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RNIS 43, November 2003 SUB-SAHARAN AFRICA
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| Survey Area | Date | % Acute Malnutrition (95% CI) |
% Severe Acute Malnutrition (95% CI) |
Mothers' BMI < 18.5 |
Mothers' BMI < 16 |
| Asmat, Hagaz and Habero, Anseba | 03-03 | 19.9 (16.9-23.2) | 2 (1.1-3.5) | 52.5% | 11.3% |
| Dekemhare, Mendefera, Dwarwa, Segheneyti and Azera, Debub | 06-03 | 13.1 (12.1-15.5) | 2.2 (1.4-3.4) | 37.1% | 5.4% |
People in the area are mostly reliant on agriculture and experienced a very bad harvest in 2002. About half of the households surveyed reported having received food aid the month prior to the survey. On average, the amount of cereal received was 243 g/pers/day, which is only about half the full cereal ration. The main coping strategies of the population were food aid, borrowing from relatives and casual labour.
Access to clean water was scarce, with only about 10% of the households having access to clean water. The average amount of water available was low: 16 litres/pers/day. Health facilities were reported to be located far from villages and to suffer from a lack of medicines. Child feeding practices were average (see box).
Breast-feeding and complementary feeding practices, Debub, Eritrea (CRS, 06/03)
| Starting breast-feeding within one hour of delivery: 53% Starting breast-feeding within 24 hours of delivery: 72% Exclusive breast-feeding for six months: 75% 94% of the 6-12 month olds were breast-fed |
Overall
The nutrition situation does not seem to have improved in 2003 (category II). The expected average next harvest will probably temper the food insecurity for some months, but food aid will probably still be required in 2004.
Food assistance has improved over the last months, with close to 100% of requirements delivered in July, August and September (FEWS, 16/10/03). The Meher agricultural production is expected to be average when compared to the years 1994-2001, and 20% higher than in 2002 (FEWS, 06/10/03). Livestock is reported to be in good condition because of the improved access to water and pasture during the rainy season (FEWS, 16/10/03). These good prospects are expected to mitigate the current food security crisis, but food distributions will still be necessary in 2004.
Negative long-term prospects in food security
A survey carried out in Wollo, Amhara Region, showed that destitution has increased over the past ten years, according to the communities and households (IDS/SCF, 04/03). They estimated that destitute and vulnerable households have increased from 5.5% to 14.6% and from 17.4% to 54.9%, respectively, over the past ten years. Most of the households are highly dependent on rain-fed agriculture and the poorest face many resource constraints such as land, livestock, labour, inputs or credits. They are highly vulnerable to shocks such as poor rainfall or loss of work force and recover from them with difficulty.
FEWS estimates that food shortage will increase over the next few years, because of slowly decreasing rainfall and steadily increasing food requirements (FEWS, 06/10/03).
Both reports recommend the development of non-agricultural livelihood activities, and the IDS/SCF report also recommends investment in physical infrastructure and public services and in social protection.
Nutrition situation
A nutrition survey carried out in the rural area of Admitulo district, East Shoa, Oromia region, in October 2003, showed an average nutrition situation (MSF-H, 10/03). The prevalence of acute malnutrition was 7.1% (4.9-9.2), including 1% severe malnutrition (0.3-1.3), and had steadily decreased since the last survey done in June 2003 (see figure). Under-five and crude mortality rates were under control (0.48/10,000/day and 0.83/10,000/day, respectively). Food distributions have been carried out since February 2003, blanket supplementary feeding since May 2003 and therapeutic and supplementary feeding programmes have been intensified since June 2003. Food distributions were, however, irregular, with oil and Famix irregularly distributed. Food distributions stopped in September 2003. The Meher crop was estimated to be generally good in the area and, at the time of the survey, food availability had already improved.
Acute malnutrition, Admitulo district, East Shoa, Oromia, 2003
Following appalling rates of malnutrition and mortality found in April 2003 (see RNIS 42) in Fik zone, Somali region, food distributions have been increased both in terms of number of beneficiaries and of ration scale; a blanket feeding programme has been implemented for under-five year olds; and supplementary and therapeutic feeding programmes have been put in place.
Exhaustive nutrition assessments were carried out in two settlements (Abrihijira and Abdurafi) of the resettlement programme of the Ethiopian government in Western Tigray, in October 2003 (MSF-H, 10/03). The prevalence of acute malnutrition was dramatically high: 36.4% acute malnutrition, including 13.2% severe malnutrition in Abrihijira; 24.7% acute malnutrition, including 6.8% severe malnutrition in Abdurafi.
A nutrition survey was conducted in Offa Woreda, Wolayita zone, Southern Nation and Nationalities People's Region (SNNPR), in September 2003 (Concern, 09/03). The nutrition situation was of concern (see table) and had remained stable since May 2003. The under-five and crude mortality rates were average (see table) and measles immunisation coverage was low.
Prevalence of malnutrition, Offa woreda, Wolayita zone, SNNPR, Ethiopia, September 2003 (Concern, 09/03)
| % Acute Malnutrition (95% CI) |
% Severe Acute Malnutrition (95% CI) |
Crude Mortality (/10,000/day) |
Under 5 Mortality (/10,000/day) |
| 19.4 (16.9-22.2) | 1.3 (0.7-2.4) | 0.5 | 1.6 |
Most of the households interviewed were eating three meals a day (64.4%), whilst 31.1% were eating two meals and 2.2% were eating one meal. The number of meals eaten was reported to have increased when compared to May 2003, especially because of the availability of "temporary food", such as sweet potatoes, green maize and vegetables, during the rainy season. The main source of staple food was own production (82.2% of the families interviewed), followed by purchase (13.3%); 25.3% of the households had received food aid.
Overall
The nutrition situation seemed mixed, with reported improvement in some areas, but still critical rates in some others. The meher agricultural season is expected to improve food security in Ethiopia. However, long-term destitution and heavy reliance on rain-fed agriculture in some areas are key factors of vulnerability. Only long-term strategies will be able to reverse the impoverishment of the population.
Refugee camps in Dadaab
The three refugee camps, Ifo, Daghaley and Hagadera, located around Dadaab town in Garissa district, were established in 1991 and 1992. The camps host about 130,000 refugees, mainly from Somalia.
A random sampled nutrition survey was carried out in the three camps in June 2003 (MSF-B, 06/03). The prevalence of acute malnutrition was 23.9% (20.0-27.7) including 3.7% (2.5-4.9) severe acute malnutrition. The prevalence of malnutrition has remained high since 1997 and has increased significantly since last year (see graph).
Prevalence of acute malnutrition, Dadaab refugee camps, Kenya
A retrospective mortality survey was also carried out. The results showed a high under-five mortality rate (2.1/10,000/day), whilst crude mortality rate remained under-control (0.5/10,000/day). These results were not in accordance with the results of the mortality routine surveillance, which showed lower mortality rates.
Household food security seems to be precarious, with the majority of the refugees having few income opportunities (see box).
Household food security and public health environment, Dadaab camps
| Household food security Food distribution Intended full ration distributions (2,100 Kcal) But, irregular distributions (see graph) Sources of food Access to wild food, livestock or agriculture is negligible Sources of income Sale of food aid to diversify the diet and buy essential non food items Wealth groups Rich: traders owning cereal grinding meals; 5-15% of the population Better-off: traders and incentive workers; 10-15% of the population Middle: small traders; 15% of the population Less poor: daily workers; 15-20% of the population Poor: no access to regular income; 35-45% of the population Assets Public health |
The main constraints to income opportunities are arid environment, government policy which restricts freedom of movement and lack of employment opportunities. Moreover, at the beginning of 2003, food distributions were lower than the intended full food ration, as recorded by food basket monitoring (GTZ, 08/03) (see graph).
Food distribution, Dadaab refugee camps, Kenya, 2003 (GTZ, 08/03)
Overall
Malnutrition rates are unacceptably high in Dadaab camps (category II). Refugees, and especially the poorest are highly dependent on external aid. Donors should ensure that adequate food rations and basic items are regularly provided to the refugees.
The Somali reconciliation conference, attended by representatives of the Transitional Government (TNG), armed factions, which control different parts of Somalia, the regional administration of Puntland and civil society groups, are on-going, without significant advancements.
The security situation is still extremely tense (OCHA, 07/10/03; IRIN, 16/10/03).
Southern Somalia
Gu cereal production and Deyr rainy season performance
The Gu cereal production is estimated to be 25% less than in 2002 and 8% less than the post-war average (see table). Key factors contributing to a decline in production are: erratic rainfall, pest infestations, insecurity and poor irrigation infrastructures (FSAU/FS, 10/03).
The Deyr rainy season has started unfavourably in most parts of Somalia, except in Lower and Middle Juba (FEWS, 12/11/03).
Gu cereal production, southern Somalia, November 2003(FSAU/FS, 10/03)
| Regions | 2002 crop harvest as a % of 1995-2001 average |
2003 crop harvest as a % of 1995-2002 average |
| Hiran | -89% | -86% |
| Bakool | -65% | -89% |
| Gedo | -53% | -42% |
| Lower Juba | -15% | -15% |
| Middle Juba | -6% | -56% |
| Middle Shabelle | +26% | -5% |
| Bay | +47% | -36% |
| Lower Shabelle | +55% | +34% |
| Total | +28% | -8% |
Western Jilib, Juba valley
Several assessments reported high rates of malnutrition and oedema in villages along the Juba river in June-July 2003. The same pattern had been reported in 2002. An MSF assessment reported that, in Marere, 26 children had died in one week from oedema. It seems that the occurrence of oedema was strongly linked to food scarcity (children were mostly fed with mangoes and maize occasionally) and a measles outbreak (MSF-H, 06/03). A MUAC assessment carried out by the FSAU at the end of July 2003 confirmed the alarming situation (see table). The assessment also found that staple food, such as plantains and pumpkins, had been unavailable since the beginning of the year, that fishing was restricted by limited fishing equipment and drought, and that wild food was also scarce. The poorest households were mainly reliant on mangoes. A TFC has been established by MSF-H.
A follow-up assessment in October 2003, showed an improvement of the situation (see table). Food security had improved with the Gu harvest and replenishment of water- ways, which improved fishing access; sources of employment had also increased. The measles outbreak was under-control.
MUAC assessments, Western Jilib (FSAU/N, 08/03; FSAU/N, 10/03)
| Date | Number of children screened |
MUAC < 11 cm and/or oedema |
MUAC < 12.5 cm and/or oedema |
Oedema |
| July 2003 | 571 | 8 % | 28.0% | 7% |
| October 2003 | 455 | 1.3 % | 14.0% | 0% |
Beletweyne district, Hiran
The 2002 Gu harvest was poor but the 2002 Deyr harvest was the best since 1997. However, the Gu 2003 rains were below normal in the area. A nutrition survey was undertaken in July 2003 and revealed worrying rates of malnutrition ( 17.1% (14%-20.9%) acute malnutrition, including 2.3% (1.5-3.6) severe acute malnutrition), which had not improved over the past years (see figure) (UNICEF/FSAU, 07/03). Mortality rates were also high; crude and under-five mortality rates were 1.43/10,000/day and 3.5/10,000/day, respectively. Poor households were reported to be unable to purchase sufficient amounts of cereals. The different interventions which had been established since the beginning of 2003, such as supplementary feeding programmes, including targeted food distribution for the families with malnourished children, intensified health service provision, and improved access to safe drinking water, do not seem to have had a major impact on the nutrition situation.
Prevalence of acute malnutrition, Belet Weyne district, Hiran, Somalia, 1996-2000
Northern Somalia
IDPs and refugees in Bossaso
An exhaustive nutrition survey was conducted in the "IDPs" settlements in Bossaso town, in August 2003 (UNICEF, 08/03). The survey revealed that 45.1% of the families were refugees from Ethiopia, the others were displaced families, mainly originating from southern Somalia. About half of the households had arrived before 1998. The nutrition situation was precarious: 16.2% of the children were acutely malnourished, including 3.2% severely malnourished. The nutrition situation had deteriorated since 2000 (see figure). About 58% of the children had been vaccinated against measles, according to cards and mothers' statements.
Prevalence of acute malnutrition, IDPs/refugees Bossaso, Somalia, 2000-2003
Nearly all of the IDPs/refugees were relying on purchasing as their source of food.
Casual employment, such as porters, loading/unloading at the seaport/shops, workers at construction sites, was the main source of livelihood. Different factors have recently affected the livelihood of the IDPs/refugees: reduction in the port activity as a result of a livestock band imposed in September 2000 by the Gulf States, inflation, and increased rural urban migration occasioned by drought. It seems that in 2003 the food security situation should have improved because of a boost in livestock exchange and in the construction sector. However, this was probably not sufficient to significantly improve the nutrition situation. Moreover, the nutrition survey was carried out during the months when there was much less activity at the sea-port.
Coping strategies included borrowing for 86% of the households, followed by begging (10%) and food aid (9%).
The population relied on tanker/truck vendors (46%), protected wells (26%) and berkads (21%) as sources of drinking water. Sanitation facilities were inadequate.
Only half of the 6-24 month olds were still breast-feeding and 70% of the children received complementary food before 6 months; 52% of the children were fed four times or more and 42% were fed three times.
Hawd of Togdheer
The area is mainly pastoralist. Land degradation has led to a reduction in livestock over the past ten years. Overall, it is estimated that livestock has declined by 45%; cattle have experienced the greatest drop with a 95% decline. However, at the time of the survey, livestock condition was good and the terms of trade were favourable to the pastoralist. A nutrition survey carried out in August 2003 showed that the nutrition situation was average: 10% (8.1-12.1) acute malnutrition, including 1.3% (0.7-2.4) severe acute malnutrition (FSAU/MOHL/SRCS, 08/03). Under-five and crude mortality rates were 2/10,000/day and 0.83/10,000/day, respectively. The food security situation was mixed, with a reduction in livestock over the past years, but with an average situation at the time of the survey (see box). Health care, water availability and child feeding practices were inadequate (see box). The nutrition situation was in the same range as in the neighbouring area, hawd of Hargeisa, as assessed by a survey conducted in June 2002.
Food security, public health and child feeding practices, Hawd of Togdheer, August 2003 (FSAU/MOHL/SRCS, 08/03)
| Food security Food availability and access Cereals and milk Few vegetables/fruits Sources of food Purchase:75.4% Own animal/product:16.9% Sources of income Small business: 33.2% Sale of animal and animal products:25% Casual work:18.7% Coping strategies Social support: 35.2% Remittances: 29.6% Sale of more livestock: 27.5% Wealth group Poor: 20-35% of the population Middle: 45-55% Better-off: 10-25% Rich: 2.5% Trends Decrease in livestock over the last decade Over the past 5 years, alternate normal and bad years Public health Sanitation Child feeding practices |
Sool plateau
The failure of the deyr rainy season will further worsen the precarious situation in the Sool plateau (see RNIS 42). A targeted response has been implemented with food distributions to 1,200 families and supplementary feeding (FSAU/N, 08/03). The Plateau has experienced a four-year drought, which has led to livestock deaths, to a drop in livestock reproduction, and to a decrease in milk availability. The purchasing power of the population has decreased dramatically, although cereals are available in the market. Even if the next Gu season (due by April 2004) is normal, the population will need some time to recover. The situation will therefore not improve for several months (FEWS, 12/11/03).
As a primary intervention, an inter-agency assessment recommends a cash-based response to improve populations' access to food which is available in the area; if not possible, a food-based intervention should be envisaged.
Overall
High rates of malnutrition are still recorded in the south of the country and among displaced and refugee populations (category I/II). The pastoralist has also experienced hardship conditions, with a high loss of livestock.
Recommendations:
From the FSAU assessment in Jilib:
The peace deal between the government of Sudan and the Sudan People's Liberation Movement/Army (SPLM/A) continues. Both parties have recently come to an agreement regarding the deployment and the size of their respective forces (AFP, 24/09/03). The security situation, however, remains tense on the ground.
The food security situation was expected to improve following the sorghum harvest in late September/October (FEWS, 27/10/03). WFP was only able to deliver 44% of the food aid planed in August 2003 (WFP, 08/03).
UNICEF reported a steady worsening of the nutrition situation from 2001 to 2003, especially in Bahr-el-Ghazal and Upper Nile, as shown by the review of nutrition survey results (UNICEF-S, 08/03).
Darfur
There has been an upsurge in violence in Darfur, western Sudan, over the past months. The Sudan Liberation Movement/Army (SLM/A) took up arms against the government in March 2003 (OCHA, 17/10/03). In addition to this, there have also been regular raids from Arab nomad militia on sedentary populations; attacks have been widespread and villages have been burned and looted (IRIN, 03/10/03). As of November 2003, it was estimated that, since February 2003, 500,000 to 600,000 people had been displaced in Darfur and that an additional 70,000 had fled to Chad (UNICEF, 10/11/03).
A cease-fire agreement between the Government of Karthoum and the SLM/A was signed at the beginning of September and was renewed for one month at the beginning of November (IRIN, 5/11/03). Humanitarian access has improved since the signing of the cease-fire agreement, but remains difficult because of insecurity and a complicated system of travel permits; some areas are totally inaccessible (IRIN, 03/10/03; UNCEF, 10/11/03). Assessments and adequate provision of assistance have therefore been limited.
WFP has, however, begun to distribute food in the most accessible areas, but has faced serious security constraints; a food convoy was attacked in October (WFP, 03/10/03; WFP, 31/10/03)
IDPs
An assessment, carried out in early October 2003, around Mukjar in West Darfur showed that the displaced persons and the host population faced appalling living conditions (MEDAIR, 10/03). There were an estimated 31,100 IDPs and 7,000 residents. The IDPs fled after their villages were raided and they have lost all their belongings and livestock. The security situation in the area was tense. Sanitation was almost non-existent; access to water was inadequate with most of the people digging water from the river; there was no health facility and food provided by the host population and the locality had run out. Screening among under-five year olds showed a high number of malnourished children. Of 902 children screened, 11% had a MUAC < 110 mm, and 29% had a MUAC between 110 mm and 125 mm.
Refugees in Chad
There are an estimated 70,000 refugees from Darfur scattered in 20 locations over 600 kms along the Sudan-Chad border. The area is unsafe, with reported incursions of raiders from Sudan (UNHCR, 09/10/03). Delivery of assistance to the refugees has been slow to start and refugees, settled among host populations, have been living in hardship conditions; they have had no shelter, no access to water, apart from digging from the river, and very little access to food and health care (MSF, 08/10/03). Malnutrition cases seemed to be on the rise (MSF, 08/10/03). Some food and non-food item distributions, and provision of medical care have been implemented recently (MSF, 30/09/03; UNHCR, 30/10/03). The remoteness of the area and the rainy season make access to the refugees difficult. UNHCR was working to find a suitable location to resettle the refugees (UNHCR, 09/10/03).
Eastern Equatoria
An assessment was carried out in seven villages in Lafon Rural Council, Imotong province in August 2003 (ACF-F, 08/03). Lafon Rural Council is an enclave controlled by the government of Karthoum. Of 621 children screened, 157 (25.3%) were moderately malnourished and 42 (6.8%) were severely malnourished. Populations rely mainly on livestock and small-scale agriculture; about 20% of the population received a three-month half ration of cereals in June 2003. There is a community health worker in each village, but the drug supply is limited.
Bhar el Ghazal
Two random sampled nutrition surveys were conducted in Gogrial county and Tonj county in May 2003 (WV, 05/03; WV, 05/03). The results showed a serious situation in Tonj, and a dramatic high prevalence of malnutrition in Gogrial (see table). In both counties, but especially in Gogrial, the nutrition situation has worsened over the past years and the prevalence of malnutrition recorded in the current surveys were higher (two fold higher in Gogrial) than any recorded from 1994 until 1999, except during the famine in 1998. 22.2% acute malnutrition, including 4% severe malnutrition was reported in Aweil East in June 2003 (WFP, 08/03).
Prevalence of acute malnutrition, Bhar el Gazal, Sudan, May 2003 (WV, 05/03)
| Survey Area | % Acute Malnutrition (95% CI) |
% Severe Acute Malnutrition (95% CI) |
| Thiet, Pagol, Warrap and Tonj payams, Tonj county |
20.1 (17.6-22.9) | 3.5 (2.5-5.0) |
| Toch and Pathuon payams, Gogrial county |
32.0 (29.0-35.1) | 5.3 (4.0-6.9) |
Eastern Upper Nile
A nutrition survey, carried out in Maban Province, Latjor State, in August 2003, revealed a nutrition situation of concern and appalling mortality rates (see table) (AAH-USA, 08/03). The main causes of under-five mortality were bloody diarrhoea, malnutrition and fever. None of the children surveyed seemed to have received measles vaccination. The area has been relatively safe for years. The survey was done during the hunger-gap period, but about three-quarters of the population had received a 75% cereal ration in July. The area is fertile and agriculture is the main source of food and income, completed by livestock. There is one health centre in the area providing curative care. Access to water is inadequate as are the sanitary conditions.
Prevalence of acute malnutrition, Eastern Upper Nile, Sudan, August 2003 (AAH-USA, 08/03)
| % Acute Malnutrition (95% CI) |
% Severe Acute Malnutrition (95% CI) |
Crude Mortality (/10,000/day) |
Under 5 Mortality (/10,000/day) |
| 13.1 (9.8-17.1) | 1.9 (0.8-4.1) | 4.4 | 8.9 |
Overall
According to the nutrition survey results made available to RNIS, the nutrition situation was still serious in Sudan (category I/II). A new crisis has emerged both among internally displaced people in Darfur, and in Chad where there are refugees. They are thought to have a high risk of malnutrition (category I), unless adequate assistance is provided. Funds are urgently required.
Recommendation:
From UNICEF
United Nations System