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Improving the Nutritional Benefit of Food Aid for Refugees

Refugees who have fled to other countries and refugees within the country; victims of war and other persecutions; those affected by natural disasters-- earthquakes, hurricanes, typhoons, and drought; all those that the international community has succeeded in reaching; rely on food aid.

Food aid arrives from other countries, and is principally grain.

Does this food aid meet the nutritional needs of those who consume it, especially those who rely on food aid long term?

The short answer is no-- while the calories provided by food aid are lifesaving, food aid does not include vegetables and fruits, principal source of micronutrients-- also known as vitamins and minerals. Thus, a key concern for those involved in food aid is how to fortify the foods that are delivered, principally grains and vegetable oil, with micronutrients.

Moreover, non-governmental organizations (NGOs) face a bewildering array of foods that can be used in emergency response situations: biscuits, grains, noodles, cans of meats, therapeutic feeding powders, Unimix and other confusing items.

Sudanese Refugee
Photo: Office of Tony Hall

Children, such as this child in a refugee camp in Sudan, as well as all other age groups, can suffer from vitamin and mineral (micronutrient) deficiencies if a long stay in refugee camps deprives them of vegetables and fruits, sources of vitamins and minerals, and forces them into excessive reliance on food aid, principally grains, which unless fortified do not contain sufficient vitamins and minerals.

For many food aid workers, it is not clear how and when to use each of them to try to reduce the occurrence of different nutritional deficiencies in large populations, where sub-clinical deficiencies, not the clinical cases seen and counted, account for the greatest proportion of death and disability.

To address this problem, the Congressional Hunger Center, Food Aid Management, the United States Agency for International Development (USAID), and the Micronutrient Initiative of Canada (MI) will co-sponsor a meeting of food managers of aid organizations to discuss approaches to improving the nutritional quality of foods delivered in emergencies, refugee camps and recovery programs.

The workshop, to be held April 28- April 30, 1999 in Washington, DC, will help NGOs learn about the benefits and limitations of the different foods available and methods for fortifying foods in the field. NGOs will compare their field experiences and technical advances, in discussion with food science experts and representatives from the Red Cross, MI, the United Nations, industry, USAID and its food technology and enterprise project SUSTAIN, and other groups actively examining new and improved ways to increase the levels of vitamins and minerals in general rations, while also protecting the shelf-life of foods and the retention of micronutrients through processing to consumption.

A key objective of the workshop is to allow NGOs to share pilot field study results directed at fortification of commodities given out in large quantities, primarily wheat, corn, rice, sugar and vegetable oil. While there is an extensive published literature on programs to fortify these foodstuffs, there is a need for more information sharing on their fortification for emergency programs and food aid. Because emergency-affected populations often depend on the food ration given, it becomes important to try to fortify these ration foods with a range of vitamins and minerals, not just one or two. Much remains to be learned.

Refugees face a number of serious micronutrient deficiencies.

Iron deficiency anemia is ubiquitous in refugee camps worldwide. It is almost universally reported as one of the top medical complaints recorded in medical clinics for refugees from Thailand to the Sudan to Honduras. In addition to harming adult work output and growth potential of children, low hemoglobin levels predispose millions of refugee women to heightened risk of maternal mortality.

Vitamin A deficiency is almost as prevalent as anemia. It is a particular hazard for populations affected by emergencies who rely for years on food aid which is typically poor in vitamin A content. Vitamin A is available mostly from meats and green leafy vegetables. Because vitamin A deficiency promotes not only more infections but also increases the fatality rate from infections, it underpins a great proportion of the deaths that occur in emergencies.

It is increasingly suspected that populations dependent on bulk grains for long periods are prone to zinc mineral deficiency, which stunts growth, though much of the evidence on this is recent.

Niacin deficiency, resulting in pellagra, is likely to occur in the ever-growing populations reliant on maize consumption (i.e., much of sub-Saharan Africa, and most of the population in southern and eastern Africa. Niacin deficiency is therefore localized to those areas where maize consumption is dominant. Because the niacin in maize is trapped, and biologically unavailable, populations consuming maize are particularly vulnerable to pellagra. Mozambican refugees living in Malawi in the late 1980s experienced a large pellagra epidemic that has subsequently dramatized the importance of paying attention to the niacin content of diets. Niacin-deficiency pellagra is not only associated with emergencies, but is also pervasive today in maize-reliant countries from Tanzania to Mozambique.

Beriberi is a thiamin (vitamin B1) deficiency seen in various refugee communities that consume primarily polished rice, without other sources of B vitamins. Because it is associated with rice-based diets, this deficiency is seen primarily in emergencies that have occurred in southeast Asia.

Even more localized than niacin and B1 deficiencies is vitamin C deficiency, which results in scurvy. Almost all the outbreaks of scurvy have occurred among Ethiopian and Somali emergency victims, principally those who have been cut off from camel milk markets for months. Though striking as an indicator of poor dietary variety, scurvy itself is not felt to be a pervasive risk nor a major life risk the way vitamin A deficiency can be.

Though not particular to emergencies, iodine deficiencies are particular to the poorest and more remote populations in the world. In any case, it has been important for aid agencies, such as the World Food Program (WFP), and United Nations High Commissioner for Refugees, to promote adherence to strict standards of salt iodination in countries where they work, that is, only purchasing iodized salt for ration distributions. This can reinforce national efforts to encourage small-scale salt sellers to iodize salt as per regulations.

There are other micronutrients that are required in all diets, which will be discussed at the workshop as well, including calcium, magnesium, and vitamins B2, B12, D, and K.

Food Response Limitations

Most efforts to deal with vitamin and mineral gaps have been untimely, and have been undertaken only on a clinical or therapeutic basis, as, for example, when a child is referred to a supplementary feeding center. This misses opportunities for prevention and neglects the larger population, where subclinical deficiencies pose a much larger problem than the few clinical cases that are brought to the attention of health providers.

The problem historically is that there have been few foods that have the requisite micronutrient(s), and those that do, such as Corn-Soy Blend, Animus, and Wheat Soy Blend, tend to be considerably more expensive than bulk grains. This is especially a problem when over four-fifths of blended foods delivered worldwide comes from the United States and U.S. food aid is appropriated in dollar, or total cost terms.

The extrusion, processing, and packaging attendant to making blended foods means that they tend to cost between $350 and $500 per metric ton. Whole grains, which make up the bulk of the general refugee ration, cost significantly less, between $90 and $200 to procure. Thus, two to four times more emergency victims can be fed using bulk grains than blended foods.

Faced with this tradeoff, most aid agencies choose to reach the greater number of people with the resources available, using the enriched foods primarily for selective (supplementary) feedings where they are targeted to those persons who already manifest deficiencies.

Another difficulty is that blended foods also spoil more readily. Blended foods and flours are more prone to infestation and fungus spoilage. Frequently, entire batches need to be condemned and destroyed.

A further problem encountered with blended foods is that they are not consumed in equal amounts by all who who would benefit from them. Studies in Central America, the Horn of Africa and Asia have repeatedly shown that recipients of food aid exchange and trade foods between households, and, even within families, foods are consumed in different proportions. For example, children may eat all the beans and blended foods, while adults will eat more of the whole grains and purchased meats and other foods.

Over and over, it has been shown that families conduct a range of transactions, such as sales, bartering and gifts, that result in many families eating little or none of some food items included in the ration– whether the vegetable oil, the beans, or the blended food. (Recent research on this subject, conducted by Barbara Reed of Cornell, and by Catherine Mears and Helen Young of Oxfam, will be discussed at the workshop).

Only the grains, the basic food aid ration, are eaten by everyone. Thus, an effective way to supply micronutrients to the entire population receiving food aid is to fortify these grains, wheat, maize and rice, that are most of people's food ration. (Fortification refers to the addition of nutrients to foodstuffs somewhere in the food processing cycle for the purpose of restoring-- often nutrients are lost in processing-- or enhancing the nutritional quality of the food).

Field-Level Fortification

Thus, in recent years research has been focused on finding ways to fortify these grains.

Options for fortification are dependent on the state of science in food chemistry– finding ways to add nutrients that do not adversely change the taste, appearance or smell of the food.

Nutritionists have long felt that fortification is affordable and effective, and brings a high return on investment. Fortification of basic foods with micronutrients is such common practice in developed countries that it is rarely debated. For example, in most European countries flour is fortified with thiamin, riboflavin, pyridoxine, niacin, calcium and iron. The World Bank, in its 1993 annual report, argued that micronutrient interventions like fortification are among the most cost-effective programs known for improving health and reducing disability-adjusted life-years.

During the 1990s, studies by OMNI, the Micronutrient Initiative of Canada, and private groups have looked at the feasibility, costs, and current practice of field-based fortification. During the last two years, it has become increasingly apparent that there are numerous low-technology, low-cost routes to achieving full fortification of grains with many micronutrients at once.

Field-based fortification is less expensive for several reasons.

First, the addition of micronutrients does not have to include the costs associated with the inclusion of protein, which drives up the cost of CSM. (Blended foods are produced using gelatinized cornmeal or wheat flour, de-fatted soy flour and soy oil, and then an added mix of six essential minerals and 11 vitamins).

Secondly, with fortification in the field, extended storage, with the consequent danger of spoilage, is much less of a problem.

Finally, the costs of adding the micronutrient is reduced as labor is available on site and much less elaborate (and costly) packaging is required.

By fortifying flour at the point of milling in a refugee camp, the shelf-life of the grain is maximized while still adding vitamins and minerals close in time to their being eaten.

Adding an off-the-shelf micronutrient mix after the milling of a grain into flour is the logical point of fortification. Small, privately operated mills can be found in almost all refugee camps. And in some camps, the WFP, or NGOs such as the International Rescue Committee, provide small mills as well. Though these small commercial hammer and plate mills generate great heat in grinding the grain, there is no reason that micronutrient mix cannot be added immediately afterward, either by hand, or by a batch mixer or, if necessary, by in-line dosing equipment.

Technologies pioneered under support from the Micronutrient Initiative of Canada will be demonstrated and explained at the workshop. For example, ODJOB is a plastic blender that can be easily introduced at any field site for batch mixing of a premix with flour. Related low-cost efforts by MI funded field trials in Zambia and Zimbabwe, working with NGOs.

Fortification can also be approached at a regional level, where food aid passes through more sophisticated roller mills to produce flour. Ironically, much of the experience in the poorer countries is in fortifying animal feeds-- though the premix and dosing techniques-- are the same for enhancing foods for human consumption, as well.

NGOs may consider field-based fortification as both an immediate response to nutritional needs of a target population and as a means to initiate and promote fortification practice into local industry practice. Field-based fortification salt iodination is well established in most of Latin America and Asia. Sugar fortification with vitamin A is now implemented on a regular basis in Guatemala, Honduras, and El Salvador. In the Philippines, rice is routinely fortified by small millers with thiamin, and more recently by them with iron.

Many of these best practices will be discussed at the April workshop; and will become part of an ongoing dialogue about how to deliver appropriate nutritional foods to refugee and displaced populations in various field-based situations.

Steve Hansch is organizing the April conference for the Congressional Hunger Center, and is an editor of Hunger Notes.

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