Field Surveys to Assess the Nutritional Status of Burmese Refugees in Thailand: Basis for Recommendations for Humanitarian Programs
It is estimated that more than a million indigenous Burmese have sought refuge in camps along its borders. An estimated 114,000 of those refugees are now seeking refuge in camps along the Thai/Burma border. This population has not been evaluated critically and is at significant nutritional risk. It is urgent that nutritional assessments be completed in this high-risk population now. It is estimated that 13 million people die each year from extreme malnutrition and hunger related causes, nearly 35,000 per day; three quarters of them are children (Young, 1997). FAO/WHO (1992) estimated that there are 786 million malnourished individuals in the world that may be suffering from dietary deficiency, secondary malnutrition or under-nutrition. Many of these individuals are refugees that have fled their countries due to political unrest and displaced populations have an extremely elevated risk of nutritional stress. The main factors contributing to elevated nutrition stress are lack of food, security risks, high population density, inadequate food procurement and preparation, remote locations, and poor sanitation.
Refugees have been fleeing Burma since the early 1980s but to this date there is little published data on the nutritional status of this highly vulnerable population. The purpose of this study is to conduct a nutritional review and assessment in the refugee population in camps along Thailand’s western border, shared with Burma. Evaluation tools will include dietary recalls, focus groups, key informant interviews, anthropometric measurements, and nutrient specific laboratory assays.
The main objectives of this study are to determine the nutritional status of women and children (age 6 months to 10 years). This subset of the population is being evaluated since they are more sensitive to nutritional stress. The aim is to test the hypotheses:
- Dietary intake for individuals residing in the refugee camps is inadequate to meet macronutrient and micronutrient requirements.
- Individuals that have recently arrived (<2 months) in the camps have an increased prevalence of nutritional deficiencies as compared to individuals that have been in the camps for a longer period of time.
- A portion of the ration that is provided to the refugees is being traded for additional foods to supplement intake and add variety. Only a portion of the ration provided is being consumed by the individual that it was intended for.
The study will provide an insight into the actual nutrition status of the Burmese refugee population by looking at food availability at the household level (Appendix 1), factors affecting nutritional deficiency outcomes (Appendix 2) and the nutritional status of individuals residing in the refugee camps. The goal of the study is to determine the extent of malnutrition and micronutrient deficiencies within the camps.
Overview of the Study
The scope of this research proposal is to conduct field surveys in refugee camps of Burmese in Thailand. Thai and U.S. team members will work together to gather information about the nutrition problems in the camps and the factors that demonstrate high relative risks for malnutrition. The project will serve as a model providing guidelines that can be exported to similar situations in other countries. Outcomes and recommendations based on the published research findings will assist in improving nutritional status in humanitarian missions throughout the world.
This research project brings together a variety of facilities and organizations in the U.S. and Thailand that will work together in a cooperative effort to ensure research project success. Miss Kongsomboon from the Thai Red Cross Society has been instrumental in coordinating research project requirements from within Thailand. Coordination and planning have been initiated with international nutrition experts, non-governmental organizations (NGO’s), Thai Ministry of Public Health, University of Washington, U.S. Army Research Institute of Environmental Medicine (USARIEM), Armed Forces Research Institute of Medical Sciences (AFRIMS), Pennington Biomedical Research Center, and Burmese Border Consortium (BBC) in Thailand. The list of research team partners is in Appendix 3. They will work cooperatively in numerous capacities, i.e., support, laboratory analysis, nutrient analysis, personnel, equipment, facilities, and/or consultant.
As of January 1999 there were approximately 114,000 refugees living within 16 refugee camps along the Thai/Burma border. The following Karen camps are tentatively selected for the survey work: Chumphon, population 275; Ban Don Yang, population 1,742; Nu Po, population 8,599; and Mawker, population 8,848 (Appendix 4). The research focuses on women and children (age 6 months to 10 years) since this population will best reflect the nutritional status of the population.
Refugees have limited or no income. Access to farmland, gardens, fishing, hunting, gathering, raising animals, and jobs is very limited. Security remains a problem. Food aid is being provided to the refugee camps. Rice rations are allocated per person on a monthly basis and each family also receives a share of calipe beans, oil, fish paste, chilies, and iodized salt.
Traditional food habits of the Karen consist of a diet high in carbohydrate that is primarily vegetarian. Protein is consumed in the form of fish, beans, and insects. Curry, onions and rice are mainstays of the diet. Additional foods consumed include vegetable leaves, marrows, pumpkin, mushrooms, water-weeds, and hot peppers (Klaver, 1998).
Most aid agencies report ongoing nutrition and food crisis within Burma. UNICEF recently reported 1 million children in Burma are malnourished. And information is poorest for the large groups of internally displaced persons (IDP’s) clustered in the eastern portions of the country. To date no data on the nutritional status of Burma’s emergency-affected population has been published internationally. Moreover, NGO’s working in the camps have not produced standardized two-stage nutrition surveys among children, a deviation from standards followed in most other emergencies.
A mission evaluation report, noted that the rate of malnutrition might increase directly month-to-month based on the deterioration of the condition of the camp and/or indirectly by the influx of more malnourished people (Klaver, 1998). The report also addresses that current supplementary feeding programs have a variety of problems and need an evaluation study.
The lack of nutrition experts to backup the feeding programs is also an issue. As addressed in Dr. Paul Spiegel’s report (1999), a majority of camps on the border report some vitamin B1 deficiency (Beri Beri), which was also common in past South East Asian refugee crises where refugees were dependent for extended periods on polished rice. Dr. Spiegel also reported that very few camps had properly completed the standardized two-stage cluster-sample surveys, making it difficult to record the prevalence of malnutrition among children under 5 years of age.
An International Rescue Committee (IRC) report stated that malnutrition has been observed as one of the major health problems in the camps (Menefee, 1997). Many refugees fleeing from Burma into Thailand, particularly children are susceptible to illnesses because of protein deficient diets. The unstable environment compromises health status, self-reliance, sanitation and nutritional status (Fox, 1996).
The causes of malnutrition are often complex and multi-factorial, especially in displaced populations. Due to the continued conflicts and population displacements in Burma, the refugees along the Thai/Burma border are a population that is at significant risk of nutrition related problems. Inadequate dietary intake and poor nutritional status plays a role in morbidity and mortality of a population by affecting the body’s ability to fight and recover from disease. Individuals that are working within the Thai/Burma refugee camps express concerns relating to the nutritional crisis facing the refugee populations.
Data Collection Procedures
In the case of all the data-collection methods, the team will use two stage cluster-sampling techniques when identifying individuals or households. When registration rosters are available random sampling will be determined using a random number table. The imperative will be to use randomization as a consistent approach that ensures general representation of the survey findings. (J Katz. “Sample-Size Implications for Population-Based Cluster Surveys of Nutritional Status” — 1995 American Society for Clinical Nutrition).
Biochemical surveys will be conducted among a representative sample of refugees. Serum will be analyzed for hemoglobin, serum ferritin, retinal binding protein (RBP), carotinoid profile (lutein, eaxanthin, betacryptoxanthin, betacarotene, lycopene), zinc protoporphyrin/heme ratio (ZPPH), mean cell volume, zinc, and vitamins A and E. Methods Reference: R. Gibson “Principles for Nutritional Assessment” (1990, Oxford University Press).
One key output of this project will be the operational insights about the feasibility of conducting blood sample assays within these refugee communities. This method will help uncover evidence of vitamin and mineral problems that are not elicited from clinic records or anthropometric measures.
Diet History surveys will be used to get an estimate of macronutrient and micronutrient intake and to outline general food diversity, availability, quality and quantity. The method of choice will be the 48-hour recall analysis, elicited via 1-hour long surveys with heads of households. Combined with information on nutrition values of foods, this will permit a best estimate of nutrient consumption and its adequacy. Information on region specific foods will be obtained from the Thai Ministry of Public Health and Mahidol University in Bangkok. Methods Reference: Pelto et al “Research Methods in Nutritional Anthropology” (1989, UN University, Japan).
Anthropometric surveys will be used to establish the prevalence of weight/height, body mass index (BMI), middle upper arm circumference (MUAC) and malnutrition among the population studied. Methods Reference: “MSF Nutrition Guidelines” (1995), Paris: Medecins Sans Frontieres.
Interview and market observation surveys will be the primary sources for information about how foods are used, how foods serve as a medium of exchange for social, political or other functions, and the extent to which food trade is an important predictive variable explaining prevalence of malnutrition. Methods Reference: Refugee Studies Programme “Responding to the Nutrition Crisis Among Refugees: The Need for New Approaches, Workshop Report” (1991, Oxford).
Food needs analysis will take into account the nutrition analysis, as well as interviews on program lessons to identify key recommendations for tailoring of food programs to help mitigate nutritional deficiencies in the future. Reference: Sphere Project “Minimum Standards in Nutrition” and “Minimum Standards in Food Aid” (1998, Geneva).
Timeline for Data Collection
The initial planning and coordination phase is underway and the pilot project will begin in the spring/summer of 2000. This research will allow a review of the nutritional issues and food security situation in the camps along the Thai/Burma border. The data collection portion of this research project will be conducted in the fall/winter of 2000. Data analysis will be completed during 2001. The findings will be shared with the BBC and Thai Ministry of Public Health. The information will also be submitted for publication to ensure that the data obtained can be used to assist other NGO’s, Ministries of Public Health, and the military in support of similar nutrition situations around the globe.
Data collection will be completed in two phases: The pilot phase will take approximately 3 weeks and is a preliminary visit to Thailand to coordinate the research project. Survey tools will be tested for validity during this phase. The camps that can be accessed will be outlined and demographic information will be obtained. Data to be gathered will include the numbers in the camps, percentages of infants and children between 6 months and 10 years of age, number of women, registers if possible, and the NGO’s working in the proposed camps.
The second phase will be the actual data collection from within the camps and will take approximately 6 weeks. All anthropometric measurements, key informant interviews, dietary intake records and laboratory assays will be obtained within this timeframe.
A combination of qualitative and quantitative data analysis methods will be used to obtain pertinent information for use in assessing the nutritional status, dietary intake and dietary adequacy of the refugee population. Analysis will use weight/height index values, BMI, MUAC, laboratory values, dietary intake records and key informant interviews.
Height for age is an indicator of chronic malnutrition. Weight for age is a composite indicator of both long-term malnutrition and current malnutrition. Weight for height is an indicator of acute malnutrition that tells if a child is too thin for a given height. MUAC is a simple fast and good predictor of immediate risk of death, and can be used to measure acute malnutrition. The results will be expressed as Z scores to allow international comparisons as well as for statistical reasons. BMI is easy to calculate, it correlates with subcutaneous total body fatness, and has statistical properties well suited for screening.
Dietary history surveys and key informant interviews will be assessed to get an estimate of macronutrient and micronutrient intake and to outline general food diversity, availability, quality and quantity. Combined with information on nutrition values of foods, this will permit a best estimate of nutrient consumption and its adequacy. This data will be evaluated against the reported ration provided. This data will also provide an insight into household eating habits and utilization of supplemental foods.
Lab data will be analyzed to determine the prevalence of micronutrient deficiencies. Serum will be analyzed for hemoglobin, serum ferritin, RBP, carotinoid profile (lutein, eaxanthin, betacryptoxanthin, betacarotene, lycopene), ZPPH, mean cell volume, zinc, and vitamins A and E. Laboratory data analysis and dietary intake data analysis will be conducted by Pennington Biomedical Research Center at no cost to the project.
This collaborative research effort conducted by team members from Thailand and the US to determine the nutritional status of this significantly at risk Burmese refugee population is urgently required. The outcomes of this research will include an up-to-date nutritional assessment and will provide an insight into the actual nutrition situation within the camps along the border. During the field surveys, the team will gather data using biochemical surveys, diet histories, anthropometric measurements, key informant interviews, and market observations. The project assessment methods will serve as an exportable model to be used within similar emergency situations in other countries. Outcomes and recommendations based on the published research findings will assist in improving nutritional status of refugees and displaced populations around the globe.
Research Team Partners:
- Principle Investigator and Team Leader: Teresa Kemmer, MS, RD, Major, USA, Registered Dietitian, University of Washington, Doctoral Program. International Committee of the Red Cross Health Emergencies in Large Populations graduate.
- Thai Team Member: Wantanee Kongsomboon, Assistant Director of Relief and Community Health Bureau, Thai Red Cross Society; International Committee of the Red Cross Health Emergencies In Large Populations graduate, USA; Seminar on Emergency/Disaster Medicine JICA, Japan; and Disaster Management Course ADPC/AIT, Thailand.
- Team Member/Consultant: Steve Hansch, MPH, Director, International Humanitarian Programs, Congressional Hunger Center, WA, DC. Works with NGO’s, Congress, Administration, media, and foundations to improve humanitarian aid.
- Team Member: Maria Bovill, Captain, U.S. Army Research Institute of Environmental Health, Registered Dietitian, MPH, Nutrition and International Health, University of California Berkeley.
- Team Member: Lab technician or biochemist. Coordination is in progress to determine if this team member will be traveling from the US or will be from within Thailand.
- Additional Team Members: Various refugee nutrition experts will be tapped as the project schedule permits their inclusion.
- Consultant: Battina Shell-Duncan, PhD, faculty and academic counselor, University of Washington, will be advising on this research project. She has done extensive nutritional anthropology research in Kenya.
- Consultant: Harris R. Lieberman, PhD, is Deputy Chief of the Military Nutrition and Biochemistry Division of the U.S. Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts.
- Consultant: Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA will be completing the nutritional analysis on the assays and the dietary records. Sahasporn Paeratakul, MD, faculty member and nutritional epidemiologist will provide consultation and help facilitate coordination with the Nutrition Institute of Thailand. He is originally from Thailand.
The completed study of this project has been reported in the Journal of Nutrition Vol. 133:4143-4149, 2003.