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Part III. Disorders of malnutrition

Part III. Disorders of malnutrition

Chapter 24. Famine, starvation and refugees

Famines are usually considered to be severe shortages of food often affecting either a large geographic area or a significant number of people. The consequence is often death from starvation in groups of the population, preceded by severe undernutrition or malnutrition. Starvation is a pathological condition in which lack of food consumption threatens, or causes, death. Refugees are persons who have been displaced from their normal homes across borders into other countries; displaced persons are those who have moved from their homes but still remain within the borders of their own country. These three conditions are described in this chapter because they are closely related.

There is very extensive literature, both historic and more recent, on famines, their causes, how they were dealt with and their consequences. In many of the publications starvation as a form of malnutrition is described, although this topic has not been very well studied. Fewer books describe refugee problems in detail or provide a complete picture of a particular refugee situation. However, there are millions of pages of reports on refugees. Many of these have been provided to or produced by the Office of the United Nations High Commissioner for Refugees (UNHCR) or the World Food Programme (WFP), two organizations much involved in refugee relief. Other literature, some of it very poignant, has been produced by numerous non-governmental organizations (NGOs) that work with refugees.

This book can only outline the important aspects of famine and refugees. Readers wanting more information are advised to consult other publications, a few of which are listed in the Bibliography.


Humans may die of extreme cold after six to 12 hours of exposure; of thirst after a few days if they consume no water or fluids; but of hunger only after a few weeks if they are in normal health when they are first deprived of food.

A healthy man weighing 70 kg has about 15 kg of adipose tissue or fat. This fat is his main usable store of energy which is used when he is in negative energy balance, when he receives inadequate food or when he is starving. The 15 kg of fat would theoretically yield approximately 135 000 kcal. This would not be exactly the amount of energy that a starving man would obtain from his fat; however, 15 kg of fat could provide about 1350 kcal per day for 100 days, or 2 700 kcal per day for 50 days. Starving individuals can also bum up some protein, mainly from their muscles.

The average weight of an Asian or African man might be 55 kg rather than 70 kg, and that of a woman perhaps 45 kg, so their energy stores from fat and muscle might be considerably lower. It should also be appreciated that many persons who as a result of famine or displacement are threatened with starvation may be poor persons who prior to the crisis were not well nourished, were relatively thin and had only modest deposits of body fat. In these situations it is young children who may be the most vulnerable, in part because they may already be malnourished but also because they have relatively greater nutritional needs than adults because they are growing. However, young children are often protected as much as possible by their families. Another vulnerable group may be women of childbearing age, who have increased nutrient needs because of pregnancy, lactation or menstruation. Old people, although they have somewhat lower energy needs than young people, may also be particularly vulnerable to starvation, in part because they cannot compete well for food or for social reasons have poorer access to food.

The classic images of starvation for most people are the emaciated, severely undernourished adults released from concentration camps in Germany at the end of the Second World War and more recently the starving children in Bosnia, Rwanda or Somalia. A condition almost identical with the starvation that results from famine is the serious wasting of the body that results from acquired immuno-deficiency syndrome (AIDS), tuberculosis, cancer, anorexia nervosa and some other diseases. This chapter considers starvation in groups of individuals caused by lack of availability of food. In such circumstances the degree of undernutrition ranges widely, from mild to fatal. A healthy adult can afford to lose one-quarter or a little more of his or her body weight, or can lose weight until the body mass index (BMI) (see Chapter 23) reaches 16. If much more is lost the person becomes ill and life may be threatened.

For example, an average adult African male weighing 55 kg may be forced to reduce his energy intake drastically during a famine year. Lacking food, he burns up body reserves. He loses fat, his muscles diminish in size and he becomes thin. At the same time he has a natural inclination to reduce his energy output. He is less energetic, and he rests and sleeps more. The energy expenditure of this average African male doing no exercise is about 1 300 kcal per day. If the food situation improves, for example with the new harvest, he is able to eat more food and hence increase his energy intake. His appetite also increases, and he regains his weight without having done his body any real harm. Many people have gone for ten days or more without any solid food at all (but with drinks of water or fluids). Under these conditions loss of weight occurs without permanent damage. People have been on hunger strikes for as long as 30 days and have fully recovered. If a person loses most of his or her body fat and some muscle and continues on a grossly energy-deficient diet, then definite signs and symptoms of starvation will develop.

Clinical features of starvation

In starvation the subject first becomes thin, the skin becomes dry and hangs loosely and the muscles become wasted. The hair loses its lustre, the pulse slows and the blood pressure is reduced. Hormonal disturbances cause amenorrhoea in women and impotence in males. If the woman is pregnant she may have a spontaneous abortion or miscarriage.

Oedema, sometimes called famine oedema, is a frequent feature of severe undernutrition. The bedridden patient looks puffy, and the ambulant person has swelling of the dependent parts of the body such as the feet and legs. Anaemia commonly develops. Diarrhoea is nearly always present. It may start early on in starvation or it may be a terminal event.

Preschool-age children are often severely affected. They develop nutritional marasmus and sometimes kwashiorkor, often accompanied by intractable diarrhoea, which may, in the very weakened child, lead to prolapse of the rectum.

The starving person usually has psychological and mental disturbances. The personality may change, and the ability to concentrate may be lost, but the person usually remains rational.

Concurrent with these signs and symptoms there may be evidence of deficiencies of vitamins and other nutrients. In Africa the mouth lesions of riboflavin deficiency and tropical ulcers commonly occur; in prisoners of war in East Asia during the Second World War the burning feet syndrome (intense burning of the soles) was a marked feature, but almost any symptom of deficiency disease may arise, depending in each case on the diet.

Untreated starvation often leads to intractable diarrhoea, vascular collapse or heart failure and death. More commonly, however, the severely malnourished individual develops an infection and dies of pneumonia, tuberculosis or some other infectious disease.


The basis for treatment is to provide adequate food in a form that can be utilized by the individual and to treat any specific conditions in the manner appropriate to them. Refeeding should be introduced progressively. In a famine area a person suffering mild undernutrition but showing few signs of starvation will often recover simply by eating whatever food becomes available at the end of the famine.

In severe starvation institutional treatment may be necessary. The patient may have a huge appetite, but the disturbed digestive tract can seldom cope with a large intake of varied rich foods. Milk, bland foods and limited roughage form the basis for successful treatment. Treatment of the young child is similar to that described for kwashiorkor and nutritional marasmus (see Chapter 12).


Famines can be defined as severe food shortages that cover a large geographic area or affect a large number of people.

They are often divided into those that are natural and those that are caused by human actions. Natural causes include most commonly inadequate rainfall, which is termed drought, and less frequently flooding, earthquakes, volcanoes, insect plagues that destroy crops or widespread plant disease. Human actions that can cause famine include most commonly war, either between nations or within a country (civil war), but also sieges, civil disturbance or deliberate food crop destruction. Widespread chronic hunger and malnutrition, although not usually termed famine, not uncommonly result from other causes, for example:

Even if the term famine is not generally used in these cases, the effects on people are the same.

The topic of famine and famine relief is very important for nutritionists and others. It is a broad subject and much has been written about it. Those who wish to know more or participate in famine relief should refer to relevant publications listed in the Bibliography.

Some past famines

Both small and large famines have occurred throughout recorded history, some of them resulting in many millions of deaths from starvation and related causes. Among the best known and best described is the great famine in Ireland in the 1840s, which resulted from a disease that reduced the potato yields in that country, where potatoes had become the staple food. Over 1.6 million Irish people emigrated, most of them to the United States.

Colonial India, prior to independence, had severe famines, for example in 1769/70 when it is believed that 10 million persons died (some one-third of the population). In 1943 another disastrous famine in Bengal killed over 1 million people (more than the total British and American war dead from the Second World War), affected 60 million people and made many destitute. A severe famine in Bihar in 1966/67, after Indian independence, has been much described; the government's handling of that famine provides lessons of how appropriate measures can greatly reduce suffering and deaths.

China has also witnessed many famines, but the more recent ones have not been very well documented. Some authorities believe that between 1958 and 1961 over 15 million persons died in China from starvation resulting from droughts and floods but much aggravated by the economic and political chaos resulting from the industrialization programme termed the "Great Leap Forward". In Europe the Second World War saw serious famine in the Netherlands because of the German occupation and the withholding of food from the civilian population and in Leningrad (now Saint Petersburg) because of the German siege of that city. In Africa there was the Sahel famine which became known throughout the world between 1968 and 1973 [especially in Chad, Mali, Mauritania, the Niger, Senegal and Upper Volta (now Burkina Faso)], and a few years later serious famine and much starvation in Ethiopia. These were both weather-related famines, and there are not accurate figures of the numbers who died. North and South America and Australia have been relatively free of large-scale famines.

The decade of the 1990s has seen famine and starvation in many countries because of crises caused by humans. Civil war in former Yugoslavia has led to serious food shortages in Bosnia; in Somalia clan strife and poor rainfall in 1992/93 brought about severe starvation and many deaths; and in Angola, Liberia, Mozambique and the southern Sudan civil unrest or the governments' loss of control of parts of these countries has caused widespread malnutrition and famine deaths. Strife in Rwanda has led to starvation deaths and to outbreaks of cholera and dysentery in refugees fleeing to Zaire in 1994.

In contrast, drought which greatly reduced food production in East Africa in 1934 and in southern Africa in 1992 saw practically no starvation deaths, because countries such as Kenya, the United Republic of Tanzania and Zimbabwe acted with speed, good planning and appropriate action to get food to those in need. It is likely that the Global Information and Early Warning System for Food and Agriculture (GIEWS) supported by FAO in southern Africa was of assistance; it permitted the governments to predict drought and low crop yields, to plan measures and obtain external assistance and to receive early help from WFP. This example illustrates that if there is no civil strife, if there is early warning, if there is a timely appeal for assistance and if governments make the political choice to deal with famine, malnutrition can be kept in check and famine deaths can be prevented.

Consequences of famine

An important consequence of famine is starvation, described above. Starvation has nutritional, health and psychological manifestations. The reader is also referred to Part II of this book, where several chapters describe the disorders of malnutrition. Many of these, such as protein-energy malnutrition (PEM), nutritional anaemias, vitamin A deficiency and several other micronutrient deficiencies, are common consequences of famine. In addition to these nutritional effects of famine, there are also important social and health-related repercussions.

One important result of famine, and also of wars or civil disturbances without famine, is population migration. The potato famine in Ireland led to substantial emigration, and recent civil wars have resulted in the creation of millions of refugees. The refugee problem is described below.

The progress of a famine is often judged by figures on deaths from starvation, but these are less a measure of the severity of the conditions causing the famine than a reflection on how the authorities have or have not coped with the famine.

Besides social disruption, population movement and sometimes civil disturbance, the next serious consequences of food shortages in famine are epidemics or increased rates and seriousness of infectious diseases. Throughout history famine and pestilence have occurred together. In past famines, serious epidemics of typhus, plague, smallpox and cholera killed many people who were affected by famine. In current famines markedly increased numbers of deaths, particularly in children, have resulted from diarrhoea (from cholera, dysentery or other causes), measles, tuberculosis and other respiratory infections. Typhus and plague can be controlled by insecticides, smallpox has been conquered, and cholera deaths are much reduced by oral rehydration as part of treatment.

Increased rates of infectious diseases and of other infections (including parasitic diseases such as malaria or intestinal worms) result often from a reduced ability of people to fight infections because of malnutrition. Other factors may include increased exposure to infections because of overcrowding in refugee camps, breakdown of water supplies and sanitation, lack of immunization for measles and other diseases and poor housing. The 1994 deaths of Rwandan refugees in Zaire provide a good example.

Famines often result in marked increases in micronutrient deficiencies as well as PEM or deficiencies of intakes of carbohydrate, protein and fat. Recent famines have seen increased rates of nutritional anaemias, xerophthalmia and aribo-flavinosis as well as outbreaks of pellagra and scurvy in populations where these deficiency diseases had not been seen. The lesson to be learned is that food relief must go beyond providing only sufficient calories or energy; it must also include adequate micronutrients (vitamins and minerals) and be accompanied by immunizations, adequate water supplies and sanitation.

Famine prevention

Natural disasters and droughts usually cannot be prevented, but it is possible to prevent these conditions from turning into famines. The ultimate preventive measure, of course, is a diversified economy and a well-developed food and agriculture sector. India experienced a severe drought in 1967, yet the country was able to prevent famine because of its spectacular progress in basic food production arising from the adoption of new agricultural technologies, coupled with an effective food reserve and disaster management plan. Famine is generally the result of a series of agricultural, economic and political failures. Effective interventions at a number of points can prevent an emergency or food crisis from becoming a famine. Crop losses from pests or plant diseases can sometimes be markedly reduced or even avoided. For example, efforts led by FAO and other organizations to destroy locust breeding sites help prevent damage in the Near East before locust swarms move south to devastate crops in Africa. Some plant diseases can be controlled or cured.

Famines arising from natural causes are the ones in which starvation and deaths related to starvation can most easily be prevented. Government and political choice are required for action to prevent starvation. A system of early warning and an established contingency plan with clearly defined responsibilities are critical elements of famine prevention. Actions or programmes to prevent famine must be sensitive to the social and cultural mores of the people in the affected areas. Poor countries such as India, Botswana, Kenya, Tanzania and Zimbabwe have proved that famine can and should be prevented in this way.

Famines that are caused by human actions are of course totally preventable. If humans chose not to undertake these actions, then these famines and starvation would not occur.

The World Declaration on Nutrition approved by over 150 nations at the International Conference on Nutrition in Rome in 1992 contains these words:

If all nations honoured these words the number of people starving in the 1990s would be markedly reduced. A ban on the use of food as a weapon of war has been solicited for years. Germ warfare and gas warfare have been banned, and most countries have accepted this ban. Nonetheless food continues to be used as a weapon of war and for political purposes. Whenever and wherever food has been used as a weapon the worst effects have been on the civilian population, particularly on women, children and the elderly. Seldom are combatants, politicians or senior government officials made hungry, and they certainly do not starve when there are blockades or food wars. In the mid-1990s there have been dozens of armed conflicts, many of which include food wars or situations where an adequate diet as well as access to adequate health and care are compromised. Such situations have occurred in Afghanistan, Angola, Cambodia, Haiti, Iraq, Liberia, Mozambique, Rwanda, Somalia, the Sudan, former Yugoslavia and other countries. Because adequate food and good nutrition are considered basic human rights, these common infringements are violations of human rights. The United Nations and member countries could help reduce famine deaths by acting to ban or even markedly reduce human actions and political decisions that cause malnutrition and starvation deaths, and by taking any action that can promote peace and reduce armed conflicts. More attention needs to be given to this issue in the years ahead.

Famine relief

The first and most important action in famine and pre-famine conditions is to procure and make available enough food to prevent starvation and malnutrition, to maintain the good nutritional status of those who are well nourished and to rehabilitate those who are undernourished. However, famine and disaster relief will be successful and deaths will be prevented only if certain conditions are present nationally and locally. Some famines are confined to` one part of a country and therefore require local actions, perhaps supported by the national government, international agencies and NGOs.

Famine conditions occur repeatedly, yet when they happen a country is often not ready to deal with the problem. Some nations do not have a plan, and those placed in charge of famine relief may have little knowledge of how other countries have acted and little experience in famine relief strategy. As a result the wheel gets reinvented and mistakes are made, mistakes that could easily be avoided. Clearly a smoothly running government, a good civil service, a sound infrastructure and well-established and well-run social and health services are all helpful. The participation of NGOs that are well run and know the country is another asset. A good relationship between the country and food donor nations is also helpful.

The authorities need to obtain, transport, store safely and finally distribute fairly sufficient food for those in the famine area who are threatened with starvation. It is important to provide foods that participants like and understand how to prepare and that are culturally acceptable to all or nearly all people.

There is some difference in dealing with food emergencies that are short-term, for example those caused by earthquakes, volcanoes and floods, and those that are long-term, for example those resulting from crop failures from drought or prolonged civil strife. In short-term food emergencies attention to micronutrient deficiencies is less important than in long-term famines.

There are several different ways of making food available when famine is threatened or exists. Decisions should be made only with local consultation and knowledge of the situation and the people affected, and they should preferably be based on the best information available. If the situation is stable (for example, no warfare, no mass movement of people) and there is simply a food shortage, for example because poor rains have reduced food production, then the simplest means of avoiding famine-related malnutrition and deaths is to ensure that food is available through normal market mechanisms. Food shortages in nations with a free-market economy often result very soon in marked increases in food prices and in food hoarding. One means of preventing this or reducing it is for the government, possibly with international assistance, to move foods in short supply, particularly cereal staples, into the area; a second means is to introduce price controls. Food shortages and increased food prices will have an especially negative impact on the poor, so attention needs to be addressed to poor families if food prices rise. Often a crisis results not so much because food itself is in short supply, but rather because incomes and markets have collapsed. Efforts to stimulate the local economy and to replace lost income through public works programmes have been very effective in many countries.

In more serious situations, or if the preceding approach is not feasible, emergency food needs to be provided. Such assistance usually entails providing foods for people to prepare themselves. Occasionally - in very severe emergencies, in certain camps or institutions for displaced persons or in medical units that have admitted seriously malnourished persons -the assistance can entail on-site feeding of prepared meals.

The first goal of emergency feeding is to ensure that all people, but especially the poorest families, have enough food to meet their energy and other nutritional needs. They must also be in a position to prepare and cook the food. Beyond these needs it is important that treatment be available for those who are malnourished, since famines often occur where chronic hunger and some degree of malnutrition were prevalent prior to the emergency. In some situations it is appropriate to target the food to those considered most in need. This is often difficult to do and requires special arrangements. Emergency feeding plus attention to health care needs should help to prevent large numbers of people from migrating from their normal places of residence. Those providing food should keep in mind the need to prevent long-term dependency on free or subsidized foods. Action to encourage and assist food production should be initiated soon after other steps have been taken and while famine deaths are being prevented.

If take-home rations are provided, local consultation or, better, local decision-making about the types of food and methods of food distribution is important. Certain important principles are almost universal:

Many publications, including FAO's Food and nutrition in the management of group feeding programmes (FAO, 1993b), state that the same ration should be given to each person irrespective of age and that the minimum average individual energy content of the ration should be 1 900 kcal. This is the daily amount, and must exclude food losses due to any cause. The standard requirement of 1 900 kcal is based on a typical demographic distribution of the population in which 20 percent would be children under five years of age; 35 percent children five to 14 years; 20 percent females aged 15 to 44 (with 40 percent of these either pregnant or breastfeeding); 10 percent males aged 15 to 44; and 15 percent males and females over 44 years of age. It should be appreciated that 1900 kcal is the very minimum. It is suggested that in the ration protein should supply 8 to 12 percent and fat at least 10 percent of the energy. This ration of 1 900 kcal has to be complemented by other locally available foods, and the recommendation assumes that beneficiaries have access to them. In some instances insufficient local foods are accessible or the age or gender distribution of the assisted population is different from the normal distribution. In these cases the ration needs to differ from the standard. [Readers wanting more detailed information on emergency rations should consult the WFP publication Food aid in emergencies (WFP, 1991).]

In the past, with concentration on the energy content of the ration, the micronutrient content of emergency foods has been relatively ignored. This should never happen. Rations should provide at least the recommended dietary allowances for micronutrients. The nutrient content of the ration and of other foods available should be appraised, and consideration should be given to adding to the ration other foods with high levels of particular micronutrients or insisting that only fortified cereals or other foods be used. Some foods, such as groundnuts, in relatively small quantities will help increase the nutrient content of the diet. In longer-term famines production of fruits, vegetables and small animals can be promoted. Seldom in localized famines are funds made available to purchase the cheapest and most nutritious fruits and vegetables available in a neighbouring district and transport them into the famine-affected area, but this action should be encouraged.

Table 32 shows three examples of rations that provide 1 900 kcal. Each of these rations provides at least 10 percent of energy as fat and about 12 percent as protein. Wheat flour, maize or rice appears as the major item in all three diets, and as mentioned earlier, the preferred local cereal should be provided as far as possible. Ration 2 provides 30 g of a fortified cereal blend to add micronutrients while reducing pulses or legumes. Ration 3 also reduces pulses and adds canned fish or meat.

Additional guidelines include the following:


Examples of typical 1 900 kcal rationsa

Food item

Quantity (g)









Wheat flour/maize meal/rice












Fortified cereal blendb




Canned fish/meat












Source: WFP, 1991.

a Each of these rations provides approximately 1 930 kcal, 45 g protein and 45 g fat.

b Examples: Maize-soybean blend, wheat-soybean blend, tikuni phala, faffa

In many famines additional supplementary feeding targeted to certain vulnerable groups of the population may be very helpful. There has been a tendency to confine supplementary feeding to children who already have moderate or serious malnutrition, perhaps those below three standard deviations of the standard weight for height. Such supplementation constitutes a treatment, an action to rehabilitate these children. However, it is better to take a preventive approach and to find some way to provide extra feeding to children and others at risk before they have serious malnutrition. The supplement might provide an extra 300 to 500 kcal per day plus other nutrients and might be in an energy-dense form. It is often a cereal-based blended food.

In other famine situations where the people have general access to food or where the government is reducing food shortages by instituting price policies, putting food on the market or subsidizing the price of staple foods, supplementary feeding may be introduced when a general ration is not provided. Again supplements should be provided for prevention of malnutrition as well as rehabilitation. Criteria may be established for selection of recipients and then for discharge from supplementary feeding.

In some instances rather than providing rations to be taken home or food for people to prepare and feed themselves, special circumstances may make it necessary to provide on-site meals. This option generally involves the establishment of feeding centres. Communal feeding is necessary when many people do not have the facilities or ability to cook their own food. For example, in a refugee camp in Kenya most of the population comprises unaccompanied minors, mainly young boys. In other instances where people are displaced from their homes, they may have no utensils or facilities and at least at first require cooked food. However, most refugees do cook their own rations in refugee camps.

Under optimal conditions on-site meals should consist of dishes that are palatable and culturally appropriate to the people being fed and should provide all the nutrients necessary for health and perhaps rehabilitation. High standards of food hygiene must be maintained if at all possible. In many famines major donors and national governments arrange to have non-governmental private voluntary organizations run the feeding centres. These centres need to be set up near where people live, otherwise people will move or camp near them. An alternative which is often more expensive is to use mobile kitchens or mobile canteens.

Other actions which might be considered by those involved in famine relief are discussed in detail in other publications (see Bibliography). These include:

In any major famine a system of weekly reporting is highly desirable.


In some famine situations food is provided to some people only in exchange for work. Food-for-work is often used by WFP and other organizations in non-famine situations. If it is decided that food will be given as a payment for work, then meaningful work has to be organized for large numbers of people, within relatively easy access of where they live. Work has often been arranged in large public works projects, for example in road building or tree planting.

Food-for-work can be successful, but before it is implemented all the pros and cons need to be examined. An advantage of food-for-work over free food is that taking food in lieu of a stipend for work gives dignity to the beneficiary. It often helps prevent the recipients from acquiring the mentality of assisted people. Often both free food donations and food-for-work are implemented together. Sometimes where this is possible there can be a phasing out of free distribution and a phasing in of food-for-work as the situation improves. Some disadvantages of food-for-work are that hard work increases energy needs and therefore the food needs of those working; that the public works involved are sometimes quickly and badly planned and serve little purpose; and that many of those most in need of food, such as children, the elderly, pregnant women and women with young children, may not be able to work or work adequately and may then not receive food.

Health actions in famines

Although providing food is the first essential in a famine, the provision of health services is also important and is often neglected. As mentioned, famines and pestilence go hand in hand, and often more people die of infections and related disease than of starvation. Prevalence and severity of infections are increased, and not infrequently epidemics sweep through famine areas and refugee camps. Therefore it is highly necessary to institute public health measures to prevent disease and to establish treatment centres where needed therapy, immunizations, health education and other health actions can be provided. Very important preventive measures include actions to ensure good sanitation, potable water, personal hygiene and safe feeding.

Assessments and monitoring of the health situation, followed by analysis and interpretation of the situation and likely interventions, can result in action to control epidemics; to distribute medicines and supplies; to immunize children; to improve sanitation and water supplies; to ensure primary health care; and where needed to introduce specific measures to control specific diseases. Nutrition and health education, especially for women, deserves a high priority. Continuous monitoring and refinement of the interventions are needed.

In famines information is needed on both nutrition and health. Without reasonable information, famine relief can often be inefficient, inappropriate and/or seriously flawed. Data are needed regarding both healthy and diseased people.


There are estimated to be close to 35 million refugees in the world today. The United Nations assigns the main responsibility for dealing with refugees to UNHCR, but that agency is assisted by other United Nations organizations such as FAO, WFP, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO). In addition, many NGOs are much involved in refugee relief, most notably the International Red Cross, based in Geneva, Switzerland.

UNHCR defines a refugee as:

According to this definition the term "refugee" refers to true political refugees but not to those termed economic refugees, i.e. those who flee their country and enter another country not for the reasons defined above but because they see better economic advantages in the country to which they have fled. The definition also excludes internally displaced persons, i.e. people who have left their homes but not their country. UNHCR is mandated to address the needs of refugees but not internally displaced persons. The definition should not be seen as suggesting that refugees are all male.

Refugees may live in refugee camps or settlements or reside freely away from their homes. What follows deals more with communities of refugees than with individual refugees or refugee families who move into the general population in an area away from their home.

This chapter briefly considers the nutrition and health of refugees, and not other refugee problems. Many books and reports have dealt with refugees, and some are included in the Bibliography.

Nutrition in refugee camps and settlements

Much in this book concerning the causes, clinical aspects, treatment and control of malnutrition is relevant to the problem of refugees. In fact there has recently been major concern that a wide variety of micronutrient deficiencies have been diagnosed in refugee camps, some of them camps where the refugees have received food for many weeks. The food provided may have provided sufficient energy but did not nearly meet the nutritional requirements for certain essential nutrients. Thus scurvy, pellagra and beriberi have been seen in countries where these are rare diseases. Beriberi resulting from thiamine deficiency has been reported in Cambodian refugees in Thailand; pellagra in Mozambican refugees in Malawi; and scurvy in Somali refugees in Ethiopia. In some refugees moderately prevalent conditions such as PEM, vitamin A deficiency and anaemias have worsened, rather than lessened. Similarly there have been serious outbreaks of preventable diseases such as measles and whooping cough in refugee camps. In the mid-1990s these problems should not occur. The world has the resources, and it should have the compassion, to ensure that the nutritional status and health of refugees improves rather than deteriorates once they are in camps or settlements and receiving UN assistance and care from NGOs.

Micronutrient deficiencies are likely to occur where few foods are provided (often less than three), where other foods are relatively inaccessible or unavailable to refugees and where there is very little diversity in the daily food pattern. Examples of solutions to recognized problems include replacement of beans with groundnuts, which was done in Malawi to control pellagra, and fortification of flour or other foods.

Much of what has been written about starvation and famine above applies also to refugees and displaced persons. Displaced persons arriving in a new area of their own country or refugees arriving in a new nation may be dying of starvation or related diseases, and they often have been or are still in famine areas. The first needs are for safe and adequate water and for shelter against the elements, most importantly against cold, because cold can kill more quickly than lack of food. Provision of adequate water and protection against cold are easier to supply, however, than the next needs, which are for food and for health services, including medical treatment and preventive measures. The health and nutritional status of refugees in camps or settlements should from time to time be appraised in an organized and regular way. As described in Chapter 1, good nutrition is dependent on adequate food, health and care. This dictate applies profoundly also to refugees, and especially to refugee children. Almost all refugees are vulnerable and usually very poor, with few resources. They have often fled with no or little money, few possessions and none of the tools or instruments needed to make a living except their minds, their bodies and their strength. Peasant farmers who have fled do not have tools to cultivate; tailors do not have their sewing-machines; and so on.

Refugees, like all people, have a human right to good nutrition, and because they are temporarily under the care of the United Nations and NGOs it is an international obligation to provide good nutrition, adequate health services, sufficient food providing all essential nutrients and care. The basic essentials are simply described:

Refugees who are likely to be in a settlement for more than a few weeks should be given assistance and encouragement to be active, to run the affairs of the camp and to use their skills where appropriate. From a nutritional viewpoint, this means that displaced farmers should be helped to begin gardening, especially to produce foods that supplement the rations and that yield a harvest within a short time after planting. Possible choices include vegetables such as amaranth and other green leafy vegetables, tomatoes and carrots and legumes such as various beans and peas, especially those that are locally familiar, perhaps chickpeas, pigeon peas or kidney beans. Production of small animals should be encouraged, not only poultry, but also perhaps pigeons, rabbits, guinea-pigs or others that are culturally appropriate. Any persons with health training should be recruited to work in the dispensary or health post, those with secretarial experience in the camp records office, and so on.

Refugees who spend more than a few weeks as displaced persons in a camp or other mass location will usually very quickly enter into various forms of trade and attempt to acquire money to purchase a variety of needed items, both perceived food wants (for greater dietary variety) and non-food needs or wants such as clothes or items to improve the level of living. Part of the rations described in the previous section on famines, which provide 1 900 kcal mainly in the form of a staple cereal and legumes, may soon be sold by refugees to obtain cash. Their intake of energy and other nutrients is then reduced, and this may be a reason for deteriorating nutritional status. Foods provided in rations are often bartered rather than sold.

Those running refugee camps or determining what is provided to refugees need to consider the economic desires and needs of the refugees and to provide them with assistance or a means to help meet these economic desires. Although donor organizations are in general opposed to providing cash to refugees, and their rules may not allow it, under certain circumstances provision of cash could be advantageous, allowing refugees to purchase food and other commodities on the open market. This would only be feasible if the market system in the area had sufficient food and other commodities.

Food rations could also be formulated to provide not only for the purely nutritional requirements but also for the economic desires of the refugees. The total amount of food provided might well be somewhat above the base amount supplying 1900 kcal; the ration might include foods besides those in Table 32, for example more sugar and animal protein foods, spices, condiments, vegetables and fruits, in other words any additional food that seems acceptable, desired and nutritionally sensible.

The authorities need also to consider whether it is wise to condemn or to try to prevent the sale of food rations. As the refugees begin to become more self-sufficient, either by raising money or by growing their own foods, the rations can sometimes be reduced below the standard 1 900 kcal per person per day.

Prevention of micronutrient deficiencies

Elsewhere in this book descriptions are provided of the most important micronutrient deficiencies and their prevention. Much of the discussion applies also to refugees. It is a duty of those involved in feeding refugees to ensure that outbreaks of micronutrient deficiencies do not occur. Consideration needs to be given in refugee camps especially to the three micronutrient deficiencies most important in developing countries, namely those of iron, iodine and vitamin A (see Chapters 13, 14 and 15). Ideally the rations consumed by refugees should contain adequate quantities of these three micronutrients. If they do not, then some fortification can be provided in a fortified cereal blend, most commonly a maize-soybean blend. Such cereal blends should always provide good quantities of minerals and vitamins.

When it is not possible for rations to provide sufficient micronutrients for any reason, or when there is a reasonable belief that significant numbers of refugees may be at risk of micronutrient deficiencies, then a means of preventing specific deficiencies should be established.

Vitamin A deficiency. Supplements should be given where risk is present, for example when refugees show signs of this deficiency or are known to come from areas with a known vitamin A public health problem, or when rations provide less than 2 500 IU (750 RE) of vitamin A per day. It is recommended that high doses of vitamin A be provided orally: 400 000 IU (120 000 RE) for all children one to five years of age and 200 000 IU (60 000 RE) for infants from age six to 12 months, given every four months. It is not generally recommended that infants under six months receive this dose. Lactating mothers should be given 200 000 IU of vitamin A soon after parturition. Treatment of cases of xerophthalmia should follow the recommendations in Chapter 15.

Anaemia. As described in Chapter 13, iron deficiency is the most important nutritional anaemia, but folate deficiency is not uncommon. Women of child-bearing age are most at risk, but anaemia occurs at all ages and in both females and males. Iron, perhaps folate and vitamin C supplements should be given to refugees when the ration contains inadequate amounts of these micronutrients or if anaemia rates are high. Corn (maize)/soybean/milk (CSM) supplements, if used, provide additional iron. Ferrous sulphate and perhaps folate should be provided, as described in Chapter 13, to pregnant and breastfeeding women in refugee camps. If there is a way to provide a good level of vitamin C intake using the food basket, this may help reduce anaemia by assisting with utilization of dietary iron.

Other micronutrient deficiencies. Where there are cases of iodine deficiency disorders (IDD), pellagra, scurvy, beriberi or other micronutrient deficiencies, then the treatment and preventive measures recommended in the preceding chapters should be implemented. It is recommended that only iodized salt be used in food rations and supplementary feeding in refugee camps.

Health services for refugees

As mentioned above, a reasonable level of both curative and preventive health services is a necessity in refugee camps and other places where refugees are living. These services, like health services everywhere, are designed to reduce deaths, to cure disease and, most importantly, to prevent disease as far as possible.

Mortality. Usually the causes of death in refugees are similar to those reported in the areas from which the refugees emanated. In the poor developing countries important causes are infections, almost always made worse by underlying malnutrition. Common infections include diarrhoea and acute respiratory infections (both having a number of possible causes such as bacteria, viruses and parasites), measles and malaria. In the more industrialized and less poor countries such as those of former Yugoslavia and Eastern Europe, the causes may be different. As discussed in Chapter 3, high mortality rates from infections are often the result of the interaction of malnutrition with the infection, so if refugee diets can improve general nutritional status, mortality and case fatality rates from infections may fall significantly.

Very high rates of starvation deaths in refugee camps early in an emergency are often the result of severe PEM, especially nutritional marasmus but also not infrequently kwashiorkor. In refugee camps in many African countries and elsewhere, measles has been an important cause of mortality although it is relatively easy to prevent. Deaths attributed to measles or diarrhoea are nearly always associated with PEM and could just as accurately be termed malnutrition deaths.

Morbidity. Causes of serious morbidity usually mirror the causes of mortality. They include gastro-enteritis (diarrhoea), acute respiratory infections, malnutrition, measles and often malaria. Other diseases may also be common and are particularly important for health personnel to treat. For example, tuberculosis requires attention because it is insidious and requires long, difficult treatment. Intestinal helminthic infections may cause anaemia, reduce growth and cause complications such as intestinal obstruction; these infections may be extremely prevalent but are easily treatable. The wide range of treatable conditions also includes, for example, scabies and conjunctivitis. In particular refugee camps and in specific situations, serious outbreaks of cholera, dysentery, meningitis and hepatitis have needed special attention.

The dispensary, clinic or first-aid post in a refugee camp will also need to be able to treat injuries. In certain situations many of those arriving in the camps have war- or violence-related injuries, and in some there are high rates of physical disabilities. Facilities are needed to provide special attention for women during pregnancy, childbirth and lactation. In some camps it may be important to ensure that sexually transmitted diseases can be treated and that measures to reduce transmission of human immuno-deficiency virus (HIV) can be taken. The situation differs from country to country and from camp to camp. In some instances refugees in camps benefit from better health services and better diets than are available to the local population in the areas surrounding the camps.

Health programmes. It is highly desirable that a system be established for surveillance of health, including nutrition (discussed below). Data need to be collected on mortality, morbidity, nutritional status and health actions [for example, staff activities, immunizations, health education and maternal and child health (MCH) activities. When many persons arrive in an area over a short length of time and are admitted to a camp or other facility, it is helpful if a rapid health assessment can be carried out; this provides baseline data for later evaluations.

A set of actions to prevent diarrhoea deaths and to control diarrhoea is important. Diarrhoea is usually treated using oral rehydration therapy, often based on oral rehydration solution from packets or commonly used fluids and foods. This therapy is life saving when there is dehydration. For diarrhoea without dehydration, foods and fluids prepared at home, plus continuing breastfeeding in the young breastfed child, may be what is needed. More difficult, but of great importance, is prevention of diarrhoea through provision of good latrines, safe water, improved personal and food hygiene and health education. The health personnel should have the training and ability to suspect cholera, and if they find this disease they should be prepared to deal with it.

Many infectious diseases can be prevented by immunizations. These include measles, diphtheria, whooping cough, tetanus, poliomyelitis and meningitis. BCG (bacillus Calmette-Gu rin) vaccine reduces tuberculosis. It is now generally recognized that a very high priority should be given to measles immunization, and that it should be a very early action in a new emergency. Only then should other immunizations be planned including oral polio vaccine and diphtheria, pertussis, tetanus (DPT) vaccine.

Nutritional surveillance

As soon as a camp for refugees is established, or as early as possible, the nutritional status of all should be assessed, and then it should be followed. A system to assess the nutritional status of all new arrivals should be initiated.

Nutritional status assessment usually means the use of anthropometric measurements to assess PEM in children or undernutrition or relative thinness and wasting in adults. Chapter 12 describes the use of anthropometry in assessing PEM. The method should be decided on the basis of what is feasible. Assessment of the extent of low weight for height and surveillance of the changes would be ideal. However, in a refugee situation it may not be possible to weigh and measure all children. If it is not feasible to obtain length or height measurements, then serial weight measurements are useful for surveillance, although they are less useful for assessment of the initial nutritional status of the refugees. MUAC is a simpler measurement because it needs only a tape-measure and not a scale. This method should be used mainly during emergencies for screening purposes, not for surveys or monitoring.

Initial examinations plus follow-up assessment should also seek to find clinical signs of malnutrition, such as oedema which may be evidence of kwashiorkor, eye signs of xerophthalmia and skin lesions of pellagra.

If it is clear that newly arrived refugees come from areas where xerophthalmia is a problem, then at the time of the first nutritional assessment a dose of vitamin A (400 000 IU or 120 000 RE for children over one year of age) and measles immunization are recommended. Information could be collected on night blindness rates as reported by mothers.

The nutrition surveillance system must funnel data to a person who has the ability to analyse and interpret them and to initiate needed action. If the rates of children who have wasting, low MUAC, clinical evidence of severe PEM, xerophthalmia or other deficiencies remain high, then action should be triggered. If the evidence comes from anthropometric data, it may indicate either defects in the food distribution system (perhaps children do not receive their fair share or families are not receiving their ration) or an adverse influence of disease morbidity (diarrhoea, intestinal parasites, malaria, etc.) on nutritional status.

Regular collection of data is invaluable if there is to be assurance that the feeding is fulfilling its objectives, which should be to improve the nutritional status of the refugee population and to prevent malnutrition. Special surveillance of micronutrient deficiencies (for example, following haemoglobin levels in at-risk groups) may be needed and would follow the lines discussed in Chapters 13, 14 and 15. Surveillance should also include monitoring of the feeding programmes and perhaps obtaining data on dietary intake in subgroups of the population, especially vulnerable groups.

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