Great Lakes Region

Burundi
Rwanda
Republic of Congo, Brazzaville, (RoC)
Democratic Republic of the Congo (DRC)
United Republic of Tanzania

There has been an escalation of the crisis in Burundi during the reporting period and the nutritional situation of the newly displaced population is critical. Humanitarian agencies cannot access very large areas of the Republic of Congo (Brazzaville) where the nutritional situation is severe. Peace in the Democratic Republic of Congo has resulted in improved access to war affected populations, but high prevalences of malnutrition have been recorded in some areas. No changes in the nutritional situation of the refugees and IDPs in United Republic of Tanzania and Rwanda have been reported. The table below shows the numbers of refugees, IDPs an returnees who require assistance in the Great Lakes Region.

Estimated numbers of refugees, IDPs and returnees in the Great Lakes Region

	Dec. 97	Mar. 98	June 98	Mar. 99	Jun. 99	Sep. 99	Dec. 99
Burundi	570,000	600,000	670,000	222,000	451,000	617,000	821,000
Rwanda	1,400,000	690,000	550,000	690,000	640,000	673,000	650,000
RoC	650,000	400,000	50,000	213,000	213,000	343,000	823,000
DRC	585,000	568,500	621,000	788,000	952,000	1,104,000	1,185,000
Tanzania	318,000	345,000	329,000	328,000	373,000	373,000	400,000
Total	3,542,200	2,603,500	2,220,000	2,241,000	2,629,000	3,110,000	3,880,000

Burundi

Burundi is on the verge of a humanitarian and human rights crisis following an escalation of the internal conflict in the past few months. Intensified fighting between government forces and rebels in several areas during the past three months, particularly in Bujumbura Rurale province, has caused loss of civilian lives, including the death of UN humanitarian workers. The deteriorating security situation has resulted in large-scale population displacement and forced a suspension of virtually all humanitarian assistance in late October and November. The Arusha Peace process stalled after its mediator, Julius Nyerere, died in mid-October. Nelson Mandela has been nominated as the new mediator (IRIN-01/12/99).

Displacement

Since early September the Government has forcibly relocated an estimated 300,000 people from Bujumbura Rurale into “regroupment” sites away from their homes. The regroupment was ostensibly to allow soldiers to better protect civilians from rebel attacks, but also prevents the civilian population from providing the rebels with food and support.

The newly displaced add to an estimated 500,000 people who were already in 300 regroupment sites. It is estimated that 821,000 people, or more than 13% of the total population, are at present in regroupment camps. The worst affected provinces are Bujumbura Rurale with 73 percent of its population displaced, followed by Bubanza (60%), Makamba (24%) and Bururi (20%). Also, in the province of Rutana, which was relatively calm until recently, the number of displaced people has increased from around 2,000 to over 16,000 since September (FAO - 05/11/99).

Excessive dry weather

Crop prospects for the first season of 1999/2000 (September-January) have been affected by unfavourable weather. Planting, which normally starts from mid-September to mid-October, was delayed by dry weather during October. In the most productive areas of Kirundo in the north, Mosso in the east and Imbo in the west, no significant planting has taken place because of insufficient precipitation (FAO-05/11/99).

A reduced harvest this season will follow the below-normal harvest of the last season, which ended in July. The current dry weather will also negatively affect planting in the first season of 2000 starting next February as harvesting of the late-planted crops this season will overlap with planting next season, and a shortage of seeds could limit the planted area (FAO - 05/11/99).

General nutritional situation

Prior to the current crisis the nutritional situation in Burundi had been improving (see RNIS 27 and 28). In general, the prevalence of wasting decreased from 1998 to early 1999, largely because of improved security and access to emergency-affected populations. This allowed a gradual return to agricultural activities and better access to health and feeding centres, as well as food distributions.

THE GREAT LAKES REGION - Update by ReliefWeb 7.6.96 - The boundaries and name es shown on this map do not imply official endorsement or acceptance by the Unites Nations or ReliefWeb. The maps may be freely distributed. If more current information is available, please update the maps and return them to ReliefWeb for posting.

The latest escalation of insecurity, however, resulted in the temporary suspension of WFP’s food distributions under the general feeding programmes, food-for-work activities, provision of transit and return packages for repatriating refugees. The nation-wide seed protection rations programmes have been temporarily suspended or significantly reduced. Over the next six months, the agency plans to provide food assistance to 350,000 displaced/vulnerable/drought-affected people and nutritional support to a further 38,000 (WFP-15/11/99, 13/12/99).

There is a considerable risk that nutritional status will deteriorate over the coming months. Nutritional centres have already witnessed a significant increase in the number of beneficiaries, due to both drought and insecurity (WFP -13/12/99).

Nutritional situation of the newly regrouped

The majority of the newly regrouped populations in Bujumbura Rurale have no, or very little, access to their fields at a time when the first cropping season has already started, and any food stocks they were able to bring with them to the sites have been exhausted. As a result of the prevailing insecurity and lack of access, the populations were largely without food assistance from mid October to late November (WFP - 15/11/99). Since late November, WFP has organised food distribution through its NGO partners to some 182,000 people in the accessible regroupment sites (WFP - 26/11/99,17/12/99).

Information on the nutritional situation of the newly displaced is very limited. Thirteen of the 58 regroupment sites are inaccessible for logistical regions. Anecdotal reports have described problems of malnutrition and disease in the most vulnerable groups (infants and older people). Conditions in the camps are reported to be appalling: they are overcrowded, with insufficient drinking water and shelter, as the rainy season is about to begin (Concern -20/11/99).

Kirundo Province

SCF-UK conducted a nutritional survey in September in Kirundo Province as a follow-up to a survey conducted by IMC in the same area in January (see annex). The prevalence of wasting and/or oedema was estimated at 7.3%, compared with 10.9% in January. One percent of children were severely wasted and/or had oedema. Moderate stunting was recorded in 27.7% of the children measured and severe stunting in a further 19.9%. The graph below shows the results of both the January and September surveys. The prevalence of oedema was lower in the more recent survey, although the prevalence of marasmic malnutrition (low weight-for-height, but no oedema) was similar. The difference in the prevalence of oedema may be due to differences in the diagnosis of oedema (SCF-UK -10/99).

The prevalence of acute malnutrition in Kirundo Province in January and September 1999

Diseases such as acute respiratory infections, fever and diarrhoea were significantly associated with wasting. Also, the loss or absence of a parent placed the child at nutritional risk (SCF-UK -10/99).

The survey concluded that acute malnutrition does not appear to be a major problem, requiring an emergency response. However, interventions are required to address the poor hygiene and sanitation, the poorly functioning government health sector, and to ensure access to services and health care by the displaced (SCF-UK -10/99).

Bubanza Province

Bubanza Province is one of the areas worst affected by the continuing unrest in Burundi and, up until the recent crisis, had the greatest number of IDPs (approximately 165,000 in a total population of 289,000). The results of a follow-up survey by CAD in Bubanza Province are shown in the graph below (see annex). The prevalence of both acute and severe wasting increased between February and August, as did that of oedema. Conversely, the number of beneficiaries in the feeding centres has decreased. This was attributed, in part, to greater access to fields for agricultural activities.

The prevalence of acute malnutrition in Bubanza Province

Poor security and limited seeds or land available for cultivation continues to affect the livelihoods of both displaced groups and residents. Theft and insecurity has left many families without small livestock. In 1999, food insecurity was exacerbated by poor harvests, drought, high market prices and a lack of agricultural inputs. Visual observations suggested that the levels of malnutrition were higher in the areas most affected by the drought, where there was less access to fields, and in those sites that were furthest from Musigati and Bubanza communes (CAD -10/99).

The survey found a large increase in the number of children fully vaccinated: 95% of the children measured had a BCG scar and 76% of the children had completed their vaccination programme (compared with 41% in August 1998). This increase has been achieved through an intensive three-month vaccination campaign throughout the province and the national polio immunisation days (CAD -10/99).

Recommendations and Priorities:

· Obtain access to the IDPs in Bujumbura Rurale and gather information on their nutritional status.

· Support the coordinating rote of UNICEF in nutritional surveillance.

· Expand and give extra technical input to the current provision of nutritional services (an emergency response Is not required); this may include establishing a programme of community nutrition workers.

· Implement an integrated community-based program to address the problems of water, sanitation, hygiene and intestinal worm control. This may include household latrine building, provision of safe-water to each colline, a mass treatment campaign against hookworm and roundworm, and provision of flip-flop sandals.

· Encourage the use of ORS therapy for diarrhoea. From the survey in Bubanza Province:

· Expand the income-generating and agricultural programmes (via women’s associations).

· Continue support and supervision of therapeutic feeding centres.

· Intensify nutritional education.

Rwanda

The transition programme in Rwanda continues. The overall objectives of the programme are to lay the basis for national reconciliation, sustainable economic growth, human resource development and the improvement of living standards (IRIN - 23/11/99). There remain, however, an estimated 620,000 IDPs in Rwanda, the majority of whom are in Ruhengeri and Gisenyi Prefectures. The government is moving ahead with its controversial “villagisation” or “imidgudu” scheme throughout the country (IRIN -13/10/99; OCHA-11/99).

Food security

The overall dry conditions in October, with only light and patchy rainfall, have harmed prospects for the 2000 season-A bean and maize crop in eastern and southern areas of the country. A joint assessment to the affected areas estimated that between 60-70% of the area planted with beans will have significantly reduced yields. Market prices have remained stable because of imports of food from the Democratic Republic of the Congo (DRC). The very dry regions of the East have also been environmentally degraded by over-population (the largest percentage of new caseload returnees are located in the dry region prefectures of Umutara and Kibungo). Massive herds of cattle belonging to new returnees have wrought untold damage. WFP will provide food assistance to 200,000 people in the affected areas. Further assessments will be carried out in early 2000 (FEWS - 26/11/99; UNHCR - 07/12/99; WFP -15/11/99).

There are significant problems in food distribution within the country, as crops in the traditional breadbasket of the Northwest become prohibitively expensive when transported to other areas of the county through private means (UNHCR-07/12/99).

Displaced population

UNHCR has reported on a recent field mission to Ruhengeri prefecture, which noted that new returnees are no more susceptible to malnutrition than long-term residents (UNHCR - 07/12/99). No other information on the nutritional status of the IDPs has been received by the RNIS in the reporting period.

Refugees

There are approximately 30,000 Congolese refugees from North Kivu in Rwanda. The latest UNHCR report states that the general nutritional situation in these camps is satisfactory (UNHCR - 07/12/99).

Returnees

Returnees from DRC have continued to arrive during the reporting period. Those originating from Ruhengeri and Gisenyi are provided with a two-week WFP ration and are registered as beneficiaries for general food distributions in their communes of origin. All other returnees are provided with a three-month resettlement ration (WFP -15/11/99).

Recommendations and priorities:

· Gather information on the nutritional situation of IDPs and refugees.

Republic of Congo, Brazzaville, (RoC)

The Republic of Congo (RoC) collapsed into an intense civil war in December 1998 after only a short period of relative stability since the large-scale fighting in 1997. Hostilities began in the Pool region in September 1998, spread to Brazzaville in December, and went on to cover most of the southern part of the country. A sustainable solution to the conflict has not yet been found, although there have been reports of an accord signed between the Government’s armed forces and representatives for the Ninja and Cocoye rebels in Point Noire in November. Sporadic skirmishes between government forces and opposition-backed militia continued over the reporting period, although on a reduced scale. Abuses of human rights continue, particularly against IDPs. Currently, opposition forces control only a few areas and all major towns are under government control. The Government has adopted a policy of normalisation and has requested all IDPs to return to their homes (IRIN-19/11/99, 26/11/99; OCHA -11/99).

Numbers affected

An estimated 810,000 people have been displaced by the conflict in RoC, mainly from Brazzaville, Dolisie and Nkayi. As of the end of October, an estimated 200,000 IDPs had returned to urban areas, but a further 170,000 remain displaced in urban centres and 440,000 people remained displaced in rural areas (see map). A further 30,000 people are refugees in DRC and Gabon, the majority of which are in Gabon (OCHA-11/99).

Republic of the Congo 810,000 displaced and returned persons

Sources: UN, Government, donor, NGO and church representatives.

Access for the delivery of humanitarian assistance up until the second half of this year was mainly restricted to Brazzaville and Pointe Noire. Only small areas of the interior of the country could be reached by humanitarian agencies on an irregular basis. WFP has been unable to distribute all of the food aid it planned and many of the IDPs in the forests or rural areas have not received humanitarian assistance (IRIN-26/11/99; OCHA-11/99).

The fighting in RoC has disrupted agriculture and marketing activities, and reduced food imports throughout the country. The two most important agricultural areas of the country, Pool region and the Niari valley, have been seriously affected by the war (ACF-F -11/99; FAO/GIEWS -10/11/99).

Brazzaville

The population of Brazzaville was estimated at 950,000 before the recent crisis. The population’s main economic activities were trade, petty trade and agriculture (mainly vegetable gardening). Approximately 70,000 people were employed by the state. However, their salaries were paid infrequently; most of them were also involved in other income-generating activities (ACF-F-11/99).

Following the fighting in December 1998, the population living in the southern parts of Brazzaville were displaced. Of these, approximately 60,000 moved into camps or with host families in the north of the city, 200,000 people fled to the Pool region and approximately 30,000 found refuge in the DRC.

The displaced population is currently returning to Brazzaville, and the most recent figures (end of October) indicate that 150,000 people have returned. A further 60,000 people from rural areas have also gathered in Brazzaville (OCHA -11/99). An ICRC assessment estimated that about 20-30% of people living in the southern quarters of Brazzaville were displaced (ICRC -10/99). There has been a decrease in the numbers of returnees in November (IRIN - 19/11/99) which could mean that the majority have now returned, and a proportion of the people still absent have died (ICRC -10/99).

Nutritional situation in Brazzaville

Extremely high prevalences of malnutrition have been recorded among the returnees to Brazzaville. Until the end of September, the prevalence of severe malnutrition (mostly kwashiorkor) in newly arrived children under-five in Brazzaville remained constant at about 20% (see RNIS 28). It is worth noting that oedematous malnutrition was unknown in the RoC prior to the current conflict. After the 1997 war, MSF reported a prevalence of severe malnutrition of 1.6%. The causes of malnutrition in the arrivals clearly originate in the Pool Region. By July 1999, the population in the Pool were effectively cut off from all food sources except cassava (ICRC-10/99).

In September, agencies in Brazzaville noticed the development of oedema in individuals who were apparently healthy on arrival. Oedema developed 1-3 weeks after arrival. As this problem also occurred in the displaced who received a regular general ration from ICRC, it is likely that the causes were related to the development of a metabolic abnormality whilst in the Pool Region, either as a result of a deficient diet or infection (Golden - 9/99). An increase in salt consumption after arrival in Brazzaville was associated with the increase in oedema. IRC/UNICEF and ACF are investigating this problem further.

Food Security in Brazzaville

ACF-F assessed food security in Brazzaville to establish what coping mechanisms people were using and which groups are the most vulnerable (ACF-F - 9/99). ICRC later assessed food security of both displaced persons from the Pool Region and returnees to Brazzaville (ICRC ~ 10/99). The main findings of the assessments are summarised below:

· The main limiting factor that prevents households from obtaining sufficient food is a lack of access to money. Food prices apparently showed little increase, although the ICRC assessment found that while the price per unit had not changed, the unit itself had decreased (i.e. people could buy less for the same amount of money). The returnees are particularly vulnerable in the first few weeks after their return to the city before they can reestablish themselves professionally or link up with groups (church, families) who may be able to support them. This vulnerability is made worse by the fact that many of the returnees actually arrived in Brazzaville in very poor nutritional condition after hiding in the forests or rural areas.

· The main way of accessing initial funds was either through collecting salaries (civil servants), loans, or gifts from friends or relatives. Assistance could be provided in kind, cash or through work. These funds would then be used to start small-scale trading activities, or market gardening (ACF - 9/99) to maximise income. A large proportion of both returnees and displaced from the Pool Region were involved in firewood collection. Initially, some obtained cash through theft of assets and garden produce from those who had not yet returned (ICRC-10/99).

· The most vulnerable were those displaced from the Pool Region, as they had much greater difficulty accessing funds to start trading activities, or land for market gardening (ICRC - 10/99). Brazzaville residents returning from the Pool Region were more vulnerable than those returning from North Brazzaville and from DRC (ACF -9/99). Those returning from DRC were generally considered to be better off, partly because they received relief in DRC. People from North Brazzaville had had time to develop the necessary connections to acquire loans (ICRC - 10/99). Among the Brazzaville residents, the self-employed and those previously working in the private sector were more affected than civil servants (ACF-9/99).

· In all these groups, the sick and the malnourished were vulnerable both from a physiological and an economic perspective. If people were not involved in any economic activity, including firewood collection, they often said this was because they felt too weak (ICRC -10/99).

· Both returnees and the IDPs adopted a variety of strategies in response to a reduction in income. These included a reduction in the number of meal/person/day, purchasing food in very small quantities, reduction in quality of meals (reduction in oil, animal products, and vegetables), switch to cheaper staples and reduction in consumption of imported foods. Almost all socio-economic groups ate the same kinds of meals. The number of people eating their main meal together increased, with households hosting displaced and Brazzaville residents whose houses had been destroyed. However, at the same time, the number of people eating alone outside the house also increased (ACF -9/99).

In the week of 17-24th September, ICRC carried out a mortality survey on every third family arriving at the transit centre in Brazzaville. The main aim of the survey was to confirm the severity of the situation as indicated by the high malnutrition rates in new arrivals. Also, interviews with new arrivals indicated that a large proportion of family members had died (ICRC-10/99).

In total, 399 families that originated from the Pool Region and 1151 families who came from Brazzaville were interviewed. Using the pre-war population of the families as a baseline, it was estimated that 4.4% of Pool residents had died between December 1998 and September 1999, and 5.6% of Brazzaville residents (ICRC -10/99).

Mortality rates in Brazzaville residents increased gradually between December and May and reached crisis proportions by June 1999 (2.6/10,000/day). By August mortality was 4/10,000/day. For Pool residents, mortality showed a sudden increase from June, and by August was 5.5/10,000/day. The major cause of death for both groups was malnutrition (usually identified as swollen feet). All age groups were affected. In both groups, about 25% of deaths were in the 15-45 year age group (ICRC -10/99). There is no new information on the nutritional situation of the IDPs or residents outside of Brazzaville. Much of the area is still inaccessible to humanitarian agencies except Kinkala, a town 65 km south west of Brazzaville (IRIN - 29/10/99; Oxfam-08/12/99).

Refugees in RoC

No new information on the nutritional situation of 8,000 Angolan or 5,000 Rwandan refugees in RoC is currently available.

Recommendations and priorities:

· Gaining access to populations in the Pool Region and other inaccessible areas is critical.

· Assess the nutritional situation of people arriving in Brazzaville, and refugees in Gabon.

· ACF recommended providing a ration of 1900 Kcal/person/day for all persons returning from Pool Region for one month. ICRC later changed this recommendation to a two-week ration, of 2400/kcals/person/day (standard ICRC ration). The value of this ration is about 10,000 CFA, which the survey showed to be the minimum required to start petty trade. ICRC are currently providing this ration.

· Continue the targeting of the vulnerable groups already in the city by WFP, in particular the IDPs from the Pool Region. Vulnerable Brazzaville residents will be particularly difficult to register. Several targeting methods were recommended: (i) Through a soup kitchen. The assumption behind this method is that only the most vulnerable will take advantage of the programme, which will assist in registering them and should help to determine more accurately the causes of their vulnerability. This programme should be for a maximum of three months. (ii) Identification of vulnerable households through the Church network. (iiii) Monitoring nutritional status through health centres, and referring those who become moderately malnourished.

· Non-food interventions should include the re-establishment of credit projects through the Church network, and the distribution of seeds and tools to those with access to land.

Democratic Republic of the Congo (DRC)

A tenuous cease-fire is being observed across the Democratic Republic of the Congo (DRC) following the signature of the Lusaka cease-fire accord. The accord charts a multi-track course that should lead to the withdrawal of all foreign forces and the restoration of Congolese state authority over the entire country. There still remain, however, formidable challenges including the demobilisation of numerous militia groups and defining a common ground for political consensus. Peace efforts must also address the humanitarian problems resulting from the war including the return and re-integration of over one million IDPs and refugees (IRIN -10/12/99; OCHA-11/99).

The UN Security council has established a peacekeeping force for the DRC that will be deployed throughout the country for an initial period of 3 months to monitor and support the implementation of the Lusaka cease-fire accord, and facilitate the delivery of humanitarian assistance in DRC (IRIN-08/12/99).

Numbers affected

Almost 14 million persons have been directly affected by the war in DRC and are in need of humanitarian assistance, although to varying degrees. An estimated 916,000 people have been displaced by fighting within the country (see map). The IDPs and their hosts remain exposed to violence and extortion perpetrated by various military and militia. A further 130,000 Congolese have found refuge in Tanzania and Zambia. Over 270,000 refugees from neighbouring countries remain in the DRC (OCHA -11/99).

Approximately 2,200,000 Congolese IDPs, returnees and socially unprotected urban groups and refugees in the DRC face severe food insecurity. This represents more than 4% of the country’s population (OCHA -11/99).

Economy

In urban areas the dire economic situation, a legacy of years of misrule, has been exacerbated by the war. The economy is characterised by major losses in state income, trade standstill between the west and east of the country, enormous military expenses and restrictive monetary measures. These factors are making urban livelihoods extremely fragile (OCHA-11/99, 15/11/99).

IDPs in DRC (from OCHA, 15/11/99)

Security, access and funding

The security situation within DRC remains critical, with the exception of Kinshasa. The Kivus, Katanga, Equateur and Orientale provinces are particularly insecure and as a result it is difficult to provide humanitarian assistance in these provinces. Little information on the nutritional situation in these areas is available, but it is assumed that conditions are very poor, given that trade with the rest of the country is severely restricted, fighting has damaged agricultural activities and medical supplies are low or non-existent (IRIN 07/12/99, 26/11/99, 25/11/99, 10/11/99, 12/10/99).

WFP’s EMOP for the DRC aims to assist 350,000 IDPs and vulnerable people; clearly more people require assistance than this, but gaining access to them is difficult, although improving. WFP’s appeal had only received 29% of its requirements in mid-December and hence cannot currently even fully support those to whom it has access (IRIN -07/12/99; 08/12/99; OCHA -11/99; WFP -10/12/99).

Kinshasa

The capital city of DRC, which is made up of 24 communes, covers a surface area of 150 km² and, according to a census in 1998, is home to approximately 5,500,000 people. ACF-USA undertook four nutritional surveys in the city in October (see annex). The surveys were conducted in four separate communes, two of which are on the outskirts of the city and have more agricultural activity (Kimbanseke and Selembao communes) and two of which are in more urban, central zones (Kinshasa and Kingabwa communes). The results of the surveys, for both children aged 6-59 months and their mothers, can be seen in the graphs below.

The prevalence of acute (wasting and/or oedema) and severe acute (severe wasting and/or oedema) malnutrition among children aged 6-59 months in four communes in Kinshasa, October 1999

The prevalence of stunting and severe stunting among children aged 6-59 months in four communes in Kinshasa, October 1999

The prevalence of moderate and severe malnutrition (defined using the BMI and MUAC) in mothers in four communes in Kinshasa, October 1999

The prevalence of malnutrition is higher, in both children and their mothers, in the peripheral communes that are more “rural”. ACF-USA is preparing to undertake a food security assessment that may provide some explanation for the differences (ACF-USA -11/99).

The nutritional situation was not considered “out of control”, but a huge number of children require supplementary and therapeutic feeding. In Kimbanseke commune alone, where there are an estimated 105,300 children under-five, approximately 3,000 children require therapeutic feeding (ACF-USA-11/99).

Mortality rates for children under-five, coverage of feeding programmes and measles vaccination rates can be seen in the table below. The coverage of the feeding programmes was very low in all four communes. Vaccination rates were also poor if confirmation was given by card alone, although this figure increased considerably when the mothers were asked about their children’s immunisation history (ACF-USA-11/99).

Results of nutritional assessments in Kinshasa

Commune	Under-five mortality rates	Coverage of feeding programmes	Vaccination
	deaths/10,000/day	(%)	With card	With/without card
Kimbaseke	n.a.	5.1	28.7	71.9
Selembao	2.3	5.6	33.0	88.8
Kinshasa	1.0	6.3	29.1	92.3
Kingabwa	1.0	7.1	28.9	92.8

In November, floods displaced 15,000 citizens of Kinshasa. The Congo River reached a historical high, although the peak of the rainy season is not expected until mid-December. As two thirds of Kinshasa is built on plains and is vulnerable to flooding, there is concern that many more citizens will have to be evacuated. The risk of cholera, already endemic in this area, is extremely high (OCHA - 02/12/99, 06/12/99).

Kisangani Town

MSF-H conducted a survey in Kisangani Town in November as a follow up of a survey conducted in January (see RNIS 26). The prevalence of wasting decreased from 13.4% in January to 9.2% in November (see graph). Fifty-three percent of the malnourished children had oedema. Female-headed households were twice as likely to have a severely malnourished child. The prevalence of stunting was estimated at 42.7%, including 19.7% severe stunting (see annex).

The prevalence of total and severe malnutrition in Kisangani Town in January and November 1999

The survey reported that under-five mortality rates and CMRs had increased since January (see graph). In addition, the number of admissions of children over five to feeding centres had increased between the two surveys (MSF-H-11/99).

The CMR and under-five mortality rates in Kisangani Town in January and November 1999

MSF-H have suggested that while the prevalence of wasting has decreased, the nutritional situation overall may in fact have worsened. The reduction in the prevalence of wasting was largely due to a decrease in the prevalence of severe malnutrition. A reduction in severe malnutrition could be a result of mortality, or therapeutic feeding, rather than an improvement in the nutritional situation of all children. However, the coverage of the feeding programme was not determined in the survey and hence it is not possible to assess whether the reduction in severe malnutrition was due to therapeutic feeding or increased mortality.

The increase in mortality may in part be because people can no longer afford to pay for health care. Health care is available, but it is too expensive. Similarly, the high prevalence of kwashiorkor may be related to the fact that much of the population cannot afford to buy a selection of foodstuffs from the market and must rely only on what they grow - thus the quality of their diet is inadequate. Increased numbers of people are reported to be leaving the city to obtain food more cheaply (MSF-H-11/99).

Bas-Congo

MERLIN conducted a nutrition survey and food security assessment among residents, refugees and returnees in the Bas-Congo health zones of Luozi and Mangembo in September and October (see annex). The survey estimated the prevalence of acute malnutrition at 26.0%. The prevalence of oedema was extremely high at 20.3%. The prevalence of stunting was estimated at 64.2%, including 38.7% severe stunting. The measles vaccination rate was 72% according to carers’ reports and the polio immunisation rate was 81.6%. These figures, however, could not be confirmed, as the number of children possessing vaccination cards was extremely low (MERLIN-11/99).

This survey was conducted at the end of the dry season, when food insecurity is worst. Given that there were no baseline data available, it was difficult to verify to what extent the prevalence of malnutrition was due to an exacerbation of a recognised, traditional seasonal problem. The very high prevalences of severe acute malnutrition, in particular oedema, however, do indicate a serious health risk (MERLIN-11/99).

The majority of the severe acute malnutrition was kwashiorkor. The population’s primary staple during the survey period was cassava, and the consumption of meat and poultry was low. High intakes of cassava, with little complements, may be linked to a high incidence of kwashiorkor (MERLIN-11/99).

Chronic food insecurity in these areas has been exacerbated by the war in neighbouring RoC. While food production was not worse than previous years, the influx of refugees and economic migrants returning from RoC placed increased demands on the local economy. Traditionally, Bas-Congo had strong economic links with the RoC. The local population exported their agricultural surplus to RoC in exchange for sugar, salt, meat, fish and manufactured goods. The closure of the border has stopped this trade and restricted access to a wider variety of food produce. Although 65% of the returned economic migrants were reported to have access to land, only half of these had access to seeds. Looting of livestock and crops by the military further marginalised household food supply. There were no differences in the prevalence of wasting, stunting or oedema between the resident, returnee or refugee groups (MERLIN-11/99).

Katanga

An inter-agency mission in Northern Katanga in October witnessed large-scale devastation of areas affected by combats. The situation of the returnees and those still living in the bush (over 120,000 persons) was described as pre-catastrophic (OCHA - 15/11/99). An MSF-B assessment mission to monitor the situation of IDPs in Duni and Pweto in the north east of Katanga Province reported that the nutritional situation was critical (WFP - 01/10/99).

Medical and food assistance has been provided to IDPs in Pweto, and Lubumbashi. The rest of Katanga’s approximately 195,000 IDPs remain unassisted (OCHA -15/11/99).

A UNHCR nutritional survey of the refugees in Katanga is described below in the refugee section.

Kivus

A recent registration of IDPs estimated that there were 155,000 IDPs in the accessible areas of North Kivu province. The total IDP figure for North Kivu is expected to rise considerably when the figures for the currently inaccessible areas are included. Preliminary estimates put the number of IDPs in South Kivu at 180,000 (OCHA - 15/11/99). In November, only 31% of the target population is assisted. WFP expects to extend assistance to additional beneficiaries when further resources for its EMOP are mobilised (WFP -12/11/99).

Insufficient stocks of cereals have created a bottleneck for the implementation of assistance programmes for IDPs in Goma. There is also a scarcity of sugar and CSB, which is required for the special feeding programmes. The movement of goods in this area has been restricted by insecurity. Population displacement due to military activities continues in both North and South Kivu (WFP-01/10/99, 12/11/99).

Orientale Province

A local conflict in the east of the country - Ituri district - between the pastoralists Hema and agriculturalist Lendu ethnic groups which began in June has expanded in the reporting period. Large numbers of people have been displaced (up to 50,000) and many villages have been burnt (IRIN -15/11/99; OCHA-15/11/99).

An MSF-H nutritional survey in late October in Bunia Health Zone, Ituri district, estimated the prevalence of wasting and/or oedema at 11.6% (see annex). The prevalence of oedema was high at 8.6%. The prevalence of malnutrition was higher among the displaced children than residents, although poor food security had affected the whole population. Market prices had increased since the conflict began. The population were employing coping mechanisms such as a reduction in the amount of food consumed, planting small gardens and seeking employment in the fields of other cultivators (MSF-H-12/99).

The authors of the survey concluded that, given the political and economic situation in the district, the outlook for food security in this area is poor. They anticipate an increase in prices of foods and eventually a shortage of staples because of the insecurity (MSF - H -12/99).

Refugees in DRC

Despite the continuous fighting in the DRC during 1999, tens of thousands of refugees fled civil strife in their country to the relative security of the DRC. Specifically, the escalation of the conflict in the Republic of Congo (RoC) and Angola resulted in a substantial influx of refugees to Bas-Congo, Bandundu, and Katanga Provinces. There are currently an estimated 260,000 refugees in the DRC.

Sudanese refugees

There are an estimated 60,000 Sudanese refugees in Orientale Province. There is no new information on the nutritional situation of these refugees.

Angolan refugees

There are an estimated 156,000 Angolan refugees in Bas-Congo, Bandundu, and Katanga Provinces. Some 56,000 Angolans fled into DRC in late 1998 and early 1999. These people joined the 100,000 refugees (67,000 of whom are assisted by UNHCR) who were already in the country (OCHA-11/99; UNHCR-16/12/99).

Kisenge camps, Katanga

There are an estimated 42,000 Angolan refugees in 3 camps in Kisenge. 22,000 of these had arrived in the 1970’s and had become self-sufficient by 1998. UNHCR was in the middle of a repatriation programme when civil war in Angola resulted in a further 20,000 Angolans arriving at the camp. The repatriation programme was halted; prospects for repatriation are very poor at the moment (UNHCR/WFP -11/99).

UNHCR undertook a nutritional survey in the 3 camps in August, which showed that the nutritional situation had dramatically improved. The survey in August estimated the prevalence of wasting at 3.5%, including 0.3% severe wasting. The prevalence of oedema was estimated at 0.14% (one child was oedematous) (UNHCR -17/09/99).

This survey took place after a three-month intensive nutritional programme in the camps, following the results of an MSF-B survey in the area in February that reported high prevalences of malnutrition (see RNIS 26),

The feeding programme coverage was estimated at 57.7%, which is relatively low, possibly because of the large distances to the clinics from some of the refugee camps. Vaccination coverage was high -89.7% of the children had been vaccinated for measles (although only 11.2% were confirmed by card) (UNHCR -17/09/99).

The improvement in nutritional status was partially due to the coping strategies adopted by the refugees, which included: working in manioc fields for Congolese or more established refugees, eating manioc tubers before complete maturity, sweet potatoes, wild honey, wild fruits, wild ignames; eating or selling vegetables, rodents or insects. WFP also provided a general ration. (although this was low in calories, averaging 820/Kcal/person/day in the five months before the survey) (UNHCR -17/09/99).

Despite of the low prevalence of malnutrition recorded, the author of the survey warned that the hungry season was approaching and that it would last until February/March 2000. A complete ration is required for the refugees during this time of year (UNHCR/WFP -17/09/99).

A higher prevalence of wasting was recorded in the newly arrived refugees compared to those who had been there longer. The interagency mission to Katanga noted that the new caseload of Angolan refugees “is far from being self-sufficient”, mainly because of insufficient land available for planting as well as a shortage of tools. Most of the old caseload has enough land to be considered self-sufficient (UNHCR/WFP-11/99).

Kilueka camp, Bas-Congo

There are an estimated 18,400 Angolan refugees in Kilueka and Nkondo camps in Bas-Congo. The health and nutritional situation of these refugees is considered acceptable, if very fragile. The UNHCR/WFP JFAM in October 1999 found no signs of nutritional problems in Nkondo camp. No reliable nutritional surveys have been conducted in these camps (UNHCR/WFP-11/99).

The interagency mission observed that there had been no planting of staple foods around Kilueka camp, primarily because of the limited land availability. A limited amount of vegetables had been planted. Other sources of income, such as petty trading and brewing, are possible for these refugees. Land availability in these areas is the major obstacle for self-sufficiency for the refugees (UNHCR/WFP -11/99).

Congolese refugees (from RoC)

There are an estimated 6,000 Congolese refugees from RoC in Bas-Congo. The resumption of civil war in RoC forced 46,000 refugees into DRC, but a tripartite agreement between the governments of RoC, DRC and UNHCR facilitated the return of 40,000 of the refugees to Brazzaville via Kinshasa.

The MERLIN nutritional survey of the refugees in Luozi, Bas-Congo (described above) found a very high prevalence of malnutrition, particularly kwashiorkor. Many of the refugees in Luozi arrive in a very poor condition, having hidden in the forests for months. Most of the refugees have urban backgrounds; in any case there is no land available for the refugees to cultivate. The refugees from Brazzaville consider Luozi to be a transit centre and will move back to RoC as soon as possible. This may not be so for those from the Pool Region who will require a full ration (UNHCR -11/99).

Burundian refugees

There are an estimated 20,000 Burundian refugees in South Kivu. Efforts by UNHCR to assist these people were shattered by the rebellion. As the rebel forces swept through South Kivu, the refugees fled to the forest. They are reported to be living in extremely difficult conditions, but there has been no new information on their nutritional situation (OCHA-11/99).

Rwandan refugees

There are approximately 25,000 Rwandan refugees in various locations throughout DRC, The situation of these refugees is precarious, as the rebels perceive that they support President Kabila. Twenty-five thousand Rwandans were recently repatriated from North and South Kivu by local NGOs and UNHCR (OCHA - 11/99; UNHCR -16/12/99). The nutritional situation of the Rwandan refugees is unknown.

Ugandan refugees

There are approximately 2,300 Ugandan refugees in Orientale province. There has been no information on their nutritional situation.

Recommendations and priorities:

· Support WFP’s emergency operation for the DRC, which is currently seriously under-funded.

· Continue to assess humanitarian needs in newly accessible areas.

· Precise recommendations must await the food security assessment, but it is clear that feeding programmes are needed in Kinshasa, particularly in the more rural zones.

· Continue and strengthen MSF-H nutritional interventions.

· Begin active screening of malnourished cases.

· Investigate the increasing mortality rates and the causes for the reduction in severe malnutrition.

· Conduct a food security assessment.

· Monitor the nutritional situation of all the refugee groups closely. Monitoring should include regular nutritional surveys, food-basket monitoring and food economy assessments. Ensure the reliability of nutritional surveys using standard techniques.

· Distribute a general ration of 2,100 kcal/person/day.

· Start targeted supplementary feeding programmes for the acutely malnourished under-fives.

· Distribute seeds and tools for the returnees.

· Improve therapeutic feeding of malnourished within existing health structures. Train health personnel on nutritional surveillance and treatment of malnutrition.

· Instigate long-term agricultural programmes aimed at improving yields and diversification of crops.

· Provide a ration of 1,900 kcal/person/day to all refugees in these camps until March 2000.

· Close the therapeutic feeding centres.

United Republic of Tanzania

Tanzania currently hosts some 400,000 refugees in twelve designated locations in the Kagera, Kigoma and Tanga Regions. These refugees are mainly from Burundi (294,000) and the DRC (95,000), but there are also some from Rwanda (7,500) and Somalia (3,300) (WFP -10/12/99).

Given the situation in Burundi, it is expected that Tanzania will continue to host large numbers of Burundians. The number of Burundians seeking refuge in Tanzania increased over the reporting period, and aid agencies are preparing contingency plans for a possible influx of up to 300,000 more. In October, the repatriation programme to Burundi was suspended as a result of security conditions. Since August 1998, over 70,000 Congolese refugees have arrived in Tanzania (OCHA -11/99; WFP -15/11/99).

The refugees in Tanzania are almost entirely dependent on the food ration provided by WFP. The food pipeline was reported to be poor in June/July. Stocks were low in early August. In addition, access to agricultural land is severely restricted by the Government, and the refugees can only produce very limited amounts of food. WFP food assistance also benefits villagers from local communities participating in food-for-work programmes.

The RNIS has received no new information on the nutritional situation of the refugees in Tanzania. The most recent survey in Kigoma and Kagera estimated low prevalences of malnutrition.

Overall, the refugees in Tanzania are not considered to be at heightened risk of malnutrition (category IV).