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ENN’s perspective on the nutrition response in the Syria crisis

by Carmel Dolan, Marie McGrath and Jeremy Shoham
5 January 2015

The conflict in Syria has given rise to the largest displacement crisis in the UN High Commissioner for Refugees (UNHCR)’s 64-year history. The refugee-hosting governments of Jordan, Lebanon, Turkey, Egypt and Iraq, with the support of the traditional and non-traditional humanitarian community, have been meeting food, health, shelter, protection and other basic needs with an impressive programme of support. In November 2014, the Emergency Nutrition Network (ENN) produced a special edition of its publication, Field Exchange, on programming experiences and learning from the nutrition response to the Syria crisis. The edition feautures over 50 articles covering Syria, Jordan, Lebanon, southern Turkey and Iraq generated through more than 100 phone interviews with key actors and a visit to the region in early 2014. This piece summarises ENN’s views on the nutrition response to the crisis.

The nutrition sector’s response

The nutrition sector’s response focused on two main programming areas: the treatment of acute malnutrition in children under five years of age and support for mothers with feeding infants and young children (IYCF)[1]. Despite low rates of Global Acute Malnutririon (GAM), for a variety of reasons – including the continued refugee influx, poor living conditions, low breastfeeding rates, the common use of infant formula, anecdotal reports of acute malnourished children and low national capacity to treat malnutrion – international agencies scaled up acute malnutrition treatment programmes in Lebanon and Jordan[2]. A survey in Lebanon in late 2013 initially appeared to confirm fears of an impending nutrition crisis, but this did not tally with the much lower numbers of children with acute malnutrition being seen in clinics. A review of the survey data revealed flaws in the original analysis, and showed that GAM prevalence was significantly lower than previously thought. Doubts were also raised about the validity of earlier surveys in Lebanon and Jordan in 2012, fuelled by a UNHCR survey in Jordan in 2014, which suggested a dramatic fall in GAM to 1.2% amongst the non-camp population, and 0.8% amongst camp refugees. These findings suggested that the drive to scale up treatment of acute malnutrition in Jordan and Lebanon was unnecessary, or at the very least that limited resources might have been used to better effect elsewhere.

The second focus of the nutrition response – IYCF – largely centred on support to protect and increase breastfeeding. There was low coverage of assistance for non-breastfed infants, particularly in Syria and amongst refugees in host communities despite identified needs. Indeed, agencies actively prevented women from accessing formula, for instance excluding it from an NGO e-voucher programme in northern Syria, due to fears of a negative impact on breastfeeding rates. Agencies were not able to ensure the amounts of infant formula required or guarantee the necessary safe water, sanitation and hygiene conditions stipulated in policy guidance for making up the formula and sterilising feeding equipment. Programmes supported by Action Contre la Faim (ACF) in Lebanon and Médecins Sans Frontières (MSF) in Syria found that formula-fed infants under six months of age comprised a significant proportion of the small numbers admitted for acute malnutrition treatment, reflecting a lack of safe formula feeding. There were riots over infant formula access in the early days of Zaatari camp in Jordan, and non-breastfeeding mothers were subject to physical assessments to determine whether they could breastfeed. Overall, ENN believes that infant formula use has been overly ‘policed’ yet inadequately managed in the Syrian crisis. Complementary feeding support was also inadequate, with limited and delayed access to fortified complementary foods.

The characteristics of the IYCF response indicate a lack of strong critical assessment and analysis, weak stewardship of the technical response and a lack of contextualised emergency preparedness by in-country actors prior to the crisis. The experiences documented in Field Exchange challenge the sector to rethink IYCF approaches in emergencies, as well as long-term IYCF programming models in the Middle East. Current IYCF emergency guidance caters for infant formula use only in exceptional circumstances, i.e. as a last resort, yet the Sphere standards on IYCF (2011) state that ‘actions must enable access and supply of breastmilk substitutes to infants who need it’. These standards have arguably not been met in the Syrian response.

Gaps in the nutrition response

The focus on acute malnutrition and promoting breastfeeding may have distracted attention from undertaking an objective sector-wide, context-specific needs assessment of the nutrition problems facing Syrian infants, children, mothers and other vulnerable groups, such as the elderly and the sick, including maternal and child anaemia, child stunting, being overweight and non-communicable diseases (NCDs) – all of which were prevalent prior to the crisis (see below). For their part, donors should have adjusted their nutrition financing lens to allow the response to address the range of nutrition problems people actually faced.


The data on anaemia suggests that it should have attracted more of an analytical focus and early prioritisation and action. Whilst anaemia was prevalent in the Syrian population before the crisis, the first survey of anaemia prevalence amongst refugees in Lebanon and Jordan only took place in 2014. Prevalence of anaemia amongst camp refugees in Jordan is close to 50% in under-fives, a ‘problem of major public health significance’ according to WHO criteria, and remains prevalent amongst refugees in the Jordanian host community and in Lebanon.


Mortality associated with severe stunting[3]) is higher than for moderate acute malnutrition (MAM) at 5.5 times (MAM 3.3 times). Given that prevalence of severe stunting has been higher than MAM[4] it is evident that the humanitarian nutrition community has not given sufficient attention to stunting. Cautious intrepretation of figures implies that stunting prevalence had, in some instances, halved by the early stages of the crisis and then deteriorated over the response, most notably in Lebanon. Although UNHCR has well-developed guidelines on assessing and managing stunting in refugee populations, these were not operationalised. It is clear that, in this context, the emergency nutrition sector did not forge links with development actors to advocate for actions to address stunting and anaemia, and vice versa. This is symptomatic of a wider global disconnect between the emergency and development nutrition sectors, whereby efforts to address acute malnutrition are largely perceived as the responsibility of emergency actors, whilst stunting and anaemia are seen as long-term development concerns.

Non-communicable diseases (NCDs)

Difficulty in accessing treatment for people with NCDs such as hypertension and diabetes was widely reported, with cost being a key limiting factor. Closer engagement between the nutrition sector and the main agencies implementing food and voucher programmes to ensure that low salt and sugar diets (for example) could be adhered to in order to manage NCDs was not evident during ENN’s visit to the region. The nutrition sector does not have guidance to inform NCD-related response in crisis contexts.

Being overweight is a risk factor for NCDs and was prevalent in children under five prior to the crisis (18%). The Global Nutrition Report[5] highlights that ‘multiple burdens are the new normal’, raising the question how the emergency and development nutrition sectors can better assess and respond to the multiple nutrition needs of populations.

Vulnerability criteria

Cash transfers and in-kind distributions were initially implemented as blanket distributions for refugees in Lebanon and Jordan and for most of the camp populations in southern Turkey. Appreciation of the complexity of vulnerability and increasingly scarce resources led to the development of vulnerability assessment tools, including UNHCR score cards and the Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR), which helped to sharpen targeting and reduce the number of beneficiaries. However, there has been little use of
nutrition indicators to help understand and define vulnerability, and specifically nutritional vulnerability. For example, nutrition indicators (including anaemia and stunting) could have been
useful in identifying households for inclusion in cash transfer programmes and monitoring targeting decisions.

Cash programming

The scale and scope of cash programming in the Syria region has been unprecedented within a humanitarian programme context, effectively replacing in-kind food aid or general rations as well as supporting access to shelter, health care and heating supplies and promoting livelihoods. Much has been achieved, although there are two stand-out issues around cash programming which ENN believes may be emerging in the Syria response.

The first relates to the availability of global resources for large-scale cash programming in a humanitarian context. Many agencies (including donors) admit that the current level of programming is unsustainable and that substantial reductions and increased targeting are necessary. One question that arises is whether the ‘sector’ can assume the same level of resource availability for cash transfers in humanitarian contexts as has been available for in-kind food aid in the past. In other words, are donor resources for in-kind food distributions completely fungible or exchangeable with regard to cash provisions? A number of factors related to trade (and trade agreements), climate change and programming preferences suggest in-kind food aid provision may be less reliable in the future, and cash transfers may increasingly need to replace in-kind food aid in certain contexts. Given that the food aid system in the past has worked largely thanks to the mutual interests of multiple stakeholders (governments, farmers, business interests and humanitarians), will the different set of stakeholders involved in cash programming be able to leverage the same political support and level of resources, and how will this be assessed? Is the Syria region the first test of this?

A second set of questions arises in relation to the institutional architecture around cash programming in humanitarian contexts. The Inter-Agency Standing Committee (IASC) system does not have a ‘Cash Cluster’ in that cash is subsumed under multiple working groups (or indeed clusters) in any given emergency depending on the level of conditionality attached to the transfers. There are a set of questions as to how the nutrition community fits into this architecture to ensure that transfers have maximum nutrition impact. We would suggest that there is a need to develop minimum standards (SPHERE) for cash programming in humanitarian contexts, and that the nutrition sector should play a key role in helping to define those standards.

Nutrition coordination and leadership

As UNHCR has overall responsibility for the refugee operation in host countries, the IASC cluster mechanism has not been activated. Sectoral working groups were established covering food security, health, shelter, protection and education with UNHCR at the overall coordinating helm, essentially mirroring the cluster system. Similar working groups (and some cluster activation) exist in Syria. Until 2014, nutrition working groups had not been established in any of the affected countries, and nutrition coordination in southern Turkey, Jordan and Lebanon was absorbed into a small sub-group of the health working group. In southern Turkey (cross-border programme), despite considerable efforts by some international NGOs and the Global Nutrition Cluster (GNC) to increase attention to nutrition, the sector occupies a very small space in information exchange and coordination meetings. The Jordan nutrition sub-working group has been particularly active with infant formula control, which has been a drain on its coordination energies. A nutrition sub-working group was formed in Lebanon in May 2014. Coordination in the nutrition sector, in contrast to food security, health and WASH, has not had dedicated staff.

It is surprising that a protracted Level 3[6] crisis should have had such marginalised nutrition coordination structures and focus. This may in part reflect the lack of a coherent sectoral overview, which could objectively clarify the nutrition situation for a wider audience to inform programme decision-making. If we accept that the nutrition community has not adapted its nutrition lens to reflect the range of nutrition needs that typify a Middle East emergency, and has been almost entirely absent from the design and implementation of an unprecedentedly large social protection programmme, a number of questions about coordination and leadership arise:

  • Should nutrition have been more mainstreamed in the overall response by having representation (sub-working groups) in other working groups, such as cash and water, sanitation and health,
    and if so how?
  • Should the Nutrition Cluster have been activated to support the host community in refugee hosting countries and the cross-border operation from Turkey?
  • What is the role of nutrition-related development actors in preparing for a crisis and ensuring that the international emergency effort delivers a context-specific and timely response?

Many of the obvious shortfalls in the collective nutrition response to the Syria emergency, including limited programming scope, speak to a lack of leadership. Was there a clear, objective lead agency for nutrition in this crisis to oversee the scope and quality of assessments, analysis and interpretation, and in turn the shape and content of nutrition-related considerations across all related sectors?


Without critically examining the overall coherence of our nutrition responses in emergencies, we risk making the same mistakes again. A sectoral evaluation following a large-scale emergency programme of this type would add real value to collective learning. Holding ourselves to account and institutionalising learning is critical, but it is also complicated by the fact that we still lack clarity around roles, responsibilities and leadership in the nutrition sector.

This Middle East emergency is uniquely challenging in its scale and complexity. There has been an extraordinary response from a vast array of stakeholders across many sectors, and a large-scale nutrition emergency has thankfully been largely averted. However, nutrition vulnerabilities remain poorly analysed and inadequately addressed and, indeed, such vulnerabilities may well worsen as the availability of resources for the Syria crisis rapidly decline[7]. The nutrition community – both emergency and development – is needed as much now as during the height of the crisis. Let’s hope we can rise to the challenge.

Carmel Dolan is Technical Director with the ENN. Marie McGrath is Field Exchange sub-editor and co-Director of the ENN. Jeremy Shoham is Field Exchange Editor and co-Director of the ENN.

[1] Before the crisis the nutrition situation is Syria was classified as ‘poor’, with a prevalence of global acute malnutrition (GAM) of 9.3%, stunting (low height for age) at 23% and anaemia in under-fives at 29%. In late 2012, nutrition survey information indicated that the GAM prevalence amongst child refugees in Lebanon and Jordan was low, at 4.4% in Lebanon, 5.1% in Jordan in the non-camp population and 5.8% in Zaatari camp, the largest refugee camp in Jordan.

[2] GAM is a measure of the nutritional status of a population. It is the most commonly used indicator for classifying the magnitude of a nutrition emergency.

[3] <-3 SD height for age.

[4] For example: Zaatari camp in Jordan (2014): MAM 0.9%, severe stunting 2.9%; Lebanon (2013): 1.8% MAM, 2.8% severe stunting.

[5] Global Nutrition Report, November 2014, http://globalnutritionreport.org.

[6] Emergency response operations are classified according to a three-level scale. Level 3, the highest activiation level, requires mobilisation of global response capabilities to support country and regional operations.

[7] For example, see https://www.wfp.org/news/news-release/wfp-forced-suspend-syrian-refugee-food-assistance-warns-terrible-impact-winter-nea.

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