Nutritional Survey in IDP Camps Gulu District Northern Uganda. Action Against Hunger (ACF-USA) May 2003

Transcription

1 Nutritional Survey in IDP Camps Gulu District Northern Uganda Action Against Hunger (ACF-USA) May 2003

2 EXECUTIVE SUMMARY A nutritional survey was carried out in Gulu District in April- May The objectives of the survey were to assess malnutrition and mortality rates among under 5 children of the district s internally displaced population. Malnutrition rates for under 5 currently stand as follows: - Global Acute Malnutrition (GAM): 6.2%, peaking at 10.2% for age group 6-29 months; - Chronic malnutrition: 41.4% Note that the rate for GAM is under emergency level, and that the rate for chronic malnutrition is very high, and represents a steady increase over the last 6 years for which comparable data is available. (It is however consistent with the figure of 39% reported by UNICEF for the whole of Uganda) Retrospective Mortality Rate (for the last three months) (RMR) stands as follows: - For Under 5 children: 5.67 deaths per 10,000 children per day. - For total IDP population: 2.33 deaths per 10,000 persons per day. These figures are critical. Note that 2 deaths per 10,000 are considered an emergency for an adult population, and figures above 4/10,000 are considered an emergency for the under 5 population. In both cases, observed rates are thus above emergency levels. Analysis against comparable figures shows that the observed RMR is the highest ever recorded in the last 5 years, about threefold the usual observed rate. There has been no noteworthy epidemic in Gulu area that could justify the spike in mortality. There is thus a very serious possibility that children have simply died of hunger. Nutritional Assessment in Gulu District ACF USA 2/20

3 INTRODUCTION The Acholi region of Uganda (Kitgum, Pader and Gulu Districts) has seen an increase in the intensity of the insurgency by the Lord s Resistance Army (LRA) since These districts have suffered looting of food and portable items, burning of property, abductions and killings of many civilians. This has resulted in people moving, spontaneously or under the direction of the Government, into near trading centers protected by the UPDF (Uganda People s Defense Forces). At the time of this survey, the population residing in the IDP (internally displaced population) in Gulu District was estimated at around 380,000. According to the 2002 Uganda Population and Housing Census, the total population of Gulu District is 468,407; thus, approximately 81% of the population of the district resides in IDP. The years between 1996 and 2002 were characterized by fluctuating insecurity. During tense periods, most farming land was inaccessible, causing displaced people to be largely dependent on food distributions. During relatively calm periods, many of the families living in IDP were able to begin re-cultivating their fields. However, in June 2002 the security situation in Acholiland drastically changed again as the LRA insurgents reentered Acholiland en masse, following the beginning of operation Iron Fist in March 2003, designed to chase the LRA from southern Sudan. The LRA returned in large numbers and began terrorizing again the local unarmed civilian population with killings, abductions and road ambushes. Several internally displaced in Acholiland have been attacked, looted and eventually burnt down. LRA tactics have caused the migration of people to the remaining, resulting in further congestion, disruption of social structures, and reduced access to land, and therefore, food. In view of the above concern, the United Nations World Food Programme (WFP) through the Norwegian Refugee Council (NRC) has been implementing a general food distribution program. As of March 2003, the ration was increased from 70% to 100%, although oil is unavailable and therefore not included in the ration. This ration is: 400gr of maize grain/person/day, 60gr of pulses/person/day, and 8 Kg of CSB/household/month (roughly 44gr / person per day). General food distributions had been irregular and are now being carried out only with heavily armed military escorts. The distribution cycle is days. This ration provides roughly 1,800 Kcal per person per day with 14% of protein and 25 % of lipids. ACF-USA has been operational in Gulu district since May 1997 implementing nutrition, water and sanitation programs. In 2001, the nutrition Programme was handed over to the Directorate of District Health Services (DDHS), with ACF providing technical support. Currently, there are two Therapeutic Feeding Centers (TFCs) in Gulu municipality and one in Anaka IDP camp. There are no Supplementary Feeding Centers (SFCs) currently operating within the district. As part of ACF-USA s nutrition surveillance activities in the district, an anthropometric survey was planned for June 2002; however, the security situation delayed survey implementation until April Nutritional Assessment in Gulu District ACF USA 3/20

4 OBJECTIVES OF THE SURVEY To estimate child (6-59 months) malnutrition rates in the IDP Camps of Gulu District. To estimate the measles immunization coverage among children aged 9-59 months. To estimate mortality rates through a 3 months retrospective survey. METHODOLOGY 1. Type of survey and sample size The survey was conducted using cluster-randomized sampling at three levels. Thirty clusters were randomly selected from the district to obtain a sample of 900 children. The minimum sample size which allows a reasonable precision of the prevalence of malnutrition is 900 children aged from 6 to 59 months (30 clusters of 30 children each), when the target population is greater or equal to 5,000 in size. (see appendix for table of selected clusters). 2. Sampling methodology The first level of sampling included all IDP within Gulu District. The probability of being selected and the number of clusters, and therefore children, to be surveyed was proportional to the population size of the camp. Forty clusters were randomly selected from November 2003 WFP population figures of the IDP. If one camp became inaccessible due to insecurity, another was randomly selected to replace the cluster. The second level of sampling was done in the selected clusters at the respective households. The team went to the center of the chosen cluster and randomly selected a direction by spinning a pen. The first household visited was randomly selected among houses counted between the center and the limit of the village in the chosen direction. The remaining houses were chosen by proximity, always taking the houses on the right hand side. Due to the time constraints resulting from the increasing insecurity, families who were absent from their homes at the time of selection were excluded from the survey. The third level of sampling was done in each selected household. One child between the ages of 6 and 59 months, with a height between 65 and 110 cm, was selected and measured. Due to the time constraints resulting from the increasing insecurity, children who were absent from their homes at the time of selection were excluded from the survey. 3. Variables measured Age The exact age of the child was noted in months, based on information from vaccination cards. In cases where documentation on the age of the child was not available, age (month and year of birth) was determined using a calendar of local events as a reference. (see appendix for calendar). Nutritional Assessment in Gulu District ACF USA 4/20

5 Sex Recorded as : male or 2: female. Weight The child s clothing was removed and the child was weighed using a Salter scale (25 kg). Weight is expressed in kg to the nearest 100 grams (g). Height or length Children above the age of two years were measured standing upright, whereas those aged below two years were measured lying down. When age was difficult to determine, those measuring less than 85 centimeters (cm) were generally measured lying down and those taller than 85 cm were measured standing upright. Height and length are expressed in cm, to the nearest millimeter (mm). Oedema Oedema was diagnosed by placing a medium thumb pressure on the upper side of the foot, for three seconds. Oedema was considered to be present if a skin depression remained on both feet after the pressure was released. Mid-Upper Arm Circumference Mid-Upper Arm Circumference (MUAC) was measured on the left arm, at the midpoint between the shoulder and elbow, while the arm was relaxed. MUAC is expressed in mm to the nearest 2 mm. Measles Vaccination (children aged 9 to 59 months) Mothers were asked for the vaccination card of the selected child. If no vaccination card was available, the mother was asked if the child had been immunized against measles. Mortality Mortality among household members was assessed by interviewing the head of the family in every household visited, including those with no children aged 6-59 months. Data collected included the number of persons per household, the number of deaths that occurred in the household in the previous 3 months, and the cause of death. Food Distribution Coverage Families were asked whether they are recipients of WFP food distributions. If not, the reason was recorded. Nutritional Assessment in Gulu District ACF USA 5/20

6 4. Indicators, guidelines and formulas used Acute Malnutrition Weight-for-Height Index For the children, acute malnutrition rates were estimated from the weight for height (W/H) index values combined with the presence of oedema. The W/H indexes are compared with NCHS 1 references. W/H indexes were expressed both in Z-scores and in percentage of the median. The expression in Z-score has true statistical meaning and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs. Both methods will be reported. Cut-off values for the results expressed in Z-score : Severe malnutrition: defined by WFH < -3 SD 2 and/or existing bilateral oedema. Moderate malnutrition: defined by WFH < -2 SD and >= -3 SD and the absence of oedema. Cut-off values for the results expressed in percentage of the median: Severe malnutrition: defined by WFH < 70 % and/or existing bilateral oedema. Moderate malnutrition: defined by WFH < 80 % and >= 70 % and no oedema. Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC is only taken for children with a height of 75 cm and more. Action Against Hunger uses the following cut-off values (risk of death due to malnutrition): MUAC < 110 mm Severe malnutrition MUAC > 110 mm and < 120 mm Moderate malnutrition MUAC > 120 mm and <135 mm Risk of malnutrition MUAC > 135 mm Adequate nutritional status Chronic Malnutrition The index height-for-age expresses the height of a child in relation to his age. It shows the growth deficit for a child compared to the reference population of the same age. Height for age cannot differentiate the level of thinness between 2 children of equal height and equal age. Height-for-age is a reflection of the effects of nutrition over a long period of time as 1 NCHS: National Centre for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, Standard deviation: SD Nutritional Assessment in Gulu District ACF USA 6/20

7 opposed to effects of nutrition at present (at time of assessment). It depicts chronic malnutrition. The classification of cut-off points for chronic malnutrition (HFA) are presented in Table 1 next page. Table 1 Guidelines for Height-for-Age (HFA) classification Z-score % of the median Severe Chronic malnutrition HFA< -3 SD HFA< 80% Moderate Chronic malnutrition -3 SD<= HFA < -2 SD 80% <= HFA 90% Global Chronic HFA< -2 SD HFA< 90% malnutrition* Normal HFA>= -2 SD HFA>= 90% *: Global chronic Malnutrition is a combination of both moderate and severe Mortality Rates Mortality rate is an indicator of the health situation in the population surveyed. It is expressed per 10,000 people per day. The following is the formula for the calculation of a mortality rate (MR): MR = n/[((n+n)+n)/2] where n is the total number of persons reported to be deceased in the households surveyed, N is the total number of living persons in those same households at the time of the survey. Mortality rates per 10,000 persons per day are obtained according to the following formula: MR 10,000/day = MR x 10,000 / 90 days Under-five mortality rates are calculated in the same manner. Mortality rates can be interpreted according to the following references 3. For children aged 6-59 months: under-five mortality rates greater than or equal to two deaths per 10,000 children per day indicate a situation of alert, 3 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugees nutrition, ACC / SCN, Nov 95. Nutritional Assessment in Gulu District ACF USA 7/20

8 under-five mortality rates greater than or equal to four deaths per 10,000 children per day indicate an emergency situation. For the total population: mortality rates greater than or equal to one death per 10,000 persons per day indicate a situation of alert, mortality rates greater than or equal to two deaths per 10,000 persons per day indicate an emergency situation. 5. Survey implementation Six teams of three people each carried out the field work. Teams were composed of staff from the DDHS, feeding centers and surveyors who had previously undertaken survey activities with ACF. All participants underwent a two day training, which included a standardization test and pilot survey. A total of 13 days was necessary to complete the field work but the schedule was interrupted frequently by insecurity. In addition, several surveyors were unwilling to travel to certain locations; therefore, the field work for approximately one half of the was completed by three teams. The survey began April 7, 2003, and was completed May 6, The thirty clusters were located in 21 IDP. 6. Analysis of results Data was compiled and analyzed using Epi Info Version 5 and EPINUT computer software. Nutritional Assessment in Gulu District ACF USA 8/20

9 RESULTS The final sample consisted of 900 children aged 6-59 months. Distribution of age and sex AGE CLASS BOYS GIRLS TOTAL SEX RATIO N % N % N % % % % % % % % % % % % % % % % 0.95 TOTAL % % % 0.96 Table 2: Distribution of age and sex, Gulu District, Uganda, May There is no evidence of a significant difference between the proportion of girls and boys in the sample. Age distribution shows an imbalance. The age group 6-29 months are overrepresented, while the age group months are under-represented. It should be noted that in most cases, ages given by parents (caretakers) are often rather approximate, which can explain such a difference. Another explanation could be an increase in mortality in the month age groups, or absenteeism of this age group on the day of the survey. Overall, the sample is validated. Anthropometric analysis Results of the anthropometric analysis have been obtained by using weight-for-height index expressed in Z-score and in percentage of the median of reference population. Prevalence of acute malnutrition in z-scores Weight-For-Height Distribution By Age Group In Z-Scores, Gulu District <-3 STD >=-3&<-2 STD >=-2 STD OEDEMA N n % n % n % n % % % % 0 0.0% % % % 3 1.1% % 3 1.4% % 1 0.5% % 1 0.7% % 0 0.0% % 3 8.1% % 0 0.0% TOTAL % % % 4 0.4% Table 3: Weight for Height distribution, z-scores, Gulu District, Uganda, May 2003 Nutritional Assessment in Gulu District ACF USA 9/20

10 Z-score distribution: Weight for Height Reference Sex Combined Figure 1: Weight for Height distribution, Z-scores, Gulu District, Uganda May 2003 There is a slight discrepancy on the left of the curve for the sample: the proportion of children included between 3 SD and 1 SD is slightly more important in our sample, with the majority being distributed around 1 SD. The status of these marginally well-nourished children is bound to deteriorate in case of any situation that compromises their nutrition security. GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP In Z-Score 6-59 months (n = 900) 6-29 months (n = 512) Global acute malnutrition 6.7% [4.6% 9.5%] 10.2% [6.8% 14.8%] Severe acute malnutrition 1.3% [0.7% 2.4%] 2.1% [0.8% 5.1%] Table 4: Acute malnutrition by Age group, Gulu District, Uganda, May 2003 There is a very high and significant difference between the prevalence of malnutrition in children aged 6-29 months and those aged months (Chi 2 =22.48, p= 0.000). The Relative Risk = 4.83 (2.32 < RR < 10.06). The risk of being malnourished for a child below 29 months is multiplied by 4 compared to a child above 30 months. Nutritional Assessment in Gulu District ACF USA 10/20

11 Evolution of Acute Malnutrition April-98 March-99 October-99 March-01 May-03 All Wasting Global % CI Severe % CI Table 5: Acute malnutrition at different points in time, Gulu District, Uganda. Overall, acute malnutrition has remained stable since March 1999, considering confidence intervals. This apparent stability may hide substantially different situations, however. Nutritional Assessment in Gulu District ACF USA 11/20

12 Prevalence of acute malnutrition as a percentage of the median Weight For Height Distribution By Age Group As Percentage Of The Median, Gulu District <70% >=70%&<80% >=80% OEDEMA N n % n % n % n % % % % 0 0.0% % % % 3 1.1% % 4 1.9% % 1 0.5% % 0 0.0% % 0 0.0% % 0 0.0% % 0 0.0% TOTAL % % % 4 0.4% Table 6: Weight for Height per age group, % of Median, Gulu District, Uganda, May 2003 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP In percentage of the median 6-59 months (n = 900) 6-29 months (n = 512) Acute global malnutrition 4.4% [2.8% 6.9%] 6.8% [4.1% 10.9%] Acute severe malnutrition 1.0% [0.3% 2.6%] 1.6% [0.5% 4.3%] Table 7: Acute malnutrition per age group, % of Median, Gulu District, Uganda, May 2003 The results expressed in percentage of the median also indicate that the children aged 6 to 29 months are at a higher risk to malnutrition compared to those aged 30 to 59 months. Statistical tests reveal that there is an extremely significant difference (Chi 2 = p=0.000) between malnutrition rates for the two age groups. The relative risk (RR) is 5.30 (95% CI: 2.10< RR <13.41). This means that children less than 30 months are 5.30 times more likely to become malnourished than children aged months. Prevalence of Stunting in z-scores It has to be noted that the age given by caretakers and parents is often rather approximate. Therefore, all following tables and curves should be interpreted very carefully. 900 records were analyzed and no records have been discarded due to aberrant values (height-for-age outside range). Nutritional Assessment in Gulu District ACF USA 12/20

13 Height-For-Age Distribution By Age Group In Z-Scores, Gulu District 6-59 months (n = 900) 6-29 months (n = 512) Moderate chronic malnutrition 41.4% [CI 95%: 36.8% 46.1%] 42.6% [CI 95%: 36.5% 48.9%] Severe chronic malnutrition 15.3% [CI 95%: 12.2% 19.1%] 13.9% [CI 95%: 9.8% 18.6%] Table 8: Stunting per age group in Z-scores, Gulu District, Uganda, May 2003 Z-score distribution - Height-for-Age Reference Sex Combined Figure 2: Height for Age distribution curve, Z-scores, Gulu District, Uganda, May 2003 There is a significant discrepancy on the left of the curve of the sample curve: a significant proportion of children in our sample is below 2 SD. The majority are distributed between 2 and 3 SD indicating higher levels of moderate chronic malnutrition in the sample. Comparison with previous surveys April-98 March-99 October-99 March-01 May-03 All Stunting Global % CI Severe % CI Table 9: Stunting at different time in Z-scores, Gulu District, Uganda. Confidence intervals between March 2001 and May 2003 are very different and show a clear and statistically significant increase in stunting. Nutritional Assessment in Gulu District ACF USA 13/20

14 Risk of Mortality: Distribution of MUAC by height The height of 75 cm is considered to correspond to the age of 1 year and that of 90 cm to the age of 3 years. The mean and standard deviation of the MUAC distribution in children are good indicators of the nutritional status of the population. Distribution Of MUAC By Height, Gulu District Height N < 110 mm >110 and <120 mm > 120 and <125 mm > 125 and <135 mm >135 mm N % N % N % N % N % < 75 cm % % % % % >75 and <90 cm % % % % % 90 cm % 0 0.0% 1 0.5% 9 4.3% % TOTAL % % % % % Table 10: MUAC distribution according to height groups, Gulu District, Uganda, May 2003 The whole sample has a mean MUAC of mm and a standard deviation of Overall, 33.3 % of the under five population is at elevated risk of mortality due to malnutrition. Retrospective mortality survey For children aged 0-59 months (under-five mortality rate): Under-five population 1,410 Number of under-five deaths 74 Under-five mortality rate 5.67 deaths per 10,000 children per day. For the total population (population mortality rate): Total population 5,450 Number of deaths 119 Mortality rate 2.33 deaths per 10,000 persons per day. Nutritional Assessment in Gulu District ACF USA 14/20

15 Cause of Death Cause of Death, Gulu District, April-May 2003 Cause of death <5years 5 years Diarrhea 10 2 Bloody Diarrhea 4 0 Measles 6 1 Fever 32 9 Lower Respiratory Tract Infection 4 5 Malnutrition 6 0 Accident 0 3 Other Unknown 2 3 Total Table 11: Causes of death as per family, Gulu District, Uganda, May Other for under-five: perinatal death(4), premature birth, sickle cell anaemia, rebel attack, RVI (HIV-related), gastrointestinal candidiasis Other for over-five: suicide(4), AIDS(4), rebel attack (3), TB(2), liver disease(2), shot while poaching, poisoning, cancer, childbirth, vaginal bleeding, RVI (HIV-related), gastrointestinal candidiasis Comparison of mortality rates April-98 Octobe r-99 March- 99 March- 01 May-03 All Mortality per 10000per day Table 12: Mortality rate, 3 months retrospective, children under 5, Gulu District, Uganda. The three months retrospective survey carried out in May 2003 shows an extremely difficult situation. The causes of death as reported by the parents during the different surveys do not globally differ (main causes cited are diarrhea, fever, Respiratory Infection ). Nutritional Assessment in Gulu District ACF USA 15/20

16 Measles vaccination coverage FOR CHILDREN AGED 9 TO 59 MONTHS N % Measles vaccination proved by the card and done at 9 months or after % Measles vaccination done, according to the mother (card absent) % No vaccination % Total % Table 13: Measles vaccination coverage, Gulu District, Uganda, May The measles coverage is very low (38.3%), according to the number of children holding a vaccination card and vaccinated at 9 months or after. However, computing for mother and cards, 92.1 % of the surveyed children have been vaccinated. The high proportion of children without vaccination cards can be partly explained by the fact that most mothers (caretakers) prefer to leave their children s health cards at the health clinics, believing them to be safer there than at home. Also, many families have lost the cards during rebel attacks and displacement. The vaccination coverage according to the mothers should, however, be interpreted with caution. The last measles immunization campaign was carried out in March 2003 in Gulu District. Food Distribution Coverage Of the 900 families selected, 794 families (88%) are receiving food distributions from WFP, and 106 families (12%) are not receiving food distribution. The reasons given are summarized in Table 14 next page. Number of families Reason given 3 absent during distribution 8 names canceled from list with no explanation given 23 recent arrivals (within past 3 month) 72 not registered Table 14: Food Distribution, Gulu District, Uganda, May WFP is currently updating registration lists within the IDP of Gulu District. The ration has been increased to 100% from 70% as of March 2003, but it is not balanced as oil is not included in the ration. Although distribution has become more regular, a large number of families report looting of their food by the rebels soon after distribution. Nutritional Assessment in Gulu District ACF USA 16/20

17 DISCUSSION The mortality rates found in the survey are of extreme concern. A rate of 4 / / day for the under 5 population is considered as an emergency. The survey indicates rates above this emergency level. Although there one should always be cautious in interpreting mortality rates due to its difficulty in collecting data, the present results are very worrying. The parents mainly report diarrhea, fever and respiratory infection as the main cause of mortality. This has been consistent across all surveys done in Gulu district by AAH-USA since It is also interesting to note that in the "other" category, rebel attack is often given. This was not the case before apart from in the survey done in October 99 after a period of intense rebel activity. However it is important to note that the underlying cause of death, especially at present, might well be malnutrition. In a screening done in early February 2003, results indicated a very high risk of mortality due to malnutrition among children under 5 years old. The screening was carried out using MUAC. The Mid-Upper Arm circumference is a good indicator of body mass and is a particularly successful way to identify children at high risk of mortality (Briend 1987; Alam 1989; Briend, Zimicki 1986). While it varies by a few cm according to age, its diagnostic value lies in the fact that it can be used without reference to age or height. Its effectiveness in estimating mortality risk is best explained by the relationship between body mass and risk of death. The MUAC is much better than other anthropometric indexes at reflecting the ratio between energy-providing organs and the consuming organs, explaining why it better describes the mortality risk due to malnutrition. (Briend et al 1989). During the screening, 4,631 children were measured. Above a quarter of these children showed to be at high risk of mortality due to malnutrition, while 7.6% of them were at very high risk of mortality with a need for a nutritional rehabilitation. Almost 2% were at extreme risk of mortality and were severely malnourished. The screening was done three months before the present survey and suggested a potential problem. It is a possibility that these children are part of those reported dead by their parents during the May survey. The food security situation in the also tends to favor this hypothesis. In Pabbo, over 30% of the families depend entirely on the food distribution as a source of food. In the were the malnutrition is the highest, the families depends the most on food distribution. This is particularly true for Cwero. Very few families rely solely on cultivation to feed themselves except for the camp of Awer. 50% of the families interrogated there said they were only relying on their own cultivation as a source of food. Generally, families use a mix of all ways of accessing food. Among those who reported relying on purchase, most said they were very often running out of money. Among the 80% of families cultivating, most of them reported having harvested. However the quantities they Nutritional Assessment in Gulu District ACF USA 17/20

18 were able to store is relatively unclear, but 72% of the families that reported having food stocks had stocks for an average one week only. Again, as shown during the February 2003 screening, the most densely populated and in the areas of highest insecurity had difficulties to harvest and had extremely low stocks. Stocks were also reported not being made for fear of looting. Most of the families interviewed (78%) said they had to reduce the number of meals per day for lack of food. Over half of the families now have only one meal per day. In this survey, 88% of the families are receiving food distributions from WFP. WFP is currently updating registration lists within the IDP of Gulu District. The ration was increased to 100% from 70% as of March However, although distribution has become more regular, a large number of families report looting of their food by the rebels soon after distribution. It is clear that, for a majority of the population in the, food accessibility is going from bad to worse and will not improve soon, since the people have fewer access to their land, while the planting season is finishing and the hunger gap is starting. We can reasonably estimate that more and more families will face food shortages in the coming year. The issue of poor access to food is indeed a major contributor to malnutrition hence mortality. The results of this survey in terms of stunting also show a catastrophic situation that is unfortunately lingering on. More than 41% of the under 5 population is stunted. The deteriorating water and sanitation conditions of the IDP is also a problem. In January 2003, the latrine coverage was estimated at over 50 per person while the standard for emergency is at 20 persons per stance. The water coverage is also very low: a person has access to 3.7 liters of safe water per day when the emergency standard is at 15 L per person per day. Access to health care is also reported to be difficult. However a very important effort has been made by the DDHS during the last months in order to supply drugs regularly as well as staff. As mentioned, sanitary conditions in the are very bad and this needs to be addressed. However in the three months before the survey, no specific diarrhea epidemic has been reported. No other specific surge of disease such as measles that could explain a high rate of mortality has been reported. In addition it has to be noted that a well nourished child does not die of measles or simple diarrhea. The very critical situation that prevails today is due to a combination of factors among which malnutrition is the most critical problem as well as the underlying if not direct cause of excess mortality. The very bad nutritional status of the population undermines their capacity of reaction to diseases, exhausts their ability to cope adequately and results in death. The rate of malnutrition found during this survey might not be elevated with regard to international emergency levels, but they are extremely worrying considering the rate of Nutritional Assessment in Gulu District ACF USA 18/20

19 mortality and previous predictions made (February 2003 screening). In addition, the rate of acute malnutrition for children below 29 months are very high (10%). The overall situation of the in Gulu district is critical. Finally, the present survey included 21 out of 31 existing in the district. Camps not surveyed were out of reach because of persistently volatile insecurity in the area. Camps deemed to be in the worst situation are those with very little humanitarian access and to the of the district. Nutritional Assessment in Gulu District ACF USA 19/20

20 RECOMMENDATIONS Implementation of supplementary feeding centers at camp level is of importance in order to prevent severe malnutrition. Implementation of a referral system will be crucial in the running of the feeding center and preventing moderate and severe malnutrition. Implementation of smaller but numerous therapeutic feeding centers at camp level is important to overcome the defaulting rates, enhance access as road trips are extremely hazardous and allow for early treatment of severe malnutrition. WFP should continue to provide full ration food aid distribution to all the IDP population for the time being. A food security assessment will be useful and urgent, in order to anticipate the Hunger Gap, and assess the number of family that are already living only on humanitarian assistance. The coping mechanism of the population has to be enhanced. Nutritional Assessment in Gulu District ACF USA 20/20