Asia

Afghanistan
Iraq
Bhutanese Refugees in Nepal
Myanmar (Rohingya) Refugees in Bangladesh

As of end-1993 (UNHCR, 1994) over half the estimated 5.2 million refugees in Asia were Afghans in Pakistan (1.4 million) and in Iran (1.9 million) (see Table 1). There are reported to be 650,000 Iraqis in Iran. Other large groups are refugees from Myanmar in Bangladesh (200,000), Vietnamese in China (290,000), Sri Lankans in India (115,000), as well considerable numbers from Cambodia, Laos and Vietnam, in other countries.

No comprehensive data are available on the numbers of internally displaced populations in Asia. The numbers are certainly in the millions. Figures of 600,000 Afghans internally displaced are quoted (USCR, 1994, p91), and up to one million each in Iran and Myanmar (USCR, 1994, p42).

Nutrition information has not yet been systematically assembled for refugees in Asia, although recently reports on nutrition for four groups (Afghan refugees, Bhutanese in Nepal, from Myanmar in Bangladesh, and in or from Southern Iraq) have been compiled for the RNIS. Because of their numerical importance, information is first given here on Afghan refugees and displaced people, and on Iraq.

Afghanistan

In the sixteen years since 1978, when civil war broke out following a coup d'etat, more than a million people were killed and over one third of the population, more than five million people, became refugees in Pakistan and Iran. The Soviet invasion in December 1979 escalated the internal war, but the withdrawal of Soviet troops in January 1989 only marked the transition from one set of conflicts to another. Although the Najibullah regime lasted until early 1992, even after that success for the Mujahideen, civil war continued to rage. In different incidents in 1992 and 1993, thousands of people were killed by rocket attacks on the capital, Kabul. Now it is estimated that added to the millions of refugees (some of whom were repatriating before 1992) there are over half a million people internally displaced in and around Kabul itself (MSF, 1993; USCR, 1994, p.91).

INDICATORS Wasting is defined as less than -2SDs, or sometimes 80%, wt/ht by NCHS standards, usually in children of 6-59 months. For guidance in interpretation, prevalences of around 5-10% are usual in African populations in non-drought periods. We have taken more than 20% prevalence of wasting as undoubtedly high and indicating a serious situation; more than 40% is a severe crisis. Severe wasting can be defined as below -3SDs (or about 70%). Any significant prevalence of severe wasting is unusual and indicates heightened risk. (When "wasting" and "severe wasting" are reported in the text, wasting includes severe - e.g. total percent less than -2SDs, not percent between -2SDs and -3SDs.) Evidence from refugee camps shows elevated levels of wasting to be associated high mortality rates (CDC, 1992). Equivalent cut-offs to -2SDs and -3SDs of wt/ht for arm circumference are about 12.0 to 12.5 cms, and 11.0 to 11.5 cms, depending on age. Oedema is the key clinical sign of kwashiorkor, a severe form of protein-energy malnutrition, carrying a very high mortality risk in young children. It should be diagnosed as pitting oedema, usually on the upper surface of the foot. Where oedema is noted in the text, it means kwashiorkor. A crude mortality rate in a normal population in a developed or developing country is around 10/1,000/year which is equivalent to 0.27/10,000/day (or 8/10,000/month). Mortality rates are given here as "times normal", i.e. as multiple of 0.27/10,000/day. [CDC has proposed that above 1/10,000/day is a very serious situation and above 2/10,000/day is an emergency out of control.] Under-five mortality rates (U5MR) are increasingly reported. The average U5MR for Sub-Saharan Africa is 181/1,000 live births (in 1992, see UNICEF, 1994), equivalent to 1.0/10,000 children/day. Food distributed is usually estimated as dietary energy made available, as an average figure in kcals/person/day. This divides the total food energy distributed by population irrespective of age/gender (kcals being derived from known composition of foods); note that this population estimate is often very uncertain. The adequacy of this average figure can be roughly assessed by comparison with the calculated average requirement for the population (although this ignores maldistribution), itself determined by four parameters: demographic composition, activity level to be supported, body weights of the population, and environmental temperature; an allowance for regaining body weight lost by prior malnutrition is sometimes included. Formulae and software given by James and Schofield (1990) allow calculation by these parameters, and results (Schofield and Mason, 1994) provide some guidance for interpreting adequacy of rations reported here. For a healthy population with a demographic composition typical of Africa, under normal nutritional conditions, and environmental temperature of 20°C, the average requirement is estimated as 1,900-2,000 kcals/person/day for light activity (1.55 BMR). Indicators and cut-offs indicating serious problems are levels of wasting above 20%, crude mortality rates in excess of 1/10,000/day (about four times normal - especially if still rising), and/or significant levels of micronutrient deficiency disease. Food rations significantly less than the average requirements as described above for a population wholly dependent on food aid would also indicate an emergency. References CDC (1992) Famine-Affected, Refugee, & Displaced Populations: Recommendations for Public Health Issues, MMWR 41 (No.RR-13). James W.P.T. and Schofield C. (1990) Human Energy Requirements. FAO/OUP. Schofield C. and Mason J. (1994) Evaluating Energy Adequacy of Rations Provided to Refugees and Displaced Persons, Paper prepared for Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa, Machakos, Kenya, 5-7 December 1994 ACC/SCN, Geneva. UNICEF (1994) State of the World's Children p.82. UNICEF, New York.

Table 1. Numbers of Refugees and Displaced People by Region - End 1993

Region			Refugees		Displaced
Asia			5.2m		N.A.
	of which Afghans in Iran			1.9m
		Afghans in Pakistan		1.5m
Africa1			6.4m		10.1m
Latin America			0.1m		1.7m2
Europe			2.6m		3.4m
North America			1.3m		N.A.
Oceania			0.1m		N.A.
Former USSR3			0.6m		1.6m
Total			16.3m		N.A. but >25m

Source: UNHCR (1994), table 1 except where noted.

1. RNIS No.3, Jan 1994, total = 16.5m; 6.4m is UNHCR figure for refugees; 10.1m displaced calculated by substraction; UNHCR figure includes 0.23m in N.Africa, mainly Algeria.

2. From USCR (1994).

3. Note this included with Europe in Fig.1.

Not much quantitative information is currently available about nutrition of the displaced population in Afghanistan. Surveys earlier this year around Kabul showed high levels of wasting (about 32%), an apparent deterioration when compared with surveys in 1990. Many displaced have fled towards Jalalabad, nearer the Pakistan border, where there are a number of camps and many relief agencies helping. Here such nutritional data as there are indicate limited food supplies, and somewhat elevated levels of wasting (around 15-20%), likely to be several percent higher than under normal circumstances in Asia.

There are about 1.4 million Afghan refugees still in Pakistan, down from 1.6 million in 1993. Repatriation has slowed almost to a standstill, and is not expected to increase until the situation within Afghanistan improves. Such information as there is indicates relatively good nutrition amongst the population in camps. In Iran much of the refugee population has been living among the local population, and although there is little information on their nutrition, it is assumed to be reasonable and similar to the local population itself.

In the 1980s, the Afghan refugees and displaced population were numerically the largest anywhere, and although the numbers have decreased due to some repatriation in the early 1990s, the situation remains amongst the worst in the world. Undoubtedly major improvement awaits a political solution. As Medécins Sans Frontières has said: "Today's chaos stems from a combination of ten years of war, ethnic strife, a surfeit of weapons, the inability of Mujahideen fighters to return to civilian life, drugs and arm trafficking, and above all, the direct intervention of the regional powers. Peace in Afghanistan depends less on increased international involvement than on the complete withdrawal of the regional powers" (MSF, 1993, p31). And for sure improved health and nutrition depend primarily on peace. Nonetheless, extraordinary efforts by external agencies have helped to alleviate the suffering, and continued support for these remains important. Where the internally displaced population is accessible such as in Jalalabad at the present time, improved water supplies, adequate provision of food and medicine, and health care, can help to improve and maintain nutrition.

Iraq

Well over one million refugees from Iraq were reported in Iran, as of end-1992, decreasing to 645,000 by end-1993 (UNHCR, 1994, p16). Moreover, there is a substantial displaced population of Kurds from Northern Iraq, both internal and in neighbouring countries. In Northern Iraq, in the Kurdish region, it is estimated that perhaps one quarter of the population of nearly four million has inadequate housing, and that some 400,000 are displaced from government-controlled areas (USCR, 1994, p104-105). At the end of 1993, WFP was providing rations for 750,000 people in the North. However, the situation of the local population in the marshlands of South Iraq has attracted particular attention in terms of destitution and malnutrition, and is described in more detail below.

Southern Iraq

The population in the marshlands of Southern Iraq has suffered massive destruction of livelihood, and many of those who could escape have become refugees in Iran. Reports on the situation are fragmented, and certainly no direct surveys are available from within Iraq. Nonetheless, the situation can be pieced together from available reports, from the UN Commission on Human Rights (UN, 1993a, 1994), the US Committee on Refugees (1994), the AMAR Appeal (1992/4), and several others. When new information on nutrition has been available, reports have been included in the RNIS. The following summary is constructed the different available sources.

The Marsh Arabs or Maadan have been long viewed with hostility by the Iraqi Government - according to the USCR (1994, p105) - and in 1989 plans were made for "economic blockade, population removal, and other measures". In early 1991 civil war broke out following the Shi'ite revolt after the Gulf War, leading to major population displacement into the marshlands between the Tigris and Euphrates rivers. Following this, there was an intensified military campaign and blockade, after August 1992 involving ground forces only, when the western countries declared a no-fly zone in the area. This involved widespread burning and shelling of villages, and forced removal of Shi'ites in and around the marshes. Extensive army and civil engineering projects began to divert water from the marshes. The shrinking of the marshes deprived the population of its livelihood and food, as well as cover, and undoubtedly caused widespread malnutrition. The campaign continued during 1993, with extensive civilian casualties. Satellite imagery showed that indeed large areas of the marshlands were drying up. (USCR, 1994, p105).

During this time, many reports of severe food shortages reached the UN. For example, in February 1993 an ECOSOC report (UN, 1993b) stated that "the inhabitants remaining in the marshes are apparently no longer able to feed themselves as the environmental destruction taking place removes local food sources and they are not able to purchase food due to the blockade...". The AMAR Appeal also reported, in February 1993, that food (rice, wheat, oil, and beans)was unavailable in the marshes due to a blockade. Clean drinking water was reportedly unavailable, and people were forced to drink polluted water (AMAR Medical Committee, 1993). All the available reports pointed to a very serious nutritional situation for many of the people within the marshland area, for example "in terms of needs, reports and testimonies indicate that malnutrition and disease are widespread within the marsh area... coupled with inadequate food, the effects of disease have been severe, particularly for infants, lactating mothers and the elderly" (UN, 1993). Access to food and health care in the marsh land area was prevented, accelerating the displacement. By the end of 1994 the "evidence (was) that the marshes have largely dried up." (Special Rapporteur statement to UN, 25 November 1994). Refugees interviewed in Iraq stated the main reason for their flight had been the drying of the marshes. The Special Rapporteur of the UN Commission on Human Rights concluded that the situation for the Marsh Arabs "has deteriorated further" (UN, 1994, para 43)

Most of the information on the situation within Southern Iraq comes from reports by refugees in South West Iran. The exact number of people affected is unknown, but earlier reports were that the original population of the region was of the order of half a million people. In mid-1994 it was reported that as many as 200,000 had fled their homes and were in hiding in the marshes; the fate of the others is not known, except that up to 50,000 people perhaps were living in camps in Iran.

Many of the reports available on nutrition refer to the refugees as they crossed the dangerous border into Iran. This population (estimated 3,700 in November) would take temporary refuge on a road spanning the marshes between Iran and Iraq, their first contact with any assistance. Here the health and nutrition conditions were reported to be very bad - for example in August 1993 80% of those seen had amoebic dysentery. Reports usually talk of severe malnutrition, with an appalling variety of suffering from disease and physical conditions - from cold weather and no shelter on firm ground, to women and children trapped in mud too hot to walk in.

While many civil conflicts devastate the economy and destroy livelihoods, in this instance the destruction especially affects the food chain, and lack of food and potable water are among the major reasons for displacement.

Bhutanese Refugees in Nepal

Late in 1990, people of Nepalese origin in Bhutan (some of whom had been in Bhutan for many generations) began fleeing to Nepal via India. In June 1994 the population had stabilized at 86,000 in eight different sites. The Nepalese Government has made several attempts to negotiate the refugees' return to Bhutan, but with little success. When the influx began, the refugees were able to enter freely, although the facilities were crowded and with poor sanitation. As numbers increased, friction with the local population became an intensifying problem, but nonetheless the Nepalese Government has remained host to the population. Attempts were made to begin screening new arrivals, in collaboration with UNHCR.

The general food distributions have been regular, and have contributed to very low levels of wasting among the refugee population. On the other hand, in part because of complete dependence upon a general ration with limited variety, there has been repeated reports of widespread outbreaks of micronutrient deficiency diseases. These have been definitively confirmed by multi-donor missions. Thus scurvy (vitamin C deficiency), beri-beri (thiamine deficiency), pellagra (niacin deficiency), and angular stomatitis (an indicator of B vitamin deficiency, notably riboflavin), and goitre (iodine deficiency) have been reported. A total of over 12,000 cases of beri-beri were identified. Recently however the food basket has been adjusted to include whole rice, vegetables, and a fortified blended food, estimated to give adequate intake of micronutrients with the possible exception of iron and vitamin B12. The beri-beri outbreak reached a peak in November 1993, while other deficiencies were reported throughout the first half of 1994, incidence rates were of the order of 0.5 to 0.7 per 1,000 per day for pellagra and scurvy. More recently the incidence rates have fallen, although cases are still being seen.

The situation amongst the Bhutanese refugees in Nepal has drawn considerable attention, as a clear case of micronutrient deficiencies, although the mortality rates and level of wasting have been generally similar, or even lower than, the local community. Micronutrient deficiencies were related to a restricted general ration, which although adequate in energy, did not provide a complete diet.

Myanmar (Rohingya) Refugees in Bangladesh

Towards the end of 1991, people of the Rohingya Muslim minority in Mynamar's Rakhine state began arriving in South East Bangladesh. By June 1992 the refugee population had reached 250,000, distributed between 15 camps in Cox's Bazaar District, which is a disaster prone area with regular flooding and occasional cyclones.

Within a short period of time data indicated that the population were experiencing a nutritional and health crisis as crude mortality rates as high as 2.1/10,000/day (7 x normal) were being recorded. Nutritional survey data from early 1992 established wasting levels as high as 27% with 9% severe wasting. Surveys also showed high levels of night blindness and angular stomatitis. By early 1994 the total refugee population had decreased somewhat to 200,000, mainly due to repatriation, some of disputed voluntariness. At that time, the health and nutritional status of the population had improved considerably and was comparable to the local host community. However, angular stomatitis was still being seen so that a decision was taken to add fortified DSM to the supplementary feeding programme ration. Nonetheless, most recent reports (June 1994) indicate that riboflavine deficiency is still a problem.

The number of refugees from Rakhine state in Bangladesh decreased to just over 190,000 at the end of July 1994. Large scale repatriation is now under way because of the "positive environment for repatriation on both sides of the border". The crude mortality rate for the month of July was estimated as 0.26/10,000/day, and the under five mortality rate as 0.45/10,000/day. Both rates are considered within normal limits. The situation was therefore brought under control in terms of nutrition and health, with adequate food supplies and access to health care when provided in the camps.