REFUGEES IN EASTERN CHAD: MALNUTRITION RATES AND

UNCLAS NDJAMENA 000814

SIPDIS


DEPARTMENT FOR AF, AF/C, AF/SPG, D, DRL, H, INR, INR/GGI,
PRM, USAID/OTI AND USAID/W FOR DAFURRMT; LONDON AND PARIS
FOR AFRICAWATCHERS; GENEVA FOR CAMPBELL,
ADDIS/NAIROBI/KAMPALA FOR REFCOORDS

E.O. 12958: N/A
TAGS: PGOV PHUM PREF KAWC CD SU
SUBJECT: REFUGEES IN EASTERN CHAD: MALNUTRITION RATES AND
FOOD SUPPLIES

REF: NDJAMENA 652


1. Summary: PRM Office Director for Assistance to Africa
Margaret McKelvey and Program Officer Hazel Reitz visited
Chad from May 4 to 18 to monitor the operations on behalf of
the Sudanese refugees in the east of Chad. This cable, one of
three reporting on the visit, focuses on efforts to
understand the reasons for the spike in malnutrition rates in
March/April and to develop a standard and regular monitoring
and surveillance system. It also examines food pipelines and
pre-positioning in the camps of sufficient food to cover the
upcoming rainy season. The PRM team recommended the urgent
establishment of a monitoring system of surveillance and
periodic surveys of malnutrition rates. Reasons for the
spike appear to be numerous, ranging from cultural and child
care practices to poor public health practices to the poor
performance of implementing partners. ACF found a lower
malnutrition rate in Oure Cassoni (12-13% GAM) than
previously reported but a higher rate in Amnabak (26%). WFP
is working hard to ensure that adequate food is prepositioned
now for the June to October rainy season. The major issue is
contracting sufficient trucks to ply the Libyan corridor. As
previously reported, Stefano Poretti, World Food Program's
Director for Chad, said he needs 7,000 MT of food now to
complete pre-positioning before the arrival of the rains. End
Summary.

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MALNUTRITION: MULTITUDE OF APPARENT REASONS
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2. One of the objectives of the PRM trip was to look into
recent reports of higher global and severe malnutrition rates
in the camps of Touloum, Iridimi, Djabal and Oure Cassoni,
and to determine the reasons for the March/April spike.
While the malnutrition rates are reported to have gone down
in several camps (ACF, doing a tent-to-tent survey of all
children under-five, was finding a GAM of 12-13% in Oure
Cassoni after surveying 30 % of the camp) and the reported
cases of kwashiorkor in Touloum camp (which appear never to
have been confirmed as classic kwashiorkor) have responded to
therapeutic feeding, an ongoing evaluation of malnutrition
rates by ACF and IMC in Amnabak camp has discovered that
earlier figures were incorrect and that the malnutrition rate
is higher than reported - now really 26%. .
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THE PERFECT STORM
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3. UNHCR Nutritionist UNV Stefano Federle (longest serving
UNHCR international staff member in Chad - 16 months) briefed
PRM mission on the recent increase in the number of cases of
malnutrition. Federle made it clear that it may be difficult
to achieve the international standard for malnutrition soon
and to avoid periodic spikes in malnutrition rates. He
provided a number of reasons including the poor nutritional
and traditional practices common among the refugees and the
relative weakness of the implementing partners in this
sector. Describing it in terms of "the Perfect Storm",
Federle said the confluence of many factors, including the
above, as well as trading of food between refugees and locals
(to pay off debts),the exchange of part of the ration for
milling and NFIs, poor weaning practices, children being left
unattended bu adults for as long as two weeks all affect the
rate. Several of the implementing partners (IRC, IMC and
COOPI) have not performed up to standard in the nutrition
sector. Other more positive elements are improved screening
and better community outreach, resulting in more cases coming
to the medical centers. When the issue was raised with WFP
Country Director Poretti, he was initially adamant that the
reduced rations of October through March had nothing to do
with the high malnutrition rate. He blamed the reasons
provided above. Ultimately, he did acknowledge that perhaps
reduced food rations were 10% of the problem.

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MORE SUPERVISORY AND EXPERIENCED NUTRITIONAL PERSONNEL NEEDED
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4. It seemed clear to the PRM team that more supervisory and
experienced personnel are required in all agencies to work


the nutritional issue. UNHCR currently has one nutritionist
based in Abeche who is single-handedly trying to cover both
the nutrition and food sectors for UNHCR. WFP, UNICEF and
WHO (who were supposed to form an inter-agency management
board on nutrition) are without nutritionists at present.
IRC has suspended its 24-hour therapeutic feeding center,
IMC's malnutrition data was found to be wrong, and COOPI was
without a nutritionist for two or more months. UNHCR is
actively addressing the issue by contracting Action Contre le
Faim (ACF) to get a better handle on the current situation in
the camps. ACF is currently conducting a statistically
significant sampling of children under-five using MUAC and
weight/height. The inter-connected issues of parenting and
cultural practices, public health, and good food management
will take somewhat longer to impact but are being addressed
through a multisectoral approach led by UNHCR's community
services. ACF will take over the nutrition sector from IRC
in Bahai, a new COOPI nutritionist arrived and appears to be
good, and IMC has replaced most of its team.

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IMPROVED MONITORING
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5. PRM officers strongly urged the international and
non-governmental organizations to set up a standard and
regular operation-wide monitoring system of surveillance and
periodic surveys, including the establishment of reliable
base-line data. There is still dissension among the agencies
as to the reliability of the CDC data from last June and some
of the data provided by NGOs over the last year. PRM
suggested an interagency approach where methodology would be
agreed upon and standardized throughout all the camps. Such
surveys could be carried out every three months. Initial
reaction appears to be positive but will require follow-up
and possibly additional expertise from CDC and/or a medical
institution such as Columbia University's School of Public
Health.

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BAHAI - IRC THERAPEUTIC FEEDING CENTER SUSPENDED
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6. The PRM team met with new IRC country director Antoine
Dupluis and later participated in a joint meeting with him
and ACF-USA Chad Program Coordinator Jason Stobbs to discuss
the nutritional situation in the northernmost camp - Oure
Cassoni. Global malnutrition in the camp spiked in March and
April and IRC had no local staff sufficiently competent to
staff the therapeutic feeding center at night (international
staff are not allowed to overnight in the camps for standard
security reasons). The newly arrived IRC nutritionist made
the decision to send all cases of severe acute malnutrition
to the 24-hour MSF center in Iriba (2 hours drive away) and
to concentrate her efforts on dealing with cases that no
longer required 24-hour care and on reorganizing the entire
approach.

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ACF IN ACTION
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7. An ACF team, which was present in Bahai during the PRM
team's visit there, was undertaking a tent-by-tent assessment
in Oure Cassoni camp and an assessment of the children among
the 1,600 "new arrivals" who had been camped out in the wadi
in Carieri right on the border with Sudan for up to two
months. ACF, using weight/height and MUAC measurements,
identified 15 severely malnourished children among the 30% of
the camp already surveyed (approximately 1.9%),and another
15 cases in the wadi. Of these, 17 were immediately referred
to MSF-Iriba with their mothers, while the mothers of others
refused to go - possibly because of their reluctance to miss
the upcoming general food distribution, because their
husbands forbade it, or because there were other children in
the household who needed to be cared for. Because of this,
ACF, during meeting with PRM and IRC, made a quick decision
to leave a nutritionist in Bahai to help care for those
children whose mothers refused to go to Iriba - a very
impressive and can-do performance on ACF's part. The plan
now is for ACF to take over the nutrition sector from IRC


over the next few weeks (with full transition no later than
early July) and to establish the therapeutic feeding center
in the hospital in Bahai rather than in the camp to ensure
24-hour care.

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RECOMMENDATIONS
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8. The PRM team's recommendations are:

-- Urge IOs and NGOs to strengthen their nutrition staff,
including urging UNHCR to add a second person to its
nutrition/food team (already discussed with UNHCR/N'Djamena).

-- Support the transfer of the nutrition sector from IRC to
ACF in Oure Cassoni and consider providing funding for
ACF-USA.

-- Press for a standardized and regular surveillance and
monitoring system for all the camps - include this in trip
report to UNHCR

-- Look into the possible of assistance of CDC and/or some
qualified school of public health such as that at Columbia
University.

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FOOD ISSUES: LIBYAN CORRIDOR
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9. WFP is working hard to ensure that adequate food is
prepositioned now for the June to October rainy season. The
major issue is contracting sufficient trucks to ply the
Libyan corridor. As previously reported, Stefano Poretti,
WFP's Director in Chad, said he needs 7,000 MT of food now to
complete pre-positioning before the arrival of the rains.
(Note it had already rained in and around Goz Beida when the
team was there.) He is looking into several possibilities to
speed up the Libyan process: one being to look into a new
route from El Kofrah through a spot near Faya Largeau in BET;
another to transfer the food from the Libyan trucks to
Chadian trucks at the border and then to deliver it directly
to the camps (this would have the advantage of saving over
$300 per truck in foreign truck fees); and a third to use
Chadian truckers for the whole trip. In response to
McKelvey's question about WFP having its own fleet, since
Libyan truckers may not want to dead head back from the
border, Poretti said that he would require 150 trucks which
would be very expensive. The maintenance of the Libya
corridor also depends upon the ability to use it for food for
Darfur as well as Eastern Chad, since the quantity of food
needed for Eastern Chad is not large enough to sustain the
Libyan corridor. As previously reported by WFP/Sudan's
Ramiro da Silva, in a test run, three weeks ago, WFP was able
to move 400 tonnes. Poretti was pleased that sufficient food
had been pre-positioned in the southern camps of Goz Amer and
Djabal to last through the rainy season. PRM team was able
to confirm that this was indeed the case for Djabal (except
for oil, which Poretti said was on the way via the Douala
route)) but was skeptical about all the food having reached
Goz Amer yet. More RubbHalls are needed in Bahai to hold
food for Oure Cassoni camp.

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WFP NEEDS
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10. Poretti said that WFP's pipeline for eastern Chad would
be empty as of September. (Note: He was very pleased with
the just-received small PRM cash contribution of $350,000 for
the refugees from the Central African Republic. End Note.)
Ideally, he would like to have a buffer stock of two months
but that has not been possible nor looks likely any time
soon. Poretti also said WFP would have to stop its air
service at the end of August. He was also looking for money
to fund CARE ($40,000) and ACF ($90,000) to conduct food
basket and post-distribution monitoring (which, contrary to
what we had initially understood, are not yet fully in
place),for additional rubbhalls and for staff accommodation.
WFP had had no nutritionist on site since December 2004 and


would welcome funding for this. Poretti also wants to
undertake a vulnerability survey ($30,000) in order to obtain
a better picture of both the situation in the camps but also
among the local population. He cautioned that Chad may face
a severe crisis next year if the rains are poor and noted
that locusts have been sighted near Lake Chad. Poretti had
no record of PRM's 2004 contribution toward the humanitarian
air services but it has since been provided to him.

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FOOD DISTRIBUTION IN THE CAMPS
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11. The PRM team was able to see a general food distribution
in Oure Cassoni camp which went smoothly and in an orderly
fashion with full rations of all commodities. Women were
participating in the distribution. The scooping method is a
more reliable and welcome method by all except for the
refugee bloc leaders (it is more difficult for them to take
extra for themselves). PRM officers were somewhat concerned
that the distribution in Farchana camp which took place May
16 was only for a period of 15 days, in order to readjust the
distribution calendar. The PRM team felt that it risked
causing a problem in a camp which had remained calm
throughout the events of the previous week (septel)
fortunately that proved not to be the case. The refusal of
refugees to be re-registered in Touloum and Iridimi and to
present their entire families (i.e., all those included on
the ration cards) at the general food distributions in
Kounoungou and Mile is believed to be indicative of fraud and
duplication of ration cards. See septel for information on
the present volatility in the camps.

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RECOMMENDATIONS
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12. The PRM team recommends the following:

-- Consider additional funding for WFP for the Libyan
corridor S.O., for the air service, and for food monitoring.

-- Urge WFP to deploy a nutritionist soonest to Abeche to
work with UNHCR and other agencies on nutrition surveillance
and monitoring.



13. Khartoum and Tripoli Minimize Considered.
WALL


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