The Nutrition Situation of Refugees and Displaced Persons

Summary of the ACC/SCN Refugee chapter by Jane Wallace

The quarterly 'Reports on the Nutrition Situation of Refugees and Displaced Populations' (RNIS) are compiled and published by the ACC/Sub-Committee on Nutrition (ACC/SCN) based in Geneva. The RNIS reports include information on major refugee and internally displaced populations (IDPs) in Sub-Saharan Africa (currently this amounts to 15 situations), along with 5 selected situations in Asia. Information included in the reports is obtained from NGOs and UN agencies. Information from country situation reports and food security analysis helps to provide a more analytical context for the nutrition survey data, as well as informing the RNIS team about issues and problems that relate to food and nutrition emergency interventions.

Information used to compile the RNIS reports is also used to write a chapter on the nutrition of refugees and internally displaced populations, which is included in the ACC/SCN's 'Reports on the World Nutrition Situation'. This chapter is written as a synthesis of information from the previous two years RNIS reports, and it attempts to identify trends and lessons learned from all the information received in compiling the RNIS reports. Some of the main points from the forthcoming refugee chapter, which is due out later in the year, are summarised below.

Nutrition Survey Data:

According to UNHCR, the total number of refugees world-wide has decreased (figure 1), as has the total numbers of refugees and IDPs in Sub-Saharan Africa over the last two years. This is mainly due to political solutions to refugee crisis and ensuing repatriation e.g. Mozambican refugees. However, in terms of numbers of refugees and IDPs at heightened risk of mortality in Sub-Saharan Africa, it appears that numbers have remained roughly stable over the past two years, according to the RNIS reports (figure 2). Also, current unstable socio-political situations in several Sub-Saharan African countries could lead to population movements because of conflict. For example, fighting in Sierra Leone, Uganda and the Central African Republic at the moment is leading to population displacements, while a deteriorating security situation in Angola could lead to renewed displacement.

One of the main types of information included in the RNIS reports is nutritional survey data on prevalence of wasting. Over the last two years, a wide range of levels of wasting has been seen, with roughly half of the reports available to the ACC/SCN showing levels of wasting over 10%, and almost one fifth of the reports finding levels of wasting over 20% (figure 3, using data from Sub-Saharan Africa, where each dot represents the results of a survey). A strong correlation is seen between wasting and crude mortality rates (plotted on a log scale in figure 4, again for data available from Sub-Saharan Africa). A prevalence of wasting above 10% is associated with a crude mortality rate of >1/10,000/day, which according to the Centers for Disease Control, indicates a very serious situation.

Efforts to preempt micronutrient deficiencies in refugee and IDP settings have been ongoing. Initiatives have included the distribution of a micronutrient fortified blended food in the general ration where populations are totally dependent on a food aid basket which lacks fresh fruit or vegetables, along with the widespread distribution of vitamin A and fortifying edible oil. Despite these efforts, however, cases of micronutrient malnutrition are still seen. For example, seasonal scurvy outbreaks have been reported in Somali refugee camps in Kenya, while a pellagra outbreak, possibly also seasonal in nature, occurred in Mozambique towards the end of 1995. A more perplexing situation has persisted in the camps for Bhutanese refugees in Nepal where, despite a varied ration which included a fortified blended food and fresh vegetables, low levels of scurvy, beri-beri and vitamin B2 deficiency (seen as angular stomatitis) have been continually reported.

Emergency Programme Implementation: some Practical Issues:

There are many issues that have emerged when reviewing information made available to the RNIS in the 1995-96 period. One general observation is that humanitarian agencies are having to work in increasingly complex environments where insecurity often poses a major constraint to the provision of humanitarian aid. More specific issues include the following:

• Ensuring adequate micronutrient intake amongst populations totally dependent on food aid remains a problem in some areas. Studies are currently underway to determine how fortified blended foods are used by beneficiaries. This should help clarify the degree to which blended foods can be relied upon to provide adequate micronutrient supplies. Other studies are also looking at the potential for fortifying other ration commodities such as cereals.
• The need for improving information collection and analysis to help identify who needs food and how much they need is being increasingly recognised. For example, the experiences in Rwandan refugee camps in early 1995, in what was then Eastern Zaire, show how important it is to have food security information on refugee populations. In this particular case an unplanned ration reduction led to fears of widespread starvation and mortality. The fact that no such emergency occurred was because many of the refugees had achieved successful economic assimilation. This was a development that took humanitarian agencies by surprise.
• The need to anticipate food distribution problems and to adopt flexible and varying distribution systems as an emergency programme evolves is also being increasingly recognised. The experiences in the Great Lakes region during 1994 when commune headed distribution systems were established showed how these systems could lead to highly inequitable general ration allocations with alarming effects on camp population nutritional status. However, agency distribution mechanisms eventually evolved into 'fairer' systems during 1995-6, which proved far more acceptable to beneficiaries.

Emergency Programme Implementation: some Ethical Considerations

In addition to the above issues, of ethical considerations also emerge from the experiences of the past two years. Many of these considerations have far-reaching political implications, and although these should not be ignored, focus is retained on nutritional implications for the purpose of this paper. Some agencies and donor governments seem to have had difficulties making humanitarian assistance available to specific groups on moral/ethical grounds. This has been seen with reference to the Hutu refugees in Zaire but more recently arises with criticisms over support to the Rwandan government. The extent to which humanitarian assistance should be affected by western ethics and moral judgements has been much debated in recent years.

In the case of the Hutu refugees in eastern Zaire, the extent to which reluctance by some western governments to support a population with known involvement in the 1994 genocide is unclear. The question arises as to whether or not a gradual reduction in food aid pledges seen during 1995 was the result of a desire among donors to encourage repatriation. Government rationales were implicit in actions rather than explicitly stated as foreign policy, resulting in a lack of transparency which often made it difficult for agencies on the ground to plan and implement food aid programmes.

These events do raise difficult human rights issues regarding both the way in which foreign policy considerations influence decisions about humanitarian food aid allocations and the practice of reducing emergency food aid to 'encourage' voluntary repatriation.

Another issue that emerges from reports received by the RNIS concerns the appropriateness of comparing the nutritional status of refugee and internally displaced populations with that of local populations. This type of comparison is often made in order to assess the success of an emergency intervention and to determine whether support should be phased out. For example, it is often true that a host population has some endemic form of micronutrient deficiency disease or a high prevalence of wasting. The question is, does this mean that equivalent nutritional status is acceptable within the refugee or IDP population and should emergency needs assessments be influenced by such comparisons?

If we accept the concept that refugees have a right to the best possible nutrition, this comparison may not be useful. It may be more relevant to look at the underlying causes of malnutrition (i.e. food security, caring practices, and adequate health care) so that these may be addressed both among the refugee and host populations. This strategy would most likely involve a shift from emergency response towards a more developmental approach, but may also reduce some of the tensions created by situations in which refugee populations are seen to be 'better off' than the local population.

One way to move forward on this issue may be for the international aid community to define a minimum standard of humanitarian aid provision for emergency affected populations. Such an initiative is already underway and is being spearheaded by the Steering Committee on Humanitarian Response.

Further clarification is required on the issues identified above. This should help move another step towards improving emergency response performance, thereby improving the overall well-being of refugee and internally displaced populations.

To receive copies of the forthcoming 'Report on the World Nutrition Situation' and/or to receive regularly the quarterly 'Reports on the Nutrition Situation of Refugees and Displaced Populations' please contact: Jane Wallace, RNIS Co-ordinator, ACC/SCN, c/o World Health Organization, 20, avenue Appia, 1211, Geneva 27, Switzerland. Tele +4122.791.04.56. fax: +4122.798.88.91. e-mail: accscn@who.ch