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Angela Berry-Koch, Regina Moench, Peter Hakewill, and Mohammed Dualeh
This paper describes deficiency diseases of concern among refugees since, without treatment, permanent disability or even death can result. The conditions under which refugee populations live, such as dependence on external food aid, limited purchasing power and access to local markets, limited land and wafer for agriculture or livestock maintenance, and overcrowding of refugee camps, can contribute to the development of nutritional deficiency disorders. Advantages and disadvantages of various options to prevent deficiency diseases are discussed.
Over the last ten years, an unprecedented number of cases and outbreaks of nutritional deficiency diseases (scurvy, xerophthalmia, pellagra, beriberi, and anaemia) have been documented in refugee camps [1-3]. Hundreds of thousands of refugees, particularly in arid regions of Africa, have been affected. The largest number have been within the traditional vulnerable groups: children, pregnant and lactating women, and the elderly. This has created an extensive social as well as physical cost for refugee communities.
This situation is extremely disturbing, since these nutritional deficiencies do not occur with the consumption of a moderately varied diet. The food rations distributed to the majority of refugees in Africa are currently not balanced in energy, protein, and micronutrient content. This ration, although following the recommendations for emergency food aid, contains almost no vitamin C, vitamin A, iron, or folic acid and in some situations very little thiamin, niacin, or trace minerals such as zinc. It is not surprising that, after a few months on such deficient diets, a dependent refugee population will develop nutritional deficiency diseases.
Table 1 summarizes some reports received over the past years concerning the prevalence of deficiency diseases for several countries, mostly in Africa. It should be noted that other countries, such as Zambia and Malawi, have also reported cases of scurvy, but these are not included in the table because of a lack of standard surveillance techniques. In addition, some reports are prevalence estimates made by technicians from the Office of the United Nations High Commissioner for Refugees (UNHCR) based on field observations where proper surveys (or trained surveillance workers) were not available.
Description of nutritional deficiencies
Three major deficiency diseases are of greatest concern because without treatment they can lead to permanent disability and eventually to death. These are scurvy, avitaminosis-A (xerophthalmia), and iron deficiency anaemia. In addition, concern must be expressed for folic-acid deficiency, niacin deficiency (pellagra), and thiamin deficiency (beriberi).
Vitamin-C deficiency (scurvy)
Scurvy develops when vitamin-C levels in the body are insufficient. The disease leads to widespread reduced mobility due to swollen joints (in particular the larger joints in the hips and knees), and painful haemorrhages on the bone surface, which can cause pseudoparalysis. Also, swollen and bleeding gums develop, causing loss of teeth. Internal haemorrhaging can be severe enough to cause death. Because of the synergistic role of vitamin C and iron absorption, the risk of mortality in pregnant women during delivery appears to increase in vitamin-C-deficient populations 13].
Until recently, outbreaks of scurvy had not been documented since the Irish potato famine in 1847, except among polar explorers and soldiers in isolated locations. This dramatizes the current phenomenon occurring in refugee camps. Scurvy does not develop because of a food shortage, but rather after the consumption of a vitamin-C-deficient diet . The lead time for the signs of the disease to develop when a deficient diet is consumed is between two and three months. Scurvy has been endemic in 30% of the camps in Somalia over the past five years and appears to be becoming so in camps in Ethiopia. An average of 25% of the populations in Somalia and Sudan have been affected.
TABLE 1. Summary of selected reports of nutritional deficiency diseases in refugee camps
|Disease and location||Date||Prevalence (%)||Main groups affected||Sources, and remarks|
|Scurvy Somalia||1982||-||-||Ref. 1. Outbreaks seasonal, occurring when fresh food is least available|
|total population children||UNHCR internal document. Camps installed in a very poor environment|
|Sudan||1985||22||women > 45 years||Ref. 4|
|Eastern Ethiopia||1988||1-2||-||Ref. 5|
|Xerophthalmia Sudan||1985||6.7||children||Ref. 6|
|Anaemia Somalia||1987||17.6-21.3||children; women||UNHCR internal document|
|Pellagra Zimbabwe||1988||(1 ,544)a||adults||UNHCR internal document|
|Malawi||1989||(1,169)a||adults||UNHCR internal document|
|Beriberi Thailand||1980||8||adults||US Centers for Disease Control internal document Personal communication from J. Seaman, Save the Children Fund, UK, 1987|
a. Number of cases.
Vitamin-A deficiency (xerophthalmia and keratomalacia)
Untreated vitamin-A deficiency leads to irreversible blindness and death. Growing children are at the greatest risk of developing signs of xerophthalmia because of their higher vitamin-A requirement and also because they have a higher rate of infections. A close association between even moderate vitamin-A deficiency and increased morbidity and mortality from respiratory and gastro-intestinal infections has been reported .
The lead time for the signs to develop depends on the level of vitamin A stored in the body. Refugees most often arrive in camps with low vitamin-A stores after subsisting on a deficient diet prior to and during their exodus, and during initial periods in the country of asylum. Thus, the lead time for developing xerophthalmia in refugees can be expected to be shorter than in a population that suffers vitamin-A deficiency without previous malnutrition.
Iron deficiency (anaemia)
Anaemia can have several causes, but in a refugee situation iron-deficiency anaemia has been the most frequently documented , affecting primarily childbearing women and young children. It is now widely recognized that iron deficiency is causally associated with less-than-optimal behaviour (or poor work performance) . In addition, recent studies show a possible irreversible cognitive retardation in children with severe anaemia .
Refugees are especially prone to anaemia because the food ration often lacks vitamin C and is high in plant fibre; both factors reduce iron absorption. In addition, the diet is usually lacking in the more readily available haem iron found in meat, poultry, and fish.
The lead time for developing anaemia is variable. Refugees often subsist on an iron-deficient diet long before their arrival in refugee camps, by which time their body iron stores are likely to be depleted. Women of child-bearing age who are depleted in body iron stores after numerous pregnancies are at particular risk if they consume an inadequate diet over prolonged periods of time. Moreover, refugees often have diseases such as hookworm and malaria that increase iron loss.
Folic-acid deficiency (anaemia)
This deficiency is cause by low consumption of animal products and fresh vegetables. Requirements are increased in women during pregnancy and lactation. Prolonged cooking destroys folic acid in foods and also contributes to deficiency of this nutrient, as do malabsorption syndromes. Folic-acid deficiency leads to another type of anaemia. Anaemia, whether caused by folate or iron deficiency (or a combination of both) carries serious health risks.
Niacin deficiency (pellagra)
Niacin deficiency is generally due to a lack of dietary niacin and its precursor tryptophan, an essential amino acid contained in protein of good quality . Cases and outbreaks have been observed and reported in 1988-1989 in refugee camps in Ethiopia, Malawi, Zimbabwe, and other African countries. Pellagra occurs where maize, which is low in both niacin and tryptophan, has been the primary relief grain and where little complementary food rich in protein has been given. Even though the distributed general ration has included beans as a protein source, the quality has often been so poor that excessive cooking has been necessary (e.g. up to eight hours) to make the beans edible. Often the beans cannot be used because fuel shortages preclude such long cooking times. When a niacin- and/or tryptophan-deficient diet is consumed, the lead time for developing the signs of pellagra is about two to three months. Cases of pellagra were reported among refugees in Zimbabwe, Swaziland, Malawi, and Zaire in 1989.
Thiamin deficiency (beriberi)
Thiamin deficiency can occur where the diet consists mainly of white (milled) cereals, including polished rice, and starchy staple foods such as cassava and tubers. There are three forms of beriberi: dry, wet, and infantile. Various forms of beriberi induce cardiovascular symptoms and cause peripheral nerve paralysis. The disease can lead rapidly to heart failure in infants. Beriberi can develop within 12 weeks of a deficient intake. Outbreaks of all three types of beriberi have been reported in camps in South-East Asia, although no formal surveys have been conducted except in Thailand.
Risk factors for refugee populations
The majority of refugee populations live under difficult conditions that contribute to the development of nutritional deficiency diseases. These can be summarized as follows:
Options to prevent deficiency diseases
Different options to provide the nutrients lacking in the diet are possible. These include distributing tablets, distributing fresh foods, monetization of relief foods, and fortifying food items with the lacking nutrients . Growing fresh foods and raising livestock here possible are the optimal and obvious long-term solutions to the problem. In addition, certain food processing techniques, such as germination of pulses or beans, will increase the vitamin-C content of these foods. These techniques are not analysed in this paper because it is assumed that micronutrients in addition to vitamin C are required and that all of them need to be provided in the general ration. Also, lack of land and water precludes growing complementary foods, and the frequent arrival of new refugee populations does not allow time for cultivating food crops.
Tablet distribution refers to the mass prophylaxis of total populations with vitamin and mineral supplements, through either the health care or the food distribution system.
Distribution of fresh foods
Distribution of fresh foods is the ideal solution but has rarely been implemented among affected populations in Africa.
Monetization refers to the allocation of surplus foods to refugee programmes so that the food may be either sold or exchanged to provide other fresh foods. This may be done on a central level-e.g. by allowing the World Food Programme (WFP) or the UNHCR to sell surplus food to host governments in exchange either for cash to procure fresh foods or for fresh foods. Or it may be done on the individual level by increasing the food ration (e.g. by giving 600 grams of cereal per person per day instead of 400 grams) and allowing the refugees to trade their surplus food at the camp level in local markets in exchange for fresh foods.
Fortification of food
The purpose of fortification is to add specific nutrients to the refugee diet in order to prevent and/or treat deficiency diseases. In the past five years this has occasionally been accomplished through providing fortified cereal blends (e.g. corn-soya milk. "CSM," or corn-soya blend, "CSB") in the general ration, though they are normally reserved for targeted supplementary-feeding programmes. However, such blended foods are about twice as expensive as the plain milled cereals normally distributed in general rations. It could be argued, therefore, that a manufacturer should incorporate the vitamin/mineral mix used in CSM in cereal flour during milling or in some other food to produce a far less costly but adequately fortified food-aid item.
Before a fortification programme could be undertaken, however, a number of essential questions would need to be addressed. Some of these are discussed below, following the lists of specific advantages and disadvantages.
Among the unanswered questions regarding such fortification are these: What food vehicle should be fortified? What nutrients and what levels of nutrients are required to ensure sufficient levels after processing, transport, and cooking? What would the cost of fortification (of, for example, wheat flour) be to the UNHCR, the WFP, and donors? Should fortification occur at the local (country or camp) level, or be done centrally by donors/manufacturers? What amounts of a fortified food would be required, and for which programmes?
If the possibility of fortification is seriously considered, the answers to these and other related questions will need to be addressed through a co-operative effort by the UNHCR, the WFP, nutritionists, food scientists, and policy makers among major donors of emergency food aid and other implementing partners.
The following are some considerations relating to these questions.
Which food(s) to fortify. Cereal flour has been proposed as the most practical food to be fortified for all nutrients except vitamin C. Although research is needed on the technology, such an item as sugar might be a more stable vehicle for vitamin-C fortification because of its inert nature and the fact that it is likely to be cooked for a shorter period than cereals. Adequate prevention for all major deficiency states therefore might require two fortified food items, perhaps with commitment from separate donors.
What nutrients and what levels of fortification. The answer to this question should be based on the recommendation of an expert committee of nutritionists and food technologists. A tentative proposal would be to add the following nutrients per 100 grams of the food vehicle:
The cost of fortification (relative to the cost of other interventions). Key food donors should investigate the cost of fortification of various food items and make a comparison with other interventions such as the purchase of fresh foods, monetization, etc. The comparison should include analysis of logistical and personnel/time costs.
Central or country-level fortification. Country-level fortification is feasible only if the manufacturing process is possible. This is not likely to be the case during the first months of a refugee influx, as time is required to set up such a process. In addition, diverting certain food-aid supplies for processing may introduce the possibility of food losses unless there is strict monitoring. Finally, in most of the countries where the majority of the affected refugee populations reside (Ethiopia, Malawi, Somalia, Sudan, Uganda, Zambia) the technology does not exist for quality control of food processing. Hence, fortification at the donor level prior to shipment is likely to be required.
The amount of fortified foods required. Given the current situation and affected populations, it is likely that some two million refugees in Africa would need fortified cereal flour in their diets. This suggests that some 360,000 metric tons would be required per year. There would have to be an updated assessment before concrete decisions regarding the amounts needed could be made.
All the available options have various advantages and disadvantages that invariably strengthen or weaken their feasibility in defferent refugee situations.
Certain options are restricted to situations where growing or purchasing sufficient quantities of fresh food (vegetables and meat) is possible. For central procurement, logistical systems must be adequate. As mentioned, this is the case for most countries in South-East Asia and Central America, but neither the UNHCR nor the WFP has to date been able to procure sufficient amounts or provide logistical systems for the delivery of fresh food in African refugee programmes.
Mass distribution of tablets is acceptable only for some micronutrients (e.g. B vitamins and vitamin C). The provision of acceptable daily doses of vitamin A and iron presents logistical difficulties because over-dosage must be avoided. Vitamin A can be given in a large parenteral or oral dose at four- to six-month intervals. Iron, however, must not be given in large doses to malnourished individuals .
Monetization is an intervention that has some potential for the general improvement of food and diet, but further trial and exploration is needed to define the conditions under which either central or local monetization would function satisfactorily.
Fortification presents a bureaucratically complex option, but one that perhaps offers the greatest potential for a systematic attack on the problem. The most obvious means of preventing and treating deficiency diseases is to provide food containing the missing micronutrients. Fortification is one convenient means of accomplishing this.
All the options will require greater scrutiny and more accurate cost comparison. This, in turn, will require a collaborative effort, perhaps in the form of an interagency task force to formulate pilot projects of the most practical options. It is proposed, for example, that Malawi could be the setting for a trial of monetization. Ethiopia could serve as a situation where the potential benefits of fortification could be addressed. Depending on the results of such trials, options could be expanded to cater quickly to total refugee populations faced with unvaried and unbalanced food rations and their consequent risks.
The authors wish to thank the many persons and agencies who contributed to this article, which stems primarily from a UNHCR Technical Support Service discussion paper of September 1989. Special thanks for comments, editing, and contributions are owed to Dr. Philip Nieburg of the Centers for Disease Control in Atlanta, Georgia, USA, and Ms. Susan Peel Morris. In addition, valuable data were contributed by Médecins sans frontières/France and other non government agencies serving refugees worldwide.
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