5.6 Case Studies: The Scale and Severity of Nutritional Problems among Refugees and Displaced Populations

Using examples that have been described by the RNIS reports in the past two years, this section illustrates that both acute and chronic nutritional crises among refugees and displaced populations continue to occur on a regular basis. This section illustrates the wide range of prevalences of undernutrition and the underlying causes, including the basic causes linked with political instability and conflict. The response of the international community to these situations is also described. The case studies presented below have been chosen represent different categories of emergency and highlight the effects of different operational responses on nutritional outcome.

Recent Displacement Emergencies: Balkans Region and Angola

The situations in the Balkans region and Angola probably represent the two extremes of operational response to nutritional crises caused by large-scale displacement in 1999. The basic causes of the crises were similar - political instability led to violence mat caused displacement Both groups of displaced people were virtually completely dependent on food assistance during the summer of 1999, as displacement prevented farmers from harvesting their crops and others from earning a wage. Before the displacement, the conflicts had seriously disrupted food security as crops and animals were looted or burnt. Trade routes were also disrupted, and access to markets was constrained. Despite the similarities of these two crises, their impact on the nutritional status of the affected populations was very different.

At the peak of the emergency in the Balkans region, an estimated 250,000 Kosovar refugees were registered in the former Yugoslav Republic of Macedonia and 440,000 in Albania. Tens of thousands of other refugees were registered in Montenegro, and still others were evacuated out of the immediate region. Table 5.1 shows the results of four AAH nutritional surveys undertaken in the region between December 1998 and July 1999. The prevalence of wasting and/or oedema among the refugees did not increase significantly during the period of displacement (wasting is defined as < -2 Z-scores and severe wasting as < -3 Z-scores as opposed to per cent below median).

The Government of Angola has estimated that 900,000 people were displaced between December 1998 and September 1999 because of fighting between the government and the rebels of the National Union for the Total Independence of Angola (UNITA). Many of the displaced fled to cities in the highland provinces, where high prevalences of wasting and/or oedema were recorded. No national level nutritional data are available for Angola, but the prevalences recorded in 1999 should be compared with the much lower levels recorded in these cities before the current crisis (see Table 5.2).

TABLE 5.1: Prevalence of wasting and stunting among the Kosovar population in situ and in refugee camps between December 1998 and July 1999

	Kosovo population, December 1998 (n = 922)	Albania camps, June 1999 (n = 906)	Macedonia camps, June 1999 (n = 859)	Kosovo population, July 1999 (n = 922)
	Total Severe	Total Severe	Total Severe	Total Severe
Wastinga (%)	2.0 0.2	4.6 0.2	2.4 <0.1	3.1 1.0
Stunting (%)	9.4 2.1	14.6 3.0	10.4 2.6	10.7 3.0

Source: 1.

Note: Data are for children 6 to 59 months old.
^a These figures include oedema.

The humanitarian response to the Balkans emergency was effective in preventing an increase in the prevalence of wasting, stunting, and oedema among the 6 - to 59-month age group. The same cannot be said for the displaced population in Angola’s highland cities. Many explanations for the differences can be given. The most important of these was the huge imbalance in assistance given. An unprecedented number of agencies and institutions were involved in the humanitarian operation in the Balkans, including UN agencies, donor organizations, NATO, and up to 350 NGOs. Enormous amounts of financial and human resources were spent on this situation compared with that in other parts of the world. In contrast, the programmes in Angola were seriously underfunded. This resulted in the delivery of insufficient amounts of food and medical supplies to the affected population. Consequently the population’s nutritional status deteriorated and mortality rates increased.

A further factor that contributed to the differences in the prevalence of wasting was the difference in the pre-emergency level of health and nutrition of the two populations. Many of the Angolan IDPs arrived at the highland cities in very poor condition, whereas in the Balkans nutritional screenings did not find the prevalence of wasting and/or oedema to be especially elevated on arrival at the camps. This is partially because the humanitarian community had access to the Balkan populations before the crisis - which was not the case in Angola.

Other factors that played an important role in determining the level of undernutrition among the two populations after their displacement included security conditions, logistic access, and wealth redistribution. In terms of logistics, access to the Balkan population (primarily by land from ports in Montenegro and Greece) was relatively straightforward. The security conditions were stable owing to the presence of NATO troops. In addition the geographical area over which the displaced were spread was smaller. In contrast, the strategic roads around the besieged cities of Angola were cut off by UNITA for many months, and ambushes on the remaining roads were frequent. Logistical capacities for food assistance were dependent on the local security situation and changed very rapidly. Frequent attacks, fluctuating road tariffs, and the scarcity of fuel all led to increased costs of transport and decreased capacity. Air deliveries were also hindered by inadequate ground facilities and very high maintenance and insurance costs.

TABLE 5.2: Prevalence of wasting in Angola’s highland cities between 1995 and 1999

	Malange				Huambo
	June 1997	Jan. 1999	June 1999	Sept. 1999	April 1995	Jan. 1999	May 1999
Total wastinga (%)	2.3	11.0	20-25	21.5	3.7	14.6	16.7
Severe wastinga (%)	0.4	4.5	5-7	10.5	0.1	7.3	3.5

Source: 1.
Note: Data are for children 6 to 59 months old.
^a These figures include oedema

Household food security assessments have found that a large proportion of Albanian households have a family member working abroad or elsewhere in the region from whom they received remittances both before and during the crisis. In contrast, few Angolan households have a family member working abroad; moreover, resources are extremely limited for the majority of Angola’s population, and thus very little wealth redistribution was possible.

Now that the majority of the Kosovar refugees have returned to their home areas, the international humanitarian community is focusing on providing assistance for their rehabilitation. Targetted food distributions coordinated by UNHCR and WFP continue via a distribution mechanism that involves a national NGO. Construction materials to provide shelter and winter seed were major priorities. The programmes are currently well funded.

The population of Angola’s besieged cities, in contrast, continue to suffer. Insecurity and the presence of landmines prevent the residents from carrying out their usual farming activities. Employment opportunities have ceased as a result of the war, and food prices have soared. The army, and possibly also the IDPs, have consumed the residents’ harvest reserves, and the prevalence of undernutrition is rising in this group. The government has tried to ease the problem of poor food supply by distributing land before the planting season, and various international organizations are distributing seeds and tools. These initiatives are, however, constrained by the lack of secure farmland where UNITA forces are based near the cities and funding shortages. The nutritional outlook for the populations of Angola’s highland cities is poor.

Protracted Refugee Emergencies: Refugees in the United Republic of Tanzania and Bhutanese Refugees in Nepal

In June 1999 the United Republic of Tanzania hosted approximately 250,000 Burundian refugees who fled from ethnic and political violence in Burundi. Some of these refugees have been in Tanzania since 1993 (when Burundi’s first democratically elected president was assassinated), although others have arrived more recently. At the same time, there were approximately 96,500 Bhutanese refugees registered in Nepal, most of whom fled Bhutan in the early 1990s as a result of the “one nation, one people” policy of cultural assimilation in Bhutan.

The nutritional status of the Burundian refugees in the United Republic of Tanzania has been stable since 1995. In the Ngara camps, levels of wasting and oedema have remained below 5% since 1997, with the most recent survey results indicating a prevalence of wasting of 1.8% (< -2 Z-scores) and no oedema. At the same time children in the villages surrounding the camps showed a 5.2% prevalence of wasting and/or oedema (compared with the national prevalence for Tanzania of 7.2%).⁵¹

The most recent estimate of the prevalence of wasting (defined as < 80% median weight-for-height) among the Bhutanese children aged 6 - 59 months, in June 1999, was 4.1%. This low level of wasting has been maintained since 1993, the year after the majority of the refugees arrived (see Figure 5.2).

FIGURE 5.2: Prevalence of wasting in the Nepalese refugee camps

Source: 1.
Note: Wasting is here defined as < 80% median weight-for-height.

The refugees in Nepal and the United Republic of Tanzania are almost entirely dependent on external assistance for their food and non-food needs. In both countries, programmes have been well funded by donors, and hence there has been a relatively constant food pipeline. Public health services include growth monitoring, malaria control, micronutrient supplementation, supplementary feeding programmes, and de-worming programmes. Social organization in the camps allows food distribution to be largely organized by the refugees themselves. The social organizations that have developed over the years also help implement other programmes.

While the prevalence of wasting is relatively low, the prevalence of stunting among refugees in Tanzania and Nepal is high (see Table 5.3). Given that the children measured were born in the camps, this indicates poor food security, caring practices, and health environment during their first two years in the camp.^{52, 53} However, it should be noted that national surveys in both Nepal and the United Republic of Tanzania have also found high levels of stunting.

Bhutanese refugees in Nepal have suffered from micronutrient deficiencies from a few months after their arrival, indicating a poor-quality diet. An outbreak of beriberi was identified in 1993, the cause of which was thought to be the distribution of polished rice as the main staple. A number of strategies were put in place to increase the amount of micronutrients in the diet. For example, parboiled rice, fortified blended food, and fresh vegetables were included in the general radon, along with iodized salt and vegetable oil fortified with vitamin A. These changes were accompanied by nutrition information and communication campaigns related to the washing of rice and the health benefits of parboiled rice and blended food. These combined strategies produced significant reductions in levels of micronutrient deficiencies and greater awareness on the part of the community.⁴³

Despite these strategies a UNHCR/CDC survey in October 1999 in the Nepalese camps, which was undertaken in response to reports of an outbreak of angular stomatitis in this population, found that low riboflavin status and low serum folate status are common among adolescent refugees. Low riboflavin and serum folate are associated with angular stomatitis. The authors of the survey report suggested that the agencies involved in the health and nutrition of the refugees should increase the available dietary folate and riboflavin.

Although the programmes for the refugee populations in the United Republic of Tanzania and Nepal are long established and relatively well funded, undernutrition in terms of both stunting and micronutrient deficiencies persist. In other refugee camps, such as those in Kenya, much higher levels of wasting may be found. For example, the prevalence of wasting among children aged 6 - 59 months in the camps in the Dadaab area was estimated at 15% in July 1999 (RNIS 29).

Complex Emergency Situations Involving IDPs: Bahr El Ghazal, Southern Sudan, and Burundi

The civil war in southern Sudan has been ongoing for 15 years. Bahr El Ghazal is one of the regions worst affected by conflict over this period. War strategies, on all sides, often target civilians. Regular attacks have led to loss of assets, destitution, and displacement for a large proportion of the population. Strategies for accessing food have declined over time and are constrained because of insecurity and little or no access to markets or employment. This has made the population more vulnerable to the regular flooding and drought in the region.

TABLE 5.3: Prevalence of stunting among refugees and nationals in the United Republic of Tanzania and Nepal

	United Republic of Tanzania		Nepal
	Refugeesa (6-59 months), 1999	National surveya (0-5 months), 1996	Refugeesb (6-59 months), 1999	National surveyb (0-36 months), 1996
Total stunting (%)	44.1	43.4	31.7	48.8
Severe stunting (%)	18.8	17.8	7.0	20.2

Sources: 1, 50.
^a The definitions of total and severe stunting are based on Z-scores.
^b The definitions of total and severe stunting are based on median values

Operation Lifeline Sudan (OLS) was established in 1989, following the 1988 famine in Bahr El Ghazal, to assist war-affected civilians.²⁹ OLS is an arrangement based on an access agreement negotiated by the UN with the warring parties. It allows humanitarian assistance to be provided to civilians during conflict. A large number of agencies provide humanitarian assistance under the UN umbrella. In non-government-controlled areas, agencies and warring parties agreed that aid should be provided according to defined humanitarian principles: neutrality, impartiality, account-ability, and transparency.

An annual needs assessment forms the basis of the annual appeal and shapes the programming of OLS. From 1994, nutritional surveillance declined in importance, and needs assessments became dominated by the food economy approach, which was introduced to more effectively target food aid. It was not until the 1998 crisis that nutritional surveys were conducted again on any significant scale.

The nutritional situation in parts of Bahr El Ghazal was catastrophic between May and August 1998. Extremely high rates of undernutrition and mortality were reported during this period. In Ajiep, the prevalence of wasting (< -2 Z-scores) and/or oedema was estimated in July at 80.3% and severe wasting (< -3 Z-scores) and/or oedema at 48.5% (using a standard two-stage cluster sampling methodology). The CMR in Ajiep was estimated at 26 per 10,000 per day (see Figure 5.3). Many of those dying were adults, indicating the severity of the situation. These prevalences and rates are among the highest ever recorded in famine-affected populations. The prevalence of wasting (<80% median) and severe wasting (<70% median) and/or oedema in Tonj County between May 1995 and 1999 can be seen in Figure 5.4. In 1998, the population of Tonj County faced its most severe humanitarian crisis in ten years. A prevalence of 33.4% wasting and/or oedema, including 9.9% severe wasting and/or oedema, was estimated in May 1998.

Food insecurity turned into crisis as a result of an attack on Wau (in Bahr El Ghazal), two consecutive years of drought, and population displacement throughout the region. The crisis worsened as the Government of Sudan suspended flights, including OLS humanitarian flights, over Bahr El Ghazal in February 1998, preventing the delivery of aid to the war-affected population. Even after the ban was lifted, WFP was initially unable to respond to the situation owing to a lack of funds. Unequal food distributions and poor coordination between the agencies assisting the population added to the problems at hand.

FIGURE 5.3: Prevalence of acute undernutrition (wasting and/or oedema) and CMRs in Ajiep, Sudan, 1998-99

Source: 1.

FIGURE 5.4: Prevalence of acute undernutrition (wasting and/or oedema) in Tonj County, Sudan, 1995-99

Source: 1.

By November 1998, the nutritional situation in southern Sudan had improved considerably. By May 1999 the prevalence of undernutrition and the CMR were only slightly higher than before the crisis, due to better security and the lifting of the flight ban. Household food security also improved due to a harvest in some areas and a seasonal increase in me availability of wild foods, milk, and fish between September and February. In addition, increased funding for OLS and other organizations allowed increased food deliveries to the affected populations, and the humanitarian community set up numerous selective and therapeutic feeding programmes.

The most recent food security studies in Bahr El Ghazal have described the nutritional situation as fragile. Very high prevalences of undernutrition and CMRs are no longer found in most areas, although pockets do exist. Many households still require external assistance, which OLS and other organizations are currently providing when the security situation permits.

In Burundi, an estimated 600,000 people, primarily IDPs, required assistance as of mid-1999. Large numbers of people have been displaced because of the ongoing political and ethnic violence, which has been widespread since the first democratic elections in 1993, despite the ongoing Arusha peace process.

In 1997 OCHA and the U.S. Office for Foreign Disaster Assistance (OFDA) asked UNICEF to be the lead agency in matters of nutrition in Burundi. In the second half of 1998, when the security situation had improved in much of the country, UNICEF, in consultation with the MOH, OCHA, and OFDA, designed a nutrition surveillance strategy for Burundi involving anthropometric surveys, food security assessments, and the analysis of clinic admission data in all provinces where security conditions allowed the work to be undertaken. This surveillance system was based at the provincial level in order to prevent any important inter-provincial differences being masked by a national survey. WFP and UNICEF implemented an MoU at the country level.

The results of anthropometric surveys conducted from January to August 1998 can be seen in Figure 5.5. The prevalence of wasting (< - 2 Z-scores) and/or oedema varied from 23.8% in Gitega North to 10% in Cankuzo. The inter-provincial differences in the prevalence of undernutrition are due to the large variations in the security situation, access, and infrastructure throughout the country, which in turn affect food security, social and care structures, and the public health environment.

FIGURE 5.5: Prevalence of acute undernutrition (wasting and/or oedema) by province in Burundi, January 1998-August 1998

Source: 54.

The results of further surveys conducted between September 1998 and February 1999 are shown in Figure 5.6. The prevalence of undernutrition declined during the period between the two survey rounds: for example, the prevalence of wasting and/or oedema in Cibitoke decreased from 21.2% to 5.6% between April and October 1998. Food security surveys indicated that the major reason for this was the improvement in the security situation, which enabled camps of displaced people to be dispersed and people to return to their homes after hiding in the forest. Many households were then able to resume their normal agricultural activities. Other reasons included food and seed distribution programmes by WFP and FAO, the supplementary and therapeutic feeding programmes run by NGOs, and the increased availability of medicines for the treatment of malaria, which is a major cause of morbidity and mortality.

FIGURE 5.6: Prevalence of acute undernutrition (wasting and/or oedema) by province in Burundi, September 1998-February 1999

Source: 54.

The examples of the 1998 famine in southern Sudan, in which an estimated 60,000 people died, and the nutritional situation in Burundi illustrate the importance of the basic causes of undernutrition, including the wider social, economic, and political situations that affect security conditions and the distribution of resources.