The UN ACC/SCN1 (Sub-Committee on Nutrition), which is the focal point for harmonizing policies in nutrition in the UN system, issues these reports on the nutrition of refugees and displaced people with the intention of raising awareness and facilitating action to improve the situation. This system was started on the recommendation of the SCN's working group on Nutrition of Refugees and Displaced People, by the SCN in February 1993. This is the sixteenth of a regular series of reports. Based on suggestions made by the working group and the results of a survey of RNIS readers, the Reports on the Nutrition Situation of Refugees and Displaced People will be published every three months, with updates where information is available every six weeks. The box above gives further details.
1 ACC/SCN, c/o World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.Information is obtained from a wide range of collaborating agencies, both UN and NGO (see list of sources at end of report). The overall picture gives context and information which separate reports cannot provide by themselves. The information available is mainly about nutrition, health, and survival in refugee and displaced populations. It is organized by situation because problems often cross national boundaries. We aim to cover internally displaced populations as well as refugees. Partly this is because the system is aimed at the most nutritionally vulnerable people in the world - those forced to migrate - and the problems of those displaced may be similar whether or not they cross national boundaries. Definitions used are given in the box on the next page.
Telephone: (41-22) 791 04 56, Fax: (41-22) 798 88 91, EMail: ACCSCN@WHO.CH.
At the end of most of the situation descriptions, there is a section entitled How could external agencies help?. This is included when there is enough information on current needs and opportunities, and when there is a substantial risk to nutrition.
The tables, and figures at the end of the report can provide a quick overview. Table 1 gives an estimate of the probable total refugee/displaced/returnee population, broken down by risk category. Populations in category I in Table 1 are currently in a critical situation, based on nutritional survey data. These populations have one or more indicators showing a serious problem. Populations at high risk (category IIa in Table 1) of experiencing nutritional health crises are generally identified either on the basis of indicators where these are approaching crisis levels and/or also on more subjective or anecdotal information often where security and logistical circumstances prevent rigorous data collection. Populations at moderate risk (category IIb in Table 1) are potentially vulnerable, for example based on security and logistical circumstances, total dependency on food aid, etc. Populations in category IIc are not known to be at particular risk. In Table 2, refugee and displaced populations are classified by country of origin and country of asylum. Internally displaced populations are identified along the diagonal line. Figure 1 shows the data in Table 1 as a current snapshot of population numbers and estimated risk. Figure 2 shows trends over time in total numbers and risk categories for Africa. Figure 3 shows the same data for specific situations. Annex I summarizes the survey results used in the report.
Wasting is defined as less than -2SDs, or sometimes 80%, wt/ht by NCHS standards, usually in children of 6-59 months. For guidance in interpretation, prevalences of around 5-10% are usual in African populations in non-drought periods. We have taken more than 20% prevalence of wasting as undoubtedly high and indicating a serious situation; more than 40% is a severe crisis. Severe wasting can be defined as below -3SDs (or about 70%). Any significant prevalence of severe wasting is unusual and indicates heightened risk. (When wasting and severe wasting are reported in the text, wasting includes severe - e.g. total percent less than -2SDs, not percent between -2SDs and -3SDs.) Data from 1993/4 shows that the most efficient predictor of elevated mortality is a cut off of 15% wasting (ACC/SCN, 1994, p81). Equivalent cut-offs to -2SDs and -3SDs of wt/ht for arm circumference are about 12.0 to 12.5 cms, and 11.0 to 11.5 cms, depending on age.
Oedema is the key clinical sign of kwashiorkor, a severe form of protein-energy malnutrition, carrying a very high mortality risk in young children. It should be diagnosed as pitting oedema, usually on the upper surface of the foot. Where oedema is noted in the text, it means kwashiorkor. Any prevalence detected is cause for concern.
A crude mortality rate in a normal population in a developed or developing country is around 10/1,000/year which is equivalent to 0.27/10,000/day (or 8/10,000/month). Mortality rates are given here as times normal, i.e. as multiple of 0.27/10,000/day. [CDC has proposed that above 1/10,000/day is a very serious situation and above 2/10,000/day is an emergency out of control.] Under-five mortality rates (U5MR) are increasingly reported. The average U5MR for Sub-Saharan Africa is 181/1,000 live births, equivalent to 1.2/10,000 children/day and for South Asia the U5MR is 0.8/10,000/day (in 1992, see UNICEF, 1994, p.84).
Food distributed is usually estimated as dietary energy made available, as an average figure in kcals/person/day. This divides the total food energy distributed by population irrespective of age/gender (kcals being derived from known composition of foods); note that this population estimate is often very uncertain. The adequacy of this average figure can be roughly assessed by comparison with the calculated average requirement for the population (although this ignores maldistribution), itself determined by four parameters: demographic composition, activity level to be supported, body weights of the population, and environmental temperature; an allowance for regaining body weight lost by prior malnutrition is sometimes included. Formulae and software given by James and Schofield (1990) allow calculation by these parameters, and results (Schofield and Mason, 1994) provide some guidance for interpreting adequacy of rations reported here. For a healthy population with a demographic composition typical of Africa, under normal nutritional conditions, and environmental temperature of 20°C, the average requirement is estimated as 1,950-2,210 kcals/person/day for light activity (1.55 BMR). Raised mortality is observed to be associated with kcal availability of less than 1500 kcals/person/day (ACC/SCN, 1994, p81).
Indicators and cut-offs indicating serious problems are levels of wasting above 20%, crude mortality rates in excess of 1/10,000/day (about four times normal - especially if still rising), and/or significant levels of micronutrient deficiency disease. Food rations significantly less than the average requirements as described above for a population wholly dependent on food aid would also indicate an emergency.
James W.P.T. and Schofield C. (1990) Human Energy Requirements. FAO/OUP.
Schofield C. and Mason J. (1994) Evaluating Energy Adequacy of Rations Provided to Refugees and Displaced Persons. Paper prepared for Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa, Machakos, Kenya, 5-7 December 1994. ACC/SCN, Geneva.
ACC/SCN (1994) Update on the Nutrition Situation, 1994 (p81).
UNICEF (1994) State of the World's Children p.82.
UNICEF, New York