United Nations System
Standing Committee on Nutrition

Nutrition in Crisis Situations

Vol 2, May2004

Greater Horn of Africa

• Eritrea
• Ethiopia
• Kenya
• Somalia
• Sudan

West Africa

• Guinea
• Ivory Coast
• Liberia
• Sierra Leone

Central Africa

• Burundi
• Democratic Republic of Congo
• Uganda
• Chad

Southern Africa

• Angola
• Zambia

Asia

• Afghanistan
• Pakistan
• Nepal

Listing of sources

Summary of the nutrition survey results

Notes on the survey methodologies

Abbreviations and Acronyms

Indicators and risk categories

Highlights

Ethiopia—Dire situation of IDPs in Somali region
The nutrition and food security situation has improved in most parts of Ethiopia compared to 2002 and 2003. This may be attributed to better weather conditions and to the humanitarian aid which have probably mitigated the situation. Whilst in some areas, the nutrition situation seems under-control, it is still average to precarious in most parts of Ethiopia. The Somali region is especially at risk, due to poor rainfall and the presence of IDPs. Urgent action is needed in the IDP camps in Somali region where dire living conditions have been reported as well as appalling rates of malnutrition since 2002.

Kenya—Nutrition crisis in north-eastern zone of Tukana district
Turkana district is chronically food insecure and households' livelihoods have been eroded over the years. In some areas such as the northeast, coping mechanisms are limited and the food security and nutrition situation has worsened within the past two years; the prevalence of acute malnutrition has increased threefold between 2001-2002 and 2003-2004. In the northwest part of the district, the situation has also worsened but to a lesser extent. The nutrition situation in Kakuma refugee camp is above acceptable levels.

Chad—Sudanese refugees at risk
The humanitarian situation of the refugees in Eastern Chad and of the host population seems to be rapidly deteriorating. Programmes should be scaled-up and integrate the host population. Donor agencies should increase their commitment to the crisis. The onset of the rainy season will further impair the delivery of assistance.

Sudan—Worsening situation in Darfur
It is estimated that more than one million people are displaced throughout Darfur. Some settled with host families whilst other gathered in camps. Access to the population is extremely difficult because of the logistic and security conditions but also owing to the restrictions imposed by the government of Karthoum. The rainy season, which starts by mid-year and coincides with the hunger gap, will further worsen the situation because of the decreased availability of food, increased risk of diseases and more difficult access to the population. Two nutrition surveys conducted in Darfur showed a worrying situation. On the other hand, due to an improvement in food security and security conditions, the situation has greatly improved in part of south Sudan but remains precarious whilst the situation remains serious in other parts which experienced bad weather conditions. IDPs and the local population will require humanitarian and development action as long as the situation is not consolidated on the ground.

Liberia—Average nutrition situation
Several surveys conducted in Greater Monrovia, in IDP camps in Montserrado county and in Bomi and Grand Cape Mount counties showed an average nutrition situation.

Angola—Insufficient funding
There has not been noticeable improvement in the nutrition situation in Angola since 2003. This may be attributed to the fragile food security situation, especially for the returnees who represent a significant proportion of the population. Unfortunately, donors' and the government of Angola’s commitment to Angola's reconstruction is weak and far from sufficient to ensure a significant improvement of the situation.

Nepal—Intensification of the crisis
The on-going conflict has led to major human rights abuses and to the displacement of thousands of people into major cities and India. Whilst the better-off may be able to cope with the displacement, the poorest may be in a more difficult situation. In rural areas, although the direct impact of the conflict on food security is unclear, the recent upsurge in violence may have further weakened the already flimsy food security of the population, and coping mechanisms may become exhausted.

The nutrition status of the refugees is average, with micro-nutrient deficiencies reported, although some measures have been taken to overcome this problem.

Risk Factors affecting Nutrition in Selected Situations

Situations in the table below are classed into five categories relating to prevalence and or risk of malnutrition (I—very high risk/prevalence, II—high risk/prevalence, III—moderate risk/prevalence, IV—not at elevated risk/prevalence, V-unknown risk/prevalence; for further explanation see section "Indicators and classification" at the end of the report).

The prevalence/risk is indirectly affected by both the underlying causes of malnutrition, relating to food security, public health environment and social environment, and the constraints limiting humanitarian response.

These categories are summations of the causes of malnutrition and the humanitarian response, but should not be used in isolation to prescribe the necessary response.

J Adequate
K Mixed
L Inadequate

Greater Horn of Africa

Eritrea

The Bahri rains (November-February) were poor and improved only in February, which was too late to benefit crops but did replenish pastures (FEWS, 25/03/04). On the other hand, despite coming later than usual, the Azmera rains facilitated agricultural activities in April (FEWS, 21/04/04).

As of April 2004, pledges for the WFP's drought emergency programme amounted to approximately 54% of the 2004 requirements (WFP, 30/04/04). When programmes through NGOs and bilaterals were also taken into account, only 38% of the food needs were covered, and food rations have therefore been reduced (OCHA, 23/04/04). Non-food needs were even less resourced, with only 37% coverage for seed needs and an overall 5% coverage for the non-food sector (OCHA, 23/04/04).

Precarious nutrition situation

The MOH in collaboration with UN agencies and NGOs has set up the National Nutrition Surveillance System (N-NSS) to develop unified methodologies, training manuals and harmonization of approaches and data systems.

As part of this system, random-sampled nutrition surveys were conducted in rural areas of Anseba, Debub, Gash Barka and Northern Red Sea in December 2003 (MOH/Joint, 12/03). , depending on the region (table 1). Moreover, a significant proportion of women had a BMI < 18.5 (table 1). The results showed that the situation was of concern, with acute malnutrition rates varying between 12.8% and 16.9%

When compared with previous surveys, the situation does seem to have improved slightly. This was mostly attributed to the seasonal harvest and general and supplementary food distributions.

Table 1 Prevalence of acute malnutrition, Eritrea, December 2003 (MOH/joint, 12/2003)

Food security

Most of the families interviewed during the assessment (96%) said that the food security situation at the time of the survey was not bad.

Food distribution
The intended food distribution was 15-17 kg cereals, 1.2 kg pulses and 0.9 kg oil per person per month (2100/Kcal/pers/day) to 60-70% of the population.

According to the survey, about 99% of the families had received regular food distributions within the four months prior to the survey. Depending on the area, the households had received an average amount of 10.4-12.3 kg cereals, 0.5-0.7 kg pulses, 0.4-0.6 kg oil per person per month (about 1400 Kcal/pers/day).

Supplementary feeding
A significant percentage of children were receiving supplementary food: 28%, 40%, 49% and 36% in Gash Barka, Debub, Northern Red Sea and Anseba, respectively. There was no common mechanism of supplementary food distribution. Supplementary feeding was targeted at malnourished children in some places, whilst there was no targeting in other areas.

Public health

The coverage of vitamin A supplementation was high as well as the measles vaccination coverage (table 2). This was partly attributed to the “polio and measles catch-up immunisation” campaigns, carried out beside the regular programme. On the other hand, a low percentage of the mothers were seeking care when their children were ill (table 2).

Table 2 Measles vaccination coverage, Vitamin A distribution coverage and health care, Eritrea, December 2003 (MOH/joint, 12/03)

* According to cards only

Access to water and to safe drinking water was very poor (table 3).

Table 3 Access to water, Eritrea, December 2003 (MOH/joint, 12/03)

Internally Displaced Persons

It is estimated that there are about 59,000 IDPs settled in camps or in host communities. Most are displaced because of the lingering effects of the border war with Ethiopia (OCHA, 23/04/04). IDPs in Koronko camp in Gash Barka region face dire conditions: IDPs were reported as lacking basic facilities such as access to water and potable water, sanitation, sufficient food rations and non-food items (OCHA, 02/04/04).

Overall

The lingering effects of the war with Ethiopia and the last years’ drought have had a significant impact on households’ food security and nutritional status in a country where the general situation was already poor. Emergency and long-term development programmes as well as reforms at the macro-economic level are crucial.

Recommendations

From the MOH/joint surveys

• Monitor the nutrition situation closely
• Develop a system to gather and analyse a larger set of food security and nutrition data
• Link relief responses to long-term actions
• Develop nutrition training and growth monitoring

Ethiopia

Despite an improvement in the food security situation owing to better harvests and rains in 2003 than in 2002, the situation remains precarious. About 7 million people are still in need of food aid in 2004. However, as of April 2004, food aid needs were only 43% funded (ENFS, 04/04). Nutrition programmes have been scaled down and NGOs have handed some facilities over to the Ministry of Health (USAID, 08/04/04).

Worrying situation in some resettlement sites

The Government of Ethiopia started a resettlement programme in 2003, with the aim of addressing food insecurity. In 2003 and 2004, approximately 350,000 people were resettled in Amhara, Oromya, SNNPR and Tigray regions (USAID, 08/04/04). A joint evaluation in some resettlement areas showed that the sites, especially in Oromya region, lacked adequate food, access to water, shelter, health care and agriculture inputs (USAID, 08/04/04). In addition to the cereal ration, a supplementary food distribution of blended food has been started for vulnerable groups (WFP, 21/05/04). A very high number of malnourished children was recorded in October 2003 in resettlement sites in Tigray (see RNIS 43).

Improved but still average nutrition situation in South Wollo zone, Amhara region

Three random-sampled nutrition surveys were conducted during the harvest in November-December in South Wollo (table 4) (Concern, 11/03; DSA, 12/03). The surveys showed average rates of acute malnutrition.

Whilst it was the first survey which was conducted in Tedhudere district, comparison with previous survey results was possible in Dessie Zuria and Kalu districts. In both districts, trends in prevalence of malnutrition showed that the situation in November 2003 was comparable to that in 2000, 2001 and the beginning of 2002. On the other hand, the situation has improved when compared to the second semester of 2002 (which corresponded to the period of drought) when the rates of malnutrition were the highest recorded since 2000.

In the three districts, 50% to 60% of the families received food through the Employment Generation Scheme (EGS) in 2003.

In Dessie Zuria and Kalu districts about 15% of the children also received food through supplementary feeding programmes. In these districts, the current harvest was better than in 2002. The main sources of income were sale of livestock, cash crops and petty trading. EGS was interrupted in September-October 2003 and was intended to restart in April/May 2004 (when the poorest may have exhausted their harvest), targeting a lower proportion of the population than in 2003.

Young children feeding practices seemed poor, with about half of the mothers not being given colostrom within the first three days of their children’s lives. Food was introduced into the children’s diet between 4-6 months of age by only 60% of the mothers.

Table 4 Acute malnutrition and measles vaccination coverage, South Wollo, Amhara region, Ethiopia, Nov-Dec 2003 (Concern, 11/03; DSA, 12/03)

* According to cards and mothers' statements

High food insecurity in Somali region

Poor rains at the end of last year have significantly affected food security in some parts of Somali region. However, rainfall improved in March and April 2004, mitigating the poor situation (ENFS, 04/04).

Precarious nutrition situation in Ayshia, Shinile, Dembel & Erer districts, Shinile zone

Two random-sampled nutrition surveys were conducted in September 2003, within the agro-pastoral and pastoral population (SC-UK, 09/03). The surveys showed an improvement in the nutrition situation compared to 2002 (figure 1), but the situation remains precarious (table 5). The surveys were conducted during the rainy season but before the harvest. The condition of livestock was reported as being good by almost all the households interviewed. Relief food had been received by most of the population within the month prior to the survey and represented the major source of staple food. The population was using coping mechanisms to get incomes.

Access to health care and safe drinking water was poor as well as the measles vaccination coverage.

Table 5 Acute malnutrition, measles vaccination coverage and mortality rates, Somali region, Ethiopia

* According to cards and mothers' statements

Figure 1 Prevalence of acute malnutrition, Pastoral and agro-pastoral population, Shinile zone, Ethiopia (SC-UK, 09/03)

Poor nutrition situation in Gode District

The nutrition situation was poor in Gode district in February 2004 (table 5) and within the same range as in November 2000, according to a random-sampled nutrition survey conducted by SC-US (SC-US, 02/04); the mortality rates were also very high (table 5). The food security situation appeared poor, partly due to the insufficient rains over the end of 2003 (see NICS 1); the general food distribution did not significantly improve the food security level of the population.

Dire situation of internally displaced persons in Somali region

There are several displaced persons camps in Somali region. Fafen and Hartishiek displaced persons camps, situated in Jijiga zone, host between 10,700 to 14,700 people (depending on the estimation) who have been displaced for some years because of drought. Recent dispute on land ownership in Bordode/Mieso areas has led to the displacement of about 14,900 people in Shinille zone (OCHA, 03/2004).

An assessment conducted in March 2004 showed dire conditions in the camps (OCHA, 03/04). Food delivery has been prevented in Fafen since the beginning of the year, because of rivalries between the local population and the IDPs. At the time of the assessment, no general food distribution was implemented in Bordode/Mieso but food had been distributed to vulnerable groups.

Access to safe drinking water was not guaranteed in the camps and cooking and shelter materials were greatly needed.

Nutrition surveys carried out in Fafen and Hartisheikh IDP camps in December 2003 showed appalling rates of malnutrition: 31.8% (27.7-35.9) and 28.5% (24.6-32.7) acute malnutrition, respectively (FSAU-N, 03/04). The malnutrition rates were within the same range as in March 2002 in both camps (see RNIS 38).

Nutrition situation under control in parts of Oromya region

According to two random-sampled nutrition surveys carried out in December 2003 and January 2004 (CRS, 01/04; SC-UK, 12/03), the nutrition situation in Meta, Kersa and Golo Oda districts is under control (table 6). These surveys were carried out just after the main harvest and so reflect an optimal situation.

Golo Oda district

Malnutrition rates have dramatically decreased in Golo Oda compared to the rates in 2001 and 2002 (figure 2). However, in 2001 and 2002, the surveys were performed at a less favourable period in regard to the food security situation (not at the harvest time).

Figure 2 Prevalence of malnutrition, Golo Oda, Oromya, Ethiopia

The indicators of the food security situation showed an improvement at the time of the survey, compared to 2001 and 2002; the health situation has also improved, although it was still average (box 1). Mortality rates have decreased over the past years and were average (table 6).

Table 6 Results of nutrition and mortality surveys, Oromya region, Ethiopia

* According to cards and mothers' statements

Box 1 Improved food security and health care in Gola Oda district, East Hararghe zone, Oromya, Ethiopia, December 2003 (SC-UK, 12/03)

Meta and Kersa districts

Similarly, the food security in these districts was reported as being satisfactory, with a good harvest and animals in a good condition. However under-five mortality rate was high (table 6), particularly due to malaria and relapsing fever epidemics.

Average to precarious nutrition situation in SNNPR

The nutrition situation was average to precarious according to several surveys conducted in SNNPR (table 7); mortality rates were under-control.

At the end of 2003, the nutrition situation had not improved in Meskan and Mareko districts, Gurahe zone compared to March 2003 (SC-US, 11/03). The food security situation was still precarious owing to an only average rainy season.

In Lanfuro and Darecha district, the malnutrition rates have remained stable since March 2003 (SC-US, 12/03). Most of the households thought they will rely primarily on their crop production within the next three months.

In Offa woreda, Wolaita zone, although the nutrition and food security situation has significantly improved compared to September 2003, it remained precarious in December 2003, despite the harvest (Concern, 12/03). The crop was reported as being worse than in previous years and most of the households were relying on coping mechanisms.

In Shebedino woreda, Sidama zone, the nutrition situation was average in February 2004 and the food security situation was reported as having improved compared to the previous six to 12 months (GOAL/SC-US/ACF, 02/04).

Table 7 Acute malnutrition and measles vaccination coverage, SNNPR, Ethiopia

Overall

The nutrition and food security situation has improved in most parts of Ethiopia compared to 2002 and 2003. This may be attributed to better weather conditions and to the humanitarian aid which have probably mitigated the situation. Whilst in some areas (such as some districts in Oromya zone), the nutrition situation seems under-control (category III), it is still average to precarious in most parts of Ethiopia (category II). The Somali region is especially at risk (category I), due to poor rainfall and the presence of IDPs.Urgent action is needed in the IDP camps in Somali region where dire living conditions have been reported as well as appalling rates of malnutrition (category I).

Kenya

Serious food security and nutrition situation in Turkana and Marsabit districts

Turkana and Marsabit districts are classified as “arid and semi-arid lands” and are amongst the driest and least productive in Kenya.

This area is chronically food insecure with a significant reduction in herds over the years. The last years of drought in 1999-2002 further weakened the livelihoods of this mostly pastoral population. The October-December short rains were poor in Marsabit district and poorly distributed in Turkana district, which prevented the pastures in the worst affected areas from being replenished. Moreover, increased insecurity in Turkana district, such as cattle raiding, has further exacerbated the poor situation. The condition of livestock was reported as deteriorating, the price of livestock was very low and the terms of trade were unfavourable to pastoralists (FEWS, 19/03/04). However, good rains in April may have mitigated the situation (FEWS, 06/05/04).

Several nutrition surveys recently carried out in these districts showed high rates of acute malnutrition, ranging from 18% to 34% (FEWS, 05/04/04).

About 230,000 persons (40% of the population) will benefit from food aid from April to July 2004, at a 50% ration (FEWS, 05/04/04).

Nutrition crisis in north-eastern zone of Tukana district

An appalling nutrition situation was found in the northeastern zone of Turkana district during a random-sampled nutrition survey conducted in February 2004 (OXFAM, 02/04). The prevalence of acute malnutrition was 34.4% (31.3-37.4), including 5.4% (4.0-7.0) severe acute malnutrition, and has dramatically increased within the last two years. The rate of malnutrition was around ten percent in 2001 and 2002 and was about 28% in March 2003. Different factors, such as the poor rains in 2002-2003, the halt in the food distribution programme at the end of 2002 and the overall destitution of households over the years, may explain the deterioration of the nutrition situation. Mortality rates were also high: CMR=2.1 /10,000/day and <5MR=2.6 /10000/day.

A significant proportion of pregnant and lactating women (42%) had a MUAC < 23 cm.

Vitamin A distribution coverage was low and measles vaccination coverage was average (table 8).

Table 8 Measles vaccination and vitamin A distribution coverage, Northern Turkana district, Kenya, February 2004 (OXFAM, 02/04)

The number of meals has significantly decreased compared to "normal times" (table 9). It is worth noting that 20% of the families reported having no meal the day prior to the survey, indicating a very worrying situation.

Table 9 Number of meals taken, North-eastern Turkana district, Kenya, February 2004 (OXFAM, 02/04)

The main livelihoods of households were pastoralism (64%), fishing (11%) and handicrafts (10%).

The traditional sources of income (from livestock or fishing) were limited by the bad condition of livestock and its low price, and by the high cost of inputs for the use of boats. People tended to shift to coping strategies such as an increase in petty trading.

As of May 2004, emergency general food distributions and food for work programmes were on-going and the implementation of treatment of severe malnutrition was planned.

Precarious nutrition situation in the north-western zone of Turkana district

A survey done at the same time as in the eastern part of Turkana district (see above), showed a precarious situation but which had not deteriorated since 2003 (OXFAM, 02/04). The prevalence of acute malnutrition was 16.8% (14.5-19.4) including 1.8% (1.1-2.9) severe acute malnutrition in February 2004, 18.9% in March 2003 and 11.4% in February 2002. The same factors as for the eastern part of the district may explain the deterioration of the nutrition situation compared to 2002. Mortality rates were also lower than in the eastern part of the district; CMR and <5 MR were respectively 1.5 /10,000/day and 1.2 /10,000/day. Measles vaccination and vitamin A coverage were low (table 8).

Most of the population was pastoralist or urban/semi-urban. The number of meals has decreased when compared to "normal times" but to a lesser extent than in the eastern zone.

The proportion of income from livestock has decreased in both groups whilst the proportion of income from petty trade has increased. The sale of wild food has also widely decreased, which may be due to scarcity or an increase in consumption.

The Kakuma refugee camp, hosting about 80,000 people and the humanitarian Operation Life Line Sudan headquarters are situated in this area. It is thought that the activities and trade opportunities they offer, may partly explain why the nutrition situation has deteriorated less than in the eastern part.

Worsening nutrition situation in Kakuma refugee camp, Turkana district

Kakuma refugee camp was set up in 1992 and hosts mostly Sudanese refugees (about 60%), Somali refugees (about 35%) and a small number of people from the Great Lakes. In December 2003, the camp was hosting about 87,000 people. Although the movement of the refugees and the employment opportunities outside the camps are restricted, some refugees manage to get incomes. The better-off also receive remittances from abroad. The poorest refugees are those who can not secure regular and significant incomes (35-45% of the refugees). Most of the refugees are highly dependant on international aid. The relation with the local population is tense and riots occur regularly.

The refugees are meant to receive a full food distribution (2,168 Kcal/pers/day), but the ration actually distributed is often lower due to frequent pipeline breaks. The distribution of CSB, which should supplement the ration in micro-nutrients is often reduced or omitted.

The nutrition situation is regularly followed with an annual nutrition survey. The situation has remained above acceptable levels for years (figure 3). The last nutrition survey carried out in December 2003 showed a significant deterioration of the situation compared to 2002 (figure 3) (IRC, 12/03).

Figure 3 Acute malnutrition, Kakuma camp, Turkana district, Kenya

During this survey, the haemoglobin status of 270 children aged 6-59 months was measured. Results showed appalling rates of anaemia (table 10), which have worsened when compared to the results of April 2001 when already 61.3% of the children were considered anaemic (Hb<11 g/dL). At the time the survey was written, the measurement of haemoglobin was repeated in order to verify these high rates of haemoglobin deficiency.

The measles vaccination and vitamin A distribution coverage, according to cards and mothers’ statement was 74.3% and 40.4%, respectively.

A small percentage of the families (about 2%) seemed not to be registered for the general food distribution.

Around 55% of the mothers interviewed during the survey reported having received counselling on breast-feeding. Some 62% of the mothers said they know that mothers can transmit HIV to their children.

The nutrition situation of the refugees seems to be comparable with that of the host population in the same regional zone (see above).

The insufficiency of aid provided may partly explain the rise in malnutrition. Although interactions between refugees and the host population are restricted, interactions exist and the actual food insecurity faced by the host population may also have some implications for the refugees.

Table 10 Anaemia among 6-59 month olds, Kakuma refugee camp, December 2003

Overall

Turkana district is chronically food insecure and households' livelihoods have been eroded over the years. In some areas such as the northeast, coping mechanisms are limited and the food security and nutrition situation has worsened within the past two years (category I); the prevalence of acute malnutrition has increased threefold between 2001-2002 and 2003-2004. In the northwest part of the district, the situation has also worsened but to a lesser extent (category II). The nutrition situation in Kakuma refugee camp is above acceptable levels (category II).

Recommendations

From the OXFAM survey in the Turkana district:

Eastern zone:

• Distribute immediately a full food ration to a minimum of 70% of the affected population for up to three months
• Include a blanket supplementary food distribution to the general ration for at least all the under-five children and consider implementing it for all the under-12 year olds
• Include a blanket food distribution for all women of reproductive age, as 70% are considered to be either pregnant or lactating
• Support the existing health facilities in the treatment of severe malnutrition

Eastern and western zones:

• Support vitamin A distribution and measles vaccination
• Follow the food security and nutrition situation closely
• Implement school feeding programmes in all schools
• Implement long-term programmes aimed at supporting livelihood recovery
• Enhance existing conflict resolution and peace building

From the IRC survey in Kakuma:

• Identify underlying determinants of malnutrition
• Strengthen community support systems
• Step up vitamin A supplementation programme

Somalia

The final round of peace-talks was due to begin at the end of May 2004 (IRIN, 25/05/04). The security situation is still tense, especially in Mogadishu, Gedo region and Sool plateau.

Deyr cereal production performance

The Deyr cereal production was considered normal but was 28% lower than in 2001 and 41% lower than in 2002. The production was especially affected by poor rains in Bakol, Hiran, Lower Juba and Middle Shabelle (table 11). The 2003 Gu production, which is the main harvest, had also been poorer than in 2002 (see RNIS 43).

Table 11 Deyr cereal production performance (FSAU-FS, 02/04)

Mitigation of the nutrition situation of IDPs in Mogadishu

A rapid nutrition assessment was conducted in six IDP camps (Coca-Cola, Dhkajo, Stadium, Fardowsa, Shabelle and Arsjisagoor) in Mogadishu in April 2004 (FSAU-N, 05/04). The results of the MUAC screening showed a precarious situation: of 515 12-59 month-olds screened, 3 had oedema (0.5%), 5 had a MUAC < 11 cm (0.9%) and 70 had a MUAC < 12.5 cm (14.5%).

Although the different assessments which have been carried out over the past years in the IDP camps are not directly comparable, because they were not done in the same camps, they do indicate that the percentage of malnourished children was lower in April 2004 than in August 2002 when 39% of the children had a MUAC < 12.5 cm (see RNIS 39), and is within the same range as in 2000, when 16.5% of the children had a MUAC < 12.5 cm.

The improvement of the situation was partly attributed to the implementation of a regular food distribution by WFP and Islamic organisations (FSAU/N, 05/04).

Acceptable nutrition situation in Belet Weyne town, Hiran region

The nutrition situation seemed acceptable in Belet Weyne town according to a nutrition assessment carried out in April 2004 (FSAU-N, 05/04). Among 919 12-59 month-olds screened, 45 (5%) were considered moderately malnourished (MUAC < 12.5 cm and/or oedema), including 6 (0.8%) considered severely malnourished (MUAC < 11 cm and/or oedema). This shows an impressive improvement compared to September 2002, when a similar kind of screening had found that 25% of the children were considered acutely malnourished (see RNIS 39).

The acceptable nutrition situation was attributed to the fact that the food security situation was good for the better-off and middle wealth groups who had several sources of income such as business, livestock and livestock products, skilled employment and remittances from abroad. It is thought that the poorest cope through social support, loans and change in diet pattern, despite increased food prices and limited income opportunities.

Worsening situation in Jilib and Buale riverine areas, Middle Juba

Several reports have highlighted the dire situation which the riverine population of the Juba valley faces, especially during the summer months when the situation is near a famine stage (see RNIS 43 and NICS 1).

Food security seems to have decreased this year (FSAU-FS, 05/04): the 2003/2004 crops were only 55% of post-war average; the drought has reduced availability of fish and wild food; and work opportunities were scarce. Moreover, food prices were very high in the area as of March, and insecurity prevailed.

MSF-H reported an increase in admission to the therapeutic feeding centre in March; 70% of the children admitted to the TFC had oedema. Several agencies have planned to reinforce the current relief and development programmes. In addition to the therapeutic feeding programme, support to health care and capacity-building initiatives, plans were made for the implementation of supplementary feeding programmes, food distribution and longer-term food security interventions (FSAU-N, 04/04).

Persistent dire situation in Gedo region

Food security in northern Gedo has gradually deteriorated partly due to insecurity. Recent renewed fighting in the area has led to new population displacement. A MUAC screening undertaken in April 2004 (FSAU-N, 04/04) showed that Belet Hawa district was the most affected district, with 27.1% of the children (12-59 months) screened considered acutely malnourished (MUAC < 12.5 cm and/or oedema) whilst the percentage of children considered acutely malnourished was 15.2%, 15.1% and 10.9% in Luuq, Dolow and Elwak districts, respectively.

Continuing food insecurity in Northern and Central Somalia

The Gu rains started in April but were inadequate. Death of livestock and rising destitution continue. As of March 2004, it was estimated that of an estimated 927,000 people in Lower Nugal, Togdheer, Central region and Sool region, 123,000 were affected by a livelihood crisis (most of them in Togdheer) and 95,000 were experiencing a humanitarian emergency (65,000 in Sool region and 30,000 in Lower Nugal) (FSAU-FS, 03/04). As of February 2004, there was a gap between the needs and the response.

The third round of nutrition screening in the sentinel sites in Sool plateau, which was done in April 2004 showed a worrying situation, but which seemed to have slightly improved compared to January 2004 (table 12). On the other hand, the nutritional status of women seemed to have worsened (table 12).

A random-sampled nutrition survey carried out in Garowe, south Gardo and Burtinle districts, Nugal region in March 2004 showed a situation of concern: the prevalence of acute malnutrition was 15.9% (12.7-19.6) including 3% severe acute malnutrition (1.7-5.1) (FSAU-N, 05/04). This rate seems to be higher than malnutrition rates generally recorded in Puntland (less or around 10%).

Table 12 Nutrition situation in Sool plateau, screening in sentinel sites (FSAU-N, 05/04)

Overall

The Northern and Central region of Somalia are especially at risk (category II). Riverine areas of Buale and Jilib districts need immediate intervention (category I) to alleviate the food insecurity and prevent a further deterioration of the nutritional status

Sudan

A new accord was signed between the government of Karthoum and the Sudan People's Liberation Movement/Army (SPLM/A) regarding power-sharing and the resolution of conflict in Abyei, Southern Kardofan/Nuba mountains and Blue Nile states (IRIN, 28/05/04). Three protocols on the status of the South (six year period of autonomy, followed by a referendum), on security arrangements during the interim period and on wealth-sharing, had been signed at the beginning of the peace talks. It is expected that a comprehensive peace-agreement will be signed within the coming months.

The conflict in Darfur was not part of the peace protocols and separate peace talks have been conducted in Chad between the government of Karthoum, the Sudan Liberation Movement/Army (SLA) and the Justice and Equality Movement (JEM). A cease-fire agreement was signed on the 8 April for a renewable period of 45 days (AFP, 08/04/04). However, continuous violence has been reported on the ground.

Dire humanitarian situation in Darfur

Violence and human rights violations have been raging in Darfur for months. According to a mission led by the Office of High Commissioner for Human Rights, there have been frequent reports of killings with men and boys especially targeted, and of sexual violence; a climate of impunity has prevailed (UNCHR, 07/05/04). Attacks of the Janjawee, Arab militias who launch raids on villages, have led to killings, violence and destruction of villages, water and food reserves (ICG, 16/05/04).

There is also a need for better protection of IDPs, who face a greater risk of attacks after the delivery of humanitarian assistance (UNCHR, 07/05/04).

It is estimated that more than one million people are displaced throughout Darfur (570,000 in West Darfur, 290,000 in North Darfur and 140,000 in South Darfur) (UNICEF, 19/05/04). Some settled with host families whilst other gathered in camps (see map).

There are reports of the willingness of the government of Karthoum to forcibly return IDPs to their home areas (USAID, 21/05/04).

Access to the population is extremely difficult because of the logistic and security conditions but also owing to the restrictions imposed by the government of Karthoum, such as the requirement of special travel permits for humanitarian workers (USAID, 21/05/04). However, the government of Karthoum announced at the end of May 2004 that they will ease access to humanitarian workers (IRIN, 21/05/04); as of 20 May 2004, there were 116 humanitarian workers waiting for an entry visa or travel permits (UNRC, 20/05/04).

WFP reported restrictions on the partnership for food distribution: the government of Karthoum has ordered that only national NGOs are authorised to distribute food, not international NGOs (UNRC, 25/05/04).

ICRC reported that access to the population has improved but could be better (AFP, 25/05/04).

The availability of non-food items is inadequate to cover all the needs (USAID, 21/05/04). Availability of clean water and sanitation equipment is also reported as being scarce (OXFAM, 25/05/04).

The rainy season, which starts by mid-year and coincides with the hunger gap, will further worsen the situation because of the decreased availability of food, increased risk of diseases such as malaria and diarrhoea and more difficult access to the population (OXFAM, 25/05/04) (see map).

Two surveys were conducted in Kutum town, North Darfur and Wade Saleh and Mukjar provinces, West Darfur, in March and April 2004, respectively (SC-UK, 03/04; MSF-H, 04/04). In both surveys, IDPs represented the majority of the households surveyed: 89% and 75%, respectively. The nutrition situation and the under-five mortality rates were of concern in Kutum town and were serious in Wade Saleh and Mukjar provinces (table 13).

Table 13 Prevalence of acute malnutrition, measles immunisation coverage and mortality rates, Darfur region, Sudan (SC-UK, 03/04; MSF-H, 04/04)

 * According to cards and mothers' statements

Kutum town was not accessible between November 2003 and January 2004. Some of the IDPs were living with relatives or in abandoned houses; the majority have gathered in an area in the town where they lack basic facilities. The main source of food was relief food for the majority of the households (87%), whilst the others relied on market (10%) or on their own production (2%).

In Wade Saleh and Mukjar provinces, morbidity was especially high: 85% of the children had been ill in the two weeks prior to the survey; major illnesses were diarrhoea (47%) and cough (28%). The food security situation has significantly deteriorated compared to before the crisis and people relied on coping mechanisms which were, however, limited (box 2).

Box 2 Food security indicators in Wade Saleh and Mukiar provinces, West Darfur (MSF-H, 04/04)

Internally Displaced People in Kassala state

Kassala state hosts both refugees, mainly from Eritrea, and displaced people; it is estimated that around 54,600 IDPs are settled in official camps. A nutrition survey was carried out in these camps by Goal in February 2004 (Goal, 02/04). The sources of income of the IDPs were mainly agricultural daily labour, wood cutting and charcoal production. Some were able to cultivate on residents' land or on small plots adjacent to the camps. The survey revealed an uncertain nutrition situation: 12.1% of the children were acutely malnourished, including 0.8% severely malnourished. Only one child had oedema. The nutrition situation was nevertheless slightly better than in 2002 and 2003 (figure 4).

The measles vaccination coverage proved by cards was 55.5% and was 75.5% when mothers' statements were also taken into account. A measles vaccination and vitamin A distribution campaign had been conducted in January 2004 in Kassala state; according to the survey, 96% of the children had received vitamin A.

Food distribution was reported as being irregular and has been halted since December 2003 for those IDPs who arrived the earliest and halved for the newly arrived IDPs.

Child feeding practices were sub-optimal.

Figure 4 Prevalence of malnutrition, IDP camps in Kassala state, Sudan

Improved situation in some areas of southern Sudan, whilst others remain at risk

Despite the signing of a new accord between the government of Karthoum and the SPLM/A, there are increasing reports of local conflicts over access to grazing land, resources and cattle, which have led to population displacements, especially in the lakes area of Bahr el Ghazal (IRIN, 19/05/04).

It seems that new restrictions have been imposed by the Sudan Relief and Rehabilitation Commission (SRRC), the SPLM/A's humanitarian wing, on humanitarian work, such as new taxes and work permits for expatriates. The SRRC would like to promote the employment of Sudanese workers; this may cause difficulties, considering the low level of education in southern Sudan (IRIN, 28/05/04).

An Ebola outbreak began in Yambio county, Western Equatoria; 19 cases have been identified as of 24 May 2004 (AFP, 24/05/04).

Wau town and IDP camps

Wau town has been a Government of Sudan enclave for the past 20 years. The town remains extremely isolated. In case of insecurity or a food gap, people from nearby villages seek refuge in the IDP camps, located in the outskirts of the town. Surveys were conducted in Wau town and in the surrounding IDP camps in February 2004 (ACF-F/joint, 02/04). The results revealed worrying rates of malnutrition, especially in some camps (figure 5).

However, the situation seemed to have slightly improved compared to 2003, when a new wave of displaced people had arrived in the area because of high food insecurity in rural areas (figure 5). Under-five mortality rates were below alert thresholds.

The decision of WFP to halt free food distribution to IDPs since December 2003 and to replace it by food for rehabilitation or food for training causes concern given the current un-acceptable nutrition situation in some of the camps. This newly established type of food distribution should ensure that the IDPs can meet their nutritional requirements.

Figure 5 Prevalence of acute malnutrition, Wau town and IDP camps, Sudan

Old Fangak, Upper Nile

The nutrition situation seemed to have greatly improved in Old Fangak district (table 14, figure 6) (AAH-US, 03/04). The same pattern was observed in Atar area (table 14) (AAH-US, 11/03). The food security was good in these areas in 2003, owing to good rainfall, few security incidents and on-going food distributions and humanitarian programmes.

Table 14 Prevalence of acute malnutrition, measles immunisation coverage and mortality rates, South Sudan (AAH-US, 09/03-02/04)

 * According to cards and mothers' statements

Figure 6 Prevalence of acute malnutrition, Old Fangak, Sudan

Gumriak, Mareang and Nyadin, Upper Nile

On the other hand, the nutrition situation was poor in Gumriak, Mareang and Nyadin districts (table 14) (AAH-US, 10/03). This was attributed to floods and locusts which damaged the crops. Mortality rates were incredibly high (table 14); major causes of death were diarrhoea, bloody diarrhoea, measles and lower respiratory infection.

Kapoeta, Eastern Equatoria

In Kapoeta district, Eastern Equatoria, the nutrition situation was also of concern due to food insecurity owing to bad rains (table 14) (AAH-US, 01/04). Mortality rates were also high; the main causes of death were diarrhoea and fever.

Overall

The situation in Darfur remains at high risk (category I) and may worsen with the unset of the rainy season. On the other hand, due to an improvement in food security and security conditions, the situation has greatly improved in part of south Sudan but remains precarious (category II) whilst the situation remains serious in other parts which experienced bad weather conditions (category I). IDPs and the local population will require humanitarian and development action as long as the situation is not consolidated on the ground.

Recommendations

From the MSF-H survey in Western Darfur:

• Ensure a regular food distribution
• Implement a blanket supplementary food distribution to under-fives, pregnant and lactating women
• Implement a supplementary feeding programme targeted at malnourished children
• Support the health facilities
• Carry out a measles vaccination campaign
• Distribute plastic sheeting and blankets

From the SC-UK survey in Kutum town, Northern Darfur

• Continue providing a general food distribution
• Support health facilities
• Provide protection to the IDPs
• Distribute non-food items

West Africa

Guinea

Guinea still hosts about 110,000 refugees in seven camps (see NICS 1) and an additional 70,000 refugees outside camps. UNHCR's repatriation programme for Sierra Leonean refugees resumed in January 2004 and is due to end in June 2004 (AFP, 04/05/04). About 6,000 refugees are still settled in camps. UNHCR has planned to stop material aid to Sierra Leonan refugees by June 2004 (AFP, 04/05/04). However, some refugees are reluctant to return because they want to harvest in Guinea before returning or because they think that living conditions in Sierra Leone are not satisfactory (OCHA, 20/02/04).

An evaluation carried out by the URD group in Guinea at the end of 2003 raised positive and negative points regarding the situation in the refugee camps and the impact of the establishment of the camps on the host population (URD, 12/2003) (box 3).

Box 3 Positive and negative points in and around the refugee camps, Guinea, December 2003 (URD, 12/03)

Ivory Coast

Peace accords have suffered a set-back within the recent months. A march organised by the rebels and opposition parties and which was officially banned took place in Abidjan on the 25th of March 2004 and degenerated into violence (IRIN, 25/03/04). The rebels and opposition parties suspended their participation in the government shortly thereafter.

A report on the events around the 25 March's march, led by the Office of the United Nations High Commissioner for Human Rights, said that at least 120 people were killed, 20 disappeared and 274 were injured. There was also evidence that some community groups were specially targeted, i.e. individuals from the north of the country or from neighbouring countries (UNSC, 13/05/04).

In protest against this report, demonstrations and sit-in have been organised by the Jeunesse Patriote, loyal to president Gbagbo (OCHA, 17/05/04); it also seems that a UN convoy was stoned (WFP, 21/05/04).

On 27 February the UN Security Council agreed to create a 6,240-strong peacekeeping force for Ivory Coast (UNSC, 27/02/04); the peacekeeping force had about 2,000 troops as of May 2004.

Violent ethnic clashes still continue in the west of the country where at least 3,000 people were displaced in May 2004 (WFP, 21/05/04). There are still several hundred thousands of displaced people and an estimated 75,000 refugees.

Decline in agricultural production

According to the FAO/WFP crop and food supply assessment mission, conducted in November/December 2003, food crop, cash crop and animal production was reduced in 2003 compared to previous years (table 15) (FAO/WFP, 03/04).

Table 15 Food crop, cash crop and animal production prospects for 2003/2004, compared to previous years (2002/2003 for food crops, 2001/2002 for cash crops), Ivory Coast (FAO/WFP, 03/04)

The decline in production may be attributed to the displacement of population, the lack of labour which resulted from it, the lack of agricultural services in parts of the country and the disruption to access to markets because of insecurity and levies at roadblocks. These factors are present to a greater or lesser degree, depending on the area (box 4).

Box 4 Factors affecting agricultural production in Ivory Coast (FAO/WFP, 03/04)

Nutrition situation under control in Bin Houye and Zouan Hounien sous-préfectures, Danane department, west Ivory Coast

Zouan Hounien is an area controlled by the force loyal to President Gbagbo, as is Bin Houye, apart from the north which is under the responsibility of the peace-keeping force. A lot of people fled the area at the end of 2002 but began to return in May/June 2003. The main source of income before the crisis was cash crops, and especially coffee. Cash crop cultivation has been badly affected by the crisis but people have been able to cultivate cassava, maize, swamp rice and vegetables. A few irregular food distributions have taken place. The health system is supported by NGOs; two supplementary feeding centres are in place and severely malnourished children are referred to a therapeutic feeding centre in Man.

A random-sampled nutrition survey was conducted in December 2003 in a 10 km radius from the two supplementary feeding centres (ACF-F, 12/03). The results showed that the situation was under control: the prevalence of acute malnutrition was 4.3% (2.7-6.6), including 0.5% (0.1-1.8) severe acute malnutrition. The measles vaccination coverage was low, with only 23.3% of the children being vaccinated against measles, according to cards and mothers' statements.

Overall

The political situation is highly volatile. Despite a decrease in food and cash crop production, the food security and nutrition situation remains average (category III) but is fragile. Any degradation of the political situation will put the population at risk.

Liberia

The security situation has improved in Liberia and humanitarian organisations have had access to a wider part of the country (WFP, 20/05/04). However, security is still perilous, with outbreaks of violence and abuses of civilians, even in the areas controlled by UNMIL (GW, 24/05/04). As of May 2004, UNMIL was at full strength with 15,000 troops deployed throughout the country (UNICEF, 24/05/04).

The Disarmament, Demobilisation, Rehabilitation and Reintegration (DDRR) process resumed on 15 April 2004, in Gbarnga, Buchanan, Tubnamburg and outside Monrovia (UNICEF, 24/05/04). So far, 26,000 fighters from LURD, MODEL and former-government forces have been disarmed and have received the US$300 resettlement grant (IRIN, 12/05/04); it is however suggested that non-combatants may have also taken part in the process. Cash-payment to demobilised children and adolescents has also raised concerns, as it is thought that the grant will probably not be used for productive investments (RI, 21/04/04).

A national measles vaccination and vitamin A distribution campaign is under-way (UNICEF, 24/05/04).

Refugees and returnees

An estimated 10,000 Liberian refugees were still in camps as of May 2004. UNHCR intended to stop aid to Sierra Leonean refugees at the end of June and encouraged them to repatriate (UNHCR, 17/05/04).

About 17,000 Liberian refugees have spontaneously returned from neighbouring countries. About 7,000 are settled in two returnee camps in Montserrado county. After registration, they will receive a re-integration package (UNHCR, 18/05/04).

Internally Displaced Persons

A census, carried out in April 2004 in the 20 official displaced persons camps concluded that there were about 261,900 IDPs in these camps, of whom the majority were in Montserrado county (table 16) (OCHA/UNHCR, 05/04). The report acknowledged that it was

difficult to know the exact number of people as there was a lot of movement between the surrounding communities and the camps. The majority of IDPs plan to return to Bong, Lofa and Bomi counties.

Table 16 Number of IDPs in official IDP camps in Montserrado, Bong and Margibi counties, April 2004, Liberia (OCHA/UNHCR, 05/04)

IDP camps in Montserrado county

The nutrition situation was good to average among the IDPs settled in six camps in Montserrado county, according to random-sampled nutrition surveys carried out in November 2003 (table 17) (SC/ACF, 11/03).

Table 17 Prevalence of acute malnutrition in seven IDP camps in Montserrado county, Liberia, November 2003 (SC/ACF, 11/03)

Greater Monrovia

A random-sampled nutrition survey conducted in Greater Monrovia in November 2003 showed average prevalence of malnutrition (category II) and mortality rates (table 18) (WFP/joint, 11/03). A similar malnutrition rate was shown in a survey carried out in six districts of Monrovia and two IDP camps on the outskirts of Monrovia (VAM, 11/03). The assessment also showed that the food security situation was of concern: on average, households were spending 70% of their income in food, this reached 95% for the IDPs. 40% of the households had no assets, whilst 26% had domestic assets and only 3% had productive assets. The majority of the families (60%) had poor dwelling conditions. Households were relying mainly on petty trading and wage labour and coping mechanisms seemed limited. Morbidity was very high: 75% of the children had been ill within the two weeks prior to the survey.

Table 18 Results of nutrition and mortality surveys, Greater Monrovia, Bomi and Grand Cape Mont counties, Liberia (WFP, 11/03; WV, 03/04)

* According to cards and mothers' statements

Bomi and Grand Cape Mount counties

The nutrition situation in Bomi and Grand Cape Mount counties appeared acceptable (category III), according to a random-sampled nutrition survey conducted in March 2004 (table 18) (WV, 03/04). Measles vaccination and vitamin A distribution coverage (77.1%) were satisfactory.

On the other hand, mortality rates within the six months prior to the survey were very high.

The main causes of death among those over five year old were war related injury (21%), diarrhoea (20%) and fever (18%), whilst they were diarrhoea (30%), fever (25%) and malnutrition (26%) among the under fives.

About 74% of the families interviewed were resident, 23% were returnees and 3% were displaced.

Food security and public health seemed precarious (box 5).

Box 5 Food security and public health in Bomi and Grand Cape Mount counties, Liberia (WV, 03/04)

Sierra Leone

UNAMSIL mandate has been extended until September 2004 and a residual force will probably remain till June 2005 (OCHA, 12/05/04). The security situation is calm but inflation is still on the rise (OCHA, 12/05/04). Some 7,400 refugees have been repatriated from Guinea (6,276) and from Liberia (1,175) by UNHCR since the resumption of the repatriation programme in January 2004 (OCHA, 12/05/04).

However, there are some weaknesses in the reconstruction process. According to the URD group, there is still a strong presence of humanitarian organisations during this rehabilitation phase, as was the case during the crisis, and some creative programmes are being implemented (URD, 12/03). On the other hand, UNHCR’s assistance to the returnees seems limited, there is a lack of housing programmes and the funding of the rehabilitation of the health system is insufficient.

Central Africa

Burundi

The security situation is still calm throughout the country, except in Bujumbura rural, which is the stronghold of the FNL (National Liberation Forces), the only rebel movement which has not signed a peace agreement with the government (AFP, 06/05/04; USAID, 14/05/04). Clashes in Bujumbura rural caused the displacement of at least 50,000 persons in April and May (IRIN, 17/05/04). Despite the FDD (Forces for the Defence of Democracy) having signed a peace agreement with the President of Burundi at the end of last year, they have withdrawn from the transitional government, protesting against the slow process in the nomination of governorships, administrators and ambassadors (USAID, 14/05/04).

Internally Displaced Persons

The number of displaced persons settled in camps has halved compared to 2002.

A survey counted about 140,000 IDPs in displaced camps in 2004, compared to 281,000 in 2002 (OCHA, 14/05/04). According to Refugee International (RI), IDPs are vulnerable but receive little attention (RI, 28/04/04).

Congolese refugees

Some 4,500 Congolese refugees were moved from a transit camp near the border to a safer camp in Muyinga province, where 4,000 Congolese refugees were already settled (IRIN, 17/05/04). The Government of Burundi estimates that there are about 40,500 Congolese refugees in Burundi.

Returnees face challenges

More than 40,700 refugees returned from Tanzania so far this year (see map); about 176,000 refugees have returned since 2002 (UNHCR, 18/05/04). However, the return of the refugees raise a number of issues, regarding their conditions of departure from Tanzania as well as their conditions of return. The mounting pressure on Burundian refugees to leave Tanzania camps was denounced by Refugee International (RI, 14/04/04). For about one year, the restriction of movement has been reinforced (see RNIS 42); refugees are not allowed to move further than a four kms radius from the camps. Those who are caught outside this limit are arrested and deported to Burundi.

When they arrive at their destination, returnees face a number of challenges (IRIN, 14/04/04; IRIN, 15/04/04). First of all, housing is a high priority, as most of the refugees’ houses have been destroyed; some housing programmes are on-going. Secondly, they have to get their fields back; in some cases, their lands have been used or sold. It seems that there is an increasing number of disputes over land and an increase in the price of land. The agricultural situation of families who returned one year ago remains critical as compared to families who have not moved. The principal limitations the returnees face are insufficient banana and cassava shoots, exhausted land, loss of revenue from cash crops, little access to agricultural inputs such as fertilisers and tools (IRIN, 14/04/04). On their return, families are highly dependent on their relatives or neighbours, especially for housing and food.

Returnees benefit from a three-month food package, which seems to last less than that because it is shared with the host community or sold to get cash. When their food stock is exhausted, they mainly depend on the host community. Returnees also receive non-food items on their arrival and agricultural inputs if they are registered by the local administration.

Health care and education are other challenges that face returnees but also Burundians who did not move. The health and education system was already stretched before the returnees add a further pressure on the infrastructure. The cost-recovery system has been implemented in most part of the country (see below); it seems however, that returnees can obtain "certificates of poverty" to receive free treatment (IRIN, 14/04/04).

Moreover, Refugees International warns that large-scale repatriation could threaten peace (RI, 12/04/04). According to RI, Burundi is not politically stable enough, the infrastructure is too weak and the UNHCR's capacity to protect refugees is insufficient, for promoting large-scale repatriation.

RI also states that refugee return seems highly-linked with political considerations both in Burundi and Tanzania: the CNDD/FDD in Burundi is calling for the speedy return of the refugees to increase their chance of winning the next elections at the end of 2004. In Tanzania, the ruling party has promised that all the refugees will have returned home before the next election due at the end of 2005 (RI, 12/04/04).

Returnees from Tanzania

Average nutrition situation

The number of admissions to feeding centres since the beginning of the year has been lower than in 2003 (figure 7) (UNICEF-B, 02/04-04/04). The highest number of admissions was in Bujumbura rural, which accounted for about 25% of the whole admissions. Bujumbura Mairie, Bururi, Cankuzo and Muramviya had the lowest number of admissions.

Figure 7 Admissions to therapeutic feeding centres (TFCs) and Supplementary Feeding Centres (SFCs), Burundi (UNCEF-B, 04/04)

High mortality rates and low access to health care

MSF-B conducted a random-sampled nation-wide mortality survey and different assessments aiming at describing access to health care (Bujumbura Mairie was excluded) (MSF, 04/2004). For the purpose of the health surveys, the total population of Burundi was divided in three categories depending on the type of health care they can access. The results of these surveys were appalling; mortality rates stood well above the alert thresholds in each of the area surveyed. CMR were 1.2/10,000/day (0.8-1.6), 1.6/10,000/day (1.2-2.0) and 1.9/10,000/day (1.4-2.3) depending on the area surveyed and the < 5 MR was 3.3/10,000/day (2.0-4.6), 4.9/10,000/day (3.4-6.3) and 3.1/10,000/day (2.3-4.0).

The main cause of death was malaria.

A cost-recovery system was put in place in Burundi at the beginning of 2002; about 80% of the population of the country fell under it, whilst the others have access to health centres applying a flat fee or a cost-sharing system (50% of the price of medicine). The survey revealed that the frequentation of the health centres applying the cost-recovery system has decreased since this system was applied. Moreover, 17% of the population has no access to health care, mainly owing to financial reasons and about 80% of the people who have consulted have been obliged to take on debts for the payment of the consultation and medicines. Patients also tend to wait too long before attending a consultation.

Recommendations

From Refugee International:

• Slow down the repatriation process until the government of Burundi has shown more progress towards addressing key social issues
• UNHCR deploy protection officers at registration and transit centres
• Donor countries make available fund pledged at the January 2004 Brussels' conference for the rebuilding of basic infrastructure

From the MSF survey on access to health care:

• Urgently implement a health care system accessible to all
• Give particular attention to the most vulnerable

Democratic Republic of the Congo

Despite a general improvement in the security situation since the signing of a peace agreement in mid-2003, part of DRC is still not accessible because of poor infrastructure or insecurity, which prevails especially in the east (see map). Violence has been reported during April and May in North Kivu, South Kivu and Katanga; it is estimated that 30,000-35,000 people were displaced in April in these areas (OCHA, 30/04/04). In late May, fighting between rival factions of the army erupted in Bukavu; more than 2,000 people fled to Rwanda (IRIN, 31/05/04). A demobilisation and re-integration project of an estimated 150,000 ex-combatants has been approved by the World Bank (WB, 25/05/04).

Between 80,000 and 100,000 people, mainly Congolese, considered to be illegal diamond miners, have been expelled from Angola to DRC in dire conditions (see Angola).

Worrying situation in Bundu health zone, Fizi area, South Kivu

The area was inaccessible for years owing to the war. Since mid-2003, the security situation has improved as well as the access to the area. The main activities are agriculture and fishing; they have been reduced during the war because of insecurity and lack of seeds and inputs. During the last few months, there seems to have been a lot of spontaneous returns of Congolese refugees to Fizzi; the number of returnees was estimated at 44,000 (OCHA, 21/05/04).

The nutrition situation in Nundu health zone is of concern (AAH-US, 11/03) (table 19). Despite the improvement in the security situation, people do not benefit from good food security or access to basic services.

Table 19 Results of nutrition and mortality surveys, DRC

Average nutrition situation in Shabunda and Lemera, South Kivu

In Lemera, security has been poor for years and is not yet completely stabilised. The main source of food is own production, essentially cassava. Although arable land is available, it is too expensive for the majority of the population. Prices of livestock have dramatically increased, following intense looting. The buying power of the population has decreased. However, the nutrition situation was average (table 19) in November 2003 (AAH-US, 11/03).

In Shabunda, the nutrition situation was also average in November 2003 (table 19) and has greatly improved compared to February 2002, when the prevalence of acute malnutrition was 20.4% (AAH-US, 11/03). The improvement has mostly been attributed to the amelioration of the security situation which allows cultivation and commercial exchanges.

Acceptable nutritional status in Moba and Kansimba, Katanga

The nutrition situation was under control in Moba and Kansimba in October 2003 (table 19) and has improved compared to November 2001 when the malnutrition rate was 6.2% (AAH-US, 10/03). This could possibly be due to the improvement in the security situation. However, mortality rates were high (table 19).

Nutrition situation of concern in Bankusu, Equateur

The main source of income before the war was coffee production but this was particularly affected during the war. The nutrition situation was of concern (table 19) as well as the food security situation (AAH-US, 02/04). Moreover, mortality rates were above alert thresholds (table 19).

Overall

The improvement of the security situation since mid-2003 seems to have played a part in the amelioration of the food security and nutrition status in some areas (category III), whilst others remain at risk (category II).

Uganda

The security situation has worsened since the beginning of 2004, leading to an increase in the number of displaced people. This may be due to a renewed military protocol between Uganda and Sudan, which allows Ugandan troops to pursue the Lord's Resistance Army (LRA) across the Sudanese border. It also seems that various armed Sudanese factions have attacked the LRA, forcing them to withdraw to Uganda (OCHA, 31/03/04).

It is estimated that between 1.2 and 1.6 million people are displaced in northern Uganda (FEWS, 16/04/04; WFP, 13/05/04); in Gulu, Pader and Kitgum districts, more than 90% of the population is displaced (see map). A major attack of the LRA in Barlonyo IDP camp in Lira district killed more than 200 people in February 2004 (OCHA, 29/02/04). In March, April and May, a number of sporadic attacks on IDP and refugee camps were reported in Gulu, Kitgum, Pader and Lira districts (USAID, 05/05/04). In Adjumani, 31,000 refugees fled after an attack. They have settled with relatives in other refugee settlements in Adjumani and Moyo districts (UNHCR, 07/05/04).

Dire situation in Northern Uganda

Conditions in most of the IDP camps are reported as being far from adequate. In most of the camps in Lira and Gulu districts, people can not get access to the 15l/pers/day of water recommended. Latrines are also reported as being scarce, in some camps there is only one latrine for 100 people or more (USAID, 05/05/04). In addition, IDPs have little access to health care (USAID, 05/05/04). HIV/AIDS prevalence is believed to be 13.2% in Gulu district (OCHA, 30/04/04).

Food security has been reported as deteriorating in Gulu, Kitgum and Pader districts, and it was recommended that the food ration distributed by WFP be increased to 75-80% of a full ration (OCHA, 31/03/04). Due to insecurity, people only have access to land within a three km radius around the camps (FEWS, 16/04/04). WFP urgently requires new donations, otherwise their stocks will be exhausted by July (WFP, 13/05/04).

The government of Uganda will allocate 630,000 US$ to IDPs, mainly to provide them with food (IRIN, 28/04/04).

A better security situation in Eastern Uganda has led to the return of some IDPs; most of the IDPs settled in Kumi district have returned to Kaberamaido, Katakwi and Soroti districts (FEWS, 16/04/03).

In Soroti district, eastern Uganda, the situation seems to have improved slightly, the number of children admitted to the TFC dropped from 430 at the peak of the crisis to 20 as of February 2004 (OCHA, 29/02/04).

Gulu district

Systematic random-sampled nutrition surveys were conducted in the 32 IDP camps of Gulu district in September/October 2003 (WFP/MOH/UNICEF, 10/03). The prevalence of malnutrition varied between 7.2% and 19.9%, depending on the camp. The malnutrition rate was below 10% in only three camps which were considered scattered and where people had appreciable access to intra-camp resources. The malnutrition rate was between 10% and 15% in 19 camps which were mixed congested and where people had access to resources. In ten camps, the prevalence of malnutrition was above 15%; these camps were overcrowded and people had low access to intra-camp resources. Access to water was reported lower than the 15 l/pers/day recommended. The malnutrition rates seem higher than was reported in May 2003, when a cluster-sampled nutrition survey in 21 of the 32 camps showed a prevalence of acute malnutrition of 6.7%.

Pader district

Malnutrition rates varied between 5.3% and 21% in seven IDP camps (of a total of 12 camps) where systematic random-sampled surveys were conducted in September/October 2003 (WFP/MOH/UNICEF, 10/03).

The nutrition situation was under control in Kalongo town, according to a random-sampled nutrition survey (GOAL, 02/04). About 70% of the families interviewed were displaced. The prevalence of acute malnutrition was 4.7% (3.5-6.4), including 0.7% (0.3-1.5) severe acute malnutrition. The situation has greatly improved compared to August 2003 when the acute malnutrition rate was 11.6% (8.6-14.2) (see RNIS 43). No hypothesis regarding the improvement of the situation could be drawn from the survey report. However, the current survey was conducted after the harvest done in December 2003, and 44% of the families surveyed reported having harvested, which may have improved their food security. 73.5% of the families were registered to receive food distribution and 89% actually received a food ration between August 2003 and February 2004; this seems to be an increase compared to August 2003 when only 70% of the families registered had received a food distribution. The main source of income was daily labour and petty trading and the main source of food was purchase. This is the same pattern as in August 2003 (see RNIS 43). 30% of the households used an unprotected source of water: this has not improved compared to August 2003.

Mortality rates were above alert thresholds: CMR= 1.5/10,000/day, < 5 MR= 2.1/10,000/day.

Kitgum district

According to seven systematic random-sampled nutrition surveys carried out in IDP camps in Kitgum district (of a total of 12 camps), malnutrition rates varied from 13.9 to 18.8%, depending on the camp (WFP/MOH/UNICEF, 10/03).

Lira district

A random-sampled nutrition survey carried out in nine IDP settlements (of a tota