Women carry sacks of food, airdropped by the World Food Programme, this past summer in Jonglei, South Sudan.

The U.N. is facing a terrible dilemma.

“Basically, when we haven’t got enough money, we have to decide who’s not going to get food,” says Peter Smerdon, a spokesman for the U.N.’s World Food Programme in East Africa.

And even though the program’s budget is at a record high, it’s not enough to keep up with the number of refugees and people in other crisis situations who need emergency food aid. Continuing conflicts in countries like Syria and Yemen and other crises led to the agency’s multibillion-dollar budget shortfall last year. It received a total of $6.8 billion from countries, organizations and private donors when it needed $9.1 billion to do its job.

WFP has already made cutbacks to the number of people it assists in some places. In Somalia, food aid was suspended for 500,000 people in December. In Ukraine, the agency plans to stop giving food to about 40,000 people in February. And in Syria, WFP is providing 2.8 million people with food aid this month, down from 4 million in 2017.

In other places, WFP has reduced the amount of calories that rations contain. “We can do a shallow cut, like 10 percent, 20 percent of the full ration,” says Smerdon. “Or we can do a deep cut if we think the contributions will not be coming in anytime soon.”

In refugee camps, a full daily ration contains 2,100 calories. That is pretty much the bare minimum for adults — to avoid losing weight, women need an estimated 1,600 to 2,400 calories a day while men need 2,000 to 3,000, according to current U.S. dietary guidelines.

The rations vary from country to country, and even within countries, explains WFP spokeswoman Challiss McDonough. In East Africa, the rations would include a cereal grain such as corn or wheat, dried peas or lentils, a fortified flour blend (usually eaten as a hot cereal), some cooking oil and iodized salt.

If funding for a particular region is not “coming in anytime soon,” says Smerdon, “we can do a deep cut.”

In Yemen, the difficulty of providing food rations has been exacerbated by the ongoing civil war and further complicated by blockades that slow down the process of getting food into the country. There have been 40 percent calorie cuts to half of the rations being distributed, says WFP.

The deeper the cuts, the greater the burden on people who are already living in crisis situations, McDonough says.

WFP is usually “the provider of last resort,” McDonough says. When it reduces the number of people it serves or shrinks the size of the daily ration, there is no guarantee that other agencies or organizations will be able to step in to fill the gap. In more stable countries, local branches of organizations such as the Red Cross or Red Crescent societies can help, she explains.

As food aid is reduced or suspended, people might have to sell some of their possessions, using money for school fees or going into debt to buy food.

“When people are trying to figure out how to survive and put dinner on the table every night, it doesn’t allow that family to think about longer-term investments like education, building jobs and businesses and things that will help them in the future,” she says.

The reductions may hit some people harder than others, depending on how much they rely on food aid. In many cases, they get all of their food from WFP, Smerdon says. In Uganda, refugees get a plot of land they can use for growing crops.

And when the cuts are sustained — or deep — there is an increased risk of malnutrition and a suite of other health problems for refugees.

“Their immune systems will be suppressed, and if cuts continue or they’re getting absolutely no food from WFP, inevitably over time, they will fall sick and ultimately many people will perish,” Smerdon says.

Apart from being a source of life-sustaining calories, food rations become key bargaining tools for people living in camps, says Peter Hailey, nutrition expert and founding co-director of the Nairobi-based Centre for Humanitarian Change. He led UNICEF Somalia’s nutrition response during the country’s 2011 famine.

“Parents might decide to reduce the number of meals they [eat] so some of the food can be used not just to feed their kids, but also to pay for health care for those kids or for access to education,” Hailey says.

McDonough and her colleagues are trying to stay positive. “We hope that any cuts like this are temporary,” she says. “That gap between what we want to do, what we think we need to be doing and what we have the resources to do is far too wide for anybody’s comfort.”