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Public health nutrition

Alleviation of nutritional deficiency diseases in refugees

Angela Berry-Koch, Regina Moench, Peter Hakewill, and Mohammed Dualeh

Abstract

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.

Introduction

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 [7]. 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

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 [8].

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 [9], 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) [10]. In addition, recent studies show a possible irreversible cognitive retardation in children with severe anaemia [11].

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 [12]. 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:

1. Nearly eight million refugees residing in camps and settlements in 1989 depended almost entirely on distributed food rations. In the last decade' such populations have depended on external food aid for an increasingly longer time. Where this ration contains mainly cereals, beans, and oil (as is the case for an estimated 60% of refugee populations, primarily in Africa), this will eventually lead to nutrient deficiencies. This is especially true in the first year of an emergency when there is insufficient time to establish vegetable gardens and market activity is limited in isolated areas.
2. Not all refugees have access to a local market or have the necessary purchasing power to buy fresh food such as fruits and vegetables or animal products. There is evidence that, where surplus food is given, refugees can trade for other food commodities if markets are available. Nutritional deficiency diseases are thereby reduced.
3. The possibility of growing vegetables or maintaining livestock is often limited for refugees because adequate land and water are scarce. This is the case for more than two million refugees in Africa.
4. Camps are often overcrowded and diseases spread quickly in such conditions' thereby increasing nutrient requirements, especially for vitamins A and C. Infections reduce appetite, lead to the withholding of food, increased external and internal metabolic losses, and frequently decreased intestinal absorption of nutrients. In addition, refugees without sufficient clothing and shelter can be exposed to cold stress, which further increases their energy requirements and hence their requirements for micronutrients (vitamins and minerals).

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 [13]. 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

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.

Advantages

1. Supplementation is very specific for treatment, and, if one nutrient deficiency is not compounded by another, the treatment should correct the disease state.
2. A politically visible form of assistance is maintained.
3. The actual cost of many vitamins, especially vitamin C, is quite low relative to that of other relief items such as medicines and food.

Disadvantages

1. Not all nutrients or minerals can be distributed in tablet form, because overdosing can have dangerous adverse effects. This is especially true in the case of iron, overdoses of which can lead to death from overwhelming infection in severely iron-deficient individuals [11]: Iron-deficient individuals are extremely susceptible to infections, and in their depleted state a sudden influx of therapeutic iron may provide optimum conditions for replication by the infectious agent and overwhelm the host's resistance to an infection that would otherwise not have been fatal. These restrictions do not apply to iron and vitamin A given in usual daily doses. In addition, massive doses of vitamin A cannot be given to pregnant women. Currently UNHCR policy is to give vitamin A to all children under five years old through mass distribution, but this procedure cannot be extended to adult women or girls because of the potential danger of toxicity to the foetus if they should be pregnant.
2. Some vitamins need to be distributed frequently because they are not adequately stored in the body. This is especially true for vitamin C.
3. Mass distribution is not easy logistically. For example, during an outbreak of scurvy in a large population (among 300,000 refugees in eastern Sudan in 1985), as many as three million vitamin-C tablets were required per month. Procurement of such quantities from standard commercial pharmaceutical companies is difficult, and urgent air shipment of consignments is often logistically difficult and expensive.
4. Trained personnel are needed to distribute tablets to ensure compliance and to avoid danger of toxicity from overuse of iron and vitamin A. However, outreach personnel are most often urgently required for other essential work, such as immunization, oral rehydration, and epidemic control, and tablet distributions can interfere with these other life-saving activities.
5. An individual who misses one distribution may have to wait some time for another (e.g. four to six months for vitamin A). Newly arriving refugees may appear just after a tablet distribution and hence be at risk of deficiency before the next campaign.
6. Compliance is not ensured among traditional populations who are unfamiliar with tablets and may view them with suspicion. Non-compliance renders the activity cost-inefficient.

Distribution of fresh foods

Distribution of fresh foods is the ideal solution but has rarely been implemented among affected populations in Africa.

Advantages

1. Procurement of local fresh foods allows the refugees to maintain a normal diet, with greater similarity to their previous consumption patterns.
2. Many trace minerals (in addition to zinc) are available in fresh foods, and these may have a synergistic role with other missing nutrients.
3. Local procurement of fresh vegetables, fruits, and animal products may stimulate production among nationals and provide economic support for areas surrounding refugee camps or settlements.

Disadvantages

1. From previous experience, distribution of fresh foods to large numbers of refugees is most often not possible (except in Central America and South-East Asia) because refugee camps are often located in remote areas, and perishable foods are subject to spoilage during transportation.
2. To purchase sufficient quantities for large refugee populations on the local market, particularly in Africa, has proved very difficult and expensive in the past. This was the case for citrus procurement in Somalia, where logistical difficulties prohibited such activities. During droughts or low-production seasons, the supplies on local markets may be unreliable. The cost of procurement and logistical/transport support is often prohibitive when distribution of fresh foods is required on a regular basis for millions of persons (e.g. approximately two million refugees in Pakistan, 800,000 in Malawi, and one million in the Horn of Africa). In addition, increased monitoring and administrative staff may be required.
3. Large-scale procurement can often create shortages and increased prices on the local market to the possible detriment of local national consumers.
4. Regular distribution is essential if fresh food is intended to supply vitamin C; logistical problems that create delayed distribution can render the entire project useless and waste precious resources.

Monetization

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.

Advantages

1. Offering surplus foods would be the most convenient option for donors, as it would not mean any change in bureaucratic procedures.
2. Central monetization and trade schemes may help host governments to meet their own food shortages without having to spend hard currency.
3. Individual monetization would allow refugees the option of trading for a more varied diet, as well as possibly increase economic opportunities for them to meet other essential needs.

Disadvantages

1. With large and rapid influxes of refugees there is not likely to be time or immediate surplus of food to allow monetization before deficiency diseases appear (e.g. within less than two to three months after arrival).
2. Central monetization would increase the management staff requirements of both the WFP and the UNHCR, and the problems related to procurement of fresh foods would still apply.
3. Individual monetization would depend on markets being available to refugee populations, which is often not the case in remote areas or at the beginning stages of an emergency.
4. It is likely that the value of the food aid traded (the "alpha factor") would be reduced substantially by the time refugees traded it at the local level.
5. Increased local trading may disrupt food prices (e.g. lower them) in areas surrounding the camp/ settlement to the detriment of local producers.

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.

Advantages

1. Fortified commodities could be kept as contingency stocks for immediate mobilization when required. Their arrival in emergencies (within four months) would be within the lead time after which most deficiency diseases emerge.
2. The actual cost of nutrients (e.g. vitamin/ mineral powder) used in fortification during normal milling or processing activities is negligible, and the technology already exists except for vitamin C.
3. Provision of certain nutrients at the same time (in the same food) would protect their synergistic mechanisms and enhance the utilization of certain vitamins and minerals.
4. Provision of the nutrients through the regular food-supply-distribution system would reduce additional logistical costs.
5. The efficacy of fortification to prevent certain nutrient-deficiency-disease states has been proved [13; 14].

Disadvantages

1. If milled cereals (e.g. wheat flour, maize meal, and ground sorghum) are used, the shelf life of such cereals may be reduced. (Note: No reference regarding the exact reduction of shelf life for milled versus unmilled cereals was located to verify this premise.)
2. Specifically for vitamin C and folate, baking of cereal flour destroys most of the vitamins. Other nutrients, being more stable, would exhibit smaller reductions.
3. Donor agencies would need to organize a logistically separate system for certain stocks of emergency versus normal food aid in order to ensure that some emergency food aid is fortified.
4. Enhanced co-ordination of food aid would be required among the UNHCR. the WFP, and donors to ensure that populations at risk receive fortified products.

Other considerations

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:

• vitamin A, 1,200 IU,
• vitamin C, 150 mg,
• vitamin B₁, 1.3 mg,
• vitamin B₁₂, 1 m g,
• niacin, 15 mg,
• folate, 100 m g,
• calcium, 300 mg,
• iron, 20 mg,
• zinc, 0.8 mg.

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.

Discussion

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 [11].

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.

Acknowledgements

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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