|Refugee Nutrition Information System (RNIS), No. 27 - Report on the Nutrition Situation of Refugee and Displaced Populations (UNSSCN, 1999, 78 p.)|
The situation in the Balkans has changed significantly since the last RNIS update (May 12th). Large numbers of people are returning to Kosovo from the Former Yugoslav Republic of Macedonia, Albania and Montenegro since the signing of a peace agreement on June 9th and the deployment of Nato troops within Kosovo. The latest figures from UNHCR estimate that up to 606,000 people had returned by July 6th. Note that this number changes constantly as more refugees are leaving. UNHCR and other agencies had not established organised-repatriations, up until very recently as security remains a concern due to mines and booby-traps on roads and in dwellings. UNHCR-organised repatriations are now underway (UNHCR - 28/06/99, 06/0799; WFP -18/06/99).
Situation within Albania and Macedonia
The camps in Albania and Macedonia are (reported to be) emptying very quickly. Reports indicate that the more at-risk refugee caseloads, for example female-headed households, the elderly or those with limited financial resources, remain in the camps. Most camps in Kukes are now almost empty and are used as transit centres for refugees coming from the rest of Albania before going back to Kosovo. In Kukes WFP is providing a basic food ration for refugees going back to Kosovo (UNHCR - 27/06/99).
In Macedonia, 3 out of an initial 7 camps have now closed (as of 4th July), and UNHCR estimate the remaining camp population to be 12,598 (as compared with 110,000 refugees in camps in early June). At the height of the crisis the total caseload was almost 270,000, which according to most recent estimates has fallen to 26,972. Estimates of refugees in host families are estimated at 14,374, although this figure is disputed by the Macedonian government.
UNHCR recommends that all returnees are provided with food aid on arrival in Kosovo, and thus a repatriation ration is not provided. Reports from NGOs indicate that refugees in camps are stockpiling food to take with them. Refugees in host families usually collect their monthly ration before they return (distribution in camps is on a daily basis and in host families on monthly basis).
The distribution of WFP food commodities continues to those refugees remaining. These distributions are carried out by national and international NGOs, some of whom have an independent food pipeline which increases the complexities for effective food co-ordination. As a result rations vary according to geographical location. A lack of food distribution reports and adequate information about different food aid pipelines means that it is not possible to know what is actually distributed
The rations scales that are available in Macedonia indicate that some camps provide as little as 1700 or 1800 kcal, which in practice may be further reduced (because of leakage or under-distribution). Many refugees were unable to cook food and received bread, canned meat, milk, cheese and later fruit and vegetables for a period of 3 months (UNHCR - 03/07/99). During April WFP distributed some 1.5 million rations of bread, 290,500 'humanitarian daily rations', 250,000 rations of biscuits and 130,000 rations of canned fish to beneficiaries in Albania. In addition, some 32,600 weekly rations of basic commodities were distributed (WFP -11/06/99,22/06/99).
As bread is the main staple food for the refugee and host family population in the region, UNHCR and WFP have agreed to produce and distribute bread instead of wheat flour to refugees in camps on a daily basis. WFP is responsible for supplying the wheat flour and UNHCR is responsible for the cost of production, transportation and distribution of the bread. WFP produced bread through arrangements with some 71 bakeries in Albania by early June. This number will probably decrease as the refugees leave the country. Some mobile bakeries will soon be moved to Kosovo (WFP - 11/06/99; 22/06/99). Refugees in host families are generally provided with a monthly ration of wheatflour (UNHCR - 03/07/99).
Wasting does not appear to be an issue in this crisis. The nutritional situation of the refugees remaining in the camps in Albania and Macedonia is reported to be satisfactory and stable. A recent survey by UNHCR/AAH/IMCH/UNICEF (see Annex), reported that the prevalence of wasting was 2.3%, which is virtually identical to the NCHS/CDC/WHO reference population. The prevalence of stunting (height-for-age) was 10.4%. This prevalence was similar to that reported in a province-wide survey of Kosovo undertaken in December 1998 indicating that the protein-energy status of the refugees in the camps has not been negatively affected by the crisis.
The most worrying finding from the survey was that 23% of children less than 4 months received neither breastmilk nor infant formula. Anecdotal evidence indicates that cows milk is given to these children. This practice is reinforced by distribution of UHT milk in the general ration and through MCH without adequate warning of the dangers of providing this to children less than six months.
All agencies managing camps have agreed to stop the unsupervised distribution of infant formula. Remaining camp stocks will be collected by AAH and stored by UNICEF. AAH is also preparing instructions in Albanian for the use of infant formula and canned baby foods. There are still some agencies distributing infant formula, and milk powder, to refugees in host families.
Virtually all households were found to receive food in the general distribution. 56% of households bought food in the camps to complement the general ration. In camps with unrestricted access, almost one third bought food outside the camp. Also, whilst refugees were not permitted to cook in camps at the time of the survey, over 40% of refugees had the ability to cook.
It is also worth noting that both in the camp and host family refugee population, the proportion of elderly people is much lower than that found in the AAH survey in December 1998. This indicates that elderly people remained in Kosovo.
Less information is available on the nutritional situation of the refugees who are housed with host families. In some cases they have been hosted by these families for several months before the escalation of the crisis in March. The resources of the host families in the affected areas are normally only sufficient for their own needs and they are being stretched by the additional burden of providing for the essential needs of the refugees in their care.
Rations for host families and related refugees
An agreement between WFP, UNHCR and the Albanian Red Cross has resulted in the Red Cross being responsible for the provision of food parcels for the majority of the refugees living with host families and for the host families themselves for June and July (FAO - 29/04/99; WFP - 04/06/99). In Macedonia, the Macedonian Red Cross distributes WFP food rations to refugees in host families, and CRS (with OFDA funding) provides food rations for host families. A number of NGOs provide complementary foods, such as milk, fruits and vegetables, canned meat, baby-foods, pasta, beans etc.
Situation within Kosovo
Many agencies have now re-opened offices which had to be closed when the war broke out in the urban centres of Kosovo, and also in Serbia. Tensions in Kosovo remain high. Although NATO troops are attempting to protect both ethnic Serbs and Albanians, some deaths, mainly Serb, have been reported. Initial assessments in the rural areas of the province have reported that extensive rebuilding will be required in many areas before commercial or agricultural activities can resume as normal (UNHCR -28/06/99).
Anecdotal reports suggest that the some of the IDPs who remained in Kosovo during the bombing, often hiding in woods around villages, may have micronutrient deficiencies. Complementary feeding programmes are being established to target children under five years old and breast-feeding mothers (AAH - 21/06/99). No further information specifically on the nutritional status of the IDPs who remained within Kosovo is currently available to the RNIS.
The most recent reports from within Kosovo indicate that there are no diseases of public health importance with epidemic potential, or any significant incidence of malnutrition. Access to most rural villages, however, is still restricted and thus a complete and comprehensive assessment of the situation has not been made yet (UNHCR-27/06/99).
The commercial food supply in Kosovo is nearly non-existent therefore creating a huge demand for food assistance. Since June 13th WFP has been organising daily convoys of food from Skopje to Kosovo. In some of the more remote areas the organisation has had to use helicopters to drop the food as the roads are unsafe (WFP - 25/06/99). Eight food distribution points are now operational throughout Kosovo and other micro-distribution points are being set-up (UNHCR - 27/06/99).
NGOs are distributing return packages, for example, CRS and Doctors of the World (DOW), with OFDA funding, are planning to distribute 3 day ready to eat food packages to internally displaced and returnees who are unable to cook for themselves for the first few days. The European Community Humanitarian Office (ECHO) is also funding the distribution of return-packages.
IDPs in Serbia and Montenegro
On June 23rd WFP started to distribute food aid to some 50,000 Kosovan Serb IDPs in central Serbia and some 10,000 in FYR Montenegro (WFP - 25/05/99). An estimated 72,000 ethnic Serbs have been displaced from Kosovo to date (UNHCR - 06/07/99).
Overall, the international community has been successful in preventing acute wasting, among the Kosovan refugees. The situation of Kosovan refugees in the region is therefore category IIa - not critical. The continued provision of humanitarian assistance to Kosovan returnees inside Kosovo is expected to reduce their nutritional risk, however, until the full situation within Kosovo is assessed, it is possible that pockets of malnutrition, particularly micronutrient deficiencies associated with acute food insecurity remain. Hence the situation within Kosovo remains category IIb - moderate risk. Little information is available about the situation of the Kosovan Serbs, and given their recent displacement they are considered to be category IIb - moderate risk.
Recommendations and Priorities:
The international community has been successful in preventing wasting and associated humanitarian crises. However, there has been much criticism of the international community's handling of the Kosovo crisis. The main criticism has centred around the issue of co-ordination of humanitarian action, which is critical in order to plan a standardised response, which both integrates the main players, and takes a multi-sectoral approach to reducing risk and addressing humanitarian needs.
There are unprecedented number of agencies and institutions involved in this humanitarian operation, including for example, UN agencies, donor organisations, NATO and more than 350 non governmental organisations, all of whom are involved in delivery of humanitarian assistance.
An enormous (and possibly disproportionate) amount of financial and human resources have been spent on this situation. The distribution of these resources, however, has been uncoordinated and uneven; recently the United Nations Assistant High Commissioner for Refugees complained to donors that only about one third of the $400 million for refugees had been donated, and that UNHCR was operating on a 'hand-to-mouth' basis (BBC website, 1/7/99). Much of the assistance has been channelled bilaterally through NGOs working in the Balkans, for example, the food directed through CRS described above. This means that a substantial part of the humanitarian assistance programme in Kosovo falls outside UN co-ordination.
The effects of this lack of co-ordination have included:
· The distribution of inappropriate and costly foodstuffs as food assistance to refugees. This includes potentially lethal breastmilk substitutes and nutritionally inadequate low protein biscuits;
· Controversial airdrops of food into Kosovo, which have been criticised as unnecessary;
· A general dearth of information on the health and nutritional problems of the affected population and how they might best be dealt with, particularly those refugees hosted in local families;
· Ad hoc as opposed to co-ordinated approaches to the provision of food supplies that resulted in great discrepancies in rations depending not on need but rather on location (WFP - 11/06/99).
· A lack of transparency and accountability due to unacceptably low reporting requirements for the millions of dollars spent.
The immediate task before the international community now is to focus on the current phase of humanitarian assistance and peacekeeping in Kosovo in order that internationally agreed principles, guidelines, and standards are adhered to by all parties - humanitarian, political, civilian and military. Proper assessments by appropriate technical staff will ensure that subsequent decision-making and response are based on sound analysis. The need for co-ordinated strategies based on humanitarian principles, should not be obviated by the wider political agenda.