Session at a Glance

Trainer's Notes for the UNHCR Emergency Management Training

S E S S I O N 7 . 2 .

Food and Nutrition in Emergencies

Session at a glance Content Approx. Instructional Activity Time Presentation of Nutrition and video 30 minutes Plenary Presentation & Q&Q exercise Presentation of Food Aid Distribution 15 minutes Presentation with Q&A Ration Calculation Exercise 35 minutes Individual/Group Exercise and And Wrap-up Presentation Total Time 90 minutes

Main objectives After completing this session, participants will be able to:

 Discuss the major nutritional and food distribution concerns during emergencies  Highlight the relationship between malnutrition and disease and the need to relate across sectors to ensure good nutrition and health  Focus on the need for an adequate basic ration adjusted for demographics as the best means to prevent malnutrition and disease  Review the methods for determining nutritional status in the population  Discuss ways to address serious and moderate malnutrition through special feeding programs and targeted interventions

Special supplies Flip chart and markers Overhead projector Applicable overheads Video player and exercise video Optional – demonstration daily ration (obtained from kitchen or market and weighed out)

General guidance This session provides an overview of the major food and nutrition program concerns and decisions that generally confront refugee emergency managers. Its main goal is to prompt managers into recognizing the signs and symptoms of malnutrition and encourage them to engage in preventative practices. The UNHCR Technical Support Service Nutritionist and Emergency Unit maintain a library and will always be a willing source of additional information for this session.

Key Points Main points and themes in this session include:

1 Trainer's Notes for the UNHCR Emergency Management Training

1. Emergency managers must consider the direct and reinforcing relationship between malnutrition and infection (morbidity) in making food programming decisions. 2. Malnutrition affects mainly vulnerable groups - children, pregnant and lactating mothers, the elderly and the chronically ill. 3. The basic nutritional requirement that must be met is 2100 kilo-calories per person per day, a standard in use by UNHCR. This figure applies to the gross refugee population for a group exhibiting “normal” demographics. In caseloads where the demographics indicate higher than normal numbers of people with greater caloric requirements, the 2100 kcal/p/d this figure may need to be increased. 4. The most common malnutrition measurement techniques are the “weight-for height” and the middle-upper-arm-circumference or “MUAC” measures. 5. Corrective measures for malnutrition are Selective Feeding Programs (SPFs) which include therapeutic feeding programs for the severely malnourished and supplementary feeding programs for the moderately malnourished. 6. Design of the basic food basket should be worked out on a case by case basis taking into account demographics, climate, food habits or taboos, and access to non-ration food sources. 7. Some of the common problems associated with the general ration distributed to refugee populations include:  insufficient total calories  logistical failure or ”pipeline” breakdown”  poor registration, hence incorrect demographic data  low vitamins, niacin, or mineral content  poor grinding or preparation facilities  insufficient cooking fuel  ineffective distribution system

Supplementary/Additional Reading Mears, C. and Chowdury, S. (1994) Health Care for Refugees and Displaced People. Oxfam Practical Guide no.9. MSF (1995). Nutrition Guidelines. WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies, December 1997 Young, H. and Jaspars, S. (1995) “Malnutrition, disease and death in times of famine.” Disasters, June. Session Activities

Presentation of Nutrition Basics 30 minutes Introduce the topic of Food & Nutrition as a critical response sector that must be addressed in every refugee emergency. Explain that this session will focus primarily on the management aspects of nutritional programs for refugee emergencies, and that although it will not make the participants into nutritionists, it should provide valuable insight into the critical aspects of the nutritionist’s work and the management of nutritional emergencies.

Select from the overheads to cover the major points of the F&N presentation, the malnutrition/ infection cycle, daily energy requirements and ration size, micro-nutrient deficiency, management of supplementary and therapeutic feeding programmes, Weight for Height and MUAC techniques of body measurement.

It is generally necessary early in the session to conduct a review of the five nutrient groups (protein, carbohydrates, fat, vitamins and minerals) and explain the functions and caloric content of each. Many people do not know or remember these facts.

To give participants some experience in recognizing the signs and symptoms of micronutrient deficiencies and PEM, photos on the overheads or slides of each condition should be used. These will provide a view to reality and are generally of great interest to participants. An explanation will be needed as to how the victim will act or behave under the condition, and the best programmatic response for each.

Video Exercise 15 minutes 1. Use the EMTP training video exercise # 8 - Emergency Nutrition - to illustrate some of the management concerns for nutrition in refugee emergencies. Tell participants to take notes on the situation, condition and numbers of affected, and planned/actual response. Question the participants on these concerns after the video and take their comments, but try to limit the discussion to the reserved time.

2. The tape runs about 6 minutes but the analysis can easily take 15-30 minutes depending on the method used to facilitate the group discussion. Alternatively, use only one of the scenarios.

Food Aid (Distribution) 15 minutes Food distribution is often covered in a separate session. If this session is not included in the program, it is necessary to discuss how the distribution system links in with nutrition, particularly the quality and availability of foods, and the supporting systems for cooking and storage. Spend a few minutes going over the details of the WFP/UNHCR MOU concerning food assistance for refugee influx emergencies. This discussion should simply clarify the guidelines and indicate areas where WFP and UNHCR have agreed to cooperate during emergencies. Be prepared to explain Extended Delivery Points if it is mentioned on the overhead. To simplify the discussion, simplify the overhead. (If there is a logistics session, the MOU may be covered there in more detail. It is advisable to have a UNHCR or WFP representative explain the details.)

Group Exercise – Ration Calculation and Demonstration Duration - 35 minutes 1. In 4-5 small groups, ask participants to turn to the Nutrition Exercise at the back the section on F&N in Emergencies (also annexed to these training notes) and do the exercise. Be sure that the exercise that you choose (either rice or corn based) is appropriate for the places that they are likely to work in an emergency. Answer sheets should be photocopied in advance or answers put on the overhead.

2. After 15 minutes ask for their results and record their answers on a flip chart (group by group.) Ask the groups to comment on the process they used to do the work, what references they found useful, what difficulties they faced, and what factors facilitated their work. (To speed the process, the task can be done individually and individuals asked to give their results. Generally, very few people get the exact results as on the answer sheet. This helps them to appreciate the difficulty of getting the perfect food basket.)

3. Finally pass out the answer sheets (also annexed to these notes) and briefly review the answers. The important distinctions on the answer sheet which the facilitator can hint at in the main body presentation are:  If the ration is for a rice eating population – it has a lower fat content. Customarily, a canned fish is added.  The grains contain some fat and the fish is high in protein which is demonstrated by use of the protein and fat calculation columns  In wheat and corn-eating populations particularly, a fortified corn soy blend may be added, although this is expensive  The calculations vary slightly from the Rations listed on page 205 of the Handbook.

4. If a demonstration ration has been prepared, show the ration around to the participants and ask them what is likely to result from this diet every day. The answers should include boredom with the same thing everyday, possible micronutrient deficiencies over the long term, and sales of some of the items.

5. Advise the participants to review the “Tools and Resources” section of the course notebook and the Annexes to the Nutrition topic paper to understand more completely the details of F&N in emergencies, and to take note of the location of the various tables for future reference. Conclude the session by summarizing and thanking the participants for their inputs.

An Emergency Nutrition/Ration Problem

20,000 refugees have just crossed into Suremia and have spontaneously self- settled in a low-lying area just across the border from Tulera. They all belong to a party in opposition to the new government in Tulera which is headed by a strong military dictator. They fled the capital city and two other large cities with their families after a public announcement that their names were known and that they were all due to be jailed due to their involvement with the opposition party.

Since they fled some two to three weeks ago, many have no provisions left, no money, and are entirely dependent on the food rations distributed to the makeshift camp by your organization. They traditionally rely on rice, without other strong religious or traditional limitations on food type or preparation.

Assignment:

1. Describe a suitable "food basket" or ration on a per person basis to be used as a general distribution for this group. Use the table below to organize and allocate the elements of your food basket. Use whatever resources or references you can find to answer the question.

Commodity g/person/ Pro/gm/kcal Fat/gm/kcal kcal/person/day day Cereals (rice) Pulses (beans)

Oil (vegetable)

Canned Fish

TOTAL/person/day

2. How many tons of food (all requirements from the table above) are required for this population for one month?

Emergency Food and Nutrition Problem Answer Sheet

Population characteristics: 20,000; Rice-eating; Completely dependent on food aid

Describe a suitable "food basket" or ration on a per person basis to be used as a general distribution for this group. Use the table below to organize the elements of your food basket.

Commodity g/person/ Pro/gm/kcal Fat/gm/kcal kcal/person/day day Cereals (rice) 420g 29.4/117.6 2.1/18.9 1,512 kcal

Pulses (beans) 60g 12.0/48 .72/6.48 201 kcal

Oil (vegetable) 30g 0 30.0/270 270 kcal

Sugar 20g 0 0 80 kcal

Canned Fish 30g 6.6/26.4 7.2/64.8 91.5 kcal

Salt 5g 0 0 0 kcal

TOTAL/person/day 565 grams 48/192 40/360 2,154.5 kcal 9% 17%

* Modified from the WFP/UNHCR Guidelines for Estimating Food and Nutritional needs in Emergencies, December 1997 "Type 4 Ration"

This ration uses rice as the cereal; the low percentage of protein is acceptable due to its high quality

How many tons of food (all requirements from the table above) are required for this population (20,000 people) for one month?

20,000 people x 30 days x .565 =339,000k = 339 tons/month

An Emergency Nutrition/Ration Problem

20,000 refugees have just crossed into Suremia and have spontaneously self- settled in a low-lying area just across the border from Tulera. They all belong to a party in opposition to the new government in Tulera which is headed by a strong military dictator. They fled the capital city and two other large cities with their families after a public announcement that their names were known and that they were all due to be jailed due to their involvement with the opposition party.

Since they fled some two to three weeks ago, many have no provisions left, no money, and are entirely dependent on the food rations distributed to the makeshift camp by your organization. They traditionally rely on cereals, without other strong religious or traditional limitations on food type or preparation.

Assignment:

3. Describe a suitable "food basket" or ration on a per person basis to be used as a general distribution for this group. Use the table below to organize and allocate the elements of your food basket. Use whatever resources or references you can find to answer the question.

Commodity g/person/da Pro/gm/kcal Fat/gm/kcal kcal/person/day y Cereals (corn) Pulses (beans)

Oil (vegetable)

Corn Soy Blend (CSB)

TOTAL/person/day

4. How many tons of food (all requirements from the table above) are required for this population for one month?

Emergency Food and Nutrition Problem Answer Sheet

Describe a suitable "food basket" or ration on a per person basis to be used as a general distribution for this group. Use the table below to organize the elements of your food basket.

Commodity g/person/da Pro/gm/kcal Fat/gm/kcal kcal/person/day y Cereals (Corn/maize) 400g 40.0/160 16.0/135 1,400 kcal

Pulses (beans) 60g 12.0/48 .72/6.48 201 kcal

Oil (vegetable) 25g 0 25.0/225 225 kcal

Sugar 15g 0 0 60 kcal

Corn Soy Blend 50g 9.0/36 3.0/18 190 kcal

Salt 5g 0 0 0 kcal

TOTAL/person/day 555 grams 61/244 45/405 2,076 kcal 12% 19.5%

* from the WFP/UNHCR Guidelines for Estimating Food and Nutritional needs in Emergencies, December 1997 "Type 1 Ration, from table on page 5."

How many tons of food (all requirements from the table above) are required for this population (20,000 people) for one month?

20,000 people x 30 days x .555k =333,000k = 333 tons/month