A fragile situation in Sudan: review of the 2001 nutritional situation

By Mutinta Nseluke-Hambayi

Mutinta Nseluke-Hambayi is a nutritionist who has been working as a Nutrition Emergency Officer for the past 3 years, supporting all WFP emergency and protracted related nutrition interventions in Sudan. Prior to 1999, she worked with the FAO Food Health and nutrition information system in Zambia. This article is a reflection of the complexity of nutrition programmes in humanitarian work.

The views expressed in this article are the authors' and do not represent those of the organisation.

Checking ration cards before food a distribution

WFP interventions in Sudan are guided by nutritional surveillance data provided by UNICEF and NGOs specialising in the health and nutrition sector. Based on such data a trend analysis showed a sharp rise in overall malnutrition rates in the second half of 2001. Prevalence figures rose from 10-15% for most locations in 1999, to 15-30% country-wide especially in the drought affected areas (figure 1). In conflictprone non-drought affected areas, malnutrition levels have fluctuated depending on the level of food aid receipts, the degree of security and seasonal effects (figure 2).

It appears that the nutritional gains achieved between 1999 to mid 2000 have been reversed by the interplay of heightened conflicts and raging drought that affected some parts of Sudan. This has resulted in widespread food insecurity, diseases and exhausted coping mechanisms. Deterioration has been especially pronounced in areas where insecurity has interrupted planned food aid deliveries. Some insecure areas such as those along the railway line of the Aweils, in Upper Nile, Eastern Equatorial, and Unity/Leech state now experience malnutrition rates between 25-30%, throughout the year.

In the Red Sea State where the drought has affected the entire state, there has been an annual deterioration since 1998. Inadequate provision of basic services such as health, water and poor sanitation throughout the Red Sea State remain an underlying complex of factors that prevent nutritional improvement.

These recent trends in nutrition also reflect national level factors which have had an impact on economic well-being including:

• the effects of the Structural Adjustment Programme
• reduced access to and provision of health services due to introduction of cost sharing schemes

Return to baseline levels of malnutrition will call for both higher levels of food aid distribution and relative stability to allow households to re-engage in livelihoods.

Typical situations are presented as scenarios 1-4.

Scenario 1

Unity State (an example of areas where continuous conflict and displacement hinders effective food aid programmes, e.g. Upper Nile, Jonglei)

Unity state

Unity State, an area prone to high levels of insecurity, has consistently shown very high rates of malnutrition (ACF 2001) since 1999. This situation has persisted throughout 2001. Overall global and severe malnutrition was reported for Bentiu at 30.7% and 4.1%; Rubkona 26.0% and 5.8%; Pariang 28.7% and 3.7%; Komagon 16.7% and 1.2%; and Tor 17.3% and 2.0% (ACF Feb 2001). Under five Mortality Rates ranged from 1.7/10000 to 4.1/10000 per day in Bentiu and Rubkona respectively. Children under three years comprise the majority of those severely malnourished. Limited information is available in non Government of Sudan (GoS) held areas of Unity (known as Western Upper Nile) although there are indications that the situation is serious and similar to Bentiu.

The major cause of malnutrition in the state is recurrent hostilities resulting in marked population movements, limited health service provision, disease epidemics, low vaccination coverage (52%), poor health and sanitary facilities, and limited access for humanitarian agencies. WFP supports one of the largest targeted and general ration programs in Unity state through NGOs implementing partners. However, insecurity in the area is an ongoing obstacle to the effectiveness of the food assistance. For example, WFP supports 54,000 beneficiaries in Bentiu. However, during 2001, food distributions were severely disrupted from June to August, coinciding with the hunger gap. Overall, food distributions were only possible for eight months of the year and therefore only achieved 66% of planned coverage for vulnerable households.

Scenario 2

Wau IDP camps (an example of areas where food aid programmes have been effective in controlling levels of malnutrition e.g. Kassala, Juba, Wau, S. Darfur IDP camps)

Wau IDP camps

Kapoeta, Food distribution in the war zone area. 98% women, men rarely seen.

WFP, working with implementing partners, succeeded in reducing malnutrition rates sharply, in the IDPs camps in Wau. Prevalence levels fell to under 15% during 1999 and to less than 10% in 2001 (ACF Jan 2001). In Wau town global and severe malnutrition rates went as low as 8.2% and 0.7% respectively; while Bariah camp registered a low of 7.0% global. This is an all time low since the height of the famine in 1998, when global malnutrition rates of over 45% were recorded in some of the worst affected areas of northern Bahr el Ghazal. In contrast, non GoS areas of Northern Bahr El Ghazal such as the Aweils continue to show unprecedented high levels of malnutrition. The highest levels of global and severe malnutrition are reported in Twic country 29%, and 4.5%; Aweil East 19.8% and 9.6%; Gogrial 17.5% and 2.3%.

In Wau IDP camps food aid remains a major controlling factor of levels of malnutrition such that levels rise dramatically even if food aid distributions are missed for one month only. Malnutrition levels are therefore highly sensitive to the degree of insecurity and accessibility of the camps to outside humanitarian agencies. In 2001 WFP distributed over 92% of estimated food requirements for 22,000 beneficiaries in Wau.

Scenario 3

Red Sea State (an example of a chronically drought affected area, e.g. Kordofan, Darfur)

Equatorial, WFP assisted school in war zone area, food pallets use

Malnutrition in the drought prone Red Sea has remained above 15% since 1998 and has been increasing annually. The highest rates of malnutrition for 2001 were reported in Halieb (28.3%), Tokar (23%) Sinkat and Rural Port Sudan at 17.8% each. This year severe malnutrition was above 5% for all provinces. The highest rates of severe malnutrition are in Halieb (8.3%), Sinkat (6.2%) Rural Port Sudan (6%) and Tokar (5.3%). Under nutrition amongst adults, measured by Body Mass Index of less than 16 (BMI <16)¹ and a sign of chronic energy deficiency, was investigated and revealed to be high. Overall, in Red Sea State, a quarter (25.6%) of women are underweight of whom nearly one in every ten (9.7%) is severely malnourished. In Sinkat alone nearly half of women (45.6%) are underweight, followed by Halieb 37.8%, Tokar 21.6% and 16% in Rural Port Sudan (MOH /OXFAM Nutrition Survey April/Sept 2001). Currently all provinces, with the exception of Red Sea Province, are in a critical situation and one which has persisted for the past 3 years. Among the provinces, Halieb has the worst indications for both adult and child malnutrition. A recent assessment (July 2001), observed women to be very thin, anaemic and lethargic. Micro-nutrient deficiencies were also evident. For instance angular stomatitis was observed while biotot spots was common in children. There is no doubt that the nutritional situation for the population of the Red Sea State is deteriorating, especially for Halieb and Tokar states. The multiple causes include reduced dietary intake, high disease prevalence and eroded livelihoods.

A series of state-wide joint assessment missions in February and July and the annual needs assessment of November 2001 have been key determinants of a WFP response. The assessments highlighted increasing vulnerability with depletion of assets and exhaustion of survival strategies. Terminal migration of entire families to urban centres was dramatic evidence of the desperation of large numbers of people.

In response to the nutritional and food security assessment data, WFP supported 238,038 beneficiaries with full rations (through implementing partners), providing a total of 15, 500 MT of food aid from August through to December 2001.

Scenario 4

Transitional Zones (for example, Khartoum, White Nile, Malakal and S. Darfur camps)

White Nile

Transitional zones encompass camps with long term internally displaced persons (IDPs) residing in one place for 5-10 years. IDPs in transitional zones subsist mainly from the urban economy because the camps are usually located in and around urban centres. Typically, sanitation and housing is very poor leading to diarrhoeal diseases, especially during the rainy season. In all camps with recent data, malnutrition rates range between 15-19% and fluctuate seasonally. The main cause of malnutrition is repeated disease episodes.

WFP assistance for these zones focuses on collaborative initiatives with the Ministry of Health, town planning and UNICEF to improve health and sanitation, e.g. pit latrine construction and training of women in health, nutrition and hygiene. Vulnerable group feeding is also undertaken during the rainy seasons to mitigate the impact of disease. Food for work and food for training is the major modality of WFP assistance.

The Outlook

This review of recent nutritional data and trends reaffirms that causes of malnutrition are ever changing in Sudan and that one intervention policy is not a prototype solution for everywhere. The data also show where interventions are succeeding and where more needs to be done.

In the short-term the nutritional outlook remains alarmingly fragile for many areas with possible further deterioration in places like Unity State. The data show that timely food aid interventions can play a key role in improving and maintaining nutritional status. However, the data also show that this can only address part of the problem as insecurity continues to undermine livelihood systems and prevents access by humanitarian agencies while poor health, water and sanitation services contribute to an unacceptable disease burden. At the same time economic and social service policies at government level do little to improve the situation.

For further information contact Mutinta.Hambayi@wfp.org

¹BMI - weight (kg)/squared height (meters). WHO Cut off points: (<9%) Low BMI - warning, (10-19%) poor, (>20%) critical situation