Widespread deficiencies of micronutrients, e.g. vitamin A, iron, iodine, niacin, thiamin and vitamin C, frequently occur among refugee populations affected by major emergencies. It is difficult to meet micronutrient requirements through the standard emergency ration of cereals, beans and oil. This is particularly true of vitamin C, which is mainly found in fresh vegetables and fruit, and which is quite unstable in foods, especially when exposed to air, metallic surfaces, light or high temperatures. Refugees who are wholly dependent on food aid often consume inadequate levels of vitamin C, and several refugee populations have developed scurvy in the past decade-a disease that was formerly mainly associated with sea voyages and long naval expeditions between the 15th and 19th centuries. Scurvy is also prone to occur in drought-and-famine affected populations where fresh vegetables and fruits are scarce.
Severe vitamin C deficiency causes scurvy, a disease that manifests itself 2-3 months after consuming a diet lacking in vitamin C. Frank scurvy in adults is preceded by a period of latent scurvy, the symptoms of which include lassitude, weakness and irritability; vague dull aching pains in the muscles or joints of the legs and feet; and weight loss. Scurvy in adults results in internal haemorrhages, swollen joints, swollen bleeding gums, and peripheral oedema, with impaired work capacity. In infants, scurvy leads to irritability, tenderness of the legs, and pseudo paralysis, usually involving the lower extremities. Scurvy in any age group causes impaired resistance to infections and internal haemorrhages can be fatal.
Even a single case of clinical scurvy seen in a population reflects a public health problem and calls for a full nutritional assessment using biochemical methods to assess the vitamin C deficiency in the population. It is difficult to clinically define scurvy and very few people in the field have been adequately trained to be able to recognize scurvy correctly.
The development and application of a strategy for the maintenance of adequate vitamin C status in emergency-affected populations has beneficial implications over and above the elimination of scurvy. Vitamin C also promotes the absorption of iron and therefore helps to reduce the incidence of anaemia that is usually highly prevalent in such populations. The benefits of an improvement in iron status include reduced morbidity, improved physical work output and improved learning capacity.
There is no single universal solution to the problem of scurvy and not all interventions to prevent scurvy are feasible in every emergency setting. The principal way of addressing vitamin C deficiency is by improving the diet. Securing an adequate diet for large emergency-affected populations can be a problem especially in the initial phase of a relief operation. Distribution of fortified foods is an important way to secure adequate vitamin C intakes of a population where natural sources of vitamin C are lacking. Table 10 summarises several of the options for interventions to prevent or control vitamin C deficiency during an emergency. The figure in Annex 3 outlines the assessment protocol for the prevention of scurvy from the initiation to establishment phases of an emergency funding operation.
Table 10. Options for the prevention of vitamin C deficiency in an emergency
A. Local production of fruits/vegetables easy
Fruits/vegetables immediately available:
1. Add some fruits/vegetables to the ration
2. Encourage barter or purchase by providing 10% extra ration
Fruits and vegetables not immediately available:
3. Encourage household food production by providing necessary inputs
B. Local production of fruits/vegetables not easy
Provision of commodities fortified with vitamin C:
4. Fortified cereal flour or fortified sugar
5. Fortified cereal/legume blended food (120mg vitamin C per ration)
6. Other vitamin C-rich foods e.g. fortified tomato paste, orange juice powder
Provision of vitamin C supplements:
7. Distribution of vitamin C tablets at least weekly