|4th Report on the World Nutrition Situation - Nutrition throughout the Life Cycle (ACC/SCN, 2000, 138 p.)|
|CHAPTER 5: NUTRITION OF REFUGEES AND DISPLACED POPULATIONS|
This section will briefly review the use of anthropometric surveys and food security assessments in displacement emergencies. Other early warning systems will also be discussed.
Anthropometric measurements of children aged 6 - 59 months are the most widely used indicators of the nutritional status of emergency-affected populations. The results of anthropometric surveys continue to be valued by decision-makers. This is because the anthropometric status of population groups is very sensitive to changes in access to food, health services, and caring practices and also because reliable data on anthropometric status are robust and are available in the majority of emergency contexts.
Problems in standardizing anthropometric surveys still exist (see Box 5.3) and can lead to difficulties in interpreting the results. Further problems may arise when generalized cut-offs for action (for example, a prevalence of more than 10% wasting and/or oedema) are employed in different settings, because appropriate local action must be based on more than just a single indicator. The relationship, between mortality, morbidity, and nutritional status differs in different settings. In other words, the risk of dying associated with acute undernutrition varies according to the local patterns of disease; it is also likely to vary according to age. More research is needed in this field in order to fully explain the significance of acute undernutrition in terms of risk of dying and other aspects of physical dysfunction in different settings.20
The Standardization of Nutrition Surveys
In estimating the prevalence of acute undernutrition in an emergency-affected population, the prevalence among children between six months and five years (65 to 100 or 110 cm in height) is usually used as a proxy. Extensive differences in health and nutrition survey methods have been identified. For example, there are wide variations in the age of the target populations, sampling strategies, units of measurement, methods of rate calculation, and statistical analysis.18 In March 1999, the RNIS reported the findings of 21 studies of nutritional status conducted in Northern Bahr-El-Ghazal Province of southern Sudan between April 1998 and January 1999. Most of these surveys were undertaken on or around airstrips where food distribution took place. The majority of surveys were conducted in communities residing within five km of feeding centres run by relief organizations. Only three surveys covered populations of complete payams (administrative units like sub-districts). Ten of the 21 surveys employed a cluster sampling strategy and had similar sample sizes. The others were either surveys of all children within a location or rapid assessment surveys with unknown or convenience sampling techniques. All but three of the surveys used Z-scores of wasting and the presence of oedema to define acute under-nutrition. The others used per cent of median.
The most reliable estimates of the prevalence of undernutrition have come from well-defined and secure refugee camps where there is a reasonable level of camp organization and a designated agency with responsibility for the collection of data. The most difficult situations have been those where IDPs have been scattered over a wide area and where surveys could take place only in relatively secure zones. These safe zones may sometimes have acted as magnets for the most severely affected groups of a population; for example, the Somali town of Baidoa was the site of the storage and distribution of massive amounts of relief food in 1992 and became known as the famine epicentre. Mortality and undernutrition rates were extremely high in this town. On the other hand, it is possible that the worst-affected communities have been in areas that have been inaccessible to those performing the surveys. In either case, it has proved difficult to extrapolate the findings of surveys on nutritional status conducted in specific locations to broader populations in conflict-affected countries.
Elements of well-standardized nutrition surveys include the use of weight-for-height/length and the presence of oedema to measure acute undernutrition, cut-offs for classifying under-nutrition, and the presentation of confidence intervals. There is a range of sampling designs and methods for obtaining a representative sample. The methods employed should be clearly explained. Information on the prevalence of severe wasting and oedema should also be made available, as children Suffering from these forms of undernutrition need specific care. Mid-upper-arm circumference (MUAC) measurements are recommended as a screening tool in emergencies as they are strongly associated with mortality.19 However, MUAC measurements are not recommended for assessing nutritional status of children in population surveys until there is agreement on cut-off points to define acute undernutrition. Survey planners should consider including questions on feeding centre attendance by persons identified as undernourished (by age group) as well as reasons for non-attendance. These data are useful for programme managers. In addition, crude mortality rate (CMR) data collected in conjunction with anthropometric data are useful in assessing appropriate future responses to a situation.
In the past two years an increasing number of anthropometric surveys have been conducted on adult and adolescent IDP and refugee groups by Concern, Action Contre la Faim (ACF), UNHCR, and the Centers for Disease Control and Prevention (CDC). The extremely high mortality rates among adults in emergencies in Ethiopia, Liberia, Somalia, and southern Sudan initially fuelled interest in the subject, as well as a consideration of the effects of adult mortality on the rest of the household. Only very limited scientific literature is available, however, on the diagnosis and treatment of undernourished adults.21, 22 In addition, the associations between the anthropometric cut-offs currently employed and mortality and morbidity are not well understood, or studied, in many population groups. These problems are compounded in adolescents because the growth spun starts at different ages depending on nutritional status, ethnicity, and possibly other environmental factors:
Famine Early Warning Systems and Food Security Assessments
Systems to warn of impending food crises are not new, although approaches to famine early warning have changed and developed considerably over the 1990s. Following the famines of the mid-1980s, a wide range of organizations became involved in famine early warning,d in the hope that better information systems could help prevent future famines.
d The OCHA ReliefWeb provides a list of early warning organizations, information, and related links (http://www.notes.relief-web.int/websites).
Early warning activities range from a global focus on national and international food availability, to a more localized focus on issues of access to food and food security. The Global Information and Early Warning System (GIEWS) run by the FAO from Rome monitors food supply and demand around the world, and its aim is to warn the international aid community and participating national governments of food shortages for food aid planning.23 The Famine Early Warning System (FEWS) of the U.S. Agency for International Development (USAID) publishes both regular regional bulletins and special alerts. These notices are based on vulnerability assessments that evaluate components of national and household food security in order to identify which people are food insecure, the nature of their problem, factors that could influence their food security, and possible interventions.
The regular joint FAO/WFP food and crop assessments undertaken to estimate national food aid needs, which are based on a food balance sheet, are an important part of GIEWS.24 In ongoing emergency refugee operations WFP and UNHCR periodically undertake joint food assessment missions (JFAMs). These missions make recommendations on number of beneficiaries, modalities of assistance, composition of the food basket, ration size, duration of assistance, and logistical arrangements. UNHCR normally provides the JFAM with a nutritionist and, if applicable, other specialists to help assess levels of economic self-reliance.
Activities with a more localized focus include regular food security monitoring systems and/or emergency food security assessments. Indicators monitored by such systems depend on the location but generally include market prices, a variety of coping strategies and migration, and sometimes anthropometric status. These systems were developed in the late 1980s and continue in most countries in the Horn and East Africa.25
In recent years NGOs have undertaken increasing numbers of ad hoc food security assessments of emergencies. The best known of these is the food economy approach of the Save the Children Fund, UK (SCF). This approach was developed in 1994 to more accurately assess food aid needs and allow more effective targetting of food aid in protracted emergencies. The approach has two main objectives: to understand how people survive and how patterns of survival have changed as a result of shocks, and second, to estimate the size of the food gap and thereby estimate food aid needs.26 The food economy approach has made a valuable contribution in highlighting the need for baseline data to interpret current events or food security indicators.
The Somalia Food Security Assessment Unit (FSAU) managed by WFP Somalia is a good example of combining various types of food security information systems. It uses the food economy approach to establish a baseline and monitors food security indicators and nutritional status over time to assess changes in food security. Where food security indicators cannot be monitored continuously, the FSAU relies on ad hoc missions, assessments, and sometimes surveys. FSAU collaborates with USAID FEWS to produce a joint newsletter, Rainwatch, issued every ten days during the main cropping season in Somalia. FEWS provides satellite data on rainfall estimates, cloud top temperatures, and the normalized difference vegetative index, while FSAU field monitors and other NGOs provide information collected locally on the ground.
Many NGOs contribute to the important field of assessing household food security, including SCF, ACF, Action Against Hunger (AAH), CARE, Oxfam, and Concern Worldwide.27 The International Committee of the Red Cross (ICRC) has developed its own method for assessing economic security. Although these agencies have similar concepts and definitions of food security, they have developed a range of approaches to assessing food security.27 This is partly because food security assessments may have different objectives, including the estimation of food aid needs, analysis of coping mechanisms, and the design of potential interventions. Thus the process of analysis and the style of the presentations vary. In all cases, however, the information is intended to help decision-makers form knowledgeable and timely decisions about the actions required to protect or improve the food security of an emergency-affected population.
Clinic admission data may also be useful as a type of early warning system and are currently used in many countries, including Burundi. These data must be carefully assessed by an experienced health worker who is aware of the countrys social and political climate in conjunction with other personnel working in sectors related to nutrition, for an increase in admissions could be due either to deterioration in the populations nutritional status or to an increase in the ease of accessibility to clinics. In addition, such data may be biased by the geographical distribution of the clinics. As an early warning system and as a tool for evaluating and assessing current nutritional programmes, however, the data are useful. Clearly, the data are also useful when assessing whether or not a supplementary feeding programme needs to be re-orientated or closed down. The coordination of clinic admission data is crucial if meaningful comparisons between the nutritional situations over time and between regions are to be made - otherwise NGOs may have different reporting formats and action criteria.