Sub-Saharan Africa

1. Angola
2. Benin/Ghana/Togo Region
3. Burkina Faso and Mauritania - Malian Refugees
4. Burundi/Rwanda (Great Lakes) Situation
5. Central African Republic
6. Djibouti
7. Ethiopia
8. Kenya
9. Liberia/Sierra Leone Region
10. Mauritanian Refugees in Senegal
11. Mozambique Region
12. Somalia
13. Sudan
14. Uganda
15. Zaire
16. Zambia

1. Angola

(see Map 1 and Figure 3)

Trend in numbers of displaced/war affected. Shaded areas Indicate those at heightened nutritional risk.

Apart from a few cease fire violations, the security situation in Angola has remained calm, and the construction of new bridges and reopening of roads are improving the free movement of people and goods. There are now only a few areas in Angola, such as Luena, where there is no road access and humanitarian aid must be delivered by air. The nutritional situation of the approximately 1.37 million people affected by the Angolan conflict and its aftermath appears to be adequate and stable with the exception of some newly accessible areas, where levels of wasting are quite high. The anticipated large scale return of internally displaced people has still not occurred, and is cause for concern as the planting season ends in the August-September period. Attempts to promote self-sufficiency are further thwarted by limited trading opportunities in many areas. An estimated 325,000 Angolan refugees are still residing in neighbouring Congo, Namibia, Zaire and Zambia [DHA 04/08/96, USAID 01/07/96].

The high levels of wasting often found in newly accessible populations are quickly reduced once emergency feeding programmes have been established. For example, a recent survey in Malange measured wasting and/or oedema at 3.8% (see Annex I (la)). This shows an improvement in the situation since April 1996 when wasting and/or oedema was measured at 8.1%. The survey team recommended the continuation of targeted feeding programmes, and the establishment of a food security system to detect any changes in household food security [WFP 09/08/96].

Emergency general ration provision and therapeutic feeding have been urgently recommended for the population of Samba Caju, Kwanza Norte, where a recent survey showed 17.5% wasting and/or oedema with 6.8% severe wasting and/or oedema (see Annex I (1b)). Unfortunately, shortages of powdered milk are delaying the opening of therapeutic feeding centres. Indeed, throughout the country, many therapeutic feeding programmes are hampered by a lack of powdered milk² [DHA 23/06/96, WFP 12/07/96].

² A policy on the acceptance, distribution and use of milk products in feeding programmes in refugee settings has been put out by UNHCR. In this policy, it is clearly stated that milk products should ‘be used under strict control and in hygienic conditions, e.g. in a supervised environment for on-the-spot consumption.’ (from: Policy for Acceptance, Distribution and Use of Milk Products in Refugee Feeding Programmes, UNHCR, 1989.)

In contrast, a recent survey in Kuito, Bie Province showed 5.1% wasting and/or oedema with 0.4% severe wasting and/or oedema (see Annex 1 (1d)). Although this showed a generally adequate nutritional situation, only about one third of malnourished children were enrolled in feeding programmes. Immunization coverage, which has been highlighted in earlier RNIS reports as a problem, was low [CONCERN 15/06/96].

Overall, the affected population in Angola can be considered to be at moderate nutritional risk (category IIb in Table 1) due to continued dependence on emergency food aid. There are pockets of high risk (for example Samba Caju, mentioned above); however census data for these populations are not currently available.

How could external agencies help? Numerous rehabilitation and resettlement programmes are underway and addressing many needs such as those noted in the June RNIS report. For example, there are resettlement projects in Kwanza Sul, Bengo and Moxico Provinces which include support to communities in the form of seeds and tools provision, immunization campaigns, supplying essential drugs to local hospitals and the continuation of supplementary feeding rations [DHA 23/06/96. WFP 21/07/96].

The June RNIS report also described the need for general ration and targeted feeding programmes in newly accessible areas where levels of wasting are found to be high. The need for programmes which aim to control communicable diseases such as trypanosomiasis, a disease whose prevalence has been increasing, was highlighted as well. In many areas where these needs have been identified, interventions are underway. For example, a number of mobile teams to combat trypanosomiasis have been established [DHA 30/06/96].

Generally, continued support for returning internally displaced people, affected host communities, and demobilised soldiers will be necessary. This support may be temporary general rations and/or targeted feeding programmes, provision of seeds and tools for agricultural production, or rebuilding community infrastructure. Also, a generalised lack of powdered milk throughout the country for therapeutic feeding programmes is becoming critical. As only a small quantity is needed for therapeutic feeding programmes, this should be relatively easy to obtain.

More specifically, recent surveys show low immunisation coverage, along with low coverage of selective feeding centres in Caala and Kuito. Programmes to improve these would be likely to positively affect the nutritional status of these populations.

2. Benin/Ghana/Togo Region

There are no reports of change in the generally adequate and stable nutritional status of the 106,800 assisted refugees in Benin/Ghana/Togo region, most of whom are of Togolese origin. The vast majority of this population left their country of origin in 1993 because of political disturbances and sought refuge in Benin and Ghana. Subsequent improvements in the political situation led to the spontaneous repatriation of most of these refugees. Organised repatriation of the remainder is now planned and it is hoped that this will be carried out in 1996.

3. Burkina Faso and Mauritania - Malian Refugees

(see Map 3)

There are no reports of change to the nutritional status of the approximately 57,500 assisted Malian refugees in Burkina Faso and Mauritania. Those in Burkina Faso (estimated at 27,000) were said to be in adequate nutritional state, while those in Mauritania (estimated at 30,500) had high levels of wasting (see RNIS #15)

Overall, the refugees in Burkina Faso are not currently considered to be at heightened nutritional risk (category IIc in Table 1). The Malian refugees in Mauritania can be considered to be at moderate nutritional risk (category IIb in Table 1).

How could external agencies help? An appeal was launched to fund a repatriation project for Malian Tuareg refugees at present in Algeria, Burkina Faso, Niger and Mauritania, but has so far met with limited response. Support is especially needed for programmes which help refugees re-assimilate into their communes of origin, e.g. food-for-work schemes. Many of these programmes may also need to extend support to local populations.

4. Burundi/Rwanda (Great Lakes) Situation

(See Map 4 and Figure 3)

Trend in numbers of refugees/displaced and proportion severely malnourished or at high nutritional risk (shaded area).

The recent coup in Burundi has not stemmed the rising tide of violence which is seriously affecting humanitarian relief programmes. Since the coup, all Rwandan refugees have returned home from Burundi, while the exodus of Burundi refugees to neighbouring Uvira, Zaire, and Tanzania continues. The Zairian Government has announced that all Rwandan refugees will be repatriated from Zaire by next year. Currently, the nutritional situation amongst this refugee population is adequate and stable. However, the continued reduction in rations in the Zairian refugee camps and the curtailment of refugee economic activity may eventually have an adverse impact on nutritional status. The overall nutritional status of refugees from the Masisi area of Zaire residing in a refugee camp in Rwanda is poor, due mostly to the continued flow of new arrivals who are malnourished.

Current estimates of affected populations by country of present residence are given in the box below:

	Jul 95	Oct 95	Dec 95	Feb 96	Apr 96	Jun 96	Sep 96
Burundi	515,000	315,000	504,000	275,400	290,000	289,000	300,000
Rwanda	800,000	725,000	800,000	737,000	737,000	749,000	598,000
Tanzania	644,000	629,000	621,000	653,000	624,000	642,000	653,000
Zaire	1,202,200	1,158,000	1,146,000	1,211,000	1,166,000	1,419,000	1,444,000
Uganda	6,700	6,400	6,400	6,800	6,900	7,000	7,000
TOTAL	3,167,900	2,831,400	3,077,400	2,883,200	2,823,900	3,106,000	3,002,000

Burundi A bloodless coup, which occurred in June when widespread insecurity throughout the country was claiming lives at an alarming rate and relief operations were under constant threat of disruption, has left Burundi in a state of political turmoil. Many countries condemned the coup and have imposed economic sanctions. Subsequently, sanctions were relaxed to allow for the importation of fuel to facilitate the distribution of humanitarian supplies and the continuation of some essential operations in country. Seeds and fertilizer have also been exempted [IRIN 07/07/96,28/07/96, 25/08/96, WFP 12/07/96, 13/09/96, 27/09/96].

Since the coup, there have been reports of continued insecurity throughout the country. Violence has been particularly acute in the north west region where the situation has been described as a “war zone”. Significant humanitarian needs are believed to exist through those areas affected by conflict. However, periodical closure of national highways and cessation of relief programmes in several provinces due to the high level of insecurity continues to hinder effective delivery of humanitarian aid [USAID 16/08/96].

The entire Rwandan refugee population was repatriated by the end of August, leaving up to an estimated 300,000 displaced people in Burundi [DHA 2/09/96]. However, a large portion of this population is only displaced for short periods and returns home to farm land within a few weeks [USAID 16/08/96]. There are no new nutritional data on the internally displaced populations in Burundi although the recent harvest may buffer the worst effects of the prevailing insecurity and diminished humanitarian aid upon nutritional status.

Rwanda The security situation in Rwanda remains generally calm. However, a number of attacks reportedly launched by infiltrators from Zairian refugee camps have occurred in the neighbouring western prefectures of Cyangugu, Kibuye, Gisenyi and Ruhengeri [UN Jul 96, USAID 09/07/96].

There are approximately 576,000 people in Rwanda currently dependent on food aid (approx. 9% of the population). Although estimated agricultural production in 1996 has increased by 15% compared to last year, levels are still 23% below those harvested in 1990 prior to the escalation in civil conflict. The two factors inhibiting a faster rate of agricultural recovery are lack of high quality seeds, and the shortage and/or high prices of pesticides and other inputs [FAO 12/07/96, UN Jul 96].

There are no recent nutritional data on the Rwandan population, although the improving agricultural situation in conjunction with ready availability of food aid would indicate an adequate and stable nutritional situation. There is, however, considerable concern over the health and nutritional status of prisoners in detention centres. The most common reported diseases amongst this group are malaria, dysentery and respiratory diseases often linked to HIV infection. Furthermore, overcrowding and lack of water for washing is leading to a high incidence of skin disease [UN Jul 96].

Food aid is mainly distributed through food-for-work and income generating programmes (over 60%), although targeted assistance to the vulnerable people, e.g. orphans, detainees, and the internally displaced, continues. Numerous activities are taking place in the health sector, including the establishment of oral rehydration therapy centres in all regions, a national polio vaccination campaign, and a national growth monitoring and promotion programme [FAO 12/07/96, UN Jul 96].

The closure of refugee camps in Burundi has led to the voluntary, and in some case, forced, repatriation of all Rwandan refugees from Burundi. Returnees have been given food rations as well as non-food items, and have been transported to their communes of origin [UN Jul 96].

A recent movement of Burundi refugees to Rwanda which began in 27 June, has resulted in 5,700 new arrivals [WFP-a 27/09/96].

After a recent meeting between the Prime Ministers of Rwanda and Zaire, it was announced that the two countries would seek a “rapid” and “massive” repatriation of Rwandan refugees from Zaire, to be completed before the beginning of Zaire’s electoral process in May 1997. A statement was made that the Government of Zaire would begin the progressive closure of the camps and that the Rwandan Government would take measures to welcome and install the returnees [IRIN 25/08/96].

Goma, Zaire There are approximately 727,000 Rwandan refugees remaining in the Goma camps. The general security situation is described as tense, with reports of mined roads and armed attacks on extended delivery points. Such incidents exacerbate mistrust between refugees and the local population [WFP 21/06/96, 05/07/96, 16/08/96].

The ration for refugees has been reduced from 1,400 kcals/person/day to under 800 kcals/person/day. This reduction arises from a ban by major donors on the delivery of their food aid to the camps pending credible refugee numbers, which in turn depends on a successful verification exercise. This exercise was originally boycotted by the refugees, but now refugees leaders are said to be willing to cooperate. However, the exercise has been postponed due to insecurity in the Uvira area [WFP 13/09/96, 20/09/96, WFP-a 27/09/96].

A recent set of nutritional surveys showed lo and stable prevalences of wasting, despite the reduced ration and the ban on economic activities. Levels of wasting varied from 1.6-3.5%, with severe wasting from 0.0-0.8%. Only one case of oedema was seen in all the camps (see Annex I 4(a-e)). Crude mortality rates in the camps are low and vary from 0.08-0.28/10,000/day; under-five mortality rates are also low at 0.39-1.1/10,000/day. However, there is some concern over cases of child mortality following the closure of a number of camp clinics which appear to have resulted in increasing numbers of refugees deferring to traditional medicines and practitioners [UNHCR 08/09/96, 14/09/96, WFP 12/07/96]. Furthermore, there is a risk that the declining level of rations may ultimately have some adverse impact upon nutritional status.

Bukavu, Zaire There are approximately 302,000 refugees in 22 camps in the Bukavu region. All economic activities have been stopped in the camps and several security incidents have occurred as a consequence [WFP-a 27/09/96].

A recent set of surveys in the camps showed levels of wasting varying from 0.9% to 7.0% with severe wasting measured at 0% in many cases (see Annex 14(f-k)). The highest levels of wasting were found in Inera camp with 7.0% wasting and 0.2% severe wasting [WFP 12/07/96, UNHCR 23/08/96].

There is concern that the embargo on refugee economic activity along with general rations levels which vary from 1400-1500 kcals/person/day, will eventually lead to an increased risk of malnutrition. Indeed, there have been reports of increased levels of anaemia amongst children as well as increasing numbers of low-birth weight children. Furthermore, the increase in frequency of certain infections is thought to be partly attributable to lower immunity as a result of poorer nutrition status [UNHCR 23/08/96].

Uvira, Zaire The influx of Burundi refugees fleeing insecurity is continuing with an average of 400 people arriving each day during July. It is currently estimated that there are 215,000 refugees in Uvira and preparations for the construction of an additional refugee camp in the area are on-going. However, insecurity is said to be increasing to the point where an unconfirmed number of refugees have fled the camps, leaving several refugee camps ‘partially empty’ [WFP 09/08/96, 30/08/96, 27/09/96].

The camps in Uvira are currently facing a shortage of cereals and pulses, due largely to technical problems at Uvira port [WFP-a 27/09/96].

Tanzania There has been an increase in the rate of influx of Burundi refugees following the coup in June and it is currently estimated that there are 653,000 Burundi and Rwandan refugees in Tanzania. It is reported that many of the new arrivals from Burundi are suffering from high levels of anaemia, and attendance at feeding centres is said to be increasing. Sites of new refugee camps to accommodate the increased population are currently being sought [WFP 09/08/96,06/09/96].

The Tanzanian Government has agreed to re-open its border with Burundi in order to allow the passage of humanitarian aid. There are no new nutritional data on the refugee population although there are concerns over a possible water shortage in the Karagwe camps (especially Chablisa I and II) with camp leaders being advised to control the use of water during the next two months [WFP 12/07/96, 16/08/96].

Masisi Region Following inter-ethnic conflict earlier in the year, the security situation in the region is now reportedly calm and some of the 200,000 people estimated to have been displaced by the fighting are returning home. Markets in some areas are operating once again. However, a number of security incidents, usually related to livestock thefts, continued to be reported. Much of the region is depopulated, with some fleeing to Rwanda or the periphery of the region, while others are in camps for the internally displaced (approx. 30,000 people).

Some groups are believed to be particularly vulnerable. For example, in Kichanga, it is very dangerous to forage for fire-wood for cooking purposes. As a result, levels of malnutrition amongst the displaced population are said to be increasing with a corresponding increase in the number of children attending the feeding centre [IRIN 23/08/96]. A nutritional survey in February had already found somewhat elevated levels of wasting of 8.2% with 0.8% severe wasting [MSF-B Aug 96].

There are now approximately 16,000 Zairian refugees in Rwanda who have fled this conflict. This population passed through Nkarima transit centre (now closed) and on to Umubano camp where the general ration level is set at 1,980 kcals/person/day. Nutritional surveys in April this year found high levels of wasting of 21.4% and 17% in the transit centre and Umubano camp respectively. The situation has improved somewhat as a more recent survey in Umubano camp found 10.2% wasting with 1.6% severe wasting. Rates of oedema were measured at 1.3% (see Annex I 4(1)). This is largely attributed to the fact that refugees continue to arrive in a poor nutritional state, having spent long periods displaced in Zaire and then a period in an over-crowded and poorly served transit centre. A supplement of 100 gms of beans/person/day to the general ration is now being provided partly as a response to these high levels of wasting [MSF-B 20/08/96, UN Jul 96, WFP 30/08/96].

Uganda Approximately 7,000 Rwanda refugees remain in Uganda. Their nutritional status is believed to be adequate and stable [UNHCR 16/09/96].

Overall, the internally displaced population in Burundi and the refugees from Masisi, Zaire in Rwanda can be considered to be at heightened nutritional risk (category IIa in Table 1). The internally displaced population in Masisi, Zaire, along with refugees in Zaire can be considered to be at moderate nutritional risk (category IIb in Table 1), while the refugees in Tanzania, the Burundi refugees in Rwanda and the affected population in Rwanda are not currently thought to be at heightened nutritional risk (category IIc in Table 1).

How can external agencies help? Many of the constraints to the regional emergency programme, which were identified in the June RNIS report, have still not been resolved. For example, there continues to be a shortage of food pledges as well as funds for regional purchase of foods. Furthermore, humanitarian goods are still not exempt from closure of the Burundi/Zaire border. These factors, along with an earlier lack of cooperation of the refugees for a registration exercise, have led to the reduction of rations in refugee camps in Zaire.

The recent exemption of fuel, seeds and fertilizer from sanctions on Burundi is a step forward in the effort to continue humanitarian assistance to populations in the country. However, it is likely that food and non-food stocks are running low, and other humanitarian goods will need to be exempt from sanctions in the near future.

In addition, a number of other more recently observed constraints and adverse factors need to be addressed in the region. In Uvira, the lack of barge capacity in conjunction with increasing numbers of damaged cranes are limiting supplies of food to the camps. In the Karagwe camps of Tanzania there is a shortage of water. This is especially acute in the Chablisa I and II camps. In Rwanda, there is a need for more supplies of seeds, pesticides and other agricultural inputs for recent returnees.

5. Central African Republic

There are no reports of change to the nutritional situation the of 27,000 assisted Sudanese refugees in the Central African Republic. There are also approximately 5,000 assisted Chadian refugees whose nutritional status is believed to be adequate [UNHCR 16/01/96].

6. Djibouti

(see Map 6)

There remain approximately 2,500 assisted Ethiopian refugees in Djibouti, almost all of whom are reportedly now ready to repatriate [DHA Apr 96, UNHCR 96].

7. Ethiopia

(see Map 7)

There are approximately 377,200 refugees and internally displaced people in Ethiopia. This total number is comprised of 276,000 Somali refugees in camps in the east, 64,000 Sudanese refugees in settlements in the west, 8,200 Kenyan refugees, 18,000 Djibouti refugees and 11,000 internally displaced people in camps around Addis Ababa. However, it is felt that in order to maintain donor pledges and the credibility of the operation, it is essential to undertake a registration of the refugees and arrive at a figure agreed upon by all partners in the programme. There are an additional 30,000 unassisted refugees in Ethiopia [WFP/UNHCR Jun 96, UNHCR 31/12/95].

The presence of high quantities of relief foods on local markets has raised questions about the suitability of commodities provided, the possible inflation of the estimated numbers of refugees, and the cost effectiveness of food assistance. This, in turn, has led to some reluctance on the part of donors to support the programme so that the operation is currently facing a significant shortfall in food aid pledges for the remainder of 1996. In order to improve the credibility of the programme so as to maintain donor support, a time frame is being worked out for a rigorous registration of refugees in camps in the east and west. Since such an exercise involves considerable planning and may therefore take some time to complete, consideration is being given to more indirect methods of obtaining population estimates as an interim measure. These include mass screening of children under five years old, or habitation counting [WFP/UNHCR Jun 96].

New surveys show high prevalences of wasting in the camps for Somali refugees in the east. The nutritional situation has deteriorated in all the camps since the last set of surveys, and levels of wasting vary from 15.2%-21.1% (see Annex 17(a-h)). The highest levels of malnutrition were seen in Kebribeyah (estimated population 10,000) and Derwanaji (estimated population 43,000) at 20.5% and 21.1% respectively. In other camps (i.e. Rabaso and Camaboker), levels of wasting have doubled since surveys conducted in July 1995. Crude mortality rates were reported to be 1-2/10,000/day (3-7x normal) [ARRA/UNHCR 19/06/96, WFP/UNHCR Jun 96]. The graph on the right illustrates the trends over time.

Levels of Wasting In Somali Refugee Camps in Ethiopia Over Time

* includes Hartishek, Kebre Beyah, Darwonaji, Tereriber.

In addition, there is also a serious water shortage in the camps. Water has been trucked into many of the camps for years, and the 3-4 litres/person/day available is far below the 20 litres/person/day recommended as a minimum. Water shortage has been linked to an outbreak of diarrhoeal disease in the camps in January and February of 1996 [WFP/UNHCR Jun 96].

Other factors which may be leading to elevated levels of wasting include a lack of ration cards for new arrivals (particularly in Rabasso and Daror camps) and increases in cereal prices due to the devaluation of the Somali and Somaliland currencies [ARRA/UNHCR 19/06/96].

The planned repatriation of approximately 10,000 Somali refugees during 1996 is unlikely to occur. A pilot repatriation of about 100,000 refugees is planned for 1997, but details have not yet been worked out [WFP/UNHCR Jun 96].

The nutritional situation for the Sudanese refugees in the west is reportedly stable and adequate. Levels of wasting in the camps are said to vary between 6-8% with almost no severe wasting. This population is situated in an area where there is greater opportunity for self-reliance than is the case for the Somali refugees in the east. The Sudanese refugees are able to supplement their rations with some limited crop cultivation, some livestock, wild foods and, in some cases, fishing. However, water is reportedly a major concern of the refugees in Fugnido camp, and existing boreholes and broken hand pumps need to be repaired [WFP/UNHCR Jun 96].

There are likely to be less than the currently estimated 18,000 Djibouti refugees in Ethiopia, and it is planned to reduce the number of assisted refugees to 8,700 in 1997. The approximately 8,200 Kenyan refugees in Ethiopia have recently been settled in camps, and assistance to this group is to be maintained in 1997 [WFP/UNHCR Jun 96].

Overall, the Somali refugees are in category I in Table 1 due to elevated levels of wasting and high crude mortality rates. Those in Fugnido camp in the west can be considered to be at moderate nutritional risk (category IIb in Table 1) due to continuing problems with water supplies. The remaining refugees and internally displaced are not currently thought to be at heightened nutritional risk (category IIc in Table 1).

How could external agencies help? The need for a re-registration of Somali refugees in Ethiopia has become more pressing as donors show increasing reluctance to fully support the programme. As such an exercise will take some time to execute, indirect methods of counting (e.g. counting of dwellings, mass screening of children under five years old) may be appropriate as an interim measure.

The high levels of wasting currently seen amongst the Somali refugees population indicates a need for certain remedial measures to address underlying factors. Some suggestions, which may require additional support in terms of finances and manpower, include:

· the improvement of water supply to Somali camps possibly including additional shallow wells, drilling of bore holes, construction or rehabilitation of small ponds;

· the provision non-food items, such as shelter materials, soap and blankets;

· efforts to improve coverage of feeding programmes, including strengthening community outreach and follow-up on discharged patients. This may require additional community health workers;

· temporarily changing the admittance criteria for feeding centres to include children <85% weight-for-height;

· registering refugees without ration cards;

· support for the project recommended by the food assessment team may be needed.

The Sudanese refugees in western Ethiopia require further support to achieve greater self-sufficiency. A number of measures may be appropriate, including:

· more timely provision of seeds and tools;
· allowing greater access to arable land and water.

8. Kenya

(see Map 8)

There remain approximately 165,000 refugees in Kenya. This total number is comprised of 6,000 Ethiopian refugees, 130,000 Somali refugees, and 29,000 Sudanese refugees. The total number has decreased due to the continued repatriation of Sudanese refugees. However, there has been an increase in the number of Somali refugees due to heightened insecurity in Somalia (see section #12 for details) [UNHCR 31/08/96].

Recent surveys in the three camps for Somali refugees in the Dadaab area show a deteriorating situation. In Ifo camp (estimated population 34,000), wasting and/or oedema was measured at 18.6% with 4.0% severe wasting and/or oedema. A previous survey in August 1995 showed 12.1% wasting and/or oedema. In Hagadera camp (estimated population 40,000) wasting and/or oedema was measured at 18.2% with 3.6% severe wasting and/or oedema. These results also compare unfavourably with those from the August 1995 survey when wasting and/or oedema was measured at 12.1%. In Dagahaley camp (estimated population 38,000), wasting and/or oedema was measured at 15.1% with 2.0% severe wasting and/or oedema; in August 1995 wasting and/or oedema was 9.8% (see Annex 18(a-c)). In addition to these elevated levels of wasting, cases of scurvy were also noted. Outbreaks of this micronutrient deficiency often occur among these refugees in the August-October period [MSF-B 25/09/96].

After a planned reduction in the food basket, the ration has recently been providing approximately 1800 kcals/person/day. Furthermore, sugar and Unimix (a fortified blended food) have not been provided in the ration over the last year. It is likely that the reduced general ration in conjunction with the limited trading opportunities around the camps are major contributing factors to the increased levels of wasting [MSF-B 25/09/96].

Overall, the Somali refugees in the Dadaab camps in Kenya are at high risk (category I in Table 1) due to elevated levels of wasting, and the presence of scurvy. The remaining Somali refugees, along with the Ethiopian and Sudanese refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).

How could external agencies help? The most direct way to address the elevated levels of wasting currently seen in the Dadaab camps would be to increase to size of the general ration and to expand selective feeding programme capacity and coverage. Scurvy appears to be seasonal among this refugee population; indeed outbreaks have been reported in the past (see RNIS #8). The present scurvy outbreak suggests a need for the immediate distribution of a vitamin C fortified blended food. Furthermore, as this appears to be a seasonal occurrence, plans to provide vitamin C in some form to this population during the August-October period need to be made in advance. A review of potential mechanisms for providing this remote Somali population with an adequate vitamin C supply would be appropriate. Such mechanisms might include: fortification of water supplies, fortification of a general ration commodity such as cereals, and the distribution of vitamin C tablets.

9. Liberia/Sierra Leone Region

(see Map 9 a, b and Figure 3)

Famine situations are being uncovered in many areas of Liberia which are now accessible due the most recent cease-fire. The peace, however, is described as fragile. The cease-fire in Sierra Leone is also holding and the overall situation is said to be improving as humanitarian agencies gain increasing access to affected populations. It is planned to phase out general ration distribution in Guinea and Cote d’Ivoire by the end of 1996, although targeted feeding for vulnerable refugee groups will continue.

Current estimates of the numbers of people affected in the region are summarised below:

Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (shaded area).

Location	Jul 95	Oct 95	Dec 95	Feb 96	Apr 96	Jun 96	Sep 96
Liberia	1,900,000	1,900,000	1,900,000	1,800,000	1,800,000	1,800,000	1,800,000
Sierra Leone	730,000	730,000	730,000	730,000	756,000	756,000	609,000
Cote d’Ivoire	227,000	305,000	305,000	305,000	305,000	305,000	305,000
Guinea	578,000	536,000	605,000	605,000	536,000	536,000	536,000
TOTAL	3,435,000	3,471,000	3,540,000	3,440,000	3,397,000	3,397,000	3,250,000

Liberia A cease-fire was successfully brokered in Liberia following the eruption of hostilities in Monrovia in April 1996. However, reports indicate the continuation of small-scale hostilities in some counties so that the security situation is generally described as stable, though fragile. A series of meetings in Abuja have led to a number of statements and resolutions concerning the dismantling of checkpoints, the commencement of physical disarmament of fighters, the resumption of ECOMOG deployment through the country and unhindered movement of humanitarian personnel and supplies. Elections have been set for May 1977 [DHA 07/08/96, 21/08/96, UNHCR 10/09/96].

The cease-fire has allowed access to many areas which had been cut-off from humanitarian assistance for several months, and in some cases, years. For example, the road from Monrovia to Vahun is now considered secure and clear for humanitarian agency travel. There has also been an assessment in Suehn and Fefeh towns (Bomi County) in early August. Most of this population have been displaced by earlier fighting in Tubmanburg and other areas of Bomi and Grand Cape Mount Counties and had been surviving on foraged foods which reportedly lacked protein. Another assessment in Buchanan and the Liberian Agricultural Company Compound found an internally displaced population of over 30,000 who reported abuses by different factional groups which had prevented attempts at agricultural production [DHA 07/08/96, 14/08/96, 21/08/96],

The problems in newly accessible areas appear to be similar in that there are alarmingly high levels of wasting and low levels of measles immunization. For example, a survey carried out in Gbanga, Bong county (estimated population 134,600) measured wasting at 23.7%, with 6.6% severe wasting. Oedema was measured at 3.1% (see Annex 19(a)). This represents a dramatic decline in the nutritional status of the population since the previous survey in February 1996 which showed a prevalence of 6.1% wasting and/or oedema. Survey respondents indicated that they had no food stocks and relied on a daily search for food involving both foraging in the bush and market purchases. The majority of families were only eating one meal a day comprised mainly of cassava or yam roots. Measles immunization coverage was only 25% [ACF 15/08/96].

Although Buchanan area was not directly affected by the violence in Monrovia in April and May 1996 (see below for details), some feeding programmes were suspended for a seven week period. A survey conducted after the resumption of activities showed a catastrophic situation with wasting measured at 47%. Severe wasting was measured at 4.9% and oedema at 0.6% (see Annex I 9(b)). This survey shows a dramatic deterioration in the situation when compared to a survey conducted in February 1996. At that time, wasting was measured at 4.7%. Some possible explanations could be a lack of availability of food either due to the ‘lean season’ or low ration distributions of 160-200 kcals/person/day, and poor public health conditions. Measles immunisation coverage was 26.3%, and an increasing number of cases of measles was being reported in June and July, indicating a possible epidemic [ACF 03/08/96].

An assessment in Tubmanburg, which had been cut-off from humanitarian aid since early 1996 showed a catastrophic situation. Signs of malnutrition are reportedly seen in vulnerable populations gathered in two separate centres. Food distribution is now underway, although roads conditions, particularly the unstable condition of one bridge, are slowing down progress [IFRC 07/09/96. WFP 13/09/96].

Another assessment was carried out in Bong Mines where recommendations made by the team included an urgent need for medical supplies, a general ration and school feeding programme, provision of chlorine tablets and supply of agricultural inputs [DHA 14/08/96].

The security situation in Monrovia is now stable following the fighting that displaced thousands of people in April and May. However, many houses have been destroyed and humanitarian aid resources, particularly nonfood items, have been looted, leaving many is a desperate situation [UNHCR 10/09/96].

A recent nutritional survey in the capital revealed an alarming situation. Amongst the displaced population (estimated at 285,000) wasting was 21.2% with 3.6% severe wasting (see Annex 19(c)). Oedema was measured at 3.6% and measles immunization coverage amongst this group was 54%. Amongst the resident population (estimated at 954,000 before the fighting in April 1996) wasting was measured at 13.3% with 2.2% severe wasting (see Annex 19(d)). Oedema was measured at 1.9% and measles immunization coverage was 69%. Although not strictly comparable, these results compare extremely unfavourably with a nutritional survey conducted in December 1995 when levels of wasting of only 9.6% with 1.7% severe wasting were recorded. The survey team recommended strengthening targeted feeding by opening up new feeding centres, increasing immunization coverage, gathering data on household food security and a follow-up survey in November 1996 [ACF/MOH/UNICEF/UMCOR/WHO Jul 96].

An outbreak of cholera was reported in Monrovia and its environs with an estimated 3,300 cases in June and July. Medical and surveillance measures have been taken and the situation is now under control. However, as the rains normally commence in September and October, it is recognized that great care will be needed to ensure that the situation does not escalate out of control [DHA 07/08/96, 14/08/96, 21/08/96].

Sierra Leone A cease-fire declared after the installation of the newly elected president in March 1996 is generally holding, although security incidents continue to be reported. These generally involve banditry and looting and are not believed to be organized military activity. The overall situation in the country is said to be improving [UNHCR 10/09/96, USAID 06/08/96].

Although the emerging view is that the internally displaced should be encouraged to return home it is also recognized that as the planting season has already begun most will wait until the harvest before moving. There are now approximately 1.2 million internally displaced, of whom an estimated 609,000 require emergency assistance [USAID 06/08/96, WFP 09/08/96]. A serious shortfall of food aid contributions for 1996 of almost 50% was signaled by WFP in early August. WFP have stated that unless food aid pledges are confirmed, gaps in the food pipeline are likely to occur [WFP 09/08/96].

The cease-fire has allowed access to many areas that were previously cut-off from relief assistance. The war has ravaged the national health infrastructure and it is estimated that only 16% of the health centres are functioning. In Kambia district (Northern Province) for example, a recent assessment found that the health centres were poorly supplied with essential drugs and sanitation, while immunization coverage was inadequate. The nutritional status of children was, however, reported to be adequate [USAID 06/08/96].

A recent survey in Makeni township showed 7% wasting and/or oedema, with 0.4% severe wasting and/or oedema (see Annex 19(e)). This survey revealed low immunization coverage of the population, despite the availability of immunization services [DHA 03/06/96]. This suggests a need for better community outreach to improve immunization coverage.

A survey conducted in Gondama (population of the town and camps was 55,000) showed 8.1% wasting with 1.7% severe wasting. No cases of oedema were seen (see Annex I 9(f)). This compares very favourably with a survey conducted in October 1995 when rates of wasting and/or oedema were measured at 29.9%. This marked improvement has been attributed to a number of factors, including the regular provision of general rations throughout 1996, the establishment of additional feeding centres, and population movements. Measles immunization coverage was estimated at 88% [ACF 01/05/96].

Pujehun and Kalihun districts had also previously been inaccessible due to rebel activity, but seeds, tools, and food were distributed in Daru, Segbwema and Kalihun (villages in the districts) in June [USAID 06/08/96].

Cote d’Ivoire There has been no significant increase in the Liberian refugee population in Cote d’Ivoire, although it is likely that there will have been a few new arrivals due to the sporadic insecurity in Liberia. Population estimates remain at 305,000 Liberian refugees [UNHCR 10/09/96].

Guinea There has been no significant increase in the Liberian and Sierra Leonean refugee populations in Guinea, although it is likely that there are a few new arrivals. Populations estimates remain at 536,000 assisted refugees [UNHCR 10/09/96].

A nutritional survey was carried out in Macenta Prefecture in July 1996, where many Liberian refugees are residing, in response to a noted increase in the number of children admitted to feeding centres. The survey showed 4.8% wasting and/or oedema with 0.3% severe wasting and/or oedema (see Annex 19(g)). This is comparable to a survey in November 1995 which found a 6.2% prevalence of wasting with 1.2% severe wasting. The under-five mortality rate was measured at 2.23/10,000/day (2x normal), while only 16.5% of children were immunized against measles. It is believed that the elevated mortality may be related to a measles epidemic in May 1996 which underscores the need to improve immunisation coverage [ACF 09/07/96].

The survey also found that 41% of households did not receive any food aid during June and that only 48% of malnourished children were enrolled on the supplementary feeding programme. The poor coverage of these programmes and the relatively low levels of wasting found in the survey suggest that refugees have developed considerable self-reliance in recent years [ACF 09/07/96].

Overall, in Liberia the displaced population in Monrovia, Gbaranga and Buchanan are at high risk with sharply elevated levels of wasting (category I in Table 1). It is likely that many other newly accessible populations in Liberia are at similar nutritional risk (category IIa in Table 1), although supporting data is not currently available. The affected population in Sierra Leone is likely to be at moderate risk (category IIb in Table 1) due to insecurity, and the refugees in Guinea and Cote d’Ivoire are probably not at heightened nutritional risk (category IIc, in Table 1).

How could external agencies help? As anticipated in the June RNIS report, with new areas in Liberia becoming accessible, famine situations are being discovered in areas such as Buchanan, Tubmanburg, and Bong Mines. It is therefore probable that there will be a need to provide general rations and selective feeding as well as essential drugs and vaccines, chlorine tablets for well chlorination, and agricultural inputs in many areas in the coming months.

The fighting and subsequent looting in large areas of Monrovia in April and May 1996 have led to a shortage of non-food items (blankets, cooking sets, plastic sheeting), which are urgently needed. There is also an immediate need for reinforcement of targeted feeding programmes as well as the opening of new feeding centres. Improvement in measles immunization coverage is also recommended, as well as a need for acquiring data on household food security. A follow-up nutritional survey in November 1996 would seem advisable.

In Sierra Leone, support for interventions to stimulate agricultural and livestock activities may be needed. Additional food aid pledges as signaled by WFP are required.

Location-specific needs in the region include:

· a one-off general ration for Gbanga before the harvest season, an increase in the number of therapeutic feeding centres, as well as a mass immunization campaign;

· In Buchanan there is urgent need for an increased general ration, expanded selection feeding programmes with improved outreach, a mass immunization campaign and better support for health services. A follow-up nutrition survey in October/November 1996 is also advised;

· improved immunization coverage in Gondama, probably through awareness programmes for refugees since clinics are operating in the area;

· In Macenta, Guinea there is a need for better community outreach in order to increase the enrollment of malnourished children in feeding centres. Measles immunization coverage also urgently needs to be increased.

10. Mauritanian Refugees in Senegal

(see Map 3)

There was a final food distribution to the approximately 52,000 Mauritanian refugees in Senegal in December 1995. This population is now considered to be self-sufficient and will no longer receive assistance. These refugees are longer included in Table 1.

11. Mozambique Region

(see Map 11 and Figure 3)

The food supply situation in country is expected to improve considerably over the next year as the recent harvest in August produced 20% higher yields than last year. Many provinces in the north and centre are expected to be entirely self-sufficient in basic foodstuffs, and some areas are reporting surpluses. There remain 154,000 people in Mozambique requiring humanitarian assistance. Most of the emergency food needs can be met with local purchases in surplus areas [FAO Jul Aug 96].

Trend in numbers of returnees and demobilised soldiers.

Food distributions have been phased out in many areas as the food security of the affected populations improves. A survey was recently carried out in Caia, Sofala, to determine if there had been any adverse effects on the nutritional status of the population after the cessation of distributions. Wasting was measured at 6.3% with 0.6% severe wasting. Oedema was measured at 1.1% (see Annex I 11(a)). These slightly elevated levels of malnutrition are likely to be explained by the fact that the rainy season was particularly long, with a resultant increase in diarrhoea and malaria. This highlights the inadequate sanitary facilities in the region. It is also possible that some families lost their crops to floods or insect infestation [ACF Jun 96].

Overall, the affected population in Mozambique is not currently thought to be at heightened nutritional risk (category IIc in Table 1).

How could external agencies help? The survey cited above points out a number of interventions that could further improve the nutrition and health situation of the population. It is likely that many of these interventions, some of which have been noted in earlier RNIS reports, would be beneficial in many parts of the country. Some of these include:

· strengthening of health service provision, particularly for control of malaria and diarrhoeal diseases;

· improving outreach to identify malnourished children and enroll them in feeding programmes;

· continuation of programmes aimed at nutritional education, especially concerning potable water.

12. Somalia

(see Map 12 and Figure 3)

In the two weeks prior to the death of General Aideed, there had been skirmishing both within and outside Mogadishu. Furthermore, UN agencies and NGOs have been facing increasing problems of logistical supply and access to the most vulnerable areas of South Mogadishu and the Juba valley. High winds and rough seas had brought imports and exports - as well as the arrival of humanitarian aid - to a trickle in the two seaports serving Mogadishu and Kismayo. Insecurity in South Mogadishu has also restricted humanitarian activities.

Trend in numbers of returnees and internally displaced with proportion severely malnourished or at high nutritional risk in shaded area.

The number of children attending feeding centres in Mogadishu increased significantly during June and July with many coming from the south of the capital. In Mogadishu, as in many places in Somalia, low purchasing power affected food security through June and July, with prices of maize and sorghum increasing substantially, and wage levels declining. The 1996 harvest only began to reach the main markets in mid-August, and predictions were that, although an improvement on 1995 production, overall food production tonnages are still significantly lower than pre-war levels [DHA 09/08/96, USAID 19/0 8/96].

In the Juba valley area, there have been reports of increasing numbers of displaced people due in large part to flooding in the Lower Juba River area. Agencies in Kismayo continued to report an influx of internally displaced people from the southern part of the Juba valley. Eight new camps for internally displaced emerged in Kismayo in late June and July, and there has been growing concern among aid agencies about the overall health status of the newly displaced. There have been anecdotal reports from agencies of malnutrition in all camps - particularly among older children and adults [DHA 09/08/96, USAID 19/08/96].

A cholera epidemic in Somalia is now considered to be over. Furthermore, the expended programme of immunization is continuing to vaccinate thousands of children against measles, polio and TB throughout the country [DHA 09/08/96].

Overall, the population currently identified as requiring assistance in Somalia can be considered to be at moderate nutritional risk (category IIb in Table 1), due to continued insecurity, price inflation, and logistic problems with delivery of humanitarian aid. It is likely that some of those displaced from the Juba valley to Kismayo are at high nutritional risk, but exact numbers are not available.

How can external agencies help? Given anecdotal reports of poor nutritional status in camps for internally displaced in Kismayo, there is a need for nutritional surveys to determine the extent and nature of the problem. As mentioned in the June RNIS report, there may be an increasing need to buffer populations against declining purchasing power, especially as the limited harvest runs out toward the end of 1996. Possible programmes might include expanded food-for-work and income generating projects, as well as expanded selective feeding programmes.

13. Sudan

(see Map 13 and Figure 3)

There remain approximately 2.1 million people in Sudan requiring humanitarian assistance. This number is comprised of 119,000 internally displaced people around Khartoum, 1.9 million war-affected people in Southern Sudan and the transitional zone, and 150,000 Ethiopian and Eritrean refugees.

Khartoum In early May 1996, NGO, donor, and UN agency representatives requested that the Government allow unrestricted access to camps for internally displaced people and that agencies be permitted to collect information relevant to programme implementation and planning among others. A working committee has been formed to review the request [OLS May 96]. Improved access to the internally displaced people could be a first step in addressing some of the needs highlighted in the June RNIS report (e.g. monitoring feeding programmes to improve programme performance, increased co-ordination of NGO activities, increased data for advocacy purposes).

However, the planned destruction of camps is continuing, with Angola settlement most recently destroyed. The majority of residents had their home demolished twice in 1995, and have been without medical care and assistance for approximately one year [OLS May 96]. It is likely that the health and nutrition situation of the displaced in camps around Khartoum remains critical.

Southern Sudan Over the last few months, the number of flights approved to deliver humanitarian aid has increased dramatically, allowing for food deliveries to over 200,000 people in August 1996. The lack of flight clearance by the Government since September 1995 for the main type of aircraft carrier used in Operation Lifeline Sudan (OLS) had meant that WFP were only able to deliver 20% of the assessed food needs between January and June 1996. During August, deliveries of food were made to many areas of Bahr el Ghazal which had recently been identified as extremely food insecure with ‘serious’ signs of malnutrition observed by OLS staff [OLS Aug 96, WFP 12/07/96].

An estimated 15,000 people were affected by flooding in the Pocalla area and in early August, OLS received approval for relief flights to reach this population. This was temporary, as flights were not approved for September. There have also been reports of thousands of people crossing from the eastern to the western side of the Yei river in Mundri county as a result of recent fighting. An assessment team confirmed the displacement of over 6,000 people and food and relief needs are now in hand [OLS Aug 96, OLS 13/08/96].

A survey conducted in Tonj county, Bahr el Ghazal in March 1996 showed 8.8% wasting with 1.6% severe wasting (see Annex I 13(a)). The months following the survey are traditionally the lean months, and more recently ‘noticeable signs of malnutrition’ have been reported among women, children and the elderly in Bahr el Ghazal. Measles immunisation coverage was low at 13.5% [OLS May 96, WV Mar 96].

A survey carried out in May 1995 in Juba showed 15% wasting and/or oedema with 2% severe wasting and/or oedema (see Annex 113(b)) [OLS May 96].

Ethiopian and Eritrean Refugees Voluntary repatriation of Ethiopian refugees is ongoing, with over 2,000 people returning to Ethiopia in May 1996 [OLS May 96].

Overall, the displaced population in camps around Khartoum is in category I in Table 1 due to vitamin A deficiency and sharply elevated mortality rates (details included in the June RNIS report). The affected population in Southern Sudan can be considered to be at moderate risk (category IIb in Table 1) due to diarrhoeal diseases and continuing restrictions on food aid delivery. The refugee population is not currently considered to be at heightened nutritional risk (category IIc in Table 1).

How could external agencies help? A government committee has now been formed to review the request made by humanitarian agencies to allow greater access to the displaced populations around Khartoum with a view to improving basic needs delivery to the remaining settlements. This step provides something of a ‘window of opportunity’ to address the problems of this population. It is therefore vital the agencies continue to reiterate requests for improved access, better NGO co-ordination and permission to collect data for advocacy purposes.

The shortfalls in food aid pledged for the Sudan programme and the deficit in funds for monitoring operations are of significant concern and could jeopardise the continuation of operations at a time when, due to the increase in flight clearances, it is possible to deliver more food aid. Given the fragility of food security for large portions of the population in Southern Sudan, it is critical that food aid and funds are pledged immediately in order to limit any further disruptions to food aid deliveries in the south.

14. Uganda

(see Map 14)

There are approximately 250,000 assisted refugees and internally displaced people in Uganda. The increase over the last few months is due to the arrival of 2,500 Zairian refugees from the Masisi region, and the identification of 20,000 people internally displaced in northern Uganda. The total number is broken down by country of origin, as follows:

Origin	Jul 95	Oct 95	Dec 95	Feb 96	Apr 96	Jun 96	Sep 96
Sudanese Refugees	322,000	324,000	217,000	210,000	214,000	214,000	214,000
Internally Displaced Ugandans	-	-	-	-	-	-	20,000
Zairian Refugees	13,400	13,700	11,800	12,300	12,300	12,300	15,800
TOTAL*	335,400	337,400	228,800	222,300	226,300	226,300	249,800

* Rwandan refugees In Uganda are included in section #4.

There are no new nutritional data on these refugees, although it can be expected that the disruption of delivery of supplies and the closing down of NGO programmes due to the insecurity, will eventually have an adverse impact on the nutritional status of the refugees. Indeed, insecurity has affected deliveries to the point that September requirements have not been delivered. There are also reports of 20,000 people internally displaced by this rebel activity in the Gulu and Kitgum areas [UNHCR 16/09/96, WFP-a 27/09/96].

The total number of assisted Zairian refugees in Uganda has increased slightly to 15,800, due to the arrival of approximately 2,500 refugees fleeing the conflict in the Masisi region of Zaire (see section #4 for details). These new arrivals are being assisted, although it is believed that many will spontaneously repatriate in the near future [UNHCR 16/09/96].

Overall, the refugees in Uganda are not currently thought to be at heightened nutritional risk (category IIc in Table 1), although continued disruptions to food deliveries for Sudanese refugees in the north are likely to have a negative impact on the nutritional status of this group.

15. Zaire

(see Map 15)

Refugees in Zaire (excluding Rwandans and Burundis included in section #4) There are an estimated 50,000 Angolan refugees in Zaire; an estimated further 119,000 are unassisted (and not included in Tables 1 and 2). It is hoped that most of the unassisted population will spontaneously return to Angola now that the situation has improved there. Organised repatriation for the 50,000 assisted refugees is scheduled to begin by mid 1996 [UNHCR 17/01/96,1995-1997].

There are approximately 94,000 Sudanese refugees receiving some assistance in Zaire. The slight increase is due to a small number of new arrivals fleeing the continued insecurity in southern Sudan [UNHCR 17/01/96].

There are over 12,000 Ugandan refugees and a further 6,000 new arrivals whose refugee status unclear [UNHCR 17/01/96].

Displaced from Shaba, Zaire There are approximately 600,000 people who have been displaced by ethnic violence which erupted in the Shaba region at the end of 1992. This population fled north into the Kasai region where many had ancestral links. During the migration large numbers stopped temporarily in villages along the route north, while others settled permanently at these sites.

Currently, there is little further displacement from the Shaba region and based on the most recent set of nutritional survey information, it is believed that many of these people are self-sufficient and no longer require humanitarian aid. The exception to this was in Mwene Ditu where critically high levels of wasting of about 43% in the displaced population, estimated at 40,000 people, and 17% wasting in the local affected population (estimated at 220,000) are reported [MSF-B 09/04/96 - from RNIS #15].

Overall, the displaced and resident affected populations in Mwene Ditu are in category I in Table 1 due to elevated levels of wasting. The remaining displaced population from Shaba is no longer considered to require assistance and so is not included in Table 1. The refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).

16. Zambia

Organised repatriation of the approximately 26,000 assisted Angolan refugees in Zambia is scheduled to begin in 1996 and will be completed over a fourteen month period. Before departure refugees will undergo health and nutrition screening and be given updated health cards while children under five will be vaccinated. There are a further 70,000 unassisted refugees who have been considered self-sufficient for a long time, and are expected to repatriate without assistance [UNHCR 1996-1997].