United Nations System
Standing Committee on Nutrition

Report of the Meeting of the Working Group on Nutrition in Emergencies

Sunday 11 April 1998, UNHCHR, Geneva
Chaired by Rita Bhatia, UNHCR and Anne Callanan, WFP
Rapporteur: Saskia van der Kam, MSF-Holland

Participants 

Among the participants were the AGN, NGOs, bilaterals and UN agency members.

The meeting noted that the name of the group had been changed from the Working Group on the Nutrition of Refugees and Displaced Persons to the Working Group on Nutrition in Emergencies.

Agenda

The agenda items addressed (i) the evolution of nutrition responses in emergencies since 1976 and (ii) the impact of the recent nutrition crisis in South Sudan on adolescents and adults.

Agenda item I: An overview of nutrition in emergencies: past, present, and future

Dr. Toole gave an overview of the trends in nutrition assistance programs in emergencies between 1976 and 1999. Although the quality of nutritional assistance has improved considerably in the last two decades some of the same problems persist, for example outbreaks of micronutrient deficiency disorders continue. Additionally, the rapidly changing geopolitical context has raised new challenges in the provision of adequate food aid.

Key Milestones:

1976-1980
During the refugee crises of the late 1970s, such as the influx of Laotians, Vietnamese, and Cambodian refugees into Thailand, there was little recognition among health-oriented relief teams of the importance of the nutritional content of the food ration.

In the camps for Cambodians, nutrition assessment surveys began to routinely use anthropometry and comparisons with the WHO/CDC/NCHS reference population were made.

1981-1985
In the early 1980s, when one million ethnic Somalis were displaced from Ethiopia into 35 camps in Somalia, local guidelines on standard treatment protocols, entry and exit criteria for selective feeding programmes, and methods of measuring malnutrition in populations were developed by consensus. Oxfam feeding kits were widely used and various manuals devoted specifically to the management of nutrition programs in refugee camps were developed.

The lesson learnt was that standard guidelines on nutrition assessment and selective feeding programmes could contribute to the sustainability of a programme by the host country and the refugees themselves.

Despite the increased attention on nutritional matters, these refugees experienced several outbreaks of scurvy, which were not predicted by standard texts on nutritional disorders in Africa.

The lesson learnt was that refugee populations require the same range of nutrients in their diet as other people.

The severe famine in Ethiopia in 1984/85 led to a mass exodus of refugees from Tigray province where food aid was deliberately obstructed by the Ethiopian government at the time. The refugee influx into Sudan was followed by extensive measles epidemics associated with very high case fatality rates of up to 30%.

The lesson learnt was that communicable disease prevention programmes, such as measles vaccination, are critical to prevent excess mortality from wasting in children.

1986-1990
A highlight of the late 1980s was consensus among the major relief agencies to increase the minimum daily ration for refugees from 1500 to 1900 kcals per person per day.

Large refugee populations in eastern Ethiopia experienced an increase in acute malnutrition prevalence despite international assistance. This increase was associated with a concurrent increase in the crude mortality rate, which declined in parallel with the eventual decrease in acute malnutrition prevalence.

The lessons learnt here included the close association between the prevalence of acute wasting in children less than 5 years and the crude mortality rate. In addition, the deterioration in nutritional status was associated with inadequate registration of refugees, the failure to issue ration cards to each family, and the resulting inequitable distribution of food rations.

Increasingly, during this period, data on health and nutrition were systematically gathered by relief agencies, which enabled better analysis and evaluation of public health programs for refugees.

1991-1995
In Mozambican refugee camps in southern Malawi, a massive outbreak of pellagra occurred, affecting at least 18,000 refugees following the omission of groundnuts from the ration, the only source of niacin in this maize-consuming population.

This was a further reminder that the deletion of sources of essential micronutrients from a food ration for food aid-dependent populations will inevitably lead to outbreaks of deficiency diseases.

In addition, some progress was made in improving ration distribution systems at this time, with emphasis on women being both the distributors and primary recipients of food rations. Systematic food ration monitoring also began during this period.

The displacement of almost 500,000 Kurds from northern Iraqi cities and towns onto the mountainous border with Turkey in the winter of 1991 confronted the aid community with a new dilemma. Because Turkey denied temporary asylum to all but a few of the refugees, the international community could not gain access through existing international conventions on refugees. Thus the international community took drastic steps and created a "safe haven" in northern Iraq. The term "complex humanitarian emergencies" was coined.

Due to the lack of clean water and sanitation, an extensive outbreak of diarrhoeal diseases occurred. This led to an increase in acute malnutrition among children aged 12-23 months. Among infants younger than 12 months, the incidence of diarrhoea was also high, perhaps due to bottle-feeding. However, after one month surveys showed low prevalence of acute malnutrition in this age group. This was explained by the fact that a very high proportion of infants had died due to diarrhoea and only very few had survived.

The lessons learnt in this crisis included: (1) the impact of diarrhoea on nutritional status in a previously well-nourished population; (2) the dangers associated with the displacement of a population where breastfeeding prevalence is low; (3) the challenges of providing aid to displaced populations denied asylum by a neighbouring country and (4) the impact of local food trade in preventing micronutrient deficiency diseases.

Following the dissolution of the Soviet Union and the collapse of communism in Eastern Europe, a number of economic crises, armed conflicts and population displacements occurred, most significantly in the republics of the former Yugoslavia.

In these settings, children were not found to be as vulnerable to nutritional disorders as the elderly, particularly those surviving on fixed pensions in urban situations and cold climates.

During the 1990s, armed conflicts in Somalia and Southern Sudan led to severe famines, which affected all age groups, including adults. Extremely high acute malnutrition prevalences (up to 70-80%) were documented among children less than 5 years in these settings. There were, however, considerable differences between sampling methods, anthropometric indices, and definitions of acute malnutrition employed in the various surveys cited. The issues of assessing nutritional status and managing severe malnutrition among adolescents and adults began to be addressed during this time. This is an issue which continues to concern relief agencies.

Lessons learnt included the need to standardise nutrition assessment methods and to improve the assessment and management of nutritional emergencies among adults and adolescents.

The large scale of some of the emergencies in this period made the organisation of camps and equitable food distribution very difficult. In 1994, up to 800,000 people fled Rwanda in to the Goma area of ex-Zaire. In the first month, almost 10% of the population died, mainly from cholera and dysentery. Nutrition surveys showed the increased risk of acute malnutrition among children who had had dysentery and those who lived in female-headed households.

Lessons learnt included the difficulty of planning for such acute and massive population migrations, the need for nutritional rehabilitation of children with diarhoeal diseases, and the need to ensure an equitable food ration distribution system.

Throughout the 1990s, sporadic outbreaks of micronutrient deficiency diseases continued to occur, including pellagra, scurvy, and beriberi. It is still difficult to organise food aid and other assistance in such a way as to prevent these recurrent outbreaks. It was recognized that a wider range of ration foods and free access to local food markets are essential for the provision of micronutrients. There has been some progress on fortification of foods, but little in the support for home gardens during emergencies. Supplementation is sometimes feasible, but definitely not a long-term solution, except for vitamin A.

1996-1999
Food crises continued to occur, particularly in the Horn of Africa, West Africa, and North Korea. The economic crises in Asia and Latin America did not cause major emergencies in most countries. The important exception to this is Indonesia which remains highly vulnerable. This is because the economic crisis has been accompanied by a political crisis and at least five ethnic and religious conflicts, as well as large numbers of internally displaced persons.

During this period, the minimum energy content of the food ration was increased from 1900 to 2100 kcals per person per day. Agreement was also reached on the inclusion of fortified blended cereals in routine food rations. Studies were conducted on the acceptability of these items. Guidelines on emergency nutrition (MSF), selective feeding programs (WFP/UNHCR), the estimation of food and nutrition needs in emergencies (WFP/UNHCR), and the treatment of severe malnutrition (WHO) were all published between 1995 and 1999.

In summary, the lessons learnt between 1976 and 1999 include:

• The direct association between acute malnutrition prevalence and crude mortality rates.
• The need for standard survey methods, measurement indices, references, and definitions of acute malnutrition among children.
• Food aid dependent populations are at high risk of micronutrient deficiencies.
• Nutritional status is related to the incidence of diarrhoeal diseases, measles and other communicable diseases, and that their prevention is an integral part of a nutrition program.
• Ration distribution systems require detailed planning, management, and monitoring to ensure equitable distribution.

Unresolved issues include:

• The assessment and management of acute malnutrition in adolescents and adults.
• The prevention of vitamin C deficiency in large African food aid dependent populations.
• The management of anaemia among severely malnourished children.
• The lack of detailed operational planning for the response to nutritional emergencies (e.g., Kosovo), and preparedness and prevention of evolving emergencies (e.g., Indonesia).

Other current operational issues include:

• The challenges of data collection under insecure conditions: data are often poorly representative and difficult to extrapolate to larger populations.
• The need for consensus on methods of nutritional surveillance and its role in nutrition programme management.
• Challenges in the prevention of micronutrient deficiencies.
• The training and capacity building of nutritional assessment, planning, and programme management among international relief agencies, governments, and local NGOs.

Agenda item 2: An Ongoing Omission: Adult and Adolescent Malnutrition in Famine Situations

Just after World War II there was a peak in interest in adult malnutrition. In the early 1990s there was a renewal in this interest, largely as a result of the confluence of two bodies of knowledge in the technical and policy domains.

The grave situations and high mortality in older children and adults in Somalia (1992-1993) and Angola (1993-1994) triggered the development of the use of anthropometry in diagnosing wasting in adults and treatment protocols for severely malnourished adults. In the policy domain, the debate surrounding vulnerability and targeting was an important factor and triggered a questioning of the traditional classification of vulnerable groups. To some extent, the focus was re-directed from absolute mortality to excess mortality. As a result, context specific approaches led to an increased prioritisation of adolescents and adult malnutrition.

However, four factors continue to constrain interest in acute malnutrition in older age groups:

• Technical knowledge on the assessment and treatment of malnutrition in adults and adolescents is lacking.
• Health staff are unfamiliar with this issue.
• There is a high prevalence of co-existing illness such as TB and AIDS.
• Media and public relations officers tend to focus on children.

A case study was presented on the situation in Ajiep, Bahr el Ghazal, Southern Sudan, in 1998. Although there were some 18 NGOs operating around 50 selective feeding programmes and 21 therapeutic feeding centres in Bahr el Ghazal, not one of these programmes was tailored for adolescents and adults. Some adults, however, were included on an ad hoc basis in the feeding centres designed for children.

Despite massive inputs from WFP and the NGOs operating in Ajiep, there were significant logistical constraints and insufficient capacity on the ground to treat all the cases of malnutrition. The prevalence rates of wasting among children were reported to be approximately 80% (<-2 Z score) and under five mortality rates were reported to be extremely high by July. These results focused the attention of the international community almost completely on the under 5 age group. In the first week of August, some months after the start of the humanitarian interventions, the CMR was reported to be equal to the under five mortality rates. In August a shigella epidemic (sd1) was confirmed.

Consequently CONCERN set up a selective feeding programme for malnourished adults and adolescents as well as community sanitation and hygiene projects. The treatment protocols employed were similar to those used in programmes for the under fives. Admission criteria for adults were a MUAC<16cm, oedema or a MUAC between 16-18.5cm plus a clinical complication (such as inability to stand). For adolescents extended weight-for-height charts were used with an entry criteria of < 70%.

This set up was quite successful despite the very severe degrees of malnutrition present (mean admission BMI of 12.5). The percentages of exits successfully discharged were over 70% and 90% for adults and adolescents respectively, and the percentages of deaths as a proportion of exits were approximately 10% and 2% (preliminary results, Concern). Compared to the Somalian situation in 1992 where 72% recovered and the death rate was 21%, this was a considerable improvement.

The conclusions were:

• Towards the end of a severe famine, adult and adolescent malnutrition is frequently a significant public health problem.
• With the correct treatment and management, even the most emaciated individuals can survive.

Recommendations:

• The need for programmes targeting adults and adolescents should be systematically investigated as part of any famine relief response.
• The ACC/SCN, possibly through an interagency working group on adult and adolescent malnutrition, should:
• Further standardise criteria and protocols.
• Determine survey methodologies and population prevalence cut-offs for malnutrition.
• Develop a common operational research agenda to prevent duplication of time and resources.

WHO offered to take the lead on these issues.

Discussion

Participants brought up these issues:

• The RNIS would be more useful for operational purposes if it took the following actions: (1) include more reports from U.S. NGOs and (2) provide reports from the field on a more timely basis through E-mail or on the ACC/SCN website. USAID is supporting these enhancements.
• The issue of expanding the RNIS to include natural disasters was raised and should be explored.
• The importance of the sustainability of humanitarian interventions and the maintenance of nutritional status in emergencies.
• The dilemma of targeting humanitarian aid when resources are restricted.
• The need for strategies to improve the micronutrient content in the general rations for dependent populations.
• The need for the development of the human rights approach to nutrition in emergencies.
• The need for new strategies to manage and implement infant feeding in emergencies amongst populations with a high rate of formula feeding prior to displacement.

Agency reports

UNICEF Nutrition in emergencies emerged as a priority during the course of year. At a meeting of all UNICEF country offices involved in emergencies it was decided that emergency capacity should be mainstreamed into all UNICEF country programmes. A full time Nutrition advisor, Yvonne Grellety, has been appointed. An emergency handbook for UNICEF programmes has been finalised. An MOU with Aberdeen University to advise UNICEF on issues related to severe malnutrition, to develop training materials and training guidelines on the management of severe malnutrition and to assist with capacity building within the agency has been signed. Dialogue with WFP concerning an MOU on joint operationalising has been initiated.

WHO said that their "guiding principles for caring for the nutritionally vulnerable during emergencies" is under preparation. In addition a background document on nutritional vulnerability and an annotated bibliography are being finalised. The manual on the management of severe malnutrition has been published. WHO SEARO office reported and commended the collaborative efforts of several UN agencies in managing the nutritional emergency during the floods (Malta). It was noted that a manual on Infant Feeding is available on the website of WHO EURO.

FAO reported on its efforts to strengthen its emergency related work, ranging from early warning to agriculture rehabilitation. "Guidelines for incorporating Nutrition into Emergency Relief and Rehabilitation" will be made available later in the year. FAO stressed the importance of increased inter-agency collaboration in dealing with emergencies and noted efforts to strengthen formal relations with other UN agencies including an MOU with WFP and UNHCR.

UNHCR and WFP announced several joint initiatives.

• The publication of guidelines on selective feeding programmes.
• A pilot project to provide iron cooking pots to refugees.
• A strategy paper on assessments in protracted operations with emphasis on the promotion of self reliance and eventual phase out of operations will be discussed later this year at a workshop.
• A study on feasibility of local level milling and fortification in conjunction with OXFAM.
• A workshop on the optimal level of micronutrient fortification in blended food in collaboration with WHO later this year.
• A study on adolescent nutrition in Kenya has been undertaken and another is planned for Nepal.

MSF announced that their nutritional guidelines of 1995 are being revised.

USAID is sponsoring a meeting with the Micronutrient Initiative (Canada), American Red Cross on the Enhancement of Refugee Diets, in Washington in the last week of April, 1999. The agency is also up-dating its food commodity guidelines and welcomed input from other agencies present.

Recommendations:

• The need for programmes targeting adults and adolescents should be systematically investigated as part of any famine relief response.
• The ACC/SCN should take up the issue of adult and adolescent malnutrition in order to:
  • Further standardise criteria and protocols.
  • Determine survey methodologies and population prevalence cut-offs for malnutrition.
  • Develop a common operational research agenda to prevent duplication of time and resources.

WHO offered to take the lead on this issue.

• There is a need to develop new strategies to manage and implement infant feeding in emergencies amongst populations with a high rate of formula feeding prior to displacement.

WHO and UNICEF agreed to take the lead in this area.

• The RNIS should be enhanced to (1) include more reports from U.S. NGOs and (2) provide reports from the field on a more timely basis through E-mail or on the ACC/SCN website

The SCN Secretariat will be responsible for this.

• Rotation of the chair of the working group on nutrition in emergencies.

UNICEF will be the Chair and WHO the Rapporteur for the next Working Group meeting.