Sub-Saharan Africa

Sudan
Rwanda/Burundi
Angola
Liberia Region
Mozambique Region
Somalia
Shaba Region in Zaire
Ethiopia
Refugees in Kenya

As of mid-1994, an estimated 18.5 million people were refugees or displaced in Sub-Saharan Africa, as a result of at twelve or more different situations. Although the distinction between refugee and displaced populations is increasingly doubtful, roughly six million of these have been defined as cross border refugees.

Since the numbers of refugee and displaced people can vary quite rapidly, one means of assessing the magnitude of the situation is to calculate the number of person-months or years of those affected - that is for example, if a million people are affected for two months, this would be counted as two million person-months. The numbers affected in these terms are given for the period October 1993 through September 1994 in Table 2, for the nine most extensive situations, which account for more than 90% of those affected. This also gives an average number per situation over one year. Figures are calculated from the data given in the RNIS reports, #s 2 through 7. Details of these nine situations are given in the sections that follow.

The nine most extensive situations in Table 2 all result from internal conflict in the country itself or in neighbouring countries. (The Sudanese situation is often regarded as two separate ones, distinguishing the South from Eastern, Central and Southern Sudan). The five worst situations -Sudan, Angola, Liberia, Rwanda/Burundi, and Mozambique - all involve around two to four million people affected, averaged throughout the year. Given that the mortality amongst the worst affected populations is often five to ten times normal, this may well represent an excess mortality of 100,000 to 200,000 people in each of these situations. Applying such a figure to all nine situations, there may be more than a million additional deaths per year.

Table 2. Refugee and Displaced Populations in Sub-Saharan Africa (Person-Years, Oct 93 - Sept 94)

Country		Person-Years	Person-Years at High Risk	Comments
Sudan:	Southern	1,828,000	489,000	Displaced and refugees in Uganda, Zaire, Ethiopia and Kenya
	East, Central, West	1,824,000	17,000	Displaced and refugees from Ethiopia
Rwanda/Burundi		3,239,000	2,276,000	Regional situation incl. Zaire, Tanzania and Uganda
Angola		2,994,000	501,000	Displaced and refugees in Zaire and Zambia
Liberia Region		2,827,000	589,000	Regional situation incl. Sierra Leone, Côte d'Ivoire, and Guinea
Mozambique Region		1,938,000	0	Including displaced, returnees and refugees in Malawi, S. Africa, Zimbabwe and Tanzania
Somalia		728,000	23,000	Displaced and refugees in Kenya and Ethiopia
Shaba, Zaire		448,000	126,000	Displaced
Ethiopia		300,000	47,000	Displaced, returnees and refugees from Somalia and Sudan
Kenya Refugees		300,000	0	Refugees mainly from Somalia, Sudan, and Ethiopia
Total		13,187,000	4,068,000

Source: Calculated from ACC/SCN (1993/4) RNIS Reports.

The evolution of the situation from November/December 1993 and September/October 1994 is illustrated in Figure 3. Here, the total numbers reported by category of risk throughout Sub-Saharan Africa are shown. Those in a critical situation of high malnutrition and elevated mortality are in the top section; for many purposes these are added to those defined as at high risk (second band, category IIa), for example in the data in Table 2. Although situations can arise rapidly, for example in Rwanda, and can also improve quite rapidly such as in Somalia, overall a fairly steady long-term trend of increasing numbers can be seen, and indeed the proportion of those at high risk is if anything rising.

The characteristics of almost all the situations involving refugees and displacement are that they result from civil wars, occasionally compounded by drought. These wars tend to be protracted, and to devastate the economies of the countries involved. Large proportions of the population get displaced, in conditions of chaos and vicious violence. In most cases this rapidly leads to malnutrition and ill health, in particular when populations congregate in towns or camps. For those inside the countries while the conflict continues, any widespread relief and improvement in conditions depends largely on political and military settlement. This has been demonstrated in Mozambique and Somalia recently. Required responses are clearly very different for the populations trapped inside areas of conflict compared with those that manage to reach situations with access to outside relief, usually by crossing borders.

Figure 3. Trends in Total Refugee/Displaced Populations in Africa by Risk Categories, December 1993 - October 1994.

Source: ACC/SCN (1993/4) RNIS Reports.

In intermediate situations, such as in Shaba, Zaire, where the displaced population is not rendered inaccessible by conflict, organizational and financial constraints have hampered effective relief by outside agencies. This is one particular type of situation where intensified efforts by external organizations might be possible and effective.

The more extensive opportunity for greater impact is in the populations, usually refugees, who have fled to locations where they are accessible to outside relief. Under these circumstances there is frequently an initial period of severe crisis- Rwandan refugees in Zaire and Tanzania recently are a vivid example - when there is clearly potential for more rapid reduction in mortality, malnutrition, and disease. But beyond that, under many circumstances malnutrition and excess mortality persist for many months after the initial crisis (Toole and Waldman, 1990). It is here that more effective application of available resources through better organization, building on previous experience, as well as increased resource availabilities, could have a major impact in reducing suffering.

The refugee and displaced population situations in Africa, as they are today, are described briefly in the next sections. This is in part to provide a baseline for future monitoring and to raise awareness, but also to indicate opportunities for more effective intervention. The recent data are drawn from those reported in the RNIS, and earlier background mainly from the documents cited in the footnote on page 58.

Sudan

"The people of Sudan are suffering one of the gravest and most enduring human crises in the world. Since the outbreak of the civil war in 1983, writers have run out of adjectives to describe the calamities that have engulfed the country." (MSF, 1993, p17). The population of Southern Sudan is estimated to have dropped by 30% to 3.5 million people in the past ten years due to death and displacement (USCR, 1994, p69). A staggering 80% of the population in Southern Sudan are estimated to have been forced from their homes at least once since 1983. According to UNHCR (1993, p56), 600,000 people are thought to have died so far, most from malnutrition and diseases.

The civil war in the south has continued through 1994 with huge numbers of people displaced and killed. For example, an estimated additional one million people were forced out of their homes in 1992, and in 1993 indiscriminate bombing of settlements and relief camps in the south took place through the year, "killing numerous displaced persons and causing thousands of terrified civilians to flee" (USCR, 1994, p69).

"The picture is further complicated by the fact that the war is not confined to the south. Since the beginning of the conflict, millions of Southerners have fled to the north, mainly to the outskirts of Khartoum. Here they have been living in appalling conditions, some of them literally on rubbish tips". (MSF, 1993, p23). This has led to forced relocation of hundreds of thousands, temporarily halted when in 1993 the bulldozers demolishing the settlements could no longer operate for lack of fuel. (This situation has been described by the UN Special Rapporteur on Human Rights for Sudan (UN, 1994b)).

Since the mid-1980s, continuing conflict in the Nuba mountains has affected perhaps one million people. Among the effects has been much reduced access to basic healthcare, education, and sometimes food (UN 1993c).

The war thus has not only displaced much of the population in the south, but many of these have fled northwards towards Khartoum, where they form a population estimated at nearly two million of displaced and homeless. Added to this, recurrent droughts in the vast areas to the west and south west of Khartoum, notably Darfur and Kordofan, have destituted the population and caused large scale migration. As a result, there are more displaced and refugees among the Sudanese population than anywhere else in Africa. From the view point of providing assistance, they tend to fall into at least two groups - those in the south, where the major problem is reaching the internally displaced, while the refugees that reach neighbouring countries are more accessible; and those around Khartoum and elsewhere in the eastern, central and western parts of the country, for whom assistance needs to come in through Khartoum. These two situations are described separately below. Trends in total numbers and those at high risk are shown in Figure 4.

SUDAN

Southern Sudan

Southern Sudan

The disruption to agricultural production and breakdown of basic infrastructure due to the war have, in conjunction with successive droughts during the last ten years, given rise to localized famine conditions in many parts of the South. The war has created large refugee populations in Uganda and Northern Kenya with a steady flow of new arrivals in Ugandan camps throughout 1993 and 1994. The Southern Sudanese population in Uganda increased from 150,000 in December 1993 to 270,000 in October 1994. The internally displaced population in Southern Sudan as of October 1994 was estimated as 2,000,000, all considered at moderate risk (RNIS #7, Table 1). This was an improvement from earlier in the year, due to greater success in delivery of food aid, by air, barge, and road. Trends in the numbers of displaced people in Southern Sudan, with estimates of their risk, are shown in Figure 4.

The provision of food aid and other relief resources to the war and drought affected in Southern Sudan through programmes such as Operation Lifeline Sudan (OLS) - which transported food from Kenya and Uganda - has saved many lives. But periodic escalations in violence and resulting displacement of large population groups continuously place large numbers of people at risk. In recent years food and relief resources have been provided through air-drop operations to inaccessible areas as well as by river cargo and road transport. However, sudden changes in security, damaged infrastructure due to fighting and bad weather, and lack of donor food aid pledges and funds for transport costs have all constrained the relief programmes. Many needy populations have therefore been cut off from food aid for long periods and as a consequence have often had extremely high levels of wasting and mortality. In mid-1994 the government authorized deliveries along the Bor-Juba route, for nearly half a million people, which brought substantial temporary relief; but the future remains totally uncertain.

Figure 4. Sudan

* Note: For Sep/Oct no information was available for EWC Sudan. The change from Sep/Oct to Nov/Dec, therefore, reflects more complete information, not a change in the situation

In sum, between October 1993 and June 1994 the numbers in Southern Sudan known to have high prevalences of wasting and/or sharply elevated mortality or to be at high risk of malnutrition varied between 230,000 and one million. This variation reflected the changing security situation and the capacity of international relief agencies to deliver emergency aid. Major impediments to delivery of relief foods have been shortfalls in cereal donations and lack of financial resources for transport. In January 1994 donor shortfalls in supply meant that less than 50% of food requirements for Southern Sudan were met, while between April and June 1994 lack of funding seriously curtailed air operations from Lokichokio (in Kenya) and from Entebbe to Juba.

Eastern Central, and Western Sudan

The number of displaced Sudanese in East, Central and Western Sudan is around 1.7 million, estimated in mid-1994. This population is mainly displaced Southerners, many of whom are in camps around Khartoum and other large urban centres. There are also large numbers of Sudanese displaced from their farming areas due to a succession of droughts and increasing environmental hazards in the areas across the centre of the country, and from the north. Efforts have been made to forcibly relocate the displaced population from around Khartoum for several years. It was reported that in 1992 to 1993 as many as 700,000 people were moved some distance away from the city. In these areas no housing or services were provided, and for much of the time international agencies were unable to gain access to this population. It is therefore considered very likely that malnutrition and ill health were extensive in this population (USCR, 1994, p40; MSF, 1993, p23). In mid-1994, the population in these camps around Khartoum was estimated to be as high as one million people, with levels of wasting in young children estimated at around 20%. In past years prevalences of wasting have periodically been at crisis levels, in part relating to seasonal grain price increases. Recent reports from UNICEF indicate the need for more intensive feeding facilities in camps and greater supplies of foods for malnourished children and key medicines such as antimalarials and antibiotics.

Populations affected by drought in Darfur and Kordofan have also needed substantial relief. Acute food shortages and rapidly rising food prices were reported in Darfur, affecting around 70,000 people in mid-1994. Food aid was distributed to approximately half a million people affected by drought in north Kordofan in March 1994, but since then there have been insufficient stocks, and government reports have indicated that up to 100,000 people may have faced starvation in mid-1994.

In parts of N. Darfur and Kordofan, environmental degradation caused by years of droughts and deforestation have increasingly marginalized large numbers of agro-pastoralists. Year-round levels of wasting in children above 25% are often seen (Young and Jaspers, 1992).

Surveys were carried out during 1993 in parts of Eastern Sudan among mainly Ethiopian refugees, showing moderately elevated levels of wasting of around 10%. Additional surveys in August 1994 found around 15 to 20% wasting, somewhat higher than in the previous year. The refugees in this area have some self-sufficiency, and some of the camps have satisfactory nutritional status.

Overall, nearly two million people are internally displaced in the central areas of Sudan. Those displaced by the war in the South are at particular hazard, in part because of relocation programmes and difficulty of access to external assistance. In addition, many people affected by recurrent drought throughout the country are logistically difficult to reach, although their situation could improve with better local harvests. Nonetheless, the mixture of ethnic conflict and environmental hazard leaves no end in sight to this situation, one of the "gravest and most enduring human crises in the world".

Rwanda/Burundi

The long-running civil conflict in Rwanda between the Tutsi-dominated FPR and Hutu-led government had produced a situation at the end of 1992 where there were 250-350,000 displaced people in camps in the FPR controlled Northern area of the country. Insufficient donor contributions, limited local market capacity and logistical problems exacerbated by insecurity had determined that ration levels for this dependent population had been grossly inadequate for many months. As a result prevalence of wasting had passed 10% in many camps and, for example, mortality rates were found to be six to eight times normal between September and December 1992 in two camps.

Escalation in fighting in 1993 led to further population movements so that by October 1993 there were 350,000 displaced people in camps north of Kigali in government held areas, while approximately 300,000 people who were displaced further south in February 1993 had returned to their land in the demilitarized zone. Throughout 1993 the emergency food rations distributed to the 350,000 camp population varied enormously with long periods where the ration averaged 800 kcals/caput/day. Nutritional surveillance established in the camps found prevalence of wasting varied from 4-17% in June 1993, while in some camps mortality rates were as high as 15-22 times normal. These findings triggered an immediate increase in rations for some camps.

The situation for this displaced population improved considerably throughout the remainder of 1993 and early 1994 as rations ranging from 1,600-2,400 kcals/caput/day were introduced for different camps, using nutritional surveillance data. In January 1994 wasting had dramatically improved to less than 2.5%, and crude mortality rates were less than 0.5/10,000/day (1.5 x normal). Numbers affected and nutritional risk for September 1993 through October 1994 are shown in Figure 5.

In Burundi following an attempted coup d'etat on 20 October 1993 and subsequent heavy fighting, around one million people were uprooted, most fleeing the country within a very short period. Estimates for November were that there were 375,000 Burundi refugees in Rwanda, 325,000 in Tanzania and 58,600 in Zaire. A further 150,000 Burundi people were believed to be internally displaced.

Figure 5. Rwanda/Burundi Region - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

The suddenness and magnitude of the crisis completely overwhelmed international relief capacity and initial relief efforts. For the refugees in twenty or so camps in Rwanda, overcrowding, poor sanitation, lack of water and inadequate food availability led to rapidly declining nutritional and health status, and mortality rates twenty times normal in some camps by November 1993. Similar problems were being reported in Tanzania and Zaire, while continued fighting in Burundi was adding to the tens of thousands already killed and displaced in the initial coup attempt.

Increased political stability in Burundi at the start of 1994 resulted in some spontaneous repatriation of refugees from Tanzania by February. However, at this time the situation for the majority of refugees was still critical and in many cases deteriorating. In Rwanda there were many reports of extreme shortage of food at camp level and very bad sanitary conditions. Nutritional data indicated a situation out of control with prevalence of wasting between 20-30% in many camps and mortality rates ranging from 3.7-5.6/10,000/day (12 - 19 x normal) in January. Dysentery and measles were major problems and food rations were less than 700 kcals/caput/day in some camps. While lack of food was partly due to limited transport capacity, the flawed registration system and high rates of ration card thefts also played a role.

Rwanda - Burundi

At this time the situation was similarly critical in Tanzania where surveys found mortality rates of between 2-7/10,000/day (7 - 23 x normal) in different camps. The main causes of death were identified as malnutrition, malaria, and dysentery, due to continued shortages of food and the absence of proper registration and distribution system in conjunction with terrible overcrowding and resulting poor sanitation. Although less data were available, the situation for the Burundi refugees was believed to be similar in Zaire.

In Burundi itself the numbers of internally displaced was estimated to have increased to 282,000 by January 1994 with many in very poor health and in urgent need of support. The food supply situation was also causing concern and fell far short of the estimated requirement of 800 metric tons/week.

The establishment of a new presidency in Burundi along with the beginning of the planting season in March 1994 led to the spontaneous repatriation of many Burundi refugees from Zaire and Tanzania. At the end of March it was estimated that there were over 500,000 internally displaced/returnees registered in Burundi and in need of assistance but only enough food resources to meet 30% of a full ration.

Food deliveries for Burundi refugees in Rwanda improved considerably through March 1994, a fact which was reflected in somewhat reduced prevalences of wasting (20-25%) and lower mortality rates averaging 0.7/10,000/day (3 x normal). The food supply also improved for the refugees in Tanzania, from where over 80% of the refugees had returned to Burundi. In February the ration ranged from 1400 - 1800 kcals/caput/day; mortality rates remained elevated at 0.5-2.2/10,000/day (2 - 7 x normal). Rwanda Crisis On 6 April 1994 the area was thrown in chaos with the death of the Rwandan President and ensuing civil war escalation in Rwanda, leading to the displacement of an estimated 2.7 million people within Rwanda, and across borders into neighbouring Tanzania, Burundi, Zaire and Uganda. It is now believed that at least 500,000 people were slaughtered within three months and that over two million people were rapidly displaced within Rwanda. Most of the Burundi refugees managed to return home. The extremely dangerous security situation prevented immediate aid agency access so that there were few reports on the condition of the displaced. However, it was assumed that by June food stocks for the displaced must have run out and that medical goods and clean water were desperately needed.

Between 28-29 April 250,000 Rwandans arrived near the town of Ngara in Western Tanzania. By June this population had rapidly swelled to 410,000 in seven camps. Although arriving in relatively good nutritional and health status, the overcrowding and poor water supplies in the camps drew predictions of imminent increases in malnutrition and mortality. Initial food distributions for these refugees were adequate.

At one point in early July, it was estimated that around 50% of the Rwandan population, about four million people, was displaced or refugees. Kigali fell to the RPF on 4 July. Between 14 and 17 July up to 800,000 Rwanda refugees moved across the border into Eastern Zaire, to the towns of Goma and Bukavu further south. UNHCR stated that this was the largest flow, in terms of numbers in a short time, of refugees ever seen. As the world now knows, cholera and dysentery broke out; it is now estimated by CDC that some 50,000 people - 5-10% of the population - died during the first month after the influx. This was equivalent to a mortality rate of between 20-35/10,000/day, noted as the highest recorded in a refugee population during the past 20 years³. In mid August it was estimated that the wasting prevalence among children under five was 18-23%⁴, a figure likely to rise since only a few weeks had passed and those surviving had not yet had time to become more malnourished. Malnutrition rates among children with a recent history of dysentery, and in households headed by women, were significantly higher. The relief programme was effective in rapidly reducing the mortality rates, to a reported 5-8/10,000/day.

³ Estimated by UNHCR, several NGOs, and CDC (U.S.). Publication forthcoming (Goma Epidemiology Group, 1994).

⁴ Surveys carried out in Mugunga, Kitale and Kibumba, by UNHCR, MSF-H, MSF-B, Epicentre, CDC; M. Toole, Pers. Comm.

In Burundi, in the latter part of 1994 there remained over half a million internally displaced, as well as over 200,000 Rwandan refugees. It was feared that conditions were also deteriorating for these populations, and reports of high levels of severe wasting (e.g. 10%) and elevated mortality rates, up to 2.5/10,000/day (8 x normal) were reported, associated with dysentery and suspected meningitis.

Finally, the most recent reports from Eastern Zaire (November 1994) are that the security situation in the camps is deteriorating, with the militia reforming, external agencies considering withdrawal, and serious risk of major deterioration again in health and nutrition. The situation in the camps is markedly reducing the effectiveness of ration distribution.

There are many lessons to draw from the handling of the disaster surrounding the Rwandan and Burundi populations. In terms of health and nutrition, on the one hand there is a limit to how rapidly preventive measures can be taken when there are such incredibly rapid flows of enormous numbers of people; on the other hand, even under the difficult conditions of Goma, the situation was brought (at least temporarily) under control within a matter of weeks. Here again, the political and military situation is the overriding influence on the health, nutrition, and survival of the population - but even given that, the extraordinary efforts of external agencies in collaboration with local people undoubtedly saved very many lives, and mitigated the catastrophe.

Angola

After independence in 1975, a long civil war ensued between the MPLA, aided by the Cuban troops, and UNITA supported by South Africa. Agreement was reached in December 1988 on withdrawal of foreign troop assistance, in arrangements that included independence for Namibia. Fighting continued up until a peace accord in 1991 between the MPLA-led government and rebel forces, which it was hoped would end the 16 years of civil war, and which led to national elections in September 1992. These results were however not accepted, and the war was resumed in late 1992 after UNITA lost the election.

The estimated population of Angola in 1992 was about 10 million. An estimated 2 million are internally displaced (MSF, 1993, p76), with a further 300,000 or more as refugees mainly in Zaire and Zambia. More than 100,000 were reported killed in 1993 (USCR, 1994, p47), and possibly more than that died in 1994. The numbers affected and at risk are shown in Figure 6. Approximately 200,000 Angolans were refugees in Zaire during 1993. Some of these had begun to move back to Angola in 1991/92 in anticipation of being able to resettle, and in fact had given up their possessions. When fighting resumed, many of these remained in Zaire destitute. Together with the instability within Zaire, many of these have not been externally assisted. Although there is no direct information on their nutrition, it is very likely that malnutrition and ill health are major problems. A similar situation affected the 100,000 or so Angolan refugees in Zambia, who also sold their possessions in the unmet expectation that they would be able to return home; but as far as is known, there are no severe nutrition problems among refugee populations in Zambia.

Figure 6. Angola - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

The war that began again in late 1992 led to massive displacement and near-famine conditions, particularly in many of the cities. Many Angolans fled towards the coast, an estimated half million ending up as squatters around the capital Luanda, where there were repeated reports of terrible health conditions and widespread severe malnutrition. While the government controlled the major cities, UNITA controlled the countryside and laid siege to many of these cities with catastrophic consequences. Tens of thousands died as a result of the fighting, and many more from famine and epidemic diseases. For example, relief workers in Malange in September 1993 counted some 10,000 orphans whose parents had been killed during the siege.

At the height of the conflict in 1993 UN officials estimated that 1,000 people a day were dying from war-related causes, mostly famine. Nutrition surveys carried out in 1993 and early 1994 found very high prevalences of wasting in a number of major towns although lack of access meant that there were a limited number of such surveys, and that much information on nutritional and health status was based on anecdotal reports. Inevitably the worst reports of malnutrition and mortality were from those towns which had been cut off from aid for long periods due to insecurity and denied access.

In April 1993 it was estimated that just under 2 million war and drought affected people required emergency assistance but that the physical limitations on moving food around in the country due to mined roads, destroyed bridges and damaged airfields meant that the maximum logistics capacity of the UN and NGOs in Angola was about 70% of requirements. The programme was also hampered by shortages of certain commodities such as beans and limited cash funds for transport, non-food items and logistical support. However, food distributions did gradually improve throughout 1993 with numbers receiving a ration increasing from 230,000 in June to over 1,240,000 in October. Much of this increase was due to successful negotiations with UNITA over access to formerly besieged towns such as Kuito and Huambo. By the end of 1993 estimates of numbers requiring assistance had increased to 3.2 million with food being airlifted to 14 major cities. The increase was largely due to continued fighting in the previous six months. In this case, the distinction between internally displaced and war affected is unclear, and the total numbers of 3.2 million needing assistance are, for these purposes, considered as displaced.

Angola

Humanitarian aid deliveries especially by air continued to improve during 1994 in spite of continued fighting around major provincial capitals and periodic interruptions to relief flights. Meanwhile peace talks in Lusaka broke down in March 1994, but resumed in mid-1994 and led to agreement, signed in late November 1994, but not yet implemented.

Between October 1993 and June 1994 the numbers of displaced and war affected known to be severely malnourished or at high risk of malnutrition varied between 200,000 and 1.6 million with the peak being in February 1994 (see Figure 6).

A nutrition survey carried out in Porto Quipiri/Boa Vista in August 1993 showed total wasting of 41% with 15% severe wasting. In October 1993 a survey in Malange found 20% prevalence of severe wasting with an overall wasting rate of 34%. Crude mortality rates ranged between 2.8-5.7/10,000/day (up to twenty times normal). However, surveys in January and February 1994 respectively found that mortality rates had much improved and were down to 1.3/10,000/day (4 x normal) while prevalence of wasting had dropped to 11%. In May prevalence of wasting had further decreased to 7% in Malange. Much of this improvement could be attributed to food aid distributions and the implementation of selective feeding programmes. A rapid survey in Huambo in January 1994 using arm circumference (for height) found wasting prevalences to be between 36-48%, while eye witness accounts from Kuito and Menongue described a catastrophic nutritional and medical situation largely due to intensified fighting and resulting lack of relief flight access. In April 1994 anecdotal reports from Kuito and Huambo were still describing the existence of grave nutritional emergencies.

Further assessments were possible after August 1994, as a number of cities became accessible again, and the effects of the break in assistance could be seen. For example, preliminary results from a survey conducted in Malange in early September 1994 found levels of wasting at 15% and severe wasting at 5%. This was a substantial increase from earlier results, e.g. 7% in May 1994. It is probable that similar deterioration took place in other cities such as Huambo and Kuito. Survey results in mid-July in Dondo gave a prevalence of wasting of 8%, with 3% severe. These lower levels were attributed to successful NGO feeding programmes.

A number of outbreaks of epidemics have been periodically reported, such as cholera in certain areas in June 1994, and meningitis in August. These no doubt have a devastating effect in the malnourished and weakened population.

Angola is estimated to have ten to 20 million mines, ringing many of the major cities. Civilian casualties, notably among children, from mine injuries are extensive, and the situation gravely hampers return to productive life. The main planting season in Angola is September, and there are fears that inputs to allow any reasonable harvests this year may be unavailable, as well as the inability of the population to work the land.

Despite the incredible difficulties, there is little doubt that the humanitarian effort, dependent in large part on expensive airlifting, did significantly reduce the extent of famine and suffering in the population. The international effort will need to continue, but clearly the possibility of fundamental improvement depends upon a political solution and peace at last for the ravaged population of Angola.

Liberia Region

Fighting broke out in Liberia at the end of 1989, between the NPFL (National Patriotic Front of Liberia) forces and those of the government, at that time headed by Samuel Doe. The fighting rapidly involved large numbers of the civilian population in widespread violence and atrocities. In August 1990 a regional peacekeeping force, the Economic Community of West African States Cease Fire Monitoring Group (ECOMOG) intervened to try to set up an interim government. A truce was established in November 1990, which brought uneasy peace until around October 1992. At this time, civil war erupted again, with a number of different factions: as well as the NPFL which in 1992 controlled most of the countryside, ULIMO attacked in the west of the country from Sierra Leone. Another faction, the Armed Forces of Liberia (AFL) joined the fighting in 1993, and ECOMOG became increasingly embroiled in the war. More recently further groups (e.g. the Lofa Defence Force (LDF) and the Liberian Peace Council (LPC) joined the fighting.

As Médecins Sans Frontières has said: "Long before Somalia, Liberia was the first African country to commit 'national suicide'. It has been ravaged since December 1989 by fighting of extreme cruelty, the initial phase of which drove out nearly 700,000 refugees." (MSF, 1993, p53).

Overall it is estimated that nearly three quarters of Liberia's 2.3 million population has been displaced. The war has involved neighbouring countries, Sierra Leone, Côte d'Ivoire, Guinea. The trend of total numbers affected, and their degree of nutritional risk, is shown in Figure 7. The distribution in October 1994 was estimated as: Liberia, 1,700,000; Sierra Leone, 300,000; Côte d'Ivoire, 330,000; Guinea, 530,000.

Figure 7. Liberia Region - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

Overall, reports of extreme malnutrition and starvation have come from different parts of the affected area at different times. When the fighting started again in October 1992, considerable attention was directed towards nearly 200,000 people cut off in North West Liberia under appalling conditions, to whom supplies had to be air lifted. At the same time there was a temporary ban on cross border deliveries in an attempt to enforce an arms embargo.

The security situation in both Liberia and Sierra Leone deteriorated in the latter part of 1994, with further movements of displaced people. In Liberia, increased levels of violence led the virtual suspension of NGO activities outside the areas controlled by ECOMOG. The elections previously scheduled for September were not held, although a new agreement was made to hold elections in October 1995.

The prolonged conflict has meant that food production and livelihoods for this largely rice subsisting economy have been severely disrupted. Peace keeping forces (ECOMOG) have attempted to safeguard cross-line deliveries of food aid to affected populations, while air drops to inaccessible areas and cross-border food deliveries, e.g. from Côte D'Ivoire, have also been extensively used. However, in spite of substantial successes in distributing food aid and other relief resources, there have been large population groups who have been effectively cut off from food aid for long periods who have experienced extreme levels of malnutrition and mortality.

Pre-war prevalence figures for wasting in Liberia have been reported at about 2%. Since the civil war restarted in October 1992 high levels of wasting and mortality have been recorded in a number of locations. At the end of 1993 levels of wasting above 30% were recorded in Upper Lofa county while in Upper Margibi county prevalences of kwashiorkor of between 39-45% and mortality rates of 14.4/10,000/day (50 x normal) were recorded in July 1993. Rapid assessments carried out in Upper Margibi, Bong, Lofa and Grand Bassa counties in January 1994 showed between 15-55% wasting with crude mortality rates of 2/10,000/day (7 x normal). Survey results in the first half of 1994 showed lower levels of wasting and mortality, but still high: e.g. 13% wasting and crude mortality rates of 1/10,000/day (3 x normal) in Nimba county in April. Much of the improvement at that time was attributed to better capacity for food relief distribution by international relief agencies, as well as some local rice harvests.

Liberia

Nutrition survey results in June and July 1994 tended to find comparatively low levels of wasting, around 10%, from a number of areas. On the other hand, in certain towns much higher levels were recorded - for example 42% wasting, 18% severe, in Garney - towns in which no food had been distributed for nearly a year, and where water and sanitation and lack of health services were a major problem. Subsequently, with the pullout of international NGOs from many areas, and only ad hoc food distribution, it was expected that nutrition would deteriorated widely again.

There is little information on nutrition amongst displaced populations in Sierra Leone, Côte d'Ivoire, and Guinea. In the less accessible areas in Sierra Leone (for reasons of distance or insecurity) serious food shortages are considered likely; some areas have not had a harvest since 1991, and the 300,000 displaced people in Sierra Leone are likely to be seriously affected by this. On the other hand, those in accessible camps may be better off, and recent nutritional survey data shows around 10-15% wasting in young children in camps in Sierra Leone. Such values are still high, but likely to be less than those where there are severe food shortages and inaccessibility. Moreover in the latter outbreaks of cholera have been reported. Poor registration systems in the refugee camps had led to a flawed distribution system with insufficient rations being distributed to some households as a result.

There are an estimated 530,000 Liberian and Sierra Leonean refugees in Guinea and a further 230,000 in Côte D'Ivoire. The health and nutritional status of these populations has generally been adequate although there have been reports of problems among new arrivals in Guinea. In Côte D'Ivoire many refugees work on local farms and are largely self-sufficient while in Guinea an estimated 120,000 are enrolled on agricultural projects leading to varying degrees of self-sufficiency. New arrivals in Guinea, many of whom are not registered immediately and who consequently do not receive a general ration, show high prevalences of wasting - up to 25% according to some reports.

The main problems in providing relief to the refugee and displaced population in Liberia and the neighbouring countries has been inaccessibility due to insecurity. These problems have been compounded by lack of vehicles for transport and roads and bridges made impassable by the rains.

Mozambique Region

The signing of the peace accord in October 1992 between the Mozambican Government and Renamo was a crucial step in ending 16-year civil war which had created over 1.6 million refugees in surrounding countries and the internal displacement of a possible further 3.7 million people. The protracted hostilities meant that over a million refugees were displaced to Malawi, 250,000 to South Africa, 120,000 to Zimbabwe with the remainder distributed between Zambia, Swaziland and Tanzania. But although the general fighting has drawn to a halt, peace has yet to spread throughout the shattered countryside.

Mozambique

The civilian population for most of the 80s and early 90s was described as "trapped between war and starvation" (MSF, 1992, p39). In 1992, it was described as an archipelago of fear and hunger, because of the movement of population into protected villages around the towns. This meant that villagers were far from their land, could no longer farm, and became totally dependent on international food aid. "Pushed by hunger and fear, the peasants of Mozambique have set out to look for a little peace and some help....Some camp outside the towns, others dressed in tree-bark and fed on roots, wander across the countryside in a pitiful state, while two million people are refugees in neighboring countries, half of them in Malawi, totally dependent on international aid." (MSF, 1992, p39). The conflict in the countryside gained its own momentum, even when the warring parties changed - South Africa renounced its support for Renamo, and Frelimo, initially pursuing socialist policies, turned towards the West. But the conflict was beyond government control, and degenerated into banditry, ruining the lives and livelihood of millions of civilians. Added to all this, in 1992, the worst drought of the century struck Southern Africa, including most of Mozambique.

In 1993, at least half a million Mozambican refugees repatriated, mainly from Malawi. The repatriation was considered: "the largest and promising to be one of the most difficult ever undertaken", including an estimated two million people who began to return to their homes (USCR, 1994, p61). "Many refugees will find no towns, no markets, no schools, no health clinics - virtually nothing with which to reintegrate" the US Committee for Refugees reported. "They will have no choice but to rebuild an entire economic and social structure from scratch" in what may be the world's poorest country. Moreover, this resettlement went on at a time when much of Mozambique was only slowly recovering from the severe drought.

With the cessation of hostilities, international agencies identified near famine conditions in many parts of previously inaccessible Mozambique. Large scale emergency feeding, health, water and sanitation programmes were therefore established and by mid-1993 the nutritional and health situation was largely under control, at least the accessible areas.

Large scale re-settlement and rehabilitation programmes were implemented by numerous agencies for returning refugees and the internally displaced so that by April 1994 an estimated 800,000 refugees had returned to Mozambique while a further 900,000 displaced people remained waiting to return to their land and re-build their homes.

The main nutritional and health problems during the recent period have been amongst the new returnees, especially those returning to relatively inaccessible areas served by poor infrastructure. Poor sanitation and water availability has also lead to periodic outbreaks of dysentery and cholera during this period. Trends in numbers and those at risk are shown in Figure 8.

Figure 8. Mozambique Region - Trend in numbers of refugees/displaced

Levels of wasting and mortality amongst the Mozambican refugees in Malawi, Zimbabwe, Zambia, South Africa and Swaziland generally remained low throughout these refugee emergencies, and the situation is widely regarded as being largely successfully controlled. However, widespread outbreaks of pellagra (niacin deficiency) occurred amongst refugees in Malawi and Zimbabwe. The peak of the outbreak in Malawi was in 1990 when over 18,000 cases were reported. Subsequent fortification of maize flour with niacin led to the virtual disappearance of this condition. In Zimbabwe pellagra remained a problem up until August 1992 when ground nuts were introduced to the general ration.

In Mozambique, crisis levels of wasting were found in several provinces following the signing of the peace accord in October 1992. Nutrition surveys, conducted in accommodation and reception centers set up for returnees and longer-term internally displaced, frequently found levels of wasting above 20%. By mid-1993 repeat surveys showed a much improved situation in these centers. Subsequently, nutrition monitoring by a variety of NGOs working throughout Mozambique have generally found low levels of wasting (under 10%) with occasional "pockets" of famine in particular provinces. Thus, in June 1993 levels of wasting in parts of Gaza province were above 15%, and were 17% in Chokwe district and 9-20% in parts of Guija district.

Cholera and dysentery were reported in Nampula, Capo Delgado and Chuire provinces in the second half of 1993 while water problems were being reported in Gaza, Inhumbane, Manica and Zambezia provinces at the same time.

The main nutritional problems throughout the resettlement and rehabilitation phase of the Mozambique programme has been amongst those refugees and internally displaced groups that have returned home after the planting season or have not had implements and inputs for agricultural production and have been cut off from emergency relief food for long periods because of inaccessibility. Problems of inaccessibility have been exacerbated by the widespread existence of mines and rains washing away infrastructure. Nutritional survey results have therefore frequently shown highest levels of wasting in areas with the largest numbers of recent returnees.

The recent history of nutrition for Mozambican refugees and displaced is one of cautious success. Most reports are that the nutrition and health situation is under control, both for the returnees that reach assistance within Mozambique, as well as continued successful protection of health and nutrition for the refugee populations in Malawi, Zimbabwe, and Zambia. The situation for the several hundred thousand refugees in South Africa in the early 90s is not clear, since this may have changed with the recent developments in South Africa. Overall the experience of Mozambican refugees demonstrates that it is indeed feasible to protect health and nutrition when there is access and adequate security.

Somalia

The catastrophic civil war of recent years was triggered in May 1988, when rebels of the Somalia National Movement (SNM) from Somaliland in the north briefly took the towns of Hargeisa and Burao. Government retaliation was brutal, the towns being bombarded and partly destroyed, with tens of thousands of civilians being killed, and over half a million people fleeing to Ethiopia (MSF, 1992, p45). This led to an increased uprising, involving a number of different clans, and leading to destruction of much of the capital, Mogadishu. General Said Barre was overthrown in January 1991, which then plunged the capital into even more extensive internecine warfare. This continued through much of 1991, and "all semblance of law disappeared in the capital, transformed into a closed battle field where the clans fought for the remains the remains of a state which had long since collapsed." (MSF, 1992, p46). Although the level of violence declined somewhat in early 1992, the towns and the countryside were wrecked, and famine began to spread from early in the year. Many thousands of the population were displaced, and for example in coastal towns near Mogadishu where many of these congregated, appalling mortality rates and malnutrition were reported. The famine peaked in 1992, with only limited assistance being provided by external agencies. In December 1992, under UN authority, 30,000 troops under US command landed in Mogadishu, with a mandate "to establish a secure environment for humanitarian relief operations in Somalia".

By this time, it was estimated that up to half a million people had died due to violence, famine, and disease; there were even estimates that up to half the pre-school children had perished (USCR, 1994, p66, quoting UN and ICRC). In a population of originally around eight million, around two million were internally displaced, another million had fled to Ethiopia and Kenya, and around 4.5 million were estimated to require food aid.

Lack of international agency presence in Southern and Central Somalia during 1991 and early 1992 meant that there were limited data on the nutritional and health situation, until mid-1992 when surveys began to show appalling levels of wasting and mortality. Surveys in and around Baidoa town in August and September 1992 found levels of wasting of 100% and 42% respectively. Here crude mortality rates between April and October 1992 and in the 30 days prior to a November/December survey were 17.2/10,000/day (60 x normal) and 23.4/10,000/day (80 x normal) for the displaced population of Baidoa. These data were believed to be representative of other areas in Southern and Central Somalia. They were at the time "some of the highest mortality rates ever recorded", according to CDC. It was estimated that there were at least 1.6 million displaced people affected by the crisis in this part of Somalia.

The situation began to improve in Somali at the end of 1992 largely as a result of the UN/US military presence and the creation of safe routes for food and other relief convoys. By mid 1993 general food distributions were phased out and relief efforts were re-directed to food for work rehabilitation programmes for an estimated 400,000 people. Nutritional surveys from mid 1993 onwards show a considerably improved situation although periodic incidents continued to threaten security and economic recovery.

Somalia

By mid 1993 the food security situation had improved so much that only a small proportion of the 1.6 million displaced were thought to be at any significant risk. Nutrition survey results from Kismayo in December 1993 found levels of wasting under 12% while a survey in Genale in February 1994 recorded levels of wasting of only 2.8%. A survey in April 1994 in Mogadishu found levels of wasting of 8.1%. It was estimated that during 1993, around 70% of all children were vaccinated against measles (USCR, 1994, p79). Estimates of numbers affected September 1993 through October 1994 are shown in Figure 9.

Figure 9. Somalia - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

By mid-1994, although there were a considerable number of security incidents, the number of displaced was estimated at about 400,000, and 380,000 were receiving emergency aid. The rainfall was good, and seed and tool distributions were quite wide, so that a good harvest was achieved in many of the fertile areas. Generally the nutrition situation be came normal for the area. Worries began to surface however that planned troop with drawals in early 1995 could lead to an escalation of insecurity, which could rapidly affect food availability, and lead to a resurgence of the problems of 1992.

The recent history of Somalia illustrates both the devastating effect of anarchy and civil war on survival, and how this can rapidly lead to terrible famine in a poor and vulnerable country. It also illustrates that when humanitarian assistance can be distributed, in this case importantly including food, the nutritional situation for the survivors can return to normal relatively quickly.

Shaba Region in Zaire

Internal ethnic conflict had caused an estimated 700,000 people to become internally displaced by end-1993 (USCR, 1994, p73). The largest group, around half a million people, were from Shaba Province (formally Katanga) in Southern Zaire, moving to Kasai. Another large group is in North Kivu, about which little nutrition information is available, but there have been reports of food shortages and epidemics. More is known about the situation in Shaba, as outlined below, and shown in Figure 10.

Ethnic violence in the mining region of Shaba starting in August 1992 led to the displacement of hundreds of thousands of people of Kasain origin North, towards their original home often from generations ago. Many resided in transit centres or camps for months while others returned to Kasai region with a view to resettlement. The majority of this displaced population had been mining for generations and so had little agricultural experience.

Throughout 1993 reports from many transit areas/centres indicated extremely high levels of wasting and mortality. This was largely due to the absence of a systematic food distribution programme, and high levels of malaria, dysentery and measles. Thus, in September, mortality amongst the displaced had reached 6.7/10,000/day (22 x normal) in the transit town of Mwene Ditu, with levels of wasting above 25%. Similarly high levels of wasting continued to be reported until March 1994. Water shortages and crowding, combined with inaccessibility, led to a critical situation for the 200,000 or so (resident and displaced) in Mwene Ditu.

Figure 10. Shaba, Zaire - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

In other transit towns, such as Mbuji Mayi (population approximately one million, of which more than 100,000 are displaced) food and water availability were reported inadequate, with malnutrition high, in mid-1994. Elsewhere, in West Kasai, for example Kananga, where local church and international NGOs were able to provide relief and assist resettlement, nutrition was better.

Zaire

Large numbers of displaced started to arrive in their ancestral place of origin in East and West Kasai in June 1993 with numbers reaching 140,000 in December. However, apart from some NGO distributions, there were no general ration deliveries in 1993. This delay was due to a variety of factors including delayed needs assessment missions, donor reluctance to pledge food due to political considerations and high transport costs, and shortage of funds within WFP. This situation led to predictably high levels of wasting with reports of 38% wasting in Kabinda in Eastern Kasai in February 1994. By March 1994 limited food supplies carried by aircraft and train began to reach this population, although inadequate donor funding seriously constrained planned delivery schedules.

This large displaced population in Zaire can be successfully resettled, if the level of ethnic conflict moderates. On the other hand, there are real fears that if ethnic violence increases and deliberate steps are not made to lower the political involvement, there could be degeneration into much widerspread unrest, displacement, and all the associated threats to survival.

Ethiopia

Many different populations of refugees and displaced people coexist in Ethiopia. Moreover, often these are from similar ethnic groups, some of which originate from within Ethiopia, others from outside, e.g. Somalis in the East. Thousands of Ethiopians have been displaced by combinations of drought and ethnic conflict, and have become dependent on food aid. This led UNHCR and other agencies to try to deal with the needs by a "cross mandate" strategy, whereby all the needy people in Eastern Ethiopia were to be assisted, whether or not they were formally refugees. The situation in Eastern Ethiopia (Ogaden region) was often very bad, in terms of malnutrition and epidemics such as malaria, and these, together with the political situation, made it particularly difficult to resettle the displaced people. Describing the nutrition situation is thus complicated, and subject to rapid change, but two particular groups have been especially badly affected: Somalis displaced into Eastern Ethiopia, near the border running South East from Djibouti, around Hartisheik; and groups of Ethiopians displaced back from Somalia together with some internally displaced, around Gode, near the border with Somalia and Kenya in South Eastern Ethiopia. The nutrition information on these two groups is summarized here, and illustrated in Figure 11.

Figure 11. Ethiopia - Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (black area).

The situation for the 300,000 Somalis displaced from the North of Somalia in early 1988 deteriorated quickly. In Hartisheik refugee camp levels of wasting increased from 8 to over 30% in a six month period as receipts of general food rations were frequently under 1000 kcals/caput/day. High levels of scurvy were also found in Hartisheik and other camps. A major reason that general rations were grossly deficient during this period was the massive over-registration of refugees which led to donors reduce pledges, to provide for more realistic population numbers. Thus, the ration became inadequate for those households with legitimate numbers of ration cards. Water and health service provision was also extremely inadequate at the start of this refugee crisis with frequent reports of water riots in the early stages of the programme.

Ethiopia

The situation for this population gradually improved as the refugees began to secure alternative sources of food apart from the general ration. By mid-1993 levels of wasting in the five camps ranged from 5-16% and although general ration provision was only between 20-70% of energy requirement the excess ration cards in the system (it was estimated that ration cards outnumber refugees by 3 to 1) and other coping strategies, provided food security for the majority of the camp populations. By mid-1993 the Somali refugee population was acknowledged to be only 100,000. However, by mid-1994 surveys had shown an increase in levels of wasting in camps in this area. Nutrition surveys in May and June 1994 showed levels of wasting ranging from 9% in Hartisheik B to 21% in Darwonji and Teferi Ber.

The civil war in Somalia in 1991-92 also led to the displacement of large numbers of Ethiopian refugees from Somalia back to the Ogaden region of Ethiopia. One such returnee population of over 50,000 people, which included some internally displaced, came to reside in camps around Gode, and in the town of Bohelagare. With limited food aid provision and inadequate health care services the nutritional and health status of this population began to deteriorate rapidly, so that by September 1992 it was experiencing a crisis. By October 1992 mortality rates were found to be as high as 20 times normal in one camp and wasting rates in excess of 40% in three camps. By June 1993, mortality rates had declined to three to seven times normal (0.7-1.7/10,000/day) although wasting rates were still around 40%. Mortality rates more or less remained the same until the beginning of 1994, when rates three times times normal were recorded (0.9/10,000/day). Wasting rates were around 25% at the end of 1993, and similar levels of wasting and mortality were reported in June 1994. Scurvy, vitamin A deficiency, and anaemia were regularly reported at clinics within the camps throughout this period, with incidences of scurvy as high as 3.5/1000/month in Gode camp in November 1993. In January 1994 the rate was 12.8/1,000/month while incidence of signs of vitamin A deficiency were 0.6/1000/month.

These consistently high mortality and malnutrition rates since mid 1992 were due in part to erratic general ration distributions caused to some extent by the level of insecurity and banditry in the area. Throughout 1993 ration receipts were less than 1000 kcals/caput/day and there had been little progress in developing self-sufficiency through rehabilitation programmes.

Refugees in Kenya

Refugees from Somalia, Ethiopia, and Southern Sudan have been living in a number of camps, mostly in the arid North of the country, although some were settled on the coast around Mombasa, and near Nairobi. The population of Somalis, which may have reached nearly 300,000 during 1992-93, was fleeing the civil war in Somalia, and began to repatriate as conditions improved in 1993 and 1994. Numbers for September 1993 to September 1994 are shown in Figure 12. During the same period, around 80,000 Ethiopians crossed the border into Kenya, and again some of these returned after the peace accord in late 1992, which specifically invited refugees to return home. The Sudanese, around 30-40,000, are in the North West of the country, and generally in well organized and secure situations. The nutrition and health situation of the Somali and Ethiopian refugees in the North East of the country has been particularly precarious, and some details are given here. In particular, not only have high levels of protein energy malnutrition and elevated mortality been reported, but persistent outbreaks of micronutrient deficiency, especially scurvy, have occurred; there are some reports of renewed outbreaks of scurvy in late 1994.

Figure 12. Kenya - Trend in numbers of refugees.

The situation amongst the Somali and Ethiopian refugees in Kenya rapidly deteriorated throughout the first half of 1992. In July 1992 mortality rates of 50 times normal were recorded in Walda camp, as well as a pronounced scurvy problem. Similar results were found in surveys in Liboi and Ifo camps. The August prevalences of wasting in camps in Mandera was 46% with 15% severe wasting. Scurvy cases were beginning to appear in the camp in November. In October mortality rates of 8-10 times normal were still being recorded in Hagadera and El Wak camps and scurvy cases were frequently being seen at health centres. The main cause of this emergency was a lack of food for the general ration exacerbated by the clan based distribution system resulting in unfair distributions. Shortage of water was also a problem for many refugee camps. By early 1993, the refugee population was reported to have risen to over 600,000.

Kenya

The situation began to improve dramatically in February 1993, as provision of food aid to the camps improved, and as some spontaneous and organized repatriation to Somalia reduced the refugee numbers to 360,000 by October 1993. Surveys at the beginning of 1994 found low levels of wasting and mortality among refugees in the previously worst affected camps. In January 1994, in Mandera mortality rates were recorded at 0.59/10,000/day (2 x normal) while in Hagadera camp levels of 0.46/10,000/day (1.5 x normal) with only 6% wasting were found.

By June 1994 there were only 220,000 Somali refugees in Kenyan refugee camp, with sufficient food stocks in the country to provide an adequate general ration. Nutrition conditions were generally good, and supplementary feeding programmes could be discontinued in most camps. However, seasonal shortage of fruit and vegetables has reportedly led to reemerging scurvy.

The situation in Northern Kenya illustrates, again, that even under difficult conditions malnutrition and mortality can be controlled, but the long time taken did mean that there were many preventable cases of malnutrition and avoidable mortality.