Fighting long-term nutritional deprivation among the Sarahawi refugees

Summary of report¹

The Saharawi refugee population (approximately 150,000) living in south Algeria have been in crisis since 1975 when conflict over the status of Western Sahara or former Spanish Sahara erupted. This refugee population has been dependent upon international aid for all this time due in large measure to the harsh desert environment in which they have been forced to live and the resulting lack of food production potential. Efforts to boost food production amongst this population have only had limited success.

Baseline survey findings

In 1997 ECHO financed a baseline survey conducted by CISP² in collaboration with INRAN³. This survey identified anaemia and growth retardation mostly in women and children as emergent problems amongst the Saharawi refugees due to the long-term impact of an unbalanced diet. The basic food basket consists of wheat flour, rice, lentils, sugar and oil, canned fish, canned meat, dried skimmed milk, tea and yeast. However, rations have varied due to interruptions in supply. Access to additional food items has been limited and few families can afford to supplement their rations. The sandy soil and saline water limits potential for household vegetable production. Only half the families surveyed were able to supplement their food rations with additional purchased foods. The ration has therefore not contained adequate quantities of iron (49% of RDA), vitamin A (36% of RDA), zinc, vitamin C (8%) and other nutrients commonly found in fresh meat, vegetables and fruit. There are also no appropriate weaning foods for children between 6 months to one year.

The survey found that approximately 15% of children were born with Low Birth Weight (LBW), i.e. below 2,500 grams. Furthermore, 70% of children under five years were anaemic while 46% were stunted (Height for Age) and 10% wasted (Weight for Height). In older children an estimated 60% were anaemic, 31% stunted and 7% wasted. Sixty percent of women of child-bearing age were considered anaemic and low BMI values were found in 15% of women and 15% of the aged.

Recommendations from the survey findings included establishing targeted nutritional interventions to address the problem.

Programme initiatives: Pilot Supplementary Feeding Programmes

In 1998 two pilot efficacy trials were conducted amongst children and infants to examine the benefits of specially formulated mineral/vitamin fortified foods supplements on the prevention and control of anaemia and growth retardation. The success of the trials led to a national supplementation effectiveness trial covering over 4000 children under the age of five years in all Saharawi refugee camps in 1999. The general objective of the programme was to measure the effectiveness of a 3-month targeted supplementation programme. More specific objectives were to:

• reduce the incidence of iron deficiency anaemia (IDA) and growth retardation in children aged 6-17 months by distributing a fortified rice based flour in the form of a porridge (RFB-G2);
• reduce the prevalence of iron deficiency anaemia and growth retardation in stunted children aged 18- 59 months by distributing a High Nutrient Density Spread (HNDS);
• use health dispensaries as a tool for health and nutrition promotion;
• set up an integrated nutrition programme implemented by the local health system;
• evaluate the implementation and impact of the intervention for applicability in other similar refugee settings.

All children under the age of 5 years were screened at health dispensary level and separated into two groups; infants 6-17 months (intervention A) and children 18-59 months with a height for age less than -2 Z-scores (intervention B). Impact of the supplementation was assessed by monitoring the nutritional status of children registered at the start of the programme and after 3 months of supplementation. Food supplements were distributed once per week at local health dispensaries by MCH staff. An on-going sensitisation campaign was implemented during the entire duration of the programme. The results were obtained on 1200 children monitored in sentinel dispensaries.

Effectiveness of interventions

Intervention A: After three months mean haemoglobin (Hb) levels were slightly but significantly reduced by minus 0.3 g/dL in infants between 6-17 months. The number with severe anaemia diminished but those with moderate anaemia increased. The overall combined prevalence of anaemia worsened by 5% after supplementation. Mean growth velocity only reached 3 mm/month. Retarded growth was reflected by a worsening of the height for age Z-score which dropped by 0.2 standard deviations indicating that linear growth faltering could not be prevented by the fortified supplementation. The percentage of infants with stunting increased by 10% at the end of the intervention.

Intervention B: Mean haemoglobin levels in stunted children were significantly increased by O.5 g/dL after three months of HNDS supplementation. The percentage of children suffering moderate to severe anaemia dropped by 10%. There was a lower percentage of children affected by severe anaemia and a higher percentage with mild anaemia and normal Hb levels. The supplementation improved mean height for age by 0.3 Z-scores and growth velocity reached 8.9 mm/month. The incidence of stunting was reduced by 15% mainly among the severest cases of retarded growth.

Discussion and Conclusions

The poor results of intervention A may have been due to a number of factors:

1. the fact that a significant proportion of targeted infants were already showing signs of chronic malnutrition and hence needed treatment rather than preventive levels of micronutrient supplementation, i.e. higher levels of supplementation;
2. there was a seasonally high prevalence of diarrhoea and younger children are more susceptible to infection;
3. compliance and acceptability of supplements was not optimal.

The rapid worsening of linear growth during the supplementation period argues for earlier detection and parallel prevention strategies such as correcting inadequate infant feeding practices and interventions to prevent intrauterine growth retardation.

In contrast, intervention B reached its aims. Reversal of stunting was achieved in children up to five with remarkable results after the relatively short supplementation period. This argues against the age limit of three years beyond which it is commonly thought that catch-up growth is not feasible.

The trial raised three important questions:

1. To what extent is stunting reversible? The data from the study did not allow conclusion. Catch up growth was markedly accelerated in the first three months of supplementation but slowed down afterwards indicating a 'plateauing off' of growth velocity.
2. Is there a later effect on adult height? Maturation should be followed up in children who had accelerated growth compared to those who stayed at low centiles of growth velocity.
3. Is supplementation that induces catch up growth safe in individuals exposed to micronutrient deficiencies since foetal life. By changing the nutritional environment dramatically from one generation to another and achieving phenomenal catch-up the individuals may be metabolically disadvantaged 'by imprinting' so that they have difficulty dealing with the new nutritional environment in other ways (diabetes, heart disease etc.) There may be an optimum rate of population improvement over time which is less than the maximum achievable rate.

Other issues to arise out of the evaluation were as follows:

Although compliance was very high, the cost of the HNDS may not be sustainable in a long-term strategy.

Nutritional surveillance is now a well established activity within the refugee supplementation programme. The integration of the nutrition intervention into local health systems facilitated contact between mothers and health staff and led to more timely treatment of common diseases.

The sensitisation campaign integrated several successful outreach strategies involving different levels of society. For example, the support of the community at large was greatly enhanced by radio broadcasts, participatory discussion groups and educational printed material. Community involvement promoted the sense of ownership of the programme and improved mobilisation and participation of the beneficiary population. Key community leaders, especially respected women, had a strong influential role to play and their contribution was increasingly valued throughout the project.

A final conclusion of the authors of the report was that vitamin-mineral fortification should be unnecessary where well balanced diets are provided and that provision of a supplementary food should not detract from efforts to provide a full balanced diet. Consequently, distribution of supplementary foods fortified with micronutrients should in most cases be regarded only as a temporary solution. However, in some situations (including the Saharawi refugees) achieving a well balanced diet may be so problematic that some form of supplementation programme is, at least in the short-term, a necessity.

¹Lopriore. C and Branca.F (2001): Strategies to Fight Anaemia and Growth Retardation in Saharawi Refugee Children. Internal report, ECHO, CISP and INRAN, Rome 2001.

²The Comitato Internazionale per lo Sviluppo dei Popoli (CISP) is part of a consortium to better co-ordinate the field operations for the Saharawi refugees.

³The Italian Institute for Food and Nutrition Research.