Persistent Micronutrient Problems among Refugees in Nepal

by Janack Upadhyay

This article describes nutritional aspect of emergency food aid in Bhutanese refugee camps in Nepal; the author was regional Food & Nutrition co-ordinator for Asia before the current assignment. - Head, Food & Statistical Unit, Programme co-ordination section, DOS, UNHCR, Geneva

The first exodus of ethnic Nepali asylum seekers who arrived from Bhutan in early 1991 started making their makeshift huts on the bank of river Kankai Mai in Jhapa district. The malnutrition rate was reported to be more than 20 % (Weight for Height Median <80%). The situation was quickly brought under control (malnutrition rate <10%) by providing food such as rice, dal (split beans), oil, salt and sugar; shifting the refugees to organised camp sites and providing medical services.

With the help of the government of Nepal, UNHCR is currently managing some 90,000 Bhutanese refugees who are residing in eight camps in the districts of Jhapa and Morang in south-eastern Nepal. The WFP provides all the food commodities except vegetables which are provided by the UNHCR. All the food as well as non-food items are distributed by the Nepal Red Cross Society (NRCS). Water and sanitation conditions as well as health delivery systems in the camps are considered to be better than other refugee camps in the developing world. Although the camps are 'open camps' Jhapa district is one of the most densely populated parts of Nepal so there are very few income earning opportunities for the refugees.

The food basket at the outset of the programme consisted of polished rice 430g, dal 60g, oil 25g, salt 5g, sugar 20g and fresh vegetables 100g per person/perday. This ration was adequate in terms of calories and protein and as a consequence levels of wasting declined to 5%

Micronutrient Deficiency Disorders (MDDs)

Despite the regular supply of these food commodities and well managed water, health and sanitation services in the camps, cases of beriberi were reported in September 1993. Following these reports SCF established surveillance of micro-nutrient deficiency disorders. Within a short time cases of pellagra and scurvy were also reported. There was some concern about possible over-reporting of beri-beri particularly amongst those over 75 years of age who complained of joint pains. Beri-beri normally affects the most active members of a population who consume large amounts of carbohydrate. Thiamin is essential to the metabolic utilisation of carbohydrates. However, many patients, including the elderly responded to thiamin injections. Investigating teams identified several factors which were likely to result in MDD in the camps. Some of these were as follows:

• Consumption of polished rice: Bhutanese refugees are basically polished rice eaters. In view of their food habits polished rice was supplied in the general ration. However, polished rice contains far less thiamin than parboiled rice.
• Freshness of vegetables: although UNHCR was trying its level best to ensure the provision of fresh vegetables, this was very difficult logistically given the perishable nature of vegetables. Thus, the vegetables provided by UNHCR often had depleted micronutrient levels. Moreover, when vegetables needed to be supplied in bulk it proved impossible to provide a variety of commodities.
• Unfavourable exchange rates for general ration commodities: the basic diet of Bhutanese refugees is rice, dal, and vegetables with the occasional addition of meat and milk products. The refugees still wanted to consume meat at least once a week and milk (especially in the form of yoghurt) once or twice a week. However, these products were relatively expensive as energy and protein sources compared to the market value of the general ration commodities so that the caloric and protein content of the refugee food basket decreased if refugees exchanged general ration commodities for these other items. This increased the refugees dependence on the supplied general ration which on its own was deficient in key micronutrients. Furthermore, there were restrictions on ration trading by the local authorities and UNHCR. This was due to the local opposition amongst traders who feared that their markets would be undercut. Some trading did occur but this was mainly in the form of direct exchange of food commodities.

There was speculation that consumption of rice beer could be an underlying cause of MDD. However, Bhutanese refugees are of Nepali origin and they are a mixture of various ethnic backgrounds such as strict Brahmins who never drink alcohol. Furthermore the majority of women do not drink alcohol. Since the disease was affecting everyone, alcohol consumption as an underlying factor was ruled out.

The Food Basket

After the emergence of MDD the general food basket was modified to include micronutrient enriched blended food at the rate of 40 g per capita and polished rice was replaced by parboiled rice. Initially the fortified blended food was imported wheat soy blend but this was later substituted with locally manufactured Unilito (June 1994). Radish in the vegetable ration was substituted with green/yellow leafy vegetables. Other commodities in the basket were kept unchanged. The current food basket is now adequate in terms of all the nutrients except for calcium, riboflavin (B2) and Vitamin A.

Nutrition Education

Although rich in thiamin, parboiled rice is not favoured. Nutrition education intended to convince them to consume parboiled rice was therefore necessary and crucial. The evidence of beri-beri and the employment of a competent nutritionist to give nutritional advice appeared very effective in changing dietary practices amongst the refugees. Now most of the refugees consume parboiled rice. However a few exchange the parboiled rice for with polished rice especially to feed children and the sick, as polished rice is softer than parboiled rice.

Blended Food (BF)

When BF was added to the basic ration refugees viewed it as food for the sick and not to be consumed by the general population. A campaign to popularise blended food was carried out by SCF and UNHCR. In a situation like this where the general food basket cannot guarantee adequacy of micronutrient intake, addition of blended foods to the general ration is one of the best strategies to prevent MDD. It was observed that people started consuming BF in the form of porridge (halwa) and by putting it in morning tea.

Micro-nutrient Deficiency

Beriberi: During the whole period no infantile beriberi was reported. The incidence of beri-beri has gone down from 0.55/10,000 population/day in January 1994 to 0.03/10,000 population/day in March 1996.

Scurvy: Scurvy incidence has been reported as highest in April 1994 (2.53/10,000/day) declining to 0.22/10,000/ day in March 1996. These results should be interpreted with the knowledge that scurvy symptoms can be confused with gingivitis and lack of oral hygiene.

Pellagra: Pellagra is usually associated with a maize diet as the niacin is not in a readily available form. The outbreak in these camps is therefore unusual. However, the incidence has now declined from a high of 0.57/10,000/day in March 1994 to zero in January 1995. There have been no reported cases since then.

Conclusion

It can be seen from the surveillance data obtained by SCF (UK) that the incidence of beriberi and scurvy has gone down significantly while pellagra is eliminated. This is most probably due to the combined effort of active case finding and management by SCF and adjustment of the food basket by replacing polished rice with parboiled rice, addition of blended food to the general ration and continued provision of green or yellow leafy vegetables in the vegetable ration by WFP/UNHCR. However, it is worth noting here that despite all these efforts beriberi and scurvy, although at a low level, still persist in the camps. This really requires careful investigation to find the root cause of the problem. The most recent household food economy assessment by SCF in May 1997 made the following points about the continuing low incidence of MDD.

1. Without biochemical cross-checking of clinical diagnosis it is impossible to verify the incidence levels of these conditions or to comment on possible over-reporting.
2. Although many nutrients are now supplied in adequate quantities, there are important exceptions; most striking are the very low supplies of calcium and riboflavin which affect all sectors of the population.
3. Intra-household distribution of food may partly explain residual levels of MDD. Previous surveys have shown that women and children receive less than their allowance of the general ration and men get more.
4. Storage and cooking practices may also affect the levels of micronutrient retained within food stuffs. In particular, prolonged boiling of vegetables could severely cut the content of water soluble vitamins in this produce.

Lesson learned

Due consideration should always be given to the food habits of refugees in planning the food basket. However, if the range of commodities which are normally consumed in their country of origin are not included in the basket, there may be a risk of MDD. For example, consumption of polished rice and unavailability of fresh green vegetables and milk products precipitated micronutrient deficiency among Bhutanese refugees in Nepal. Caloric adequacy of the general ration does not automatically mean that the ration is adequate for all types of nutrient required by the human body. Due consideration should always be given to micronutrients in planning the emergency food basket.
In an emergency situation where access to a variety of micronutrients containing food commodities is not feasible, incorporation of fortified blended food into the general ration should be mandatory. Given the time between international procurement and delivery that often occurs, local production of blended foods should be encouraged wherever possible. In fact, in Jhapa when WFP/UNHCR decided to add blended food to the general ration, locally produced BF was available. Where MDD persists in spite of improvements made to the general ration, which should theoretically eradicate these deficiency diseases, other factors should be investigated and acted upon. Factors which might be considered include inequitable intra-household distribution of general rations and storage and cooking practices which reduce micronutrient content of the foods.