Chad + 1 more

Strengthen the WHO presence in Eastern Chad to protect the health of the Sudanese refugees and the resident population

Context and background
The humanitarian crisis in the Darfur states of western Sudan has spilled over into neighbouring Chad. Since July 2003, more than 180,000 Sudanese refugees have crossed the largely unguarded 1,350-km border separating the two countries. So far, more than 140,000 refugees have moved to camps away from the border. The total combined (refugee and local) population in of the principally affected regions of Biltine and Ouaddai is 867,000. However, approximately one-third of this population is nomadic so numbers shift considerably by district. The land is very arid. The rainy-season starts in mid- May in southern areas, and late July in northern areas. It normally lasts around three months. Throughout the rainy period, dry wadis become impassable torrents cutting road access to the refugee-affected areas.

Problem assessment

Current evidence suggests that refugees are experiencing crisis conditions with difficulties in fulfilling their basic needs for water (and sanitation), food, shelter and public health services in many camp sites. These conditions have increased the risk factors for ill-health among refugees in at least some settlements. Risk factors include limited amounts of potable water, low standards of environmental hygiene, declining nutritional status, and low vaccination coverage. Both the refugee and local host populations are at risk. Principal causes of disease among both groups, now, are Acute Respiratory Infections, Diarrhoeal diseases, Malaria and conflict-related trauma. So far, the crude mortality rate is reported to be in the order of 1/10,000. The risk of outbreaks of communicable diseases is, however, particularly high. Polio and meningitis and suspect cases of yellow fever have been reported from within Chad recently.

Despite the fact that most of the refugees are of nomadic origin and, in normal circumstances, able to survive even extreme climatic conditions, the effectiveness of existing coping mechanisms continues to diminish. Inadequate food availability and the lack of local water supply, both in quantity and quality, are the principal physical factors impacting on the health and nutritional status of these populations. Water and sanitation issues are of the highest concern. It is clear that the refugee influx has resulted in further pressure on already scarce water resources in a very fragile and complex ecological system.

An inter-agency survey nutrition was conducted in mid-June - in conjunction with CDC Atlanta - in three refugee camps and in the border area of Bahai. The final report on the survey is not yet available, but preliminary findings indicate a serious crisis, with malnutrition among 36 to 39 percent of refugee children under five years of age. High levels (35 per cent) of malnutrition were also found among the local Chadian population. The survey also detected low levels of measles immunization among refugees at the border and high rates of diarrhoeal diseases. Indeed, much of the malnutrition reflects interaction between nutrition and illness, and the recommendations following the survey include:

- Increase and expand supplemental and therapeutic feeding programs

- Increase the general food ration for the entire refugee population.

- Expand measles vaccination to children ages 6 months to 15 years.

- Increase prevention and treatment of Malaria and Acute Respiratory Infections (ARI).

- Support the referral system to reduce maternal mortality.

- Increase treatment and prevention of diarrhoeal diseases.

- Increase water, shelter, sanitation and health services.

International response

In addition to WHO, UNHCR, UNICEF, WFP, IFRC and various international NGOs have been active in the field since the beginning of the crisis. They have worked to provide shelter, food, relief items and first medical aid. Main international organization opened field offices in Abeche. UNICEF organized a measles campaign coupled with Vitamin A distribution for refugee and host community children. MSF, Action Against Hunger and other international NGOs are addressing the basic health and nutritional needs of the affected population.

WHO response

The country office conducted a preliminary rapid health assessment along the Chad-Sudan border in October 2003. A broader health assessment was performed in late February 2004. The assessment findings showed the need of strengthening public health actions in the area affected by the refugee influx to improve the control of communicable diseases, and strengthen the coordination of the international health assistance. As immediate action, WHO seconded to UNHCR a Public Health Officer with the aim of improving the health coordination mechanism in Eastern Chad and establish a standard system for the surveillance of most dangerous communicable diseases. Since then, a surveillance system has been agreed upon and implemented by the major health agencies in collaboration with the national health authorities, a basic coordination mechanism has been set up and health assessments are systematically conducted. However, the above mechanisms are still very fragile and need continuous supervision and follow-up. WHO also provided technical advice for the implementation of a mass measles vaccination campaign implemented by UNICEF.

WHO plans

The priorities, now, are: (1) to improve the regularity and reliability of reports through better disease surveillance and health assessments among the refugee community, in ways that involve all national, NGO and UN health stakeholders; (2) to reduce the fragility of coordination (and joint working) among different groups, so that health coordination meetings in Abeche and other centres are regular and well attended; and (3) to identify gaps in the response to ill-health among the refugees, and initiate prompt and effective action to fill these gaps.

WHO will contribute to these priorities through establishing a team - and satellite office base - in Abeche before the end of August 2004. The team would work with national, NGO and UN stakeholders to address the major public health concerns related to the crisis. The specific focus will be on improving the effectiveness of the existing health coordination mechanisms and strengthened systems for surveillance disease - with emphasis on communicable diseases, health conditions faced by women and environmental health risks.

This work will be undertaken in strict operative collaboration with the WHO offices working in Darfur, particularly the office in Al Geneina.

Hence, the immediate tasks envisaged for the WHO team and satellite office base in Abeche are:

  • Strengthen coordination of international health humanitarian assistance, optimizing available resources and liaising/streamlining international programmes to national strategies.

    - Output: WHO participation in and facilitation of weekly coordination meetings (at locations that are suitable and convenient for participants) with records, points for joint action, and follow-up in Abeche and in camps.

  • Improve the health information management directly performing health assessment and collecting, analysing and disseminating available health data.

    - Output: Weekly morbidity and mortality reports with forecasts under different scenarios, and identification of health priorities, to be discussed and agreed at co-ordination meetings.

  • Enhance communicable disease prevention and control monitoring and following up on the existing surveillance system, providing technical advice for outbreak management and regularly producing data on crude mortality.

    - Output: Analysis of public health issues and follow-up responses including investigation of specific concerns and focused action to reduce morbidity and mortality.

  • Supplies of medicines and medical items as required.

  • Continuous technical advice, capacity building, and support to national health authorities and other stakeholders.

    - Output: Support for both the recovery and improved competencies of health services in the affected region, including support for critical national individuals and groups via WHO expert missions that respond to specific incountry needs.

Main tasks for the WHO satellite office in Abeche include:

  • Strengthen the coordination of the international health humanitarian assistance, optimizing the use of the available resources and liaising international programmes to national strategies;

  • Improve the health information management directly performing health assessment and collecting, analysing and disseminating available health data;

  • Enhance communicable disease prevention and control monitoring and following up on the existing surveillance system, providing technical advice for outbreak management and regularly producing data on crude mortality;

  • Supply medicines and medical items as required to strengthen the capacity of the existing health services;

  • Ensure continuous technical advice to national health authorities and other stakeholders including ad hoc WHO expert missions.


WHO has borrowed resources to initiate this work. The international public health officer (the same person as was previously working with UNHCR in Chad) will return to Abeche in early August 2004 with the international logistician (recruited and contracted by 29 July). The international epidemiologist has already been located and moved to Chad. Other inputs are being located. It seems likely that additional public health professional(s) and nutritionist(s) may be needed as the health needs in Eastern Chad become clearer.