Having access to adequate and safe food is a fundamental right of everyone, and it is protected by international law.

In the humanitarian environment, interactions in the field require coordination, cooperation, and conflict resolution. For that purpose, in 1991 United Nations created two organizations: the Office for the Coordination of Humanitarian Affairs (OCHA, no date) in partnership with national governments and humanitarian organizations, including United Nations (UN) partners, Non-Governmental Organizations (NGOs), and local communities, and the Inter-Agency Standing Committee (IASC) to set strategic policies, guidelines and prioritizing tools in response to humanitarian crises (The Inter-Agency Standing Committee | IASC, no date). 

“OCHA’s mission is to coordinate the global emergency response” (Coordination, 2016) to mobilize international assistance, improve prioritization, reduce duplication, and provide protection for those who need it. OCHA works as the central hub for humanitarian information and manages global and country-specific humanitarian response funds. On the one hand, it collects, analyses and shares critical humanitarian data and management services to ensure that the decision-making in delivering humanitarian aid lies on evidence-based practice (Coordination, 2016). On the other hand, the Central Emergency Response Fund (CEPF), with an annual funding target of $1 billion, helps aid organizations and local partners on the ground to prioritize the most urgent types of assistance to allocate funds strategically (Humanitarian Financing, 2016). The health cluster approach has generated successful outcomes, but there are coordination gaps regarding security, communication, and mobilization of resources within the health systems that need to respond. 

The security approach is an ongoing negotiation of humanitarian principles that can often conflict with the realities in the field. Insecurity, growing needs, and the obstruction, denial or politicization of humanitarian assistance create an environment unfavourable to neutral, independent, and impartial humanitarian action. Likewise, information-sharing services and networks are vital to humanitarian operations. However, bringing national and international partners together is complex, especially when negotiating access and aid delivery for people caught in armed conflicts or natural disaster zone. In addition, mobilizing the humanitarian response is based on prioritization: who needs it most within the existing budget. At the beginning of 2021, 239 million people required life-saving aid (Minasi, no date). Conflicts and climate change have threatened food supplies increasing the number of displaced people with malnutrition disorders (Climate emergency | MSF, no date). Social, political, and economic inequalities within and among countries have also been amplified in the context of the COVID-19 pandemic (Ismail et al., 2021; Manirambona et al., 2021). In this scenario, the expenditure in managing global emergency response is higher, and the scarcity of resources too (Ekezie et al., 2019). Technical and management tools and monitoring systems for better accountability can help to fill the gap. 

What can nurses contribute to cluster meetings? First, voicing the claim, “No one is safe until everyone is safe” (UN agencies issue urgent call to fund the global emergency supply system to fight COVID-19, 2020). Nurses make decision-makers understand what is happening in the world’s humanitarian crisis. Second, nursing knowledge can explain how the lack of food, water, sanitation, hygiene promotion, safety, security, and protection generates poor health outcomes and dire consequences in the short and long term. Third, as skilled human resources, nurses can provide essential health service advice and case management, including the most vulnerable community members, like children, women and persons with disabilities. 

Having access to adequate and safe food is a fundamental right of everyone, and it is protected by international law. The United Nations High Commissioner for Refugees (UNHCR) and the host government coordinate the nutrition issues inside and outside refugee camps. Malnutrition is common in refugee camps (Doocy et al., 2011), but moderate acute malnutrition (MAM) can be prevented and treated. UNHCR and the World Food Program (WFP) adopted 2,100 kcal as their initial planning figure for designing acceptable basic food rations that meet the population’s minimum energy requirements for survival and light physical activity, providing adequate protein, fat, and micronutrients (vitamins and minerals) (‘food-and-nutrition-needs-in-emergencies.pdf,’ no date, p. 1)

“MAM, also known as wasting, is defined by a weight-for-height indicator between -3 and -2 z-scores (standard deviations) of the international standard or by a mid-upper arm circumference (MUAC) between 11 cm and 12.5 cm.” (Types of Acute Malnutrition, no date). Causes and determinants are multifactored (Kravitz, 2019, p. 412). Inadequate food intake and repeated disease are interconnected with an unhealthy household environment, poor feeding and care practices, and insufficient healthcare. To tackle the given assignment, the feeding program data comes from the sphere handbook (Sphere Project, 2018), the global nutrition report (‘GNC MID YEAR REPORT 2021_Global_0.pdf’, no date), and the MAM task force (‘DECISION-TOOL-FOR-MAM_w-exceptional-cicumstances_-May-2017-update-final1.pdf’, no date), and the food and nutrition needs in emergencies report (‘food-and-nutrition-needs-in-emergencies.pdf,’ no date).

The primary strategy for preventing and treating MAM is directly providing food supplements and routine medical treatment through the Targeted Supplementary Feeding Program. TSFP key priorities are distributing specialized nutritious food and meeting the nutritional needs of vulnerable groups. They are not meant to replace the diet but to complement it.

In line with the Food and Agriculture and the World Health Organizations (FAO/WHO) technical reports, a ration should provide at least 10-12 percent of proteins, 17 percent of fat (up to 40 percent for some young children, and 20 percent in pregnant and lactating women) of total energy, and cover the deficiency in iron, vitamin A, and iodine, which are the three most significant micronutrient-deficiency diseases worldwide. Fortified blended foods (FBFs) like iodized salt, micronutrient powders or vitamin A-fortified vegetable oil provide these micronutrients (Stuetz et al., 2012). They are mainly used in young children, pregnant, lactating women, and the elderly. Ready-to-Use Therapeutic Food (RUTF) is designed explicitly for MAM treatment in children 6-59 months (Dalglish et al., 2020). It is given for six to eight weeks, with no other foods during treatment than breastmilk. Special commodities are used only for an immediate response when no other foods/cooking facilities are available. They include high-energy/protein biscuits, humanitarian daily rations (HDRs) and meals ready to eat (MREs). Factors to consider in selecting the specialized foods for MAM treatment include the household’s ability to cook and cultural food preferences. The taste preferences of communities affected by the crisis are considered. Improved fortified blended foods are available in a corn-soy blend, wheat and maize (Nane, Hatløy and Lindtjørn, 2021). Ready-to-use specialized foods are peanut-based and chickpeas.

Infants and young children (Carroll et al., 2017), pregnant and lactating women (Stuetz et al., 2012), older persons (Khatib IM, Samrah SM, and Zghol FM, 2010), and people with disabilities (Dator, Abunab and Dao-ayen, 2018) are the most vulnerable population. In children aged 12–59 months, TSFP delivers appropriate vitamin A, iron and folic acid supplementation combined with zinc for treating diarrhea, malaria screening and treatment, prophylaxis for intestinal parasites and immunizations. The nutrition program includes infant stimulation activities and early child development care practices. Malnourished infants less than six months are not admitted for treatment. The mother will be enrolled in the MAM programme for nutritional support, not the child. Pregnant women require an additional 285 kcals/day, daily supplements of iron (60mg/day) and folic acid (400 𝜇g/day). Lactating women require an additional 500 kcals/day, plus vitamin A 400000 IU in 2 doses of 200000 IU in at least 24 hours within six weeks after delivery. “UNHCR, UNICEF, WFP and WHO comply with the international guidelines on the protection and promotion of breastfeeding.” (food-and-nutrition-needs-in-emergencies.pdf, n.d., p.17). It includes clear information on the importance of exclusive breastfeeding in children up to six months and continued breastfeeding for up to 24 months for both mother and child’s physical and psychological health. HIV mothers should be supported to breastfeed for at least 12 months and up to 24 months or longer while receiving antiretroviral therapy. TSFP prioritizes pregnant and breastfeeding women’s access to food and skilled breastfeeding counselling in maternity services. Those over 60 need access to easily digestible, micronutrient-rich foods and family and community support for food preparation. Lastly, people living with HIV, tuberculosis, or other chronic diseases are discharged from care but require therapeutic support to avoid relapse. Persons with disabilities may also benefit from supplementary feeding (Al-Rousan et al., 2018).

There are two key implementing phases. The first one occurs within the first two to three days from the outset of the emergency. It includes initial rapid food security and nutrition assessments to distribute food immediately and set the basis for designing programmes within two to three weeks. Once the situation is stabilized, a risk of deterioration assessment within 3 to 12 months identifies the risk factors that increase morbidity and mortality due to epidemics, decreased food security, significant population displacement, and dense population concentration. The duration of MAM treatment ranges from 1-4 months. A scaled-down plan usually starts when MAM and treatment patients are low -Global Acute Malnutrition (GAM) rates below 5%- and no aggravating factors exist. It includes monitoring food security and coping strategies after adjusting rations to ensure that the reduction does not have adverse effects and allows long-term sustainability.

Delivery mechanisms should be addressed. For example, it may be necessary to provide rations weekly or every two weeks if there is a high population density or access difficulties. Working with the target population to locate programme sites and share clear and comprehensive information on the available support in accessible languages is essential. TSFP sites require large areas for waiting, measuring, monitoring, and providing food supplements, but it does not require healthcare staff for implementation. However, they can be established adjacent to the outpatient treatment centres (OTPs) and health care systems, facilitating access and maintaining links to inpatient and outpatient therapeutic care. Coordinating with the water/sanitation programming and food security sectors also helps provide clear information on how to prepare and store supplementary food hygienically and how and when to consume it (Al-Rousan et al., 2018)

Essential data for these assessments come from primary sources of information like quantitative and qualitative public health reports. Secondary key informants are local leaders, representatives, especially women and their community’s perceptions and opinions. Working with community stakeholders helps to identify vulnerable individuals and households. Admission and discharge protocols are based on nationally and internationally accepted anthropometric criteria. Discharge statistics reflect the percentage of discharge recovered, not recovered, died, and defaulted individuals. Monitoring systems include the population’s participation, acceptability of the programme, the quantity and quality of food coverage, reasons for transfers to other programmes and the number of individuals admitted and in treatment. Follow-up strategies may require adaptation after specific time intervals because trends in nutrition vary. 

The unavailability of data is one of the challenges in implementing the feeding programme in refugee camps. It affects the capacity of existing systems for service delivery, monitoring coverage, adherence, acceptability and rations provided. When data are not available or not updated, international databases, surveillance systems, and older data are used. Another primary constraint is the food pipeline. The availability of supplementary foods on national or international markets and the food distribution process at the community and household level can be an issue. Therefore, the exchange and trade of rations should be carefully monitored. In addition, there are factors affecting food processing, preparation, and use. Proper packaging and labelling and regular quality control check are necessary. Last but not less, there may be difficulties related to insufficient staff. Assessment methodologies are costly and require specially trained male and female nutrition staff that do home visits and screening, understand admission criteria and teach caregivers to identify signs of malnutrition.

References

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Carroll, G.J. et al. (2017) ‘Evaluation of Nutrition Interventions in Children in Conflict Zones: A Narrative Review’, Advances in Nutrition: An International Review Journal, 8(5), pp. 770–779. doi:10.3945/an.117.016121.

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