United Nations High Commissioner for Refugees (UNHCR)

By Jeremy Shoham, ENN

The ENN interviewed Caroline Wilkinson from UNHCR's Nutrition and Food Security unit in the Public Health and HIV section. Although UNHCR appeared in an early Field Exchange agency profile section many years ago, so much has moved on in the organisation since then that it was time for a revisit.

Caroline spent many years of her career as nutrition advisor for Action Contre la Faim in Paris and has only recently moved to UNHCR. She started the interview by explaining recent changes with respect to how nutrition and other technical units operate within the organisation. The various units are now much more integrated so that nutrition, health, reproductive health, HIV, water, sanitation and hygiene (WASH), food security, Health Information System, malaria, and epidemic preparedness all work more closely together. There is only one nutritionist within the Public Health and HIV Section in headquarters. However there is also a regional nutrition and food security coordinator overseeing the programmes in the Horn of Africa, as well as several nutritionists working in country programmes.

Caroline explained how UNHCR's core nutrition approach aims to build integrated programmes that tackle the causes of malnutrition, i.e. working on prevention as well as treatment. This approach emerged over the past decade and to some extent, was triggered by the major micronutrient outbreaks seen in a number of refugee camps in the nineties which provoked considerable outcry. UNHCR, together with partners, routinely conduct nutrition surveys to understand the extent and nature of nutritional problems and then plan accordingly.

Recent surveys have shown how much micronutrient deficiency still exists amongst refugee children and women. This has led to the anaemia strategy, which started in 2008. The name of the strategy is slightly misleading in that although anaemia is identified as a huge problem, the UNHCR response to high levels of anaemia is meant to also tackle other micronutrient deficiencies, which may not be so measurable or obvious. The levels of anaemia found in UNHCR surveys in 2009 are truly alarming. Almost all surveys found levels of anaemia over 20% in children under five years, while 60% of surveys have found anaemia levels in excess of 40%. Since 2008, tackling anaemia and micronutrient deficiencies in UNHCR programmes has been one of the High Commissioner's priorities.

The anaemia strategy aims to reduce the global burden of anaemia in refugee populations. This will be done through reinforcing the capacity of health structures to diagnose and treat anaemia and other micronutrient deficiencies appropriately, controlling the prevalence of diseases that affect anaemia status (e.g. malaria, diarrhoeal diseases and worm infestation), improving access to fresh nutrient rich foods through small scale agricultural activities and improving the dietary quality, specifically for the youngest children, through effective infant and young child feeding (IYCF) programmes. These are to be combined with the use of products aimed at improving the nutritional intake of specific target groups.

UNHCR and partners have introduced micronutrient powders into the programmes in Bangladesh, Nepal and Kenya and have shown very positive effects in Bangladesh and Nepal, where anaemia in children has declined by 40% and 20% respectively. The powder is added to the World Food Programme (WFP) general ration.

UNHCR are working concurrently with Lipid Based Nutrient Supplements (LNS). In Bangladesh they are providing Plumpy'Doz during the peak hungry season for a five month period to 6-36 month old children. Nutributter will soon be used in Algeria, Dadaab and Djibouti. As can be seen, UNHCR do not use a standardised product and they are working closely with the Centre for International Child Health, London on guidance around product choice given the specific nutrition context, as well as developing tools for improved monitoring and evaluation.

In addition, UNHCR have been working on a robust yet simple methodology for acceptability testing before introduction of new products, piloting tests in Djibouti and Algeria, with Yemen and Ethiopia soon to follow.

The products are just part of the anaemia strategy, which also aims to improve dietary quality through activities like supporting income generation activities, small scale agriculture and expanding coverage of IYCF programmes. The strategy has so far been rolled out in seven countries in 2009, with the hope of rolling out in a further four countries in 2010.

So what has happened to all those major micronutrient outbreak deficiencies seen in the eighties and nineties, e.g. scurvy, pellagra and beriberi? Although surveys suggest that sub-clinical deficiencies are still widespread, Caroline felt that better access to fortified foods has undoubtedly made a big difference. UNHCR and WFP have been working closely on improving the fortification of general rations and blended foods in refugee situations for a number of years. At the same time, UNHCR are still responsible for complementary foods to the general ration in their memorandum of understanding with WFP, which means provision of fresh food items and condiments. Caroline feels that this is something UNHCR don't do very well, due principally to logistical and economic constraints.

UNHCR's IYCF activities are implemented well in some countries and less well in others. In the Dadaab camps in Kenya, UNHCR and CARE have created hundreds of community support groups and managed to significantly increase rates of exclusive breastfeeding. There are also possible links between camp gardens and IYCF, which should helping to increase dietary diversity for younger children. For example, they have introduced 'baby gardens' that target families with young children to improve access to fruit and vegetables. Fresh food vouchers are also being targeted towards younger children in Kenya. UNHCR are trying to strengthen growth monitoring promotion, as well as working closely with the malaria section to combat anaemia through rolling out treated bed net coverage, systematic spraying and use of rapid diagnostic tests. The nutrition unit works closely with the WASH unit.

Although UNHCR are measuring the effectiveness of their anaemia strategy and programmes by looking at rates of anaemia (because it is relatively easy to measure in the field compared to other kinds of micronutrient deficiencies), the indicator is used as a proxy for overall improvement or deterioration in micronutrient status.

Another core element of UNHCR's nutrition work is addressing high levels of global acute malnutrition (GAM) still found in many camps and urban populations, e.g. Bangladesh, Chad and East Sudan. A typical response is to set up selective feeding programmes and UNHCR is striving to improve their quality. UNHCR is also supporting transition to the use of the 2006 WHO growth standards and the use of midupper arm circumference (MUAC) as an independent admission criterion, as well as providing community based management of acute malnutrition (CMAM) services in all operations where these are required. Quality of selective feeding programmes is a real issue, especially since UNHCR work with a diverse range of partners, many of which are not specialised in nutrition as such and may not follow internationally agreed protocols. The majority of partners are local NGOs who work with long-term refugee populations.

Another challenge for UNHCR is that their programme case load is increasingly made up of urban based populations. Provision of services in these urban settings is not straightforward and it can be very difficult to identify target vulnerable groups in these contexts. Furthermore, it is important to work with, and through, the national government system in situations where the local population also have considerable needs. A critical policy for UNHCR in urban areas is to work together to strengthen the existing government services rather than to set up parallel services.

In urban contexts it is often not appropriate to implement a general food distribution specifically for refugees, mainly because it is so hard to target and very impractical. There are also issues of equity, e.g. it is inappropriate to exclude an equally needy local population. UNHCR are therefore finding that a greater number of their programmes provide food assistance through vouchers based on vulnerability rather than entitlement on the basis of refugee status alone.

In light of all this work, three key medium term goals for the nutrition unit in UNHCR are to increase the quality of nutrition programmes (prevention and treatment of malnutrition and micronutrient deficiencies), increasing the understanding of the impact of LNS and other products on anaemia and GAM, and to develop a workable strategy for urban-based populations.

In answer to a question about bigger-picture challenges for UNHCR's nutrition work, Caroline ventured the following; "UNHCR is a house full of lawyers whose main mandate relates to refugee protection. Nutrition is therefore only a small part of what UNHCR does. Furthermore, compared to other actors like UNICEF and WFP, UNHCR is a relatively small player in the nutrition world. At the same time, there are a lot of refugee-specific issues to deal with so that international protocols and strategies may not always fit easily with how UNHCR has to operate. For example, refugees often have very limited access to a diversified diet. As a result, UNHCR may have to do some things differently or think longer-term". Although Caroline didn't 'dot the i's or cross the t's', I inferred from this comment that nutrition constantly has to fight its corner within UNHCR and that this task is not made easier by the fact that nutrition strategies and approaches within the organisation cannot simply be lifted 'off the peg' but have to be tailored to the unique contexts within which UNHCR work. In short, implementing a nutrition strategy within UNHCR is always going to be challenging. The ENN can only wish UNHCR every luck and success in this endeavour.