DARFUR - USAID NUTRITION UPDATE

UNCLAS SECTION 01 OF 04 KHARTOUM 001771

SIPDIS

AIDAC
SIPDIS

STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W
USAID FOR DCHA SUDAN TEAM, AFR/SP
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS
GENEVA FOR NKYLOH
NAIROBI FOR SFO
NSC FOR PMARCHAM, MMAGAN, AND TSHORTLEY
ADDIS ABABA FOR USAU
USUN FOR TMALY
BRUSSELS FOR PBROWN

E.O. 12958: N/A
TAGS: EAID PREF PGOV PHUM SOCI UN SU
SUBJECT: DARFUR - USAID NUTRITION UPDATE

REFS: A) KHARTOUM 1297 B) KHARTOUM 1018

KHARTOUM 00001771 001.2 OF 004


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Summary
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1. Recent nutrition surveys in pockets of Darfur reveal that the
nutrition status of children under five has deteriorated since May
2007 to levels approaching those recorded in 2004 -- the beginning
of the Darfur humanitarian response when the nutritional situation
was at its worst. From September 15 to 25, a USAID and U.S. Centers
for Disease Control (CDC) team rapidly assessed the nutrition
situation in all three Darfur states. The team discussed nutrition
trends with UN agencies, non-governmental organizations (NGOs),and
state ministries of health. The causes for the high malnutrition
rates are not easy to pinpoint and include a variety of factors.
Given the protracted nature of the Darfur conflict, the humanitarian
community needs to find creative ways to address acute malnutrition,
including transitioning to longer-term preventive approaches while
continuing to ensure appropriate and timely emergency nutrition
interventions. End Summary.


2. A USAID Office of U.S. Foreign Disaster Assistance (USAID/OFDA)
public health advisor and a CDC epidemiologist traveled to Khartoum
and Darfur to review the nutrition situation and make technical
recommendations for the nutrition programs supported by USAID/OFDA.
This cable summarizes the team's findings.

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Trend Analysis
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3. In early 2007, with the exception of Ed Daein, nutrition surveys
from camp and non-camp areas reported global acute malnutrition
(GAM) rates below the 15 percent emergency threshold. Since May
2007, GAM rates have increased, ranging from 15.9 percent to 30.4
percent, approaching rates reported in 2004 in the same areas. The
USAID team notes that severe acute malnutrition (SAM) remains below
2004 levels and mortality levels remain below the emergency
threshold.


4. Data from routine nutrition surveillance and feeding centers
support these trends, for the most part. Therapeutic feeding
center (TFC) and supplementary feeding center (SFC) admissions
follow a seasonal trend. From January to July 2007, SFC admissions
rose and then leveled off but remained below 2006 levels. TFC
admissions for the same time period increased steadily, exceeding
2006 levels. Transfer rates from SFC to TFC, signifying
deterioration in nutritional status, increased from 4.3 percent in
April to 8.5 percent in June.


5. Key areas of concern are internally displaced person (IDP) camps
and settlements such as Abu Shouk, As Salaam, Ed Daein, and Kalma.
These IDP areas have humanitarian challenges that include
overcrowding in camps, public health problems particularly during
the rainy season, and the precarious physical condition of
individuals resulting from limited access to diversified diets
either through their own production or market mechanisms. The
nutrition assessment team reported that possible causes for the
increase in malnutrition rates include deteriorating security and
subsequent limited access to populations; seasonal deterioration of
nutrition during the rainy season; care and feeding practices for
children and pregnant women; appropriateness of supplementary
feeding products; effectiveness of nutrition programs; and lack of
communities' understanding of treatment modalities for malnourished
children leading to high default (drop out) rates from supplementary
feeding programs.


6. Consistently since 2004, young children (6 to 29 months) continue
to be most at risk of acute malnutrition compared to children 30 to
59 months. This trend is a clear indicator that infant and young
child feeding is a major problem that humanitarian interventions
have not adequately addressed.


7. Access to clean water has remained at minimally acceptable levels
in IDP camps, but seasonal deterioration in sanitation has been
reported in all nutrition surveys in the larger camps. In addition,
new influxes of IDPs increase the need for additional water,
latrines, and hygiene promotion activities.


8. Since March 2007, the prevalence of easily preventable and

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treatable diseases has steadily increased. A number of surveys have
shown strong correlation between diarrhea and acute malnutrition,
and acute respiratory infections and acute malnutrition. The
surveys also demonstrate, although to a lesser extent, a correlation
between fever/malaria and acute malnutrition. Vaccination rates
remain below Sphere guidelines. For example, the measles
vaccination rates reported in camp surveys do not exceed 55 percent.
The surveys demonstrate a clear correlation between measles and
increased malnutrition and mortality rates.


9. Nutrition coverage of current programs remains limited and
inadequate, only reaching between 6.7 to 53 percent of children who
should be enrolled in feeding programs. (Note: This data is mostly
from camp settings. End Note.) According to Sphere standards,
coverage of supplementary and therapeutic feeding programs should
reach more than 90 percent of the population in a camp setting, more
than 70 percent in urban areas, and more than 50 percent in rural
areas.


10. Another indicator of the quality of programs is the number of
children who drop out from the programs. In Darfur, this rate
exceeds the Sphere standards of less than 15 percent.


11. Although nutrition programs in Darfur have shifted from strictly
center-based treatment of malnutrition to a community-based model,
the shift has not resulted in the high coverage rate the
community-based model was intended to have. The team reported a
visible integration of the community management of acute
malnutrition into the health care system at the expense of community
outreach, a critical component in reaching high coverage rates and
treating more than 90 percent of malnourished children. The
community-based approach needs to be linked to the health system and
also reach out to the community in order to identify children in
need of these services.

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Constraints to Improving Nutritional Status in Darfur
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12. USAID staff attended a two-day nutrition meeting in Khartoum
hosted by the UN Children's Fund (UNICEF) and the Ministry of Health
to analyze the nutrition situation in Darfur based on inter-sectoral
information. The participants also reviewed the current nutrition
interventions, identified gaps in coverage and program areas, and
refined the nutrition strategy in order to better address the short-
and medium-term nutritional needs in Darfur. The discussions in the
meeting and at the field-level corroborate USAID's understanding of
some of the possible underlying causes of malnutrition. The
findings are summarized below.

--POOR BREASTFEEDING PRACTICES: Exclusive breastfeeding for the
first six months of life is not practiced in Darfur. Although
relief organizations have implemented nutrition education, including
the promotion of exclusive breastfeeding, in many nutrition programs
during the last four years, the response has lacked systematic
effort and innovative approaches to change breastfeeding practices.


--LACK OF APPROPRIATE COMPLEMENTARY FOODS: In Darfur, there is a
lack of appropriate complementary and weaning foods for infants and
young children, as well as a lack of knowledge about appropriate
feeding practices. Mothers are not familiar with best practices for
introducing solid food and are introducing them too early. Within
the general food distribution there are few options for weaning
foods and a relative lack of dietary diversity. Although not
intended as a weaning food, a six month old child would need to
consume a large quantity of corn-soya blend (CSB),which is included
in the general food ration, in order to meet the daily nutritional
requirements. Preparation of CSB as a weaning food is time
consuming for mothers.

--CARE PRACTICES AND EMPLOYMENT OPPORTUNITIES:
Relief organizations consistently identified child care practices as
a significant factor contributing to the poor nutritional status of
children. Mothers leave their infants in the care of older children
for more than eight hours a day while they seek employment
opportunities outside of camps. While this is a common cultural
practice in Darfur, aid workers are observing that child care
responsibilities are now passed down to even younger children than
before. As a result, relief agencies believe that the young
children are insufficiently fed during the day, as caretaker

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children are not capable of preparing CSB. In addition,
breastfeeding ceases during the hours when the mother is outside of
the house, further compounding the problem.

--LACK OF KNOWLEDGE ABOUT MODERATE MALNUTRITION: Many organizations
identified the lack of recognition of moderate malnutrition as a
significant issue. Many parents do not perceive a moderately
malnourished child as malnourished because that child still appears
healthy, possibly impacting the effectiveness of supplementary
feeding programs and contributing to the high default rates. The
workshop participants noted a need for strong educational activities
that communicate the seriousness of moderate malnutrition.

--QUALITY OF SUPPLEMENTARY FEEDING PROGRAMS (SFPs) AND PRODUCTS: UN
and NGOs questioned the effectiveness of SFPs and the acceptability
of CSB. Performance indicators from feeding programs are below the
Sphere standards as previously noted. Some aid agencies claim CSB
is not accepted by the population because it is a maize-based
product and the taste of soy is strong and not liked by the
population. (Note: Reports of the unacceptability of CSB have
mainly been anecdotal, without data to support the claims. In an
effort to gain a more concrete understanding of the issue, WFP and
its nutrition NGO partners have recently completed post-distribution
monitoring surveys to gauge acceptability of CSB in all three states
of Darfur. Data analysis is underway, with results expected soon.
End Note.)

--CAPACITY: Capacity was highlighted as a significant gap impacting
the nutrition situation. Several NGOs do not have the technical
capacity for specific nutritional interventions, such as therapeutic
feeding. Also, relief agencies have a hard time recruiting staff to
work in Darfur. Additionally, capacity among local staff and state
ministries in nutrition prevention and treatment is limited and
needs improvement. The state ministries of health are unable to
properly take on nutrition programs handed over to them by nutrition
partners. As the nutritional situation stabilized in 2005 and 2006,
many agencies downsized their staff and programs. For example,
UNICEF had 12 implementing partners in 2005 in South Darfur and only
four in 2007. The lack of partners significantly limits the
activities and program coverage that UNICEF is capable of supporting
and the ability to scale-up in response to a nutrition crisis.

--COORDINATION: Participants noted a general lack of coordination
at both the Khartoum and state level, except in West Darfur. Aid
agencies report good coordination within each sector, but very
little cross-sectoral interaction. Since malnutrition is a
cross-sectoral issue, strong coordination between sectors is
required to improve the nutrition situation.

--CHRONIC SITUATION NEEDS NEW APPROACH: The chronic nature of the
conflict now requires nutrition interventions to prioritize
preventive activities, including behavior modification, in addition
to treatment. A stronger focus on capacity building of national
staff and ministries is also needed.

--INSECURITY: Security incidents frequently impede access to
programs and beneficiaries. Limited access to populations and the
disruption of services have impacted the effectiveness of programs.
Additionally, some populations are completely without access to
services or humanitarian aid. Insecurity can prevent vulnerable
populations from accessing existing services, particularly if the
programs are facility-based and not community-based.

--REPEATED DISPLACEMENT: A lack of stability and constant movement
among much of the conflict-affected population may be a major
contributing factor to the spike in malnutrition. Populations do
not have access to their land, impacting their food security. Also,
repeated displacement impedes the ability of humanitarian aid
agencies to access the vulnerable populations. When displaced
populations finally reach an official camp, the IDPs' nutritional
and health status is often significantly deteriorated.

--EXHAUSTION OF COPING STRATEGIES: Partners also identified the
exhaustion of coping strategies as a contributing factor. In the
beginning of the conflict, people fled with some assets, such as
livestock or household items. After four years of conflict, these
assets have been depleted and families are left without coping
strategies. As a result, minimal shocks -- even seasonal changes --
may have a larger impact on the nutritional status of the
population.


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Responding to the Current Situation
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13. In response to the recent nutrition findings, UNICEF, state
ministries of health, and NGOs quickly mobilized resources to
support nutrition interventions in Mukjar in West Darfur, in Abu
Shouk camp in El Fasher, in Kalma camp near Nyala, and in Ed Daein
in South Darfur. To better understand child care practices, UNICEF
and the Ministry of Health conducted a household survey across
Sudan, including Darfur, which gathered data on infant and young
child feeding. Further surveys and research on the underlying
causes of malnutrition are currently underway in Darfur. The UN
World Food Program (WFP) is conductingQ monitoring survey to
address the CSB issue.

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Conclusions
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14. Due to the protracted nature of the humanitarian crisis in
Darfur, the assessment team determined that the quality and scope of
nutrition interventions need an overhaul in order to remain
effective within the current Darfur context. USAID staff will work
with USAID-funded partners to review nutrition strategies and
develop and implement new approaches to improve nutrition programs
in Darfur, in an attempt to keep malnutrition rates below emergency
threshold levels. USAID will closely monitor the nutritional status
in Darfur paying close attention to the short- and long-term impact
that insecurity, exhaustion of coping mechanisms, and repeated
displacement has on the nutritional status of the population.

FERNANDEZ