How to assess and respond to Iraqi refugee needs in Syria

By Lucia Oliveira

Lucia Oliveira has been working with ACF Spain since 2005 and is currently Head of Mission in Syria. Her background is International Relations, European studies and professional training in nutrition and food security. With ACF, she has worked also on programme management in nutrition, food security and livelihoods, in South Caucasus and in the Middle East.

The author would like to acknowledge the support of Elisa Dominguez of ACF Spain, Elena Vallespin ACF volunteer, Ester Ogonda from LATH, ACF Spain Syrian team and SARC volunteers.

This article shares the challenges of conducting a survey of the health, nutrition and livelihood conditions of Iraqi Refugees living amongst the local population in the North East of Syria.

Iraqi families, displaced by sectarian violence and increasing economic hardship, have been moving both within and outside their country for many years. Iraqis started leaving Iraq in the 1990s after the first Gulf War and their departure intensified after December 2007, when the second Al Asquari Samarra Mosque bombing took place. Since the onset of this protracted crisis, several Middle Eastern countries have received a considerable influx of Iraqi refugees. Syria continues to host the largest population of refugees from Iraq. The total number of Iraqi refugees in Syria remains unconfirmed - official figures from the Syrian government point to the presence of 1.2 million refugees, while UNHCR's registered number has fallen to 163,000 refugees in 2010.

Iraqi refugees have settled mainly in rented accommodation in the suburban clusters on the outskirts of Damascus, Aleppo, Homs and in the border governorates in North East Syria. Integration in the northern governorates is very good in the North-East (Hassakeh Governorate) of the country, since refugees and the local population belong to the same ethnic group¹. Those living in Hassakeh have settled within a relatively stable Syrian population that is mainly agricultural but also keeps some animals for meat and milk production. Cotton, wheat, lentils, barley and chick peas are the main agricultural products.

Iraqi refugees are totally dependent on the humanitarian assistance provided by the aid agencies in Syria, namely UNHCR, WFP, UNICEF and international non-governmental organisations (INGOs). These agencies operate together under the umbrella of the Syrian Arab Red Crescent (SARC). One of the main types of assistance provided is in the form of food aid (bi-monthly ration of rice, pasta, sugar, tomato paste, bulgur, oil, pulses, tea, non food items and hygiene kits) and monthly cash assistance to the most vulnerable households selected by UNHCR. In addition, Iraqi refugees have free access to health services and education, provided by the Syrian government. In education, there have been many projects providing school kits and uniforms, school rehabilitation and extension, and remedial extra classes for children who drop out of school.

Interviewing an Iraqi mother regarding nutrition practices and breastfeeding

ACF in Syria

Action Against Hunger Spain (ACF) started operations in Syria in January 2009. With funding from UNHCR and materials support from UNICEF, ACF has focused on prevention of malnutrition through a community based programme in the North Eastern governorates, which is one of the poorest regions of Syria. In order to plan and design a programme, information on the needs of an affected population was required. This has not been easy in Syria due to a lack of accurate and reliable information and statistics, especially primary data. This is, in part, a consequence of Syria's 'closed institutional culture' which restricts assessments and limits access to potential beneficiaries. Therefore, the first challenge of the new mission was to secure government approval to conduct a survey to identify the problem, confirm whether or not the Iraqi refugees needed assistance and if so, what form should this take. The second challenge was to overcome some of the limitations in access to the population.

The study was conducted by ACF and SARC from 29th October to 11th November 2009 in the North Eastern Governorates of Hassakeh and Der Ezzor of the Syrian Arab Republic. The survey targeted urban and rural refugees in these catchment areas.

Survey objectives and methods

The objectives of the survey were to ascertain the current nutritional status of the Iraqi refugees in the target areas and to prioritise health, nutritional and food/livelihoods needs in order to initiate, intensify and/or recommend appropriate interventions. The target population was 13,964 Iraqi refugees, 11,165 in Hassakeh and 2,799 in Der Ezzor with an estimated under 5 population size of 2,793 (20% of total population). Based on SMART methodology, the evaluation used a simple random sampling to select children surveyed. A four day training that included a pilot evaluation was conducted with all the data collectors prior to the actual fieldwork.

Challenge around household surveying

A key challenge to surveying was that refugees could not be visited in their homes. This delayed the survey for some time.. The eventual solution was to employ a simple random sampling methodology using the UNHCR food distribution list of Iraqi refugee households of July 2009. The households from the list were selected at random (using random tables generated by ENA software), giving each household and child in the total population an equal chance of being selected. Families were then contacted by phone to verify location and organise their visit to the closest SARC clinic, rather than assess at home. All the children in the randomly selected households between the ages of 6 and 59 months were included in the evaluation and were measured and interviewed at specific SARC clinics. This proved a successful methodology and a considerable achievement since, to date, ACF Spain has been the only INGO so far to carry out a survey of this population.

Target groups

The target group for the survey was Iraqi refugee's households with or without children aged 6-59 months. The nutritional survey was complemented by a qualitative study using focus group discussions (FGD). In addition, a food status survey was conducted among 304 families to contribute to analysis on the potential causes of malnutrition. Thirteen FGDs were conducted with key informants, leaders, men and women belonging to the target population. The nutrition element of the survey included anthropometric assessment as well as biochemical tests for anaemia. The sample size was 555 children aged 6 - 59 months for anthropometry and 353 children for anaemia. A total of 643 households were sampled for mortality information. The survey was divided in two phases (see Box 1)

Results: Phase 1 Anthropometry and Nutrition Evaluation

Anthropometry

Focus group discussion with Iraqi men

Results indicate a low proportion of moderately malnourished children with 5.4% global acute malnutrition (GAM) prevalence and 3.5% moderate acute malnutrition (MAM). Underweight prevalence was 5.9% and stunting prevalence was 11.9% of the children sampled. Major concerns are the relatively high proportion of severely malnourished children (1.9%) and the presence of anaemia in just over 50% of all children, which indicates serious micronutrient deficiencies (see Figure 1 and below). Prevalence by gender, age groups or governorates were not statistically significant. However, the highest prevalence of acute malnutrition (2.4%) was recorded amongst the youngest (aged 6-17 months), indicative of the influence of poor feeding practices.

Infant and young child feeding practices

Cross tabulation of diarrhoea cases and malnutrition cases indicates that 48% of the malnourished had suffered diarrhoea. Coupled with the higher percentage of malnutrition among the youngest, this suggests that poor breastfeeding and poor complementary feeding practices are significant contributing factors. The rate of exclusive breastfeeding in infants < 6 months is much lower in the North Eastern governorates when compared to refuges in Damascus (18.8% vs 35.7%). This could be attributed to a lower level of awareness among the less educated residents in the north or be the result of less support to mothers in the North. Although a high proportion of mothers (41%, n=127) give breastmilk as the first drink to their newborn, a significantly higher proportion (53.5%, n=166) also give either water or sugared water in the first few hours after delivery. Some also mix breastmilk with water in the first hours of breastfeeding, while others gave foods, camomile or juice. It was suggested that the high numbers of mothers giving water and sugar is likely to be as a result of religious beliefs that encourage newborns to be given honey on delivery. Mothers who cannot afford the honey may substitute this with water and sugar, which is less costly. This contributes to the low exclusive breastfeeding rate of 18.8% (n=59) at 6 months of age.

It was observed that 2% of mothers continued exclusive breastfeeding for infants aged 6-12 months. However the majority of the mothers (66%) gave breastmilk and semi-solid foods at this age while 10.5% gave only solid foods. Amongst the remaining mothers who had stopped breastfeeding, 8% gave mainly commercial processed fresh milk to their infants, while 6% gave yoghurt and 7.5% gave other foods/drinks such as soups, tea and juices.

Between the ages 12-24 months, one third (30.5%) of mothers introduced semi-solid food in addition to breastfeeding. Of all mothers of children in this age group:

• 29.8% gave breastmilk and solid foods
• 1.3% were still exclusively breastfeeding
• 15% gave only semi-solid foods
• 9.5% gave only commercial processed milk
• 3% gave only solids
• 10.9% gave either yoghurt, a combination of breastmilk and water, soups or tea.

The frequency of feeding reduced as the children became older. Feeding patterns with respect to iron rich foods available locally were also analysed. This found that iron consumption in foods was very low. The majority of the population (69.8%) never give their children liver. Only 13.6% eat liver once a week and 16.6% rarely eat liver. These percentages were almost similar for fish paste, kidney, heart, sardines, and much lower for tongue, which is eaten by just 1% of the sampled population although commonly eaten amongst adults.

Refugee children also showed low immunisation coverage for measles (6.3% with card and 73% including caregiver recall) and low Vitamin A supplementation (10.9%). Vitamin A supplementation is much lower than the national coverage rate of 35.6% and the coverage of 47% amongst refugees in Damascus.

Anaemia a significant problem

The high anaemia prevalence and low percentage of iron rich complementary foods used show that anaemia is a huge nutrition concern in the area². Half of the children surveyed had a haemoglobin (Hb) level under 11 g/dl, although the rates of severe anaemia are low (1.4%). The highest anaemia rates were recorded in the 6-12 months age group. This may be attributed to the mothers' unawareness of the optimal complementary feeding age and/or their failure to introduce appropriate complementary foods at the right time, since breastmilk does not contain sufficient iron to meet the infant's requirements and to protect the baby from anaemia. Other factors include mothers giving tea, which inhibits iron absorpthan, inadequate attention during pregnancy and delivery, and low intake or sub-optimal cooking of iron rich foods to preserve their iron content. Clearly, this issue merits further consideration from ACF and partners. Children with severe anaemia should be promptly referred to secondary health facilities for diagnosis and treatment.

Access and use of safe water

The insufficiency of safe, protected water amongst this refugee population could be linked to poor hygiene practices reported and closely associated to diarrhoea diseases which were found to be highly (42.9%), prevalent among malnourished children and in the community and one of the main causes of deaths in the population. The lack of accessibility to safe water points and preventive health education services needs addressing in this population.

Results: Phase 2 Food and Livelihood Evaluation

Although the majority of the children and the adults ate 3 or 4 meals per day, they still consumed less than 2100 kcal per day. The average size of the households was 6 members, and 14.5% of households were female headed households.

The majority of the refugees live in rented houses and have no access to kitchen gardens or agricultural activities. Their expenditure priorities are rent, food, and health services. A key economic issue is their lack of legal status and therefore their entitlement to work. Their sources of income and coping mechanisms in order of importance are the sale of the food rations, followed by loans, UNHCR cash allowance, sales of assets and savings. The reason given by three-quarters (75%) of Iraqi families surveyed as to why 40.9% of them sell the food ration is that the UN diversified food basket distributed cannot fulfil their essential food needs. The food basket comprises 25 kg of rice, 2 kg of sugar, 5 kg of lentils, 2 kg of bulgur (cereal), one box of tea, 2 kg of pasta, 1 kg tomato paste, 2 litres of oil. The remaining 25% of those interviewed considered the ration to be sufficient. The survey also found that as household size increased so did the reported dissatisfaction with the food basket.

There are five main foodstuffs that are traditionally considered to be priority items amongst the refugee population: oil, sugar, meat, rice and milk. Oil, meat and milk were all considered 'missing' or inadequate from the diet by those surveyed. Other items such as vegetables, fruits, dairy products, pasta, bread, chicken, bulgur, potatoes, lentils and fish were consumed by the population but reported as insufficient amounts.

The majority of the Iraqis said they usually sought help from local Syrian families who responded by helping without asking for something in return, despite the fact that some Syrian families were no better off financially absorpthan the Iraqis. As one participant said, many of the families in the community were poor and all "have the same pain". This situation is reflected in the basic causes element of the malnutrition conceptual framework presented in Figure 2 and which, in this case, is compounded by a 3 years consecutive drought cycle. This drought has severely affected many Syrian farmers and herders who lost the majority of their animals, fodder, harvests as well as income so that they could neither afford to purchase seeds and feed for the next season or repay back their loans. The Iraqis are therefore living in a distressed economic area where agriculture used to provide a source of seasonal labour.

The overall livelihood conditions presented in the report show continued economic deterioration and worsening debt leading to a decrease in food access and intake. The coping strategies being used, i.e. debt, are not sustainable. While these strategies allow payment for accommodation and diversified food access they do not allow for treatment of chronic health diseases, education fees, transport, fuel, and water costs. Savings and remittances from abroad are too low to make up these shortfalls or allow these other critical expenditures.

Conclusions

In conclusion, while the Iraqis may not be suffering from high rates of malnutrition or unusually high mortality rates, there are considerable concerns over issues that affect their day-to-day living. The refugee population is clearly vulnerable to poorer nutrition and health of both children and adults. Anaemia is already a significant problem and Syria is not alone in this; iron deficiency is a widespread problem globally. WHO states that 2 billion people have iron deficiency, while studies have shown that half of refugees suffer from iron deficiency anaemia³. ACF is currently negotiating with UNHCR and UNICEF and the Ministry of Health for an extension of the project that could include mass distribution of micronutrient powders (Sprinkles) to prevent anaemia in the area. However, it is also important to address these problems with longer-term strategic food and public health measures that tackle the underlying problems of malnutrition, in addition to managing existing acute malnutrition through the health infrastructure currently in place.

At policy level, there appears to be a gap regarding coordination among all actors involved in nutrition that hampers addressing nutrition problems in Syria. Regular meetings or set up of specific working groups of specialists regarding issues identified are recommended.

The absence of a legal framework to allow work and consequent inadequate purchasing power amongst the refugee population will contribute to further increases in malnutrition rates. If not adequately addressed, the nutritional and health status of this population can only get worse. It is therefore imperative for this refugee population that health and nutrition preventive responses must be implemented in conjunction with food access and income monitoring.

For more information, contact: Lucia Oliveira, email: hoc-sy@acf-e.org and Elisa Dominguez, email: edominguez@achesp.org

¹June (2009) WFP/UNHCR/SARC/SPC JOINT ASSESSMENT MISSION Refugees in Syria- Syria Assessment Joint Mission.

²Anecdotal information from Al Qamishly hospital estimated the prevalence of anaemia for both Syrian and Iraqi refugees in the region as 25-30%.

³CRED, (2009). Anaemia in Complex Emergencies