United Nations System
Standing Committee on Nutrition

Nutrition Information in Crisis Situations - Nepal

NICS 13, May 2007

As another step in the peace agreement, an interim coalition government was formed at the beginning of April 2007 (OCHA, 05/04/07). However, some groups protested that they were not included. Clashes and disruption of official activities were still reported throughout the country.

Although no reliable figures exist, about 200,000 people were estimated to have been displaced by the conflict (see NICS 7) (IDMC, 16/10/06). Few returns seemed to have taken place so far.

Poor food security and nutrition situations in vulnerable areas of Nepal - A mission of experts on the human right to food has described hunger and food insecurity across the country as "pervasive" (IRIN, 23/04/07). The mission stated that the government has no comprehensive strategy to address hunger, and that there is a lack of coordination between the capital and the regions and between ministries. Main obstacles to food access were found to be endemic discrimination; insufficient and insecure access to land, and evictions; and discriminatory access to resources such as forests and fishing areas.

According to a WFP assessment conducted in November/December 2006, 197,905 people were experiencing an acute food and livelihood crisis and another 215,463 were facing a deteriorating food security situation, due to drought and other adverse weather conditions (WFP, 01/07). However, these numbers had decreased compared to the previous assessment when 900,000 people were facing a deteriorating or acute food security situation.

According to the families interviewed during the assessment, the main problems they were facing were adverse weather conditions (20.5%); human illness (18.9%); lack or loss of employment (17.1%), and unavailability of food (16.3%). All the households were worse off compared to the same season last year with 63% of them experiencing a food shortage. The poorest were the most affected with 93.8% of the extremely poor and 67.7% of the poor experiencing a food shortage compared to 17.9% of the better-off. A significant proportion of the populations reported a reduction in income, especially in the Terai (close to 70%). A decrease in access to food was even more pronounced with more than 60% of families affected in the Terai and the Far-West. The poorer the families were, the higher the decrease in income and access to food was. The most common coping mechanisms were shifting to less expensive/preferred foods; reducing meals, borrowing and migration. Sale of assets or lands was not widely practised. Casual labour represented the main livelihood for the poor, followed by crop farming and remittance. Assistance programmes only represented a very low proportion of the livelihood of all the wealth groups.

However, the winter harvest was reported to have been good, especially in the Terai (OCHA, 12/04/07). In the Hills and Mountain districts of Mid and Far Western Regions, a substantial localised decrease in production was reported.

A nutrition survey conducted in the eight most vulnerable Village Development Committees of Bahjang district in the Far-West region in December 2006, showed a poor nutrition situation (ACF-F, 01/07). The prevalence of acute malnutrition was 11.0% (7.6-14.4), including 1.2 % (0.0-2.4) severe malnutrition. Night blindness was reported in 0.5% of the children and 15.4% of the women. Mortality rates were under control. The survey was conducted before the traditional hunger-gap period between February and June, and the situation might worsen further.

The nutrition situation was comparable to that of the nearby Humla and Mudug districts where a survey was conducted at the beginning of 2006. Feeding patterns were inadequate, with 46% of the women having consumed neither vegetables nor fruit the day prior to the interview, and 23.7% having eaten neither animal foods nor pulses. Only 21.2% of the women had had antenatal care during their current/last pregnancy. Access to health services appeared low with more than half of the women reporting there was no functioning health post in the community. The main obstacles to going to a health post were distance and cost. On the other hand, most women have had contact with the Female Community Health Volunteers, especially during vaccination campaigns.

Refugees

About 104,000 refugees are sheltered in seven camps in Jhapna and Morang districts, south-eastern Nepal. They are ethnic Nepalese who left Bhutan in the early nineties when the kingdom launched cultural reforms, and have lived in the refugee camps ever since. Although talks have been held repeatedly, no agreement about repatriation of the refugees has been reached yet.

As of the end of May 2007, violence erupted at the Nepal-India border as a group of about 7,000 refugees tried to cross the border to reach Bhutan via India (IRIN, 30/05/07). Two refugees were killed and hundreds injured. Tension between the refugees who want to go to a third country and those who insist on being given the right to return to Bhutan had increased since the US offer to resettle 60,000 of the refugees (AFP, 29/05/07).

A random-sampled nutrition survey conducted in January 2007 showed an acceptable level of acute malnutrition (CDC/joint, 03/07) (table 6). However, stunting was significant as well as anaemia. Night blindness was also reported in 2% of the children and 10% of their mothers. Angular stomatitis, a sign of riboflavin deficiency was present in 1% (0.4-2.3) of the children, while about 10% showed scarred angular stomatitis, a sign of past riboflavin deficiency.

Table 6 Results of a nutritional survey, Bhutanese refugee camps, Nepal, January 2007 (CDC/joint, 01/07)

Compared to previous years, the prevalence of acute malnutrition and angular stomatitis has decreased (figure 8 & 9). However, the present survey was conducted in January, a time when food security is better than in June-July when the previous surveys had been conducted. It is therefore difficult to interpret the apparent improvement in the situation.

Figure VIII Trends in prevalence of acute malnutrition, refugee camps, Nepal

Figure IX Trends in prevalence of angular stomatitis, refugee camps, Nepal

Comparison with the results of the 2006 Demographic and Health Survey in the south-eastern areas of Nepal (DHS, 2006), showed that stunting, wasting, and anaemia in women seemed lower among refugees than Nepalese (stunting = 36.9%; wasting = 11.2%; anaemia among women = 36.9%), but that anaemia in 6-59 month-olds was at about the same level.

Although breastfeeding was almost universal at ages 1 and 2, exclusive breastfeeding below six months was low with about 76% of the children having received water, tea or other liquids before three months of age. Mothers' practices of complementary feeding were poor because of inadequate knowledge and possibly high cost of nutrient-rich foods.

Refugees receive a full food ration as well as some non-food items, such as cooking fuel (WFP/UNHCR, 06/06). Refugees have not been accorded the right to work or to access agricultural land. Many, though, work outside the camps but only on a limited scale with earnings far less than what is needed for sustainability (WFP/UNHCR, 06/06).

According to the survey, about 92% of the mothers reported that at least one of the household members earned cash income. Only 33% and 19% of the mothers owned a kitchen garden and chicken or goats, respectively. Almost all women bought food in the market, especially vegetables, potatoes, milk, meat and fruit.

Access to good quality water, with an average of 20-25 l/pers/day, and sanitation were reported to be adequate in the camps (WFP/UNHCR, 06/06). Health status also seemed satisfactory and the mortality rate was under control.

NICS 9, May 2006

Following 19 days of pro-democracy protests called by the Seven Party Alliance, King Gyanendra announced that the parliament which had been dissolved in 2002 would be reconstituted (OCHA, 05/05/06). A new government was formed and peace talks between the new government and the Maoists were set to begin by end of May (IRIN, 26/05/06). Maoists and the government declared a three months cease-fire, starting at the end of April. It is hoped that these new developments will restore peace in Nepal. Meanwhile, drought in some of the districts of the impoverished Karnali province has raised concern about a possible food crisis in the area (IRIN, 08/05/06). A random-sampled nutrition survey conducted in Mugu and Humla districts, which are among the least developed districts in Nepal, in March 2006, showed a precarious nutrition situation, although mortality rates were under control (table 6) (ACF-F, 03/06). Further food security assessments are on-going.

Table 6 Results of a nutrition and mortality survey in Humla & Mugu districts, Karnali province, Nepal, January 2006 (ACF-F, 03/06)

NICS 7, August 2005

Buthanese refugees

Some 100,000 Buthanese refugees are still hosted in seven camps in eastern Nepal. The annual nutrition survey conducted in July 2005 showed that the nutrition situation has remained stable and was average (AMDA/UNHCR, 07/05) (figure 16). The prevalence of stunting was 26.5% and has also remained stable over the past six years. Measles vaccination and vitamin A distribution coverage was near 100%. Prevalence of angular stomatitis was 6.7% and was within the same range as in the previous years (figure 17). More than half of the families stated that they had a regular source of income and 82% of the families were supplementing the food distribution, mostly with vegetables but also eggs/meat and dairy products.

Nepalese crisis

The Maoist insurgency is still on-going. Estimates of the number of displaced in Nepal vary from 200,000 to 500,000 (RI, 11/07/05). They are difficult to evaluate as a number of displaced are reluctant to identify themselves out of fear of retaliation. For this reason, it is also difficult to assess the conditions in which IDPs are living and to provide aid targeted at them. It seems that IDPs are virtually indistinguishable from the equally vulnerable urban poor and that IDP response could be concentrated on assistance to the poor, regardless of their status. RI also states that the government is virtually non-functional in many areas controlled by the Maoists (up to 80% of the country) and that provision of services by NGOs and UN agencies is required on an emergency basis. RI appeals to emergency NGOs for implementing programmes beside existing development programmes. A joint appeal might be soon launched by OCHA (WFP, 09/09/05).

Figure 16 Acute malnutrition in Bhutanese refugee camps, Nepal

Figure 17 Angular stomatitis in Bhutanese refugee camps, Nepal

NICS 3, August 2004

Bhutanese refugees

The annual nutrition survey was conducted in June 2004 in the seven camps where about 104,000 were settled (AMDA, 06/04). The results showed a stable situation in terms of acute malnutrition and prevalence of angular stomatitis, compared to 2003 (figures 8 & 9). The prevalence of stunting was 25.3%, including 7.7% severe stunting, and has remained stable over the past five years.

Measles vaccination and vitamin A distribution coverage were satisfying: 97.2% and 97.6%, respectively.

The proportion of families who had kitchen gardens decreased by 12% compared to last year: 60% vs. 72%. On the other hand, the number of families reporting having regular income seems to have increased from 54% in

2003 to 69% in 2004. The main sources of income were daily work, incentives from aid agencies and petty trade. 93% of the families reported purchasing food in addition to the general ration, mainly vegetables (100%) and dairy products (49%).

According to ante-natal care records, 9.3% of the children surveyed weighed less than 2,500 g at birth, which is similar to 2003 (11.4%). Among the children with a low birth weight, 25% were acutely malnourished at the time of the survey, compared to 6.3% who were acutely malnourished amongst the children who had a birth weight above 2,500 g.

Nepalese crisis

The political crisis is still raging in Nepal (see NICS 2). A blockade recently paralysed the capital, Kathmandu (AFP, 25/08/04). A natural disaster also occurred, with floods devastating the eastern and central regions (IFRC, 20/08/04). 800,000 people have been affected and 185 killed.

The pressure of the Maoists on NGOs and donors has increased over the recent months, leading to the suspension of programmes previously benefiting about 55,000 people (IDP Project, 06/04).

A joint OCHA/IDP unit mission to Nepal reported that Nepal "is not yet experiencing a humanitarian crisis. Basic needs in terms of food, health, shelter and water continue to be met, at least according to the standard of a very poor developing country" (OCHA/IDP Unit, 06/04). The report highlights that most of the aid agencies involved in Nepal have a development perspective and are reluctant to engage in humanitarian activities, for fear of undermining population's coping mechanisms.

There are no specific programmes targeting IDPs partly because most of them are hosted in local communities. The mission recommends not establishing such programmes for fear of destabilising the situation, but recommends that a broader approach based on the protection of civilians be adopted.

The report also stated that women and children are especially at risk, with, among other things, an increasing risk of being involved in trafficking and prostitution.

The mission emphasised the fact that little information exists on socio-economic conditions, population movements, and human rights abuses, and that the existing information is of low quality.

Figure 8 Prevalence of acute malnutrition, Bhutanese refugee camps, Nepal

Figure 9 Prevalence of angular stomatitis, Bhutanese refugee camps, Nepal

Recommendations

From the joint OCHA/IDP Unit mission:

• Establish a countrywide monitoring network on protection and assistance needs.
• Further assess population movements on an continuing basis, to better understand the causes and impacts both in Nepal and India.
• Develop a comprehensive protection strategy and address protection needs.
• Develop assistance programmes. These should be community based and ensure provision of basic services and livelihoods, while maintaining a medium/long term development focus.
• When appropriate, humanitarian tools may be used, such as early warning mechanisms and direct program implementation.
• Attention needs to be given to pre-positioning stocks in case there is a deterioration in the humanitarian situation

NICS 2, May 2004

Buthanese refugees*

Ethnic Nepali refugees from southern Bhutan began to arrive in Nepal towards 1991 following the Bhutanese authorities' enforcement of restrictive immigration and citizenship laws.

As of June 2003, around 103,000 refugees were settled in seven camps in Jhapa and Morang districts, eastern Nepal. Despite several rounds of negotiation over the last years, no solution to the refugee crisis has yet been found (HRW, 28/10/03).

Average anthropometric nutrition status

Regular yearly nutrition surveys have been conducted since 1992. Apart from the survey done in 1992 which showed a high level of acute malnutrition, the surveys carried out later revealed an average nutrition situation: the prevalence of acute malnutrition, expressed in percentage of the median until 1998, was about 5% (UNHCR/WHO, 03/04). Acute malnutrition rates expressed in Z-scores are available for 1999, 2000, 2002 and 2003 and also show an average nutrition situation (figure 9).

Prevalence of stunting has remained around 30.0% over the last four years (UNHCR/WHO, 03/04).

Figure 9 Prevalence of acute malnutrition in refugee camps, Nepal

Micro-nutrient deficiencies

High levels of micro-nutrient deficiencies such as scurvy, beri-beri and pellagra were reported in 1993-1994 (FE, 10/98; RNIS 5 to 7). After various actions had been taken to prevent micro-nutrient deficiencies, such as replacement of polished rice by parboiled rice and inclusion of fortified blended food in the general ration, distribution of green vegetables and nutrition education, cases of micro-nutrient deficiencies have decreased. However, a rise in the number of cases of angular stomatitis (deficit of vitamin B2) occurred in early 1999. This may have been linked with the withdrawal of the blended from the general ration and the irregular supply of green vegetables. The situation improved in late 1999 (see RNIS 26 to 31).

Clinical assessment of angular stomatitis is included in the nutrition surveys. The prevalence among the 6-59 month olds seems to have regularly declined since 1999 (figure 10). On the other hand, a significant number of new cases were still reported in the health facilities, in May and June 2003. Cases of mild beri-beri, vitamin A deficiencies and scurvy were also reported, whilst no case of pellagra was detected. However, health facilities do not seem to have written case definitions of micro-nutrient deficiencies (UNHCR/WHO, 03/04).

Bi-annual distributions of vitamin A capsules for children 6-59 months are implemented and, according to the nutrition surveys, the coverage seems to be adequate: 93.2%, 95.3% and 98.4% coverage in 2001, 2002 and 2003, respectively (AMDA, 08/01; 06/02; 06/03).

Figure 10 Prevalence of clinical signs of angular stomatitis assessed during nutrition surveys, refugee camps, Nepal (AMDA)

Average food security situation

Food distribution

Regular food distributions of parboiled rice (410 g7pers/day), lentils (60 g/pers/day), chick peas (20 g/pers/day), salt (7.5 g/pers/day) and vegetable oil (25 g/pers/day) provide 2000-2100 Kcal/pers/day (UNHCR/WHO, 03/04). Fresh vegetables are also provided.

Other sources of food

In 2003, about 86% of the households declared having purchased food, mainly vegetables and dairy products (AMDA, 06/03).

A significant number of households have kitchen gardens: 53%, 71% and 61% in 2001, 2002 and 2003 respectively (AMDA, 08/01; 06/02; 06/03).

Sources of income

About half of the families surveyed reported having regular sources of income in 2003 (AMDA, 08/01; 06/02; 06/03). The main sources of income were petty trading, daily work and incentives from aid agencies.

Child care practices

The 2003 survey found that 98% of the 0-1 year olds were breastfeeding (AMDA, 06/03). However, mothers tend to introduce complementary feeding such as blended food or cow milk in the first 1-2 months of life (UNHCR/WHO, 03/04).

Nutrition programmes

Selective feeding programmes are being implemented in all camps for malnourished children, pregnant and lactating (0-6 months after delivery) mothers, children aged 6-11 months, TB and elderly sick (UNHCR/WHO, 03/04). The bulk of the ration provided is a locally-produced fortified blended food. Some problems regarding the follow-up and the weight gain of the malnourished children were reported as well as an inadequate expertise in counselling the mothers about child feeding. No therapeutic feeding centres are in place (UNHCR/WHO, 03/04). Growth monitoring (weight-height and weight-age) is implemented for children aged 0-24 months. Whilst 0-12 month children regularly attend monthly growth monitoring because their mother receive supplementary food, only 30% of the one to two year olds are followed-up. No counselling is provided to mothers of children who fail to gain weight adequately.

* Reviewed by Oleg O.Bilukha from CDC and consultant for the WHO/UNHCR evaluation in refugee camps

Nepalese crisis

The "People's war", a civil insurgency led by the Maoists, an opposition force to the Monarchy, erupted in 1996. The conflict escalated in late 2001 with the involvement of the army and the declaration of a state of emergency. A ceasefire agreement was signed in January 2003 but broke down in August the same year and the conflict has since escalated. As of the beginning of 2004, it was estimated that 73 of the 75 districts of Nepal were affected by the conflict (RI, 23/03/04).

Human rights abuses and violations by both parties have been on the rise and the war has created thousands of victims (RI, 23/03/04; AFP, 11/04/04).

Whilst until 2001, civilians targeted by the Maoists were mostly from the upper class, including teachers, it seems that in recent years, actions of both Maoists and government forces have been affecting any category of the population (NRC, 10/10/2003). Education has broken down and business, the local economy and public services have been disrupted.

The civil unrest has also led to displacements, mainly from the rural areas to district headquarters and city centres, and to migration to India. These are the same patterns that poor economic migrants traditionally follow. Estate and rent prices have gone up considerably in towns (Nepal news, 18/09/03). The number of IDPs is not known precisely and may be between 100,000 and 150,000 (NRC, 03/03). Whilst the better-off seem to have had the means to restart a new life in towns, poor IDPs are more at risk. Assistance to IDPs seems low, with no government policy and few assistance programmes (RI, 23/03/04). Estimation of the number of IDPs and the provision of assistance to IDPs are made difficult by the political situation.

As of 2003, it was not clear how far the current crisis had affected the food security of the population. According to an ICRC survey conducted in the west-central region in January 2003, there was no acute food crisis at the time but the persistence of the conflict could precipitate a crisis (ICRC, 13/01/03). Another study stated that as of 2003, although a significant proportion of the population was food-insecure, it was not clear whether there has been a decline in food security over the past five years and if this decline may be attributed to the conflict (EC, 2003). The study also recognised that the restrictions on the movement of people and goods may have the effect of increasing food insecurity, especially in the areas where self-reliance is impossible.

A rapid nutrition and food security assessment in four districts of the Mid-West region, carried out in January-February 2003 found a high level of food insecurity, but this had not changed significantly from the previous five years (WV, 01-02/03). Traditional coping mechanisms were becoming stretched.

Rapid nutrition assessments showed level of acute malnutrition slightly above 10% in three districts, whilst it was 5% in Lamjung district (WV, 01-02/03). According to a Demographic and Health Survey, the prevalence of malnutrition was 8.1% in the mid-western region in 2001 (MOH/ORC, 2001).

Overall

The on-going conflict has led to major human rights abuses and to the displacement of thousands of people into major cities and India. Whilst the better-off may be able to cope with the displacement, the poorest may be in a more difficult situation. In rural areas, although the direct impact of the conflict on food security is unclear, the recent upsurge in violence may have further weakened the already flimsy food security of the population, and coping mechanisms may become exhausted.

The nutrition status of the refugees is average, with micro-nutrient deficiencies reported, although some measures have been taken to overcome this problem.

Recommendations

From the UNHCR/WHO assessment in refugee camps:

• Additional training of the staff of nutrition unit
• Pay more attention to counselling of mothers
• Improve the coverage of the growth monitoring for children more than one year
• Implement treatment of severe acute malnutrition
• Improve food basket monitoring

RNIS 32/33, April 2001

Refugees from southern Bhutan, began to arrive in Nepal towards the end of 1990 following the Bhutanese authorities enforcement of restrictive immigration and citizenship laws. The birth rate in the camps is over two percent and it is estimated that the current camp population is around 98,500 people. Since the beginning of the refugee operation there have been 16,000 registered births in the camps.

The situation in the seven camps has been stable for some time and the most pressing concern now is how to resolve their plight. Negotiations are underway between the Nepalese and Bhutanese governments and the decision has been taken to conduct a verification exercise to check the validity of refugee claims for Bhutanese citizenship. The verification process is seen as the prelude to the ultimate repatriation of the refugees. The verification process began on the 27^th of March of this year and will take some time before it is completed. The RNIS has not received any new information on the nutritional status of the refugees but the last survey (see RNIS 28) indicated less than critical levels amongst children under five and there is no reason to believe that the situation has changed. One nutritional problem of concern has been the presence of angular stomatitis (Vitamin B2 deficiency), but increased awareness of the problem and qualitative changes in rations have resulted in far lower levels of the deficiency. For details of a recent WFP/UNHCR Joint Food Assessment mission see RNIS 31.

Priorities

• Unless substantial changes in the humanitarian situation occur the RNIS will not report further on the Bhutanese refugees.

RNIS 31, July 2000

Bhutanese refugees started to enter eastern Nepal towards the end of 1990 following the Bhutanese authorities' enforcement of restrictive immigration and citizenship laws. The total population registered in the seven camps in March 2000 was 97,940.

The most significant change for this refugee population since the last RNIS report has been new developments with regard to the resolution of their plight. Definite commitments have now been given by both His Majesty's Government of Nepal and the Bhutanese Government to begin the process of establishing a basis for repatriation. Bhutan is committed to relaxing its citizenship definitions and has given a general agreement to repatriate those refugees who can meet the requirements. It is hoped that a joint verification of the refugees will begin within the next few months (WFP/UNHCR - 05/00).

WFP/UNHCR Joint Food Assessment Mission

WFP/UNHCR undertook a Joint Food Assessment Mission to the Bhutanese refugee camps in Nepal in May, the following points were noted (WFP/UNHCR - 05/00):

General nutritional and health situation

• The overall situation of the refugees in the seven camps continues to be adequate. Health indicators show a satisfactory situation. CMR for January to March 2000 was estimated at 0.09/10,000/day and under-five mortality at 0.07/10,000/day (UNHCR - 04/00).
• Regular reports from SC (UK) show a low and constant level of wasting among children aged 6-59 months (RNIS 28).

Angular Stomatitis and anaemia

• There has been a substantial decrease in the incidence of Angular Stomatitis (AS) (deficiency of vitamin B2) over the dry season this year compared to 1999 (<20 cases/1,000 people/month, SC(UK) - 13/07/00) (see graph). Possible explanations for the decrease include: the refugees' increased awareness of the deficiency, improved and regular supply of fresh vegetables by UNHCR and the WFP-supported home gardening project, which was started in April 1999. In addition, the availability of fresh vegetables on local markets (with marked price reductions) is also seen as a main factor in increasing refugee access to these foods this year.
• During the mission the population was offered several options to improve the food basket so as to provide additional micronutrients, by replacing part of the rice and/or sugar ration with fortified wheat or com flour. The refugees clearly stated their preference for keeping the current food basket unchanged as they consider AS a minor problem that can be treated on a case-by-case basis with vitamin tablets. They also felt that the situation had improved as a result of the above factors.
• In order to respond to the increased requirements for micronutrients of adolescents, a school feeding programme distributing fortified foods was proposed. This programme will be implemented instead of a blanket general distribution of fortified food to the whole population. An estimated 38,000 children will receive 25g of fortified UNILITO (locally-produced fortified blended food) during the three dry season months (March-May) when the availability of fresh foods is low and the incidence of AS tends to be highest. Additionally, SC(UK) will conduct active screenings of all school-going children to detect and treat AS.
• Approximately one-third of all adolescent girls were found to be anaemic. SC(UK) will provide all girls aged 14 to 18 years in schools with routine iron folate/vitamin tablets to treat and prevent anaemia.
• SC(UK) will also continue with the de-worming programmes in schools as these parasites compete actively for micronutrients with the body.
• Part of the pulses ration (currently all split lentils) will be supplied as whole beans to allow sprouting, which increases the micronutrient content of the pulses. Sprouting whole pulses and fermentation of leafy vegetables are both indigenous food preparation practices.

Incidence of reported angular stomatitis among Bhutanese refugees of all ages

Food supply

• Food basket monitoring shows, that for most commodities, the average requirements received were within +/- 5% of the entitlement. However, calculations of the nutritional value of the food commodities received show that households are receiving inadequate amounts of calcium and vitamin B2, when compared to the Recommended Daily Allowance (RDA).
• The supply of vegetables was regular and sufficient from April 1999 to March 2000, which is a major improvement over 1999 when there were long periods of supply shortfalls. The vegetable basket includes potato, onion, green chili cabbage or pumpkin or green banana (depending on seasonal availability) and also dry garlic and turmeric. Given that the refugees are not permitted to work outside the camps and have no access to agricultural land, further reductions in the ration are not considered an option in the foreseeable future. Current rations are in line with the minimum level of requirements for this population.

Recommendations and priorities:

Note that most of these recommendations will not be implemented until 2001 as there is no budget provision for them this year (UNHCR - 20/07/00).

From the WFP/UNHCR assessment Mission (WFP/ UNHCR - 05/00).

• Maintain the basic food basket composition and general ration scale at the current level. The support should cover a period of 24 months during which time it is expected that there will be agreement on the movement of refugees out of the camps and this food support will be converted into a repatriation or reintegration package.
• Partially substitute the pulse ration for whole peas to improve micronutrient availability.
• Introduce a targeted school-feeding programme to provide 25 grams of UNILITO to each school child to help address AS during the dry season.
• Provide all girls aged 14 to 18 years in schools with routine iron folate/vitamin tablets to prevent and treat anaemia.
• Screen all school-age children for AS and treatment.
• Conduct a bi-annual de-worming campaign for children through the school system.
• Revise camp rules to allow the refugees more opportunity and flexibility to undertake supplementary activities. For instance the home garden project should be incorporated in all the camps.

WFP to continue to purchase food commodities on the local or regional markets in order to provide a cost-effective and reliable supply.

RNIS 30, March 2000

An estimated 83,000 ethnic Nepalese fled Bhutan between 1990 and 1993 in fear of the enforcement of new citizenship laws and the “one nation, one people” policy of cultural assimilation passed by the Government of Bhutan in the late 1980s. These refugees were settled into seven camps in the Jhapa and Morang districts in south-eastern Nepal. There are currently some 97,600 Bhutanese in these camps. There has been no effective resolution of their plight to date.

In general, the health and nutritional situation in these camps is adequate. The most recent nutritional survey among children aged 6-59 months estimated the prevalence of wasting at 9.9% (see RNIS 28).

UNHCR/CDC adolescent survey

At the request of UNHCR and WFP, CDC undertook a survey of protein-energy and micronutrient malnutrition among adolescent (10-19 years of age) Bhutanese refugees in October 1999. The results of the protein-energy survey were reported in RNIS 29. Although micronutrient deficiencies had been noted since these camps were created in 1990, there had been an increase in the number of cases, especially of angular stomatitis (AS), since March and April, 1999.

The key finding from the micronutrient survey was that AS, which was found in 29% adolescents examined, was found to be statistically associated with low riboflavin status and low serum folate, therefore confirming bio-chemically and clinically the presence of micronutrient deficiency diseases.

The results of the micronutrient survey are summarised below (see annex for methods):

• AS was found in 133 (29%) of 463 adolescents examined. The prevalence of AS was not significantly associated with age or sex. Biochemical analyses showed that both low riboflavin status and low serum folate were significantly related to AS. AS was not related to serum vitamin B12 or vitamin A status.
• Eighty-six percent of the 183 adolescents chosen at random that had not received recent vitamin B complex supplementation had abnormally low serum riboflavin level. Low riboflavin status was not related to age or sex; however, low riboflavin status was related to camp of residence. Adolescents with a riboflavin level at or below the survey population mean average were 2.3 times more likely to have AS than those with riboflavin levels above the mean.
• Of the 190 adolescents without recent iron and folate supplementation, 67 (35%) had subnormal serum folate levels (< 2.6 ng/ml). Low serum folate was not related to sex or camp; however, the prevalence of low folate levels increased with age. AS was 1.6 times more likely among those with low serum folate levels than those with normal levels.
• Among the 154 adolescents without recent vitamin B complex supplementation, 32 (21%) had subnormal serum levels of vitamin B12 (< 201 pg/ml). Low serum vitamin B12 status was not related to camp or sex; however, as with folate, the prevalence of low vitamin B12 increased with age. There was no significant association between low serum vitamin B12 status and AS.
• Twenty-four percent of the adolescent sample were anaemic using the WHO recommended age and sexspecific definitions. Seven percent of the sample had haemoglobin levels less than 11 g/dl and one adolescent was found to be severely anaemic (haemoglobin < 7 g/dl). The prevalence of anaemia rose sharply after 11 years of age, with females aged 12 and older having an anaemia prevalence of 33%. Females who had experienced menarche had significantly more anaemia than their pre-menarche counterparts. Among males the prevalence of anaemia peaked at 14-15 years of age and then fell in older age groups, Anaemia was not related to riboflavin, folate, or vitamin B12 status; however, it was related to low vitamin A status.
• Among the 190 adolescents who underwent phlebotomy and who denied recent iron supplementation, 109 (57%) had an elevated serum transferrin receptor level (TfR > 8.0 ug/mL) indicating decreased iron stores. High TfR was related to being anaemic. Elevated serum TfR was not related to age, sex, or camp; however, it was more common in girls who had achieved menarche than those who had not.
• Among the 190 adolescents assessed, 26% had retinol levels below 20 ug/dl suggesting low vitamin A status and 83% had retinol levels below 30 ug/dl. There was no association between low serum retinol status and night blindness. Low serum vitamin A status was not related to age, sex, camp of residence, or AS.

In response to these findings fortified cereal blend (WSB) will be distributed to 5,000-6,000 school aged children from vulnerable families for two and half months and to all children under five for four months. UNHCR is also extending its fresh vegetable supplies and expanding the kitchen garden project. It is hoped that these changes will increase the average daily consumption of riboflavin, other important B-vitamins, and other micronutrients to levels more consistent with international and U.S. daily recommended intakes. Increasing the available riboflavin and folate in the refugee diet may decrease the rate of reported AS.

Overall, the nutritional situation of the Bhutanese refugees in Nepal is not considered critical (category IV). However, the biochemical results of the October 1999 survey suggest that the micro-nutrient status of the adolescent refugees is marginal and that surveillance measures need to be continued.

Recommendations and priorities:

• Because a high proportion of adolescent females are anaemic, and an even higher proportion is iron deficient, it is recommended that all adolescent females should receive iron supplementation. Such supplementation could be through distribution of tablets containing iron and folate, or through distribution of iron pots for home cooking, or other means.

Additional long-term strategies that may enhance the overall nutritional value of the general ration include:

• Providing fortified flour in place of part of the rice ration. If acceptability of fortified flour is not immediately assured, there may be a need for communication/education program to create demand for fortified flour.
• Reassessing the feasibility of the poultry project that has already been pilot tested.

RNIS 29, December 1999

There are approximately 96,500 Bhutanese refugees registered in seven camps in Nepal’s Jhapa and Morang districts. Refugees began entering Nepal in late 1990; the influx peaked in the first half of 1992. Since the beginning of 1998 no new arrivals have been accepted by His Majesty’s Government of Nepal (HMGN). The refugees, who are mostly ethnic Nepali speaking groups from the southern plains of Bhutan, fled their country in fear of the enforcement of new citizenship laws and the “one nation, one people” policy of cultural assimilation in the late 1980’s. Eight official ministerial-level talks have been held between the Bhutanese government and HMGN without any effective resolution being achieved thus far.

In general, the health and nutritional situation in these camps is adequate. The nutritional situation of children has been stable over recent years; the most recent survey in June estimated the prevalence of wasting at 9.9%, which is lower than the national prevalence in Nepal. Growth monitoring and supplementary feeding programmes are well established. The most recent report from UNHCR states that (CMR) for the month of October and November 1999 were 0,11/10,000/day and 0.09/10,000/day respectively (UNHCR -14/12/99).

UNHCR/CDC adolescent nutrition survey

UNHCR/CDC conducted a nutritional survey on adolescents aged 10-19 years in October in order to assess the prevalence of low BMI and micronutrient deficiencies (see annex). The survey was partially initiated in response to reports of high prevalences of angular stomatitis (AS) in the camps (see RNIS 27). The reported rise in prevalence followed the withdrawal of the blended food component of the ration. AS may be caused by riboflavin deficiency and the study attempted to assess the relationship between riboflavin and various food groups with AS.

The methodology involved medical examinations and the extraction of venal blood as well as anthropometric measurements and questionnaires. Anthropometric measurements were also obtained from 200 adults aged 20-39 years. The preliminary findings described below do not include the results of the blood analyses.

• Based on WHO BMI-for-age references, 36.1% of the adolescents had low BMI: Younger adolescents had higher prevalences of low BMI than older adolescents. BMI was adjusted for level of maturation, which reduced the prevalence of low BMI to 33.6%. The authors of the report questioned the validity of using the BMI and the WHO cut-offs as an indicator of protein-energy malnutrition in adolescents in this population.
• One third of the adult population had low BMI (<18.5 kg/m²); 2% were severely malnourished (BMI<16kg/m²). If MUAC and BMI were used in conjunction to define malnutrition, the prevalence was reduced to 21%, including 2% severe malnutrition. Comparable data from the adult Nepali population are unavailable; however, the prevalence of malnutrition among adults in other South Asian populations may be similar or higher. Again, the validity of the BMI and MUAC cut-offs employed were questioned by the authors.
• The prevalence of anaemia in adolescent females above age 11 was 33%. This level of anaemia among women of reproductive age is of concern. As expected, menstruating females had a higher prevalence of anaemia than males. Forty-three percent of female adolescents aged 16-17 years were anaemic as were 34% of females aged 18-19 years. Women who enter pregnancy with adequate iron stores have a greater chance of completing their pregnancy without developing iron deficiency.
• Very few survey subjects had detectable goitre (a clinical sign of iodine deficiency). The prevalence of goitre is higher in the indigenous Nepali population. This may in part be due to the routine distribution of iodised salt in the general ration. Although a large proportion of adolescent survey subjects reported night blindness (29%), none had Bitot’s spots, a clinical sigh of severe vitamin A deficiency. The laboratory testing on the serum collected will provide definitive information about the level of vitamin A deficiency among adolescent Bhutanese refugees in Nepal.
• The role of riboflavin deficiency as a causative factor in AS in these camps must await the laboratory testing of the blood specimens, AS was found in 28.7% of the adolescents examined. This is a relatively high prevalence. Although a large proportion of the lesions seen were acute, there were few accompanying lesions such as superinfection with other bacteria or viruses. AS was associated with other non-specific signs and symptoms of riboflavin deficiency such as cheilosis, tongue pain, and abnormal tongue on examination. AS was not related to mouth ulcers, oral thrush, or symptoms of neural neuropathy, which are not part of the syndrome of riboflavin deficiency. AS was also more common in those who ate less dairy products and eggs (foods high in riboflavin). The functional significance of AS itself is not well understood.

Recommendations and priorities:

• Continue to monitor the nutritional status of the population.

From the survey on adolescents:

• If the goal of organisations providing food and health services to this population is to eliminate all protein-energy malnutrition for adults and adolescents and the WHO cut-offs for the definition of malnutrition are considered acceptable, then the amount of kilocalaries provided to adults and adolescents should be increased.
• Given that the prevalence of anaemia is highest among female adolescent refugees, who are capable of child-bearing, health resources should be targeted specifically at prevention or treatment of anaemia among females aged twelve years and above.
• Definitive recommendations regarding AS must await the results of the laboratory testing. Nonetheless, anecdotal impressions and observation of survey subjects do not indicate that AS poses a serious health threat to individuals.
• A more thorough evaluation of the nutritional and non-nutritional effects of including blended foods in the ration should be carried out before recommendations on the re-inclusion of the blended food component can be made.

Overall, the Bhutanese refugees in Nepal are not considered to be at high risk of malnutrition (category IIc).

RNIS 28, September 1999

There are approximately 96,500 Bhutanese refugees registered in seven camps in Nepal's Jhapa and Morang districts. These refugees began entering Nepal in late 1990; the influx peaked in the first half of 1992. Since the beginning of 1998 no new arrivals have been accepted by His Majesty's Government of Nepal (HMGN). The refugees, who are mostly ethnic Nepali speaking groups from the southern plains of Bhutan, fled their country in fear of the enforcement of new citizenship laws and the "one nation, one people" policy of cultural assimilation in the late 1980's. Eight official ministerial-level talks have been held between the Bhutanese government and HMGN without any effective resolution being achieved thus far - this indicates that the problem is unlikely to be resolved in the near future.

Nutritional Survey

SCF-UK conducted its annual nutritional survey among children aged 6-59 months in June (see Annex). The prevalence of acute wasting was estimated at 4.1% (<80% median weight-for-height). No child surveyed was severely wasted or odematous. The graph opposite compares these findings to those of previous years. It can be seen that the level of malnutrition has been below 6% since 1993. The survey estimated the prevalence of acute stunting (height-for-age) at 31.7%, which included 7.0% severe stunting. This figure is lower than the national prevalence in Nepal.

Prevalence of wasting (<80% median weight-for-height) in the Nepalese Refugee Camps

Note that the prevalence of wasting defined in terms of z-scores was somewhat higher - 9.9% of the children surveyed were classified as acutely wasted (<2z scores) and 0.5% were severely wasted (<3z scores). This finding may require an increase in the requirement of supplementary food commodities for the camps.

SCF-UK also examined factors which may be associated with nutritional problems in these camps:

• Measles vaccination status - was high at 97.3%.
• Vitamin A supplementation campaign - 98.7% of children were covered by the most recent campaign in April.
• Breastfeeding - 98% of children less than 12 months old and 92.2% of those less than 24 months old were breast-fed. This data is difficult to interpret, however, as no information about weaning practices were reported.
• Morbidity - according to parental reports, 35.9% of all children had been sick in the fifteen days prior to the survey. 62.5% of the wasted children were reported to have been ill compared to 34.7% of the non-wasted children. This implies a cross-sectional association between illness and malnutrition, but the relationship was not statistically significant.
• Income - 29.7% of the households interviewed had a regular income of some sort. Only 11% of the families with a malnourished child had an income source whereas 89% of these families had no income. Again, caution must be used when interpreting these results as no statistical association was shown.
• Gardens - 42% of all households had a kitchen garden. No association was seen between malnutrition in children and the possession of a garden.

The last RNIS described an increase in the prevalence of micro-nutrient deficiencies in the camps between January and June of this year. More information on this subject will be available in the next RNIS when the results of a survey due to be undertaken by CDC in October are available.

Overall, the refugees in the Nepali camps are not considered to be at heightened nutritional risk.

RNIS 27, July 1999

There are approximately 96,500 Bhutanese refugees registered in seven camps in Nepal's Jhapa and Morang districts. These refugees began entering Nepal in late 1990; the influx peaked in the first half of 1992. Since the beginning of 1998 no new arrivals have been accepted by His Majesty's Government of Nepal (HMGN). The refugees, who are mostly ethnic Nepali speaking groups from the southern plains of Bhutan, fled their country in fear of the enforcement of new citizenship laws and the "one nation, one people" policy of cultural assimilation in the late 1980's. Seven official ministerial-level talks have been held between the Bhutanese government and HMGN without any effective resolution being achieved thus far - this indicates that the problem is unlikely to be resolved in the near future.

The natural increase in the refugee population has declined over the years and is currently 2% per year, reflecting the effective family planning campaigns and the education efforts in the camps. The population is young with 47% under the age of 17 years and a large and growing number of up to nearly 18,000 individuals who were born in the camps. A total of 5% are over the age of 60 years.

General health and nutritional situation

The health and nutrition of the camps is generally stable. The prevalence of wasting and mortality rates have been maintained at low levels. Average CMR is 0.84/10,000/day and the under-five mortality rate is 1.35/10,000/day. The latest SCF-UK survey in June 1998 reported a prevalence of acute wasting of 4.3% and 0.5% severe wasting. The incidence of acute wasting has remained low since this time (UNHCR - 18/05/99). It should be noted, however, that this survey showed that only 57% of the undernourished children sampled were enrolled in the selective feeding programme. No serious epidemics have been reported. Health-related needs are adequately covered by SCF-UK and referrals to the district and regional health facilities for those requiring special medical treatment. Sanitary conditions in the camp are also reported to be satisfactory. An uninterrupted and adequate (approximately 22 litres/person/day) supply of chlorinated water was available in all camps throughout 1998. The proper disposal o human waste and vector control is well managed (SCF-UK - 05/99; UNHCR -18/05/99; WFP - 11/06/99).

Micronutrient deficiencies

Concerns raised in the previous issue of RNIS about a possible increase in micronutrient deficiency disorders (MDD) following the withdrawal of fortified blended food from the general ration have been confirmed. Since the beginning of 1999, there has been a steep increase in the number of cases of angular stomatitis - vitamin B2 deficiency (see graph). Micronutrient deficiency disorders have been the main nutritional problem reported among these refugees, dating back to shortly after their arrival in Nepal 1992. A range of strategies have been put in place to address this problem, including in particular, the inclusion of parboiled rice (rather than polished rice), fortified blended food and vegetables in the general ration. Iodized salt and vegetable oil fortified with vitamin A is also included in the ration. These changes were accompanied by nutrition information and communication campaigns related to the washing of rice and the health benefits of parboiled rice and blended food. These combined strategies were followed by significant reductions in levels of MDDs and greater awareness on the part of the community (Mears -1995).

Trend for Angular Stomatitis

Note that angular stomatitis can be confused with viral infections of the mouth and although it has not been possible to confirm through biochemical assay that the current increased incidence is attributable to B2 deficiency, most cases have been successfully treated with a one week course of vitamin B complex tablets (SCF - 9/06/99). Responding to treatment is often taken as confirmation of micronutrient deficiency, where facilities for biochemical analysis are unavailable (there are no facilities in Nepal).

The incidence rates of a range of micronutrient deficiency incidences for 1999 and 1998 are shown in the table. The graph shows the increase in incidence in the first four months of 1999. The incidence varied between camps and was as high as 44.5/1,000/month in Khundunabari camp. The rate was similar in both sexes, but highest (almost twice as common) in the 5-18 year old age group. According to SCF the disease is rarely seen among people who are in supplementary feeding (SCF - 09/06/99).

Disease/deficiency	Jan.-Apr. 1998 (per 1.000/month)	Jan.-Apr. 1999 (per 1,000/month)
Vitamin A deficiency (eye signs)	0.33	0.27
Mild Beriberi	3.2	2.5
Severe Beriberi	0.06	0.11
Angular Stomatitis	5.97	24.2
Scurvy	0.54	0.76
Pellagra	00	0.01

An insufficient intake of riboflavins causes Angular stomatitis. Other points to note about the distribution of the disease in this refugee population include:

• The withdrawal of blended food from the standard ration at the end of 1998 reduced the amount of vitamin-B2 available in the diet (see RNIS 26). The current general ration provides 0.37 mg vitamin-B2, which is only about one third WHO minimum recommended daily requirements for emergency affected populations (1.4 mg) (WFP - 11/06/99; WHO, 1997)
• The camps in which refugees have more opportunities to earn income and supplement their rations have lower levels of angular stomatitis, whereas the more restrictive camps, particularly Kundunabari reported the highest incidences of angular stomatitis.
• The incidence was lower amongst those families who said they consumed more green leafy vegetables (SCF - 09/06/99).
• Refugee families with an additional income source (e.g.: a member earning incentive payments) have lower incidences
  (SCF - 09/06/99).
• The supply of fresh fruit and vegetables to the camps to supplement the general ration, which is the responsibility of UNHCR, has been very erratic and often during the past fifteen months (January 1998 to March 1999) the supply has fallen short of the agreed requirements by the following amounts (WFP -11/06/99):

• The aetiology of micronutrient deficiencies among these refugees is no doubt complex, with a range of contributing risk factors. The response strategies available to address these problems are limited, and to be most effective a range of combined strategies are usually applied. The withdrawal or failure of key strategies to prevent micronutrient deficiency diseases, such as the distribution of vegetables and blended foods, places these vulnerable refugee populations at increased risk.
• In prior years the incidence of angular stomatitis was always higher amongst the under five year olds compared to those aged 5 to 18 years. That the problem is now more prominent amongst the school age group is unexplained (WFP -11/06/99).

The observations described above suggest that the distribution of angular stomatisis is indeed related to micronutrient deficiencies in the diet in this population. It should be noted that lack of effective nutrition education, inappropriate food preparation practices and oral hygiene were also identified by UNHCR as likely contributing factors that may require attention, particularly for children (UNHCR - 01/07/99)

Overall, the nutritional situation of the Bhutanese refugees appears to have stabilised, although the history of micronutrient deficiency disorders in this population and current concerns about increased incidence of angular stomatitis mean that they are considered at moderate nutritional risk (category IIb).

Priorities and Recommendations:

In terms of the micronutrient problem:

• In the short/immediate term the UNHCR/WFP food assessment mission recommended that the most vulnerable group, children under five years old, be provided with an emergency supply of blended food for the next three months. However, given the obvious nutritional benefits of blended food, every possible consideration should be given to reinstating blended food as part of the general ration, or at the very least extending the target group for blended food to include older children and adolescents, who suffered higher incidence of angular stomatitis.
• UNHCR should explore every possibility for the timely procurement and regular delivery of green vegetables to the camps. Contractual arrangements with vegetable suppliers should be scrutinised with a view to improving the delivery of vegetables according to the requirements of the programme and providing green vegetables to the greatest extent possible.
• UNHCR spends over US$ 500,000 annually for the purchase of vegetables from external suppliers. UNHCR, Nepalese Red Cross Society (NRCS) and Helen Keller International (HKI) should explore the possibility of promoting large scale, and possibly irrigated, green vegetable production in local villages surrounding the camps. The produce could be bought by UNHCR and supplied to the refugees through NRCS.
• WFP's new home gardening project, which is being implemented by HKI and NRCS, offers the potential to increase the production of green vegetables within the camps. This project should move quickly to incorporate all of the camps with maximum coverage of the refugee communities as soon as possible. Those refugee families with extremely limited space should be encouraged and allowed to cultivate vegetables in public areas within the camps (school grounds, health centres, etc.).
• In the same context, other efforts to further address micronutrient deficiencies should be supported. For example, evaluating and developing the WFP-sponsored backyard poultry project (launched mid-1998 in Khudunabari and Goldap, but soon stopped due to apparent non-acceptance by refugee organisations and camp authorities).
• Regular nutritional surveys (that also track micronutrient deficiencies) should be undertaken every six months (or even on quarterly basis when nutritional problems persist).

More general requirements and priorities for this population include:

• Given that the majority of the refugees have been in the camps for eight years, a long-term view must be taken. More active encouragement is required to provide an effective enabling environment so that the refugees can continue to better meet their needs. It is necessary for the refugees to be given every opportunity to supplement their food requirements through improving the potential for own-production, or through income earning activities. There is also a need for support to better equip the refugees for their self-reliance and repatriation in the future. As part of this strategy, the implementation of refugee food assistance as well as WFP-sponsored income generating, vocational training and home gardening activities should be encouraged.
• The current level of assistance for non-food items (i.e., kerosene, soap, stoves, replacement parts etc.) is adequate and should be maintained. An urgent alternative to the lack of funding from NRCS/IFRC for the provision of clothing during 1999 is required. The ration composition and scale for the supplementary feeding programme should be maintained for malnourished children, pregnant and nursing women, and TB and elderly sick patients needing intensive support. Efforts to increase programme coverage must be made.

RNIS 26, March 1999

There are approximately 98,105 assisted Bhutanese refugees in Nepal (UNHCR, 18/01/99), most of whom fled Bhutan in the early 1990s. Since 1996, the increase in the total number is due to births within the camp. Most of the refugees are ethnic Nepalese from the southern plains of Bhutan who fled the Citizenship Act of 1985 and the "One nation, one people" policy of cultural assimilation of 1968. A solution to the Bhutanese refugee problem does not seem apparent in the near future, given the absence of progress for the return of the refugees to Bhutan and the fact that the host Government still maintains its policy of non-integration of the refugees in Nepal (WFP - 18/09/98).

A joint WFP/UNHCR food assessment mission to the camps in May 1998 reviewed the level of the general food ration and determined that there was a basis for re-adjustment (WFP - 18/09/98). This decision was partly taken in response to the finding that although the refugees are not officially allowed to engage in any agricultural or income-earning activity, which is thought to have negative effects on the local economy and labour markets, many of the refugees obtained short term or seasonal work and that considerable interaction existed between the refugees and the host population. There was also considerable concern raised by all partners, including the refugees themselves, that greater self-reliance and less dependency needed to be encouraged. However, the degree of "self-reliance" and the extent to which the refugees were able to supplement their needs were felt by the Mission to be generally difficult to determine because of the official government policy of non-integration and strict 'camp rules'.

The mission concluded that the general ration could be reduced by withdrawing the blended food component, which had been introduced in 1993 as a response to an outbreak of beri-beri. This reduces the energy level of the ration to 2,022 kcal/person/day, and considerably reduces levels of micronutrients. The Mission advised that general micronutrient requirements should be met through the promotion of more fresh fruit and vegetables, although the source of these was not specified (the ration contains 100g of fresh vegetables). Other than the removal of blended food, the ration remains unchanged. UNHCR continues to supply non-food items such as kerosene, soap and cooking utensils. Additional items such as blankets, clothing and mosquito nets are distributed by other organisations.

The overall nutrition situation is reported as adequate and stable, and has been so in recent years. The most current CMRs available, which were for December 1998, were low at 0.08/10,000/day (UNHCR - 18/01/99). Growth monitoring of children under five, and supplementary feeding programmes are well established in the refugee camps and will continue. Nutrition surveys of the under-fives are conducted annually (see Annex I(15a)). The most recent survey, in June 1998, found 4.3% acute wasting (defined as <80% of the median weight-for-height) and 0.5% severe acute wasting (defined as <70% of the median). These prevalences are slightly lower than those recorded for 1997.

Coverage of the supplementary feeding programme was relatively low at 47.1%, indicating that the growth monitoring programme's role in referring malnourished children was not as successful as expected. Measles vaccination coverage was high at 97.4%, and an earlier vitamin A supplementation programme had benefited 98.5% of the children. 43% of parents of the children in the survey reported that their child had been ill in the 15 days before the survey. This figure was elevated to 58.8% among children who were acutely malnourished, which indicates the importance of disease as well as food, as the immediate causes of malnutrition in this context.

As in previous reports, a few cases of beri-beri (1.33/1,000/month in December 1998), angular stomatitis (5.46/1,000/month) and scurvy (0.4/1,000/month) have been recorded at health clinics (UNHCR, 18/01/99).

Overall, the Bhutanese refugees are not considered to be at heightened nutritional risk (category IIc).

Recommendations and priorities:

• There is a need for a more enabling environment for the refugees to pursue a greater degree of self-reliance. This widespread concern applies especially to the growing frustration of the large mass of youth in the camps with no prospects for an active life after having moved out of the educational system (WFP - 18/09/98).
• Given the removal of the blended food component from the general ration and the occasional reporting of cases of beri-beri, albeit at very low levels, the incidence of micronutrient deficiency diseases should be closely monitored.

The survey's recommendations included:

• Strengthening the growth monitoring programme to cover all malnourished children and maintaining the early referral of sick children
• Increasing health education in the camps.

RNIS 25, October 1998

RNIS 25 was devoted to reviewing some of the changes in emergency response over the last five years. We will first highlight situations where wasting was brought rapidly under control. We will then look at some of the factors that have led to less than optimal results, followed by what has been accomplished to improve response over the last five years. We conclude with some ideas for future improvements in the RNIS Reports that could even further enhance communication, stimulate thought, and promote improvement.

RNIS 24, June 1998

There are approximately 94,000 assisted Bhutanese refugees in Nepal, most of whom fled Bhutan in the early 1990s. This small increase in the total number is due to births in the camps. As in the past, the overall nutrition situation remains adequate and stable, and mortality rates are low at 0.1/10,000/day [UNHCR 01/05/98, 18/05/98].

The ration of rice has been slightly reduced in 1998. Food distributions, including the distribution of vegetables and a fortified blended food (WSB), continue uninterrupted. However, micronutrient malnutrition continues to be reported at health clinics; for example the incidence of beri-beri was recently reported at 2.6/10,000/day. Incidences of angular stomatitis, a general symptom likely to indicate more serious micronutrient malnutrition, and anaemia were also elevated [UNHCR 01/05/98].

Non-food distributions including soap and kerosene, are also being carried out regularly, and water and sanitation facilities are adequate. A food assessment was recently conducted to establish the proposed food basket for 1999. The Assessment Mission recommended that fortified blended foods be omitted from general ration distributions starting in 1999. The Mission further recommended that the withdrawal of blended food from the general ration be accompanied by efforts to increase the access of refugees to fresh fruits and vegetables and that monitoring of micronutrient malnutrition should continue [UNHCR 01/05/98, 18/05/98, WFP/UNHCR 06/05/98].

On-going interventions Careful monitoring of nutritional status of the population is needed in light of slight change in rations in 1998. There is a continued need for more information on the causes of micronutrient malnutrition in the camp, and this could become particularly important if recommendations to discontinue the general distribution of fortified blended foods are followed in 1999.

RNIS 23, March 1998

There are approximately 93,000 Bhutanese refugees in Nepal who fled their country of origin in the early 1990s. Reports over the past few years have indicated an adequate and stable nutrition and health situation for this population, although there have been continuous reports of a few cases of pellagra, beri-beri and scurvy. At the start of 1998, there was a small reduction in the amount of rice provided in the general ration. So far there have been no reports of any adverse effects of this reduction, and this population is not considered to be at heightened nutritional risk (category IIc in Table 1) [UNHCR 05/03/98].

Ongoing interventions

The annual nutritional survey which is usually carried out in June, should be carefully scrutinised to determine whether there has been any adverse effect of the general ration reduction on the refugee population.

RNIS 22, December 1997

There are approximately 92,000 Bhutanese refugees in Nepal who fled their country of origin in the early 1990s. Reports over the last few years have been of an adequate and stable nutrition and health situation for this population, despite continual diagnoses of a few cases of pellagra, beri-beri, and scurvy.

In 1998, the general ration provided will be very slightly reduced with a small reduction in the amount of rice to be provided [UNHCR 21/11/97].

Ongoing interventions: The annual nutritional survey which is generally carried out in June, will be particularly important to verify whether there have been any effects of the general ration changes on the population.

RNIS 21, September 1997

There are estimated to be 92,000 Bhutanese refugees in Nepal. Most of these refugees arrived in the early 1990s, allegedly fleeing persecution in Bhutan. There are currently no plans for the repatriation of these refugees.

Levels of wasting in the camps have been low for quite some time. The figure on the right shows levels of wasting over time in the camps. Crude mortality rates (CMR) have also been quite low. For example, the CMR in June 1997 was 0.09/10,000/day and the under-five mortality rate was 0.15/10,000/day [SCF Jun. 97].

Taken from: SCF(UK) (1997) Household Food Assessment of Khudunabari and Beldangi Refugee Camps, Jhapa District. South-east Nepal SCF(UK). London.

Despite the regular provision of a food basket which provides approximately 2,200 kcals/person/day and included a fortified blended food and fresh vegetable, cases of micronutrient malnutrition continue to be reported at camp clinics. For example, in June 1997, cases of vitamin A, scurvy, vitamin B deficiency (seen as angular stomatitis, and beri-beri) were seen [SCF Jun. 97]. A study on the uses of blended food at the household level is being finalised, and it is hoped that this study will help identify reasons for the continued low-level incidence of micronutrient malnutrition.

A recent household food economy assessment was conducted in the camps to help improve understanding of food security and food needs. It was determined that an overwhelming proportion of the food supply for households was provided by the general ration, and that there is very limited access to other food sources. There is little opportunity for the refugees to farm, or keep livestock and little demand for labour outside of camps. Furthermore, levels of calcium, riboflavin and niacin fall seriously below minimum requirements. Based on these findings, a WFP/UNHCR

Joint Assessment Mission recommended that current ration levels be maintained and that blended food fortification levels should be re-assessed [SCF May 97].

Overall, this population is not considered to be at heightened risk of malnutrition and associated mortality (category lie in Table 1), despite the continued presence of low levels of micronutrient malnutrition.

RNIS 20, June 1997

There are approximately 92,000 Bhutanese refugees and asylum-seekers who sought refuge in Nepal in the early 1990s. Results of recent Food Economy Assessment and Food Assessment missions are expected to be released shortly.

RNIS 19, March 1997

There are approximately 92,000 Bhutanese refugees and asylum-seekers who sought refuge in Nepal in the early 1990s. The total number of refugees in the camps has increased slightly due to births and a few new arrivals, mainly family members of refugees. There is reportedly no change in the nutritional status of this population. Most recent reports are of low levels of wasting; however, some new cases of scurvy, beri-beri and angular stomatitis continue to be reported [UNHCR 26/02/97].

RNIS 18, December 1996

There are just over 90,500 refugees from Bhutan in Nepal. Any slight increase in population numbers are due largely to births in the camps; there are very few new arrivals. The nutritional situation is said to be stable and a recent screening of children under five years old showed 2.4% wasting with .06% severe wasting (see Annex I (17a)). However, cases of scurvy (incidence rate 0.59/1,000/month), beri-beri (3.31/1,000/month) and angular stomatitis (8.05/1,000/month) continue to be reported. Reasons for the continued presence of these micronutrient deficiencies in this population is being investigated [SCF Oct 96, UNHCR 22/11/96].

Overall, a proportion of these refugees is at high risk due to micronutrient deficiency diseases (category I in Table 1) while the remaining population is not considered to be at heightened nutritional risk (category IIc in Table 1).

RNIS 17, September 1996

There are just over 90,500 refugees from Bhutan in Nepal; this slight increase in number is due to the continuing registration of births.

The health and nutritional status of this population is reportedly stable and adequate, except for a few cases of beri-beri, scurvy and angular stomatitis continue to be reported [UNHCR 19/09/96].

Overall, these refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).

RNIS 16, June 1996

There are approximately 90,000 Bhutanese refugees living in camps in Nepal and a further 15,000 living outside the camps who do not receive humanitarian assistance.

The nutritional and health situation of this population remains essentially adequate. However, despite regular and complete general ration deliveries, including fortified blended foods, fresh vegetables and parboiled rice, a few cases of beri-beri, scurvy and angular stomatitis continue to be reported [UNHCR 21/05/96].

Overall, this population is not considered to be at heightened nutritional risk (category IIc in table 1), although a small number of people are at high nutritional risk due to the existence of micro-nutrient deficiency diseases.

RNIS 15, April 1996

There are approximately 90,000 Bhutanese refugees living in camps in Nepal. An additional 15,000 refugees reside outside camps and do not receive humanitarian assistance. The next round of bilateral talks between the Bhutanese and Nepali governments concerning the refugee situation is scheduled to take place in April 1996.

Levels of wasting reportedly remain low among this refugee population. However, despite regular and complete general ration deliveries, including fortified blended foods, fresh vegetables and parboiled rice, a few cases of beri-beri, scurvy and angular stomatitis continue to be reported. The reasons for this are currently being investigated. The crude mortality rate amongst this refugee population in February 1996 was 0.11/10,000/day, and the under five mortality rate was 0.23/10,000/day. Both these rates are considered low [UNHCR 14/03/96, 19/03/96].

Overall, the population is not currently considered to be at heightened nutritional risk (category IIc in Table 1), although a small number of people are at risk due to micronutrient deficiencies.

RNIS 14, February 1996

There are approximately 90,000 Bhutanese refugees remaining in Nepal. Although there are currently no plans for repatriation, it is hoped that talks about a potential repatriation programme will resume in the near future. Crude mortality rates are very low, with high birth rates. Agreement to implement improved health (including family planning) services in 1996 has been reached [UNHCR 26/01/96].

The nutritional situation of these refugees remains adequate. A recent screening of children under five years old found only 1.3% levels of wasting (see Annex 1 18(a)). Cases of micro-nutrient deficiency diseases such as scurvy, angular stomatitis and beri-beri, are reportedly declining, and fortified blended foods, fresh vegetables and par boiled rice are now being distributed and are apparently well accepted amongst the refugee population. The incidence rate of ARI, which was recorded as high in the last RNIS report, is now decreasing [SCF 19/01/96, UNHCR 26/01/96].

Overall, this population is not currently considered to be at heightened nutritional risk (category I in Table 1).

RNIS 13, December 1995

It is currently estimated that there are 90,000 Bhutanese refugees in Nepal (an increase of 3,000 recently to account for births in the camps, not an influx of new refugees). Although talks between the governments of Nepal and Bhutan are ongoing, there are currently no plans for the repatriation of these refugees [UNHCR 16/11/95, WFP 30/11/95].

The nutritional situation of these refugees is reported to be improving. A recent screening of children under five years old showed 2.8% wasting with 0.1% severe wasting (see Annex 1 (18a)). Over 5,000 beneficiaries are enrolled in supplementary feeding programmes but only 9% are children. There have been some recent concerns that the supply of oil in the general ration is inadequate [SCF 15/11/95, WFP 30/11/95].

Reported cases of micronutrient deficiencies are declining. For example, the incidence of beri-beri (both mild and severe) has decreased from 0.005/10,000/day in June 1995 to 1.83/10,000/day in August 1995 to 0.85/10,000/day in October 1995. This rate is, however, still higher than the 0.005/10,000/day reported in June 1995. The incidence of scurvy continues to decrease from 0.63/10,000/day in June to 0.23/10,000/day in August to 0.12/10,000/day in October 1995. This incidence is still higher than that recorded in December 1994. Fresh vegetables and CSB are included in the general ration [SCF 15/11/95].

There had been a significant increase in cases of acute respiratory infection (ART). In August the incidence was 22/10,000/day. In-patient clinics were opened in response to this escalation in cases and by October the incidence rate had fallen to 7.7/10,000/day. Mortality rates, while still considered to be low, have begun to rise. In August, the crude mortality rates was 0.06/10,000/day and the under-five mortality rate was 0.2/10,000/day. Both of these rates show a sharp increase from those reported for July which probably reflects the increased incidence of ARI cases [SCF 15/11/95, UNHCR 16/11/95, WFP 30/11/95].

Overall, the nutritional status of this population appears to be improving, despite the presence of decreasing number of cases of micronutrient deficiencies (category IIc in Table 1).

How could external agencies help? The continued presence of low levels of micronutrient deficiencies suggests that there may be households who lack access to the fresh vegetables and/or CSB in the distributed ration or who have additional nutritional needs. It may also be due to seasonal factors or work or disease patterns This may require further investigation. Regular surveillance for these deficiencies should be maintained.

RNIS 12, October 1995

There are approximately 87,000 Bhutanese refugees in Nepal. Given the lack of progress in recent intergovernmental meetings between Bhutan and Nepal, most observers do not expect any significant repatriation of refugees in the near future [IFRC 05/07/95].

Towards the end of 1993, there were confirmed reports of widespread micronutrient deficiency diseases including beri-beri, scurvy, pellagra, and angular stomatitis among this population. Various curative and preventive measures were taken to bring the situation under control. These included the addition of blended foods and fresh vegetables to the ration. A follow up survey was conducted in June 1995 which showed wasting rates among children under five of 5.7% with 0.9% severe wasting (see Annex I 19(a)). In general, rates in central and western camps were higher than in northern camps, as ascribed by some as reflecting overcrowding in the former. Adult malnutrition using BMI measurements was recorded at 18.1%. A cut-off of BMI<18 was used to define malnutrition. These results only show a marginal increase in malnutrition compared to an equivalent survey conducted in Bhutan in 1989. Measles immunisation coverage was 97%. The under-five mortality rate was 0.17/10,000/day and has been declining for the past 6 months [IFRC 05/07/95, SCF/UNHCR 25/07/95].

There were no cases of pellagra seen among the population surveyed. However, there was a 2.3% prevalence of beri-beri which, although significant, was not considered to be an alarming rate as symptoms take some time to be alleviated and the incidence of the disorder has dropped from 0.55 new cases/10,000/day in January 1995 to 0.005/10,000/day in June 1995. There was more concern over the rates and apparent increase in the incidence of scurvy and angular stomatitis. The scurvy incidence was estimated at 0.62 new cases/10,000/day in June 1994 compared with 0.17/10,000/day in December 1994; the incidence of angular stomatitis was 2.49/10,000/day compared to 1/10,000/day in December 1994. While both rates are much lower than peak levels in May 1994 and seasonal factors are know to have an impact, the persistence of both these conditions is worrying [SCF/UNHCR 25/07/95].

Overall, although beri-beri and pellagra do not currently appear to be problems in this population, these deficiencies should be guarded against. Scurvy and angular stomatitis appear to remain a problem and the approximately 3-4% of the population affected can be considered to be at high nutritional risk (category I in Table 1).

How could external agencies help? The continued, although diminished incidence of micro-nutrient deficiency disease indicates the need to carefully monitor receipts of blended foods and vegetables in camps and to assess which groups remain vulnerable to these conditions.

RNIS 11, July 1995

There have been no recent reports of any change in the satisfactory nutritional condition amongst the 87,000 Bhutanese refugees described in the previous RNIS report. There has recently been a large scale vitamin A distribution campaign for all children under 15 years of age [UNHCR-c 14/06/95].

RNIS 10, April 1995

The number of Bhutanese refugees in Nepal has continued to increase and has now reached 87,000. The main reason for leaving Bhutan was stated to be a new census conducted by the government of Bhutan since December 1994 [UNHCR 05/04/95].

The health and nutrition situation of this refugee population appears satisfactory. There are currently no children enrolled in the therapeutic feeding programme and the general health situation is reported to be improving with incidence of diarrhoea and ARI decreasing [UNHCR 05/04/95].

RNIS 9, February 1995

The situation for the Bhutanese refugees in Nepal is stable and well-controlled. The number of refugees rose slightly in December and is now just over 85,000. There are currently no plans for repatriation [IFRC 1994, UNHCR 19/01/94].

Due to a miscommunication, the last RNIS report indicated an outbreak of plague in the camps which in fact never occurred. Rather than an outbreak, plague prevention training took place [SCF, UNHCR pers.comm.].

Overall, with the improved food basket available, it can be assumed that the incidence of micronutrient deficiencies, reported on in previous RNIS bulletins, is continuing to decline and that this population is not currently at heightened nutritional risk (category IIc in Table 1).

RNIS 8, December 1994

The estimated number of Bhutanese refugees in Nepal remains at just under 85,000 [SCF 29/11/94, UNHCR 20/10/94]. The overall situation seems well controlled, with normal indicators. For instance, crude mortality rates amongst this population were recently estimated to be 0.09/10,000/day, while the under five mortality rate was 0.06/10,000/day, levels of wasting measured by screening under fives was found to be 2.9% (see Annex 1 (19a)) [SCF 29/11/94].

However, at the end of September the incidences of micronutrient deficiency diseases were 2.2/10,000/day for mild beri-beri, 0.09/10,000/day for severe beri-beri, 1.37/10,000/day with angular stomatitis, 0.005/10,000/day with pellagra, and 0.6/10,000/day with scurvy. This is a significant reduction compared to earlier in the year but a continuing cause for concern.

UNILITO (a micro-nutrient fortified blended food) is continuing to be distributed as pan of the general ration. Dried skimmed milk, which had been unavailable for supplementary feeding programmes due to lack of stock, has now arrived in the camps [UNHCR 20/10/94].

During this period an epidemic of plague occurred in the camps although the disease is now reportedly under control.

Overall, this refugee population can be considered to be at high risk of micronutrient deficiencies (category I in Table 1). With the changes made to the food basket, the tendency in the population should be one of improvement.

RNIS 7, October 1994

There are approximately 85,000 Bhutanese refugees in Nepal. General food distributions continue to be regular and have contributed to very low levels of wasting found amongst this refugee population. However, as reported in the last RNIS, complete dependence upon the general ration was causing widespread outbreaks of micro-nutrient deficiency disease.

A recent joint WFP/UNHCR/SCF mission definitively confirmed the presence of micronutrient deficiencies amongst this refugee population. Cases of scurvy, beri-beri, pellagra, angular stomatitis and goitre were noted. Over 12,000 suspected cases of beri-beri were reported. However, analysis of the food basket showed that with the current ration (which had been adjusted since February to include parboiled rice, green or yellow vegetables and a fortified blended food called UNILITO) average micro-nutrient requirements would probably be met with the possible exception of iron and vitamin B12 [WHO 9/07/94].

RNIS 6, August 1994

The number of assisted Bhutanese refugees in Nepal has remained stable at approximately 85,000 people. Food continues to be distributed regularly, and there are no reported problems with water availability [WFP 5/08/94].

In response to ongoing reports since the second half of 1993 of significant levels of micronutrient deficiencies in the camps (see RNIS #5) there was recently an assessment to confirm the presence and determine the severity of these conditions. The presence of beriberi and scurvy were confirmed during the assessment and it was agrees that the supply of fresh fruits and vegetables should continue to be pan of the ration as should a supply of micro-nutrient fortified blended foods. Further details on the mission will be available at a later date [WHO 8/07/94].

How could external agencies help? Donors should support any initiative to supply fortified blended food for the general ration while every effort to ensure the supply of fresh vegetables should continue to be made. Inter-agency coordination is improving and should greatly facilitate the on-going monitoring of the situation (i.e. quality of food basket, nutritional status etc).

RNIS 5, June 1994

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 [IFRC 24/9/92]. While small numbers of refugees continue to arrive, the major influx appears to have stopped and the current population is approximately 86,000 in eight different sites. There are also large numbers of refugees (at least 20,000 in September 1992) living with relatives and friends outside the camps [UNHCR 27/01/93, UNHCR 12/08/93, UNHCR 31/05/94].

Mortality rates and levels of wasting are currently at lower levels than those found in the local/host community. Immunization coverage is reported to be "high". The refugees regularly receive a basic ration of rice, pulses, oil, salt and sugar with a complementary ration of fresh vegetables. Apart from minor interruptions, delivery of the basic ration commodities has been consistently adequate throughout the programme. However, there are continuing logistical problems with the speed of vegetable delivery thereby reducing the micronutrient value of these commodities. Approximately 20-25 litres of water per capita are available [UNHCR 27/01/93, UNHCR 31/05/94].

Since the second half of 1993 there have been numerous reports of micronutrient deficiencies occurring. A beri-beri outbreak reached its peak in November 1993 but is now reportedly under control [SCF Jan 1994, UNHCR 9/03/94]. In January 1994 the first cases of pellagra and scurvy were noted and recent anecdotal evidence in May suggest that people mainly between the ages of 10-30 years may be affected.

In early February the overall incidence rates measured by Save the Children for the various deficiencies were as follows:

Scurvy	0.7/10,000/day
Pellagra	0.5/10,000/day
Angular Stomatitis (primary)	3.6/10,000/day
Angular Stomatitis (secondary)	3.1/10,000/day

It is unclear whether increasing reports of these deficiencies occur due to increased incidence or better surveillance and diagnosis, and there is some disagreement as to the validity of these diagnoses. Micronutrient supplements are being given to patients and a fortified food will soon be added to the food basket. Furthermore, parboiled rice has been distributed since March 1994 in the ration. It was initially reported to be poorly accepted by the refugees, but now it is well accepted. Current recommendations are to continue fresh vegetable distribution wherever possible [SCF 6/06/94, UNHCR 31/05/94, UNHCR 10/06/94].

How could external agencies help? Donors should support any initiative to supply fortified blended food for the general ration while every effort to ensure the supply of fresh vegetables should continue to be made. Inter-agency coordination is improving and should greatly facilitate the on-going monitoring of the situation (i.e. quality of food basket, nutritional status etc).