Persistent Micronutrient Problems among Refugees in Nepal
by Janack Upadhyay
This article describes
nutritional aspect of emergency food aid in Bhutanese refugee camps in
Nepal; the author was regional Food & Nutrition co-ordinator
for Asia before the current assignment. - Head, Food & Statistical
Unit, Programme co-ordination section, DOS, UNHCR, Geneva
first exodus of ethnic Nepali asylum seekers who arrived from Bhutan in
early 1991 started making their makeshift huts on the bank of river Kankai
Mai in Jhapa district. The malnutrition rate was reported to be more than
20 % (Weight for Height Median <80%). The situation was quickly brought
under control (malnutrition rate <10%) by providing food such
as rice, dal (split beans), oil, salt and sugar; shifting the refugees
to organised camp sites and providing medical services.
With the help of the government
of Nepal, UNHCR is currently managing some 90,000 Bhutanese refugees who
are residing in eight camps in the districts of Jhapa and Morang in south-eastern
Nepal. The WFP provides all the food commodities except vegetables which
are provided by the UNHCR. All the food as well as non-food items are distributed
by the Nepal Red Cross Society (NRCS). Water and sanitation conditions
as well as health delivery systems in the camps are considered to be better
than other refugee camps in the developing world. Although the camps are
'open camps' Jhapa district is one of the most densely populated parts
of Nepal so there are very few income earning opportunities for the refugees.
The food basket at the outset
of the programme consisted of polished rice 430g, dal 60g, oil 25g,
salt 5g, sugar 20g and fresh vegetables 100g per person/perday. This
ration was adequate in terms of calories and protein and as a consequence
levels of wasting declined to 5%
Despite the regular supply
of these food commodities and well managed water, health and sanitation
services in the camps, cases of beriberi were reported in September 1993.
Following these reports SCF established surveillance of micro-nutrient
deficiency disorders. Within a short time cases of pellagra and scurvy
were also reported. There was some concern about possible over-reporting
of beri-beri particularly amongst those over 75 years of age who complained
of joint pains. Beri-beri normally affects the most active members of a
population who consume large amounts of carbohydrate. Thiamin is essential
to the metabolic utilisation of carbohydrates. However, many patients,
including the elderly responded to thiamin injections. Investigating teams
identified several factors which were likely to result in MDD
in the camps. Some of these were as follows:
- Consumption of polished
rice: Bhutanese refugees are basically polished rice eaters. In view of
their food habits polished rice was supplied in the general ration. However,
polished rice contains far less thiamin than parboiled rice.
- Freshness of vegetables:
although UNHCR was trying its level best to ensure the provision of fresh
vegetables, this was very difficult logistically given the perishable
nature of vegetables. Thus, the vegetables provided by UNHCR often had
depleted micronutrient levels. Moreover, when vegetables needed to be supplied
in bulk it proved impossible to provide a variety of commodities.
- Unfavourable exchange
rates for general ration commodities: the basic diet of Bhutanese
refugees is rice, dal, and vegetables with the occasional addition of meat
and milk products. The refugees still wanted to consume meat at least
once a week and milk (especially in the form of yoghurt) once or
twice a week. However, these products were relatively expensive as
energy and protein sources compared to the market value of the general
ration commodities so that the caloric and protein content of the refugee
food basket decreased if refugees exchanged general ration commodities
for these other items. This increased the refugees dependence on
the supplied general ration which on its own was deficient in key micronutrients.
Furthermore, there were restrictions on ration trading by the local authorities
and UNHCR. This was due to the local opposition amongst traders who feared
that their markets would be undercut. Some trading did occur but this was
mainly in the form of direct exchange of food commodities.
There was speculation that
consumption of rice beer could be an underlying cause of MDD. However,
Bhutanese refugees are of Nepali origin and they are a mixture of various
ethnic backgrounds such as strict Brahmins who never drink alcohol. Furthermore
the majority of women do not drink alcohol. Since the disease was affecting
everyone, alcohol consumption as an underlying factor was ruled out.
The Food Basket
After the emergence of MDD
the general food basket was modified to include micronutrient enriched
blended food at the rate of 40 g per capita and polished rice was replaced
by parboiled rice. Initially the fortified blended food was imported wheat
soy blend but this was later substituted with locally manufactured Unilito
(June 1994). Radish in the vegetable ration was substituted with green/yellow
leafy vegetables. Other commodities in the basket were kept unchanged.
The current food basket is now adequate in terms of all the nutrients except
for calcium, riboflavin (B2) and Vitamin A.
Although rich in thiamin,
parboiled rice is not favoured. Nutrition education intended to convince
them to consume parboiled rice was therefore necessary and crucial. The
evidence of beri-beri and the employment of a competent nutritionist to
give nutritional advice appeared very effective in changing dietary practices
amongst the refugees. Now most of the refugees consume parboiled rice.
However a few exchange the parboiled rice for with polished rice
especially to feed children and the sick, as polished rice is softer than
Blended Food (BF)
When BF was added to the
basic ration refugees viewed it as food for the sick and not to be
consumed by the general population. A campaign to popularise blended
food was carried out by SCF and UNHCR. In a situation like this where the
general food basket cannot guarantee adequacy of micronutrient intake,
addition of blended foods to the general ration is one of the best
strategies to prevent MDD. It was observed that people started consuming
BF in the form of porridge (halwa) and by putting it in morning tea.
the whole period no infantile beriberi was reported. The incidence of beri-beri
has gone down from 0.55/10,000 population/day in January 1994 to 0.03/10,000
population/day in March 1996.
Scurvy: Scurvy incidence
has been reported as highest in April 1994 (2.53/10,000/day) declining
to 0.22/10,000/ day in March 1996. These results should be interpreted
with the knowledge that scurvy symptoms can be confused with gingivitis
and lack of oral hygiene.
is usually associated with a maize diet as the niacin is not in a readily
available form. The outbreak in these camps is therefore unusual.
However, the incidence has now declined from a high of 0.57/10,000/day
in March 1994 to zero in January 1995. There have been no reported
cases since then.
It can be seen from
the surveillance data obtained by SCF (UK) that the incidence of
beriberi and scurvy has gone down significantly while pellagra is
eliminated. This is most probably due to the combined effort of active
case finding and management by SCF and adjustment of the food basket by
replacing polished rice with parboiled rice, addition of blended
food to the general ration and continued provision of green
or yellow leafy vegetables in the vegetable ration by WFP/UNHCR. However,
it is worth noting here that despite all these efforts beriberi and scurvy,
although at a low level, still persist in the camps. This really
requires careful investigation to find the root cause of the problem. The
most recent household food economy assessment by SCF in May 1997 made the
following points about the continuing low incidence of MDD.
- Without biochemical cross-checking of clinical diagnosis it is impossible
to verify the incidence levels of these conditions or to comment on possible
- Although many nutrients
are now supplied in adequate quantities, there are important exceptions;
most striking are the very low supplies of calcium and riboflavin which
affect all sectors of the population.
- Intra-household distribution
of food may partly explain residual levels of MDD. Previous surveys have
shown that women and children receive less than their allowance of the
general ration and men get more.
- Storage and cooking practices
may also affect the levels of micronutrient retained within food stuffs.
In particular, prolonged boiling of vegetables could severely cut the content
of water soluble vitamins in this produce.
Due consideration should
always be given to the food habits of refugees in planning
the food basket. However, if the range of commodities which
are normally consumed in their country of origin are
not included in the basket, there may be a risk of MDD. For example,
consumption of polished rice and unavailability of fresh green vegetables
and milk products precipitated micronutrient deficiency among Bhutanese
refugees in Nepal. Caloric adequacy of the general ration does not
automatically mean that the ration is adequate for all types of nutrient
required by the human body. Due consideration should always be given to
micronutrients in planning the emergency food basket.
In an emergency situation
where access to a variety of micronutrients containing food commodities
is not feasible, incorporation of fortified blended food into the
general ration should be mandatory. Given the time between international
procurement and delivery that often occurs, local production of blended
foods should be encouraged wherever possible. In fact, in Jhapa when
WFP/UNHCR decided to add blended food to the general ration, locally produced
BF was available. Where MDD persists in spite of improvements made to the
general ration, which should theoretically eradicate these deficiency diseases,
other factors should be investigated and acted upon. Factors which might
be considered include inequitable intra-household distribution of general
rations and storage and cooking practices which reduce micronutrient content
of the foods.
Taken from Field Exchange Issue 5, October 1998