United Nations System
Standing Committee on Nutrition

RNIS 41, April 2003

GREAT LAKES REGION

Despite signs of progress in the DRC and Burundi crises, especially the signing of peace agreements between the parties in conflict, the situation on the ground has improved very slowly or has even worsened. The number of people fleeing the upsurge in violence in eastern DRC increased in late 2002 (see table). The decades-long destabilisation of the region is well reflected in the fact that a significant number of people from DRC, who are seeking refuge in Burundi, are the offspring of parents of Burundian origin or are themselves Burundian origin and had fled to DRC over the last 30 years (UNHCR, 23/01/03).

The number of refugees from DRC and Burundi in Tanzania and Uganda has also increased over the past six months (see table). In Uganda, renewed fighting in the north-east has led to an increase in the number of displaced persons (see table). On the other hand, the number of displaced persons has decreased in Burundi (see table).

Affected populations, Great Lakes Region, 2002 (OCHA, 31/01/03)

Burundi

In line with the stipulations of the Arusha peace agreement, Burundi's two major political parties, the UPRONA, which leads the Tutsi political family, and the FRODEBU, which is the biggest Hutu political party, signed an agreement at the end of March 2003. The current President, Pierre Buyoya from the UPRONA, will step down at the end of April and will be replaced by the current Vice President, Ndayiezeye, from the FRODEBU (GoSA, 30/03/03). However, despite the ceasefire agreements signed at the end of 2002 between the government and all rebel factions (except the FNL) fighting has intensified over the last months.

Refugees, returnees

As of 12 April 2003, since the beginning of the year UNHCR has reported 7,782 facilitated and 6,000 spontaneous returns (OCHA, 20/04/03). In addition, about 300 Congolese refugees entered the country in April 2003.

Food security and nutrition situation

The poor last harvests, compounded by insecurity, have led to an increase in the number of affected people. A UN inter-agency food and crop yields assessment mission indicated that the number of people in need of food aid in the first semester of 2003 has doubled compared to the same period last year (WFP, 11/03/03). A 19% fall in bean production has been reported; the next harvest might also be disrupted because of poor and delayed rains (OCHA, 30/03/03). Insecurity has hampered food distribution; at least 54,000 people did not receive any food distribution in February 2003 because of insecurity (WFP, 11/03/03).

FAO launched a seeds and tools distribution to 266,500 vulnerable households at the end of February 2003 (OCHA, 02/03/03).

The number of admissions to TFC has been reported to have increased in Ruyigi, Ngozi, Kayanza and Karuzi provinces (WFP, 11/03/03; MSF, 07/02/03).

Kayanza province

A nutrition assessment was carried out in Kayanza province (excluding Kayanza town and camps) in November 2002 (ACF-F, 11/02). The results showed that the prevalence of acute malnutrition was 7.1%, including 2.1% severe acute malnutrition. Although this prevalence is average, it is higher than in November 2001, when the rate of acute malnutrition was 3.9%. Crude and under-five mortality rates were respectively 0.32/10,000/day and 0.85/10,000/day. 114 infants aged 0 to 6 months have also been measured; 2.6% had a weight-height index < - 2 Z-scores, none had a weight-height index < -3 Z-scores. The measles vaccination coverage was estimated at 79% according to cards and 97.2% according to cards and mothers' statements.

Overall

The food security and nutrition situation in Burundi has deteriorated in the last few months (category II/III).

Democratic Republic of Congo

Despite the peace agreement signed between the government of DRC and two main rebel groups (the Congolese Rally for Democracy (RCD) and the Congolese Liberation Movement (MLC) in December 2002, and discussions held in late February 2003 to discuss details of the peace deal, fighting is still raging in eastern DRC. Atrocities against civilian populations have been reported (MONUC, 15/01/03; UNSC, 24/02/03). People are trying to escape the conflict by hiding in the forest or seeking refuge in nearby countries. The number of IDPs has increased from 2,275,000 to 2,706,993 over the last six months (OCHA, 31/01/03) (see map). The most affected provinces were North Kivu and Orientale provinces, where 500,000 have been displaced in the last six months. In addition, somewhere between 5,000 to 11,000 people (OCHA, 31/01/03) have recently sought refuge in Uganda, and about 10,000 have fled to Burundi (UNHCR, 23/01/03). At the beginning of the year, fighting was still on going near Bunia but WFP has been able to airlift food to Bunia town (WFP, 31/01/03).

A study done by the Henry Dunant Centre for Humanitarian Dialogue (HDCHD, 02/03) criticised the minimal political, military, and humanitarian response to the DRC crisis.

The study particularly noted that development activities have been more commonly implemented than life-saving actions, the latter being constrained by security, the complexity of the conflict, and above all the political considerations of the peace building agenda. The study also deplored the lack of detailed information on the affected populations, which has further impaired the adequate provision of humanitarian assistance.

North Kivu

Bwito, Rutshuru

The security situation has improved in the area since 2001 and has led to the return of the displaced population in 2002. A food security survey done by SCF-UK in November 2002 showed that the population has been able to carry out "normal" cultivation and petty trade (SCF-UK, 11/02). In 2002, crop production was 70% of pre-war level. However, livestock holdings, which were an important determinant of wealth before the war, have been almost entirely destroyed during the war. At the time of the survey, restocking was starting gradually. The wealth of the population was dependent on access to land, the livestock owned, and volume of beer produced for sale. It was estimated that 45-55% of the households were poor, whilst 30-40% were middle and 10-20% were better-off. The sources of food of the poor households were mainly purchase and labour exchange; 70-80% of their expenditure was going towards purchasing food. September, October and December (before the harvest) are traditionally the most difficult months for the poor households because food availability and job opportunities are reduced. At the time of the survey, the main constraints to food security were: poor access to land; poor access to markets in central and western DRC which has led to low prices of staple food produced in the area and high prices for imported goods; loss of livestock during the conflict and over-dependency on the agricultural sector.

Masisi

SCF-UK undertook a Household Economy Analysis survey in Masisi in November 2002, as an update of a 1999 survey (SCF-UK, 11/02).

The security situation has greatly improved in Masisi since 1999, which has led to the return of the displaced. Those whose areas of origin were not accessible have gathered into camps in eastern Masisi, but the majority of the displaced, who had already settled in the area in 1999, have returned to their area of origin while the remainder have integrated within the host community. Agriculture and petty trade were the main economic activities in the zone. Brewing, sale of wood and charcoal has intensified since 1999. Small livestock activities have also progressed significantly and cattle restocking was also starting. Humanitarian interventions were more common than in 1999; they were mainly directed towards infrastructure rehabilitation, provision of materials and medicines, and livestock activities.

The proportion of the different wealth groups has changed due to the improvement of the food security situation (see table). The observed decrease in the better-off group may be explained by their migration to more secure urban centres. The poor group was obtaining more food from their own production than in 1999, but food still represented a very significant part of their expenditure and they had very little flexibility in purchasing other items or services. Poor access to Kinshasa and Western Congo markets has led to great difficulties in the export of the food produced (food exportation was very high before the war) and therefore to low prices of the staple foods in the area.

The region was therefore considered as cash poor but not food deficient. It was estimated that if security situation remains stable, the food security may continue to improve.

Wealth groups, Masisi, North Kivu, DRC, 11/02 (SCF-UK, 11/02)

South Kivu

Fizi health zone

Since 2000, insecurity has prevented implementation of programmes by international NGOs in the zone. A nutrition survey was carried out in October 2002 (AAH-USA, 10/02); the sample only included areas where security allowed access (Baraka-Kandali, Baraka-Fizi axis). At the time of the survey, some health structures were functioning but were lacking medicines and materials, and water systems were not functional. Among the families surveyed, 27% were displaced. The prevalence of malnutrition caused concern; the severe malnutrition rate particularly was elevated by a high percentage of oedematous children (2.4%) (see table). According to MUAC measurements, 1.2% of the children's mothers were severely malnourished (MUAC < 190 mm) and 7.9% were moderately malnourished (MUAC >= 190 mm and < 210 mm). Measles vaccination coverage was very low (see table). The most recent cultivation seasons were poor, rainfall was inadequate, people were prevented by insecurity from cultivating fields distant from their villages, there were seed shortages. In addition, people were often obliged to move due to insecurity and lost assets during displacements. The overall situation in the zone seemed very precarious. Moreover, the survey only targeted villages where security conditions were adequate to allow the implementation of the survey; the situation of inaccessible populations may be even worse.

Results of nutrition surveys, DRC (AAH-USA, 10/02; 01/03)

¹ According to card or mother's statement

Maniema province

Kindu town

Maniema province has experienced a high level of civil unrest since 1998, which has led to large population movements. A nutrition survey carried out in Kazongo health zone at the end of last year showed that the malnutrition rate had doubled since February 2002 (see RNIS 40). Kindu town and surroundings have been the theatre of fighting between the RCD, which controls the town, and the Maïmaï. The town has become more and more isolated. Most of the railroads, waterways, and airlines have been closed and there were very few exchanges between Kindu town and surroundings.

A nutrition survey was carried out in Kindu town (excepting one area for security reasons) in January 2003 (AAH-USA, 01/03). Acute malnutrition, and especially the percentage of children who had oedema was very high (see table). Households where children have been measured have also been asked about mortality over the previous six months; the result showed that 12% of the under-five children and 5% of the whole population died during this period. The major causes of under-five mortality, according to mothers' statement were malnutrition (42%) and fever (38%). Even though this survey was not completely representative of the entire population because only the families which had an under-five years old child were selected, it showed that mortality in the past six months was very high and that the situation in Kindu town was very poor.

Some 23% of the households interviewed were displaced. The two major waves of arrivals in the town were in December 2000-January 2001 and August-September 2002. The food security of the population seemed very weak. All economic activities in Kindu have collapsed. Moreover, access to fields outside the town was very restricted due to volatile security conditions. The situation was however starting to improve at the time of the survey; transport by river and movements between Kindu and surroundings were increasing, and market prices were decreasing. WFP airlifted some food to the town in February 2003 (WFP, 07/03/03). It was hoped that people would be able to use the seeds they had been distributed and if the town continues to be less isolated, the food security situation may improve. However, it is very important that the food security situation be closely followed, especially for the poorest, given the prevailing high prevalence of malnutrition and the elevated number of deaths.

Kasai Oriental province

Kabinda, Kalonda and Lubao health zones

These areas are hosting large numbers of displaced persons. Three nutrition surveys have been carried out, in Kabinda, Kalonda and Lubao health zones respectively, in September 2002 (PSF, 09/02). The results showed discrepancies between the health zones (see table). Whilst the nutrition situation seems acceptable in Lubao, it is of concern in Kalonda, especially the high percentage of oedema. In Kabinda, a very high percentage of oedema was found (22.1%); if this high prevalence is confirmed, it shows an alarming situation. The NGO which performed the nutrition survey (PSF, Pharmaciens sans Frontières) does not have the capacity to implement a larger nutrition programme and is calling for additional agencies to help tackle the problem.

Malnutrition prevalence, Kabinda, Kalonda and Lubao health zones, Kasai Orientale, DRC, September 2002 (PSF, 09/02)

* Needs to be confirmed

Katanga

A measles epidemic has been declared in the areas of Kamina Lengue and Mukubu. MSF is in charge of a measles vaccination campaign (MSF, 06/03/03).

Malemba N'Kulu health zone

Malemba N'Kulu has had a high level of insecurity since 2001 and populations were displaced or isolated in villages. The security situation has improved since September 2002; and the populace has returned to their villages, but in their absence livestock, food stocks, and tools have been looted. Consequently, people have not been able to cultivate their fields, and insecurity has rending food exchange with other areas difficult. Most of the infrastructure has also been destroyed or looted. MSF was running a TFC and AAH-USA had implemented several supplementary feeding centres and was supporting some health centres. Access to health services overall was however very poor, as was access to safe drinking water.

A nutrition assessment was carried out in Lwamba, Lubinda and Musao health areas in November 2002 (AAH-USA, 11/02). About 95% of the families surveyed were residents who had been displaced during the fighting and 5% were displaced persons. The majority of the residents had spent one to three months in the bush and came back to the villages between September and November. MUAC measurements and presence of oedema were assessed among 956 6-59 months old children, randomly selected according to a cluster sampling methodology (30 clusters). The nutrition situation seemed average (see table). The number of admissions to the TFC has decreased over the last months.

Dilala and Manika health zones, Kolwezi district

Kolwezi district has not suffered very much from war and population displacement. However, the war in the rest of the country has had a major economic impact on the district. Before the war the economic activities were mostly mining in the urban area, and agriculture in the rural areas. This supplied the town. The mining industry not only gave jobs to the population but also caused the roads and other services to be maintained, which effectively provided a safety net to the vulnerable population. The mining industry has collapsed with the war, which has led to unemployment and loss of purchasing power in the town. The urban population is no longer able to purchase food from the rural population and now subsist by cultivating small plots and selling mineral scraps. The rural population conversely is now only producing food for their own consumption. A nutrition assessment was carried out by AAH-USA in January 2003 (AAH-USA, 01/03). MUAC measurements and presence of oedema were assessed among 900 6-59 months old children, randomly selected according to a cluster sampling methodology (30 clusters). The MUAC results showed an average situation, though the percentage of oedema was very high (see table).

Results of MUAC surveys, Katanga, DRC (AAH-USA, 11/02;01/03)

Bandudu province

Inongo

In contrast to the eastern provinces, Inongo area has not been hit by war. A nutrition assessment was carried out by AAH-USA in November 2002 (AAH-USA, 11/02). 1289 6-59 months old children were screened in Inongo town and in three villages; no children had oedema, 0.7% of the children had a MUAC < 110 mm, 2.5 % of the children had a MUAC < 120 mm and 5.3 % had a MUAC < 125 mm. The nutrition situation seemed acceptable. The main problem in the area was the very poor transportation infrastructure, which impaired the circulation of goods and people and limited access to health structures. Safe water availability was also very poor.

Overall

The situation in war-affected areas in DRC remains extremely poor (category II), despite some apparent advances in peace negotiations. For several reasons, inadequate numbers of life-saving programmes are being implemented.

Recommendations and priorities

From the SCF-UK survey in Bwito, Rutshuru, and Masisi, north Kivu:

Short-term:

• Distribute tools
• Increase availability and access to small livestock
• Rehabilitate roads to improve access to market and health centres
• Implement cash-for-work programmes and support alternative livelihoods activities in addition to agriculture
• Implement training/awareness-raising in conjunction with agricultural and livestock programmes

Long-term:

• Assess mechanisms for improving poor farmer's access to fair market prices for their produce
• Study areas for building local capacity to produce items currently imported regionally or internationally

From the AAH-USA survey in Fizzi health zone, South Kivu:

• Implement a nutrition programme
• Support health centres

From the AAH-USA survey in Kindu town, Maniema:

• Provide management of acute and severe malnutrition
• Harmonise the nutrition interventions between the different organisations involved

From the PSF surveys in Kabinda, Kalonda, and Lubao, Kasai Oriental:

• Implement a nutrition programme
• Carry out regular nutrition surveys
• Develop food security programmes

From the AAH-USA survey in Malemba N'Kulu, Katanga:

• Strengthen and follow-up the food security situation
• Continue the nutrition programme
• Support health care
• Support road rehabilitation

From the RNIS:

• Urgently undertake verification of oedema cases in Kabinda health zone and if a high prevalence is confirmed, immediately implement appropriate actions
• Support life-saving programmes

Uganda

Northern Uganda

Attempts to organise peace-talks between the government of Uganda and the LRA (Lord's Resistance Army) fighting movement have not succeed to date.

Despite a decline in the intensity of fighting, the situation remains highly precarious with difficulties accessing the estimated 800,000 IDPs in Gulu (395,000), Kitgum (99,000), Pader (271,000) and Lira (47,000) districts (OCHA, 31/01/03). People have not been able to prepare land adequately and plant, and will therefore have a poor harvests in August 2003; they will still be highly dependent on food aid for several more months.

WFP faced food aid shortages at the end of 2002/beginning of 2003: the cereal ration (which provides the bulk of the food ration) was reduced by 30% in the last quarter of 2002, and was totally suspended in January 2003 (OCHA, 31/01/03). However, donors responded positively to the emergency appeal launched by WFP in January 2003 for IDPs and refugees in northern Uganda. WFP has received 90% of the funds required to provide food to the affected population from January to June 2003. Cereal distributions resumed in IDP camps in February 2003 and pipeline is guaranteed until April 2003. However, food shortages are already expected by April 2003 (OCHA, 28/02/03).

Gulu district

A nutrition assessment was undertaken by WFP/MOH in two of the main IDP camps in Gulu district in January 2003 (WFP/MOH, 01/03). A systematic sampling methodology was used; 155 children were measured in Pabbo IDP camp and 114 children were measured in Anaka camp.

A high percentage of children were acutely malnourished, especially in Anaka camp. The percentage of children who had oedema was particularly high (see table) although the method for assessing oedema was not reported in the survey report. On the other hand, preliminary results of a screening carried out on 2047 children in 11 IDP camps in northern Uganda reported a far lower percentage of oedema (less than 1%) (AAH-USA, 02/03). The high prevalence of oedema found in Pabbo and Anaka IDP camps needs to be confirmed. Whatever, these assessments indicate that the nutrition situation of children in IDP camps in Gulu district is worrying.

The number of admissions to TFC has gradually increased over the last months; about 200 children were admitted to TFC in December 2002 compared to about 100 in January 2002 although TFCs are situated in hospitals which are far from some of the IDP camps. According to the survey, households were more dependent on their own sources of food than on the general distribution during the two months prior to the survey because of the disruption to the food distributions. About 50% of the IDPs had access to their own production, which was mainly cassava. Prevalence of diarrhoea and fever was particularly high (> 40%) in 6-59 month olds. Access to safe drinking water, adequate sanitation, and health services were also reported to be low.

Prevalence of acute malnutrition in two IDP camps in Gulu district, Uganda, January 2003 (WFP/MOH, 01/03)

Pader district

A joint emergency food needs assessment was carried out in 20 isolated IDP camps in Pader district in February 2003 (GoU, UN agencies, NGOs and Pader district authorities, 02/03). About 240,000 people were reported to be displaced (which accounted for 74% of the district's population) in 13 camps. The district was relatively spared by insecurity until mid 2002, when attacks from LRA spread out. As a consequence, the government of Uganda asked the population to gather in protected camps in September 2002. The camps were not prepared to receive such an influx of people and there was a lack of food, safe water points and health care.

The traditional and local council structures have been lost as people from the particular areas of origin dispersed to a variety of different camps. In addition, Pader district had only been created two years ago, and the capacity of the local administration is limited. The humanitarian capacity was also very restricted because of the presence of few NGOs, their limited capacity, and the insecurity.

The quality of health services was inadequate; a large number of qualified health staff have moved out of the district because of insecurity, and replenishment of drug stock has also been made difficult by the same insecurity. Safe water availability was low, and latrine coverage was only 7%. Both a therapeutic feeding centre and a supplementary feeding centre have been established at Kalongo hospital with the support of UNICEF and WFP. The district authorities also plan to open seven additional supplementary feeding centres and one therapeutic feeding centre.

The mission concluded that depending on which camp the displaced are settled in and the period they have been displaced, people experience different levels of vulnerability. Five categories have been defined: the host population; the old caseload IDPs, who have been displaced for 3-5 years; the new caseload IDPs, who were displaced from June 2002 onwards and integrated within the host community within the trading centres; the new caseload IDPs, who were displaced from June 2002 onwards and have settled into the camps; and the IDPs in transit who were in the process of establishing in the camps.

The host population and the old caseload IDPs were considered to be able to meet their food requirements by themselves, but they were more vulnerable than in the past in accessing basic services due to the new caseload IDPs. The other groups were considered to be food insecure and in need of food distribution, but a difference was drawn between IDPs living in the new camps and IDPs living in the old camps. The former were able to meet about 50% of their daily food requirements (defined as 2,100 Kcal/pers/day), whilst the latter are able to meet 60% of their daily food requirements (see table). The assessment however was carried out during the post-harvest period so the proportion of food people are able to access by their own means may decrease over the coming months.

Food sources in different camps, Pader District, Uganda, February 2003 (Joint assessment mission, 02/03)

Eastern Uganda

Karamoja (Kotido, Moroto and Nakapiripirit districts) was reported to suffer from high food insecurity because of the very poor 2002 harvest, which has led to low household food stocks and decreased market supplies. Some people have started moving to urban centres in search of work, which is however scarce. Agro-pastoralists have also moved in search of food, which will limit livestock product access in the area. Price of sorghum has risen significantly compared to years of good production. Households were selling livestock to earn income to purchase food, and terms of trade were worsening. The situation will probably worsen as the hunger period intensifies until June. There have been contradictory reports of hunger related deaths in the area. WFP has started to increase food distribution in the three affected districts (OCHA, 19/02/03).

As a consequence of the current crisis in Karamoja, some armed pastoralists have been raiding other communities, especially in Katakwi district. This district has suffered from intense raiding by Karamojong warriors over the past five years leading to population displacements. The raiding was particularly fierce in 2000 and resulted in the displacement of about 85,000 people into protected settlements, of whom 75,000 remained displaced in 2002. Raiding significantly decreased in 2002, bringing the hope of returnee among IDPs but unfortunately the food insecurity which Karamoja is currently facing is reviving the raiding. About 10,000 people have fled the recent raids. They are in need of food, water supply, shelter materials, and non-food items (OCHA, 31/01/03).

Refugees

An increasing number of arrivals in Moyo district from Sudan has been reported. Over 1,400 persons arrived in Morubi settlement in Moyo district in January 2003, compared to 110 in December 2002 (WFP, 28/02/03).

The upsurge in violence in eastern DRC has also caused several thousand people to cross the border with Uganda into Nebbi district. The security conditions in the district are volatile, as the conflict in DRC tends to spread into the neighbouring Ugandan district (OCHA, 12/02/03). UNHCR considers that only refugees who agree to be transferred to a designated refugee camp in Arua district should be assisted. UNHCR conducted an assessment in Nebbi and Arua district in November 2002. They estimated 5,000 people have sought refuge in these districts, of whom only 190 agreed to be relocated in a camp (OCHA, 31/01/03). On the other hand, an assessment done by IFRC in February 2003 estimated that at least 11,000 Congolese were settled in Nebbi district and commented that the real number may even be as high as 15,000 (IFRC, 20/02/03). Refugees were hosted with relatives or in public buildings. The reasons cited for unwillingness to move to the UNHCR designated camp were: the camp was too far from the border with DRC and refugees want to be near their area of origin to monitor the situation and reach their home to collect food and other items; some refugees have planted some crops in lands they obtained from the host community; some thought they could lose access to their livelihoods and lifestyle if moved to the camp. Overall, the majority preferred to receive services where they live. It seems that the Ugandan government has agreed with the provision of services to the refugees in this area. The public system is overwhelmed by the refugee influx. Major needs are provision of additional services such as water and sanitation installations, distribution of non-food items, and strengthening of the health facilities. These needs should be covered by IFRC and MSF Switzerland. No information has been received by RNIS concerning the food security and nutrition situation of the refugees.

Overall

The food security and nutrition situation is worrying in Gulu, Kitgum, Pader and Lira districts in northern Uganda, and in Karamoja and Katakwi districts in Eastern Uganda (category II).

Recommendations and priorities

From the WFP/MOH survey in two IDP camps in Gulu district:

• Provide a general full food ration
• Implement therapeutic feeding centres at camp level
• Provide supplementary food for moderately malnourished children, and pregnant and lactating women
• Strengthen IDPs food security by intensifying efforts to curtail rebel activities
• Strengthen public health measures: water, sanitation, and health services

From the joint mission in IDP camps in Pader district:

• Strengthen capacities to enhance delivery of humanitarian assistance
• Provide non-food items, including seeds and tools
• Distribute food
• Support health and nutrition activities by providing training and food
• Provide access to safe water
• Support education
• Provide psycho-social support