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Halfway to 2000: Mid-Decade Goals (1995) for Health of Women and Children

In 1990 the World Summit for Children (WSC) - attended by 71 heads of state or government and by ministers representing 81 other countries - adopted the World Declaration on the Survival, Protection, and Development of Children, and a related Plan of Action outlining specific goals for the health of women and children throughout the world by the year 2000. Almost 90 countries have now prepared National Programmes of Action to implement strategies for the achievement of these goals. In addition to these longer-term goals, the UNICEF/WHO Joint Committee on Health Policy - which has met annually since the World Summit - at its February 1993 meeting, identified eight mid-decade goals which could serve as intermediate targets for the facilitation of the end of decade goals. And in October 1993, a WHO/UNICEF Inter-Secretariat Meeting proposed that, in addition to the 8 mid-decade goals already established, a stronger focus should be given to three additional goals of the World Summit, namely with respect to the reduction of malnutrition, water supply and sanitation, and knowledge of Human Immune Deficiency Virus (HIV) related preventive practices. The Joint Committee on Health Policy met again in Geneva in January 1994 to discuss progress made towards the achievement of the mid-decade goals - and further actions needed. The following list of mid-decade goals is extracted from a background document prepared for the January 1994 JCHP meeting. More detail of the progress made and action needed is given for those goals relating to nutrition.

1. Elimination of neonatal tetanus by 1995 (This means that a rate of less than one case of neonatal tetanus per 1000 live births will be considered as evidence of elimination in every district of every country)

2. Reduction by 95% in measles deaths and reduction by 90% of measles cases compared to pre-immunization levels by 1995.

3. By 1995 to achieve poliomyelitis-free status in the American, European, and Western Pacific regions of WHO as well as selected countries in other regions, comprising at least 60% of the world population.

4. Achieve at least 80% use of oral rehydration therapy (increased fluids) and continued feeding. In addition, two priority programme targets need to be met - 80% access to oral rehydration salts (ORS) and 80% of mothers knowing the three rules of home case management of diarrhoea.

5. (a) Ending of the distribution of free or low-cost breastmilk substitutes in all maternity centres and hospitals in developing countries by June 1993, and in all countries by June 1994; and (b) all health facilities providing maternity services achieve “baby friendly” hospital status in keeping with the Baby-friendly Hospital Initiative (BFHI) global criteria based on the Ten Steps to successful breastfeeding recommended by WHO and UNICEF.

As of 1993 all but three developing countries had initiated necessary procedures to prohibit distribution of free and low cost supplies and most industrialized countries had agreed to take action towards this end. Of the almost 4000 hospitals targeted for achieving “baby-friendly” status by the end of 1995, nearly 700 have already achieved this designation.

Action Required: Regulations and administrative circulars plus agreements with manufacturers and distributors of breastmilk substitutes are needed to end distribution of breastmilk substitutes: national monitoring mechanisms required to ensure implementation. BFHI requires government commitment, training of health workers and establishment of designation and reassessment mechanisms. UNICEF and WHO will continue to support through advocacy, provision of programme guidelines, training materials and global assessment criteria.

6. Iodize all salt used for human and animal consumption, including salt used for food processing, (universal salt iodization) in all countries where iodine deficiency disorders (IDD) are a public health problem; where full salt iodization is not possible in areas where IDD is a severe public health problem, supplementation with oral or injected iodized oil will be recommended as a temporary measure.

110 countries have identified their main IDD-endemic areas. Some still need to do the assessment. It is not necessary to define in great detail the magnitude and distribution of the problem nor is it necessary to perform time-consuming analyses of alternative strategies, since the solution generally will be universal salt iodization in the country.

Action Required: Action can and should be taken quickly to iodize salt in all countries with an IDD problem. The technology is feasible, relatively simple, cheap. Some countries require assistance in purchasing equipment. An annual update of the IDD information component of WHO’s Micronutrient Data Information System (MDIS) is envisaged and the cooperation of national programme managers, UNICEF and WHO representatives is essential. A good monitoring system is also essential as inadequate vigilance can allow a good control programme to relapse. Universal salt iodization will go a long way towards resolving all IDD problems by the year 2000.

7. Ensure that at least 80% of all children under 24 months of age, living in areas with inadequate vitamin A intake receive adequate vitamin A through a combination of breastfeeding, dietary improvement, fortification and supplementation.

Vitamin A deficiency is a likely problem in up to 75 countries and may afflict as many as 80-90 million children. By 1995, all countries should have identified whether they have a problem of vitamin A deficiency and will have established approaches to ensure elimination of the problem by the year 2000. By 1995 steps will be taken to ensure adequate vitamin A intakes in the group of children at highest risk of the consequences of deficiency - those under 24 months of age and those in areas where clinical vitamin A deficiency is recognized.

Action Required: In countries where a 2-dose measles immunization scheme is in effect, providing 100,000 IU at the 6 month contact and another 100,000 IU at the contact after 9 months will bring the infant into the second year of life in adequate vitamin A status. Subsequent booster immunization in the second year could be used to deliver a 200,000 IU dose, thus providing at least 400,000 IU by 24 months of age. This action is enhanced by parallel strategies to control infectious diseases and parasitism. It is crucial to increase the economic status of the poor, in particular focusing on the literacy of women, as reflected in other goals of the Summit.

8. Interrupt transmission of guinea-worm disease (dracunculiasis) in all affected villages.

9. The reduction in severe as well as moderate malnutrition among children under five years of age by 20% or more of 1990 levels.

In 1990, malnutrition affected 192 million children under 5 years of age. Globally the prevalence of malnutrition fell from 41.6% in 1975 to 35.8% in 1990 in all regions though not as rapid as the rise in population. Over 50% of the world’s underweight children are in the South Asia region. In contrast, nutritional status is improving rapidly in many countries of South East Asia, in line with, inter alia, considerable economic development. Countries of Sub-Saharan Africa, in contrast to all other regions, generally remained static or deteriorated during the 1980s.

Action Required: WHO and UNICEF will support preparation and implementation of national action plans and play a catalytic role in mobilizing and proposing optimal use of resources in support of these plans. Reduction of malnutrition is central to overall reduction of child mortality and morbidity and accelerated efforts are warranted.

10. Increase water supply and sanitation so as to narrow the gap between the 1990 levels and universal access by the year 2000 of water by one-fourth and of sanitation by one-tenth.

11. Increase the proportion of adults and youths who are able to cite at least two acceptable ways of protection from HIV infection. (Text proposed by WHO and UNICEF for consideration by JCHP)

(Source: World Summit for Children - Mid-Decade Goals, 1995: An Overview of Implementation. Document prepared for the UNICEF/WHO Joint Committee on Health Policy Special Session, Geneva, 27-28 January 1994 JCHPSS/94/2)

World Bank Backs Campaign to Restore Sight to Millions of Blind in India

A massive campaign has been launched to restore sight to 8 million blind people in India, a fifth of the world’s blind.

At 1.3 per 1,000, India currently has one of the highest prevalences of blindness in the world, and accounts for a third of all blind people. More than 80% of the 13 million Indians who are blind in both eyes are sightless due to treatable cataracts - a clouding of the eye - and unlike other countries where cataracts are most common among over 60 year olds, 40% of those suffering in India are between 40 and 60 years of age - particularly in rural and tribal populations. Thus, not only does cataract blindness reduce the quality of life of the sufferer, families face loss of income, and the added burden of caring for a sightless family member.

The target for the new effort in India - backed by funds from the World Bank - is to reduce blindness prevalence to 0.3 per 1,000 within six years, which means that more than eight million Indians will undergo cataract surgery in project-funded treatment centres in seven states. Teams of surgeons and ophthalmologists will attempt to reach even the most isolated areas where health care is scarce.

The project’s conception has been a cooperative effort involving India, the World Bank, the World Health Organization, bilateral agencies, and numerous international and Indian non-governmental organizations.

Extracts From The Statement by Mr James P Grant, Executive Director of the United Nations Children’s fund (UNICEF) at the Meeting of the Sub-Committee on Nutrition of the Administrative Committee on Coordination. New York, 7 March 1994.

I want to welcome all of you to this important meeting - partners in our sister agencies as well as distinguished experts from outside the UN system. The work of everyone in this room to reduce malnutrition in the world has never been more important and in many ways never so well positioned for success. With the nutrition goals endorsed by 71 heads of state and senior representatives from 88 other countries at the World Summit for Children in 1990 - goals affirmed and endorsed at the International Conference on Nutrition (ICN) over a year ago - there is a great consensus on which to build as we together continue to fight malnutrition at a time when so many enemies of children - measles, tetanus, polio, illiteracy, etc. - are on the run. Advances in immunization and ORT alone are now saving 4 million children annually.

What are the principal elements of consensus on the nutrition front? We have come a long way from the World Food Conference of 1974 in which the focus was largely on food and food production as determinants of nutrition outcomes. In the 20 years since that ground-breaking conference, there has been an increasing realization, as the ICN declaration clearly shows, that nutritional security does not depend on food alone.

In addition to food, access to health services and a healthy environment, and care of women and children, are all necessary conditions for good nutrition. No one of these is sufficient in itself. We all know this from our own experiences. All of us can recount stories of countries or communities in which we have worked where food was plentiful and households had access to it, but malnutrition continued to be a problem.

The importance of all three necessary conditions - food, health, and care - relays a clear message to the UN system: No one agency alone can or should take up the full mandate of addressing malnutrition. Rather, knowing what we know about the multidimensional nature of the problem, we all should take up some part of that mandate, complementing each other’s work as much as possible. Indeed, some aspect of malnutrition reduction should be part of the work of every development-oriented UN agency. This should include using nutritional indicators in the evaluation of the effectiveness of our work in many sectors, since we understand that child nutrition is a telling indicator of development progress of many kinds.

Our complementarity around such a complex problem is the key to the success we have had and will have. As you know, donors are especially concerned about reducing overlap among our agencies, as all of us are as well. For this complementarity and harmonization of activities to take place, we need to ensure frequent and rapid exchange of information on nutritional outcomes and on activities meant to improve them. We need to ensure that the science that informs our consensus on nutrition and our related activities is up to date and sound...

...The coordination of nutritional information related to our efforts to realize our common nutrition goals will also help us to assess progress on other related goals. In this respect, the goal to reduce protein-energy malnutrition by 20 per cent from 1990 levels by 1995 and by 50 per cent by the year 2000 is especially important. We know that the achievement of this goal will be affected not only by success in reaching other nutritional goals in such areas as breastfeeding and micronutrient deficiencies, but also by the progress made on reducing and preventing infectious diseases, improving access to clean water, and in the long run, ensuring universal education of boys and girls.

I trust that this common focus on nutrition will be strengthened in this meeting and that we will all come away with a sense of better ways in which to complement each other’s efforts, with renewed energy to overcome the multiple challenges we face.

Never before have we had so much going for children. In addition to the World Summit for Children and its 27 year 2000 goals - many dealing with nutrition - there is the almost unbelievably rapid progress on the Convention on the Rights of the Child, now ratified by an historically-unprecedented 155 countries. For the first time ever, universal ratification is in sight by 1995. National programmes of action to achieve the goals now cover more than 90 per cent of children in the developing world, and in several major countries - China, India and Mexico among them - every state and province has a plan of its own, also with many nutrition goals. The heads of state and government of most developing countries have explicitly endorsed the mid-decade targets and UNDP Administrator Gus Speth has written to all Resident Representatives calling on them to exercise active leadership for the achievement of both the 1995 and year 2000 sets of goals. The task ahead remains formidable - but we are off to a good start.

As Secretary-General Boutros Boutros-Ghali said at the mini-summit commemorating the third anniversary of the World Summit for Children: “Of all the subjects of development, none has the acceptance, or the power to mobilize, as does the cause of children. Our children are our future.” And I would add that the fight against hunger and malnutrition has a similar power to mobilize. Putting the two together - children and nutrition - we have a very powerful level for human development as a whole. To do so at this time is both an opportunity and an obligation. Let us use it to move the world into a 21st century worthy of our children and of ourselves.

(Source: UNICEF, 7 March 1994)

According to Maria Donoso Clark, the World Bank’s task manager for the project “this is the boldest effort yet to reduce blindness in a developing country.”

(Source: “India Launches Campaign to Restore Sight to Millions of Blind People”, World Bank News, 19 May 1994)

EuronAid/ODI Relief and Rehabilitation Network

The Overseas Development Institute (ODI) in the United Kingdom has established a relief and rehabilitation network (RRN) in conjunction with EuronAid (the European Association of Non-Governmental Organizations (NGOs) for Food Aid and Emergency Relief) with the aim of facilitating the sharing of views and experience between key personnel within NGOs who are involved in the provision of relief and rehabilitation assistance. Although international and local NGOs now have a greater role in providing relief and rehabilitation assistance, useful exchange of professional information among them is often hindered by language barriers, institutional factors, and a lack of suitable mechanisms for information exchange between busy people often working in remote locations around the world in difficult conditions. It is hoped that the new RRN will provide such a mechanism.

The membership of the RRN will primarily be NGO field-based personnel involved in the design and implementation of relief and rehabilitation activities - as they are the ones that usually find it most difficult to get hold of specialist information and participate in professional information exchange. In the first instance, RRN membership is being established through the EuronAid member agencies and those with observer status - around 132 members have so far been nominated.

Individuals and personnel of government and UN agencies are also able to become RRN members - but are charged more to join than NGO personnel. Subscription rates per person per year are as follows: £60 for NGOs, £70 for universities and research institutions; and £100 for consultants, civil servants and personnel of UN agencies. For the first three years of operation the fee will be waived for all member agencies of EuronAid and those with observer status. For NGOs which are not member agencies of EuronAid, the fee will be waived for the first year only.

Each year RRN members will receive four mailings in either English or French. The March and September mailings will consist of a Newsletter and Network papers of which there will usually be three in each mailing. Each June and December, members will receive a “State of the Art” review on a selected sector or activity within the relief and rehabilitation field. Reviews will be prepared by a recognized specialist in that particular field and will explain, in a form readily accessible by non-specialist field personnel, what is generally agreed and what is not agreed in how to plan and implement certain types of interventions and what are the common pitfalls in undertaking those types of intervention. The first State of the Art Review will be on Water and Sanitation, a sector indicated as an area of interest by the majority of those members who have so far returned their registration forms.

The RRN is coordinated by John Borton who began his involvement in relief work in Botswana in 1982 where he was Planning Officer for the Government’s National Drought Relief Programme and has since been involved in numerous research studies, evaluations and consultancies in the relief and disasters field.

For further information on the Relief and Rehabilitation Network contact: Relief and Rehabilitation Network, Overseas Development Institute, Regent’s College, Inner Circle, Regent’s Park, London NW1 4NS, United Kingdom. Tel: (44 71) 487 7413 Fax: (44 71) 487 7590.

(Source: Relief and Rehabilitation Network Newsletter, No. 1, March 1994 and information note on the RRN, December 1993)

Preventing Famine: Zambia in the 1991/2 Drought

Network Paper No. 2 of the ODI/EuronAid Relief and Rehabilitation Network describes the successful involvement of local and international NGOs in the response to the 1991192 drought in Zambia. The following is extracted from the introduction to the paper.

As with the other countries in the Southern African region, Zambia experienced exceptionally low rainfall during the 1991-1992 rains. The rains had started well in many areas of the country during October but halted in January - a key month for the cultivation of maize, the country’s staple cereal. The southern half of the country was most effected, including the traditional maize surplus areas of southern and eastern provinces. As a result, the impact of the drought on domestic cereal production was particularly severe, production for the subsequent marketing year was only 40% of the average for the previous three years. Total cereal import requirements (commercial and food aid) for the 1992-93 marketing year were approximately 1 million tonnes.

The drought came at a particularly difficult time for the country both economically and politically. The Zambian economy had been in recession for over a decade as a result of declining copper prices, the country’s principal export, and economic mismanagement. A key agricultural sector policy of the government of the United Independence Party (UNIP) had been pan-territorial maize pricing and the provision of fertilizer subsidies which encouraged the cultivation of hybrid maize in areas distant from markets and in areas ecologically less suited to the crop. At the same time, the price of maize meal was held down in the interests of the large urban population (42% of the population live in urban areas) and the result was massive, and ultimately unsustainable subsidies to the food sector. The resources available to the civil service had declined and, without improvements in productivity, so had its effectiveness. The country had accumulated one of the highest per capita debt burdens in the region. Chronic deprivation in rural areas was reflected in high rates of childhood malnutrition well above that of most other countries in the region.

In the first multi-party elections in October 1991, the Movement for Multiparty Democracy (MMD) won a landslide victory and embarked on a far reaching programme of reforms including a Structural Adjustment Programme (SAP) and the reform of the civil service. In the short term, such reforms threatened increased hardship and further reductions in the capacity of the government administrative machinery.

The new government was quick to recognize the severity of the situation. On 12th February 1992, President Chiluba declared southern, western and eastern provinces to be disaster affected and two weeks later widened the declaration to the national level, making Zambia the first country in the region to make a national declaration. A Drought Relief Task Force coordinated by the Minister of Agriculture formed interministerial sub-committees to develop the components of the overall response. It was decided that the bulk of the imported cereals would be fed directly into the commercial marketing system by a newly formed National Bulk Import Control Agency (NBICA) through the existing Zambia Cooperative Federation (ZCF), a former parastatal organisation with an extensive network of depots and personnel throughout the country.

In deciding how to manage the relief distribution component of the programme, the government was faced with difficult decisions concerning the extent to which it relied upon the administrative system inherited from the previous regime. In response to earlier, more localized food security problems, the administrative system had performed poorly. For instance, the relief programme implemented in 1987, though nowhere near the scale of the 1992-93 operation, was by most accounts ineffective. Maize had been channelled through the local government and UNIP structures. Favouritism had been widespread and many of those in greatest need had failed to receive any assistance. The reform of the civil service had barely started and its capacity to effectively handle a large scale relief operation was in serious doubt.

Moreover it was felt that the limited capacity and lack of credibility of the existing system might deter donors from contributing generously to the response. Although the electoral process for central government had been completed the previous year, local government elections were scheduled to be held during 1992 and the government was concerned that if the local government structures were too closely involved in administering the relief activities that relief assistance might be diverted and the programme become entangled in the politics of the electoral contest.

After consideration of the situation, the Cabinet decided that 10% of the total import requirements (implying 94,000 tonnes) would be allocated for use in the direct relief component of the overall response (i.e. food-for-work, subsidized sales and free food distributions) but that this component would be handled not by the local government administration but by local and international NGOs working with decentralized committees. As far as possible this component would be apolitical and be kept separate from the government’s administrative structures. To effect this radical departure from previous practice, a Programme to Prevent Malnutrition (PPM) was set up. The principal components of the PPM were the National PPM - a policy body; the Programme Against Malnutrition (PAM) - a quasi-NGO set up to receive and allocate the food aid to be used in the programme; Area PPM Committees composed of representatives of the private and public sector and NGOs involved in the distributions within particular areas; and the NGOs themselves. The amounts eventually distributed through the PPM/NGO system were substantially greater than the amounts initially envisaged. Between May 1992 and May 1993, the system distributed just under 250,000 tonnes of maize in the southern half of the country largely through food-for-work programmes but also through food-for-sale programmes and free distributions. In addition, the PPM/NGO network distributed supplementary foods and 2,380 tonnes of seeds to assist agricultural recovery in the 26 areas.

By any standards this programme was a substantial achievement and reflects the high level of commitment and support to the programme by the international community, NGOs and those officials involved. Though NGOs have shouldered the responsibility for direct relief provision in many other emergency situations this has often been the result of the channelling decisions of donor organizations. What makes the Zambia case unique is that the policy decision to rely upon NGOs rather than the government’s own agencies was taken by the government itself.

(Source: Mukupo, D. (1994). Responding to the 1991/1992 Drought in Zambia: The Programme to Prevent Malnutrition (PPM). RRN Network Paper No. 2, ODI, London.)

The Growth of Numbers of Refugees and Displaced People

Contributed by Philip Payne, Centre for Human Nutrition, The London School of Hygiene and Tropical Medicine, 2, Taviton St., London WC1H OBT, United Kingdom.

Relief and assistance agencies have long been aware that they are facing a rapidly increasing global problem posed by the growing numbers of people, either seeking political refuge, or who for various reasons have been displaced from their means of livelihood. Although there is a continual flow and return of such people, the total numbers registered as being in receipt of protection and assistance by WFP and UNHCR at any one time continues to rise. At the present time, the global numbers probably approach 40 Million - equivalent to the population of a medium sized country. What can be said about the prospects for the future? Will the numbers continue to grow, or will they stabilise at some point? Will coping with this kind of humanitarian relief demand an ever increasing share of the resources available to the International community? What kind of action might help to stabilize or reverse the trend?

So far, the underlying causes of the individual crises which characterize this problem, seem so varied in nature and so randomly distributed over time, that answering these questions except in the most general terms, is impossible. The graph shows the result of plotting on a logarithmic scale, a series of estimates for African countries, published over the past 24 years. The sources are various, but basically all the figures are derived from WFP and UNHCR records.

Numbers of Refugees and Displaced Persons in Africa

Sources: Harrell-Bond - from “Imposing Aid”. Oxford University Press, 1976; Cimade et al - from “Africa’s Refugee Crisis” Zed, 1986; Greenfield - from “The OAU After Twenty Years”. Praeger 1984; SCN 1992 - from ACC/SCN (1993). Nutritional Issues in Food Aid. ACC/SCN Symposium Report Nutrition Policy Discussion Paper No. 12. ACC/SCN, Geneva; and RNIS 3 - from SCN Refugee Nutrition Information System, No. 3, February 1994.

It seems from this that the numbers in Africa have grown from 1M in 1970, to the present 16M, doubling regularly about every six years - a rate of increase of 12% per year, which is four times the average natural growth rate of population for the region. Perhaps the most unexpected feature, is the apparent smoothness of the rate of increase, remembering that the origins of the displacement will have been diverse acute events - climatic, political, military, taking place within the separate 20 or so affected countries of the region.

Before we could safely extrapolate the line, and predict 32M by the end of the century, 64M by 2006, and so on, it would be essential to have a better understanding of the nature of the underlying processes. Is the apparent regularity of growth in the past, simply an artefact due to the nature of the reporting systems and to the effect of averaging over a group of countries - hence not a reliable indicator of future trends? Alternatively, is there a common underlying factor, namely the pressure on less secure minority groups, due to continued population growth in a region where agricultural productivity has barely kept pace with increasing numbers? If that is the case, the diverse acute events, might be simply seen as the ‘triggers’ which precipitate the transfer of increasing numbers away from autonomous self-support to dependency on international relief. Even tentative answers could be vital for determining future strategies for assistance.

(Source: as given at beginning of article)


There are currently tens of millions of anti-personnel mines worldwide; about 30 million mines in Africa alone, scattered over 18 countries. They are small and inexpensive - as little as 3$US to buy but as much as 1,000$US to remove once the conflict is over. Anti-personnel mines are often designed to maim their victims because a wounded person is thought to be more of a drain on the country’s resources than a dead one.

Anti-personnel mines are indiscriminate weapons. Mines are theoretically for military use only, but depending on the stage of the conflict, the victims are most often civilians. Once the conflict has ended, children, women and men are likely to victims of mines for decades to come as they go about their daily work.

The use of anti-personnel mines is clearly a violation of four human rights: the right to life, the right to physical and psychological integrity and to an adequate standard of living. Children’s rights are also violated: the right to a family, to be protected from hazardous work and to play. Children make up a high percentage of mine victims after a conflict has ended.

Mines pose a particular problem to refugees who fled during a conflict and who wish to return. First, much of the available land is often heavily mined, as in Cambodia or Mozambique. Often fertile farming areas have been heavily mined, leaving many returning refugees no safe farmland. UNICEF states that this practice “has lead to malnutrition and even famine or starvation.” Without safe land to farm, the returning refugees remain dependent on food aid and therefore nutritionally vulnerable.

Second, the returning refugees have no experience with land mines. Those who stayed behind may well know where mine fields are and what to do if they see what may be a mine. The returning refugees have no such experience, and this is dangerous and sometimes fatal for them. A sharp increase in mine-related injuries was noted in Afghanistan once the rate of repatriation began to increase.

To help in this, UNHCR has begun education of refugees in camps before repatriation. The focus is on raising awareness of the problem and education regarding not handling what may be a mine.

Given the human rights violations, and the cost both in human life and additional aid, the only solution to the anti-personnel mine problem appears to be a ban on mines.

Contributed by Jane Wallace, ACC/SCN

(Sources: 1. Macrae, J. & Zwi, A. (1994) Food as an Instrument of War in Contemporary African Famines: A Review of the Evidence. Disasters, 16(4), 299-321. 2. UNICEF (1994). Statement by Mr James P. Grant, Executive Director of the United Nations Children’s Fund (UNICEF) on Children and Anti-Personnel Landmines. Draft. 3. UNHCR (1994). Refugees newsletter, No. 96.)

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