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An Epidemiological Analysis of Malnutrition, Morbidity and Mortality Rates in the Darfur Humanitarian Crisis, Sudan 2003-2005

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This study was funded by the International Food Policy Research Institute through the USAID university linkage program and looked at mortality, morbidity and malnutrition rates in the Darfur conflict and how they were affected by the humanitarian intervention from 2003 through 2005. It also looked at how the intensity and type of humanitarian intervention affected vulnerability among displaced and affected residents as well as the various ways that relief services could have been made more effective in reducing vulnerability to food insecurity. Although the mortality, morbidity and malnutrition surveys were not directly comparable due to differences size, they nevertheless offered an important understanding of the impact of the humanitarian intervention. It was found that global acute malnutrition rates mostly remained high and above emergency thresholds, but severe acute malnutrition rates remained mostly below the emergency threshold, which could have been due to deaths of the most vulnerable children or amelioration of their health (into the global acute malnutrition category or above) attributable to the humanitarian assistance.
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An Epidemiological Analysis of Malnutrition, Morbidity and
Mortality Rates in the Darfur Humanitarian Crisis, Sudan
2003-2005



April 2007


Maina H. Muthee
MS Food Policy and Applied Nutrition
MA Law and Diplomacy
Humanitarian Studies Initiative
Gershoff Scholar of Nutrition Science and Policy
Hargens Scholar of International Relations





This report was funded by the International Food Policy Research Institute, Washington
DC, through the USAID University Linkage Fund.

Submitted to

Dr. Patrick Webb, Academic Dean, Friedman School of Nutrition Science and Policy,
Boston, Massachusetts

And

Dr. Marc Cohen, Research Fellow, the International Food Policy Research
Institute (IFPRI), Washington, DC


1

Acknowledgments
Many thanks go to Dr. Marc Cohen at IFPRI whose support and encouragement led me
to apply for funding from the USAID-IFPRI linkage fund. Dr. Cohen has been extremely
resourceful and I particularly enjoyed working with him. Many special thanks also go to
Marie Ruel at IFPRI for her support and positive comments which I got through Dr.
Cohen. Both Drs. Cohen and Ruel were very supportive and encouraging during my
internship at IFPRI in the summer of 2005. I appreciate their friendliness and
professionalism.
My special thanks also go to Dr. Patrick Webb at the Friedman School of Nutrition
Science and Policy at Tufts University, who I regard both as a friend and mentor. I am
humbled by his experience and knowledge, which I tapped onto through extempore
meetings which he always had time for, I was grateful that he always took the time to
comment and review my progress even when he was extremely busy juggling his duties
as the dean of the nutrition school, professor, academician and the host of other duties
and responsibilities that he has. I could always count on him to give me new insights.
Many thanks also go to Claudine Prodhuron at NICS. Even though we never met face to
face, she was extremely helpful in giving me contacts on where to obtain survey reports
to. The other group that I am grateful to are the people who sent me their survey
reports, they are too numerous to list here, but this report would not have been possible
save for their cooperation.

2














I dedicate this thesis to the memory of my teen brother, Joseph Mwangi Muthee.
Forever in my heart and in my thoughts.

3

Table of Contents

Acknowledgments ........................................................................................................... 2
Definitions……………………………………………………………………..…………………5
List of Acronyms.............................................................................................................. 7
Executive Summary ........................................................................................................ 8
Background of conflicts in Sudan…………………………………………………………… 9
Introduction ................................................................................................................... 10
Scope and objectives of the study................................................................................. 12
Methods ........................................................................................................................ 12
Study limitations ............................................................................................................ 14
Results and discussion.................................................................................................. 15
Epidemiological Surveys in Complex Emergencies: Role and Evolution ................... 15
Malnutrition ................................................................................................................ 18
Malnutrition Cycle………………………………………………………………………… 19
Malnutrition and mortality in children under five ………………………………………21
Mortality ..................................................................................................................... 24
Morbidity .................................................................................................................... 27
Empirical effects of the war on food security ................................................................. 30
An Overview of Vulnerability in Darfur ...................................................................... 30
Access and Availability of food in the midst of insecurity and displacement .............. 33
Rethinking the Humanitarian Aid Portfolio..................................................................... 36
Progression and Intensification of the Conflict: 2003 – 2005......................................... 30
Initial outbreak of violence (March – September 2003) .......................................... 40
Breakdown of ceasefire agreement / escalation of violence (Oct 2003 – Mar 04).. 42
Increased humanitarian response (Jul 2004 – Jan 2005) ...................................... 45
Huge increases in the affected population: Jan - Dec 2005 ................................... 48
Conclusion ……………………………………………………………………………………52
References …………………………………………………………………………………. 55
ANNEXES ..................................................................................................................... 57


4

Definitions
Complex humanitarian emergencies
Complex humanitarian emergencies are defined as “situations in which mortality among
the civilian population substantially increases above the population baseline, either as a
result of the direct effects of war or indirectly through increased prevalence of
malnutrition and/or transmission of communicable diseases, particularly if the latter
result from deliberate political and military policies and strategies” (Salama et al, 2004)

Global Acute Malnutrition (GAM)
Global acute malnutrition (GAM) is defined as either a weight-for-height of less than - 2
standard deviations below the mean of the CDC/NCHS/WHO reference population and/
or with bilateral oedema or a weight-for-height less than 80% of the reference
population median and/ or with bilateral oedema.

Severe Acute Malnutrition (SAM)
Severe acute malnutrition (SAM) is defined as weight-for-height more than 3 standard
deviations below the reference mean (Z-score less than ?3) or less than 70% of the
reference median. All children with edema are classified as having severe acute
malnutrition

Oedema
The presence of excessive amounts of fluid in the intercellular tissue. It is the key
clinical sign of kwashiorkor, a severe form of protein-energy malnutrition, carrying a very
high mortality risk in young children.

Crude Mortality Rate (CMR)
The rate of death in the entire population, including both sexes and all ages. The CMR
can be expressed with different standard population denominators and for different time
periods, e.g. deaths per 1,000 population per month or deaths per 1,000 per year, or
per 10,000 per day


5

Under-5 Mortality Rate (U5 MR)
The rate of death among children below 5 years of age in the population. Express as
the number of deaths per ten thousand children under five years old per day in an
emergency setting.

Cause-specific mortality rates
The proportion of deaths attributable to a specific disease or cause


6

List of Acronyms

ACF
Action Contre la Faim
AMIS
African Mission in Sudan (African Union)
ANA
Annual Needs Assessement
ARI
Acute Respiratory Infection
CMR
Crude Mortality Rates
CP

Cooperating Partner (WFP)
CPA
Comprehensive Peace Agreement
EMOP
Emergency Operation (WFP)
FAO
Food and Agriculture Organisation of the United Nations
FCND
Food Consumption and Nutrition Division (IFPRI)
FMOH
Federal Ministry of Health
FSNSP
Friedman School of Nutrition Science and Policy (Tufts University)
GAM
Global acute malnutrition
GNUS
Government of National Unity of the Sudan (since 2005)
GOS
Government of the Sudan (pre-2005)
HAS
Humanitarian Air Service (WFP)
IDP
internally Displaced Person
IFPRI
International Food Policy Research Institute
IOM
International Organization for Migration
IRIN
Integrated
Regional Information Network
IRIN
Integrated
Regional Information Networks
JEM
Justice and Equity Movement
MOH
Ministry of Health (GOS/GNUS)
NICS
Nutrition information in conflict situations
OLS
Operation Lifeline Sudan (a WFP EMOP for Sudan)
PPS
Population Proportional to Size
SAM
Severe acute malnutrition
SCN
Standing Committee on Nutrition of the UN system
SC-UK
Save the Children – United Kingdom
SC-US
Save the Children – United States
SLA
Sudan Liberation Army
SO
Special Operation (auxiliary to a WFP EMOP)
SPLA/M
Sudan People’s Liberation Army/Movement
U5MR
Under Five Mortality Rates
UNHCR
United Nations High Commissioner for Refugees
UNICEF
United Nations Children’s Fund
UNMIS
United Nations Mission in Sudan
UNOCHA United Nations Office for the Coordination of Humanitarian affairs
UNSECORD United Nations Security Coordinator
USAID
United States Agency for International Development
WFP
World Food Programme
WHO
World Health Organization

7

Executive Summary
This study was funded by the International Food Policy Research Institute through the
USAID university linkage program and looked at mortality, morbidity and malnutrition
rates in the Darfur conflict and how they were affected by the humanitarian intervention
from 2003 through 2005. It also looked at how the intensity and type of humanitarian
intervention affected vulnerability among displaced and affected residents as well as the
various ways that relief services could have been made more effective in reducing
vulnerability to food insecurity.

Although the mortality, morbidity and malnutrition surveys were not directly comparable
due to differences size, they nevertheless offered an important understanding of the
impact of the humanitarian intervention. It was found that global acute malnutrition rates
mostly remained high and above emergency thresholds, but severe acute malnutrition
rates remained mostly below the emergency threshold, which could have been due to
deaths of the most vulnerable children or amelioration of their health (into the global
acute malnutrition category or above) attributable to the humanitarian assistance.

Abu Shouk camp was studied to showcase the cyclical nature of malnutrition and
mortality among children under five in Darfur. During the hunger periods in 2004 and
2005, the camp experienced remarkably high global acute malnutrition and under-five
mortality rates, both of which “significantly” improved after the harvesting season. This
was also consistent with the explanation that severely malnourished children either died
during the hunger period or the health of surviving children was improved by both the
humanitarian assistance and/or increased access to food during the harvesting season.

The study found evidence to suggest that the humanitarian assistance intervention was
effective in decreasing malnutrition and mortality rates in Darfur once it got under way in
February 2004 as there was a general reduction of global acute malnutrition, severe
acute malnutrition, crude mortality rates and under-five mortality rates.

8

Background of Conflicts in Sudan
Since independence from the British in 1956 Sudan has experienced numerous
civil wars, insurrections and insurgencies in the East (Kassala), West (Darfur), Center
(Nuba Mountains), and in the entire Southern sector. The grievances and reasons for
armed rebellion have partly stemmed from marginalization of entire regions by the
Khartoum government, making failure of governance a primary cause of armed conflict
in Sudan. The largest and longest civil wars have been between the government of
Sudan (GOS) and rebel movements in the South, notably the Sudan People’s Liberation
Army (SPLA). The first Sudanese civil war was fought between the North and South
(1955 -1973) and ended with the signing of the Addis Ababa Agreement, which was
followed by ten year peaceful hiatus. In 1983 president Jaffar Nimeiri abrogated the
Addis Ababa Agreement, federated the Sudan and attempted to introduce Sharia Law in
the South, which led to a mutiny in Bor County that was led by Colonel John Garang
and which later spread to eventually become the longest civil war in the modern history
of Africa. The conflict spawned the SPLA and resulted in the loss of more than 2 million
lives before a peace treaty was signed on 9th January 2005 in Machakos, Kenya. Before
the civil war ended, contemporaneous insurgences raged on in the West (Darfur) and in
the East (Kassala), and have persisted to date.
The current political boundaries of Greater Darfur were curved out after the
implementation of the federal system in Sudan in 1994. The region was split into three
states: North, South and West Darfur, and each state was divided into jurisdictions
called Mhalia which are led by the equivalent of a commissioner. The population of
Greater Darfur is about 5.9 million people, with South Darfur being the most densely
populated with about 2.8 million people followed by West Darfur and North Darfur with
1.6 and 1.5 million respectively.
The current conflict in Darfur begun in April 2003 when the Sudanese Liberation
Army (SLA) attacked an airport in El Fasher, the capital of North Darfur, and took over
the vital military outpost, destroying government military aircraft and killing around 100
government soldiers (Coalition for International Justice, 2006). This signaled to the

9

government that the SLA could no longer be considered an outfit of bandits, but rather
had become a serious contender of political capital in Darfur.
Introduction
The complex humanitarian emergency and crisis in Darfur has both been
described as the worst humanitarian crisis in the world. In February 2004, the term
“genocide” entered the international legal and political lexicon describing the Darfur
crisis. The conflict is characterized by many facets that make it complex and multi-
dimensional: with fighting going on between government forces and different rebel
groups, among different rebel groups, between elements of the same rebel group
(SLA/M), between different tribal elements, between nomads and sedentary tribes,
between the notorious government allied militia (Janjaweed) and “African tribes” etc.
Like many African conflicts, the root causes of the conflict could be traced as far back
as the 19th century, and they include economic and political marginalization, an
environment that produces ethnic and armed militia and manipulation of ethnic identities
by the GOS which led to a collapse of institutions and development (Young et al,
2005)1.
Information on affected and displaced people from the Darfur Humanitarian
profiles and other sources indicate that the insecurity and conflict was on the increase
from the start of the conflict to the end of 2005. The number of displaced people
increased from about 140,000 in 2003 (Guha-Sapir and Degomme, 2005)2 to 1.8
million by 2005, while the affected population increased from about 500,000 to 1.8
million people from the end of 2003 to the end of 2005 (Darfur Humanitarian Profiles).
The humanitarian response in Darfur has been hampered by insecurity, travel
restrictions for aid workers imposed by the GOS, denial of access to vulnerable people
by rebel groups, poor infrastructure and lack of access to vulnerable people during the
rainy season and killings of both humanitarian aid workers and peace keepers.
The WFP begun to deliver food in Darfur in 2002 under the pre-existing
Operation Lifeline Sudan (OLS) and scaled its operations in June 2003. In April 2005, a

1 Young, H., Osman, A.M., Aklilu, Y., Dale, R., Badri, B. and Fuddle, A.J.A. (2005) Darfur –
Livelihoods under Siege. Feinstein International Famine Center, Tufts University.
2 Guha-Sapir and Degomme (2005), figures given for September 2003

10

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