|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 reviews key developments in relation to specific strategies and types of nutrition related interventions in emergencies, including strategies to support and strengthen food security, general food distribution, supplementary feeding, therapeutic feeding, strategies to prevent micronutrient deficiencies, and to address the health and care related causes of undernutrition. The transition to self-reliance is also discussed briefly.
Strategies to Support Food Security and Strengthen Livelihoods
Food security initiatives are elements of programmes in some protracted refugee emergencies. They help integrate refugees in the host country and returnees in their country of origin, as well as the displaced and ex-combatants. Usually concerned with agricultural activities, these initiatives are intended to restore the assets and production levels of affected communities as soon as possible. The food security initiatives are often designed from the findings of food economy and livelihood assessments.
FAO, through its Special Relief Operations Service, buys and delivers agricultural essentials such as seeds, tools, fertilizers, fishing gear, and livestock and veterinary supplies to permit immediate resumption of basic food production.23 In Rwanda, for example, FAO coordinated the procurement and distribution of seeds and basic agricultural equipment, as well as seed multiplication schemes. With the war in Bosnia Herzegovina, markets and the supply system for seed, fertilizer, and insecticides experienced almost total breakdown. FAO led a major operation to provide 1,100 tonnes of winter wheat seed to farmers in the most destitute area (the former Bihac pocket) for the 1995 autumn planting.23
The WFP may complement these activities by distributing a food ration that allows the affected population to engage in these critical activities. The distribution of a seed protection ration, to prevent people consuming their seeds, is also common, and occurred during recent agricultural cycles in Burundi (see section 5.6).
For returnees, UNHCR has developed a system of quick impact projects (QIPs), which are small-scale projects with rapid implementation. The projects are intended to address urgent reintegration needs and create suitable conditions for repatriation. QIPs include agricultural and veterinary support, fishing, transportation, education, sanitation, and income-generation projects. In Somalia (1992-94) agricultural QIPs were the largest group. QIPs are set up not only to benefit returnees, but also to help other sections of war-affected populations rebuild their communities and to assist reconciliation. UNHCR expects to hand over rehabilitation activities to other development actors such as UN agencies, NGOs, and government ministries after a limited period.28
In agro-pastoralist areas of Africa, like southern Sudan, where livestock forms the basis of livelihoods, livestock health programmes have been one of the most successful means of supporting food security, even in a complex emergency. Operation Lifeline Sudan has included a variety of other activities to support livelihood, including the provision of seeds, tools, and fishing equipment. A number of bartering schemes were attempted in which local goods could be bartered for essential items such as mosquito nets and soap.29 In Afghanistan animal production suffered when veterinary services collapsed as a result of the war. FAO and other international organizations and NGOs have worked to establish community-based veterinary field units.23
For refugee crises and internally displaced populations, the most common constraints to implementing food security programmes are the political and security conditions that restrict access to land and the mobility of the affected population (for example, in Angola, Burundi, Nepal, Rwanda, Tanzania, and around Khartoum). A process of sustainable recovery requires stable government and security; otherwise, conflict will undermine any attempts at rehabilitation and reconstruction.
The distribution of an adequate general ration continues to be the most important humanitarian response to nutritional emergencies, both in fiscal terms and in terms of its importance in alleviating and preventing suffering and saving lives.
Over the past ten years general rations have improved.e The composition and quality of the general ration are critical to the well being of emergency-affected populations, especially where they have no other source of food. Internationally agreed guidelines and policies, developed by WFP and UNHCR with inputs from WHO and others, have helped improve planned rations.30 These improvements include the following:
e The general ration is the food ration given to everyone in the affected population irrespective of age and sex; that is, all receive the same quantity and type of food.28
· The minimum planning figure (initial reference value) for energy requirements for populations entirely dependent on external food aid has increased from 1,900 to 2,100 kcal.
· Guidelines have been developed for adjusting this planning figure to suit local circumstances. Adjustments are made according to the age and gender composition of the population, their activity levels, their health, their nutritional and physiological status, the environmental temperature, and their access to additional sources of food.
· Recommended levels of fat and protein as a percentage of total energy have been established (17% and 12% respectively).
· Fortified food aid commodities, in particular salt (iodized) and vegetable oil (fortified with vitamin A), are now used routinely.
· Fortified blended food is now included in general rations for populations susceptible to micro-nutrient deficiency diseases.
· Provision of milled flour, rather than whole grains, is now recommended, particularly in the early Stages of an emergency.
Other recent developments include the increasing use of Humanitarian Daily Rations (HDRs)f and Meals-Ready-to-Eat (MREs).g These rations were distributed in the Balkans region, but their use has not been evaluated yet.
f Humanitarian Daily Rations, developed by the U.S. Department of Defense, are specifically designed to meet the nutritional needs of civilians in humanitarian crisis. One HDR provides the average daily needs of the civilian population with about 1,900-2,200 kcal and adequate protein, fat, and micronutrients.
g Meals-Ready-to-Bat are based on American recipes and are designed to provide one meal three times a day (3,600 kcal). MREs contain fish and meat products, and there are over 25 different varieties.
Distribution and Targetting Mechanisms
In the early 1990s the balance in WFPs activities shifted from predominantly development-related programmes to emergency programming. At the same time an increasing number of NGOs were becoming WFP operational partners in food distribution programmes. Given the paucity of good practice guidelines on general food distribution, increasing attention was paid to improving systems of distribution and developing guidelines.31 The first detailed UN guidelines were published in 1997 by UNHCR.28
Agencies increasingly recognize the role of women in providing food for their families in emergencies. As a direct result of this, WFP has made policy commitments to giving women direct access to and control over food aid by targetting women directly and encouraging them to participate in designing, implementing, and monitoring food distributions.32
Attempts have also been made to increase, the role of affected communities more generally in the distribution of food. Community-based distribution systems give responsibility for food distribution and targetting in part to locally elected committees. These systems have been tried in protracted refugee situations (Uganda), drought-affected communities (north-east Kenya, Tanzania), and even complex emergencies (southern Sudan), with varying degrees of success.33
Novel or alternative approaches to food distribution have been developed in many situations where the distribution of a standard food basket has proved problematic and even dangerous. Examples include complex emergencies where food aid was at risk of being misappropriated by rival factions, or following periods of prolonged displacement in harsh conditions where people lacked the wherewithal (fuel, cooking pots, cooking skills for new foods, etc.) to prepare food, or were in an extremely poor physiological state. Examples of successful approaches described in the RNIS include
· cooked food distribution (Somalia, 1992; Democratic Republic of Congo, 1997; Liberia, 1996)
· community kitchens, where people cook for themselves (Angola, 1999; Balkans region, 1999; Armenia, 1994; Georgia 1994)
· support of subsidized bakeries (Afghanistan, 1997-99; Balkans region, 1999)
· snow drop technology, in which a cargo plane is deployed to drop 200 g plastic packets of high-energy biscuits, which are packed in such a way that they float and circle as they fall through the air, ensuring a soft landing (East Timor, 1999)
Supplementary feeding programmes are required to correct moderate wasting and to prevent moderately undernourished children from becoming severely undernourished. In contrast to general food distribution programmes, practical and technical guidelines for implementing supplementary and therapeutic feeding programmes have been in existence for more than 25 years.
An early example of supplementary feeding guidelines is the set of local guidelines developed by the Somali Ministry of Healths Refugee Health Unit in collaboration with UNHCR and NGOs in the early 1980s. Since then several practical guidelines have been produced by NGOs34, 35 and WHO.36 More recently, WFP and UNHCR have produced their own guidelines for selective feeding programmes in emergency situations.37 In contrast to earlier guidelines, these distinguish between targetted supplementary feeding programmes where assistance is provided selectively according to specified criteria of need, to some people or households but not to all, and blanket supplementary feeding programmes that target an entire group of people, such as children under three.
Recent years have seen a consolidation of existing knowledge in relation to the treatment of severely undernourished children. This should lead to significant reductions in fatality rates. The consolidation of knowledge has resulted from several related initiatives, including the development and dissemination of WHO guidelinesh, 38 and the efforts of NGOs, including ACF, MSF, and Concern, which have developed appropriate nutritional and medical protocols and systems for their application amid the most difficult working conditions. Consequently, there have been considerable advances in the quality and effectiveness of therapeutic feeding programmes in emergencies.
h These can be found at http://www.who.int/nut/Manageme.pdf. Meetings to develop training materials from these guidelines are planned for the near future.
Commercial companies have produced and marketed new milk (F100 and F75 milki) and porridge formulas, based on the WHO guidelines and on the type I and II nutrient concept.39 Recently a ready-to-use therapeutic food (RTUF) that has a nutritional component similar to F100 and can be eaten directly (without the addition of water) has been developed. This product may be useful in contaminated environments or where residential management is not possible, as it decreases the problems of bacterial contamination via unclean water.40
i Two formula diets, F100 and F75, are used in the treatment of severely undernourished children. F-75 (315 kJ/100 ml) is used during the initial phase of treatment, while F-100 (420 kJ/100 ml) is used in the rehabilitation phase, after the appetite has returned. These formulas can be prepared from the basic ingredients: dried skimmed milk, sugar, cereal flour, oil, mineral mix, and vitamin mix. They are also commercially available as powder formulations that are mixed with water, although the commercial formula is expensive.
It is increasingly recognized that therapeutic feeding is as much a medical intervention as a nutritional intervention, given that most severely undernourished patients are also extremely sick. Greater attention is also now paid to the non-food and non-medical inputs, including clean water, sanitation, hygiene, emotional care and stimulation, and the presence of enough appropriately trained personnel.
A model to assess the risk of mortality for children treated for severe undernutrition in different centres, taking initial anthropometric status and the presence or absence of oedema into account, has recently been developed. This will be useful in assessing the effectiveness of different treatment centres.41
There remains a need to transfer knowledge concerning therapeutic feeding practices from NGO personnel to Ministry of Health (MOH) personnel. This is particularly relevant at the end of an emergency during the recovery stage, when national health capacities need to be strengthened before the NGOs phase out their operations. Demonstration centres and local training guidelines would be useful to achieve this end.
Strategies to Prevent Micronutrient Deficiencies
In emergencies it is likely that micronutrient deficiencies, particularly iodine deficiency disorders, iron deficiency, and vitamin A deficiency, are amplified where there may be restricted access to food. Since the sporadic outbreaks of the more uncommon deficiencies in the late 1980s, including scurvy (Ethiopia), pellagra (Mozambican refugees in Malawi), and beriberi (Bhutanese refugees in Nepal), UNHCR and WFP have implemented a number of strategies to prevent micronutrient deficiencies occurring in at-risk populations. In order of priority these include:42
· promoting the production of fresh fruit and vegetables, such as in Nepal
· providing fresh food items in the general ration, such as vegetables in the Balkans region
· adding a food to the ration that is rich in vitamins and minerals, such as fortified blended food, which is now routine practice in many refugee situations
· promoting access to sources of food rich in micro-nutrients, such as groundnuts as a source of niacin in a maize-based ration
· providing fortified foods in the ration, including iodized salt and vegetable oil fortified with vitamin A
· distributing a prophylactic dose of vitamin A to infants and young children every six months in refugee and displaced populations.j
j The distribution of micronutrient supplements generally is a very low priority, particularly for water-soluble vitamins and minerals that must be taken on a daily basis (vitamin A is an exception to this).
· research assessing how wild indigenous foods may be used to prevent micronutrient deficiencies.43 In some areas of southern Sudan wild indigenous foods may account for up to 50 - 60% of the energy content of the poorest households diets. They also contain relatively high levels of micronutrients.
In the majority of refugee and IDP contexts there are major constraints to implementing some of these strategies, particularly promoting access to food through food production or other means. For this reason investments in a range of strategies are likely to be more effective than focusing on a single approach.44
Despite the strategies employed, micronutrient deficiencies persist in refugee and displaced populations. For example, in 1998 a UNHCR/CDC survey undertaken in Kenyan refugee camps indicated that high prevalences of vitamin A deficiency exist among adolescents. Another UNHCR/CDC survey in the Bhutanese refugee camps in Nepal investigated an outbreak of angular stomatitis in 1999 (see section 5.6). Over 600 cases of pellagra were confirmed in Kuito in Angola between August and November 1999 (RNIS 29).1
Strategies to Promote Care
Successful strategies to promote care require an understanding and analysis of how displacement and forced migration cause disruption and upheaval for families and communities and affect their ability to care for themselves and their children. Social networks may be weakened or collapse altogether, and the support mothers once relied on from family, friends, and, for example, the local health worker, may no longer be available.
Strategies to promote and support caregiving behaviours in emergencies have tended to focus on the individual caregivers and particular nutritionally vulnerable groups, including infants and young children, pregnant and lactating women, and the elderly. For example, in Eastern Europe, in Bosnia Herzegovina in the early 1990s, and more recently in the Balkans region, the promotion, protection, and support of breastfeeding was of special concern because the emergency-affected populations were considered dependent to a greater or lesser extent on breastmilk substitutes.
During the 1999 Balkans crisis, donations of breastmilk substitutes and commercial complementary foods were received and distributed through the aid operation either under the auspices of key UN agencies or directly by voluntary agencies delivering donated aid by road. As a consequence, breastmilk substitutes, bottles, and UHT milk were included in general distributions. Mother-and-baby tents, which became the foci for infant feeding interventions within the refugee camps, were also used in some instances to distribute infant foods to target groups. However, survey results indicated that among the refugees in Macedonia, 80-90% of mothers initiated breastfeeding, indicating great potential for the promotion of breastfeeding.45 This potential was not effectively realized, which may have had long-term implications for infant feeding practice. In addition to their inappropriate supply, infant feeding products were almost exclusively labelled in foreign languages.
These activities were conducted in spite of various UN and NGO policies aimed at protecting breastfeeding. The International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly Resolutions are perhaps the most long established and overarching of these international agreements (see Chapter 3). Many contraventions of the Code by international agencies were documented. Infant formula was oversupplied and the extra formula was passed on by international aid agencies to established Ministry of Health maternity units. Thus the violations were not restricted to emergency interventions.45, 46
This recent experience highlights the importance of communication, training, and coordination in meeting the nutritional needs of infants during emergencies and further underlines the need for assessing normal infant feeding practice before providing breastmilk substitutes.
In selective feeding programmes, international agencies are paying more attention to supporting caregivers both through nutrition education on infant feeding practices and through more material support that will enable them to take care of themselves and their children more effectively. This includes ensuring that pregnant and lactating women have access to extra quantities of good-quality food, adequate time to rest, and appropriate health care from trained practitioners.
Emotional care and stimulation of infants and young children in selective feeding programmes, particularly therapeutic programmes, are now recognized as an essential part of their treatment and recovery.38, 47, 48 In Kisangani, eastern Democratic Republic of Congo, more than 600 severely undernourished unaccompanied children were treated in the therapeutic feeding programme run by Concern. Apart from being severely undernourished, these children were also traumatized. There was evidence of disorientation, withdrawal, extreme grief, and other behaviours indicative of psychological stress. The absence of the families was a major constraint to providing adequate care. As a result Concern employed, trained, and supported local women who worked in shifts as caregivers, with a special emphasis on creating a secure and comfortable environment for the children. This included child-focused activities to maintain the childs physical comfort (hygiene and warmth) and conversing and motivating the children to take food and medicines provided. Another important initiative was to ensure that siblings were not separated.49
How relief programmes are organized, in terms of community consultation and active involvement in running programmes, can affect social systems, and even help to restore and rebuild both formal and informal networks of support.
Transition to Self-Reliance
The transition to self-reliance involves strengthening livelihoods among refugee or displaced populations. The political and security context, which restricts the affected populations mobility and access to land, is the most common constraint. The process of transition requires several conditions: some degree of political stability and security, a reasonable guarantee of access to necessary means of livelihood (particularly access to land and/or wage labour opportunities), and an acceptable level of legitimacy of the controlling political authority of the refugee or displaced population.
To assess possibilities for transition, information is required about needs, livelihood strategies, the nature of the relationship between host and displaced populations, and the external operating environment - that is, markets and host-country government policy toward economic activities on the part of refugee or displaced populations. To obtain this kind of information, a more comprehensive kind of livelihoods assessment approach is required than the focused food aid requirements assessment methodologies can provide. This in turn may require more diversified expertise on assessment teams.
Monitoring systems must be expanded beyond inputs and outcomes. First, all the usual threats to livelihood security (like rainfall, prices) are critical in circumstances of limited potential for self-reliance. Second, changes in the external environment could rapidly reverse improvements and undermine the ability of vulnerable populations to achieve or maintain self-reliance. Third, changes in the demographic composition of the displaced population can lead to the deterioration of self-reliance strategies. Fourth, the impact and sustainability of self-reliance strategies themselves must be monitored, in terms of environmental impact, relations with the host community, and physical safety. Monitoring is critical, because these changes may require a change in programme activities to protect livelihoods or provide safety nets.