Somalia

Monthly Nutrition Update for Somalia Feb 2003

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OVERVIEW
While the acute, drought related food insecurity abates in many parts of the country, many poorer households in almost all household economy groups struggle to re-establish livelihoods and in many cases fail to acquire the minimum requirements of a health diet. In Gedo as well as other areas in the northern part of Southern Somalia, humanitarian organisations debate the merits of continuing 'relief' interventions in the knowledge that the much needed longer term interventions present enormous challenges to implementing organisations.

The effects of the severe food insecurity in neighbouring Ethiopia have been noticed in border areas so FSAU and partners have intensified monitoring in border areas.

Workshops on nutrition and food security, supported by FAO and FSAU, have been held in Mandera and in Hargeisa in response to a growing interest in the subjects among partners.

The preliminary results of UNICEF led nutrition surveys in Jeriban and Galgodob are presented.

AWDAL

Influx of people and livestock in a fragile ecosystem threaten significant recovery in the Awdal coastal belt

In mid December 2002, an FSAU led inter-agency nutrition and food security assessment in the coastal belt of Awdal and Sahil Regions in Somaliland described substantial food and nutrition insecurity for the predominantly pastoral population in the coastal areas of the two regions. (See Nutrition Update January 2003). Successive poor rains and water scarcity have resulted in livestock deaths and deterioration resulting in unfavourable terms of trade and causing further erosion of livelihoods. Health of the population has also been adversely affected with a reported high incidence of water borne diseases. Access to health services is generally low in this sparsely populated area. Malnutrition rates were most severe (36% using MUAC <12.5cm for total acute malnutrition) in the transitory settlements.

The long expected Haiz rains began on 27th December 2002, leading to significant deaths among weak animals but leading to good recovery of pasture and water points. However, the rain has also attracted a massive influx of people and animals from Shinille and Dire Dawa Districts in Ethiopia (estimated at 5,000-7,000 families) into the Awdal coastal belt. The new arrivals appear to consist mainly of men with their animals, exerting further strain on the harsh and fragile ecosystem and heightening the possibility of depletion of the recovering grazing lands.

Between mid December 2002 and January 2003, inter-agency meetings (Somaliland government authorities, UN organisations, local and international organisations) in Hargeisa have adopted a common intervention strategy to address high malnutrition rates and food insecurity, and to cope with the long term effects of the harsh climatic conditions in Awdal and Sahil coastal belts. Short-term emergency responses as well as medium-long term interventions have been proposed.

UNICEF in collaboration with the Ministry of Health and Labour (MOHL) has begun a nutrition and health intervention in the two regions aimed at reducing malnutrition rates among under-fives. The intervention package, provided through a network of mobile clinics, includes provision of high energy biscuits to malnourished children, immunisation of all under-fives in the regions, medical treatment to children, provision of vitamin A and iron supplements, and health/nutrition education to all caretakers/mothers of children who present for screening. This currently covers a total of 27 locations in the coastal belt of the two regions (14 in Awdal and 13 in Sahil).

Mobile teams screen all under-five children using weight for height measurement in order to identify beneficiaries. All children whose weight for height falls below 80% of the reference median are provided with high-energy biscuits.




In the first round of operation that ended on 31st January 2003, a total of 2,738 children had been immunised, 1,421 children provided with high-energy biscuits and many more treated for various illnesses. The total number of children screened during the exercise and those determined as malnourished in the two regions are presented on the graphical illustration in the previous page. The intervention and screening exercise for case findings will continue on monthly basis for a minimum of three months depending on the impact of the continuing Haiz rains.

WFP provided general food rations in the affected areas of the two regions in late December 2002. A total of 250 MT comprising of cereals, pulses and vegetable oil was distributed to 15,520 households.

Although the Haiz rains have been good, the coastal belt remains vulnerable to food and nutrition insecurity, as the area has only experienced the seasonal short-term improvement. A significant recovery is now threatened by the increased pressure on the fragile ecosystem due to the increased concentration of animals and human beings, and that fact that only minimal and uncoordinated long term interventions are in place. More meaningful interventions are required and need to include:

  • Decentralisation of services (health care services, water provision etc) to avoid any pull factor to one locality

  • Critical analysis of current interventions and longer term strategy that considers the entire region, traditional animal movements and human settlements.

  • Consideration of mobile veterinary services.

  • Rehabilitation of infrastructure.

  • Effective coordination of all humanitarian activities.

Close monitoring of this area and activities in the border areas of Ethiopia will continue.

SANAAG - A SLOW RECOVERY

Sanaag Region, on the northern coast if Somalia, had three successive seasons of below normal rains resulting in acute water and pasture shortage resulting in a severe reduction in the herd size of most pastoral household. Concurrently, the negative impact of inflation that accompanied livestock ban also continued along with increased pressure on the available resources caused by in-migration of people fleeing the political tensions in Puntland. Limited fishing activities were available for the coastal inhabitants due to adverse monsoon weather conditions that prevailed between June and October 2002 and crop cultivation by the agro-pastoral households was also constrained. Thus, market prices for the staple (rice, pasta and maize) rose to about 50% higher than normal prices. A nutrition survey conducted in mid 2002 confirmed a food insecure population with malnutrition levels about 14% (using WT/HT - 2 z-scores as the cut-off). The survey also reported a negative impact on care practices for infants and young children as families engaged in activities for survival. Uptake of healthcare and immunisation services was low and the incidence of diarrhoeal diseases and appeared to be high. In response to the acute food insecurity, WFP initiated food for work activities and beneficiaries were involved in rehabilitation work. At the same time UNICEF in collaboration with Ministry of Health and Labour (MOHL) supported an intervention package that included provision of vitamin A, treatment of common illnesses, immunisation against measles, and provision of supplementary food to malnourished children in selected locations.

The 2002 Deyr rains were good in most areas of the region giving opportunities to both water sources and pasture to recover. Animal production and livestock value improved. There is also an increased fishing activity by the coastal residents due to the establishment of the Lasqorey fish-canning factory. Health service provision also improved in some locations with UNICEF's involvement. With the observed improvement in food security in the region, much of the malnutrition currently observed appears to be more closely related to high incidences of diseases, inadequate health and nutrition services and sub-optimal childcare practices (For example, unhygienic handling of eating equipments and food preparation in unsanitary conditions are common).

The SRCS-managed Erigavo MCH indicated a slight decline in the proportions of malnourished children between November and December 2002. While 12.2% (15) of the 123 children that attended the MCH in November 2002 were malnourished, only 9% of the 77 screened in December 2002 were malnourished using <-2 z-scores as the cut-off. The decentralised approach in the UNICEF supported intervention has led to a decrease in attendance at some of the static clinics.

However, sustained improvement will depend on the outcome of the expected Gu rains. Interventions directed at improving sustainable livelihoods of the pastoralists will still be important especially the construction and rehabilitation of water points in line with the normal migration patterns of the people, mobile veterinary services as well as decentralised provision of health services (immunisation, health and nutrition education etc.).

SOOL

Sool Region hosts a predominantly pastoral community. The region has remained relatively insecure due to the continued political tensions between the Somaliland and Puntland. This tension has restricted humanitarian activities and access to the region for the collection of quantative data on the nutrition situation. UNICEF and FSAU hope to undertake a nutrition survey when the security situation permits adequate access.

In the 2002 Deyr season, most of the Region received good rains that resulted in the recovery of pasture and water sources, improved animal condition, milk production as well as improved terms of trade for the pastoralists. Food security is therefore stable in most areas. However, available qualitative information reveals recurrent episodes of common child illnesses (diarrhoea and other parasitic infections) due to poor and/or inadequate water sources, inadequate health services, widespread lack of understanding by caretakers on optimal childcare practices, and recurrent food insecurity. Addressing water quality and access in the region remains a priority for survival and maintenance of livelihoods in the region.

GEDO - INSECURITY THE MAIN CONSTRAINT TO RECOVERY AND DEVELOPMENT

Gedo Region's nutrition situation remains a source of concern with the principle factors delaying a good recovery still closely related to the continuing insecurity in the region as well as a significant depletion in asset levels of many households as a result of the recent years of drought. In addition to the direct effects on the population, insecurity has continued to have a significant effect on access for humanitarian organisations involved in both short-term and longer term interventions. The recent Deyr rains and pasture conditions are generally considered good, offering opportunities for both pastoralists and agro-pastoralists to begin a recovery. However, poorer wealth groups in all household economy groups in the region, including those settled in urban and peri-urban areas, remain food insecure and will be unable to meet their minimum dietary requirements for some time. Without assistance, members of these food insecure households face a high risk of malnutrition. In addition to poorer wealth groups, the middle wealth groups among agro-pastoralist and riverine households also continue to be food insecure.

With a nutrition survey in Belet Hawa just two months ago showing a Global Acute Malnutrition rate of over 20%, active relief interventions will be required until household food security approaches normal levels.

No substantial food distribution has taken place in the region since November 2002 due to a pipeline supply gap and humanitarian organisations are currently re-evaluating mechanisms for the targeting of food aid in the coming months. ACF has no immediate plans to return to Luuq and Gedo Health Consortium faces regular security related problems in the delivery of basic health services.

Belet Hawa MCH reopened in December 2002 after a closure in October following looting of the facility by bandits. Supplementary feeding activities resumed in January 2003 and outreach activities cover seven villages.

A summary of figures for the therapeutic and supplementary feeding programme for 2002 is presented here. These intensive nutrition interventions in Belet Hawa District were triggered by the unacceptably high malnutrition rates in December 20011. Records demonstrate the significant challenges experienced by humanitarian organisations in the establishment and maintenance of selective feeding interventions in one of the most insecure districts in the country.

The therapeutic feeding programme aimed at a recovery rate of at least 80%, less than 5% deaths and less than 10% defaulting. Significantly, these targets were mostly achieved during periods of relative peace during which adequate access for supervision was possible. During the frequent periods of insecurity, when better qualified staff were forced to relocate, higher mortality was recorded. Defaulting levels were periodically high due to other factors such as registration processes for general ration, insecurity and reduced access to the centre due to issues related to clan affiliation.






SFP data from Belet Hawa MCH also manifests the effect of insecurity with 50-60% of the beneficiaries defaulting in April and July. In April, inter clan fighting was at its peak limiting access to the feeding centre while 237 children left during the refugee relocation to Dadaab camp in July. About 69% of the children were referred to the TFC in February 2002.
SFP beneficiaries in Belet Hawa MCH

Total exit Proportion of children exiting through:
2002
Cure
Default
Death
Transfer
Jan
103
22.3
47.6
2.9
27.2
Feb
32
31.3
0
0
68.8
March
4
100
0
0
0
April
195
41
59
0
0
May
12
75
0
25
0
June
13
100
0
0
0
July
475
45.7
49.9
0.4
4.0
Aug
64
100.0
0
0
0
SFP beneficiaries in Belet Hawa MCH
2002
Admission
In-charge
January
279
335
February
173
476
March
72
544
April
30
379
May
60
427
June
196
610
July
71
206
August
62
204

JERIBAN NUTRITION SURVEY - PRELIMINARY RESULTS

Jeriban District, located northeast of Galkayo has four main food economy groups, Addun pastoral; Coastal Deeh; Haud pastoral and Urban. The estimated population in the district is 70,000 (WHO, 2001) majority (65%) of whom fall within the Addun pastoral food economy group. The food security situation in the district has been below normal following poor 2002 Gu rains and delayed 2002 Deyr season in some parts of the district particularly the eastern Haud of Jeriban (Salax, Qalanqal, Malasle and Balanbal villages). All these had devastating effects on both pasture and water availability. However, the situation has gradually improved following good Deyr rains that commenced in late October 2002.

Nutritional indicators and some related characteristic
Variable
Proportion
No.
Total malnutrition (W/H < -2Z score + oedema)
9.8% (C.I. 8.0-12.)
89
Severe malnutrition (W/H< -3Z score + oedema)
1.7% (C.I. 1.0-2.8)
15
Children with acute respiratory infection in past two weeks
15.4%
140
Children with diarrhoea in past two weeks
15.8%
143
Malaria in the past two weeks
14.4%
131
Measles cases in last one month
4.1%
37
Vitamin A supplementation in past six months
56%
508
Measles immunization
50.2%
427
Received at least three doses of OPV in last one year
46.5%
422

Jeriban District depends on three boreholes located in Jeriban town, Ballibusle, and Semane as permanent water sources. Nomads rely on a number of Berkads filled in the rainy season, but are prone to drying up during prolonged dry seasons. Functional health facilities in the district include Jeriban MCH which has screened relatively low proportions of malnourished children ranging from 4% to 12% in the year 2002. However a clear understanding on the nutritional status of the Jeriban District population was still lacking.

UNICEF, in collaboration with the Ministry of Social Affairs (MOSA) and FSAU, conducted a nutrition survey from 18th to 29th December 2002 aimed at assessing the nutritional status of under five children in Jeriban District. Additionally, the survey sought to determine the potential risk factors associated with malnutrition, household characteristics and coverage of measles, polio and vitamin A supplementation.

Using a two stage cluster sampling methodology a total of 907 children aged 6-59 months or measuring 65-110 cm were surveyed. Survey results indicate a global acute malnutrition rate of 9.8% (CI: 8.0% - 12.0%) and severe acute malnutrition of 1.7% (CI: 1.0% - 2.8%). With reference to morbidity, measles recorded the lowest incidence as summarised on the table.

Global acute malnutrition was found to be associated with diarrhoea, malaria and vitamin A supplementation. Children with history of diarrhoea and malaria were both at a 1.6-fold increase in risk of being acutely malnourished while those children who had received vitamin A were significantly (RR=0.64) less likely to be acutely malnourished (Jeriban District Nutrition Survey, UNICEF January 2003).

Though the malnutrition rate is relatively low compared to malnutrition rates reported in other parts of Somalia, the rate is nevertheless a reflection of chronic and structural issues affecting the populations in the area. Chronic food insecurity, accompanied by frequent episodes of acute food insecurity appear to be negatively affecting the nutritional status of the population. In this area, seasonal shortage of essential food items exposes vulnerable groups to the likelihood of disease in an environment where water quality and access to health services are also serious issues.

The significant association between acute malnutrition and morbidity need to be addressed. Some of the proposed interventions include introduction of impregnated mosquito nets and an improvement of vitamin A supplementation coverage due to its positive impact on good nutritional status.

GALGODOB NUTRITION SURVEY - PRELIMINARY RESULTS

Galgodob town is located in Galgodob District, Mudug region. With an estimated population of 50,500 (WHO 2001), Galgodob District comprises two food economy zones namely Haud pastoral and Urban. Majority (90%) of the population fall within the Haud pastoral food economy zone and only a minority (10%) are in the Urban food economy zone. Following below normal 2002 Gu rains in North Mudug and South Nugal abnormal migrations were reported around Galgodob town, putting pressure on the poorly maintained boreholes. The overall food security situation in the area worsened when a prolonged Hagai season followed (FSAU Food Security report, September 2002). However, 2002 Deyr rains were finally received in October and situation began to improve gradually though pressure on the one and only borehole in Galgodob town is still reported.

Functional health facilities in Galgodob District are limited with MSF-Holland, UNICEF and MOSA supporting PHC activities in Galgodob and Bursalax health facilities. Information on the nutritional status of the population in Galgodob District is limiting, more so for Galgodob town which is the largest urban centre in the District and a key water point too.

From 14th to 25th December 2003, UNICEF in collaboration with the Ministry of Social Affairs (MOSA) and FSAU carried out a nutrition survey in Galgodob Town aimed at determining the children's nutritional status, identifying the factors associated with the children's nutritional status, demographic characteristics of study population, measles immunisation, Oral polio vaccine (OPV) and vitamin A supplementation coverage.

A summary of nutritional status and other factors

Global acute malnutrition
(W/H<-2 z score + oedema)
12.5%
CI: 10.7%-14.6%
Severe acute malnutrition
(W/H<-3 z score + oedema)
3.7%
CI: 2.7% - 4.9%
Acute respiratory infection cases in past two weeks
21.9%
Diarrhoea cases in past two weeks
22.7%
Malaria cases in past two weeks
14%
Measles cases in past one month
16.2%
Vitamin A supplementation in past 6 months
62.5%
Measles immunization
66.7%
OPV coverage in October 2002
65.9%
Received at least three doses of OPV in last one year
29.9%

Using an exhaustive methodology, a total of 1205 children aged 6 to 59 months or measuring 65-110 cm were surveyed. Results indicate a global acute malnutrition rate of 12.5% and a severe acute malnutrition rate of 3.7%.2 The table below gives a summary on morbidity among other factors. A significant measles incidence was reported.

Factors found to have a significant association with children's nutritional status were sanitary facilities; child sex; child age group; diarrhoea; ARI and malaria. Children whose families utilised toilet facilities were significantly less likely to be acutely malnourished. Male children, young children (6-23 months), children with history of diarrhoea, ARI and malaria two weeks prior to the survey were at an increased risk of being acutely malnourished (Galgodob survey report, UNICEF January 2003).

More than half (57.4%) of the children aged 6 - 23 months had stopped breastfeeding at the time of the survey. Majority (50.5%) of these children had actually stopped breastfeeding at the age of 0 - 6 months while a minority (20.3%) had stopped at 12 months and above. Introduction to foods other than breast milk was also done at an early age of between 0 - 6 months for 81.7% of the children.

The reported malnutrition rates are significant. While key food security indicators now appear to be improving, the population, especially poorer households have been adversely affected and their ability to maintain healthy diets has been diminished. Recovery can be slow, especially for households that have lost significant proportions of their assets. The dynamics of relationships between pastoralist livelihoods and urban residence are complex.

In a population where morbidity seems to be playing a key role in influencing the children's nutritional status, measures towards controlling these illnesses are key. The breastfeeding and weaning practices are not positive and may in part account for the fact that children aged between 6 and 23 months are at a higher risk of being malnourished than their older counterparts. Interventions proposed so far include appropriate curative care; introduction of impregnated mosquito nets and intensification of health and nutrition education at household level. In the long run, it may be useful to have additional permanent water points set up in other locations in the district so as to ease the pressure on the only borehole located in Galgodob town.

NUTRITION SURVEY IN RETURNEE SETTLEMENT AREAS OF HARGEISA

From February 1997 to date, UNHCR in collaboration with the Ministry of Resettlement, Rehabilitation and Reconstruction (MRRR) has supported voluntary repatriation of an estimated over 200,000 individuals mainly from the neighbouring camps in Ethiopia but also from other countries like Djibouti and Kenya. An equally large number of people are also estimated to have come back to the country without going through the formal repatriation processes. It is estimated that 40-50% of these returnees have so far settled in Hargeisa town where they have established both formal and informal settlements. Previous studies in the settlement areas (UNICEF nutrition survey 2001, IRC led inter-agency assessment 2002) reveal widespread lack of basic services, overcrowding and poverty especially in the informal settlements. For example, the 2001 nutrition survey showed a high malnutrition rate (15% WT/HT with <-2 z-scores and/or oedema as the cut-off) while the 2002 inter-agency assessment reported unsanitary conditions, inadequate water, high incidences of diseases and poverty to be widespread.

UNICEF in collaboration with FSAU, Ministry of Health and Labour (MOHL) and other partners have just completed a nutrition survey in the returnee settlements of Hargeisa. The survey aimed at determining the current malnutrition levels in the settlement areas, establishing the food security and other contextual data influencing nutritional status and providing guidance on decision making related to future interventions in these areas. The implementation of the survey started on 5th February 2003 and its findings will be presented in the March issue of this update.

NUTRITION SURVEYS

Planning of the survey schedule for 2003 is now in progress. All organisations interested in conducting surveys in their areas of operation are invited to contact FSAU. Technical and other support is available.

FSAU NUTRITION WORKSHOP IN HARGEISA

Since 2000, the Nutrition Project in FSAU has been carrying out nutrition surveillance support activities in Somalia that have resulted in the availability of better nutrition related information. The awareness raising activities that have accompanied the availability of better nutrition related information have promoted an increase in demand for support from partners. Aiming to respond to these needs, a three day workshop was undertaken in Hargeisa from 15th to 17th February 2003. A total of seventeen participants from partner organisation attended the workshop which focussed on data collection, analysis, interpretation and use for design and implementation of nutrition related projects.

Similar training workshops will be held in other areas during the year. Please contact FSAU for further information.

TRAINING COURSES & ANNOUNCEMENTS

As part of its Short Course Series, the Regional Centre for Quality of Health Care (RCQHC), Institute of Public Health, Makerere University, Uganda will be offering courses on i) Facilitative Supervision in Maternal and Neonatal Health from 10th to 14th March, 2003. ii) Improving the quality of Malaria Prevention and Control Services from 19th to 30th May, 2003. Contact Ms. Sheila Magero, Programme Coordinator at Email: mail@rcqhc.org

The New York group for Technology Transfer, is offering scholarships to pursue short term courses in Agriculture - New and Advanced Technologies and Disaster Management - Prevention and Control among other areas. These trainings are scheduled throughout the year and include Disaster Management in May and August; Agriculture in March, June and September. For more details contact the Deputy Education Director on Email: wreader@nygtt.org or contact@nygtt.org.

WEBSITES

This 'Nutrition Update', along with other relevant materials, is available on:
UN Somalia Website. http://www.unsomalia.org/FSAU/nutrition_updates
ReliefWeb. http://www.reliefweb.int/w/Rwb.nsf/vLCE/Somalia?OpenDocument&StartKey=Somalia&Expandview

RECENT REPORTS

  • Food Utilisation Study. September, 2002. Nutrition Surveillance Project. FSAU/FAO

  • Monthly Food Security Report for Somalia, FSAU.

  • Greater Horn of Africa Food Security Bulletin. Issue No. 8. January 10, 2003. FEWS NET/LEWS/RCMRD/USGS

  • Kenya Vulnerability Update. January 10, 2003. FEWS NET and WFP.

  • Kenya Food Security Update. January 10, 2003. FEWS NET and WFP.

  • Ethiopia Network on Food Security. Issue No. 1/03. January 21 2003. FEWS/NET/EU-LFSU

Footnote:

1 Global acute malnutrition of 37% (W/H<-2 z score or oedema)
2 Global or Total Acute Malnutrition - W/H<-2 Z scores plus oedema. Severe Acute Malnutrition W/H<-3 Z scores plus oedema.