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Tulane University Health Sciences Center, New Orleans, Louisiana
3To whom correspondence should be addressed. E-mail: masonj{at}tulane.edu.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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KEY WORDS: • refugees • food supplies • emergency assistance • feeding programs
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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,2
), as shown in Figure 1
, where the extraordinarily high mortality rates for populations in camps persisted for months after their arrival, or even began to rise again. Even if the initial high death rates could not be readily avoided, it seems that once people were in camps, in touch with assistance, that the continuing large numbers of deaths should surely be preventable. This presentation is about how this prevention could be improved and in a more timely manner.
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) (3
). Indeed it is still not fully prepared. The institutions responsible for helping refugees and displaced populations (these face similar problems and are regarded here together) stemmed from the aftermath of World War II, and were initially designed to deal with displaced populations mainly in Europe. However, these populations were in societies that had significant social and physical infrastructure, even though this had been damaged by the war, and were in a situation entirely different from that faced by the refugees displaced some 30 y later. Many of these now came from the internal conflicts in Africa, and the global total of refugees alone was estimated to reach nearly 20 million people by the mid-1990s, with probably the same number or more of displaced people, so that about 50 million people are affected. The very high mortality rates experienced by these populations in Africa can be calculated to account for a significant proportion of the overall child mortality in the continent.
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Food supplies |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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, p. 81). When linked to the reported mortality rates (Fig. 3
), it could be seen that below 1500 kcal/person/d, virtually no camps had a normal mortality, and in many mortality was extraordinarily high. In Figure 3
, it should be noted, a normal mortality of around 0.3/10,000/d is right near the bottom of the y-axis. Although these results are associations, not strictly causal, it is extremely likely that grossly inadequate food supplies were contributing both to mortality and to malnutrition and ill health. Considerable energy was spent on estimating requirements to the nearest 100 calories on theoretical grounds (5
,6
), but much more important would have been ensuring that an approximately adequate diet was actually made available in camps. Nonetheless, the estimates of kcal need were for many years set on the very low side, in part responding to what was well described as "the quartermaster syndrome," in which food supplies were eked out by minimizing distribution.
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. Here, as in other tables, a historical view is taken that also includes a future perspective; that is to say, using history as a guide, envisaging how we would like the situation to look if we were reviewing the topic from, say, 2010. Thus at the bottom of the tables there is an area that includes decisions now needed. The tables show, by timing, the main features of policies and programs, and then in the last column some examples of the information or influences that led to these policies and programs.
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). (Note this is an average, dividing the overall supply by the total population numbers, irrespective of the demographic composition; it can be roughly compared with other food supply and requirement estimates, such as national data related to food balance sheets.) These were based on estimates of energy requirements from parameters such as body weight, demographic composition and activity levels (8
). The survival ration calculation used a low energy expenditure level of 1.1 x basic metabolic rate (BMR); this can be compared with the value of 1.5 to 1.6 x BMR, equivalent to light activity, now used for making national estimates. In fact, if one comes to think about it, why should there be such a thing as a "survival" or "emergency" ration? People need food in emergencies to do more than just keep alive but inactive—even if just survival was a humane concept—and unless provided with enough energy to be at least normally active they will deteriorate. That is what was seen in mortality and malnutrition data. In 1989 this was replaced by a "minimal level" set at 1900 kcal/person/d (6
), which was intended as a standard preliminary estimate before more detailed assessments could be made. It was aimed to provide for a temporary minimum supply to go beyond survival, to be followed by better-estimated supplies as situations came under control. Perhaps predictably, but unintendedly, the minimum level rapidly became the target for sustained periods, and was used as such for much of the early 1990s. With increasing information on the continued starvation and mortality in refugee camps, such as that shown in Figure 3
, a closer look came to be taken at the issue of determining overall supplies.
More realistic estimates of energy requirements of around 2000 kcal/person/d became current, together with the recognition that among destitute people food supplies would be traded to contribute to other needs if there was no other economic resource. This pushed the intended supply as high as 2400 kcal/person/d, at least on the part of the International Committee of the Red Cross (ICRC) (9
). The view was that with an ample food supply there will be less if any need for additional feeding programs, plus a small margin to allow trading for the essential diversity of the diet, and possibly for other needs (10
).
This process was helped along considerably in 1995 by the U.S. National Academy of Sciences committee, which was charged with recommending to USAID the best policy on refugee food needs (11
). This committee recognized that a single calorie figure to be applied to all emergency food assistance was preferable, as a practical matter to support planning of supplies and logistics. They therefore decided on recommending a single minimum target figure of 2100 kcal/person/d, which was in line with estimates of requirements at the national level.
This level of 2100 kcal/person/d was endorsed by UNHCR and WFP in 1997 (12
). Finally, WHO issued its long-awaited manual on emergencies in 2000, also recommending an average figure of 2100 kcal/person/d, with a range of 1900 to 2300 kcal/person/d (13
, pp. 4–5).
Thus the intended ration had changed from the minimum of 1200 kcal/person/d to up to 2400 kcal/person/d over about 20 y, doubling the recognized needs. It is impossible to avoid the feeling that, had a more generous approach been taken earlier, at least some of the suffering associated with displacement and malnutrition could have been avoided.
This evolution was also part of a wider movement to increase awareness of the human rights of displaced people, and to establish more humane guidelines, such as through the mechanisms such as the Standards for Public Health in Emergencies (14
). At the same time, there was some belated recognition that trading was actually a mark of destitution and should not be regarded as necessarily an abuse of supplies (15
).
Looking to the future, as shown at the bottom of Table 1
, we might hope that the trend will continue to aim at an ample food supply, recognizing the economic as well as nutritional contribution of food. Relief efforts become easier to organize if multiple feeding programs are not needed, specifically if supplementary feeding can be avoided because the general ration is adequate to cover the needs of everyone—for example, following the ICRC lead. The additional resources needed are relatively minor compared with the costs of staffing and organizing more complicated programs.
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Food quality and micronutrients |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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)]. Four of the misconceptions we highlighted were as follows: 1) "starving people can eat any thing"; 2) "refugees can manage with less"; 3) "trading foods indicates that people do not need all of the rations"; and 4) "energy adequacy means nutritional adequacy." On the first three of these there is progress, although these misconceptions are still to be found. The fourth, referring to the quality of the diet, still needs considerable work (see Table 2
) (17
,18
).
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). However, the extent and gravity of micronutrient deficiency in developing countries was becoming recognized—perhaps most widely with the observed impact of vitamin A supplementation on mortality, as well as the increased recognition of mental retardation attributed to iodine deficiency—which increased awareness of the risk of deficiencies in displaced populations. Equally, clinicians became increasingly horrified to see the reemergence of specific micronutrient deficiencies whose existence had been considered as passing into history: scurvy seen in the Horn of Africa; pellagra again in East and Southern Africa; and beriberi in Nepal (20
,21
). This increased awareness led to improved rations when the missing micronutrients could easily be added as fortificants, although for those such as vitamin C (expensive) or iron (difficult) solutions were slow in coming.
The simple task of calculating the micronutrient supply in rations is still not universally done. Such calculations show that it is predictable that micronutrient deficiencies will emerge after a while with the usual general ration of three or four commodities (more certainly when these do not contain a fortified blended food). In Table 3
the calculation is shown both in principle for the intended food supplies and as in practice received by (in this example) Rwandan refugees (22
). In both cases it is clear that without the fortified food, there would be a grave risk of deficiency of at least vitamin A and vitamin C. Even with fortified foods, vitamin A may be short in the theoretical ration. In the real ration as received in Rwanda (in 1994), all four of the vitamins and minerals assessed were in short supply. Thus it is no wonder that widespread micronutrient deficiencies are found.
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Feeding programs |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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, initially divided into general and selective. Selective programs are of two types. First, therapeutic feeding programs for treatment of the severely malnourished (as the name implies) are now well established and recognized as necessary where there are such severe cases of malnutrition that normal foods will not save lives. The second type of program has been referred to as supplementary feeding, and it is in this area that there is still considerable lack of clarity. Supplementary feeding programs are often distinguished into those targeted, either toward the moderately malnourished alone, or toward the moderately malnourished plus other groups. When these become wide enough, they are referred to as blanket supplementary feeding programs, for all of the specified vulnerable groups (e.g., all mothers and young children).
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). They stemmed from research in treatment of individual children in experimental wards (e.g., in Uganda and Jamaica) and, to begin, with the transferred use of expensive hospital diets to refugee situations. In particular, casein was used rather than milk products alone because of concerns for lactose intolerance; however, it soon became clear that this concern was minor compared with the need to have readily available and not-too-expensive mixtures. Thus the procedures of frequent feeding with high energy milk-based diets were successfully introduced into refugee situations in the 1970s; in fact, the procedures are much the same to this day. For example, the procedures described by WHO in 2000 (13
) are virtually the same as those for 22 y earlier (19
). One example of early application is in Mason et al. (23
), where we showed in a refugee setting that very rapid catch-up could be achieved using a simple dry skim milk/sugar/oil/micronutrient mix, fed as a milk-like preparation at a concentration of 1 kcal/g and at an intake of 150 kcal/kg body weight/d. The growth rates were such that children could recover within a few weeks, and the mortality rates even under the difficult circumstances of refugee camp were no worse than those in a hospital setting. However, this mortality of 10–20% has persisted for many years, and the next stages of evolution of treatment of severe malnutrition should involve reducing this mortality while at the same time maintaining high recovery rates (24
). This seems to be related, as shown by Golden (25
), to different syndromes of malnutrition in different areas, themselves related to previous diets, and to be controllable by some modifications of established procedures. Improvements in the future would focus on this, together with greater efficiency of running therapeutic feeding, for example, with prepackaged products and better training.
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). In part, these programs stemmed from experience with applied nutrition programs in nondisplaced populations, which in turn derived from concerns for protein availability some 40 y ago, a concern that still can haunt nutrition to this day. A commonsense view would be that if the general ration is adequate, except for the severely malnourished, supplementary feeding should not be needed. Moreover, the diet should be sufficiently diverse and appetizing that, as soon as the appetite returns in treatment of severe malnutrition, the general rations will continue the recovery process. Equally, the diet should be good enough to prevent deterioration of moderate malnutrition into severe, indeed to allow recovery of an affected population. This is the view, for example, of ICRC and of an increasing number of nutritionists.
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We would hope that in the future most supplementary feeding would be made obsolete by much improved general rations, perhaps with other means of covering micronutrient problems such as fortification or sometimes distribution of vitamin/mineral supplements, and that the policy on the role of supplementary feeding would be clarified. A start was made on this at a meeting in 1995 (26
, pp. 31–32), although changing the habits of agencies takes longer than the intervening 5 or 6 y.
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Information for decisions |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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). Through the 1980s most information was anecdotal, linked to appeals for resources. The experience was that television pictures were particularly effective in generating action, beginning with the well-known case in the Ethiopian drought in the early 1970s, where children scrambling for grain were shown on European television, which launched relief operations.
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Important studies led by CDC vividly documented the extraordinarily high mortality rates and prevalences of severe malnutrition, especially in the Horn of Africa, in the 1990s (1
). These and others led both the humanitarian and the health agencies to take more seriously the effectiveness of relief. Again, these matched an increasing activism among NGOs, such as Médecins sans Frontières (MSF), which managed to get medical and humanitarian assistance more and more effectively into the most serious situations, sometimes at substantial risk. Another important event was the U.S. intervention in Somalia, which coincided exactly with the International Conference on Nutrition in 1992, reinforcing the Pope’s appeals for prevention of starvation at that conference (27
). Within the UN, this was followed by increasing frustration at realizing the magnitude and severity of the situation was continuing, itself highlighted by improved information. Among the UN's initiatives to improve the effectiveness of its relief, the Refugee Nutrition Information System (RNIS) began regular publication in 1994, which at least had the benefit of ensuring that information was no longer suppressed, and demonstrated that in fact much data were available that, brought together, would create a consistent picture (28
). This has contributed to a better understanding of the situation of refugees and displaced people, especially in Africa, and highlighted unmet needs for relief.
During this period increasing agreement on norms was achieved, stemming from CDC’s proposal of mortality rates, measured in deaths per 10,000 per day, such that 1 per 10,000 per day was regarded as a crisis and 2 per 10,000 per day as being out of control (2
). To communicate such figures, in the UN we also interpreted these rates as "times normal" (i.e., as a multiple of 0.3/10,000/d), which is about the expected nonemergency mortality. Thus 1/10,000/d is roughly 3 times normal and 2/10,000/d is 6 times normal. Definitions of malnutrition also became more standardized, with the concept of "global malnutrition," which includes prevalence below a cutoff corresponding to moderate and severe malnutrition, and including edema (29
). (There is some question as to whether including edema is desirable for estimating trends, but it certainly helps to have an accepted figure.) Nonetheless, work remains in establishing agreed measures and cutoffs; for example, prevalences of low arm circumference use cutoffs that range from 11 to 12.5 cm.
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Using wasting to predict and prevent mortality |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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). Recently, a new compilation was made from the RNIS, and these data from the 1990s were combined with those from the 1980s. The results are shown in Figure 5
. The relationship seems very stable through time, being almost exactly the same in the two sets of data from the 1980s and 1990s. The association is strong, with 10% prevalence of wasting (<-2 SD weight/height) being equivalent to a mortality of 1 per 10,000 per day. Although there is considerable scatter around the fitted line, nonetheless the relationship is close enough to lead to a possible use of wasting prevalences to predict mortality rates, more specifically to identify camps that are likely to be in a crisis. Estimating from prevalences of severe wasting (in contrast to mild to moderate in the previous figure), an algorithm can be suggested from the specificity/sensitivity in the relationships in these data, as shown in Figure 6
. This indicates that severe wasting (<-3 SD weight/height), which is normally very rare in most populations, can be used as a flag for raised mortality. This method of "zero reporting" implies that if any severe wasting is seen (in Fig. 6
the cutoff is taken as 1% prevalence), then the probability is high that there is a mortality rate certainly above normal, possibly very much above normal. The converse is true for prevalence less than 1% in relation to severe mortality, but in the middle with the cutoff of 0.3 per 10,000 per day mortality is where the relationship needs further work. Nonetheless, given that the main problem is often knowing with any degree of certainty the population, there is great advantage in a method that is based on existence or nonexistence of a particular condition (zero reporting). This method now needs to be tested, but would be a useful contribution to assessment procedures.
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FOOTNOTES |
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2 Supported in part by a grant from CARE International, done in collaboration with P. Spiegel, CDC Emergency Unit.
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LITERATURE CITED |
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TOPABSTRACTINTRODUCTIONFood suppliesFood quality and micronutrientsFeeding programsInformation for decisionsUsing wasting to predict...LITERATURE CITED |
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1. Centers for Disease Control (1992) Famine-affected refugee and displaced populations: recommendations for public health issues (no. RR-13). MMWR Morb. Mortal. Wkly. Rep. 41:1-25.
2. Toole, M. J. & Waldman, R. J. (1990) Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 263:3296-3302.
3. ACC/SCN (2000) Fourth Report on the World Nutrition Situation. Nutrition throughout the Life Cycle 2000 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva, Switzerland. .
4. ACC/SCN (1994) Update on the Nutrition Situation 1994 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva, Switzerland. .
5. WHO/UNHCR (1988) Nutrition in Times of Disaster. ACC/SCN/INPF/USAID Report of an International Conference held at the World Health Organization Headquarters, Geneva, Switzerland, September 27–30, 1988 1988 World Health Organization Geneva, Switzerland. .
6. ACC/SCN (1989) Nutrition in Times of Disaster. Report of an International Conference held at the World Health Organization Headquarters, Geneva, Switzerland, September 27–30, 1988. ACC/SCN Symposium Report Series Paper no. 1 1989 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva. November 1989.
7. Rivers, J. P. W. & Seaman, J. A. (1989) Nutritional aspects of emergency food relief. Nutrition in Times of Disaster 1989:97-132 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva, Switzerland. .
8. Schofield, C. & Mason, J. (1996) Evaluating energy adequacy of rations provided to refugees and displaced people. Disasters 20:248-260.[Medline]
9. Norton, R. & Nathaniel, L. (1995) Quantity and quality of general rations. University of Nairobi (1995) Report of a Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa. Machakos, Kenya, December 5–7, 1994 1995:33-46 .
10. Mourey, A. (1995) Some issues regarding humanitarian assistance operations. University of Nairobi (1995) Report of a Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa. Machakos, Kenya, December 5–7, 1994 1995:129-135 .
11. National Academy of Sciences (1995) Estimated mean per capita energy requirements for planning emergency food aid rations. Committee on Nutrition, U.S. National Academy of Sciences 1995 National Academy Press Washington, DC. .
12. UNHCR/WFP (1997) Guidelines for Estimating Food and Nutrition Needs in Emergencies 1997 UN High Commission for Refugees Geneva, Switzerland. .
13. WHO (2000) The Management of Nutrition in Major Emergencies 2000 World Health Organization Geneva, Switzerland. .
14. SPHERE Project (2000) Humanitarian Charter and Minimum Standards in Disaster Response 2000 Oxfam Publishing Oxford, UK. .
15. Reed, B. A. & Habicht, J. P. (1998) Sales of food aid as a sign of distress, not excess. Lancet 351:128-130.[Medline]
16. Mason, J., Gillespie, S., Clugston, G. & Greaves, J. P. (1992) Misconceptions in the nutrition of refugees. Lancet 340:1354.
17. United Nations (1990) World Summit for Children. World Declaration and Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s 1990 United Nations, New York, NY. .
18. WHO/UNICEF/World Bank/CIDA/USAID/FAO/UNDP (1991) Ending hidden hunger. Proceedings of a Policy Conference on Micronutrient Malnutrition, October 10–12, 1991, Montréal, Canada 1991 World Health Organization Geneva, Switzerland. .
19. Ville de Goyet, C., Seaman, J. & Geijer, U. (1978) The Management of Nutritional Emergencies in Large Populations 1978 World Health Organization Geneva, Switzerland. .
20. Toole, M. (1993) Protecting refugees’ nutrition with food aid. ACC/SCN (1993) Nutritional Issues in Food Aid. ACC/SCN Symposium Report: ACC/SCN State-of-the-Art Series Nutrition Policy Discussion Paper no. 12 1993:87-90 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva, Switzerland. .
21. Toole, M. J. (1995) Preventing micronutrient deficiency diseases. University of Nairobi (1995) Report of a Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa. Machakos, Kenya, December 5–7, 1994 1995:47-61 .
22. USAID (2001) Commodity Reference Guide 2001 U.S. Agency for International Development Washington, DC. .
23. Mason, J., Hay, R., Leresche, J., Peel, S. & Darley, S. (1974) Treatment of severe malnutrition in relief. Lancet (2 March 1974):332-335.
24. WHO (1999) Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers 1999 World Health Organization Geneva, Switzerland. .
25. Golden, M. H. N. (2002) The development of concepts of malnutrition. J. Nutr. 132:2115S-2121S.
26. University of Nairobi (1995) Report of a Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa. Machakos, Kenya, December 5–7, 1994 1995.
27. FAO/WHO (1992) International Conference on Nutrition Goals: World Declaration and Plan of Action 1992 Food and Agriculture Organization, Rome, Italy/World Health Organization Geneva, Switzerland. .
28. ACC/SCN (1994–2001) Refugee Nutrition Information System 1994–2001 Agency Committee on Coordination/Sub-Committee on Nutrition Geneva, Switzerland. .
29. MSF (1995) Boelaert, M.et al eds. Nutrition Guidelines 1995 Médecins sans Frontières Paris, France. .
30. Person-Karell, B. (1989) The relationship between child malnutrition and crude mortality among 42 refugee populations. Masters thesis 1989 Emory University Atlanta, GA. .
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