for Australia: Bush Books, PO Box 1370, Gosford South, NSW 2250, Australia; tel. 043 23274; ..... close monitoring of mill technicians to ensure in ...... If it could, or if manual mixing was ...... specifically Hindu classification of food items is ...... VD rH. 00 rH. P I in rH n. *. £ o o d in n t H o in. fH. VO d. rH m. 0 a0. Ot. Cam p. A. O.
Acceptability and Use of Cereal-Based Foods in Refugee Camps: Case-Studies from Nepal, Ethiopia, and Tanzania
Catherine Mears with Helen Young
An Oxfam Working Paper
©OxfamGB 1998 First published by Oxfam GB in 1998 ISBN 0 85598 402 3 A catalogue record for this publication is available from the British Library. All rights reserved. Reproduction, copy, transmission, or translation of any part of this publication may be made only under the following conditions: • with the prior written permission of the publisher; or • with a licence from the Copyright Licensing Agency Ltd., 90 Tottenham Court Road, London Wl P 9HE, UK, or from another national licensing agency; or • for quotation in a review of the work; or • under the terms set out below. This publication is copyright, but may be reproduced by any method without fee for teaching purposes, but not for resale. Formal permission is required for all such uses, but normally will be granted immediately. For copying in any other circumstances, or for re-use in other publications, or for translation or adaptation, prior written permission must be obtained from the publisher, and a fee may be payable. Available from the following agents: for Canada and the USA: Humanities Press International, 165 First Avenue, Atlantic Highlands, New Jersey NJ 07716-1289, USA; tel. 732 872 1441; fax 732 872 0717; for Southern Africa: David Philip Publishers, PO Box 23408, Claremont, Cape Town 7735, South Africa; tel. 021 644136; fax 021 643358; for Australia: Bush Books, PO Box 1370, Gosford South, NSW 2250, Australia; tel. 043 23274; fax 029 212248. For the rest of the world, contact Oxfam Publishing, 274 Banbury Road, Oxford OX2 7DZ, UK. Published by Oxfam GB, 274 Banbury Road, Oxford OX2 7DZ, UK Oxfam GB is registered as a charity, no. 202918, and is a member of Oxfam International. Typeset by Oxfam CSU Printed by Oxfam Print Unit
This book converted to digital file in 2010
Contents
Acknowledgements 4 Preface 5 Executive summary 8 Abbreviations 10 1 Main report 11 Introduction 11 Methodology 12 Cereal fortification and blended food 13 Food and nutrition in the study sites 14 The 'pragmatics of preference' 18 The use of food and micronutrients 20 What made food 'acceptable'? 24 Cereal fortification at the regional, camp, and household levels 27 Conclusions 30 Appendices: l(a) Methods 33 l(b) Fortified pre-cooked blended food: definitions and examples 37 l(c) Prices, nutritional value, and unit cost of WFP-supplied commodities, January 1997 39 l(d) Composition and nutritional analysis of planned rations 40
2 Case-study: Bhutanese refugees in Nepal (January/February 1997) 41 The context 41 The field study 46 Conclusion 60 Appendices: 2(a) Map of Jhapa and Morang Districts 61 2(b) Age and gender composition of camp population 62 2(c) Market prices at time of study 63 2(d) The process of parboiling rice 64 2(e) List of key informants and interviewees 65
3 Case-study: Somali refugees in Ethiopia (May/June 1997) 66 The context 66 The field study 74 Conclusion 88 Appendices: 3(a) Ethiopia: regions and zones 90 3(b) Location of camps, Somali Region 91 3(c) Characteristics of the refugee population 92 3(d) Refugee numbers 93 3(e) Market prices at time of study 94 3(f) Chronology of malnutrition and micronutrient deficiencies 95 3(g) List of key informants and interviewees 96
4 Case-study: Burundian refugees in Tanzania (August/September 1997) 97 The context 97 The field study 103 Conclusion 118 Appendices: 4(a) Map: Kigoma Region and location of camps 119 4(b) Age and sex composition of population, Muyovosi camp 120 4(c) Refugees Statistics Report on Registration, Kigoma Region, July 1997 121 4(d) Market prices at time of study 122 4(e) WFP report of market prices to July 1997 123 4(f) Summary of food ration scales and kilo calories, January-August 1997 124 4(g) Proposed milling set-up, Isaka 125 4(h) List of key informants and interviewees 126
Glossary 127 References 131
Acknowledgements
This work was carried out with the aid of grants from the United Nations High Commissioner for Refugees (UNHCR) and from the Micronutrient Initiative, an international secretariat housed in the International Development Centre, Ottawa, Canada. We would like to thank Rita Bhatia, Arnold Timmer, Gloria Sagarra and Janak Upadhay (UNHCR, Geneva) and Peter Dijkhuizen (WFP, Rome) for information and facilitation during the course of the project. We also acknowledge the help of Dr Sue Chowdhury, Dr Steve Collins, and Maurice Herson, who commented on the draft, and
Dr Johan Pottier for advice and comments on each case-study. Thanks and appreciation are due also to all the people from UN, NGO, and government agencies in the three field-study sites who were so helpful and supportive during the field research, in particular the staff of Oxfam Nepal, Tanzania, and Ethiopia, and UNHCR and WFP staff in all three sites. These and others are too numerous to mention, but many are included in the list of key informants at the end of each case study. Thanks also to the three interpreters, Purnima Sharma, Ebla Abdi, and Mary Ruheta, for their work and friendship.
Preface
Episodes of scurvy, pellagra, and beriberi among refugees during the 1980s were a stark reminder of the inadequacies and failures of the international humanitarian response. There was a public outcry when the range and extent of micronutrient-deficiency diseases became more widely known and publicised, both in expert meetings (Oxford, 1988) and in television documentaries (such as Killed by Kindness, LWT, 1990). The reactions were swift, as international agencies and organisations sought solutions and strategies to overcome both the endemic micronutrient-deficiency diseases (vitamin A deficiency, iron-deficiency anaemia, and iodine-deficiency disorders), and the intermittent outbreaks of more unusual deficiency diseases that were thought to have been all but eradicated. There is not a single solution to the problem of micronutrient deficiencies; rather a range of strategies must be devised and adapted according to the local context.1 This research represents one part of the process of developing more effective strategies to combat micronutrient deficiencies among vulnerable refugee populations. The two particular strategies of interest are the inclusion of fortified blended food in die refugee food rations, and the fortification of cereals at local or household level. In broadest terms, die aim of the research is to provide a clearer understanding of the reality of refugees' lives and the way in which they make use of the food assistance they receive. Without such a perspective, how can outsiders have any confidence that their particular technical solutions will work? Various approaches to solving the problems of micronutrient deficiencies have their own shortcomings and weaknesses. For blended food, a problem frequently mentioned is one of acceptability: it is widely assumed that for most people it is a new food, not previously encountered or used. In contrast, the strategy of fortifying cereals with micronutrients is far more a technical issue, concerned with the operational feasibility of local fortification. Thus the practical problems of adopting either strategy are quite different, which means that as policy options or
strategies they are not directly comparable. It is at best awkward to discuss which strategy is more likely to succeed, because for either approach this depends on a different set of questions and answers. For example, the feasibility of cereal fortification is, in the first instance, dependent on the type of cereal (rice being particularly difficult to fortify) and the availability of local milling/ fortification capacity. At worst, direct comparisons of these two optionsriskruling out completely one or other option. It is far better to identify the limiting factors or practical constraints associated with either strategy. Our knowledge of what refugees think and do in relation to food is weak indeed. Much of what we know about food use and acceptability is to a large extent based on 'received wisdom', built upon over-repeated anecdotes whose origin can rarely if ever be traced. This received wisdom cannot be questioned or challenged without proper evidence. There have been attempts in the past to look at use and acceptability of newly introduced foods,- but none to our knowledge has involved in-depth studies of emergency-affected populations, taking into account the wider determinants of use and acceptability, as this study has done. A further distinguishing characteristic of this study is the structures upon which the research process was based. It represents an unusual and probably unique collaboration between an international non-government organisation (Oxfam GB); the United Nations High Commissioner for Refugees; the Micronutrient Initiative; and the World Food Programme. Such collaboration represents far more than simply a secure funding base (for which we are very grateful to UNHCR and the Micronutrient Initiative). In these organisations there was a range of individuals contributing their expertise and assistance, each of whom has an inestimable knowledge and experience of the refugee situations under investigation. The field researcher herself was familiar with refugee emergencies, having worked for more than 12 years in refugee health and nutrition, with Oxfam and Red Cross inter alia. Qualitative
Acceptability and use of cereal-based foods in refugee camps
investigations of this nature require considerable sensitivity towards both the system of humanitarian response and the refugees themselves. The most recent refugee crises have given rise to a climate of criticism and questioning about the role and effectiveness of the humanitarian response. In relation to nutrition, the focus is often on the frequently reported nutritional deficiencies, and the failures of the international response (which are indeed described in this report). But such a view misrepresents the efforts and successes of a wide range of agency interventions aimed at providing food assistance. Over the years, as the challenges of meeting the needs of emergency-affected populations hasve grown almost exponentially (as have the numbers of people affected), many aspects of humanitarian programmes have improved. This might not be immediately apparent from a reading of this document, but we should bear in mind the situation ten to fifteen years ago in many refugee crises, such as Eastern Sudan in the mid-1980s, where the warehouses were crammed with inappropriate foods, such as slimming biscuits, special drinks, out-of-date tinned food, snack foods and other worthless items. Today such foods are the exception, not the norm. In their place we have a commitment by UNHCR and WFP to provide fortified foods, such as oil, salt and blended food, which are now a regular part of refugee rations, as this report shows. This represents a significant improvement in the nutritional quality of the rations received and is but one of many advances. Although a critique of the nutritional composition of the rations encountered in these studies goes beyond the objectives of this report, there are a few points worth noting here, particularly in relation to the difference made by the inclusion of fortified foods. In all three sites, the salt and oil included in the ration were fortified (with iodine and vitamin A respectively), which for iodine meant that the rations met the WHO-recommended nutritional requirements for emergencies; but levels of vitamin A in the ration were still only approaching 50 per cent (even where blended food was distributed). The addition of blended food did not necessarily result in a marked improvement in the micronutrient content of the ration, as other changes
were made simultaneously. For example, in Ethiopia the positive impact of adding blended food to the ration was negated by the simultaneous reduction in the amount of wheat grain and fortified oil. However, in Ethiopia the major concern was scurvy, which was addressed partly by the addition of blended food (although the precise amounts after storage and preparation are open to question). Thus blended food does indeed raise the levels of micronutrients in the ration, but in the amounts given in these particular contexts they were far from sufficient to meet requirements. It is likely that the micronutrient deficiencies that are reported are the tip of the iceberg, beneath which lie the untold human costs of living on food rations that are nutritionally marginal for months, if not years, on end. A tribute must be paid to the refugees who must daily survive on these meagre rations. Once they receive the food, there is almost certainly very little wastage, unlike the 'leakages and losses' that occur while the food is en route to them. With few resources at their disposal, refugee women must find ways to maintain the quality of the food they receive, and maximise its palatability and acceptability to their families. At the same time they must make the ration last until the next distribution, while deciding how much to trade or sell in order to purchase other essential items. Managing such a tight, often inadequate budget is no small achievement. Gaps in the food-aid pipeline and subsequent shortfalls in food provision to refugees were a key factor affecting food consumption and use. All the careful fine-tuning of rations is going to make little difference if refugees do not then receive what was promised. The reasons for the shortfalls in food provision represent huge obstacles to any organisation. They include problems of restricted access, insecurity, and most significantly a lack of resources. All external resources emanate from donors; in the absence of clear political commitment and action, the technical solutions will continue to address only partly the suffering of millions of refugees affected by micronutrient deficiencies. Helen Young Oxfam GB
Preface
1 This is not particularly surprising; even where there is an excellent means of prevention, such as distribution of vitamin A supplements, this does not diminish the need for increasing vitamin A consumption through other means, such as fortification of oil, and promotion of home gardens producing green leafy vegetables. 2 Jean Gladwin undertook field trials of an instant blended food among Burmese refugees in Bangladesh in 1992/93. Her findings concur with those of this study, as she found the product was very well accepted by all age groups, and that the product appeared
to be extremely adaptable, being consumed with a variety of foods both sweet and savoury, and was not considered alien to their usual foodstuffs. In contrast to the other foods provided in the ration to these refugees, the instant blended food was not sold. These findings are not widely known, because the report remains unpublished (J. Gladwin, 'Results of a Field Trial of Instant Blended Food Produced by the Milk Marketing Board, UK, Used in Supplementary Feeding Programmes for Moderately Malnourished Children in Rohingya Refugee Camps, Cox's Bazaar, Bangladesh', Liverpool School of Tropical Medicine, UK, 1993).
Executive summary
Micronutrient deficiencies constitute a major public-health problem in refugee populations, and fortification of the cereal staple and/or the provision of a fortified blended food are key strategies identified for prevention. This study aimed to contribute to current discourse on these prevention strategies by providing fieldbased data about use and acceptability of cerealbased foods (cereals and fortified blended food), which is crucial to successful implementation. The study also reviewed opportunities for the fortification of cereals with micronutrients at local or household level. Field studies were undertaken in three sites (7-8 weeks in each):
of food, the intra-household processing and allocation, and levels of acceptability were investigated, with the focus on the cereal staple and blended food supplied in the general ration. In all sites a proportion of food was sold by refugees, the amount judged in two cases to be within 'acceptable' limits and not adversely affecting the local economy. In the third case, the camps had become integral to a complex regional and political economy. Blended food was sold on a very small scale relative to the sale of other commodities. When told of the sales, women expressed surprise and disapproval of those who were allegedly selling. The items purchased were mostly food items, principally vegetables and more of the same or an alternative staple. There was a range of reciprocal arrangements in all sites. Foods were acquired for palatability and flavouring, for an increase in variety to break the monotony, and for special occasions. Storage of meal and blended food inside the home was a problem in all sites, because of the presence of rodents and the problem of contamination with dust. No preparation methods were observed which seemed to be more than usually detrimental to the micronutrient content of the ration food, except multiple washing of rice (Nepal) and sieving of blended food (only by a small minority). In the African sites, methods of preparing whole grain and reasons for using the machine mill and/or milling at home were explained. Methods of cooking blended food varied between sites, but were considered appropriate. Only in Nepal had refugees been explicitly informed that blended food was precooked and that cooking time could be shortened accordingly. Fuel for cooking was an issue in all cases. In Nepal and Tanzania, where kerosene stoves and 'improved' stoves (respectively) had been introduced, women mentioned benefits related to safety and easier tending. A preferential bias in food allocation to men at mealtimes was implied by women interviewees. These patterns varied according to type of household and to circumstances peculiar to
• Bhutanese refugees in Nepal: all camps • Somali refugees in Ethiopia: Kebribeyah and Hartisheikh A • Burundi refugees in Tanzania: Muyovosi camp. The visits included key-informant interviews, formal and informal observation, householdlevel semi-structured interviews, briefing and de-briefing sessions, and reviews of secondary sources. A history of malnutrition and micronutrient disorders was compiled, together with an analysis of the micronutrient content of the planned ration and comment on why the planned ration was not always delivered in full and consistently. In all sites the planned ration was deficient in micronutrients, but the scale of problems of supply differed. There was a history of acute malnutrition and micronutrient deficiency in all sites; incidences were not always co-existent, nor were they confined to one particular phase of the 'emergency' programme. The quality of the monitoring of micronutrient-deficiency disorders also differed between sites.
The use and acce cereal-based foo
of
The concept of refugee preferences within the range of ration and non-ration foods available was examined. The sale, purchase, and exchange
8
Executive summary
daily life as a refugee. Blended food was used and valued in all sites as a complementary food for infants. All members of the household in all sites were said to be eating blended food, but children tended to be given another serving later in the day if they asked. This is not the same as saying that it was mostly eaten by children. Acceptability was associated strongly with familiarity, but unfamiliarity did not always indicate low acceptability. Blended food was highly acceptable. Even though the productp6'r se was not familiar, it was easily recognisable as a porridge and/or fashioned into an already familiar dish.The perceived and actual quality of the blended food and/or the cereal staple was an issue in all sites. In Nepal acceptability of a particular ration food increased when associated with a visible improvement in health. In all sites, blended food was identified with a nutritious porridge which they had known before. Refugees' traditional practices did not detract from the acceptability of blended food in the three sites to any major extent. Differences in customary practices were evident between the educated and non-educated (Tanzania), between pastoralists and town dwellers (Ethiopia), and between the public and the private domains (Nepal). Resale value was a factor, particularly in the level of acceptance of the staple grain, but it was not the over-riding consideration at all times. The resale value of blended food was relatively low, while its general level of acceptability was high. If refugees perceived the food item to be included in the ration at the expense of the reduction or removal of another commodity, this reduced its acceptability. Familiar foods and cooking methods were largely maintained, but not to the exclusion of innovations which were understood to be beneficial, such as parboiled rice, blended food, yellow maize meal, and improved stoves.
Fortification of cereals with micronutrients The second part of the study, related to cereal fortification, found that regional-level fortification would require adequate milling capacity relatively close to the refugee population; a
medium- to long-term commitment by donors; and considerable technical and management expertise at the milling site. Regional-level fortification would be most appropriate where the flour (milled cereal) being distributed was highly acceptable and mostly eaten, not sold or exchanged. Camp-level fortification would require adequate, affordable, and accessible milling capacity; training and health education; and close monitoring of mill technicians to ensure in particular the even mixing of the fortification mix. Camp-level fortification would be most appropriate where the staple grain being distributed was eaten in milled form and highly acceptable; or, if not, was sold or exchanged to obtain an alternative whole grain eaten in milled form. Fortification of cereal at the time of grinding or pounding at household level did not appear to be feasible. This was because of lack of time, containers, space, and standard measures. Furthermore, the staple grain was not always milled to flour prior to consumption; or, if so, was taken to the machine mill. However, a household-level fortification mix in the form of a salt could be added during cooking, as salt and/or spices were used routinely in all sites. Use and acceptability of such an additive would need to be researched. Locally and regionally produced fortified blended food had been distributed in the general ration in all sites. In Nepal and Tanzania, imported blended food had also been distributed interchangeably with the local product. In both cases, there was a preference among the refugees for the imported product, but the local product had not been rejected. There was no facility in-country to analyse samples for their micronutrient content; thus a key aspect of quality-control remained problematic. The study did not reveal major problems with either use or acceptability of blended foods, but did highlight some technical and operational issues of quality-control and timely supply of the locally produced products. As expected, the strategy of cereal fortification was shown to involve major issues of technical and operational feasibility in the two African sites. However, the study revealed aspects of cereal use and acceptability which would also need to be considered for successful implementation.
Abbreviations
Administrative Committee on Co-ordination/Subcommittee on Nutrition
MR
ADFL
Alliance of Democratic Forces for the Liberation of Congo-Zaire
MUAC NFE
ARRA
Administration for Refugee and Returnee Affairs (Ethiopia)
mid-upper arm circumference non-formal education
NGO
non-government organisation
BFP
banket feeding programme (for 90% of households had completely consumed their Unilito ration by the end of the week (the ration period) and there was no evidence of its being sold or exchanged. • There was no significant difference between age-groups in terms of the way that Unilito was prepared and cooked. The study suggested that the fuel issue rather than personal preference influenced the cooking method (i.e. the prohibition on firewood in the camps, 2.1.5). Also it was distributed to all members of the household regardless of age, and all said that all members of the household liked it. • Two out of three of the respondents (almost all were women) were aware that consumption of Unilito could prevent occurrence of beriberi and other micronutrient disorders; they had received this information through the SCF voluntary health workers and community health workers. • The proportion of respondents who washed theirricemore than once before cooking was 95%, die majority of these washing it twice. Most (77%) said that they retained the rice water for use in curry or daal, while the rest threw it away. • Of 106 households asked, the majority (63%) claimed that, given the choice, they preferred polished rice to the parboiled rice. The main reasons given were that parboiled rice is not suitable for the sick, elderly, and small children, nor for performing religious rites. Some also mentioned its bad smell as a reason. • The reporter observed that refugees were prepared to accept blended food, as long as it did not replace any of the rice ration. Graeme Clugston of WHO visited in early July 1994 to review the situation. At the time of his visit, vitamin A deficiency appeared to be controlled, with all children
