The social life of nutrition among Syrian refugees in Jordan
By Luigi Achilli and Raymond Apthorpe
Luigi Achilli is research associate at the Institut Français du Proche-Orient (IFPO) in Amman. He holds an M.A. and a Ph.D. in political anthropology from the School of Oriental and African Studies (SOAS). His research and writing focus on everyday forms of political engagement and disengagements, political identity, nationalism, Palestinian issues, refugees and refugee camps, and the politics of space. He is currently working on the reverberation of the Arab Spring in Jordan.
Raymond Apthorpe is an anthropologist specialising in applied humanitarian and development aid studies. He is currently the Vice President of Council of the Royal Anthropological Institute, London. Currently Raymond is a Visiting Professor-elect, London School Economics and Political Science; and a professorial research associate at School of Oriental and African Studies, University of London. He undertook this work with ENN on a voluntary basis.
Luigi, Raymond and the ENN editorial team extend sincere thanks to UPP, UNHCR, Medair, Save the Children Jordan; many other humanitarian agencies’ staff, national and international, who helped us in various ways; the individual scholars and other professionals who shared insights with us and at times accompanied us, and Tara Shoham (ENN volunteer) for setting up most of our meetings and taking part in them.
As the ENN embarked on developing this special edition of Field Exchange in September 2013, it was clear that most of the articles would describe the experiences of programming staff. We wished to redress the balance a little by featuring refugee and host population social experiences of the multi-faceted area of nutrition. Given very limited resources, this capture could only extend to the collation of a small number of individual refugee experiences in Jordan. We engaged two enthusiastic anthropologists, Luigi and Raymond, and an equally enthused volunteer graduate, Tara, to undertake this work and add a fresh perspective. This article shares what they found and their personal reflections on what they saw and heard in the process.
As the authors state at the outset, this is not a study of a representative sample of affected refugees and no conclusions should be drawn regarding the nature and impact of the response in Jordan; there is extensive work on this that can be accessed at the UNHCR Syria response portal (http://data.unhcr.org/syrianrefugees/regional.php).
Method
The collection of data relied mainly on 40 individual interviews and two focus group discussions held over a period of 20 days in February 2014. The interviews of refugees, aid personnel, scholars and others on which this paper is based were planned in advance where possible and based on a schedule of questions covering key thematic areas of interest as developed with input from ENN and the nutrition sub-working group in Jordan. Nevertheless, in the event much depended on the vagaries of chance and access, and who, when it came to an actual meeting, were willing to make themselves available to us, and how far they would go in addressing what turned out to include some highly controversial issues. The research was carried out in various parts of the country. Our interviews involved several visits to non-governmental organisation (NGO) field offices in Amman, Karak and the Jordan Valley, one visit to Za’atari camp and two visits in two informal tented settlements (ITS) - Deir ‘Alla and Mafraq respectively. Of course, for a properly social anthropological study (that would be based more on social observation, participant involvement, and generally ‘being indeed living there’ than reliance on interviewing), a much longer time for fieldwork is needed, besides time to access all the available literature that directly or indirectly could be of help to this type of study. The analytical perspective we designed emerged as our observations proceeded.
Setting the scene
This special edition of Field Exchange contains descriptions of the different situations of Syrian refugees in Jordan. Some live in official camps, others do not; some did, but many have moved out since. Through our research we were told of a number who were in ‘informal tented settlements’ (ITS) who chose or in instances, were moved1 to camps whether they originated there or not; most ITS dwellers we heard about, for now anyway, remain in these largely service-less places. Some Syrians fled to Jordan at the very outset of the conflict, others are still coming. In addition, while the total number of Syrian refugees in Jordan (and elsewhere) is very high, those who already resided in Jordan prior to the civil war should also be taken into account. An added complication is that while many refugees have registered with the UNHCR, many others have not, or must manage while their re-registration is still pending. The vast majority of Syrian refugees we met by most accounts are totally or only partly unaware of what relief services there are for refugees, while those that are – and have registered – are not all accessing them2. Furthermore, from our inquiries, it appears some Syrians do not register, either as refugees or asylum seekers, as they consider themselves in transit and en route to another country. They believe that having the label ‘refugee’ would only hinder that. In one informal tented settlement we were told that no one had registered as a refugee because of fear of their information being made known to Syrian officials or because they saw no benefit to registration since they normally moved in search of work (see Box 1). So, simply what a ‘refugee’ is exactly – or inexactly – can be a puzzle. Equally important, forced migration may be due to a number of different factors – social, economic, and political. Any overall nutritional profiling must allow for this complex picture.
BOX 1: e-voucher and the issue of registration
We visited a Jordanian Women’s Union (JWU) centre in the Jordan valley region, opened in 2007 by a former school teacher, followed by two nearby ITSs. The JWU runs social, educational, awareness raising and vocational activities, as well as occasionally providing medical services by visiting doctors in at least one of the ITSs. Many in the medical tents are ill due to exposure to the pesticides they use in the greenhouses where they work3, moreover there are no facilities in the tented settlements to wash, go to the toilet, and no clean water. “The poverty is taking away our children’s childhood” someone said. Households pay 25JD per month to have a tent on the land where they work. Syrian refugees work alongside Egyptian refugees but earn less money: Syrians - 1JD per hour, Egyptians- 1 ½ JD per hour.
It is mainly the women who work in the greenhouses, and sometimes the children. The northern Syrian’s have brought this culture here. Southern Syrian men do work (especially if they are educated). Their diet is poor in protein. They receive some vegetables, as well as pay, but they sell them for extra income. Their e-cards, which are not exchangeable for cash, are for purchasing food and other items for up to 24JD per month (12 JD every two weeks) per family. It costs however 1JD to go to the mall in Salt to use them. The e -card was introduced to stop refugees selling their vouchers – agency staff considered that, assuming the proceeds would not be spent on food, this would inevitably negatively affect refugees’ diet. However, as most people in the tents don’t register as refugees, they are not entitled to receive e-vouchers. Interviewees gave two reasons behind this decision: first, they are too afraid, thinking that their information might be given to the secret police who will then send them back to Syria and secondly, many have a very nomadic style of life, moving from one work place to another, so it is not beneficial for them to register.
As two social anthropologists, the ENN asked us to ponder and probe some of the social – and human – aspects of emergency nutrition for the Syrian refugees in Jordan as a contribution to this special issue of Field Exchange. On the basis of a month’s ‘fieldwork’ in Jordan (March 2014 plus a few days reflecting and writing, in April), what we could aim to do was of course limited, but threefold: (a) to model the social side of nutrition arranged and integrated with the bio-medical side and bring it to the fore as ‘the social life of nutrition’; (b) to rehearse something of what a ‘beneficiaries’-oriented study of the social aspects of nutrition in a refugee population should aim to consider4, and why; (c) to interview as many refugee households or household members and ‘focus groups’ as possible in the circumstances as to their nutritional status and issues, and report briefly our findings.
Nutrition as a social as well as a bio-medical process
Nutrition is integral to and arranged as part of the social life of people. It has social, economic and political pre-conditions, dimensions, and aspects. Refugees’ social lives, like other peoples’, affect and are affected by their nutrition and malnutrition (see Box 2). That refugees do have social lives of their own, despite being treated by relief agencies for administrative purposes just as displaced demographic categories – such as ‘refugee women’, ‘refugee men’, ‘refugee infants and children’, and such – must itself be a major point to make at the outset of this analysis. Refugees should be studied as people as well as refugees. Besides their refugee needs and concerns, they have everyday agendas of their own about their non-refugee ordinary lives5, whether or not these agendas are known to the authorities.
Box 2: What type of nutrition?
Fatima is a 25 year old woman from Homs. On the 20th July 2013, she left Syria and crossed the border into Jordan with her husband and her two children aged 8 and 10 years. They spent one night in Zatari Camp for registration purposes; the following day, the whole family moved to Karak, where they are now living.
Fatima works part time for Save the Children Jordan for 10 JOD per day, three days per week. She is the only one to work: her children are too young and her husband is disabled – his right arm was severely injured by a bomb in Syria. The work is regular but the salary too meagre to cope with the daily expenses. To pay the rent of the house, the family sell their monthly food vouchers. The voucher value is 96 JOD, but they sell it only for 60 JOD.
The family would like to have different types of food, but they cannot afford to. They eat potatoes almost every day, only on Friday can they afford to have meat, generally poultry. Fatima laments her incapacity to feed her children and husband with a more varied and balanced diet, especially meat and vegetables. However, she also claims that her first priority would be to give her children sweets. She comments: “you know, if I could buy food, the first food I would buy is chocolate for my children. At the school, (Jordanian) children make fun of them. All the other children have snacks, but they don’t have anything but bread. They mock them calling Syrian dogs6 because they are different. I’m afraid; I don’t want my children growing up thieves because of the hardships that they have to endure!”
By way of introduction, three points are highlighted to begin with. First, we soon found that for all kinds and categories of refugees in Jordan we met, ‘food security’ is the overriding issue in their estimation. Second, the overwhelming household priority for those who do not live in refugee camps and settlements – generally said to amount to some 80 per cent of the total – is somehow to meet the high rent that landlords demand for basement accommodation space7. Third, food has not only nutritional values but it is also politically, socially, and culturally defined.
During our fieldwork we could observe, for example, how refugees’ political economy and institutions shape and limit individual and household choice over what to eat and when (see Box 3). Likewise, individual tastes are strictly intertwined with cultural preference; all affect people’s nutritional patterns. Virtually everywhere we went we were told no one liked the taste of the World Food Programme (WFP) supplied Super Cereal relief ration food. Apparently, unless you were in a position to afford to find and add sugar, no one would want to eat it (see Box 4). Neither, again according to what we saw or heard practically everywhere we went, would refugees eat frozen meat or fish, even where it was available and affordable. Some said it had a bad taste, others doubted that the use-by dates on frozen food were reliable (given the common practice in some stores of switching off power at night to economise on costs). Yet others said that “though those who travel and are modern eat frozen food, we [ordinary folk] do not” (see Box 5). Regarding dairy products, in Za’atari camp and elsewhere, people told us that while at home in Syria these were available and affordable, they had do without them in Jordan and use only powered milk; an inferior substitute, as they saw it, which again they would avoid.
Box 3: Political economy
Umm Khalil lives in Za’atari Camp. She left Syria with her two children in 2012 to join her husband who was already living in the camp. The husband had left Syria one month earlier after deserting the regular army.
The woman does not work. Her two grown up children and her husband are not in steady employment; they alternated between petty jobs and long periods of economic inactivity. Like many other refugees in and outside Za’atari Camp, the family sells the food vouchers that it receives periodically from the WFP to afford diverse types of food such as dairy products and fresh meat.
Umm Khalil says that they cannot afford healthy complementary foods such as fruit and vegetables as the voucher will not cover this price. She also blames the family’s poor diet on the logic of “wasta” that relegates them to the margins of refugees’ political economy. The term “wasta” indicates the use of family connections and relationships of patronage that are central in the search of jobs, credit, and favours in the region. Umm Khalil claims that access to regular jobs, and hence to better food, in the camp’s informal market is determined by a small community of Syrian refugees originating from a specific part of the Syrian governorate of Dara’a. Being one of the first communities of Syrians to settle down in the camp, they have had the time to consolidate their power over the newcomers. According to Umm Khalili, “there is mafia in the camp! These people are generally related through kinship. This means that they decide who can work and who cannot work. They are also those who can decide who can sell their vouchers and who cannot. Others decide what kind of food can be bought, and they have access to better food because they have money.
Box 4: Super Cereal Plus
Shadi and his wife, a young couple in their early twenties, have a 2 year old daughter and another child, only days from birth, when we met them. They came to Jordan partly because they felt unsafe in Syria. They spent 15 days in Za’atari camp and then left because of its poor conditions, to join an aunt who was living nearby.
Shadi farmed sheep in Syria and is now doing the same for a Jordanian employer. They do not pay rent for their accommodation in season, only out of the season, but they have to travel far into the centre of the city to buy the food with the vouchers provided by WFP, which is expensive. They seek to buy the same food that they bought in Syria, but lament the lack of sheep’s milk and cheese. They do not like the meat which they could buy with the WFP voucher as it is frozen and so, they claim, unhealthy.
Shadi’s wife was identified as moderately malnourished during screening, on account of inadequate calorie intake during her pregnancy. She is, however, suspicious of the WFP’s specialised Super Cereal Plus for the treatment and prevention of moderate acute malnutrition among Syrian refugee women and children with which she has been supplied. It tastes wrong, she claims, the procedure to cook it is too complicated, and as we observed, there is not always agreement on how to prepare it (the international aid worker, and the national nutrition staffer, robustly disagreed as to exactly what quantities to mix). Social protection in the sense of household socio-economic-health security may involve a family selling its WFP-supplied Super Cereal Plus at the roadside for a much lower price than its value to supplement a meagre family budget.
Box 5: “Dangerous” food
Abu Omar spent two weeks in Za’atari Camp before moving to Deir Alla in the Jordan Valley. He left the camp because one of his children was very sick, and he knew a Syrian doctor who lived in the Jordan Valley. He rented a house in Deir Alla where he now lives whit his wife and children.
Abu Omar used to be a teacher in Syria but is now a plasterer/decorator. He is earning 7JOD per day. Despite living in hardships with a salary that barely covers the rent of his flat, the man claims to be in a far better situation of those Syrian refugees who live in ITSs near his house. These people have established their settlements on the very lands where they work. Households rely primarily on agricultural waged labour - an unsteady source of income that tends to vanish as the winter approaches.
Abu Omar has a fridge and, with that, a far richer diet than his country mates who leave just nearby in the ITS, who relay mostly on tinned/boxed foods. He and his family can afford to eat cheese, olives, olive oil, rice, lentils, beans, vegetable and eggs.
However, despite the “luxury” of owning a fridge, like people living in the ITS, Abu Omar does not eat meat. The WFP voucher allows him to buy only frozen meat. Frozen meat, however, is widely believed among Syrian refugees to be poisonous and toxic. Dishonest sellers are rumored to change the ‘use by’ date on the packaging of the meat or turn of the fridges at night – to save electricity – and then refreeze the meat. As Abu Omar put it, “people who travel might eat it, but it is not good, it tastes different. We don’t even know whether is halal [‘permissible’ under Islamic dietary guidelines]”.
All in all, to what extent, even in extremities of situations, people, refugees included, will or will not change their cultural values and preferences and for example, accept to eat whatever they can get simply to survive, remains to be socially researched as a matter of refugees’ knowledge, attitudes, and practices anywhere, let alone in Jordan specifically. Our impressions are that perhaps even in emergencies, cultural preferences may tend to harden. Despite the popular idea that in emergencies and other stressful times there is nothing but social breakdown, our fieldwork and other accounts document the extents to which ordinary social institutions and practices continue to be part of the social scene despite disruptions and other changes. Refugee camp, and non-camp, life is no exception. That in some extremities such avoidances and indeed other social and cultural practices do change and perhaps break down is another scenario – but under what kinds of pressures, against which alternatives, at what thresholds, and with what outcomes?
Nutrition is already an inter-sector
Nutrition is not just one thing, with sharply defined boundaries, but many things, itself an inter-sector. Towards better addressing ‘nutrition’ amongst Syrian refugees in Jordan, it must be remembered that nutritional status depends on many things at once, not on diet and food intake alone.
To begin with, it is worth noting how ‘shelter’ and ‘health’ are part and parcel of refugees’ nutrition issues. For example, chronic health conditions can have a big impact on all age categories. At the same time, extremes of climate and weather as in Jordan can mean that poor shelter can be deleterious, especially in the winter, to health and nutrition. Similarly, all of our informants – either development and humanitarian aid agency staff or Syrian refugees – appreciated the many contributing factors to malnutrition. None pointed to material shortage of food to explain the cases of undernutrition among them.
Another consideration is the new policy in Jordan of cash aid that has gained ground in the form of ordinary vouchers and, more recently, e-vouchers. Indications from our work are that vouchers for food items are actively traded by a range of purchasers. Social protection, in the sense of household socio-economic-health security, may involve a family selling its vouchers for a much lower price than its value (often at a loss to the seller of 12 per cent) in order to supplement a meagre family budget. As to whom such vouchers are sold, it is to other refugees, to the host population, and sometimes even to aid-workers, as for instance in the Za’atari camp (where there are currently an estimated 3,000 aid staff). Needless to say, these transactions are detrimental to refugees’ ‘proper’ nutrition. From our discussions, we cannot judge what overall difference the introduction of vouchers has made to nutrition amongst those we spoke to and certainly not in the refugee population at large, What we can reflect is that much is likely to depend on specifics, such as what food/non-food items, if available, vouchers can be spent on; where, at what time intervals; and as a market in vouchers develops (including in Za’atari camp) precisely who sells and who buys, why and what then is done with the proceeds.
In this context, nutrition’s social protection dimension is also evident in several regards. Violent social relations among refugees and between them and/or the host community may be directly or indirectly interconnected with nutrition in various ways. For example, most of the cases of malnutrition reported to us were amongst Syrian refugees living in the ITS. It is likely that sub-standard living conditions and inadequate WASH contributed to the poor nutrition situation that we observed. Yet, ITS have increasingly become a default option for those refugees – mostly coming from the governorates of Aleppo, Hama, and Rural Damascus – who left Za’atari also because of the inter-community tensions within the camp as well as issues like lack of privacy and freedom of movement, feelings of being imprisoned, and humiliation. Another example of refugee host population tensions surfacing occurs in relation to the strong dislike of the taste of WFP-supplied relief food - one refugee interviewed wondered whether it might be poisonous, given that it was not also made available to their poor Jordanian neighbours!
Finally, in this short listing of essential influences, household social-time management needs to be taken into account towards understanding refugees’ decision-making about nutrition. For example, on being told by a refugee that she “had not enough time” to take best care of the nutrition of her infants, it turned out this was because of the elderly and infirm she had to care for too. Since she was largely confined to her home space, she was not able to get about much – for example, to the clinic to have her children screened, vaccinated or looked after when ill. She had become socially isolated compared with her life before and as a result, not able to cope and manage well. The nutrition and health of her children suffered as a result.
Nutrition and humanitarian relief
Nutrition is intimately linked with personal matters of health, individual and household income and a whole range of issues important for social policy and administration – such as vulnerability criteria, ease of access, and effective targeting.
For Syrian refugees in Jordan, access needs to be considered in terms of access on the part of the relief agencies to their target populations, and access on the part of these populations to the agencies (see Box 6). This dichotomy has obvious implications. For example, international agencies’ views on who are the most vulnerable and in greatest need may differ considerably from those of the refugees themselves. In addition, NGO and UN vulnerability criteria tend to change over time. In the short time we had for this research and with the resources available to us, we were unable to track such changes and come to any conclusion about overall outcomes and impacts.
Box 6: A special diet
Nadia is a 43 year old woman, from a village near Damascus. In May 2013, she crossed into Jordan with her four children aged between 6 – 15 years. Her husband remained in Syria. She went directly to Karak by-passing Za’atari Camp, choosing that destination because a relative who moved to Jordan before the war would help them settle. Nadia youngest son is very sick, diagnosed with a rare chromosome disorder, “he looks 3 years old but is already 6”. An expensive private doctor she consulted prescribed a diet rich in protein, however she said she can only afford to buy potatoes. She does not work. Her two eldest children carry out occasional jobs, but irregularly and without earning enough to cover even food costs.
Nadia is not enrolled in any programme of assistance. She said that she was never contacted by any humanitarian organisation. She had rectives eived cash assistance just once, from Save the Children International, she said, but since then nothing, no assistance of any kind from any organisation. It appears that like Nadia, there are numerous other refugees who are unaware of the services available and/or the criteria of access.
A further complication is that straightforward emergency response is rarely unbound from what we consider a developmental agenda or at least a longer term strategy. Nutrition as we have seen is itself inter-sectoral. Like other emergency assistance provision, a nutritional programme may also be, besides one of targeted relief, a project of selective nutritional reform. A case in point is, for example, what came across to us as an “educational war” in Jordan between, on the one side, the advocates of breastfeeding and, on the other, users of infant formula. If such a war is indeed being waged, it is hard to tell which side is losing or winning – and at what costs. Organisations such as Save the Children Jordan (SCJ) strongly advocate breastfeeding support as do international agencies such as Medair who kindly invited us to see some of their work first hand. SCJ’s Coordinator for Nutrition - who co-chairs with UNHCR the Nutrition Working Group for the Syrian refugees - showed us in Za’atari camp how SCJ provides education and skilled support on optimal breastfeeding practices9. The challenge for SCJ and similar agencies is that most Syrian refugees in Za’atari are from rural areas in Syria where infant formula is commonly used to feed infants. For those we interviewed, this is because, besides the convenience offered through formula feeding, “it is also the modern way to go”. For us this raises some questions we found impossible to answer, such as what level of compromise is appropriate between an aid agency’s public health interest approach and the individuals own choice, which in turn, is a function of their own values and responses to their circumstances and conditions. And furthermore, to what length should the aid response go to, to achieve behavioural and social chance in an emergency context?
As we see it, a relief organisation that embarks on this type of social and nutritional re-education in the context of a relief programme, sometimes using the same programme and staff, has both emergency relief and development objectives in that they are relying on behaviour changes in an emergency context that may take some time. A question this poses for us (and perhaps research) is whether what may be best for the health of the population at large is difficult for the individual to accept and accommodate and consequently gives the agency a bad name in the eyes of its intended target population. This is a complex matter to resolve.
Conclusion: The complex social relations of nutrition
The social relations of nutrition are to be sought in its sociography, that is who knows and interrelates with who, as well as its social and cultural institutions at large, such as what and whose knowledge, attitudes and customary, seasonal practices prevail with regard to food, health, nutrition, domestic and political economy and so forth. Hence, as our fieldwork illustrates, there is need for a household and community social context-informed approach to the management of aid programmes and their implementation and evaluation. Refugees affairs are not simply ‘spontaneous’ or automatic ‘reflex’ reactions to challenges and opportunities. Rather, actual health and nutritional outcomes are beyond the bio-medical. They are underpinned by social, political, economic and security variables. They are therefore informed by patterns of communication and choices whether in the circumstances they can be well-informed or not.
We do not doubt that those working with Syrian refugees appreciate the human nature of their needs and situation. Unfortunately, rarely in emergency relief studies do the social relations and social issues in refugees’ everyday lives that affect their nutrition and health, and indeed all aspects of their lives, get the attention they deserve.
For more information, contact: Luigi Achilli, email: luigiachilli@yahoo.it and Raymond Apthorpe, email: raymond.apthorpe@gmail.com
1 “On Sunday 5 January, residents of Informal Tented Settlements around Greater Mafraq municipality were evicted and forced to move.” See minutes Informal Tented Settlements Taskforce Meeting (meeting date: 9 January 2014). Also, during the researchers field visit in the Jordan valley, a former site was pointed out to us, with the information from the Jordanian Women’s Union (JWU) that its former occupants had been relocated.
2 It is important to note that UNHCR evidence shows that 96% of registered refugees have access to MoH services. In a UNHCR supported survey of registered refugees, nearly all households (91.7%) knew refugee children younger than 5 years have free access to vaccination, and 96.3% knew that all UNHCR registered refugees have free access to governmental services at primary health centres and hospitals. Only 65.8% were aware that refugees who can't access governmental health services could seek services at UNHCR-supported health facilities.
3 This is based on reports from the refugees and staff from the JWU
4 What are generally termed ‘beneficiary’ studies tend to focus on selected target groups or supposed representatives of these at a particular point – or points – in time. Loose use of the ‘beneficiary’ word – such as ‘we have served 10s of 1000s of beneficiaries’ – is practically meaningless sociologically as well as administratively. Cf. Raymond Apthorpe. 2012. Effective aid: the poetics of some aid workers’ angles on how humanitarian aid ‘works’. Third World Quarterly. Special Issue, Vol 33, No 8.
5 Cf. Achilli, L. Palestinian refugees and identity: nationalism, politics, and the everyday, I.B.Tauris. Forthcoming.
6 The researchers felt it important to cite the exact words used and not sanitize others’ statements. However in doing so, it is equally important to reinforce the point that the opinion expressed reflects the experience of a single person and, as such, should not be extended to the totality of Syrian refugees’ experience.
7 See http://data.unhcr.org/syrianrefugees/country.php?id=107.
8 Information note from ENN: The supplementary feeding programme only targeted Syrian refugees given their higher vulnerability. Recognising the population’s negative experiences around Super Cereal Plus, considerable work has been done since its introduction to sensitise the population to its value and how it should be prepared. Satisfaction has increased as a result (see articles by Save the Children Jordan and Medair in this 48th edition of Field Exchange).
9 Save the Children Jordan and UNHCR also support targeted provision of infant formula to infants who are not breastfed in Za’atari camp. This aspect of the programming was not encountered by the researchers.