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. Mozambique Region
11. Somalia
12. Sudan
13. Uganda
14. Zaire
15. Zambia
(see Map 1 and Figure 3)
Trend in numbers of displaced/war affected. Shaded areas indicate those at heightened nutritional risk.
There are approximately 1.37 million war affected and/or internally displaced people in Angola, although this number is likely to gradually decline as more families return home. For example, it is estimated that in the past year 45,000 internally displaced people have left Saurano, Lunda Sul, to return to their home communities within the government controlled areas. Over 5,000 refugees returned home in October 1996 [DHA 07/10/96, 10/11/96].
In recent months the focus of humanitarian activities has been upon rehabilitation of village infrastructure to encourage the return of internally displaced people country wide. Several bridges have been rehabilitated and roads have been declared open thereby facilitating the free movement of people and goods throughout the country. It is now estimated that 75% of food transported since early 1996 has been by road, rather than air transport which is significantly more expensive [DHA 07/10/96, 10/11/96].
The nutritional situation in the country appears to be generally stable. For example, a recent survey in the areas around Kuito (excluding Kuito town) showed 9.7% wasting and/or oedema with 1.9% severe wasting and/or oedema (see Annex I (1a)). These results compare favourably with those from last year when wasting and/or oedema was measured at 28% [DHA 10/11/96]. The implementing agency recommended continuing health interventions to reduce prevalence of disease which is believed to be a significant contributing factor to current levels of wasting. Another example of an improving nutritional situation comes from Uige city where a 2% prevalence of wasting was found within a 15 mile radius (see Annex I (1b)). These results have led to a decision to phase down therapeutic feeding in Uige hospital [DHA 10/11/96].
However, there are still concerns over the food security of demobilised soldiers. Due to the prolongation of the quartering process, food stocks earmarked for soldiers and their families have been close to depletion. Urgent appeals to donors for more food pledges have been made [WFP 08/11/96].
Numerous initiatives in the health sector prevail in Angola with widespread support for immunisation campaigns and restoration of health infrastructure. However, periodic outbreaks of disease continue to be reported. For example, a measles epidemic was reported in an inaccessible area of Malango province killing 111 children. Immunisation to prevent the spread of the epidemic is underway [DHA 10/11/96]. In Huila province, a recent meningitis outbreak killed 30 people. Essential drug kits and chlororamphenicol were immediately distributed to local health posts.
Overall, this population is not currently considered to be at heightened nutritional risk (category IIc in Table 1)
Haw could external agencies help? As peace continues to hold, the extension of projects designed to encourage internally displaced people to return home, such as provision of seeds and tools, and rehabilitation of villages infrastructure are essential. Equally important is the process of demobilisation of soldiers. As this programme is taking longer than anticipated, food resources are dangerously low and need to be replenished immediately in order to avoid the type of nutritional crisis affecting families of former combatants described in earlier RNIS reports.
The task of rehabilitating the health infrastructure in country will require long-term commitment from donors although there are short-term priorities which still need to be addressed. Immunisation coverage, in particular and noted in earlier RNIS reports as inadequate, remains a problems in some areas. Efforts of the mobile immunisation teams therefore need to be supported, and in some cases enhanced.
There remain approximately 33,000 refugees in the region. This number is comprised of 12,000 Togolese refugees in Ghana, 11,000 Togolese refugees in Benin, and 10,000 refugees from Ghana in Togo. The vast majority of this population left their country of origin in 1993 because of political disturbances and sought refuge in Benin and Ghana. A further group of people fled ethnic fighting in Ghana and took refuge in Togo. The refugee population affected in the region continues to decline due to repatriation which is being encouraged by a shift in humanitarian aid policy from relief to rehabilitation and the reduction in food aid allocations. It is hoped that in Togo the provision of seeds and also money for small businesses will lead to self-sufficiency of the entire refugee population [IFRC 14/10/96]. There are no reports of change to a generally adequate and stable nutritional status of this population (category IIc in Table 1).
(see Map 3)There remain approximately 25,000 Malian refugees in Burkina Faso. The decrease in numbers from the previous RNIS report is due to repatriation. There are no reports of change to the adequate and stable nutritional situation of this refugee population.
Repatriation of Malian refugees has resumed from Mauritania, and it is currently estimated that there remain 28,000 refugees in one camp. Numbers are declining as the repatriation process continues; approximately 3,000 people repatriated in October 1996, bringing the total number of returnees since June 1996 to over 17,000. It is expected that the repatriation process will be completed my mid-1997 [UNHCR 22/11/96].
Overall, these refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).
(See Map 4 and Figure 3)This information is as of 14 December 1996.
Fighting which erupted in Eastern Zaire in early November led to the dispersal of most of the 1.2 million refugees in the region and also caused the displacement of an unknown number of Zairians. The insecurity resulted in approximately 600,000 Rwandan refugees returning home, mainly without incident. The large-scale returnee influx into Rwanda is generally being well-managed by the international community. The number of refugees remaining in Zaire and the number of internally displaced Zairians is unknown but likely to be in the hundreds of thousands. Some refugees have fled to Uganda while some Burundi refugees have returned home. The continued insecurity in Burundi is also causing tens of thousands of people to flee their homes, mainly heading for Tanzania. The Tanzanian government has served notice that it intends to repatriate the large refugee population by the end of the year.
Trend in numbers of refugees/displaced and proportion severely malnourished or at high nutritional risk (shaded area).
Current estimates of affected populations by country of present residence are given in the box below:
|
Location |
Oct 95 |
Dec 95 |
Feb 96 |
Apr 96 |
Jun 96 |
Sep 96 |
Dec 96 |
|
Burundi |
315,000 |
504,000 |
275,400 |
290,000 |
289,000 |
300,000 |
296,000 |
|
Rwanda |
725,000 |
800,000 |
737,000 |
737,000 |
749,000 |
598,000 |
1,179,000 |
|
Tanzania |
629,000 |
621,000 |
653,000 |
624,000 |
642,000 |
653,000 |
759,000 |
|
Zaire |
1,158,000 |
1,146,000 |
1,211,000 |
1,166,000 |
1,419,000 |
1,444,000 |
668,000 |
|
Uganda |
6,400 |
6,400 |
6,800 |
6,900 |
7,000 |
7,000 |
11,500 |
|
TOTAL |
2,831,400 |
3,077,400 |
2,883,200 |
2,823,900 |
3,106,000 |
3,002,000 |
2,913,500 |
Approximately 600,000 Rwandan refugees have returned home, mainly without incident, but the total number of refugees remaining in Zaire and the number of internally displaced Zairians remains unknown. It is believed that there are up to 500,000 refugees gathered in at least five separate areas in Eastern Zaire and as many as 170,000 internally displaced. Some refugees have fled to Uganda while others have returned home to Burundi where the continued insecurity is also causing tens of thousands of people to flee their homes with many seeking refugee status in Tanzania [USAID 22/11/96, 12/05/96, IRIN 03-4/11/96 04/11/96, 08/11/96].
The high level of insecurity has forced most humanitarian agencies to evacuate the region and it is currently virtually impossible to deliver food and other relief supplies to the area. The risk of an emerging nutritional and health crisis increases daily as this situation persists [USAID 22/11/96, IRIN 03-4/11/96, 04/11/96, 08/11/96].
The plan to dispatch a multi-national military force, whose mandate would be limited to assisting food deliveries and the voluntary repatriation of refugees, has been “put on hold” partly so as not to interfere with the large-scale repatriation to Rwanda and also because of the enormous difficulties that are being encountered in locating hundreds of thousands of refugees and internally displaced people in the area. The security risk to such a force has also been a factor in the delay. Relief agencies have launched airlifts of high energy biscuits, medical supplies, plastic sheeting and blankets into areas where refugees have been located [USAID 22/11/96, IRIN 03-4/11/96 04/11/96, 08/11/96, 12/12/96].
Bukavu By mid-November the Bukavu refugee camps were reportedly empty although the whereabouts of the refugees was unclear. Very few of the returnees to Rwanda have been from the Bukavu camps and it is believed that most of this refugee population has moved westward [IRIN 22/11/96].
Agencies have been planning small-scale targeted distributions to vulnerable groups in hospitals, orphanages and to 8-9,000 refugees and internally displaced persons who are in or near Bukavu and in need of assistance. Out of this population, up to 4,000 are reportedly in a very bad condition [WFP 29/11/96].
Uvira Initial reports suggested that as fighting between rebel and government forces escalated all of the 220,000 refugees (143,000 Burundian and 73,000 Rwandan) fled the camps which were subsequently burnt. Up to 36,000 of the Burundi refugees in the Uvira area have reportedly returned to Burundi. Most of the Rwandan refugee appear to have moved north of Uvira with others fleeing south towards Fizi. A UN/NGO team was able to visit the town for the first time in early December and found the situation to be very calm with markets now re-opened and quite well supplied. There were no refugees visible on roads. Most of the refugees who were in the Uvira camps have not received food aid since the middle of October as access by relief agency staff has not been possible. High levels of malnutrition have been found among refugees who have returned to Burundi from Uvira [IRIN 08/12/96].
Rwanda Approximately 600,000 refugees returned to Rwanda by the end of November and were being assisted with food and non-food items during transit and on return to their communes of origin. Due to the scale and speed of return (200,000 returned between the 15-16th of November) it has not so far been possible to conduct nutritional surveys. However, the returnees are generally reported to be in good health, although more recent returnee children are said to be suffering from dehydration, exhaustion and hunger [IRIN 17/11/96, 22/11/96]. There are also approximately 576,000 people in Rwanda who will require emergency assistance probably until the harvest in January 1997.
Relief agencies established eight way stations between Gisenyi and Ruhengeri in Rwanda to address the needs of the returnee population. The size of the population precluded distribution of a general ration during transit so that returnees were allocated high energy biscuits. However, resupplying way stations has proven problematic at times due to refugee congestion on the roads. NGOs therefore began to restock warehouse after dark when the roads were clear for the night [IRIN 22/11/96].
General rations lasting between one to four weeks are being supplied to returnees on arrival at their communes of origin and the registration of the 600,00 Rwandan returnees is said to be continuing in the communes without major disruption. However, there have been some administrative problems with food distribution in Gisenyi and Ruhengeri [IRIN 03/12/96, WFP 21/11/96].
In spite of the fact that the nutritional state of the returnees has been generally better than expected, the need for supplementary feeding at commune level has increased due to the influx. However, in order to avert the need for establishing large numbers of feeding centres it has been decided to incorporate a 100 gms of UNIMIX/child/day into the general ration. There is also increasing concern over the food security situation in both Butare and Gikongoro prefecture where irregular rainfall during the past two months and increasing demand for food from refugee returnees from Burundi in July and August is increasing the pressures on food supplies [WFP 29/11/96].
A recent nutritional survey in Kibangira camp (approximately 3,000 Burundi refugees) in Rwanda showed 6.1% wasting with 2.8% severe wasting. No cases of oedema were seen (Annex 1 (4a)). The crude mortality rate was 0.4/10,000/day and the under-five mortality rate was 1.9/10,000/day. The ration distributed was 1950 kcals/person/day just prior to the survey while measles immunisation coverage was 97%. These indicators describe a generally adequate situation [MSF-B 11/10/96]
Burundi At least 46,000 Burundi refugees have recently returned to Bujumbura and Cibitoke provinces from Zaire with many reportedly in an appalling nutritional state. A recent screening among those arriving at Gatumba transit camp, regardless of age, showed 18.2% wasting with 4.2% severe wasting. Another screening showed 13% severe wasting for those under 15 years old, with 17.6% severe wasting for children under five years old (see Annex I (4b-c)). This situation is thought to be due to the combined effects of a reduced ration in the camps prior to departure and the lengthy period of transit from Zaire which may take up to one week. The transit camp is now reportedly empty as people return to their communes; food rations are being provided to returnees [IRIN 03-04/11/96, UNHCR 17/11/96, WFP 14/11/96].
A total of 3,000 returnees who transferred from the Gatumba transit camp are living on a site in Rugombo and are awaiting transfer to their home communes. Although this population has sufficient food, their limited access to water and sanitation is said to be alarming. A further 16,000 returnees are camped near Buganda and have not passed through Gatumba camp. They have therefore not received any assistance and are lacking both food and non-food items. Their lack of access to water and sanitation is also causing grave concern [WFP 29/11/96].
Widespread insecurity persists throughout Burundi with approximately 75,000 Burundians having fled to Tanzania in the first two weeks of November. Most of this population have come from the provinces of Bururi, Rutana, Gitega and Ruyigi. The slaughter of 298 Burundian returnees who were killed in Murumba church in Cibitoke province at the end of October received widespread media coverage. At the end of November the dramatic deterioration of security in Kayanza province led to a displacement of up to 100,000 people. Further large scale security induced displacements have also recently been reported in southern Bujumbura rural province and northern Bururi province [WFP 29/11/96].
There are estimated to be at least 250,000 internally displaced people in Burundi. Many of these people are inaccessible for varying periods of time due to insecurity and receive rations as and when security allows. A further problem for this population has been the inclusion of fuel and food aid on the list of items which sanctions preclude from entry into Burundi. As these restrictions have now been reduced it is hoped that humanitarian aid activities can increase in scale and scope [WFP 18/10/96, 01/11/96].
A survey among the internally displaced in Karuzi province, Burundi (affected population estimated at 50,000 in approximately ten camps) showed 13% wasting, with 2.7% severe wasting. Oedema was measured at 1.1 % (see Annex 1 (4d)). Measles immunisation coverage was 85.6%. These somewhat worrying results can, in part, be explained by the fact that this population has little or no access to farmland, and that humanitarian food deliveries have often not been possible due to insecurity. In order to redress this situation, it has been proposed to increase the capacity of feeding centres, and to organise weekly food distributions. This is, however, only feasible where security allows [DHA 15/10/96, MSF-B 30/08/96].
Tanzania More than 100,000 refugees fleeing insecurity in Burundi and a further 35,000 from Zaire arrived recently in Tanzania in the Kigoma region. Tanzania now hosts more than 759,000 refugees including 535,000 Rwandans, 189,000 Burundi refugees, and 35,000 Zairian refugees [MSF 24/11/96, USAID 12/12/96].
Recent nutrition assessments have revealed generally low levels of wasting and oedema among the under-five population of refugees in Tanzania. However, cases of adult malnutrition were seen in most of the camps, which were determined to be largely attributable to medical and socio-economic problems. In addition, signs of micronutrient deficiencies were noted, particularly in the Ngara camps. Ration supplied during 1996 were on average 1880 kcals/person/day. Food distribution systems were changed in late 1995 from family to communal level distribution, based on community participation. This system is said to be more successful than previous ones as there is greater transparency and equity and refugee families do not have to spend such long periods distribution queues. Furthermore, agencies spend less time implementing the distributions. Provision of firewood remains a problem in many camps, with the notable exception of Kigoma [WFP/UNHCR Oct 96].
In Kigoma (estimated population 43,000), recent surveys showed levels of wasting which varied from 3.0-12.5% with 0.0-1.1% severe wasting. Almost no cases of oedema were seen (see Annex I (4e-h)). Crude mortality rates varied from 0.17-0.33/10,000/day, and the under-five mortality rate was 0.3-1.14/10,000/day. Water supply is on average 15-30 litres/person/day. However, in Mtendeli camp where 40,000 Burundi refugees have arrived since the beginning of November, the most recent arrivals are reportedly in a poor nutritional state. Rates of malnutrition for children under five were recorded at almost 19%. The overall prevalence of wasting is 12.5%. A new camp has been opened to help accommodate the recent case load and despite what is described as overcrowded conditions, the health and food situations are reportedly under control. However, there are reports that only approximately 4 litres of water/person/day are available and that soap and blankets are in short supply [WFP/UNHCR Oct 96, WFP 29/11/96].
The most recent nutritional surveys for the Ngara camps (estimated population 490,000) are from September 1996. These surveys showed levels of wasting ranging from 1.9-3.6% with severe wasting from 0.1-0.3%. Oedema varied from 0.0-0.8% (see Annex I (4i-k)). Crude mortality rates were measured at 0.14-0.59/10,000/day and the under-five mortality rates were 0.39-1.96/10,000/day. Water availability ranged from 8-12 litres/person/day. This is below the recommended 20 litres/person/day. A survey amongst school children in the camps (6-15 year olds) found prevalence rates of angular stomatitis of 8.% to 15.5%. This suggests the need to review the availability of micronutrients in both the general ration, and through alternative (e.g. markets, gardens) [WFP/UNHCR Opt 96].
In Karagwe (estimated population 125,000), surveys showed wasting and/or oedema from 0.3-1.8% with severe wasting and/or oedema 0.0-0.4% (see Annex I (41-p)). No land is officially designated for farming, however many refugees have small home gardens. Water availability is problematic during the dry season when only 3-4 litres/person/day are available. During the rainy season, 8-17 litrers/person/day are available [WFP/UNHCR Oct 96].
UN sources have said that the repatriation of the approximately 535,000 Rwandan refugees from Tanzania could take place before the end of the year. Indeed, it is reported that Rwandan refugees appear to be preparing to leave the camps, but in some cases there are population movements further into Tanzania, not toward Rwanda. Agencies are preparing for a large scale return to Rwanda by prepositioning food at commune level and high energy biscuits “en route” [IRIN 11/12/96, 12/12/96, WFP 22/11/96, 29/11/96].
Uganda There are approximately 11,500 refugees from Rwanda and Zaire in Uganda [USAID 05/12/96]. There are no current reports on the nutritional status of this population.
Overall, the returnees in Burundi are at high risk (category I in Table 1) due to elevated levels of wasting seen as they came through transit centre. The refugees in Ngara, Tanzania are also at high risk due to micronutrient deficiency diseases. The refugees and internally displaced people in Eastern Zaire along with those in Burundi can be considered to be at high risk (category IIa in Table 1) due to inaccessibility. New returnees to Rwanda and new arrivals in Tanzania can be considered to be at moderate risk (category IIb in Table 1). The population in Rwanda dependant on food aid until the harvest and the remaining refugees in Tanzania are not currently thought to be at heightened nutritional risk (category IIc in Table 1).
How could external agencies help? Until access to Eastern Zaire improves, perhaps facilitated through the dispatch of a multi-national military force, little humanitarian work can proceed. However, it can be surmised that the majority of those refugees and internally displaced people remaining in the region are increasingly in need of humanitarian aid support in the form of food, shelter, clean water and sanitation facilities, and health service provision. It is therefore vital that the relief community prepare for an intervention involving large numbers of malnourished and sick people. It is also essential that governments and UN agencies arrive at a clear policy regarding the ultimate destination of this newly displaced refugee population in order to plan for the most appropriate type of humanitarian aid support. Aid workers in the region have identified the following major impediments to resumption of humanitarian operations in Eastern Zaire once security problems are resolved; shortage of aid vehicles and logistic equipment, destruction of relief structures, chronic fuel shortages and poor road access.
In Rwanda there is an ongoing need for nutritional and food security monitoring in communes which are receiving large numbers of refugee returnees, This need is particularly acute in the prefectures of Gikongoro and Butare where poor harvests are posing an additional strain on food security. It is also important that agencies carefully monitor the equity of general ration distribution systems put in place as the speed of influx into communes may well necessitate distribution through commune leaders with an inherent risk of high levels of leakage to privileged groups.
In Burundi, the high level of insecurity continues to thwart efforts to adequately support newly displaced populations. These populations invariably require expanded selective feeding programme facilities and general ration distributions and it is important that distribution systems are selected on the basis of posing least risk to beneficiaries while ensuring greatest likelihood of disbursement. The new influx of returnee refugees is an additional problem. Water and sanitization facilities need to be urgently improved at the transit camp at Rugumbo, while new returnees camped near Bugongo need to be urgently registered for food distributions and supplied with water and sanitation facilities.
In Kigoma region in Tanzania, the large influx of refugees leading to over-crowded camp conditions, insufficient water supplies and lack of soap and blankets in Mtendeli and newly established camps, is increasing the risk of outbreaks of cholera and measles. A high level of preparedness is needed in the event that such diseases occur. Furthermore, the high incidence of vitamin B2 deficiency leading to angular stomatitis indicates the need to review the quality of the ration and the efficiency of the distribution system.
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].
(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].
(see Map 7)There are an estimated 396,700 assisted refugees and internally displaced people in Ethiopia. This total is comprised of 72,000 Sudanese refugees, 287,000 Somali refugees, 8,700 Kenyan refugees, 18,000 Djibouti refugees and 11,000 internally displaced people from Kenya and Somalia who have moved into Moyale district of Ethiopia [DHA-a Sep 96]. There are an additional 30,000 unassisted refugees in Ethiopia.
The last RNIS report included details on an assessment mission to Ethiopia which revealed levels of wasting varying from 15.2%-21.1% among the Somali refugee population. These surveys showed a marked deterioration in nutritional status over the previous year. The nutritional situation for the Sudanese refugees, who are partially self-sufficient, was considered to be adequate and stable with levels of wasting varying from 6-8%.
Recommendations of the assessment mission, which included the extension of supplementary feeding programmes, diversification of the general ration for Somali refugees and a reduction in the ration in light of partial self-sufficiency for the Sudanese refugees, have not yet been implemented [DHA-a Sep 96, UNHCR 14/08/96].
Preparations are underway for the repatriation of the first 10,000 Somali refugees, which is expected to start before the end of 1996. The idea has reportedly been well received by the refugees and it is possible that many more than the 10,000 being targeted will register for the programme. Also, approximately 7,000 Kenyan refugees have expressed an interest in repatriating in the near future [DHA-a Sep 96, UNHCR 14/08/96].
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 refugee and internally displaced populations are not currently thought to be at heightened nutritional risk (category IIc in Table 1).
How could external agencies help? Most of the recommendations of the earlier assessment mission, especially with regard to the Somali refugee population, have not yet been implemented. Specific interventions, many of which were noted in the September RNIS report, that still need to be implemented, include:
· the verification of the number of refugees in Ethiopia and the registration of Somali refugees without ration cards;As the Sudanese refugee population has attained some degree of self-sufficiency, a reduction in rations may be appropriate although the nutritional status of this population should be carefully monitored in order to detect any potentially adverse effect of such an action. Furthermore, this population should be encouraged to achieve a greater degree of self-sufficiency through:· the extension of supplementary feeding programmes in the Somali refugee camps;
· diversification of the ration for Somali refugees to include fortified blended foods;
· provision of non-food items such as soap, blankets and shelter material in the Somali camps.
· the more timely provision of seeds and tools;
· allowing wider access to arable land and water.
(see Map 8)There are approximately 167,000 refugees in Kenya comprised of 4,500 Ethiopian refugees, 130,500 Somali refugees and 32,000 Sudanese refugees. There has been a decrease in the number of Somali refugees due to repatriation, and an influx of Sudanese refugees. In August 1996, the Kenyan government announced that all Somali refugee camps would be closed by the end of 1996. It is however, unlikely that this deadline will now be met as it would involve the repatriation and/or resettlement of over 130,000 refugees over the next few weeks [IFRC 17/10/96, UNHCR 30/11/96].
The most recent RNIS report contained details of a nutritional survey in the Dadaab camps where there are approximately 113,000 Somali refugees. At that time it was reported that cases of scurvy were noted by the survey team. More recent information indicates an epidemic of scurvy with at least 700 cases being reported per month (5.8/10,000/month). Vitamin C tablets have been distributed amongst this population [MSF-B 06/11/96].
Overall, the refugees in the Dadaab camps are at high risk (category I in Table 1) due to micronutrient deficiency diseases. The remaining refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).
(see Map 9 a, b and Figure 3)A fragile peace process in Liberia is holding although there have been some cease-fire violations. It is hoped that as the peace process advances with disarmament and demobilisation continuing, confidence will grow to a point where repatriation of refugees is possible. As hitherto insecure areas become accessible to humanitarian agencies, extremely high levels of wasting and mortality are being discovered. However, these situations appear to respond well to rapid emergency interventions. In Sierra Leone, there is a growing sense that despite some insecurity in the countryside and a continued need for targeted emergency relief, there is now scope to commence more developmentally oriented projects.
Trend in numbers of refugees/displaced and proportion severely malnourished and at high risk (shaded area).
Current estimates of the numbers of people affected in the region are summarised below:
|
Location |
Oct 95 |
Dec 95 |
Feb 96 |
Apr 96 |
Jun 96 |
Sep 96 |
Dec 96 |
|
Liberia |
1,900,000 |
1,900,000 |
1,800,000 |
1,800,000 |
1,800,000 |
1,800,000 |
1,800,000 |
|
Sierra Leone |
730,000 |
730,000 |
730,000 |
756,000 |
756,000 |
609,000 |
609,000 |
|
Cote d’Ivoire |
305,000 |
305,000 |
305,000 |
305,000 |
305,000 |
305,000 |
305,000 |
|
Guinea |
536,000 |
605,000 |
605,000 |
536,000 |
536,000 |
536,000 |
536,000 |
|
TOTAL |
3,471,000 |
3,540,000 |
3,440,000 |
3,397,000 |
3,397,000 |
3,250,000 |
3,250,000 |
Implementation of the peace process in on-going. The disarmament programme began on schedule in November and is progressing slowly. Repatriation has not yet begun although it is hoped that as the peace process advances, refugees will be encouraged to return home [DHA 10/10/96, WFP 11/10/96, 06/12/96, UNHCR 19/11/96, USAID 30/09/96].
There are at least 1.8 million people affected by the war and its aftermath. Many areas of the country have been inaccessible for long periods of time and catastrophic nutrition and health situations are being discovered as these areas become accessible. For example, a recent joint assessment mission visited Bo-Waterside in Grand Cape Mount, where the population is estimated at 2,000, half of whom are thought to be Sierra Leonean refugees. A nutrition screening in the area showed 28% wasting with 11% severe wasting. Oedema was measured at 13% (see Annex I (9a)). Many people reported having access to arable land, but that much of the harvest had been taken by factional fighters. Refugees appeared to have less access to land than the local population. Some limited market activity was noted, but households seemed to depend heavily on foraged foods and would spend many days in the bush searching for wild foods. Households identified security and freedom of movement, food (but not without security from ECOMOG), medicines/health care, seeds and tools, as priorities for intervention. Individuals spoke of high levels of abuse by factional fighters, confiscation of food supplies and extortionate transport charges for moving products to market. Villagers in the area were adamant that no relief supplies should be delivered without the provision of security by ECOMOG forces. An outbreak of cholera in the area seemed to be subsiding although there were frequent reports of lack of drugs and medical supplies in health centres. Cholera cases have also been reported in Montserrado and Bomi County [DHA 10/10/96, 01/11/96].
Tubmanburg (estimated population 22,000) in Bomi County became accessible in September 1996, after being cut off from humanitarian aid for many months. In response to obvious need, food distributions were started immediately while severely malnourished people were transported to Monrovia and targeted feeding programmes implemented by the end of the month.
A rapid health assessment was carried out in October which measured wasting and/or oedema at 38% with 32% severe wasting and/or oedema (see Annex I (9b)). Mortality rates were equally horrifying. In August 1996 the crude mortality rate was 18.5/10,000/day (40x normal) with an under-five mortality rate of 51.2/10,000/day (around 50x normal). In the first ten days of October, the CMR was 5.4/10,000/day (approximately 10x normal) and the under-five mortality rate was 11.8 (roughly 10x normal) [EPICENTRE Oct 96].
Although much reduced, the mortality rates in mid-October were still ten times normal and triggered a number of recommendations from the assessment team. These included the continued implementation of a general food distribution and supplementary feeding programmes, the implementation of a medical care programme, mortality surveillance and a follow up anthropometric survey in the coming weeks. The assessment team recognised that an important factor in the relative improvement in health and nutrition of this population, in addition to the provision of food aid, may have been the reduced harassment by factional fighters who still control the “bush”. These fighters have benefited from the re-opening of roads, the assistance programmes, looting of food distributions, presence of their families in nutritional programmes and improved trading links with Monrovia [EPICENTRE Oct 96].
Data from ‘Demographic and Nutrition Assessment Tubmanburg, Bomi County, Libera’ Medecins sans Frontieres, EPICENTRE. October 1996.
Sierra Leone A cease-fire was signed on 30 November 1996, and it is hoped that the accord will pave the way for resettlement and rehabilitation programmes to begin. Inter-agency registration exercises in Kenema, Bo and Makeni have confirmed that while some internally displaced people have begun to return to their areas of origin, large numbers who are dependent on food aid still remain in camps and urban areas. For example, there are still 10,000 inhabitants in Gondama camp in Pujehun district [DHA Sep 96, DHA 11/11/96, WFP 06/12/96].
As rebel forces are increasingly being pushed to the west of the country, some alarming situations are being uncovered. For example, a group of 500 people who had apparently been held captive for up to four years and forced into slave labour by the RUF were recently discovered in Blama, near Kenema. Among this population, estimates of adult malnutrition were 25% (see Annex I (9c)). This group have now been moved to RTI camp near Kenema, where preparations had been made for their arrival. It is believed that there are at least a further 1500 similarly affected people hiding in the bush, whose nutritional status is likely to be deteriorating rapidly [MERLIN 07/11/96]. It is also believed that this situation is not unique and that there are many other brutalised captive populations throughout the country who will emerge from the “bush” in the coming months.
A recent survey in the camps for internally displaced around Bo (population estimated at 93,000) showed 21.8% wasting with 3.5% severe wasting; oedema was measured at 0.2% (see Annex I (9d)). These results are similar to those obtained from a January 1996 survey when wasting was measured at 23%. The ration provides approximately 1200 kcals/person/day, and it has been recommended that it be increased to 2100 kcals/person/day to improve the nutrition situation of this population. Measles immunisation coverage was almost 80% [ACF 03/09/96].
In Bo town (population estimated at 250,000), wasting was measured at 9.4% with 0.9% severe wasting; oedema was measured at 0.1% (see Annex I (9e)). Half rations of approximately 920 kcals/person/day have been provided for the past seven months. Since June 1996, CSB has also been distributed. Measles immunisation coverage was 74% [ACF 03/09/96].
Stocks of cereals are reportedly depleted in Freetown, and CSB and vegetable oil stocks are at extremely low levels. In addition, vehicles for implementing and monitoring programmes are urgently needed [WFP 08/11/96].
Guinea There are approximately 650,000 Liberian and Sierra Leonean refugees in Guinea, 536,000 of whom are assisted with emergency food aid. Overall, the health and nutrition situation of these refugees is considered to be adequate, and it is hoped that as the peace process in Liberia and Sierra Leone continues to progress, the refugees will begin to repatriate [UNHCR 19/11/96].
A survey carried out in August 1996 showed a much improved situation for the Liberian refugees in the eastern zone of Guinea Forrestiere. Wasting varied from 1.1-3.2% with virtually no severe wasting or oedema seen (see Annex I (9f)). These results compare favourably with those from 1995 when levels of wasting were 14.7%-16.4%. It was felt that the improved quality and regularity of general rations have been key factors in effecting this improvement [MSF-B Aug 96].
However, measles immunisation coverage varied from 50-72% which is below the minimum coverage recommended of 80% [MSF-B Aug 96].
Cote d’Ivoire There are approximately 305,000 Liberian refugees in Cote d’Ivoire whose health and nutritional status are reportedly adequate and stable [UNHCR 19/11/96].
Overall, the populations of Tubmanburg, Bo Waterside and the internally displaced population around Bo, Sierra Leone are at high risk (category I in Table 1) due to sharply elevated levels of wasting and mortality. The population outside of Monrovia in Liberia can be considered to be at moderate risk, while the remainder of the population affected regionally is probably not currently at heightened nutritional risk (category IIc in Table 1).
Haw can external agencies help? In Liberia, as new areas become accessible extremely high rates of wasting and mortality are being found. The international community has shown in Tubmanburg that if access is possible, these situations can be quickly brought under control. Efforts to rapidly assist newly accessible populations must continue to be supported. These interventions will most likely be comprised of general food distributions, targeted feeding, immunisation programmes and health service provision along with the provision of seeds and tools.
However, it is vital that allocation of food is only under-taken where ECOMOG forces can guarantee some level of protection for beneficiaries or lives may be put at risk. The efficiency of interventions therefore rely on political decisions regarding the creation of protection zones where access is allowed. ECOMOG may need further encouragement and support to act as an interposition force in some areas.
There remain many internally displaced people in Sierra Leone who are dependant on emergency food aid. Funds to support the continuation of these distributions, along with funds for monitoring and logistics, remain a priority. At the same time it is important to support programmes which will encourage internally displaced people to return home. For example, the distribution of seeds, tools and other agricultural input could be important incentives for potential returnees. To date, the response to consolidated appeals for returnee and rehabilitation programmes has been minimal, and in order to take advantage of the present opportunity to progress from relief to development, pledges are urgently needed from donor governments. Stocks of cereal, CSB and oil are in urgent need of replenishment.
In Guinea there is a need to continue general ration distributions to the refugee population or there is a risk that previous high levels of wasting, which were due to inadequate general ration allocations, may recur. Efforts to increase measles immunisation coverage also need to be supported, e.g. strengthen mobile teams and ensure that stocks of vaccine are replenished. The longer-term initiatives to encourage self-sufficiency amongst this population must also continue.
(see Map 10 and Figure 3)Emergency food assistance is currently being provided to approximately 60-70,000 returnees and internally displaced people who returned too late in 1995 to clear and cultivate sufficient land to obtain a reasonable crop. It is hoped that these people will be self-sufficient after the harvest in April 1997. A ‘Crop and Food Supply Assessment Mission’ is planned for April 1997 to determine what, if any, the emergency food needs of this population will be for the coming year [WFP-a 06/12/96].
Trend in numbers of returnees and demobilised soldiers.
(see Map 11 and Figure 3)Despite the forecast improvement in the 1996/7 food crop harvests over 1995/6 levels, overall crop production is still 37% lower than the pre-civil war years and the food supply situation is described as precarious. Many areas of the country remain insecure, with sporadic fighting being reported in most areas of southern Somalia. It was estimated at the end of August 1996 that 150,000 people remained in need of emergency food assistance. The most vulnerable populations are probably those where the Gu harvest has been reduced and where an improvement in security is necessary to ensure that food aid can be transferred from surplus to deficit areas. For example, in the Lower Juba Valley the Gu harvest was predicted to only last two months. This, combined with insecurity and low purchasing power is causing extreme vulnerability in this population. Urban populations are also considered to be at risk [DHA-a 11/11/96, FAO 25/09/96].
Trend in numbers of returnees and internally displaced with proportion severely malnourished or at high nutritional risk in shaded area.
Mogadishu remains insecure, despite apparent progress made when the Kenyan president brought Somali factional leaders to the negotiating table in October. At that time warring factions agreed to end hostilities, however there has been no cease-fire apparent on the ground. There is concern that the food security situation for large numbers of unemployed people could rapidly deteriorate if food prices rise in the next few months. Despite the restrictions insecurity places on humanitarian activities and concerns for household food security, a recent nutrition survey showed 7% wasting and/or oedema in Mogadishu (see Annex I (11a)). In early November 1996 heavy flooding was reported in Mogadishu with the camps for the internally displaced reportedly worst affected [DHA 07/11/96, DHA-a 11/11/96].
Some NGOs are reporting a slight improvement in nutritional status in areas outside of Mogadishu. A recent survey carried out in the Bay region showed 13.1% wasting and/or oedema. Other surveys carried out in Dinsor, Berdale, and Quansaghere showed wasting and/or oedema at 11.8%, 4.6% and 14% respectively (see Annex I (11 b-e)) [DHA-a 11/11/96].
However, another survey in Bulla Huwa showed a very alarming situation. The town is situated near the Kenyan and Ethiopian borders and has an estimated population of approximately 59,000 people, which is at least double the 1992 population. More than 65% of the population are nomadic pastoralists. It is believed that many in the town are displaced from other parts of Somalia. Over 90% were living in temporary housing structures and most were only eating one meal a day. Wasting was measured at 37% with 10% severe wasting (see Annex I (11f)). This dramatic nutritional situation is partly explained by a lack of food at household level due to lack of employment opportunities and resulting poverty. Indeed, families are reportedly selling off personal possessions in order to be able to survive [Trocaire Oct 1996].
Overall, the population in Bulla Huwa can be considered to be at high risk (category I in Table 1) due to elevated levels of wasting. The remaining affected population is likely to be at moderate nutritional risk (category IIb in Table 1) due to continued sporadic insecurity leading to population displacements and lack of food availability in crop deficit areas. It should be noted that other population groups in Somalia may require emergency aid in the coming months in the wake of displacement caused by outbreaks of insecurity in combination with crop failure.
How could external agencies help? Targeted feeding programmes are needed to bring the high levels of malnutrition recorded in Bulla Hawa under control as quickly as possible. Longer term solutions to the food insecurity in the area might include programmes designed to increase access to productive resources such as land for farming, water, equipment, and seeds and tools. Food for work programmes and subsidised food on the market are other possibilities.
Throughout Somalia, there is a need for judicious use of food aid to support rehabilitation of flood control and irrigation schemes and provision of agricultural inputs through monetisation and food for work schemes. These activities should be prioritised in areas where agricultural production has been particularly poor. On-going nutritional surveillance in these areas is also important. Food security and resulting changes in the nutritional situation in urban areas also need to be carefully monitored, especially if food prices increase markedly.
(see Map 12 and Figure 3)There remain approximately 2.1 million people in Sudan requiring humanitarian aid. This total number is comprised of 119,000 displaced in camps around Khartoum (there are many more internally displaced people living among the local population in Khartoum), 1.9 million war-affected people in Southern Sudan and the transitional zone, and 150,000 assisted Ethiopian and Eritrean refugees. In addition, there are a further 240,000 people in the Red Sea Hills area in a catastrophic nutritional state experiencing exceptionally high levels of wasting and micronutrient deficiencies.
Southern Sudan An FAO/WFP/UNICEF joint crop assessment mission to Southern Sudan was completed in early October and yields for 1996 are estimated to be higher than 1995. There are however, wide variations between states and persistent insecurity along with poor road conditions will most likely make transport from surplus areas of Western Equatoria state and parts of Upper Nile state to deficit areas such as Jonglei and Juba extremely problematic. As few coping strategies are available to the populations in Gongrial and Juba (estimated population 500,000) where insecurity has resulted in cattle raiding and in high unemployment, the food situation in these areas is considered to be particularly critical. These problems are compounded by price rises of key cereals. For example, the price of sorghum in Juba is over 300% higher than at the same time last year [FAO 05/10/96].
An outbreak of measles has been reported in the western area of Upper Nile region, with another outbreak reported in areas of Bahr-el-Ghazal. A similar outbreak took place earlier this year and immunisation programmes have been on-going [OLS 23/10/96, 05/11/96].
A recent nutrition survey in Bahr-el Ghazal showed 21% wasting and/or oedema (see Annex I (12a)). Efforts to improve the situation are underway with food distributed to approximately 14,000 people. Many of these people are newly displaced due to insecurity in Thiek and Lietnhorn [OLS 05/11/96].
Red Sea State The food security situation in Sinkat and Tokar province has been markedly deteriorating for at least four months with food prices, particularly sorghum (300% in the past six months) increasing dramatically. These price increases were largely due to a lack of rain and subsequent harvest failure. Livestock prices have been declining simultaneously as households have been selling animals. This has resulted in a dramatic decline in the livestock: grain ratio. A recent survey showed a catastrophic nutritional situation which has led to some population displacement. There is concern that without significant humanitarian intervention, this displacement could become widespread [IFRC 22/10/96, Oxfam 23/10/96].
Food security in the area has been declining for many years now as successive drought have led to large numbers of livestock death which has significantly affected animal husbandry activities. Furthermore, employment opportunities and wages have been declining while the gradual reduction in food availability has affected traditional coping strategies such as community sharing [Oxfam 23/10/96].
The survey found wasting among the displaced people around Sinkat at 47.8% with 7.8% severe wasting. Results of a survey carried out among displaced people in Tokar are not yet available, but are likely to be as high as those seen in Sinkat. Surveys conducted in rural areas among the non-displaced populations near Sinkat showed 30.4% wasting with 7.4% severe wasting (see Annex (12b-c)) [Oxfam 23/10/96].
Micro-nutrient deficiency diseases were noted in both Sinkat and Tokar provinces. These included a serious epidemic of vitamin A deficiency and high levels of anaemia. In addition, some cases of scurvy were noted as well as isolated cases of beri-beri. Immunisation coverage was low at 30% [Oxfam 23/11/96].
A follow-up visit to the region three weeks after the assessment discussed above revealed no change in the situation. Indeed, displacements to urban ares was continuing and increased population movements were expected. With the onset of winter rains, it is anticipated that the situation will deteriorate [IFRC 11/11/96].
Refugees from Ethiopia and Eritrea Repatriation of Ethiopian refugees from camps is almost completed, and the repatriation of refugees living outside the camps has begun. It is hoped that 100,000 Eritrean refugees will be repatriated in 1997 [USAID 12/11/96].
Overall, the affected population in the Red Sea Hills and the displaced population in camps around Khartoum are in category I in Table 1 due to micronutrient deficiencies and sharply elevated mortality rates. Large numbers of people in Bahr-el-Ghazal where high levels of wasting are evident are also at high risk (category I in Table 1). The remaining affected population in Southern Sudan can be considered to be at moderate risk (category IIb in Table 1) due to diarrhoeal diseases and on-going difficulties with food aid delivery. The refugee population in Sudan is not currently considered to be at heightened nutritional risk (category IIc in Table 1).
How can external agencies help?
Southern Sudan There is a continued need for rapid assessments and interventions following new displacements, with particular attention to Juba and Gongrial where the food situation is believed to be especially critical. Periodic outbreaks of measles indicate that efforts to improve immunisation coverage must remain a priority.
Continued insecurity is hindering implementation of rehabilitation programmes and in many areas completely preventing these activities. However, progress towards self-sufficiency can be made with the continuation of initiatives to provide agricultural inputs, which remain in short supply as well as technical assistance to farmers for improving cultivation methods.
The recent OLS review suggests a number of ways in Which response capacity can be improved. These include:
· a more aggressive pursuit of humanitarian access to war-affected populations;Red Sea Hills Extremely high levels of malnutrition, loss of traditional coping mechanisms coupled with severe food insecurity demand immediate intervention. The mortality risk of these populations is already very high and would only be increased if large numbers began crowding into camps for the internally displaced. Urgent intervention measures are therefore needed to deal with the existing problem and prevent a massive displacement. Some high priority interventions for the displaced would be:
· the use of relief/rehabilitation activities to strengthen coping capacities of local communities;
· strengthening integration between northern and southern sector programmes.
· a general ration of 440 gms cereal, 50 gms pulses, 20 gms of oil and 50 gms of fortified blended foods;Assistance to rural areas should include:· vitamin A capsule distributions;
· therapeutic feeding programmes to be implemented by the MOH but supported with donor resources;
· supplementary feeding programmes should admit all other children until wasting rates are below 25% at which stage these programmes should only feed those under 80% wt for ht. It may initially be optimal to establish on-site feeding given the immediate difficulties faced by the displaced in preparing nutritious foods;
· immunisation campaigns against measles as coverage is currently so low,
· shelter and blankets in Sinkat province.
· adequate general rations for all those in rural areas and rural towns;· support for destitute during the current agricultural season, e.g. transport to areas of cultivatable land and provision of agricultural inputs;
· strengthening health care provision in rural areas.
(see Map 13)There are approximately 429,800 refugees and internally displaced people in Uganda, broken down by country of origin as follows:
|
Origin |
Oct 95 |
Dec 95 |
Feb 96 |
Apr 96 |
Jun 96 |
Sep 96 |
Dec 96 |
|
Sudanese Refugees |
324,000 |
217,000 |
210,000 |
214,000 |
214,000 |
214,000 |
214,000 |
|
Internally Displaced Ugandans |
- |
- |
- |
- |
- |
20,000 |
200,000 |
|
Zairian Refugees |
13,700 |
11,800 |
12,300 |
12,300 |
12,300 |
15,800 |
15,800 |
|
TOTAL* |
337,400 |
228,800 |
222,300 |
226,300 |
226,300 |
249,800 |
429,800 |
* Rwandan refugees in Uganda are included in section #4.Insecurity in Northern Uganda is escalating, with two separate rebel movements operating. Their attacks against the population are causing massive displacement of Ugandans and Sudanese refugees, and the insecurity is hampering efforts of humanitarian relief agencies. It is now estimated that there are 200,000 internally displaced people. A major consequence of this displacement is that farmers cannot harvest their crops as they would normally be doing at this time. This has implications not only for the day-to-day survival of these people, but also for longer-term food security since they are not building up food stocks [DHA 04/12/96, WFP 29/11/96].
It has further been reported that many Sudanese refugees have been displaced from one camp to another. The growing insecurity has prompted changes in humanitarian aid delivery to these areas. Road transport has become dangerous, and most of the humanitarian aid is brought in by air, at a far greater cost [DHA 04/12/96].
There are no reports of change to the generally adequate and stable nutritional situation for the approximately 16,000 Zairian refugees in Uganda.
Overall, the Sudanese refugees and the internally displaced people in Northern Uganda can be considered to be at heightened nutritional risk due to escalating insecurity (category IIa in Table 1), while the Zairian refugees are not currently considered to be at heightened nutritional risk (category IIc in Table 1).
(see Map 14)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. 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. There are over 12,000 Ugandan refugees and a further 6,000 new arrivals whose refugee status unclear [UNHCR 17/01/96, 1995-1997].
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).
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].
There are 1,000 refugees newly arrived from Zaire [USAID 05/12/96]. No further details are currently available on this population.
