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Misconceptions on nutrition of refugees
1354
Misconceptions on nutrition of refugees SIR,-We are disturbed by misconceptions about nutrition that seriously jeopardise the successful control of malnutrition in refugees and displaced persons. The United Nations coordinating body in nutrition, the UN Advisory Committee on Coordination, Sub Committee on Nutrition (ACC/SCN), has a working group on refugees and displaced people, which met on July 7 and 8,1992, and urged that we draw attention to these misconceptions. The group represents all the UN agencies concerned and several donor * governments and non-governmental organisations.* of staff and and inadequate Although shortages money organisation constrain the effective prevention and treatment of malnutrition among refugees and displaced people, the correction of misconceptions could save lives and safeguard health. Six serious misconceptions that need correction are: "Starving people can eat anything. "It is widely held that people who are starving will be very hungy and eat any food that can be supplied. This attitude is inhumane and incorrect. Even if hungry initially, people often do not consume adequate quantities of unvaried and unfamiliar foods for long enough. More importantly, starving people are often ill and may not have a good appetite. They will therefore languish in an emaciated state or get even sicker. Even someone well-nourished would fail to thrive on the monotonous diets of three or so commodities (eg, wheat, beans, and oil) that is all that is available, month in, month out, to many refugees and displaced people. And this is aside from the micronutrient deficiencies that often develop. This misconception starts, in part, from a failure to agree on explicit objectives for food assistancewhich should surely be to provide for health, welfare, and a reasonably decent existence and help in attaining an acceptable state of self-reliance and self-respect. "Children with diarrhoea should not be intensively fed."A view from many years ago, and from non-emergency situations, sometimes persists-namely, that children must be rehydrated (and diarrhoea prevented) before re-feeding. This policy is incorrect and, with severely malnourished children, it can be fatal. Any child with diarrhoea must be fed, if necessary with a liquid diet by nasogastric tube, at the same time as additional fluids are given. Even if the diarrhoea is profuse, some nutrients are absorbed and can start the recovery process. To begin feeding after rehydration will often be too late. "Refugees can manage with less. " This misconception dehumanises the refugee. It implies that, once uprooted, he or she no longer has the basic human rights to food, shelter, and care-that these are now offered as charitable acts and that refugees can (or should) make do on much less than non-refugees. In fact they will often need more than their normal food requirement at first if they have become malnourished and sick before arrival at a camp and need rehabilitation; and may suffer exposure from inadequate shelter. "Trading foods indicates that people do not need all of the rations. If the only food source is provided by camp organisers, these rations have to be adequate in all nutrients. This requires a mixed food basket, including fruits and vegetables. If this cannot be ensured then trading may have to be encouraged if refugees are not to become undernourished and deficient in micronutrients. The fact that some foods may be traded, to add variety to the diet, is no grounds for reducing the ration. ’;4 standard ration is suitable for all populations. " The recommended per caput calorie output for a refugee population should vary according to demographic composition, nutritional and health status of the population (allowing for an extra "catch-up" allowance where people are malnourished), the activity level the "
*The participants were: Dr B. Austveg (Norway), Dr M. Boelaert (Mededns sans Frontieres, Belgium), Dr G. Clugston (WHO), Dr J-C. Dillon (France), Mme M-J. Floret (DHA/UNDRO), Dr M. Gastellu-Etchegorry (Medecins sans Frontieses, France), Dr S. R. Gillespie (ACC/SCN), Mr L. Glensvig (UNHCR), Dr J. P. Greaves (UNICEF), Mrs N. Haidar (HDA/UNDRO), Mrs J. Katona-Apte (WFP), Mrs J. Koch (NGO Committee on UNICEF), Mr C. La Muniere (DHA/UNDRO), Dr S. Male (UNHCR), Dr J. B. Mason (ACC/SCN), Mrs M. Mokbel (WHO), Dr H. Schellenberg (Switzerland), Dr J. Seaman (Save the Children, UK), Dr F. Simmersbach (UN Food and Agriculture Organisation), Dr R. Waldman (WHO), and Dr L. Weingarmer (Germany).
intake is intended to support, environmental temperature, and likely wastage in the chain from supply of food in a country to its consumption by individuals. In other words there is a range of requirements for dietary energy, which will depend on the circumstances, and use of a single figure is likely to lead to either deficit or wastage. The figure of 1900 kcal (commonly assumed to be of general application) often underestimates what is needed. "Energy adequacy means nutritional adequacy." The diet needs to be adequate in both quantity and quality, meeting requirements for calories, protein, and micronutrients. Where refugees are completely dependent on the ration provided-for example, in the early stages of an emergency or in closed camps, where trading for diversity cannot be ensured-the ration must be designed to meet the requirements of all nutrients in full. Often, a ration is designed to meet minimum energy requirements and micronutrients are left to look after themselves. How micronutrient needs are to be met must be made explicit, especially when the ration provided is calculated on the basis of fully meeting energy needs. Foods should be diverse and palatable, and the special needs of weaning children must be met. These and other issues are being addressed in a collaborative inter-agency revision of the 1978 manual The Management of Nutritional Emergencies in Large Populations, to be published soon by WHO. UN ACC Subcommittee on Nutrition, c/o World Health Organization, 1211 Geneva 27, Switzerland
JOHN MASON
WHO Nutrition Unit
GRAEME CLUGSTON
UNICEF Nutrition Cluster
PETER GREAVES
STUART GILLESPIE
Living kidney donors SIR,-Dr Najarian and colleagues (Oct 3, p 807) provide that the short-term and long-term risks to a healthy kidney donor are quite small. These data are very important since they lend support to the notion that increasing the use of living donors is safe. Indeed, several transplant centres are now successfully using emotionally related (though genetically reassurance
unrelated) donors.1 On the other hand, Najarian’s finding that
seven donors have died since 1988 is worrisome. I assume that these deaths were not all perioperative, since only five were reported between 1980 and 1991. It would be very helpful to know the details of these seven deaths if we are to prevent further tragedies. I doubt that these deaths were due to "relaxed eligibility criteria" as Najarian et al suggest, since staff at most transplant centres are still somewhat uncomfortable about the use of living donors.2 Furthermore, I am concerned that this suggestion, by such a respected transplant group, may inhibit the occasional acceptance of a donor at small or unknown added risk. Staff at transplant centres, though well intentioned, seem a little too paternalistic. In general, donors are excluded from the decision-making process with respect to their own suitability. Such an approach fails to consider that the decision to donate a kidney involves much more than an assessment of medical risks and benefits. Of at least equal importance are the values of the donor who may be willing to undertake whatever risks are necessary to restore the health of a loved one.3 For many, the value of a successful outcome would be immeasurable. Furthermore, Simmons et al4 at the University of Minnesota demonstrated that most living donors also benefit through meaningful and persistent feelings of increased self-worth and self-esteem. Najarian and his colleagues at the same university have done perhaps more than anyone to promote living donation. I believe that what is good for the recipient is often good for the donor. Therefore, although a medical evaluation is critical, the decision to donate should not be made on this basis alone. When a donor wants to accept risks that we think ill-advised, we do not have to accept that donor; but we do need to examine closely the values of the donor, realise that they may differ from our own, and try to understand his or her point of view.3 Hopefully, in so doing, we can achieve a
Misconceptions on nutrition of refugees SIR,-We are disturbed by misconceptions about nutrition that seriously jeopardise the successful control of malnutrition in refugees and displaced persons. The United Nations coordinating body in nutrition, the UN Advisory Committee on Coordination, Sub Committee on Nutrition (ACC/SCN), has a working group on refugees and displaced people, which met on July 7 and 8,1992, and urged that we draw attention to these misconceptions. The group represents all the UN agencies concerned and several donor * governments and non-governmental organisations.* of staff and and inadequate Although shortages money organisation constrain the effective prevention and treatment of malnutrition among refugees and displaced people, the correction of misconceptions could save lives and safeguard health. Six serious misconceptions that need correction are: "Starving people can eat anything. "It is widely held that people who are starving will be very hungy and eat any food that can be supplied. This attitude is inhumane and incorrect. Even if hungry initially, people often do not consume adequate quantities of unvaried and unfamiliar foods for long enough. More importantly, starving people are often ill and may not have a good appetite. They will therefore languish in an emaciated state or get even sicker. Even someone well-nourished would fail to thrive on the monotonous diets of three or so commodities (eg, wheat, beans, and oil) that is all that is available, month in, month out, to many refugees and displaced people. And this is aside from the micronutrient deficiencies that often develop. This misconception starts, in part, from a failure to agree on explicit objectives for food assistancewhich should surely be to provide for health, welfare, and a reasonably decent existence and help in attaining an acceptable state of self-reliance and self-respect. "Children with diarrhoea should not be intensively fed."A view from many years ago, and from non-emergency situations, sometimes persists-namely, that children must be rehydrated (and diarrhoea prevented) before re-feeding. This policy is incorrect and, with severely malnourished children, it can be fatal. Any child with diarrhoea must be fed, if necessary with a liquid diet by nasogastric tube, at the same time as additional fluids are given. Even if the diarrhoea is profuse, some nutrients are absorbed and can start the recovery process. To begin feeding after rehydration will often be too late. "Refugees can manage with less. " This misconception dehumanises the refugee. It implies that, once uprooted, he or she no longer has the basic human rights to food, shelter, and care-that these are now offered as charitable acts and that refugees can (or should) make do on much less than non-refugees. In fact they will often need more than their normal food requirement at first if they have become malnourished and sick before arrival at a camp and need rehabilitation; and may suffer exposure from inadequate shelter. "Trading foods indicates that people do not need all of the rations. If the only food source is provided by camp organisers, these rations have to be adequate in all nutrients. This requires a mixed food basket, including fruits and vegetables. If this cannot be ensured then trading may have to be encouraged if refugees are not to become undernourished and deficient in micronutrients. The fact that some foods may be traded, to add variety to the diet, is no grounds for reducing the ration. ’;4 standard ration is suitable for all populations. " The recommended per caput calorie output for a refugee population should vary according to demographic composition, nutritional and health status of the population (allowing for an extra "catch-up" allowance where people are malnourished), the activity level the "
*The participants were: Dr B. Austveg (Norway), Dr M. Boelaert (Mededns sans Frontieres, Belgium), Dr G. Clugston (WHO), Dr J-C. Dillon (France), Mme M-J. Floret (DHA/UNDRO), Dr M. Gastellu-Etchegorry (Medecins sans Frontieses, France), Dr S. R. Gillespie (ACC/SCN), Mr L. Glensvig (UNHCR), Dr J. P. Greaves (UNICEF), Mrs N. Haidar (HDA/UNDRO), Mrs J. Katona-Apte (WFP), Mrs J. Koch (NGO Committee on UNICEF), Mr C. La Muniere (DHA/UNDRO), Dr S. Male (UNHCR), Dr J. B. Mason (ACC/SCN), Mrs M. Mokbel (WHO), Dr H. Schellenberg (Switzerland), Dr J. Seaman (Save the Children, UK), Dr F. Simmersbach (UN Food and Agriculture Organisation), Dr R. Waldman (WHO), and Dr L. Weingarmer (Germany).
intake is intended to support, environmental temperature, and likely wastage in the chain from supply of food in a country to its consumption by individuals. In other words there is a range of requirements for dietary energy, which will depend on the circumstances, and use of a single figure is likely to lead to either deficit or wastage. The figure of 1900 kcal (commonly assumed to be of general application) often underestimates what is needed. "Energy adequacy means nutritional adequacy." The diet needs to be adequate in both quantity and quality, meeting requirements for calories, protein, and micronutrients. Where refugees are completely dependent on the ration provided-for example, in the early stages of an emergency or in closed camps, where trading for diversity cannot be ensured-the ration must be designed to meet the requirements of all nutrients in full. Often, a ration is designed to meet minimum energy requirements and micronutrients are left to look after themselves. How micronutrient needs are to be met must be made explicit, especially when the ration provided is calculated on the basis of fully meeting energy needs. Foods should be diverse and palatable, and the special needs of weaning children must be met. These and other issues are being addressed in a collaborative inter-agency revision of the 1978 manual The Management of Nutritional Emergencies in Large Populations, to be published soon by WHO. UN ACC Subcommittee on Nutrition, c/o World Health Organization, 1211 Geneva 27, Switzerland
JOHN MASON
WHO Nutrition Unit
GRAEME CLUGSTON
UNICEF Nutrition Cluster
PETER GREAVES
STUART GILLESPIE
Living kidney donors SIR,-Dr Najarian and colleagues (Oct 3, p 807) provide that the short-term and long-term risks to a healthy kidney donor are quite small. These data are very important since they lend support to the notion that increasing the use of living donors is safe. Indeed, several transplant centres are now successfully using emotionally related (though genetically reassurance
unrelated) donors.1 On the other hand, Najarian’s finding that
seven donors have died since 1988 is worrisome. I assume that these deaths were not all perioperative, since only five were reported between 1980 and 1991. It would be very helpful to know the details of these seven deaths if we are to prevent further tragedies. I doubt that these deaths were due to "relaxed eligibility criteria" as Najarian et al suggest, since staff at most transplant centres are still somewhat uncomfortable about the use of living donors.2 Furthermore, I am concerned that this suggestion, by such a respected transplant group, may inhibit the occasional acceptance of a donor at small or unknown added risk. Staff at transplant centres, though well intentioned, seem a little too paternalistic. In general, donors are excluded from the decision-making process with respect to their own suitability. Such an approach fails to consider that the decision to donate a kidney involves much more than an assessment of medical risks and benefits. Of at least equal importance are the values of the donor who may be willing to undertake whatever risks are necessary to restore the health of a loved one.3 For many, the value of a successful outcome would be immeasurable. Furthermore, Simmons et al4 at the University of Minnesota demonstrated that most living donors also benefit through meaningful and persistent feelings of increased self-worth and self-esteem. Najarian and his colleagues at the same university have done perhaps more than anyone to promote living donation. I believe that what is good for the recipient is often good for the donor. Therefore, although a medical evaluation is critical, the decision to donate should not be made on this basis alone. When a donor wants to accept risks that we think ill-advised, we do not have to accept that donor; but we do need to examine closely the values of the donor, realise that they may differ from our own, and try to understand his or her point of view.3 Hopefully, in so doing, we can achieve a