|Emergency Supplementary Feeding Programmes - Good Practice Review 2 (ODI, 1995, 122 p.)|
|6. Typical Scenarios|
The early stages of a refugee or internal displacement crisis, when large numbers of refugees or internally displaced people arrive at a camp location seeking assistance, are usually the most difficult for the aid agency community. Often, but not always, such migrants arrive in a weakened state and the scale of the problem completely overwhelms international resources. The situation for these individuals often deteriorates before it improves. In the initial stages of this type of emergency, adequate general rations may not be established for several weeks. Furthermore, camps may be overcrowded, with poor sanitation facilities, limited availability of water, absence of health-care infrastructure and shortage of drugs. In such a situation quick decisions may need to be taken about operating an emergency SFP which does not conform to many aspects of current guidelines. Thus, a large-scale preventive SFP may be advisable, if resources allow, to include all children under the age of five. The early establishment of a SFP in the absence of adequate general rations may also be justifiable on the grounds that data on numbers admitted to the programme, re-admissions and the performance of those on the programme can be used to press for more urgent provision of an adequate general ration (Annex 2).
Examples of rapid deterioration in the nutritional status of recently arrived refugee populations: Bangladesh and Ethiopia
There are numerous examples of refugee populations arriving in a relatively good nutritional state but within a short period of time experiencing near-famine conditions. Recent well-documented examples can be found in Cox's Bazaar in Bangladesh where between the end of 1991 and June 1992 approximately 250,000 refugees from Mynamar and Rhakine state in India arrived. The population was distributed between 15 camps in Cox's Bazaar District which is a disaster-prone area with regular flooding and occasional cyclones. Within a short period of time (six months), the population was experiencing a nutritional and health crisis due in part to an inadequate international food aid response and also to poor sanitary conditions in the camps. By June 1992 levels of malnutrition in excess of 25% were seen in several camps with high levels of vitamin A and vitamin B2 deficiency.
Another well documented example of a population arriving in relatively good condition but deteriorating rapidly was seen in Hartisheik refugee camp in South-East Ethiopia in 1989. Here over 100,000 Somali refugees from a relatively affluent section of northern Somali society experienced levels of malnutrition in excess of 30% after several months in the camps. Average malnutrition rates on arrival were only 8%.
Programmes may also need to be established where there are severe water and sanitation difficulties, even though overall food availability is adequate. The effects of poor sanitation, rather than lack of food, on nutritional status in the early stages of a refugee emergency have recently been witnessed in Tanzania and Zaire, where Rwandan refugees have experienced appallingly high rates of cholera and dysentery leading to high levels of malnutrition and mortality. Some estimates are that the peak mortality rate caused by the epidemic in Zaire was between 100 and 180 times the normal, which is the highest ever recorded in the early stages of a refugee crisis.
Normal types of data collection for monitoring and evaluation may in some cases have to be waived due to lack of weighing equipment and trained staff. Data collection can be introduced gradually by prioritising the information which is most critical: for example, weighing and monitoring severely malnourished individuals in therapeutic feeding and subsequently those in the SFP, but compiling data on attendance and coverage only at a later stage.
In some situations it may also be most appropriate to opt initially for an on-site feeding programme. For example, where measles immunisation rates are low or there is a significant (epidemic) level of disease caused by poor sanitation or the threat of epidemic, and there is little primary health-care infrastructure in the camp and therefore no outreach, on-site SFPs may provide the best available opportunity to tackle health problems or risks rapidly. Clearly, in such circumstances those with conditions such as measles would have to be isolated in special 'measles units' and away from children attending the SFP who had not contracted the disease. Also, in situations where there are large numbers of severely malnourished individuals but not sufficient facilities for adequate therapeutic feeding, on-site programmes can provide a 'reservoir' for the severely malnourished which allows such cases to be more closely monitored. However, these advantages have to be carefully weighed against the increased risk of cross-infection in on-site programmes, which in turn will be determined by the degree of crowding at feeding centres, hygienic practices and levels of aeration (Annex 3).
In the early stages of an acute refugee or internal displacement camp emergency the definition of the target group may also need to be expanded to include others apart from children under five and pregnant and lactating women. In a situation where the population has been on the move for a long period during which they have received little assistance, or the population is fleeing a long-term environment of poor food security due to drought or conflict, then many different groups may be malnourished. The old and infirm are particularly vulnerable in transit, although adolescents and adults may also comprise a predominant group of malnourished individuals particularly where there has already been high mortality amongst young children and the old.
Epidemics may also dictate the choice of target groups. Outbreaks of diseases such as shigella (a form of dysentery), which fares particularly well in overcrowded and poorly planned camps, can rapidly cause malnutrition in all affected age groups but particularly the young and the old. Mortality rates can rise quickly as opportunistic infections attack those with compromised immunity because of malnutrition. Some agencies have recently established emergency SFPs for all individuals suffering from shigella (Annex 4).