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High-Energy, Nutrient-Dense Emergency Relief Food Product 1 Introduction PROJECT DESCRIPTION AND SCOPE The Subcommittee on Technical Specifications for a High-Energy Emergency Relief Ration was established by the Food and Nutrition Board, Institute of Medicine (IOM) of The National Academies under the oversight of the standing Committee on Military Nutrition Research. The subcommittee was formed to address a request from the U.S. Agency for International Development (USAID) of the Department of State and the Department of Defense (DOD). These agencies asked IOM to develop technical specifications to be used in their solicitation of bids from the U.S. food industry for the production of a high-energy, nutrient-dense emergency relief food product (EFP). The scope of the subcommittee’s task centered on defining the specifications of an EFP that would satisfy the nutritional requirements of populations of all ages above 6 months, be appropriate for use as the sole source of subsistence for up to 15 days, be acceptable to a wide spectrum of cultures and ethnic and religious backgrounds, be eaten on the move without need for preparation, be stable for at least 3 years, and be amenable to land or air delivery. The specifications requested for an EFP encompassed the following: nutritional composition, including water and macro- and micronutrient content; food properties related to stability, consistency, and sensory properties and acceptability; product configuration, size, color, shape, and primary and secondary packaging for long-term prepositioning under severe environmental conditions and for land or air delivery; feasibility of manufacture; quality assurance and control parameters; and estimated cost.
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High-Energy, Nutrient-Dense Emergency Relief Food Product In addition, the subcommittee was asked to make recommendations on when the EFP should and should not be used. Finally, it was requested that the report present all relevant product characteristics and other processing and quality control parameters in performance specification format. ORIGIN OF THE STUDY Feeding refugees or disaster victims depends on being able to deliver a nutritionally appropriate diet quickly and at low cost. USAID, through its recently created Democracy, Conflict and Humanitarian Assistance Bureau (which includes the former Bureau for Humanitarian Response), assists foreign countries in famine and disaster relief by providing food rations for distribution. Similar humanitarian aid is provided by DOD in emergency situations. This food relief is often the only source of food available to affected individuals during the initial period after such natural disasters as hurricanes or earthquakes, or during emergencies such as evacuations or fleeing from combat zones. The energy value, nutritional composition, and sensory appeal of emergency food rations are of utmost importance in meeting the nutritional needs of recipients. In general, emergency food relief has traditionally relied on distribution of bulk food such as grains or corn- or wheat-based mixes that require preparation prior to consumption. The aim of the present study, in contrast, is to provide specifications for a stand-alone product that can be delivered and used as a sole source of food while a more permanent, stable food relief system is established. It is possible that the EFP could be used later in circumstances other than emergencies as a supplemental source of nutrients to more traditional diets. In addition to the overriding importance of having a food ration that provides the required energy level, protein, vitamins, minerals, and other essential nutrients, sensory appeal is an important factor to be considered when developing formulations that may be acceptable to a wide spectrum of cultures. Maintaining quality and appropriate package design, in turn, are critical to meeting the food relief objective because the rations must be able to endure very harsh conditions during handling and storage with minimal nutrient losses. The size and type of packaging has also proven to be important to avoid diversion of the EFPs to military use during emergencies involving civilian populations and combatants. Because of logistic problems during many emergencies, it is also essential that packaging of the EFPs be specially designed to withstand an airdrop without being destroyed or harming recipients on the ground. Although the United States is a major contributor to global food relief, U.S. companies do not currently manufacture the type of food products necessary for the initial stages of emergency food relief. As a result, and because USAID is required to purchase only U.S. products with Public Law (P.L.) 480 funds, purchases of such products from European manufacturers (see Chapter 3) can only be made by USAID using other limited funds. The availability of specifications
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High-Energy, Nutrient-Dense Emergency Relief Food Product for use in solicitations of bids from the U.S. food industry, therefore, will allow not only procurement of the most appropriate product, but also one that is manufactured within the United States. THE NEED FOR AND USES OF A HIGH-ENERGY, NUTRIENT-DENSE EMERGENCY RELIEF FOOD PRODUCT Emergencies Requiring Relief Operations Disasters requiring food relief operations include natural disasters, manmade disasters, and complex humanitarian emergencies. Natural disasters are those caused by fire, flood, drought, earthquake, and disease outbreak, whereas man-made disasters are caused by human error, as in industrial accidents. Complex humanitarian emergencies are usually the result of or complicated by armed conflict, genocide, or rural famines, and tend to cause massive population displacements aggravated by the lack or collapse of basic services (Keely et al., 2001). The extent and level of complexity of these emergencies may be further compounded by natural weather phenomena such as droughts or by unique circumstances such as the presence of large populations of prisoners of war. Some 30 complex humanitarian emergencies existed worldwide at the end of 1999 (Keely et al., 2001). Natural disasters and their impact on people are on the increase, according to U.S. relief organizations. Causes identified by USAID (2001a) include the continuous degradation of natural environments that magnify the impact of natural events, and population increases in coastal areas and other regions exposed to floods, eruptions, landslides, and other geological or meteorological threats (USAID, 2001b). Examples of environmental degradation contributing to natural disasters are destruction of forests, desertification, and overall climate change. The number of natural disasters in the 1990s—designated by the United Nations General Assembly in its resolution 44/236 as the International Decade for Natural Disaster Reduction—tripled that seen in the 1960s. The Office of the U.N. Emergency Relief Coordinator estimated that from 1970 to 1990 some 800 million people were affected by natural disasters, including more than 3 million deaths, with cumulative economic losses in the order of $30 to $50 billion per year (UNEP, 1992). According to USAID, almost 2 billion people were affected by natural disasters globally during the 1990s (USAID, 2001b). In 1999 alone, 212 million people were affected by hurricanes, typhoons, earthquakes, and floods that required immediate response from national and international relief organizations. This number did not include the hundreds of millions of people affected by droughts and their sequel of famines, many of whom abandoned their homes, villages, and regions in search of food for survival, nor the some 35 million
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High-Energy, Nutrient-Dense Emergency Relief Food Product people uprooted by 25 armed conflicts in 27 countries that year. Among the latter, 21 million were classified as internally displaced persons (IDPs), while the other 14 million, having crossed international boundaries, were classified as refugees (Crisp, 2000; USCR, 2000). Statistics from the office of the United Nations High Commissioner for Refugees (UNCHR) for 2000 list 21 million people as “refugees and others of concern”; 12 million of these were refugees (UNHCR, 2001). Emergency relief is provided by the United States and other donors in regions of the world where natural disasters occur and the affected country does not have the capacity to cope with destruction of the public service infrastructure. It is also provided when complex humanitarian emergencies induce massive population displacements through or into areas where public services are nonexistent or insufficient (Keely et al., 2001). Many situations requiring emergency relief arise in the least developed, poorest areas of the world, where human populations are frequently afflicted with chronic malnutrition and various debilitating diseases such as dysentery and malaria (de Onis, 2000; Snow et al., 1999). The threat to life as well as the psychological distress associated with the loss of homes and livelihoods, and sometimes the horrors of combat situations, are other important contributing factors to the overall weakness and poor physical state of populations in need of emergency relief (Burkholder et al., 2001). These often result in high mortality rates, particularly among children in developing countries and the elderly in more developed areas (Keely et al., 2001). Although it has been said that the only common denominator in emergencies requiring relief is that they are all unique and different, the need for foods with acceptable quality attributes and in quantities appropriate to sustain those affected is also common to all, as is the need to deliver such food promptly and at low cost. It is generally agreed among relief organizations that the quality of food relief provided to affected individuals during the initial stages of an emergency is a determinant in minimizing mortality rates. It is during flight and the time immediately after arrival in camps or other relief stations that the highest mortality takes place (Sphere Project, 2000). It is also during the first stage of emergencies when people who are on the move or under the trauma of arrival in camps do not have appropriate food preparation utensils and facilities, and hence must rely on ready-to-eat EFPs. This has been the rationale behind the development of various compact EFPs currently produced in other countries (Grobler-Tanner, 2001; Young et al., 1988). Target Populations for an Emergency Relief Food Product Although food relief situations involve people of all ages, there are differences in the composition of populations affected by various types of emergencies. Natural and man-made disasters, on one hand, affect the entire population in the disaster area. Complex emergencies, on the other hand, may affect groups
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High-Energy, Nutrient-Dense Emergency Relief Food Product within a population in ways that differ depending on gender, age, or ethnic group. Situations that involve combat, for example, may result in displacement of women and children while older boys and adult men stay behind. UNHCR provisional statistics indicate that there were slightly more women than men among refugee and IDP populations in 2000 (52 vs. 48 percent, respectively). Infants aged 0 to 4 and youngsters aged 5 to 17 years constituted more than 14 and 31 percent, respectively, of the total refugee population, whereas the proportion corresponding to the elderly (aged 60 and above) constituted 8 percent. The largest group was, by far, adults aged 18 to 59, who comprised 46 percent of refugees (UNHCR, 2001). Population composition in terms of age, sex, health, nutritional status, activity level, and climate are important considerations to ensure that food relief properly addresses the nutritional needs of intended recipients. However, clear international guidelines currently available for estimating food rations for refugees refer mostly to foods provided through the stable supply pipeline that relief agencies establish after the initial stages of an emergency. Little has been published on the appropriate composition of a high-energy, nutrient-dense EFP for use at the onset of emergencies before the food supply system has been established. The energy level of emergency food rations, in contrast, has been defined. A 1995 report by IOM, also sponsored by USAID, estimated the mean per capita energy requirements (EMPCER) for planning emergency food aid rations at 2,100 kcal (IOM, 1995). This level refers to the average daily energy requirement of individuals in a “typical” population in developing areas of the world, engaged in a light level of physical activity. The estimated EMPCER in the report was based on the following assumptions: (1) the population is distributed as indicated in the World Population Profile 1994 report for developing countries; (2) the average height of adult males of 170 cm and of adult females of 155 cm, which are the approximate heights of average males and females in sub-Saharan Africa and slightly greater that those of adults in South and Southeast Asia; (3) the weights of these adults are at the median for U.S. adults of the stated heights; and (4) the total energy expenditure of the adults is 1.55 and 1.56 times the BMR [basal metabolic rate] for males and females, respectively, which is consistent with a light level of activity. (p. 24) The report did not elaborate on potential food sources to provide that level of energy or on formulations for such rations. Given that the EFP under study is for use during the initial stages of all types of emergencies when there would be few or no other sources of food or when the prevailing conditions would not be amenable to preparation of other foods, the EFP composition must satisfy the nutritional needs of the subgroup in the population with the greatest needs. In so doing, it can then be assumed that
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High-Energy, Nutrient-Dense Emergency Relief Food Product the needs of other population groups—with the notable exception of nursing infants up to 6 month of age, for whom human milk is best—would also be covered by the EFP. USAID requested that the EFP specified by the subcommittee not be a therapeutic food product, although, as mentioned earlier, its eventual use as a supplemental source of nutrients in other feeding programs is possible. U.S. Food Relief Programs and Emergency Relief Operations The United States is the largest donor of humanitarian assistance. The U.S. government contributes to emergency relief and humanitarian assistance in response to natural disasters, man-made disasters, and complex humanitarian emergencies mainly through USAID. This agency’s 2000 Performance Report (USAID, 2000a) lists promoting humanitarian assistance as its goal number 6 and states that in 1999, “… the Bureau for Humanitarian Response’s Office of U.S. Foreign Disaster Assistance (OFDA) responded to 65 declared disasters in more than 63 countries. These included 17 complex humanitarian emergencies, 41 natural disasters, and 7 man-made disasters.” As a result, $294 million was allocated in 1999 to these efforts compared to $186 million in 1998. In addition, the Office of Food for Peace provided $513 million in food assistance for these declared disasters (USAID, 2000b) Other U.S. agencies coordinate disaster response with USAID, including the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services, the U.S. Geological Survey of the U.S. Department of the Interior, the National Oceanic and Atmospheric Administration of the U.S. Department of Commerce, and DOD. DOD often provides logistic and personnel support to U.S. relief operations, particularly when rapid airlift of emergency food and medical supplies is necessary. USAID’s Office of Food for Peace takes a leading role in defining the modality and extent of the U.S. food aid response. Food aid is procured from U.S. suppliers and shipped from the United States to the emergency sites. If there is an ongoing food relief program sponsored by USAID in a country neighboring the emergency, available food may be rapidly transferred to the emergency area. From the operational standpoint, USAID normally provides emergency food assistance directly through U.S. private voluntary organizations (PVOs) and local nongovernmental organizations (NGOs), or indirectly through the World Food Program (WFP). USAID or WFP handles the logistics and the PVOs or NGOs identify the recipients and their needs. However, rapid response in the aftermath of catastrophic events is often undertaken with the cooperation of DOD. The United States provides emergency food assistance through two programs, Title II of the Food for Peace Program under P.L. 480, which is administered by USAID, and under a surplus disposal program administered by the U.S. Department of Agriculture (USDA), section 416(b) of the Agricultural
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High-Energy, Nutrient-Dense Emergency Relief Food Product Development Act of 1949. All food used in the food assistance programs, including 36 commodities (USAID, 2001b) as well as all other food products—including such foods as the EFP under study—are procured solely by USDA’s Commodity Credit Corporation through public solicitation of bids from food producers, distributors, or manufacturers. The importance of having specifications for a high-energy, nutrient-dense EFP for manufacture in the United States lies in the severe regulatory restrictions that USAID faces for purchasing non-U.S. products. Because there are no American suppliers of EFPs for the agency to purchase under P.L. 480, such products must be purchased abroad using very limited funds available to the agency for non-U.S. purchases. Purchases are made as the need arises, thus incurring long delays in the delivery of desperately needed food relief during emergencies. These factors not only severely limit the amounts that can be purchased, but in the past have forced USAID to forego stockpiling and prepositioning of EFPs at strategic locations around the world for rapid delivery. In contrast, funds from Title II could be used to purchase up to several hundred metric tons of EFPs needed per year if EFPs from U.S. manufacturers were available, and they could be prepositioned to optimize emergency response. Thus, the availability of a U.S.-manufactured EFP that is easily delivered and consumed without further preparation, and appropriately formulated to fulfill the nutritional requirements of individuals undergoing severe physical and mental stress, would undoubtedly facilitate a wider and more rapid response to emergencies by U.S. relief agencies. It could also mean the difference between life and death to thousands of individuals. Developing specifications for such a product is consistent with the passionate appeal for appropriate food for refugees made by Mason and colleagues (1992) and it is also, by any humanitarian measure, a worthy endeavor. REFERENCES Burkholder B, Spiegel P, Salama P. 2001. Methods of determining mortality in the mass displacement and return of emergency-affected populations in Kosovo, 1998–1999. In: Reed HE, Keely CB, eds. Forced Migration and Mortality. Washington, DC: National Academy Press. Pp. 86–101. Crisp J. 2000. Africa’s refugees: Patterns, problems and policy changes. Working Paper No. 28. New Issues in Refugee Research. Geneva: United Nations High Commissioner for Refugees. de Onis M. 2000. Measuring nutritional status in relation to mortality. Bull World Health Organ 78:1271–1274. Grobler-Tanner C. 2001. A Study of Emergency Relief Foods for Refugees and Displaced Persons. Washington, DC: U.S. Agency for International Development.
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High-Energy, Nutrient-Dense Emergency Relief Food Product IOM (Institute of Medicine). 1995. Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations. Washington, DC: National Academy Press. Keely CB, Reed HE, Waldman RJ. 2001. Understanding mortality patterns in complex humanitarian emergencies. In: Reed HE, Keely CB, eds. Forced Migration and Mortality. Washington, DC: National Academy Press. Pp. 1–37. Mason J, Gillespie S, Clugston G, Greaves P. 1992. Misconception on nutrition of refugees. Lancet 340:1354. Snow RW, Craig M, Deichmann U, Marsh K. 1999. Estimating mortality, morbidity and disability due to malaria among Africa’s non-pregnant population. Bull World Health Organ 77: 624–640. Sphere Project. 2000. The Sphere Humanitarian Charter and Minimum Standards in Disaster Response. Oxford, UK: OXFAM. UNEP (United Nations Environmental Program). 1992. Agenda 21. Online. Available at www.unep.org/Documents/Default.asp?DocumentID=52. Accessed June 13, 2001. UNHCR (United Nations High Commissioner for Refugees). 2001. Provisional Statistics on Refugees and Others of Concern to UNHCR for the Year 2000. Online. Available at www.unhcr.org. Accessed June 20, 2001. USAID (U.S. Agency for International Development). 2000a. USAID 2000 Performance Report. Washington, DC: USAID. USAID. 2000b. U.S. International Food Assistance Report 1999. Washington, DC: USAID. USAID. 2001a. Commodities Reference Guide. Online. Available at www.usaid.gov/hum_response/crg/sec1.htm. Accessed June 15, 2001. USAID. 2001b. USAID Humanitarian Response. Online. Available at www.usaid.gov/hum_response/. Accessed June 12, 2001. USCR (United States Committee for Refugees). 2000. Worldwide Refugee Information. Online. Available at http://www.refugees.org/world/statistics/wrs00_table_asylum2.htm. Accessed June 12, 2001. Young H, Owen M, Clark J. 1988. A comparison of biscuits used in emergency relief feeding programmes in Ethiopia and Eastern-Sudan 1985/86. Eur J Clin Nutr 42:261–271.
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