Somalia

Monthly Nutrition Update for Somalia Jun/Jul 2004

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OVERVIEW
In this month's issue, summaries of two nutrition surveys are presented. The surveys highlight the differing responses to a deterioration in food security for two communities in Somalia and the resulting nutritional and mortality outcomes.

The vulnerability of the Jilib Riverine nutrition and the weak social support mechanisms have resulted in devastating consequences for the population in terms of malnutrition and mortality. Meanwhile, in Sool Plateau, the capacity to move and to benefit from very strong social support systems have enabled affected populations to withstand the crisis for a much longer period. Both situations require substantial attention with both short and longer term interventions indicated.

JILIB NUTRITION SURVEY REPORT - Summary

Over the past three years, the Southern Juba Riverine livelihood group of Jilib District has experienced successive drought that has led to a decline in crop production and increased food insecurity particularly among the poor socioeconomic group.

MAP - Somalia: M. & L. Juba - Food economy zones

Since September 2002, over five rapid nutrition assessments have been conducted by FSAU, WFP, ICRC, MSF-Holland and SRCS in the southern Juba riverine livelihood zone, all highlighting vulnerability, serious malnutrition much of which manifested as oedema, and high mortality among children. These have been attributed, partially, to declining food security and outbreaks of communicable diseases. MSF Holland established a day care therapeutic feeding centre (TFC) and out-patient's department (OPD) in June 2003. About 70% of the Marere TFC beneficiaries have had oedema on admission. A survey involving FSAU, UNICEF, UNOCHA, SRCS and the southern Juba riverine livelihood group was undertaken in May 2004 to estimate the levels of malnutrition and mortality, the underlying causes and to examine how these factors can be addressed.

A total of 913 children aged 6-59 months and measuring 65- 110 cm, from southern Juba Riverine livelihood group were surveyed using a 30x30 cluster sampling methodology. Results indicate global acute malnutrition (WFH < -2 z score or oedema) of 19.5% (CI: 17.0 -- 22.2) and severe acute malnutrition (WFH < -3 z score or oedema) of 3.7 (CI: 2.6 -- 5.2). About 82% of the surveyed children were from Bantu households. Among the malnourished, about 79.8% of them came from the Bantu households. Findings on the retrospective under-five and crude mortality rates of 5.4/10,000/day and 2.2/10,000/day, depict an emergency situation (WHO). A summary of findings is presented in the table on page 2.

Production for household consumption needs has declined due to the successive poor crop harvests. This has led to a decline in the income accessed through agricultural labour and crop sales. Coping mechanisms currently employed to access the food and income include self employment, intensified bush product collection and charcoal burning, change of food preferences from cereal to dried mangoes and family splitting for labour to urban area.

Vulnerability within the southern Juba riverine livelihood group is increased by their lack of livestock, a subsistence farming livelihood, and a fragile social support network system with limited access to remittances. This situation has been exacerbated by civil unrest in the district. The number of road blocks between Kismayo and Jilib is high. Taxes are extorted at each of the road blocks resulting in high retail prices of food and non food commodities.

Most of the surveyed children came from households that depend mainly on open hand dug wells, river and stagnant pools (97%), (refer to photo, page 1) for water. Only about 3% of the children came from households using borehole/protected wells. The water is of poor quality, and is neither treated nor boiled prior to consumption. The river is inhabited by crocodiles which often attack those fetching water or fishing. About 92% of the children came from households which do not own pit latrines. Human waste disposal in the open ground is common thus contributing to poor environmental sanitation and contamination of the water points. This practice, coupled with infrequent hand washing before feeding children has exacerbated prevalence of diarrhoeal diseases (43%) and infestation with intestinal parasites. These factors are also identified at MSF- Holland OPD as the leading causes of morbidity. Unfortunately, due to the long distance covered in accessing health services, most children do not receive treatment promptly, resulting in malnutrition and mortality. Diarrhoeal diseases and oedema/ malnutrition were identified to be the leading causes of the under five mortality (30% and 22%). For crude mortality, the leading causes were diarrhoeal diseases (16%), tuberculosis (11%), child-birth related problems (11%) and malnutrition (11%). Statistical analysis of the survey data found significant association between malnutrition and diarrhoea (p=0.0002). Children aged less than 24 months were more malnourished than those aged 2 years and above (p<0.05).

Indicator
No.
%
Children aged 6-59 months assessed
913
100
Number of households
514
100
Global acute malnutrition (WFH <-2 Z-score or oedema)
178
19.5
GAM: Ages 6-23 months (n= 350)
99
10.8
Ages 24-59 months (n=563)
79
8.7
Severe acute malnutrition (WFH <-3 Z-score or oedema)
34
3.7
SAM: Ages 6-23 months (n= 350)
17
1.8
Ages 24-59 months (n=563)
17
1.8
Severe acute malnutrition, no oedema
33
3.3
Oedema
4
0.4
Children with diarrhoea in 2 weeks prior to the survey
392
43
Under-five mortality rate (per 10,000/day)
69
5.4
Crude mortality rate (per 10,000/day)
88
2.2
Children with ARI in 2 weeks prior to the survey
311
34
Children with measles in 1 month prior to the survey
46
5
Children with Malaria in 2 weeks prior to the survey
293
32
Measles vaccination coverage(n=836, aged 9-59 oedema)
194
23
Vitamin A supplementation coverage
645
71
Source of water: Borehole
23
3
Source of water: Unprotected wells/springs/river
885
97
Faecal disposal: Use pit latrines
73
8
Do not use pit latrines
840
92
Frequency of feeding: less than 3 times a day
394
43
Access to health services: NGO health clinics
365
40
Private clinics
192
21
Traditional healers 320 35

A relatively high prevalence of diseases during the two weeks preceding the survey was revealed in the study group. About 34% of the assessed children had suffered from respiratory infection, 43% diarrhoea, 32% suspected malaria two weeks prior to the survey, and 5% had suffered measles a month before the survey. About 71% of the assessed children had received Vitamin A supplementation in the previous 6 months, 23% of immunizable age had been vaccinated against measles while about 84% had received at least one dose of polio vaccine during the polio campaign. About 61% of the assessed children were taken for medical assistance when sick (about 40% to the four NGO-sponsored public health facilities and 21% to private clinics). Unfortunately, the distance to the NGO-sponsored clinics (which were located in the major villages of Marere, Gududei and Jilib) ranged from 1-50 km thus limiting attendance from villages located beyond 12 km radius.

Medical assistance from the clinics was often sought at advanced stages of infections when signs of malnutrition had manifested. The survey also found inadequate technical capacity and limited supplies in some of the public health clinics leading to overstretched services at the MSF-Holland sponsored OPD in Marere where most of the services could be accessed. These factors have contributed to high malnutrition and mortality rates.

About 97% of the assessed children had been introduced to foods other than breast milk in their first three months of life. About 18% of the children had stopped breastfeeding within their first year of life while about 43% of the children received less than three meals a day. (Care takers spent little time on child care practices, mainly due to farm labour engagement). These practices limit appropriate nourishment of children and contributed to malnutrition.

The critical levels of global acute malnutrition and mortality rates were therefore attributed to the southern Juba riverine livelihood group's lack of access to adequate food, lack of access to safe water, poor sanitation, health services, fragile social support network system and a poor social care environment for women and children with the insecure environment being a major contributor.

Based on the analysis of the situation, the survey team made several recommendations to address the situation. The following interventions are required urgently to avert increased mortality, between now and the next harvest :

- Improve access to safe water for consumption, including storage services.

- Increase the household access to food.

- Improve the access to health and immunization services.

- Improve the immediate environmental sanitation and hygiene at household level through health awareness and facilitating construction of pit latrines.

- Opportunities to restore livelihoods include: o Construction of canals from the river for irrigation purpose o Flood protection and river bank initiatives o Provision of farm inputs, fruit trees and fishing gear o Control the crocodiles in the Juba river o Tse-tse fly control initiatives

- Closer monitoring of the situation is essential.

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