Food and nutrition situation for refugees from Western Sahara

in camps in Algeria

Ingrid BarikmoAkershus University College (AUC)

Norwegian Church Aid (NCA)Kommittén för Västsaharas kvinnor,Stockholm, February 2010

Refugees in harsh environments in the Sahara desert more than30 years

Cease-fire in 1991 Total dependency on food aid as well as all other

needs for survival Water: a considerable scarcity Health problems such as undernutrition, anaemia

and goitre are common

Background

Background (cont.)

Reduced beneficiaries from 158.000 to 90.000 for 8 months in 2006

In November 2006 increased beneficiaries to 125.000 which still are the number of people given basic ration

Undernutrition increased disturbingly in 2008 Indication of violation of the International

Covenant on Economic, Social and Cultural Rights – article 11 on the right to adequate food

NCA and AUC in the Saharawi refugee camps Nutrition project at the hospitals (since 2000) Iodine Survey, 2007 (report 2008) Nutritional and Food Security Survey, (report 2008) Saharawi Nutrition Strategy, (report 2009) Increased nutrition education, 2009 Cooperation with MoH, UNHCR, WFP, MdM, PNSS in

a Integral Program of Infantile Health Saharawi (PISIS), 2009

Food Basket research, 2009 Local milk research, 2009

Iodine Survey, 2007

Prevalence of enlarged thyroidgland measured by ultrasound: Women (405, age 15-45): 22 % (cut-off volume

thyroid gland > 12.5 ml) Children (419, age 6-14): 86 % (international

reference values (thyroid gland volume - Tvol) for BSA with cut-off point at the 97 percentile)

Excretion of iodine in urine Women: Median 466 µg/L (range 54-3.640) Children: Median 565 µg/L (102-3.594)

2

9

16

38

29

7

0

3

13

38

34

12

0

5

10

15

20

25

30

35

40

45

<100 100-199 200-299 300-600 601-1100 >1100

Urinary iodine excretion µg/L

%Iodine in urine, women

Iodine in urine, children

1100 µg/day: Tolerable upper level of daily iodine intake for adults (Food and Nutrition Board, USA, 2006).

600 µg iodine/day: Proposed safe upper level for adults (Scientific Committee on Food in the European Union, 2002)

Median iodine content (µg/L) in water and urine (women and children)

0

100

200

300

400

500

600

700

800

900

1000

Iodine in water Iodine in urine,women

Iodine in urine,children

Iodi

ne µ

g/L 2 camps (Ausserd, El Aiune)

1 camp (Dakla)

1 camp (Smara)

Local milk

Goat milk (n=16) Content of iodine: median 370 µg/L,

(70-13.071)

Camel milk (n=3) Content of iodine in the 3 samples 540 µg/L,

4.170 µg/L and 11.980 µg/L

Sources of the iodine intake among women

Salt7 %

Water48 %

Tea water6 %

Local milk38 %

Dairy products1 %

Conclusion The prevalence of enlarged thyroid gland was severe,

especial for the children The majority of the Saharawi refugee women (74 %)

and children (84%) had excessive intake of iodine It was differences between the camps:

of those with iodine excretion more than 600 µg/L88 % of the women and 91% of the children came from the two camps Ausserd and El Ajune

The content of iodine in local milk was extremely high and need to be more investigated

The high concentration of iodine in water are affecting the humans directly and probably also indirectly through the local milk

Nutritional and Food Security Survey, 2008Prevalence of: Acute malnutrition (too thin) (wasting, WHZ):

Global (total) 18.2 % Severe: 5.4 %

Chronic malnutrition (too short) (stunting, HAZ): Global (total) 31.4 % Severe: 9.0 %

Anemia, children In total 62 % Severe 6%

Anemia, non- pregnant women In total 54 % Severe 11%

Anemia, pregnant women In total 66 % Severe 15%

Trend in acute malnutrition (wasting) from 1997 to 2008

1013

118

19 18

24

2 2 35

0

5

10

15

20

25

30

Prev

alen

ce %

Total (WHZ<-2,00 SD) Severe (WHZ <-3,00 SD)

Trend in chronic malnutrition (stunting) from 1997 to 2008

46

35 3339

2631

24

14 1116

7 9

0

10

20

30

40

50

Prev

alen

ce %

Total (HAZ<-2,00 SD)

Severe (HAZ <-3,00 SD)

Trend in anaemia in children (6-59 months) from 1997 to 2008

71

44

35

6861

14

3 07 6

0

10

20

30

40

50

60

70

80

1997 2001 2002 2005 2008

Prev

alen

ce %

Total (<11Hb)

Severe (<7 Hb

Trend in anaemia in non pregnant women, from 1997 to 2008

62

48 48

66

46

55

92 4

137

11

0

10

20

30

40

50

60

70

1997 2001 2002 2005 2007 2008

Prev

alen

ce %

Total Hb<12

Severe Hb<8

Trend in anaemia in pregnant women, from 2002 to 2008

7276

64 66

5 7 915

0

10

20

30

40

50

60

70

80

2002 2005 2007 2008

Prev

alen

ce %

Total Hb<11

Severe Hb<7

Saharawi Nutrition Strategy

Potential resources

Malnutrition/ Nutrition related diseases

and early death or disability

Inadequatedietary intake

Disease

Foodinsecurity

Inadequate

“Care”

Inadequateprevention and control of disease, water and

sanitation

Control and managementof resources

Human, Economic, Organizational

Political and Ideological SuperstructureEconomic structure

Symptoms and signs

ImmediateCauses

UnderlyingCauses

BasicCauses

Conceptual framework for the causes of malnutrition(Adapted from Jonsson, 1995)

Inadequate education

Saharawi Nutrition Strategy

1. To change the diet for all in line with the international recommendations of the FAO/WHO

2. To coordinate the nutritional work in the camps

3. To reduce malnutrition in children

4. To reduce anaemia and other type of micro-nutrient malnutrition, particularly among women in reproductive age, infants and young children and school age children

5. To promote healthy dietary habits in accordance with local food culture for an adequate food intake for all.

6. To strengthen the nutrition skills among the Saharawi public staff.

General objectives Focused areas

Access to food for a healthy diet

Fight against malnutrition and nutritional deficiencies

Capacity development

Care for the children

Breastfeeding in the camps: 60 % started during the 1. hour, 8 % later than 12 h 90 % were given water, sugar water, oil when they

were new born 2 % was exclusive breast feed to 6 month 95 % of the children had been breast feed 50 % breastfeed in 2 years

Children’s meal:

3 meals/day – 11 % 2 meals/day – 75 % 1 meals/day – 6 % 0 meals/day (only milk) – 3 % “Between meals” – 33 %

Complementary feed by 6-7 months – 32 %

3 (n=100)2 (n=664)1 (n=81)

Groups of Children eaten main meals

-0,75

-1,0

-1,25

-1,5

-1,75

95%

CI W

HZ-

scor

e

Figure 12 Effect of eating main meals on acute malnutrition among children 6-59 months, Saharawi refugee camps, March 2008

3 (n=100)2 (n=664)1 (n=81)

Groups of Children eaten main meals

-0,8

-1,0

-1,2

-1,4

-1,6

-1,8

-2,0

-2,2

95%

CI H

AZ-

scor

e

Figure 13 Effect of eating main meals on chronic malnutrition among children 6-59 months, Saharawi refugee camps, March 2008

3 (n=100)2 (n=664)1(n=81)

Groups of Children eaten main meals

11,0

10,5

10,0

9,5

9,0

95%

CI H

emog

lobi

n

Figure 14 Effect of eating main meals on anaemia among children 6-59 months, Saharawi refugee camps, March 2008

Diaré

NoYes

Children with diarrhoea during the last 2 weeks

-0,8

-1,0

-1,2

95%

CI A

cute

mal

nutr

ition

(WH

Z)

Figure 15 Effect of diarrhoea on acute malnutrition among children 6-59 months, Saharawi refugee camps, March 2008

NoYes

Children with diarrhoea during the last 2 weeks

10,5

10,25

10,0

95%

CI H

b m

easu

red

with

Hae

moc

ue

Figure 16 Effect of diarrhoea on anaemia among children 6-59 months, Saharawi refugee camps, March 2008

Diaré

Care for the women Birth control – 60 % Give birth at home – 72 % Iron supplement when pregnant – 8 % Have lost one or more child – 46 %

Eat as usual during the pregnancy – 41 % Eat more than usual – 2 % Eat less than usual– 55 %

What characterized the anemic women? If they was pregnant or breast feeding Had children less than 5 years Their own age; less than 20 and more than

40 years old women had significant higher Hb than the other

Those that ate 1-2 meals/day had sign.lower Hb than the other

Food insecurityFood insecurity

In refugee camps, In refugee camps, we saw that when we saw that when access to food access to food declined, sharply declined, sharply increased the increased the under nutrition. under nutrition.

Inadequate careIn the refugee camps In the refugee camps we saw that exclusive we saw that exclusive breastfeeding was breastfeeding was almost absent, the almost absent, the special child feeding special child feeding is not normal and that is not normal and that the feeding rate is the feeding rate is low. low. Only slightly more Only slightly more than half goes to the than half goes to the maternity control, and maternity control, and most give birth at most give birth at home home

Inadequate prevention and control of disease, water and sanitation

In refugee camps, we In refugee camps, we found that one of the found that one of the causes of malnutrition causes of malnutrition among children was among children was (in addition to (in addition to inadequate food inadequate food intake) diarrheaintake) diarrhea.

Possible causes of the under nutrition

Measures1. Food and supplements that meets the needs for

pregnant, mothers and children2. Training of health personnel how they can give

advices to pregnant and mothers regarding: health before, under and after pregnancy breast feeding good complementary feeding practice

3. Training of the mothers4. Campaigns for good health and diet in the

population.

How to improve the situation? Use the Saharawi Nutrition Strategy Increase the nutrition education Work in cooperation with MoH, UNHCR, WFP,

MdM, PNSS in a Integral Program of Infantile Health Saharawi (PISIS)

Continue to fill the Food Basket Contribute to the local milk research Other?

Takk for oppmerksomheten

Food distributed

0123456789

101112131415

kg c

erea

ls/p

erso

n/m

onth

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June

July

Aug

ust

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tem

ber

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ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Apr

il

2006 - 2007

Wheat

Sum cereal

Wheat and cereals distributed in the camps in 2006 and the first 4 month in 2007

Food distribution and acute malnutrition

The quantity of distributed cereals/person/month in 2005, 2006, 2007 and 2008 when using number of 160.000 or 125.000 beneficiaries and the prevalence of acute malnutrition

02468

101214161820

2002 2005 2006 2007 2008

Cereal (kg/person/month)if distributed to 160.000beneficiers

Cereal (kg/person/month)if distributed to 125.000beneficiers

Prevalence of acutemalnutrition

Women needs and food distributed in 2008

0102030

40506070

Protein, g Iron, mg Vit C, mg

Needs for a women 19 -50 year/dayReceived in 2008 if125000 beneficiariesReceived in 2008 if160000 beneficiaries

0

500

1000

1500

2000

2500

Energy, kcal Calcium,mg Vit A,µg

Needs for a women 19 - 50year/day

Received in 2008 if 125000beneficiaries

Received in 2008 if 160000beneficiaries

Food distributed in 2008 to 160.000 g/dayCereals 281

CSB-blended 13

Lentils/beans 46

Oil, fortified 24

Sugar 23

Tuna fish 2

Vegetables 70

Fruit 30

Meat 5

Milk/Cheese 9

Sources to the nutrients

Nutrients in %Energy Protein Calcium Iron Vitamin C Vitamin A

Cereals 63 66 20 39 0 0

CSB-blended 3 5 47 23 27 26

Lentils/beans 9 22 14 33 2 1

Oil, fortified 14 0 0 0 0 56

Sugar 6 0 0 0 0 0

Tuna fish 0 1 0 0 0 0

Vegetables 2 2 6 1 33 15

Fruit 2 0 4 2 38 1

Meat 0 2 0 1 0 0

Milk/Cheese 1 1 9 0 0 1

Adapted Food Basket Ration/kg/month

Food given monthly by

WFP

8 Wheat flour, fortified

2 Barely

2 Rice

1 CSB-soya, fortified

2 Lentils/beans/peas

1 Oil fortified

1 Sugar

Suggested food items that can be

given by other

organisations

1 Gofio

1 Soya beans

1 Pasta

5 Milk

1 Cheese

1 Mackerel in brine

3 Potato

3 Carrot

2 Onion

1 Apple

1 Orange

1 Tomato in tetra pack

0

20

40

60

80

100

120

Protein, g Iron,mg Vit C, mg

Needs for a women 19 -50 year/day

Adapted FoodBasket/day

0

500

1000

1500

2000

2500

3000

3500

Energy, kcal Calcium,mg Vit A,µg

Needs for a women 19 -50 year/day

Adapted Food Basket/day

Highly recommended Food Groups as support to the refugees

Vegetable and fruit Canned fish (mackerel or sardines) or meat Milk and cheese Other foods such as gofio and pasta and

soya beans

Hva slags matvarer som flyktningene ønsker å kjøpe hvis de har penger

01020304050607080

Linse

r

Fisk,b

oks Te

Sukke

rPas

ta RisGjæ

rMelk Olje Kjøt

tEgg

Fruk

t

Grønn

sake

r

Produkter som kjøpes

% fa

mili

er

Hva slags matvarer og tilsetninger For behandling av alvorlig akutt underernærte

(wasting): Før – F100 NÅ – PlumpyNut

(olje og peanutbasert) For moderat akutt underernærte:

Hvete/mais-soya blanding+ olje og sukker (CSB)

For forebygging av kronisk underernærte (stunting): Før – ingenting NÅ – olje og peanutbasert produkt

Anemi Sprinkelprodukter

Nutrition throughout the life cycle

WomanMalnourished

AdolescentStunted

PregnancyLow Weight Gain

ElderlyMalnourished

ChildStunted

BabyLow Birth

Weight

Higher maternal mortality

Inadequate food, health &

care

Inadequate food, health &

care

Inadequate food,

health & care

Reduced mental

capacity

Reduced mental

capacity

Reduced capacity to care for baby

Inadequate foetal nutrition

Higher mortality rate

Impaired mental

development Increased risk of adult

chronic disease

Untimely / inadequate weaning

Frequent infections

Inadequate food, health &

care

Inadequate catch up growth

“Window of Opportunity” for Improving Nutrition is very small…pre-pregnancy until 18-24 months of age

-2.00

-1.75

-1.50

-1.25

-1.00

-0.75

-0.50

-0.25

0.00

0.25

0.50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Wei

ght f

or a

ge Z

-sco

re (N

CH

S)

Latin America and CaribbeanAfricaAsia

Kilde: Shrimpton et al (2001)