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. 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Typeset by Oxfam CSU Printed by Oxfam Print Unit This book converted to digital file in 2010 Contents Acknowledgements 4 3 Case-study: Somali refugees Preface 5 in Ethiopia (May/June 1997) 66 The context 66 Executive summary 8 The field study 74 Abbreviations 10 Conclusion 88 Appendices: 1 Main report 11 3(a) Ethiopia: regions and zones 90 3(b) Location of camps, Somali Region 91 Introduction 11 3(c) Characteristics of the refugee Methodology 12 population 92 Cereal fortification and blended food 13 3(d) Refugee numbers 93 Food and nutrition in the study sites 14 3(e) Market prices at time of study 94 The 'pragmatics of preference' 18 3(f) Chronology of malnutrition and The use of food and micronutrients 20 micronutrient deficiencies 95 What made food 'acceptable'? 24 3(g) List of key informants Cereal fortification at the regional, and interviewees 96 camp, and household levels 27 Conclusions 30 Appendices: 4 Case-study: Burundian refugees l(a) Methods 33 in Tanzania (August/September 1997) 97 l(b) Fortified pre-cooked blended food: The context 97 definitions and examples 37 The field study 103 l(c) Prices, nutritional value, and unit cost Conclusion 118 of WFP-supplied commodities, January 1997 39 Appendices: l(d) Composition and nutritional analysis 4(a) Map: Kigoma Region and of planned rations 40 location of camps 119 4(b) Age and sex composition of population, Muyovosi camp 120 2 Case-study: Bhutanese refugees 4(c) Refugees Statistics Report on in Nepal (January/February 1997) 41 Registration, Kigoma Region, July 1997 121 The context 41 4(d) Market prices at time of study 122 The field study 46 4(e) WFP report of market prices to Conclusion 60 July 1997 123 Appendices: 4(f) Summary of food ration scales and kilo 2(a) Map of Jhapa and Morang Districts 61 calories, January-August 1997 124 2(b) Age and gender composition of camp 4(g) Proposed milling set-up, Isaka 125 population 62 4(h) List of key informants and 2(c) Market prices at time of study 63 interviewees 126 2(d) The process of parboiling rice 64 2(e) List of key informants and interviewees 65 Glossary 127 References 131 Acknowledgements This work was carried out with the aid of grants Dr Johan Pottier for advice and comments on from the United Nations High Commissioner each case-study. for Refugees (UNHCR) and from the Micro- Thanks and appreciation are due also to all nutrient Initiative, an international secretariat the people from UN, NGO, and government housed in the International Development agencies in the three field-study sites who were Centre, Ottawa, Canada. so helpful and supportive during the field We would like to thank Rita Bhatia, Arnold research, in particular the staff of Oxfam Timmer, Gloria Sagarra and Janak Upadhay Nepal, Tanzania, and Ethiopia, and UNHCR (UNHCR, Geneva) and Peter Dijkhuizen (WFP, and WFP staff in all three sites. These and oth- Rome) for information and facilitation during ers are too numerous to mention, but many are the course of the project. included in the list of key informants at the end We also acknowledge the help of Dr Sue of each case study. Thanks also to the three Chowdhury, Dr Steve Collins, and Maurice interpreters, Purnima Sharma, Ebla Abdi, and Herson, who commented on the draft, and Mary Ruheta, for their work and friendship. Preface Episodes of scurvy, pellagra, and beriberi strategies they are not directly comparable. It is among refugees during the 1980s were a stark at best awkward to discuss which strategy is more reminder of the inadequacies and failures of the likely to succeed, because for either approach this international humanitarian response. There depends on a different set of questions and was a public outcry when the range and extent answers. For example, the feasibility of cereal of micronutrient-deficiency diseases became fortification is, in the first instance, dependent on more widely known and publicised, both in the type of cereal (rice being particularly difficult expert meetings (Oxford, 1988) and in tele- to fortify) and the availability of local milling/ vision documentaries (such as Killed by Kindness, fortification capacity. At worst, direct comparisons LWT, 1990). The reactions were swift, as inter- of these two options risk ruling out completely one national agencies and organisations sought or other option. It is far better to identify the solutions and strategies to overcome both the limiting factors or practical constraints associated endemic micronutrient-deficiency diseases with either strategy. (vitamin A deficiency, iron-deficiency anaemia, Our knowledge of what refugees think and and iodine-deficiency disorders), and the inter- do in relation to food is weak indeed. Much of mittent outbreaks of more unusual deficiency what we know about food use and acceptability diseases that were thought to have been all but is to a large extent based on 'received wisdom', eradicated. There is not a single solution to the built upon over-repeated anecdotes whose problem of micronutrient deficiencies; rather a origin can rarely if ever be traced. This received range of strategies must be devised and adapted 1 wisdom cannot be questioned or challenged according to the local context. without proper evidence. There have been This research represents one part of the attempts in the past to look at use and process of developing more effective strategies acceptability of newly introduced foods,- but to combat micronutrient deficiencies among none to our knowledge has involved in-depth vulnerable refugee populations. The two partic- studies of emergency-affected populations, ular strategies of interest are the inclusion of taking into account the wider determinants of fortified blended food in die refugee food rations, use and acceptability, as this study has done. and the fortification of cereals at local or house- A further distinguishing characteristic of this hold level. In broadest terms, die aim of the study is the structures upon which the research research is to provide a clearer understanding of process was based. It represents an unusual and the reality of refugees' lives and the way in which probably unique collaboration between an they make use of the food assistance they receive. international non-government organisation Without such a perspective, how can outsiders (Oxfam GB); the United Nations High Com- have any confidence that their particular missioner for Refugees; the Micronutrient technical solutions will work? Initiative; and the World Food Programme. Such Various approaches to solving the problems collaboration represents far more than simply a of micronutrient deficiencies have their own secure funding base (for which we are very shortcomings and weaknesses. For blended grateful to UNHCR and the Micronutrient food, a problem frequently mentioned is one of Initiative). In these organisations there was a acceptability: it is widely assumed that for most range of individuals contributing their people it is a new food, not previously encoun- expertise and assistance, each of whom has an tered or used. In contrast, the strategy of forti- inestimable knowledge and experience of the fying cereals with micronutrients is far more a refugee situations under investigation. The field technical issue, concerned with the operational researcher herself was familiar with refugee feasibility of local fortification. Thus the practical emergencies, having worked for more than 12 problems of adopting either strategy are quite years in refugee health and nutrition, with different, which means that as policy options or Oxfam and Red Cross inter alia. Qualitative Acceptability and use of cereal-based foods in refugee camps investigations of this nature require consider- were made simultaneously. For example, in able sensitivity towards both the system of humani- Ethiopia the positive impact of adding blended tarian response and the refugees themselves. food to the ration was negated by the simultan- The most recent refugee crises have given eous reduction in the amount of wheat grain rise to a climate of criticism and questioning and fortified oil.