Refugee Nutrition Information System (RNIS), No. 25 − Report on theNutrition Situation of Refugee and Displaced Populations

Table of ContentsRefugee Nutrition Information System (RNIS), No. 25 − Report on the Nutrition Situation of Refugee and Displaced Populations..............................................................................................................................1

Foreword.................................................................................................................................................1I. Introduction..........................................................................................................................................2II. Our Mission is Possible!.....................................................................................................................4III. Why, then, hasn’t this always happened?.........................................................................................5

A. Quantity of available food............................................................................................................6B. Type of food available..................................................................................................................8C. Shortcomings outside the realm of food......................................................................................8D. Lack of understanding of context...............................................................................................10E. Special case of IDPs..................................................................................................................10

IV. What has been done to improve response?....................................................................................10A. Exchanging ideas and raising awareness.................................................................................10B. New practices and policies........................................................................................................11C. Food distribution modalities.......................................................................................................13D. Combating micronutrient deficiencies........................................................................................14E. Gaining a better understanding of the context...........................................................................14F. Considering care of the vulnerable, especially young children..................................................15

V. Where do we go from here?.............................................................................................................15A. Promotion of human rights.........................................................................................................15B. Improved presentation of evidence of successes and needs....................................................16C. Increased consideration of emergency context.........................................................................17D. Preventing and combating micronutrient deficiencies...............................................................17E. Capacity building, including training..........................................................................................18F. Increased geographic coverage.................................................................................................18

VI. Conclusion.......................................................................................................................................18Bibliography..........................................................................................................................................19Annex I: Reports of Micronutrient Malnutrition......................................................................................20Annex II: Guiding Principles on Caring for Nutritionally Vulnerable in Emergencies............................22Indicators..............................................................................................................................................22

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Refugee Nutrition Information System (RNIS), No. 25 − Report on theNutrition Situation of Refugee and Displaced Populations

Foreword

The Refugee Nutrition Information System (RNIS) is an inter−agency collaborative effort, started in 1993 atthe initiative of the United Nations High Commissioner for Refugee (UNHCR) and the World Food Programme(WFP), and coordinated by the Secretariat of the Administrative Committee on Coordination’sSub−Committee on Nutrition (SCN). RNIS Reports focus attention on the most vulnerable people on earth −those forced to flee their homes and live either as refugees or internally displaced persons. These Reportsbring together data from a wide variety of sources − both UN and NGO − to provide a comprehensive pictureof the nutritional situation of such persons. They also provide insight into the varied elements underlyingforced movements of populations as well as factors affecting nutrition. The broad scope of informationprovided in the Reports has extended their relevance beyond technical analysis into the areas of advocacyand public awareness.

As of 1 January 1998, there were 22.4 million persons of concern to UNHCR world−wide, including refugees,returnees, asylum seekers and some internally displaced persons. Most of the food provided to these personscomes through WFP. In 1997, WFP provided food aid to 19 million refugees, returnees and internallydisplaced persons world−wide. In the past five years, despite an overall decline in food aid availability, thetonnage made available for relief has remained stable.

A Memorandum of Understanding signed by WFP and UNHCR in 1994 and updated in 1997 has more clearlydefined their working relationship and engendered improvement in emergency food aid provision. A bettermatching of the food basket to the cultural and nutritional needs of the beneficiary population has beenachieved through increased access to milling facilities, the regular provision of fortified blended foods toprevent micronutrient malnutrition, and the recently revised minimum ration for populations totally dependenton food aid from 1900 to 2100 kcals/person/day.

In addition to providing data and helping to guide the direction of the RNIS project, UNHCR and WFP providefinancial support. Invaluable funding has also been provided by CIDA, DFA (Ireland), DFID, NORAD, USAID,and UNICEF.

Over the years, the Reports have documented successful operations such as the repatriation of Mozambicanrefugees and the provision of aid to the large number of refugees affected by the crisis in the Great Lakesregion. In addition, they have highlighted unmet needs and interventions to be undertaken to resolve ongoingproblems.

We look forward to the continued publication of the Reports to help us track the nutritional status of uprootedpopulations and improve our responses. This is particularly important as we strive to promote access toappropriate and adequate nutrition as a basic human right.

Catherine BertiniExecutive DirectorWorld Food Programme

Sadako OgataHigh CommissionerUN High Commissioner for Refugees

This report is issued on the general responsibility of the Secretariat of the U.N.’s ACC/Sub−Committee onNutrition; the material it contains should not be regarded as necessarily endorsed by, or reflecting the officialpositions of the ACC/SCN and its U.N. member agencies. The designations employed and the presentationof material in this publication do not imply the expression of any opinion whatsoever on the part of theACC/SCN or its U.N. member agencies concerning the legal status of any country, territory, city or area orof its authorities, or concerning the delimitation of its frontiers or boundaries.

This report was compiled by Jane Wallace, ACC/SCN Secretariat, with the help of Barbara Reed.

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If you have information to contribute to forthcoming reports, or would like to request back issues ofthe Reports on the Nutrition Situation of Refugees and Displaced Populations (RNIS), pleasecontact:

RNIS CoordinatorACC/Sub−Committee on Nutrition (V222)20, avenue Appia1211 Geneva 27SWITZERLAND

Tel: +(41−22) 791.04.56Fax: +(41−22) 798.88.91Email: accscn@who.ch

Web: http://www.unsystem.org/accscn/

Funding support is gratefully acknowledged fromAED through the LINKAGES Project, CIDA DFA (Ireland)

NORAD, DFID (UK), UNHCR, UNICEF and WFP

Cover photo courtesy of UNHCRKenya/Refugees from Somalia/Dagahaley Camp/ArrivalUNHCR/22039/05.1992/P. Moumtzis

I. Introduction

The Refugee Nutrition Information System (RNIS) was set up in 1993, under the guidance of the ACC/SCN’sWorking Group on Nutrition of Refugees and Displaced People1. At that time, “at least 35 million peopleworldwide [had] either fled their country as refugees or been displaced internally due mainly to civil war.... Ifwe include internally displaced people, the ‘refugee nation’ of 30 to 40 million people would easily be thepoorest in the world ranking as a medium−sized country” (ACC/SCN, mid−1991).

1 The name of the Working Group was changed to the Working Group on Nutrition inEmergencies at the SCN’s annual session in Oslo in April 1998. This Working Group isco−chaired by UNHCR and WFP.

Funding for the RNIS project has been provided over the years by Canadian International DevelopmentAgency (CIDA), Department of Foreign Affairs (DFA(Ireland)), Department for International Development(DFID(UK)), Norwegian Agency for International Development (NORAD), United Nations Children’s Fund(UNICEF), United Nations High Commissioner for Refugees (UNHCR), US Agency for InternationalDevelopment (USAID) and the World Food Programme (WFP).

The original aims of the RNIS project were to track and report outcome indicators, including wasting andmortality, in refugee and displaced populations, to raise awareness of their situations and to provideinformation to better advocate for improvements. “The purpose is to identify and prevent specific problemsthat persist... not to provide comprehensive monitoring or early warning.” (ACC/SCN, 1992).

The Reports focus on emergency situations, many of which are not covered in the media, and may quickly be‘forgotten’. Recurring problems are highlighted, and often suggestions for response are made.

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Figure 1: Number of Refugees and Internally Displaced People in Sub−Saharan Africa and EstimatedNutritional Over Time (Dec 98−Jun 98)

Between 1993 and 1998, the number of refugees and internally displaced people covered in the RNISReports has fluctuated, reaching a peak at the height of the crisis in the Great Lakes in early 1995 (figure 1).The first RNIS Report included information on eleven situations. New situations were added as crises erupted,and reporting was discontinued as repatriation programmes came successfully to an end, such asMozambique and the Benin/Ghana/Togo region. The 24th issue covered sixteen situations, five of which wereoutside Sub−Saharan Africa.

Special topics have also been covered. For example, there was a supplement on the nutrition situation inNorth Korea and a report on food security in Liberia. Also, information taken from RNIS reports wassynthesised into chapters included in the ‘Update on the Nutrition Situation, 1994’ and the’ Third Report on theWorld Nutrition Situation’, both published by ACC/SCN.

Approximately 800 copies of the RNIS Reports are distributed to UN agencies, NGOs, donor governmentsand academic institutions on a quarterly basis. The most recent readership survey indicated that, on average,ten people read each copy. Updates on rapidly changing situations are distributed by e−mail and appear onthe ACC/SCN website (http://www.unsystem.org/accscn).

We are taking the opportunity presented by the publication of the 25th issue of the RNIS Reports to reviewsome of the changes in emergency response over the last five years. We will first highlight situations wherewasting was brought rapidly under control. We will then look at some of the factors that have led to less thanoptimal results, followed by what has been accomplished to improve response over the last five years. Weconclude with some ideas for future improvements in the RNIS Reports that could even further enhancecommunication, stimulate thought, and promote improvement.

Photo courtesy of UNHCR. Ghana/Refugees for Liberia/Gomoa Buduburam Camp near AccraUNHCR/25026/03.1995/L. Taylor

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II. Our Mission is Possible!

“Experience has shown that once crises erupt, the international community can move swiftly to address thesuffering of innocent civilian victims. The United Nations and its humanitarian partners −donors,non−governmental organizations, the Red Cross Community − have raised billions of dollars to deliver foodto the hungry, provide shelter to refugees and internally displaced persons, and support children, womenand the elderly. This has been accomplished despite the major constraints that often accompany deadlyconflicts: difficulty in reaching populations in need, a lack of security for relief personnel and disregard forfundamental principles of humanitarian law and human rights.”

Kofi Annan, Message to the United Nations High Commissioner for Refugees Carnegie CommissionConference on Human Response and Preventing Deadly Conflict, Geneva, 16 February 1997(SG/SM/6164)

The RNIS Reports have shown that when humanitarian agencies have continual access to a population andare able to maintain regular food aid deliveries, high rates of malnutrition can rapidly be controlled. Threeexamples follow.

Repeatedly in 1994 and 1995, encircling troops cut off Angolan cities from aid for months at a time.Landmines and widespread destruction of the road system hindered deliveries to cities and rural areas.However, once regular delivery of a general ration was possible, levels of wasting came down quickly. Figure2 shows the decline in levels of wasting among children in Malange, Angola, during a period of stabilityfollowing restored access in January 1993.

In Upper Bong Liberia, levels of wasting declined markedly when improved security allowed continual accessto populations in need of assistance (figure 3).

In Kahindo camp for Rwandan refugees in Eastern Zaire, levels of wasting were rapidly brought under controlonce clean water supplies and food distribution systems were in place (figure 4).

Figure 2: Change in malnutrition over time in Malange, Angola

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Figure 3: Change in malnutrition over time in Upper Bong, Liberia

Figure 4: Change in malnutrition over time in Kahindo Camp, Goma, Zaire

III. Why, then, hasn’t this always happened?

A conceptual framework that is useful for understanding causes of malnutrition among young children inemergency settings is shown in figure 5. The immediate causes are inadequate dietary intake and disease. Todate, the RNIS has focused on malnutrition, mainly as reflected in wasting and oedema. Some attention hasbeen given to causes, such as diseases or low food availability. The RNIS Reports are now beginning to lookmore closely at underlying and basic causes.

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Figure 5: Conceptual framework of the causes of malnutrition

A. Quantity of available food

Displaced populations are heavily reliant, or completely dependent, on general food aid rations. Thedistribution of rations inadequate in food energy in these cases can lead to malnutrition. Failures in the past toprovide adequate rations have been due mainly to problems of food supply, delivery, or distribution.

The supply of food aid depends on donations. Annual appeals are made to donors for each on−goingemergency. These appeals are based on the location and estimated numbers of beneficiaries at the time, butconditions change rapidly. Complex emergencies are characterised by prolonged crises that rise and fall in

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intensity. Target populations move, often repeatedly, and numbers of beneficiaries change rapidly as newareas are accessible or inaccessible. These uncertainties make both planning and adherence to plansdifficult. This was illustrated in Liberia in 1995, and in Zaire in 1996.

In addition, donor dissatisfaction with beneficiary enumeration, especially in conjunction with evidence of foodaid sales, has led them to refuse to make or fulfil pledges. This was reported in Ethiopia and Zaire in 1996.

Timing of the receipt of pledges from donors also affects when food is delivered to beneficiaries. Even when,over the course of an appeal, full resources are available, there have been examples when periods of severecommodity shortages have led to ration shortfalls. This has mainly been due to a lack of timely fulfillment offood and monetary pledges, as seen in Angola in 1994 and 1998, and Liberia in 1994 and 1997.

Political circumstances also influence how and where assistance can be administered. Where embargoes areenacted, such as those in Burundi and Sierra Leone in 1997−98, humanitarian aid was exempted.Nevertheless, restrictions on fuel and food imports hampered efforts to deliver aid. Frontier closures not onlyprevented refugees from crossing to safety, but also made transport of aid to refugees in Tanzania and Zairemore difficult and expensive throughout 1996. Flight bans, common occurrences in Southern Sudan, severelylimit the delivery of aid. Government constraints on the movements and economic activities of the displaced inGoma, Zaire and Tanzania in 1996, and Kenya in 1997 limited the possibilities for displaced households toachieve self−sufficiency.

Local transport capacity is often not enough to support sudden rises in demand, as was reported in Tanzaniain 1997 and Burundi in 1994, or local ports cannot handle the large volume of food aid (Burundi − 1995, Zaire− 1996). Emergencies force people into locations where inadequate road systems are subjected seasonally tofurther deterioration during heavy rains. This has impacted on ration deliveries in many places, includingKenya and Tanzania.

Especially when assisting internally displaced populations, conditions of insecurity halt or delay deliveries (e.g.Angola − 1993−94, Burundi −1996−98, and Liberia − 1996−97) and force personnel to abandon activities.Such reports were common, for example in Burundi in 1996 and Rwanda in 1997. Losses from looting,banditry or diversion by military factions (e.g. Angola − 1995, Liberia − 1996, Zaire − 1996) reduced foodsupplies before arrival at emergency distribution sites.

After food has reached the final delivery point, there may be further problems. The way in which food aid isdistributed influences beneficiaries’ access to food, and, consequently, the nutritional status of the population.Equitable distribution is not guaranteed. In Tanzania in 1997 and Ethiopia in 1998, distributions to groups offamilies seemed to lead to inequitable ration receipts at the household level. Subsequent adjustments to thesedistribution systems are discussed in section V B below.

The consequence of shortcomings in food supply, delivery or distribution is that general rations agreed uponin annual planning do not always correspond to the food that reaches beneficiaries. Figures 6 and 7 comparea planned ration with that actually delivered based on food monitoring in Kenya and Tanzania.

Figure 6: Food Deliveries in Dadaab Camps, Kenya, over time and based on food basket monitoring

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Figure 7: Food Deliveries in Tanzania, over time

B. Type of food available

Even when general rations are distributed regularly and provide adequate food energy, protein−energymalnutrition, micronutrient malnutrition or both may still appear. In these cases, problems often relate to thetype of food provided − the quality, its acceptance by the beneficiaries or its appropriateness for use.

Until about 1995, the typical food aid basket included only basic commodities (cereal, pulse and oil), andprovided insufficient levels of micronutrients. This, combined with the fact that people often arrive at campswith micronutrient malnutrition, means deficiencies of vitamins C and A, riboflavin (B2), thiamin (B1), niacin,and iodine have been noted in RNIS Reports over the past five years. Reports of anaemia2 were also noted.

2 Iron deficiency occurs when the amount of iron absorbed is insufficient to meetrequirements, and if prolonged, results in iron deficiency anaemia.

Frequently, the diagnoses of micronutrient deficiencies have been questioned. Misdiagnoses in Bangladesh ofpersistent cases of angular stomatitis as a vitamin deficiency were finally confirmed in 1998 when response totreatment with antibiotics indicated that symptoms were due to infection. It is difficult to understand why therewas such a delay (6 years) before antibiotic treatment was tried. In Nepal, elevated incidence of symptoms ofmultiple micronutrient deficiencies (i.e., scurvy and beri−beri) has persisted for nearly as long, in spite of theintroduction of fortified blended food, parboiled rice and fresh fruit and vegetables in the general distribution.The reasons have not yet been identified.

The lack of suitable foods for young children was associated with preschool malnutrition in Ethiopia (1996)and Sierra Leone in 1998. Fortified blended food is suitable for feeding young children because it is easy toprepare, palatable and nutritionally dense. In the past, this commodity has frequently been absent or reducedin distributions because supplies were exhausted or in short supply. Some example of this include Kenya andZaire in 1994−95.

The cultural unacceptability of the ration commodities, difficulty in digestion of foods, the lack of millingcapacity and unsuitability of rations for children have led to low consumption or sales and exchanges of foodaid. Some examples noted in RNIS Reports include Tanzania in 1997−98, Liberia (1998) and Ethiopia in1997.

C. Shortcomings outside the realm of food

Disease and inadequate supplies of non−food items often contribute to malnutrition. Sometimes they are evenmore important than food−related factors.

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Generic “health problems” were cited as the primary cause of prevalent wasting in Sierra Leone (1994). Theeffects of a shortage of water and poor sanitation were blamed in Zaire (1993) and over−crowding andunhygienic conditions were contributing factors in Burundi (1997). A deterioration in nutritional status wasattributed to diarrhoea, over−crowding and poor water supply, not lack of food in Tanzania (1994). Diarrhoeawas also a contributing factor to deteriorating status among Afghan children in Pakistan (1996). There was anassociation between measles and malnutrition/oedema in Liberia (1994).

Anaemia associated with malaria has also been noted as a problem in some areas, for example in Tanzaniain 1998 where anaemia and malaria together accounted for the most deaths.

Efforts to acquire non−food necessities, such as fuel or soap, can affect diet and health.

• Faced with a shortage of fuel, as was the case in Tanzania in 1995 and Zaire in 1996,women and children search the environment for wood and other combustible materials. Theymay be away from home for extended periods while small children, including breastfeedingchildren, are left alone with nothing to eat. The fuel gathered may be insufficient so that eitherthe food is undercooked, or the number of meals is reduced. At times, especially when thereis rain, it is not possible to gather any fuel; other times the search is futile. This may meanthat families go the entire day with no food or leftovers are eaten without re−heating.

• Fuel gathering often creates tension between displaced and resident populations. Residentshave threatened to retaliate for the loss of their fuel resources by attacking food supplies forthe displaced (Tanzania − 1995). Women and children are put at risk of injury, rape, or deathwhile gathering. Resulting debilitating injuries, loss of life, trauma and household divisionconsequent to rape, can permanently reduce household capacities.

• Without both soap and water, personal and environmental hygiene cannot be maintained.Illness and its nutritional consequences follow. As an example, in Zaire in 1995, aninadequate supply of soap for domestic hygiene hampered efforts to prevent the transmissionof dysentery. Wasting and mortality rates soared and most deaths were associated withdiarrhoeal diseases.

• To acquire non−food essentials not provided by the international community, recipients offood aid who lack money and other resources that can be sold, are often forced to sell orbarter their food (e.g. Ethiopia − 1998). Sales of this nature were identified as a major causeof malnutrition among Sudanese schoolboys in Kenyan camps in 1997.

Photo courtesy of UNHCR. Kenya/Refugees from Somalia/Dagahaley Camp

UNHCR/22044/05.1992/P. Moumtzis

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D. Lack of understanding of context

Too often, those involved in relief view emergency−affected populations as faceless masses. However,understanding the population − their lives before the emergency and how they have changed, the problemsthey are facing and the actions they are taking to overcome them − would allow for the “tailoring” ofassistance to satisfy the particular needs and sensibilities of the beneficiary population. In addition, contextualadvantages and disadvantages could be taken into account.

There has been much discussion about populations becoming dependent on relief and much rhetoric abouttheir need to become self−sufficient. Some host governments have allowed refugees access to land forfarming, such as in Uganda and Guinea. During resettlement and rehabilitation, food−for−work andincome−generating projects become the primary pathways through which food aid is channelled and seeds,tools and other inputs are disbursed to encourage agriculture. However, there have been few reports ofinterventions by international agencies to support initiatives towards self−reliance during displacement. In ourexperience, only negative incentives, for example reduced rations, have been cited to motivate self−helpefforts (e.g. Cote d’Ivoire − 1995).

E. Special case of IDPs

‘Internal displacement, affecting some 25 million people worldwide, has become increasingly recognised asone of the most tragic phenomena of the contemporary world. Often the consequence of traumaticexperiences with violent conflicts, gross violations of human rights and related causes in whichdiscrimination figures significantly, displacement nearly always generates conditions of severe hardship andsuffering for the affected population. It...denies access to such vital necessities as food, shelter andmedicine...’

Guiding Principles on Internal Displacement, Commission on Human Rights at its 54th Session, GenevaFeb., 1998. (E/CN.4/1998/53/Add.2)

Governments have a primary responsibility for protecting and assisting their own populations. However,during emergencies many have sought assistance from the international community. Presently, ‘theinternational community is more inclined than it is prepared, both normatively and institutionally, to respondeffectively to the phenomenon of internal displacement.’ (Guiding Principles on Internal Displacement, para.4). No one UN agency is mandated to safeguard the welfare of IDPs. One of the main impediments tointerventions in IDP situations is certainly the sovereignty of states.

IV. What has been done to improve response?

A. Exchanging ideas and raising awareness

There have been a number of initiatives aimed at improving response to emergencies. The RNIS project hascontributed to improved understanding and cooperation by providing a forum for discussion and exchange ofideas.

One outcome was the ‘Workshop on the Improvement of the Nutrition of Refugees and Displaced People inAfrica’, which took place in Machakos, Kenya in December 1994. This was an initiative of the ACC/SCNWorking Group on Nutrition in Emergencies. The workshop was organised by UNHCR and the AppliedNutrition Programme, University of Nairobi, Kenya, with support from the German bilateral agency, GTZ.Approximately 100 participants with technical, policy and managerial responsibilities for nutrition of refugeeand displaced populations working with host governments, non−governmental organisations, and internationalagencies attended. The meeting considered five specific topics − quality and quantity of food rations,prevention of micronutrient deficiencies, selective feeding programmes, health issues in the prevention andtreatment of malnutrition in refugees and displaced persons, and health and nutrition information systems −with the objective of defining areas for follow−up. Two issues highlighted at the meeting were the need for atwo−stage approach to ration setting, and the need for better training for those working in emergencies. Bothof these issues are discussed in more detail below.

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In addition to the RNIS, other initiatives have been undertaken over the past five years to facilitatecommunication among humanitarian workers and improve the quality of response to humanitarian crises.

The Emergency Nutrition Network (ENN), based at Trinity College, Dublin, began in November 1996. TheNetwork produces the quarterly publication of “Field Exchange”, a newsletter primarily containing short articleswritten by field personnel working in the food and nutrition sector of emergency response. The ENN aims to:

• provide a forum for the exchange of field level experiences between staff working in the foodand nutrition sector in emergencies;

• strengthen institutional memory amongst humanitarian aid agencies working in this sector;

• help field staff keep abreast of current research and evaluation findings relevant to theirwork;

• better inform academics and researchers of current field level experiences, priorities andconstraints thereby leading to more appropriate applied research agendas.

The ‘Inter−Agency Group on Food and Nutrition’ is an informal group of nutritionists who meet about once ayear to discuss a specific topic. Different agencies organise meetings; there is no formal chair for the group.Past meeting topics included typologies for selective feeding programmes and food security assessments.These meetings foster communication between nutritionists and help to promote a common understanding ofthe issues discussed.

NGONUT is an internet discussion group moderated by Dr. Michael Golden at Aberdeen University, Scotland.This forum has stimulated discussion and disseminated information on technical issues related to nutrition inemergencies.

All of these new initiatives are interagency efforts that bring together interested people from the UN and NGOsand involve those from the North and the South.

B. New practices and policies

A number of new policies and operational practices for humanitarian response have been agreed upon oradopted in the past 5 years.

1. Coordination

Memoranda of understanding among UN agencies are implemented to improve coordination by clearlydefining areas of responsibility for agencies. An example of this is the memorandum of understanding signedby WFP and UNICEF that applies to ‘situations caused by natural or man−made disasters, in which peopleaffected by the emergency remain in their country of origin, including internally displaced’. This MOU definesWFP’s responsibility for the supply of basic food commodities and UNICEF’s responsibility for sanitation,water, health and protection (WFP/UNICEF, 1998).

UNHCR and WFP recently signed an MOU which sets out responsibilities for each agency in emergencysituations, along with areas of joint responsibility. Some of the joint responsibilities highlighted in this MOUinclude:

• assessment of numbers eligible for food assistance;

• establishment of modalities of food assistance, composition of the food basket, ration size,duration of assistance and related non−food inputs;

• periodic food assessment missions for the purpose of reviewing food needs;

• public information activities to promote awareness of beneficiaries’ needs;

• promotion of food and non−food aid to encourage and support the self−reliance ofbeneficiaries;

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• coordinated appeals to donors.

Responsibilities reserved for UNHCR include:

• determination of the nutritional status of refugees and the implementation of selectivefeeding programmes;

• enumeration and registration of refugees as potential beneficiaries of food aid;

• mobilisation of complementary food commodities: fresh foods, spices, tea, dried andtherapeutic milk;

• transport and distribution of the food from extended delivery points to the beneficiaries.

Responsibilities reserved for WFP include:

• mobilisation of basic food commodities: cereals, oils and fats, pulses and other sources ofprotein, blended foods, salt, sugar and high−energy biscuits;

• timely transport of food to extended delivery points;

• mobilisation of necessary resources for milling and the provision of milling facilities.

In addition, this MOU has more clearly identified a key role for WFP in planning and implementation ofrepatriation operations and post−conflict rehabilitation (WFP/UNHCR 1997, Sections 3.12−3.13).

2. Ration Planning

A recommendation of the Workshop on the Improvement of the Nutrition of Refugees and Displaced Peoplewas a two−stage approach to ration planning in emergencies. This approach was adopted by WFP andUNHCR (WFP/UNHCR 1997). In the first stage, 2100 kcals/person/day is used as an initial planning figure forfood aid rations. This allows for rapid planning and response before detailed information on the beneficiarypopulation is available. In the second stage, the estimated per capita requirements should be adjustedaccording to demographic, health, nutritional and food security information.

WFP has solicited an agreement from USAID that all oil received from the US will now be fortified with vitaminA. Other donors, including Canada and Sweden, are already supplying vitamin A−fortified oil.

Allowance for making up ration shortfalls was introduced in the new WFP/UNHCR MOU. While retroactiveentitlement will not be automatic, allowance was made for retroactive distribution when UNHCR and WFPjointly agree. The decision will take into account the nutritional status of the beneficiaries, measures taken bythem (i.e., the beneficiaries), liabilities incurred in coping with the shortfall, the economic impact, and thefuture availability of resources (WFP/UNHCR 1997, Section 5.6)

The MOU also puts forward new policy that may serve to safeguard ration levels by stipulating that anychange in ration levels or beneficiary numbers can no longer be made unilaterally. Both WFP and UNHCRmust agree on any change, and pending resolution, food assistance will be provided at the level establishedby the last agreed assessment (WFP/UNHCR 1997, Section 3.14−3.15).

This MOU also specifies that food resources received from donors should be accompanied by full cashresources needed to cover transport and other related support costs, including milling (WFP/UNHCR, Section6.4).

3. IDPs

Guiding Principles on Internal Displacement, put forward in the 54th Session of the Commission on HumanRights, identify rights and guarantee protection to those displaced within their own countries. Specifically,Principle ten discusses the elimination of starvation as a method of combat and Principle 18 states thatdisplaced people have the right to safe access to:

• essential food an potable water;• basic shelter and housing;

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• appropriate clothing;• essential medical services and sanitation.

Recent UN reforms led to the creation of the United Nations Office for the Coordination of HumanitarianAffairs (OCHA), one of whose core functions is to coordinate humanitarian emergency response. As was thecase with the Department of Humanitarian Affairs (DHA) before it, OCHA is the coordinating agency in IDPsituations. For example, a coordinating unit was established in Angola and charged with overseeinghumanitarian efforts − including the coordination of relief activities in the country, facilitation of the delivery ofaid, the assembly and dissemination of information, and needs identification. In addition, this coordination unitparticipated in capacity building among Angolan nationals in preparation for handing over activities toresponsible government bodies.

UNHCR has taken responsibility for IDPs in certain situations at the request of the Secretary−General of theUN or other principle organs of the UN (from Refugees and others of concern to UNHCR 1997, pg. 9). OCHAwill determine a need to be involved in IDP situations on a case by case basis (OCHA, 1998). However, in theabsence of an international agency with a clear mandate to assist and protect IDPs, it will be difficult to putthese guiding principles into practice.

Operation Lifeline Sudan (OLS), is a consortium of UN and NGO agencies ‘assist[ing] internally displaced andwar−affected civilians during and on−going conflict within a sovereign country’ (Operation Lifeline Sudan −AReview July 1996, pg. 1). OLS members work to support displaced and war−affected populations in−country.The formation of this consortium established a model for other coordinated humanitarian efforts that followed,such as Angola and Somalia.

4. Improved standards and accountability

In response to a need for more consistent, effective humanitarian relief, the development of a set of minimumstandards in the core areas of humanitarian assistance of nutrition and food security, health services, shelterand site management, and water and sanitation is underway. The Sphere Project, a collaborative processinitiated in July 1997, is led by the steering committee for humanitarian response (SCHR)3 and InterAction4,and involves front−line NGOs, interested donor governments and UN agencies. The objectives are to improvethe quality of assistance provided to people affected by disasters (whether natural or man−made) and toimprove the accountability of agencies to their beneficiaries, their membership, and their donors.

3 An alliance for voluntary action of: Care International, Caritas Internationalis, InternationalFederation of Red Cross and Red Crescent Societies, International Save the ChildrenAlliance, Lutheran World Federation, Médecins sans Frontières, Oxfam International andWorld Council of Churches.

4 InterAction is a coalition of over 150 US−based non−profit organizations (“private andvoluntary organizations,” or PVOs) working to promote human dignity and development in165 countries around the world).

C. Food distribution modalities

For efficient food distribution, modalities must take local culture into account. Recent guidelines from UNHCRand policy statements from WFP5 on involvement of refugee women in distributions intend to raise awarenessand give practical advice on how to implement equitable distribution systems.

5 Commodity Distribution A Practical Guide for Field Staff, Provisional Version, UNHCR June1997 and WFP Policy Commitments to Women: 1996−2001.

When Rwandan refugees arrived in what was then Eastern Zaire, food distributions were organised throughheads of communes. High levels of wasting were partly attributed to inequities due to discrimination againstcertain segments of the community. The system responded by shifting to distribution to groups of manyfamilies, then to ‘cellules’ of a few families, and eventually to heads of households. In addition, the use ofmultiple distribution points, each serving a unique family size, allowed for distribution of equal quantities to allrecipients at each site. These changes were associated with decreased levels of wasting (ACC/SCN, 1997,Chapter 3).

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Photo courtesy of UNHCR. Tanzania/Refugees from Rwanda

UNHCR/24153/07.1994/L. Taylor

Likewise, the food distribution system is being revised in Ethiopia to distribute rations to heads of households.Previously, rations were distributed to selected group leaders representing twenty families or more. The newdistribution system, recommended by the WFP/UNHCR Joint Food Assessment Mission in 1997, incorporatesactive participation of women. It was successfully piloted in one camp in May 1998 and was to be introducedto the other camps.

On the other hand, in Nepal distributions to sub−sector representatives of about 500 individuals who divideand distribute to families works efficiently and equitably (ACC/SCN, 1997).

D. Combating micronutrient deficiencies

The use of fortified food commodities has been effective in combating micronutrient malnutrition, (e.g. Nepaland Bangladesh throughout the RNIS Reports). However, poor supply of blended foods has led to reduceddistributions in some situations such as in Kenya (1997), Tanzania (1994) and Zaire (1994−95).

Distributions of fresh foods have also been effective (Nepal, Kenya, and Bangladesh), but only rarely havesustained distributions been logistically possible.

The WFP/UNHCR Memorandum of Understanding, recognising the difficulty of meeting micronutrientrequirements through general rations, stipulates that ‘UNHCR will assume responsibility for the provision ofthe necessary micronutrients until the ration can be adjusted or fortified to meet the needs.’ (WFP/UNHCR1997, Section 4.5).

Only in one instance (Mozambique) has nutrition education been reported as a preventive measure. At leastwith the new WFP/UNHCR MOU, UNHCR has accepted responsibility for providing guidance to beneficiarieson how to prepare food in a manner that safeguards its nutritional content (WFP/UNHCR MOU, 1997 Section5.4).

E. Gaining a better understanding of the context

Increasingly, we have tried to present reports of food security and livelihood assessments in the RNISReports. Presentation of information on food security assessments have been received from our contacts inKenya, Burundi, Tanzania, and Angola. These reports provide insight into how refugees try to meet their ownneeds and, when they can not, how they could be assisted. With this information aid can be moreappropriately targeted to more effectively meet the needs of the beneficiary populations.

An example of an on−going assessment was highlighted in RNIS#22 in 1998. In Liberia, humanitarianagencies are trying to coordinate food security assessments in many parts of the country, but particularly in

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areas of likely refugee return. A WFP−initiated ‘Food Security Forum’ whose members − both UN and NGO −are concerned with food security are developing common assessment methods and sharing results. Thisshould inform programming decisions and identify location−specific food security indicators that can bemonitored for early warning. Better monitoring and targeting will become critical as emergency food aid isphased out.

Segments of populations have sometimes achieved different levels of self−sufficiency. In two cases, differentrations were distributed to the same population (e.g. Cote d’Ivoire − 1995, Sudan −1997). Newer arrivalsreceived a larger ration than their counterparts who had been in the camps longer. This was based on theassumption that the longer−term refugees had developed some level of self−sufficiency.

Under the new Memorandum of Understanding, WFP and UNHCR maintain joint responsibility for overall foodaid and relief requirements. Both agencies will agree on the modalities of food assistance programmes,composition of the food basket, ration size, duration of assistance, and directly related non−food inputs.

Assessments will take into account a number of factors including socio−economic and nutritional status,cultural practices, overall food availability, prospects for self−reliance, availability of cooking fuels, and theenvironmental impact. The MOU stresses that the views of the beneficiaries, particularly women, should besought (WFP/UNHCR, 1997, Section 3.6).

F. Considering care of the vulnerable, especially young children

Care of the nutritionally vulnerable was considered at a recent interagency meeting entitled Caring for theNutritionally Vulnerable in Emergencies (Feb. 98). At this meeting, a set of guiding principles (attached asAnnex II) was drawn up to inform programme planning to promote the best caring behaviours.

‘Experience has taught that even when there is adequate food in the house and a family lives in a safeand healthful environment and has access to health services, children can still become

malnourished.’(UNICEF, 1998, pg. 27)

Caring practices, as defined in UNICEF’s State of the World’s Children (1998) are behaviours that translateavailable food and health resources into good child growth and development. These include feeding practices(including breastfeeding), protection of children’s health, cognitive stimulation and support for mothers. In ourexperience, caring practices are infrequently assessed during anthropometric surveys, but this is beginning tochange. As one example, a survey carried out among war−affected people in Sierra Leone found higherlevels of wasting in the 6−29 month group than in the 30−59 month group (June 1998). This was becausecomplementary foods were introduced too early and were being watered down to compensate for reducedingredient availability on local markets.

V. Where do we go from here?

A. Promotion of human rights

A human rights approach to food and nutrition problems is fundamentally different frombasic−needs−oriented approaches to development... A rights approach implies that ‘beneficiaries’ ofdevelopment are active subjects and ‘claim holders’ and stipulates duties or obligations for those againstwhom such claims can be held... Such an approach introduces an accountability dimension not present inbasic−needs strategies.

The Right to Food Report of the High Commissioner for Human Rights (ECOSOC E/CN.4/1998/21 para 26)

Until now, humanitarian assistance has been provided to ensure survival. If we are to move past thisminimalist approach toward a human rights approach, practices must be adjusted to achieve goals thatguarantee emergency−affected populations a healthy environment in which they can live with dignity and theirchildren can grow to their full potential. Measures of accountability can no longer be limited to mortality,

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malnutrition or morbidity.

The theme of the SCN’s 26th annual session is ‘The Substance and Politics of a Human Rights Approach toFood and Nutrition Policies and Programming’. It is hoped that this session will generate practical ideas onhow to operationalise actions to promote, protect and fulfil the human rights of refugees and internallydisplaced populations.

B. Improved presentation of evidence of successes and needs

1. Indicators of nutritional status

The prevalence of wasting in preschool children is a useful indicator for assessing the general health andnutritional status of a population during acute periods of emergency. However, additional indicators could beused to monitor underlying causes, the impact of relief assistance, and for signalling signs of nutritionaldistress. Some indicators worthy of consideration are low BMI in adults, low birth weight (LBW) and stunting inpreschool children.

Populations affected by protracted emergencies may experience repeated periods of extremely restricteddietary intake separated by longer periods when intake is less severely restricted, but not fully adequate. Theaccumulation of the effects of these restrictions is reflected as stunting, that is, inadequate attainedheight−for−age. ‘Height−for−age reflects achieved linear growth and its deficits indicate long−term, cumulativeinadequacies of health or nutrition’ (WHO, 1995). Childhood stunting is associated with lifelong reductions inindividual capacities, both intellectually and in terms of work productivity. Precise determination of a child’sage is the primary barrier to accurate assessment of stunting. However, in camps and many emergencysettlements, pre− and post−natal care should facilitate birth registration, making it easier to assessheight−for−age.

Rates of stunting have rarely been reported to the RNIS Reports. In camps for refugees from Myanmar inBangladesh, 63% of surveyed children aged 6−59 months were stunted6 in 1998. These children were mostlikely born and raised in the camps. In Ethiopian camps of displaced persons in 1995, a high prevalence ofstunting can be inferred from the disparity between wasting (3.2%) and weight−for−age prevalence (38%).Indeed, national survey data from Ethiopia document very high rates of stunting.

6 For comparison purposes, national data from Bangladesh showed 56% of children 0−5years were stunted.

Rates of malnutrition among children under five are used as an indicator for the general condition since youngchildren’s nutritional needs per kg of body weight is greater than for any other age group. Nutritional distressis quickly reflected as weight loss in this age group. However, households in some cultures are inclined duringextreme crises to channel food first to young children. The monotony of a diet limited to food aid may leadadults to trade or sell their rations to buy ingredients to make the food more palatable for children whootherwise refuse to eat. In such cases, adult malnutrition may be more common than malnutrition amongyoung children. Other than anecdotal reports, malnutrition in adults have rarely been reported to the RNIS. InKigali, Rwanda in 1995, a nutritional survey revealed higher rates of malnutrition among women aged 15−87years (11%; BMI < 18.5) than among children aged 6−59 months (5%). WHO is gathering data to provide ‘anup−to−date instrument... for establishing the magnitude and distribution of... underweight in adult populationsworldwide (ACC/SCN, SCN News No. 16, July 1998, pg. 59).

In Bangladesh a high prevalence of low birth weight babies was noted in 1998. Birth weight is influenced bymaternal nutrition during pregnancy. It can be reduced by inadequate energy intake during the last trimester.Micronutrient deficiencies may also be reflected in birth weights. As stated in a recent ACC/SCN publication:

‘Low birth weight is an important indicator of foetal/intrauterine nutrition and a strong predictor ofsubsequent growth and well−being’ (ACC/SCN, 1997 p.8).

We encourage agencies conducting surveys or routinely collecting data on nutritional status to considerincluding additional, appropriate indicators, depending on the population served. We would welcome thisinformation for the RNIS Reports.

2. Monitoring ration adequacy

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The RNIS could consider a method for systematic analysis of the adequacy of rations as planned, pledged,donated, distributed and received. This would involve tracking and reporting on: the planned ration (annualplan for ration and annual planned number of beneficiaries), the level of pledges received from donors, theactual rations distributed to the exact number of beneficiaries, and the results of food basket monitoring. Thistype of analysis, over time, would show what refugees are actually receiving.

3. Adequacy and effects of shortages of non−food items

We are aiming to include, wherever possible, information about non−food items in future RNIS, andencourage agencies to send information about distributions of such items in emergency settings. The potentialimpact of shortages of non−food necessities (e.g. fuel, cooking utensils, soap, land, agricultural inputs) ondietary practices, food aid consumption, or nutritional status should be considered in food security and foodsupply and crop assessments. We will welcome reports of any formal or informal observations.

C. Increased consideration of emergency context

Each circumstance is different. Effective intervention will depend on local resources and barriers.Emergencies are dynamic; interventions may need to change. Therefore, there is a need to establishprocesses for monitoring food availability, household food security, dietary practices, and purchasing poweras a routine part of humanitarian assistance during emergencies, from onset to final resettlement.

In particular, more attention should be given to understanding a populations’ own efforts towardsself−reliance. There must be an increased awareness among those working in emergencies that populations’familiar coping mechanisms may no longer work − because they are weakened physically or materially andhave moved to a new location where the resources for coping are no longer available or their activities areunusually constrained. Consequently they may require outside assistance to learn new methods of coping orinitial inputs to catalyse known methods.

D. Preventing and combating micronutrient deficiencies

Humanitarian assistance should take into account the heightened risks of micronutrient malnutrition, bevigilant in watching for early signs of its appearance and be prepared to promptly control it. This requiresinformation on the population’s food intake and how and why they change. A close examination of persistentcases may be necessary to understand whether the problems stem from unusual dietary restrictions or if thesymptoms reflect factors other than diet. Health and nutrition workers should be equipped to identify and treatmicronutrient deficiencies, and when symptoms of micronutrient deficiencies persist in the face of nutritionintervention, they should be prepared to do further assessment. We should always be looking for effectiveways to promote:

• production of fruits, vegetables and animal products rich in vitamins and minerals missingfrom the general food aid basket;

• acquisition and intake of local foods that are rich in vitamins and minerals missing from thegeneral food aid basket through nutrition education;

• income generation and exchanges that diversify intake.

WHO is about to publish three new books on micronutrient malnutrition − one each on scurvy, pellagra andberi−beri − focused on emergency situations. The manuals discuss ways to prevent such deficiencies bypromoting access to an adequate food basket (i.e. provision of fresh fruits and vegetables, or fortified foods;promotion of home gardening and/or market access). The manuals stress the importance of nutritioneducation and training of field workers in the diagnosis of the deficiencies. RNIS will welcome reports on theprogress of such programmes.

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E. Capacity building, including training

A major issue discussed at the Machakos Workshop in 1994 was the need for improved training for thoseworking in emergencies. Participants stressed the need for technical training, including:

• training in aspects of information systems including assessment and monitoring methods,and production of easily interpretable reports and recommendations;

• training of decision−makers in technical matters related to nutrition;

• training in the diagnosis of micronutrient malnutrition.

Furthermore, a need to develop regional training facilities, particularly in Africa, was highlighted. UNHCR hasdeveloped a proposal to build training capacity in Sub−Saharan Africa in the management of severemalnutrition in young children in emergencies.

It would be useful for RNIS to publish notices of workshops, bibliographies of training manuals and otherresources to support training of international and regional aid workers. In addition, a special report on currentprocedures for pre−posting orientation and briefing within agencies could be a first step in improving trainingof personnel before going to the field.

Problems associated with poor nutritional status in emergency−affected populations could be addressed bybuilding the capacities of the affected population to fully exploit and protect their few resources that remain.Examples of means for building capacity include:

• breastfeeding support, protection and promotion;

• nutrition education (e.g. about the relative nutritional value of food aid commodities andlocally available foods, or the frequent, safe, preparation of complementary foods forbreastfeeding children);

• and health education to promote environmental and personal hygiene.

Reports describing activities aimed at strengthening the capacity of local NGOs and relevant governmentinstitutions to assist emergency−affected populations have rarely been received for inclusion in the RNISReports. We would appreciate information about these and other innovative activities undertaken to promotebetter nutrition during emergencies and their outcomes, so that we can include them in our Reports.

F. Increased geographic coverage

The RNIS Reports focus mainly on Sub−Saharan Africa, plus a few situations in Asia. We intend to increaseour coverage of situations in Central Asia, and add information on Eastern Europe and the Americas in duecourse.

VI. Conclusion

This 25th issue of the RNIS has highlighted some of the major changes in emergency response over the lastfive years, as chronicled previous RNIS Reports. Other issues which are important, such as infant feeding inemergencies or home gardening to control micronutrient malnutrition, are not discussed here since the RNISReports do not contain information on these topics.

Some of the most important improvements in emergency response include:

• inter−agency initiatives aimed at improving response and communication;

• the signing of a number of MOUs to improve emergency response. Of particular importanceare provisions to control micronutrient malnutrition;

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• increased awareness of the context and culture of displaced populations;

• more awareness of the special case of IDPs.

The proposed enhancements will build on advances made over the last five years. This will help to improveour understanding of beneficiary populations, and fine tune our responses to actual needs. By reflecting theseadvances, the RNIS Reports become an even stronger information and advocacy tool for better nutrition ofrefugees and internally displaced populations.

Photo courtesy of UNHCR. Ghana/Refugees from Liberia/Gomoa Buduburam Camp

UNHCR/23090/10.1993/L. Taylor

Bibliography

ACC/SCN (1993−98) Refugee Nutrition Information System (RNIS) Reports Nos. 1−24. ACC/SCN, Geneva.

ACC/SCN (July 1998) SCN News No 16. ACC/SCN, Geneva.

ACC/SCN (1997) Third Report on the World Nutrition Situation. ACC/SCN, Geneva.

ACC/SCN (Mid−1991) SCN News No 7. ACC/SCN, Geneva.

OCHA(1998) OCHA: Visions, Priorities and Needs. Talking Points for HLWG Meeting. Geneva.

OLS (1996) Operation Lifeline Sudan A Review. July 1996.

UNHCHR (1997) Fact sheet No. 20, Geneva.

UNHCR (1998) Refugees and Others of Concern to UNHCR − 1997 Statistical Overview. UNHCR, Geneva.

UNHCR (1997) Commodity Distribution: A Practical Field Guide. UNHCR, Geneva.

UNHCR (1994) Populations of Concern to UNHCR − A Statistical Overview 1993. UNHCR, Geneva.

UNICEF (1998) State of the World’s Children. UNICEF, New York.

United Nations (1998) ECOSOC The Right to Food − Report of the High Commissioner for Human Rights,E/CN.4/1998/21, Geneva.

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United Nations (1998) Guiding Principles on Internal Displacement E/CN.4/1998/53/Add.2. Geneva.

United Nations (1997) Kofi Annan, Message to the United Nations High Commissioner for Refugees CarnegieCommission Conference on Human Response and Preventing Deadly Conflict, Geneva, 16 February 1997(SG/SM/6164).

University of Nairobi, Applied Nutrition Programme (1995) Report of a Workshop on the Improvement of theNutrition of Refugees and Displaced People in Africa. University of Nairobi (ANP), Nairobi.

WFP (1997) WFP in Statistics. WFP, Rome.

WFP Policy Commitment to Women 1996−2001. WFP, Rome.

WFP/UNHCR (1997) Memorandum of Understanding on the Joint Working Arrangements for Refugee,Returnee and Internally Displaced Persons Feeding Operations. Rome and Geneva.

WFP/UNHCR (1997) WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies.

WFP/UNICEF (1998) WFP/UNICEF Memorandum of Understanding on Joint Operations.

WHO (1995) Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO ExpertCommittee. WHO, Geneva.

Annex I: Reports of Micronutrient Malnutrition

Country ofassistance

(Nationality)

Vitamin A Anaemia Scurvy Angularsomatitis

Pellagra Beri−beri Goitre

Ethiopia(Somali)

late1993−early1994: 1% offeeding centreadmissions

before11/1993−7/94:2.5% of feedingcentre admissions

late 1993: 40 cases

Ethiopia(Ogaden:Sudanese,Ethiopian IDP& returnees)

8/93−8/94:“many cases”of “deficiency”

8/93−11/93:“manycases”

7/93−8/94:incidence3.5/1000/mo in11/93;12.8/1000/mo in1/94 (Gode)

Ethiopia(Returnees toTigray)

8/94:Xerophthalmiaprevalencereached 4−8%

8/94:1.7−50%amongdifferentgroups

Sudan (IDPKhartoum)

10/95: nightblindnessKhartoum:prevalence6.7%

Sudan (IDPRed SeaState)

11/96: “seriousepidemic” of“deficiency”;10/97: nightblindness,Bitot’s spots

11/96: highlevels

11/96 some cases 11/96: isolatedcases

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Bangladesh(Burmese)

6/92: nightblindness(prevalence1.2%)

5/98 6/92 − 5/98 highlevels

Kenya(Somali)

1/97: presenceof “deficiency”

1/97 verylargenumber ofcases

late 93: anecdotalreports8/94−10/94: majoroutbreak11/96: epidemic(5.8/10,000/mo)9/97−2/98: cases

Kenya(Sudanese)

2/97−9/97(5/97: 69%of 6−11yr−olds and75−86% of12−20yr−olds)

Nepal(Bhutanese)

6/97:“deficiency”

5/98:“elevated”incidence

1/94−6/976/94:.62/10,000/d9/94:.6/10,000/d12/94:.17/10,000/d6/95: 63/10,000/d8/95:.23/10,000/d10/95:.12/10,000/d11/96:.18/10,000/d

7/94−5/989/94:1.37/10,000/d12/94:1.0/10,000/d6/95:2.49/10,000/d11/96:2.7/10,000/d5/98: elevatedincidence

1/94−9/949/94:.005/10,000/d

late 1993−5/98:9/94:2.29/10.000/d1/95:0,55/10,000/d6/95:.005/10,000/d8/95:1.83/10,000/d10/95:0.85/10,000/d11/96:1.1/10,000/d5/98:2.6/10,000/d

7/94:confirmedcases

Malawi(Mozambican)

peak 199010/93: nearlydisappeared

Mozambique(Returnees)

8/95−12/95:outbreak9/96−12/96:some cases

Zaire/DRC(IDPs)

9/94:unconfirmed(Likasi)

Burundi (IDPs) 8/97:unconfirmed(Bubanza)

Afghanistan(IDP)

1997: nightblindness(Jalalabad &Kandaharprevalence3%)

7/95: confirmedcases(Mazar−i−Sharif)

1997:children6−35 mos(Kabul)

Tanzania(Barundi)

10/96−6/98:assocw/malaria

9/96: 8.0%−15.5%among schoolchildren

Iraq(residents)

1994: nightblindnessprevalence1.6% under−5s6/95:prevalence

2/94: verycommon inmarsh1/94−5/94:widespreadamong

3/95: largeincreasein numberof cases

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1.3% amongboys: 1.2%among girls

refugeesarriving inIran3/95: 48%“severe”amongpregnantwomen9/95:widespread3/96:commonoccurrence

Annex II: Guiding Principles on Caring for Nutritionally Vulnerable in Emergencies

1. Care alone will be ineffective without meeting basic needs. Basic needs will be moreeffectively provided with the catalyst of care.

2. Ensure participatory and community−based approaches in programme planning anddevelopment (assessment, early detection of nutritional vulnerability, monitoring andevaluation).

3. Empower individuals and community to prevent and respond to nutritional vulnerability.

4. Recognise and support the potential resources, skills and useful traditional culturalpractices for caring for the vulnerable.

5. Ensure integrated approach to individual and community for programme design andimplementation.

6. Ensure co−ordination of policies, and actions between agencies and with local authorities.

7. Establish mechanisms for information dissemination and education.

8. Promote advocacy and training on special care needs.

9. Provide support and training in caring attitudes to caregivers at all levels.

10. Prevent separation from support (family, community) and promote family reunification.

11. Approaches need to be flexible according to the type of emergency or situation.

WHO (1998). Caring for the Nutritionally Vulnerable during Emergencies. Report of a Joint WHO/UNHCRConsultation. Rome, Italy, 24−27 February 1998. (WHO/NUT/98.2)

Indicators

WASTING is defined as less than −2SDs, or sometimes 80%, wt/ht by NCHS standards, usually in children of6−59 months. For guidance in interpretation, prevalences of around 5−10% are usual in African populations innon−drought periods. We have taken more than 20% prevalence of wasting as undoubtedly high andindicating a serious situation; more than 40% is a severe crisis. SEVERE WASTING can be defined as below−3SDs (or about 70%). Any significant prevalence of severe wasting is unusual and indicates heightened risk.(When “wasting” and “severe wasting” are reported in the text, wasting includes severe − e.g. total percentless than −25Ds, not percent between −2SDs and −3SDs.) Data from 1993/4 shows that the most efficientpredictor of elevated mortality is a cut off of 15% wasting (ACC/SCN, 1994, p81). Equivalent cut−offs to−2SDs and −3SDs of wt/ht for arm circumference are about 12.0 to 12.5 cms, and 11.0 to 11.5 cms,

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depending on age. BMI (wt/ht) is a measure of energy deficiency in adults. We have taken BMI < 8.5 as anindication of mild energy deficiency, and BMI < 16 as an indication of severe energy deficiency (WHO, 1995).

STUNTING is sometimes included in anthropometric surveys and is usually defined as height−for−age <−2Zscores from the median of the international reference population. When the age groups are different, this isspecified in the text and tables.

OEDEMA is the key clinical sign of kwashiorkor, a severe form of protein−energy malnutrition, carrying a veryhigh mortality risk in young children. It should be diagnosed as pitting oedema, usually on the upper surface ofthe foot. Where oedema is noted in the text, it means kwashiorkor. Any prevalence detected is cause forconcern.

A CRUDE MORTALITY RATE in a normal population in a developed or developing country is around10/1,000/year which is equivalent to 0.27/10,000/day (or 8/10,000/month). Mortality rates are given here as“times normal”, i.e. as multiple of 0.27/10,000/day. [CDC has proposed that above 1/10,000/day is a veryserious situation and above 2/10,000/day is an emergency out of control.] Under−five mortality rates (U5MR)are increasingly reported. The average U5MR for Sub−Saharan Africa is 175/1,000 live births, equivalent to1.4/10,000 children/day and for South Asia the U5MR is 0.7/10,000/day (in 1995, see UNICEF, 1997, p. 98).

FOOD DISTRIBUTED is usually estimated as dietary energy made available, as an average figure inkcals/person/day. This divides the total food energy distributed by population irrespective of age/gender (kcalsbeing derived from known composition of foods); note that this population estimate is often very uncertain.The adequacy of this average figure can be roughly assessed by comparison with the calculated averagerequirement for the population (although this ignores maldistribution), itself determined by four parameters:demographic composition, activity level to be supported, body weights of the population, and environmentaltemperature; an allowance for regaining body weight lost by prior malnutrition is sometimes included.Formulae and software given by James and Schofield (1990) allow calculation by these parameters, andresults (Schofield and Mason, 1994) provide some guidance for interpreting adequacy of rations reportedhere. For a healthy population with a demographic composition typical of Africa, under normal nutritionalconditions, and environmental temperature of 20°C, the average requirement is estimated as 1,950−2,210kcals/person/day for light activity (1.55 BMR). Raised mortality is observed to be associated with kcalavailability of less than 1500 kcals/person/day (ACC/SCN, 1994, p81).

INDICATORS AND CUT− OFFS INDICATING SERIOUS PROBLEMS are levels of wasting above 20%,crude mortality rates in excess of 1/10,000/day (about four times normal − especially if still rising), and/orsignificant levels of micronutrient deficiency disease. Food rations significantly less than the averagerequirements as described above for a population wholly dependent on food aid would also indicate anemergency.

REFERENCES:

James W.P.T. and Schofield C. (1990) Human Energy Requirements. FAO/OUP.

Schofield C. and Mason J. (1994) Evaluating Energy Adequacy of Rations Provided to Refugees andDisplaced Persons. Paper prepared for Workshop on the Improvement of the Nutrition of Refugees andDisplaced People in Africa, Machakos, Kenya, 5−7 December 1994. ACC/SCN, Geneva.

ACC/SCN (1994) Update on the Nutrition Situation, 1994 (p81).

UNICEF (1997) State of the World’s Children p.98. UNICEF, New York.

WHO (1995) Bulletin of the World Health Organization, 1995, 73 (5): 673−680.

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