was similarly from large government-linked companies.⁶⁰ When international food aid declined, from 2008 onward, government food reserves (funded by oil revenue) became more important and were aimed at government support rather than those most in need.⁶⁰ Locally, international food aid has often been distributed to all rather than targeted and camp leaders have been accused of diverting aid. ¹³

More direct actions on land or food resources include state acquisition for commercial farming or the looting, theft, or destruction of farms and food stocks during times of acute conflict. In Darfur, control over and access to land has changed with shifting power relations during the conflict: early in the conflict, Arab groups from whom former President Bashir originally recruited his militia occupied land from which they had displaced others. From 2020, as part of the now failed Juba Peace Agreement, those displaced (usually associated with the rebellion) are entitled to return to that same land. The late 2021 military coup shifts power back again because of the role of the RSF (formed from Arab militia) in the new military government—all of which contribute to renewed attacks and displacement in Darfur. ⁶¹ In 2023, some analysts have compared RSF violence in Darfur to the war crimes committed in 2003 to 2004. ⁶² Nationally, the sale of land along the Nile to regional and international actors as part of the financialization of food systems further undermines national food security (see political ideology and international institutions below). ⁶³ Food aid influenced both violence in Darfur and national food security because Internally displaced persons (IDPs) in camps and food insecure villagers received different types and quantities of food assistance. In 2022, local procurement continued to be from commercial farms in central Sudan using companies with military links. ¹⁴

In Somalia, aid, trade, and land institutions have also long been intimately linked and used as a source of power. In the 1980s, in addition to fertile land being used to buy or maintain the political loyalty of powerful clans, 85% of refugee aid was reportedly diverted (Askin, 1987, referenced in study by De Waal ⁶⁴ ). During the conflict in the 1990s, the arrival of the United Nations Operation in Somalia (UNOSOM) and World Food Programme (WFP) led to aid contracts (and associated protection rackets) becoming Somalia’s biggest business, with some of today’s largest businesses making their initial capital at this time. ^65,66 A business class emerged which also developed extensive and oligopolistic trade networks. ⁴⁵ In addition to diversion by contractors, “gatekeepers” taxed aid intended for displaced populations. ⁶⁷ Food aid as big business resumed from 2006 to 2010, when food aid quantities increased massively in response to displacement. Three companies received the bulk of WFP transport contracts and were found to collude with WFP staff and implementing partners to divert food. ⁶⁸ They were also engaged in other economic and political activities; from managing the ports, to funding armed groups, to influencing political positions as high as the Presidency (past and current President Hassan Sheikh was a WFP contractor). ¹⁵ A shift to cash transfers (including vouchers) with the 2011 and 2017 famines or food crises led these contractors to reinvest in construction, fuel storage, and security services. Power through food assistance was diffused as many small businesses were now involved as retailers for voucher programs. More aid stayed in areas in need, but district authorities gained power from greater control over distribution. In government areas, diversion by contractors, local authorities, and through gatekeepers remained an issue, and large numbers of vulnerable people in the hardest hit (Al-Shabaab) areas could still not be reached. ^69,70

Cash transfers increased the power of money transfer companies enormously. ¹⁵ Other than benefiting from charging for the transfer and through the sale of mobile phones and SIM cards, they can invest the funds that it holds in agriculture and trade. Hormuud, the largest telecoms agent, has invested in land and the production (and export) of cash crops, in the import of sugar, as well as real estate, electricity, and water supply.¹⁵ In the last 10 to 15 years, with increased displacement, cash crop production has increased and so has the concentration of trade within a few big businesses. In times of drought or floods, people with land along the river are coerced into selling it when their food insecurity becomes acute. Land has become more attractive for commercial purposes because of an increase in demand for sesame and dried lemon for export (to the Middle East, India, and China). ⁷¹ Often the same large businesses support cash crop production, import foodstuffs, and are involved in aid. They depend on the maintenance of displaced populations as a source of aid and as a source of flexible and exploitable labor. Such labor is needed for construction, the service sector, and farming and is essential in a context where businessmen need to be able to shift the nature of their business quickly to where profits are largest. ¹⁵

To conclude, the political economies of Sudan and Somalia are such that political and military actors can benefit from the manipulation of institutions of land, trade, and aid; more specifically from high food prices, aid diversion and exclusion, and the resulting sale of land and livestock. This also keeps large sections of the rural population in a state of precarity and dependent on casual and sometimes exploitative labor. These are key factors in determining the risk of malnutrition for populations in places like Darfur in Sudan and Bay and Bakool in Somalia.

Ideology and International Institutions

International ideologies and institutions also need to be considered in examining basic causes. In both countries, Islamism and counterterrorism legislation can be linked to malnutrition at the level of basic causes. In Sudan, the 1990s were the ideological phase of the Islamist regime when institutions were turned into agents of Islamization. Aid and services were linked to Islamist aims while at central level Islamists took over state assets, private companies, and financial institutions. ^48,52 The ideological years were also associated with aims of self-sufficiency, which included refusing international food aid and denying famine (and thus worsening it). Al-Shabaab in Somalia similarly refused Western food aid. In some sense, this was not surprising as populations in their territory had in the past largely been excluded from international aid, powerful clans who have exploited them have benefited, including from distribution during harvest time. ⁷² In both countries, it led to reductions in international aid. Sudan received mostly humanitarian aid from the 1990s to the early 2000s. Populations in Al-Shabaab held areas, once it was designated a terrorist organization by the United States and later the EU could not receive aid, thus contributing to displacement and the concentration of aid in government-held urban areas (and arguably their exploitation). Western scope to improve nutrition or to address humanitarian crisis is increasingly overridden by political priorities, whether counterterrorism or preventing migration to Europe or the United States. ¹ In Sudan, for example, the EU made a deal with the Sudan government to prevent migration in the last years of Bashir’s oppressive regime. ⁷³ Regional geopolitics is another factor: Ethiopia, Egypt, Libya, Chad, Saudi Arabia, Qatar, and Turkey play varying roles in the conflicts in Sudan and Somalia, but space does not permit a detailed analysis of this here.

Economic and aid policy has changed over time with changes in ideology. From the 1980s, external development interventions minimized the role of the state and focused on the creation of responsible and entrepreneurial individuals, who with the right skills and agency would become self-reliant. ^74,75 This neoliberal way of governing emphasizes strong private property rights, free markets, and trade. ⁷⁶ In Africa, this was first applied as structural adjustment in the 1980s, and in Sudan precipitated economic crisis and, later, famine. These economic strategies of focusing on individual rather than state or society have been criticized for increasing inequalities (eg, see study by Chandler⁷⁵). Recent resilience approaches take this ideology further; with aims of promoting autonomous subjects who can adapt to, and survive in, protracted crisis while the causes of crisis (and its associated malnutrition) are not addressed. ^{77 -79} Current food aid and nutrition policy practices, and their failure to consider basic causes, can be seen in this light, as is discussed further.

Political Effects and Functions of Focusing on Treatment and Behavior

Given the importance of predatory political economies and failing institutions as basic causes of malnutrition, a key question is why has this not had more attention from nutritionists? Nutritional surveys and food security assessments often focus on feeding and hygiene behaviors, and individual and household actions to access food, as key to understanding why certain groups of people are malnourished. ^30,31,80,81 Such an approach implicitly considers what people are doing to make them malnourished rather than what structural factors are causing malnutrition in this particular population group. The focus is on individual and household actions and behaviors. This individual focus has been reinforced by an emphasis on the treatment of severe malnutrition in recent nutrition strategies, 2 series of articles in the Lancet, and on nutrition-oriented resilience strategies. This section briefly considers how this focus came about, why it is maintained, and its effects.

New medical and treatment protocols in the early 2000s dramatically improved the survival of children with severe malnutrition, including treatment at home with specialized food products, and soon became an established part of nutrition practice. ^82,83 Later in that decade, the first series of Lancet articles included a review of “what works” in terms of nutrition interventions, and an analysis of risk factors, which concluded that interventions such as food fortification, supplements (such as Vitamin A), and nutrition education (eg, breast-feeding counseling) could lead to substantial reductions in undernutrition (later called “nutrition-specific” interventions). ^4,5 The later series introduced nutrition-sensitive interventions such as agriculture, safety nets, and education. ⁸⁴ These articles form the basis of many donor and UN nutrition strategies today. ^85,86,87 Since 2010, donors and aid organizations, as well as researchers work closely with governments and private sector institutions to promote a standard package nutrition-specific and nutrition-sensitive interventions as part of the Scaling Up Nutrition movement. ⁸⁸ For WFP Sudan and Somalia, this entails having social and behavior change communication (SBCC) and specialized nutritional products as a large component of nutrition programming. In both countries, this includes education on child feeding, household food choices, hygiene practices, and health-seeking behavior. ^89,90 Nutrition-specific and sensitive approaches, and in particular SBCC, are further promoted as part of resilience strategies because well-nourished people are considered to be stronger and better able to withstand shocks. ^{86,90,91(p21),92(p6)}

The view of malnutrition as caused by people’s behavior can also be seen in what aid workers say, even in conflict situations, and in nutrition assessments.

Mothers do not know how to cook…It is a desert area, people breed animals only for cultural purposes, they do not know how to farm. They have a child every year which means they wean too early. (Aid worker in Darfur, 2013)^13(p165)

Some people are at a low level. They are different in terms of their civilisation…their farming systems are bad…the way they live, marry, or spend money, this would be very difficult for pastoral communities. They take more wives instead of building and saving. It is their own culture that is keeping them malnourished. (Aid worker in Somalia, 2019)^15(p37)

The forced sale or occupation of land, elite control over trade in food, the taxation of aid resources, or exploitative labor relations are rarely mentioned in assessment reports. Even less common is a recognition of regional and global politics. Despite global financial systems playing a key role in the 2008 food crisis, the response has been to encourage individuals to change their behavior rather than examining the financialization of food systems and how this has influenced vulnerability to food insecurity and malnutrition. ⁹³

There are a number of other possible explanations for the neglect of the basic political causes of malnutrition (including the functioning of institutions) by nutritionists. First, nutritionists tend to consider basic causes beyond their control. In Darfur, for example, discussions with aid workers about a nutrition causal analysis revealed that interventions on caring behaviors were considered feasible, but addressing differential access to land was not. ^{13 (p170)} Second, analyzing the basic causes of malnutrition is a political exercise and can lead to agency expulsions or security risks in highly politicized environments such as Sudan and Somalia. Local Somali aid workers reported that often donors or their managers in international nongovernmental organizations would rather not know what really happens to aid on the ground. ^15(p38) An apolitical approach enables international organizations to maintain a presence. It is politically convenient. Even UNICEF itself did not necessarily want to address basic causes, as its policy on “[structural] adjustment with a human face” shows. ⁹⁴ A focus on people’s behavior as cause does not link malnutrition to a government’s war strategies, unequal development, or discrimination. It absolves governments and warring parties from responsibilities to provide for their citizens, and the international community’s responsibility to protect. These are powerful political motivations to maintain the status quo. It could be argued, however, as Freire did, that a problem-solving approach involving community reflection should lead to political repercussions and ultimately social change at the population level. ^7(p198)

For crisis-affected populations, a focus on immediate life-saving interventions is necessary in the acute stages of an emergency, but focusing on immediate and underlying causes (often treatment and behavior change) means that basic causes are not addressed or even analyzed. This in turn means that the inequalities in distribution of land, production, and aid that cause persistently high levels of acute malnutrition will remain. In Sudan and Somalia, the focus on behavior change goes further: It actually feeds into the discrimination of particular ethnic groups and assumptions about the superiority for others; specifically, Arab supremacy in Sudan, and the supremacy of particular dominant pastoral clans in Somalia. A focus on the behavior and traditions of politically vulnerable groups has therefore become a basic cause of malnutrition itself.

Conclusions

This article has shown how the political economy of food creates power in some groups and vulnerability in others, and that the way in which systems and institutions function is integral to that. In situations of protracted crisis, political systems are often based instead on patronage, kleptocracy, and violence; turning governance into a political market place in which transactions or deals to purchase political loyalty dominate laws, institutions, and regulations. Wealth and power tends to be concentrated in a political-business elite. Politically marginalized populations are unrepresented, excluded, and exploited. In countries like Sudan and Somalia, this has meant that the same population groups have repeatedly suffered persistently high malnutrition levels—including in Sudan’s peripheries (eg, Darfur) and the riverine and inter-riverine populations in southern and central Somalia.

The concentration of power can be illustrated in detail for trade, land, and aid. These institutions are intimately linked and can be manipulated to boost power but which involves the exploitation of vulnerable groups, in particular the displaced. Food import, export, and trade are usually controlled by a few large businesses closely linked to government, military, or powerful clans, which in Sudan benefited from beneficial exchange rates and tax exemption. Similar or even the same businesses often dominated food aid—benefits being gained through transport and procurement contracts, as well as being able to manipulate markets. In Sudan in the 1980s and 1990s and in Somalia up to today, food aid has been a key resource for governments, rebel movements, and business and was diverted, taxed, and otherwise manipulated. Land could be looted or stolen directly or confiscated for commercial farming, and farmers could be coerced into selling through market manipulation. High food prices and restriction of food aid would eventually lead to sale of land (or livestock) and displacement. In both Sudan and Somalia, it was repeatedly the same population groups from which assets were transferred to the powerful and who became acutely malnourished.

Little of these dynamics are seen in nutrition assessments or causal analysis, where the focus in the last 10 to 15 years has been on causes at the individual and household level and on treatment and behavior change as interventions. This can be linked to a neoliberal ideology promoting market-based and entrepreneurial approaches, and individual responsibility, and specifically to a series of papers in the Lancet, which suggested that food supplements, fortification, and nutrition education could substantially reduce malnutrition. It can also be linked to the fact that looking at basic causes is inherently political, which is not something that nutritionists are comfortable with, and is controversial in politically sensitive situations, potentially leading to expulsions. It also means, however, that governments or political actors can continue to manipulate institutions as a source of power or to buy political loyalty and marginalized populations continue to be unrepresented, exploited, and become malnourished.

Basic causes are complex and need time on the ground to explore. Knowledge cannot be gained only through the quantitative data, often collected remotely, that dominate assessments today. It needs long-term presence, participation, and problem-solving by communities themselves and recognition that looking at basic causes will bring about political repercussions but also that this is the only way to bring about social change and reduce acute malnutrition sustainably. Analyzing issues of power, social relations, historical marginalization, and class needs to become a key component of a nutrition causal analysis.