SAHEL NUTRITION SURVEY

1974

Theodore I. Kloth, M.D. Medical Epidemiologist Bureau of Smallpox Eradication Center for Disease Control Atlanta, Georgia 30333

Field Investigators

Winthrop A. Burr, M.D. Jeffrey P. Davis, M.D. C Gary Epler, M.D. , Cornelius A. Kolff, M.D. Robert L. Rosenberg, M.D. -'

C. C.

ifs rr~k n r4V Algiers TUNISIA

SPANISHEALGERIA Cairo

SAHARA CAPE VERDE IS. ENEG. Khartoum Dakar THE GAMBIA SUDAN F.T.A. Banjul anjul GUNADiot GUINEA*I1SSALBrssau" Conakry DAHOMEYPorto Nov•M o ETHOPIA

Freetor IVORY NIGERIA SIERRALEONE COAST GHANA Lagos Mono a Abidjan Acca CENTRALAFRICAN TOGOCMEC REPUBC RaoundI QUATORIALGUINA

Maab eBAND

Kishs Bu.m =. :r • t' MBA TAAI ZANOB

Lome~ig Maqe e rea• Dares~aa

ANGOLAAN 04MLAA"

Maseru As a result of severe drought and resultant crop failures for the past several years, superimposed on demographic and agricultural changes in the area, inhabitants of the West African Sahel* have been subjected to food shortages which-have resulted in increased malnutrition. During times of food scarcity, certain customs of West African culture may dictate that children receive less than their proportionate share of food. Young children, as a result of their rapid growth rate and their increased susceptibility to infection, are at a greater risk than adults to the effects of nutritional depiivation. Body measurements of children are con­ sidered a sensitive index of nutritional status and growth patterns are likely to be significantly different from normals if undernutrition is present; anthropometrics of children are accordingly central to this survey.

Height and weight are the two most commonly used measures of physical growth, and with sufficient care and adequate instruments, accurate measure­ ments can be made on many children in a relatively short time. Observed height and weight are commonly compared with expected age specific values.

Height for age is observed height in relation to expected height of a reference child of the same sex and age. Chronic undernutrition results in

linear growth retardation ("stunting" - a deficit in height for age) often

.accompanied by a proportionate failure to gain weight. Weight for age is observed weight in relation to expected weight of a reference child of the

*The Sahel is both a climatic region and a vegetation zone which lies immediately south of the Sahara, from the Atlantic Ocean on the west to the Red Sea on the east. It begins at approximately 15 degrees north and extends northward in most areas for about 300 miles to 20 degrees north latitude. 2 same sex and age. This index, weight for age, consists of two separate nutritional states - chronic undernutrition (as described above) and acute undernutrition. Acute undernutrition results in a loss of body weight which is disproportionate to body length ("wasting" - a deficit in weight for height). Therefore, in order to identify more clearly the effects of acute undernutrition (wasting of body mass) that may be superimposed upon a population suffering from chronic undernutrition

(stunting of body length), it is more useful to emrloy weight for height determinations, i.e. observed weight in relation to expected weight of a reference child of the same sex and height.*

The advantages of this last anthronometric index, weight for height, are multifold. First, it is nearly impossible in rural West Africa to ascertain exact ages of children (which are obviously necessary in the determination of weight or height for age.) Secondly, weight for height has been found to be relatively independent of sex, race, and age (up to about age 10). Repeated observations have shown that well-nourished African children do follow the western standards of weight for height reference data.

In other words, in young children, weight for height remains quite constant under most conditions except acute undernutrition (and overnutrition) and is thus a most useful anthropometric index in disasters in which food scarcity and famine are prominent.

*The weight for height reference values used here are the age specific median values for weight and height of the Stuart-Meredith reference population. 3

The criterion in this study for the "acute malnutrition threshold"

(AMT), below which a child can clearly be considered to be undernourished, has been designated as 80% of the median weight for height values derived from the Stuart-Meredith reference population. Because this value closely approximates the third percentile of the Stuart-Meredith reference population within this age range, about 3% of a normal population would be expected to fall below this level. Any appreciable excess over 3% below the AMT (80%) is therefore indicative of a population which has

recently been subjected to food shortage. In this study, the nutritional

status of a population group will also be characterized by calculating

the mean of all of the individual percent of median weight for height

values. For convenience, this "mean percent of median" weight for height will be designated the MPM.

The following report represents the latest information on the current nutritional status of inhabitants of certain defined regions in five

Sahelian countries - Chad, Niger, Mali, Mauritania, and Upper Volta. It

is the first nutrition related study that examines certain regions of

these countries suspected to be affected by the drought by a systematic

probability random sampling method, and as such contains information which

may validly be extrapolated to that part of the country from which the

sample was chosen.

Methods

The problems of obtaining adequate population data for establishing

a statistically sound sampling base are particularly difficult in the 4

West African Sahel, where census data and registration systems are inadequate at best. Nevertheless, attempts were made to obtain the most up-to-date census information available so that a systematic probability sample could be drawn.

The initial step was to specify and limit the universe from which the sample was to be drawn, with the understanding that all extrapo­ lations and conclusions from the data would be applicable only to that universe. The sampling methodology was geared to producing estimates for the aggregate drought affected area sampled within each country.

Estimates for subsets of these areas, therefore, cannot be statistically reliable due to an insufficient number of clusters within these subsets.

Furthermore, the group of children drawn from an individual village are not necessarily representative of that village but are simply a geographic clustir which when taken collectively with all clusters, are representative of the sample area. In some cases the report touches on large differences between regions within a country. Although not statistically valid, they suggest hypotheses which could be tested with more extensive sampling.

The inability to reach all of the selected villages within the sample represents potential bias in the estimates made for the universe.

Population estimates for the total area and for the divisions within this area were obtained, although it was recognized that within some areas only the crudest population estimates would be available. The number of sampling units per major division was computed based on population proportions in each division. This division was then visited 5

and individual village population data, again based on best available

population estimates, was cumulated and the sampling unit selection made by systematic interval selection. Once within the village, the in­ vestigator selected a random starting point. He then went house to house, in an orderly fashion, and measured all children 65 centimeters to

115 centimeters, (about 6 months through 6 years of age). Twenty-five

children were examined in each cluster. If less than 25 children were

found in the village, the investigator moved to the geogranhically

nearest village and continued the process until 25 children were measured.

In addition to gathering the heights, weights, and ages (when

known) of the 25 children in each village, certain additional information was recorded. General information about the village was usually obtained

from the chief in collaboration with the elders. More specific information was gathered from individual households. Anecdotal information sought

included the number of children examined who had evidence of avitaminoses,

the number of individuals in the sample households and the village, the

number of cases of measles and deaths in the sample households and the

village, the amount and type of food available, the presence or absence

of relief supplies, the frequency of relief operations, and the nresence

of any other serious infectious disease currently present in-the village.

This information-was obtained without random samnling methods and without

specific judgemental criteria. Therefore, while it contains useful in­

formation, broad inferences based on this material should be avoided. 6 The areas designated for study in this survey are noted in Figure I.

They include: Chad, the prefectures of Kanem and Lac;

Mali, the cercles of Keyes, Yellimane, Nioro in the Kayes

Region, Nara in the Bamako Region, and Gourma Rharous, Gao and Ansongo in the Gao Region;

Mauritania, specific areas within Regions I through VII;

Niger, the Departments of Niamey, Dosso, Tahoua, Maradi,

Zinder, and a portion of Agadez; and

Upper Volta, the cercles of Djibo, Barsologho, Kongoussi,

Dori, and Ouadalan.

Results - General

Within the sampled portions of the Sahellan countries, a total of

3,928 children between 65 centimeters and 115 centimeters were evaluated with regard to weight and height. Twelve and seven-tenths percent (497 children) were found to be less than 80% of the median weight for height; i.e., below the Acute Malnutrition Threshold (AMT). Specifically 10.7%

(67/6251:of the children examined in Mali, 9.9% (87/875) in Mauritania,

11.4% (88/774) in Niger, 9.1% (80/875) in Upper Volta, and 22.5% (175/779)' in Chad were below the AMT (Table 1). The difference in the prevalence of acute undernutrition between children in Chad and the other countries is statistically significant (p <.001), The analysis of the mean percent of the median (MPH) lends further credence to the impression that the prevalence of undernutrition is much greater in Chad than in the other

Sahel countries surveyed. Indeed, the mean percent of the median weight for height for the children in Chad was 85.6, while the MPM in Mali was 90.2, in Mauritania 89.7, in Niger 89.9, and in Upper Volta 90.6 (Table .1). 7

Additional perspective on the amount of undernutrition in the Sahel can be gained by looking at Table 2, which categorizes the reference popu­ lation by decile; that is, 10% of the reference population children, based on weight for height, are allocated to each decile, from the lowest-10% to the highest 10%. If the children measured in each country had the same level of nutrition, based on weight for height status, as the reference population, then 10% of these children would be expected to fall in each decile. It is obvious that children in the Sahel do-not follow the normal distribution.

While in the field, the CDC investigators noticed that as expected, the younger children seemed to have a greater prevalence of undernutrition than the older children. We evaluated those children under 85 cm (who have a maximum age of approximately 2 1/2 years) and those children over 85 cm separately and then compared them (Table 3). In this year's five-country

Sahel Nutritional Survey, 12.7% (497/3,928) of the children were found to be below theAMT, weight for height. While only 8.0% (212/2,636) of the older children were below the AMT, 22.1% (285/1,292) of the younger children were below the AMT. These totals may even underestimate the differences in undernutrition between younger -and older children. This is because of the inclusion of the children in Kanem and Lac in Chad, where 22.5% (175/779) of the children were found to be below the AMT. If this area is excluded, younger children account for 70% (226/322) of the children below the AMT, while accounting for only 35% (1,094/3,149) of all children measured. The difference in the prevalence of acute undernutrition found in the older children between Chad and the remaining four Sahel countries is significant

(p <.001) but not totally unexpected. In Kanem and Lac despite the marked overall increase in undernutrition, the percent of younger children below 8

the ANT was only about one-third greater than the other countries, but

the percent of older children below the AMT increased 2-1/2 times. It

appears that early in a food shortage the younger children are affected

first, but as the food shortage becomes mare severe the number of older

children affected increases.

Several explanations for the increased number of younger children below the AMT have been offered. One is that older children usually have more antibodies to infectious agents and are therefore less susceptible to

infectious disease, which process itself has been shown to precipitate undernutrition. In addition, older children can compete more vigorously with their younger siblings for available food, enabling them to get more food than they would be proportionately due. Thirdly, even if food were

equally rationed to the children, the same absolute deficit in calories

accounts for a larger proportion of the total intake in smaller children

than in larger children, and this greater deficit percentage-wise probably manifests as a deficit of weight for height more swiftly. Lastly, if the younger and older children were equally undernourished (i.e., at the third percentile of weight for age and height for age) and were then evaluated by

the index of weight for height, an arithmetic artifact results in a lower mean weight for height in the younger children.

Mortality

Households of the children randomly selected for the study were questioned as to the number of people usually residing in the household, by age, and the number of people in the household who had died within the past year, also by age. From this data a crude death rate was formulated.

In two countries, the number of deaths sought were restricted to those 9 occurring in the past month or 2 months. Because the time period of a month might not have been fully realized as to its limitations (versus a year which was reasonably well marked by the onset of the rainy season) and because death rates are usually different during different months of the year in West Africa, we do not recommend extrapolation of these data to a yearly death rate. Accordingly, only estimated mortality data for Chad,

Niger, and Upper Volta will be presented.

In 35 villages of Upper Volta, the sample household population totaled

3,786 people and a total of 111 deaths were identified. The crude mortality rate in Upper Volta was estimated to be 30 deaths per 1,000 people per year

(Table 4). This is comparable to the generally observed death rate of 25 per 1,000 in West Africa.

On the other hand, based on the same household population information, these same calculations estimate crude mortality rates to be 49 per 1,000 in Niger (182 deaths in a sample household population of 3,694) and 49 per

1,000 in Chad (194 deaths in a sample household population of 3,982). In the under-5 age groups, the death rates were significantly higher--68 per,

1,000 in Upper Volta (54 deaths in a sample of 862), 106 per 1,000 in Chad

(102 deaths in a sample of 1,007), and 166 per 1,000 in Niger (119 deaths in a sample of 750) (Table 4), Again, these figures are not based on sound statistical methods and caution must be exercised to limit the extrapolations made from these data.

Discussion

Nutritionally,. the critical months for the inhabitants of the Sahel are from June through August, that period of time immediately before and during th. rany s o efr h hv .y im fp the rainy season and before the harvest. By this time, many of the people 10

have used all of their millet for eating and planting and cannot expect

new food crops until October. To compound this problem, many villages are

relatively inaccessible. during these months because of the heavy rains and

the washed out roads. Consequently, they are cut off from food and relief

supplies. Traditionally, then, this"is the period of food shortages-even

in good years, and the' time when acute undernutrition is most apt to be

present.

The current survey was thus performed during a time when some seasonal

acute undernutrition might be expected in the Sahel. 'Nevertheless, because

the surveyed sample consisted of statistically valid clusters frorm selected

regions, the data compiled can serve as baseline information for future

studies. Comparisons of these data with data of future studies will help

the observer to adequately evaluate the impact of foreign aid (or the lack

---.. LA-apecific- areas, and provide a basis for correction of inadequacies

and discrepancies in food allocation.

In Upper Volta, Niger, Mauritania, and Mali, about 10% of the children

examined had anthropometric evidence of acute undernutrition. In Chad,

over 20% of the children were affected. These children fell below 80%

of the median weight for height level of the Stuart-Meredith reference

population, which approximately corresponds to the third percentile; i.e.,

in a normal population distribution, 3% could be expected to fall below

this level. In our samples from the Sahelian countries, a large excess of

the population, 6 months through 6 years, fell below the AMT, especially in

Chad. The excessive number of children below the AMT is most likely the

result of inadequate nutrition of short duration. This statement by no

means excludes the concurrent existence of chronic undernutrition which causes stunting (deficit in height for age). However, since age can not be determined accurately in the Sahel, the quantitative evaluation of chronic undernutrition is not possible.

In our sample universe of the five Sahelian states studied, consisting of, an estimated population of 6,178,000 people, we estimate (5ased on anthro-. pometrically determined evidence of undernutritton) that between 136,000 and 198,000 children, aged 6 months through 6 years, are now suffering from moderate to severe acute undernutrition (Table 5). This figure does not include an additional number of children below and above these ages or any children outside of the most severely affected regions of the countrv who are also suffering from undernutrition (e.g., places like Chari Baguirmi in Chad). This information is most disturbing and indicates that the number of children in the Sahelaffected by acute undernutrition is excessive.

But, what indeed does this evidence of acute undernutrition mean?

The measurements of weight for height provide an index of the current nutritional status of the subject. The child with a low weight in relation to height has received inadequate nutrition in the period immediately prior to the measurements. If prolonged, this nutritionally deficient diet may result in a failure fo reach the full potential for physical growth.

Furthermore, recent evidence indicates that undernutrition may have other ' ­ concomitant relationships which are even more important than the mere attainment of potential physical stature. 12

In several papers, the synergistic effect of undernutrition and infection has been reported. In Guatemala, Scrimshaw found that "when children were classified into categories of malnutrition...both the frequency and severity of diarrhea increased with the severity of malnutrition." Conversely, Morley has shown that illness, with its concomitant fever, increased metabolic rate, and decreased caloric intake, can often precipitate acute undernutrition in those who are already on the borderline of undernutrition. Puffer and Serrano found that in Latin

American countries, over 35% of childhood deaths implicated nutritional deficiency as an underlying or associated cause, and that if neonatal deaths were excluded,, this rate rose to over 50%. The measles death to case ratios observed in Mali (see Mali section) tend to substantiate-this synergistic effect-between undernutrition and infection. In the eastern region of Gao, that area which was thought to have the worst drought conditions and the severest levels of undernutrition, measles death to case ratios were.almost twice as high as any other region and over three times as high as the most southernmost region, Sikasso, which is thought to have the best nutritional status.

Additionally, several studies suggest that undernutrition is one of-the important etiological factors in defective learning ability and retarded mental development. Undernutrition, especially in children,- is obviously a situation that warrants immediate attention and full remedial measures.

Crude mortality rates were calculated for the countries of Chad, Niger, and Upper Volta. Data from Upper Volta seem to indicate only a slight 13 increase in the crude death rate, whereas the-death rates in Chad and

Niger are almost twice as high as those seen in most of the West African population in "normal" times. This is not unexpected, given the synergistic effects of infectious disease and undernutrition. Although not derived in a potally controlled manner, these estimates are probably useful'for several reasons. First, the household data on which the crude death rates are based were gathered individually from each household. Information about the total number of individuals presently in'the household, by age, and the number of deaths in the household members within specifitc age groups is quite similar in all three countries, and compare favorably to other demographic surveys,performed in West Africa. Thus, the household population data can be ,considered accurate. One might suggest that the number of deaths reported is inflated in order to make the situation appear worse than it is and in so doing, entitle the village to more aid and food relief. This was considered unlikely for several reasons. First, the increase in death rates was mostly in the younger age group (under 5 years). If misinformation about death rates was purposely being given to influence a foreigner's "decision about food relief, all age groups would show an increased death rate, and not only the young children. This is especially true in a culture which values the adult more than the child. Second, these death rate estimates appear to be valid, and if anything, lower than actual, due to the possible under reporting of neonatal deaths. Probably as a result of the very high neonatal death rate and the reluctance of the parents to make an emotional

investment in an infant whose chance of surviving is not great, infants in

West Africa are not usually named until at least 1 week of age. Consequently, 14

the deaths of these babies are likely to be overlooked, and not included in the household deaths reported to the investigator. Lastly, in

Upper Volta, the crude death rate from household data very closely approached the expected death rates of West Africa. The validity of responses to simple questions by a large number of peonle within nations is unlikely to be so different as to-falsely create major differences in death rates observed.

The major argument against the validity of the mortality rates rests on the inability of the resDondents to accurately recall one year. However, people in the Sahel generally-remember the yearly rainy season. Given the time of year when this survey was done, (i.e. immediately prior to and during the rainy season) it seems fair to conclude that recall errors while possibly altering death rates to some slight degree, might have either raised or lowered them, and nonetheless would probably not account for the

two-fold difference observed between Upper Volta and Chad and Niger.

Because of limited funding and manpower; the number of sites visited per country was insufficient to make within-country comparisons. The number of accessible-villages was further limited because of inadequate gasoline, very few good roads, poor cooperation at times, and the onset of the rainy season. Thus, the original decision to limit the study plus

the problems noted above restricted the number 'of villages which were accessible to our workers and made within-country comparisons statistically and inferentially invalid. The data provided are valid therefore only for comparisons between affected arejis of countries, given the limitations of the definition of the saMpling i;rame.

Many will attempt to compare this year's nutritional survey, done T

in June and July 1974, with last year!s study done in July and August 1973.

Inferences drawn from those comparisons will not be well based, as last

-year's samples were.not selected statistically. They were chosen because

they we're thought to be at higher risk for malnutrition, because they were more accessible to .the inves-igotor or because the chiefs of some villages

were friendlier and more wjLling to coonerate than chiefs of other villages.

Fn other words, the villages examined last year are not necessarily

rep csetatie cif a speci'ftmlly deiied universe and are as suah repre­

centative only of tbemselve-u Extrapolations to whole sections of the

cottntr7 or Lhe whole nouuil:v ar.- !hus statistically invalid. t

Bama ,Ouagadoug UPPER VOLTA\\

Figure.I. Sample Universe for 1974 Nutritional Survey in The Sahel Table 1. Distribution of Weights as a Percentage of Median Reference Weight for Given Height for Sampled Areas June - July 1974

No. of Children Percentage of Reference Median Weight for Height Mean % of Country Examined 100+ 95-99 90-94, :85-89 80-84 75-79 70-74 65-69 60-64 (60 <80 Reference

Chad 779 3.7% 7.7% 13.5% 26.1% 26.6% 16.2% 5.3% 0.'8% 0.1% 0.1% 22.5% 85.6%

Mali 625 11.2% 17.1% 20.5% 25.3% 15.2% 7.47. 2.2% 0.6% 0.2% 0.3% 10.7% 90.2%

Mauritania 875 10.4% 15.2% 22.4% 24.8% 17.3% 6.2% 2.3% 0.8% 0.3% 0.3% 9.9% 89.7%

Niger 774 '11.9% 14.7% 21.6% 25.2% 15.2% 7.2% 2.5% 1.0% 0.4% 0.3% 11.4% 89.9%

Upper Volta 875 13.1% 15.4% 23.4% 24.3% 14.5% 7.4% 0.9% 0.6% 0.2% - 9.1% 90.6% Table 2. Distribution of Weights by Percentile of Median Reference Weight for ,Given Height for Sample Area

No. of Children Decilea Examined First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Reference Population* 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

Chad 779 61.2% 19.1% .8.0% 5.1% 2.8% 1.7% 1.2% 0.4% 0.4% 0.1%

Mali 625 35.5% 21.0% 14.1% 10.7% 7.5% 4.3%, 3.2% 2.2% 0.6% 0.8%

Mauritania 875 39.4% 18.1% 15.0% 10.2% 7.0% 5.1% 3.2% 1.4% 0.1% 0.6%

Niger 774 38.5% 20.3% 13.3% 9.2% 6.8% 5.3% 3.0% 2.1% 1.0% 0.5%

Upper Volta 875 34.3% 19.8% 15.9% 9.8% 7.1% 5.6% 4.5% 2.3% 0.6% 0.2%

,a - The First Decile contains the lowest 10% of the reference population and the Tenth Decile contains the highest 10%. *Stuart-Meredith Table 3. Children Below the AMTa for Sampled Areas by Height June - July 1974

Total Children Examied Children Under 85 cm Children 85 cm or More Country Number % Below AMT Number % Below AMT Number % Below AMT

Chad 779 22.5 198 29.8 581 20.0

Mali 625 10.7 186 21.5 439 6.2

Mauritania 875 9.9 303 20.8 572 4.2

Niger 774 11.4 303 20.8 471 5.3

Upper Volta 875 9.1 302 19.9 573 3.5

Total Sample 3,928 12.7 1,292 22.1 2,636 8.0 a AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from .the Stuart-Meredith reference population.

* H W)

Table 4. Estimated Mortality Rates for Sampled Areas of Chad, Niger, and Upper Volta

Estimated Estimated Population Reported Death Population Reported Death Under 5 Deaths Rate a Country ,in Sample Deaths Ratea in Sample Under 5 Under 5

.Chad 3,982 194 49 1,007 102 106

Niger 3,694 182 49 750 119 166

Upper Volta 3,786 ill 30 862 54 68

a - The assumptions are that the'birth rate is 50 per thousand and that half of the biiths and deaths occurred before the mid-point of the year.

N 21

Table 5. Projected Number of Children Within the Samled Areas 6 Months through 6 Years of Age Below the AMT

Population of Percent Number of Individuals Country Sample Universeb Below AMT 6 Mos. through 6 Yrs. c Below AMT

Upper-Volta .533;000 9.1 9,000 - 14,000

Niger 3,362,000 11.4 77,000 - 107,000

Mauritania I163,000 9.9 22,000 - 339000.

Mali 776,000 10.7 15,000 - 25,000

Chad 344,000 19.3 13,000 - 19,000

Total 6,178,000 136,000 - 198,000

a - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for -height.values-derived from the Stuart-Meredith reference population.

b - Does not include refugee camps.

- c - Within the defined universe, 90% confidence limits, assuming 24%° of the population is aged 6 months through 6 years old. The totals are sums- of. the upper and lower limits for the individual countries.

t 22

Chad

The United Nations 1972 projected mid-year population of Chad was estimated to be 3.8 million people. However, the latest available data which had local population counts is the 1968 Chadian census. This

census estimated the total population of Chad to be 3 million people

and contains data from which our population proportional sample is derived.

Since Chad contains a large area of land in-which access is restrict&d to the military only, the universe from which the sample was to be chosen was limited to Kanem, Lac, and Western Chari Baguirmi. The sample universe was then limited to Kanem and Lac because these areas were felt to be the most severely affected by the drought. As there is no food distribution in the rebel areas, save military convoys which travel only to the capitals

of these restricted areas, the Kanem and Lac areas, plus Western Chari

Baguirmi, constitute the geographical area receiving food relief. No food is currently being distributed below Chari Baguirmi although there are rumors that the rice crops are failing and the rice roots are being &aten.

Between 13 and 15 degrees north latitude, 31 villages were visited and

surveyed between May 17, 1974, and July 3, 1974--20 villages in Kanem

(estimated population 155,000) and 11 villages in Lac (estimated population

93,000). Thirty-five villages were originally chosen but four villes

could not be reached because of car trouble, poor roads, and poor information.

Anthropometric Data

Overall, 22.5%. (175 of 779) of sedentary and nomadic* children visited were found to be below the Acute Malnutrition Threshold (AMT)--157 of 655

*Nomads-defined as those groups having no cultivation of millet or sorghum. 23

sedentarists and 18 of 124 nomads .(Table 6 and Figure II). As noted

throughout the Sahel, those under 85 centimeters accounted for more

children below the-AMT than would be expected if rates for undernutrition

were equal in both" the above 85 centimeter and below 85 centimeter groups.

.Whereas only 20.0% (116/581) of the older children were below 'the AMT,

29.8% (59/198) of the younger children were below the AMTI The mean.

percent of the median-reference weight for height for the 779 Chadian

children examined was 85.6--for 655 sedentary children 85.4 and for 124

nomad children 86.7.

In light of these high rates of undernutrition, the CDC investigator

felt that perhaps the drought-affected area extended further south than

originally anticipated. Therefore, based'on the same sampling interval

used for the-original survey (7,000), a population proportional statistical

sample was drawn in Chari Baguirmi (sous-prefectures of rural N'Djamena

and Massakory) between 12 and 13 degrees north latitude. In this area, 13

sedentary clusters (325 children) and one nomad cluster (25 children) were

evaluated on a weight, height, and edema status basis only (Table 7). In

this sample 12.3% (43/350) of the sampled children were below the AMT.

Comparison.of undernutrition between younger and.older children supports

previous observations. Indeed, 23.2% (23/99) of younger children were

below the AMT while only 8.0% (20/251) of older children were below the

AMT. The 11PM of these additional 350 children studied was 88.3. These

results indicate that undernutrition, while not as prevalent as in the Lac

and Kanem regions of Chad, is evident in Chari Baguirmi and comparable to

the other Sahelian countries sampled. 24

Anecdotal Information

No children with kwashiorkor or famine edema were observed, but four

children with marasmus were seen in Moussoro, two of whom had been recent victims of measles. Provisional clinical diagnoses of avitaminosis were made in 1.9% (10/515) of the children examined (5 possible Vitamin C

deficiencies, 3 possible riboflavin deficiencies, 1 possible Vitamin A

deficiency, and I possible Vitamin D deficiency). Except for the one

child with possible rickets in Lac, however, evidence to corroborate a

definitive diagnosis of other vitamin deficiencies was lacking. Neverthe­

less, the very small amount, at most, of vitamin deficiency suggests that

the problem is not"one of a particular micronutrient deficiency but rather

of a general nutritional deficiency. The CDC investigator was impressed

by the number of fruits (especially dates) and other natural foods in many

of the villages. In some villages, these fruits and foods apparently

accounted for more than half of the total nutritional intake and in one

or two villages, they accounted for all the nutritional intake. Perhaps

the large consumption of these foods was responsible for the low level of

specific micronutrient deficiency.

Fifteen of 31 villages, including 4 of 5 nomadic clusters, reported

measles epidemics in the past year, and most of the cases were reported to

be in the 0-4 age group. The incidence appeared to be much higher in the

Nomad population (about 20%) than in the sedentary population (about 5%),

though precise documentation of these data is not available. Although one

or two villages in Kanem reported an increased incidence of measles this

year, the numbers did not approach the epidemic levels seen in 1973. 25

However, deaths related to measles were reported to be high. In the town

of Massakory, there were 41 cases of measles in March and April resulting

in 10 deaths. All of these deaths were in children less than 5 years old

who were -reportedly "undernourished." In other villages, the chiefs

described deaths due to undernutrition, but it was impossible to determine

whether these deaths were attributable exclusively to famine or whether

they were due to concurrent illnesses (such as measles) which were aggra­

vated by severe undernutrition.

In March and April of 1974, there were 75 physician-diagnosed cases

of cholera along Lake Chad (12 were confirmed by positive cultures) resulting

in 21 reported deaths. The goverrnment responded by administering to the

people in these areas 6,330 doses of-cholera vaccine within aimonth, demon­

strating theirability to respond quickly and efficiently to public health

problems. .

Data obtained from the Ministry of Health reveal some very interesting

information. These data, consisting of cases and fatalities for a number

of diseases for the years 1967, 1970, and 1973 are gathered from hospitals,

dispensaries and mobile health teams. This surveillance system has not

varied much over these years, and the data should therefore be comparable.

Fatality per case ratios were tabulated (Table 8) for several diseases.

Many refugees have been incorporated into larger villages or towns,

either joining extended families of tribesmen in existing compounds or in

.mat teats near dispensaries or food distribution centers. The International

Red Cross has set up tents at several important sites (e.g., Mao, Massakory) 26 where open kitchens supply one-half liter of cooked soup or porridge per child every morning. This usually consists of fish protein, enriched wheat flour and powdered milk, when available. Adults are also given wheat flour and milk powder, but preparation of this food must be done by the recipients.

One camp located at Mongo in the heart of "rebel territory" has accumulated 750 refugees in an open plain without shelter. The Red Cross has managed to provide 10 tents (by no means sufficient) , but the government has not established a permanent camp or a kitchen and, in fact, at the time of this survey opposed sending in any more tents.

In Kanem, of 21 villages visited, 9 had received some food relief within the past 4 months, 11 had received some food relief within the past 6 months, and the remaining 10 villages had never received food relief.

One village chief said that he had repeatedly asked for relief but had received absolutely no aid. In Lac, there had been either no relief since

1973 or no relief at all in all villages surveyed. It appears that the system for food distribution affords much room for improvement.

Despite moderate to severe cattle loss, many villages had some small food reserves which in general were adequate for about I week, whil in other villages, a total absence of reserves was noted, indicative of the emergency of. the situation. Some chiefs indicated that they lacked not only food for immediate consumption but seeds for planting as well.

The people along the lakes and the rivers seemed to fare better nutritionally as they had ready access to fertile soil in dried lake beds, a shallow water table, and relatively good access to fish. Indeed, on the 27 way to one of the sample villages, which was located on an island in Lake

Chad, fish were constantly leaping into the boats. The MPM for this cluster of children was 93.3, easily the healthiest cluster seen judging by anthro­ pometric data. The lake has been receding rather rapidly over the years, and tribes which used to live on the lake now find themselves up to 5 miles away from the shore, a distance which renders most of the nutritional values of the lake inaccessible.

Markets generally were active, but except for occasional high-quality foods (milk, peanuts, cereal grains), these were stocked mostly with spices

(pimentos, mint, tea, etc.). 28 Table 6. Identification of Villages Containing the Sampled Clusters in Chad May - July 1974

No. of Sons- Children Prefecture Prefecture No. Village Typea Examined Kanem Mao 1 All Alifi S 25 (Population- 2 Sonda S 25 155,000) b 3 Djougou I S 25 4 Ngailo N 25 5 Guidi S 24 6 Kalia S 25 7 Matay Kabire S 25 Moussouro 8 Bechir S 25 9 Sakerdema S 25 10 Mechia II S 25 i Lekem S 25 12 Ettymia II S 25 13 Birkoloc Rig Rig 14 Arfo I-II S 25 15 Sabourigali S 25 Salal 16 Saff-Rahaye N 25 17 Torosea Dirg N 25 Nokou 18 Kere Kadua N 24­ 19 Arkina S 25 20 Arkineyc Michmire 21 Amjinemi 11 N . 25 22 Rimele S 24 Lac Bol 23 Konkia S 8 (Population- 24 Marakou IIG 93,000) b 25 Tchou Kouli S 25 26 Ira S 25 27 Lougoumi II S 25 28 Boudou-Manga S 25 29 Nguiloudou-Haddad S 25 Ngouri 30 Ngouri Borno S 24 31 Mokor S 25 32 Kourouri S 25 33 Safaye Kindjeram S 25 34 Boltirom S 25 35 Borizaria S 25 Total - Kanem(Population-248 and Lac , )b 779* 0 0 0 *175 were below the AMTd a - Nomads (N) were defined in Chad as those groups having no cultiva­ tion of millet or sorghum. S stands for rural sedentary populations. b - From 1968 Chadian census. c - Villages selected in the sample but not accessible. d - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart-Meredith reference population. 2r FIGURi II. LOCATION OF VILLAGES WHICH CONTAIN THE CLUSTERS SAMPLED IN CHAD (Numbers correspond to villages listed in Tables 6 & 7 for Chad)

KANEM

LAC 16

S15 6 5 4

29.i 3 2 G 1 KE 2772

1

SM L N

I! GJ

CHAD N'DJAMENA1 .. ,BOM, '

// 2/

*M.nssakory Refugee Camp LAtA

@20 - Villages which could not be reached.

F1 -Only 8 children could be examined in this village. Onlyl

LOGO", O~C~ iA L 30

CHAD

LEGEND

PREFECTURES

BORKOU-ENNEDI-TIBESTI MOYEN 'CHARI 1. Ennedi 1.Fort-Archambaumi 2. Borkou 2. Kyabd 3.Tibesh 3.Molesala 4. Kograra BILTINE 1. Iriba LOGONE OCCIbENTAL 2. Arada 1.Moundou 3. Biltine BATHA LOGONE ORIENTAL 1.Oum Hadjer 1. Doba 2.Djada 2. Baibokoum 3. Ati I TANUJILE KANEM 1. Kilo 1.Moussoro 2.Lai 2.le Lac 3. Nord-Kanem GUERA 4. Mao I.Mongo Malfi CHARt BAGUIRMI 2. 1. Bokoro. - SALAMAT­ 2. Massakory.A -a 3. Fort-Lamy -1. Abon-DaFa 4.Massanya 2. Am-Timan 5.Bousso 3. Harazi

MAYO KEBBI OUADDAI L Bongor 1. Adr6 2. Fianga 2. Abeche 3.- Lr& 3.Am-Dam 4. Pala 4.Goz-Bafda 31

Table 7. Identification of Villages Containing the Additional Sampled Clusters in Chari Baguirmi, Chad May - July 1974

No. of Children Prefecture Letter Village Typea Examined

Chari Baguirmi A Foudore S 25 (Population - 9 6,000 )b B Angoudjou S 25 C Diguel S 25 D Logone-Gana S 25 E Meskene S 25 F Ndjamena N 25 G Assoumta S 25 H Tchoukla S 25 I Boutel Wall S 25 J Torora S 25 K Oule-Dadam S 25 L Himera S 25 M Diriti Kangara S 25 N Dagana Bualas S 25 Total'- Chari Bagdirmi 350* *43 were below the AMTC -

Massakory Refugee Camp 35** *,18 were below the AMT a - Nomads (N) were defined in Chad as those groups having no cultivation of millet or sorghum. S stands for rural. sedentary populations. b - From 1968 Chadian Census c - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart-Meredith reference population. 32

Table 8. Reported Number of Cases of and Deaths from Specific Diseases for Selected Years in Chada

1967-1973

1967 1970 1973 D/Cb D/Cb Disease Cases Deaths Ratio Cases Deaths Ratio Cases Deaths Ratio

Tuberculosis 1,666 120 7.2% 1,128 91 8.1% 1,695 105 6.2% Typhoid-Fever 69 1 1.4% 197 15 '7.6% 207 3 1.4% Amebiasis 24,043 164 0.7% 36,599 123 0.3% 35,983 81 0.2% Bac. Dysentery 394 0 138 4 2.9i 25,377 81 0.3% Pertussis 4,327 13 0.3% 2,571 3 0.1% 5,057 26 0.5% Meningococcus 657 129 19.6% 3,721 283 7.6% 2,376 216 9.1% Tetanus 267 101 37.8% 229 81 35.4% 521 229 44.0% Measles (Rubeola) 2,448 21 0.8% 1,814 24 1.3% 8,239 245 3.0% Inf. Hepatitis 10,575 206 1.9% 8,772 195 -2.2% Malaria 87,858 212 0.2% 127,487 110 .1% 99,766 384 .4% Varicella (Chickenpox) 5,287 3 .1% 5,396 1 .1% 4,784 6 .1 Pneumonia 719 11 1.5% 1,085 45 4;1% 3,416 58 1.7% Influenza 8,475 24 2.8% 665 6 .9%

aData from hospitals, dispensaries, and nutritional health units of the Ministry of Health bDeath per case ratio. 33 Mali

Best available data indicate that the population of Mali is about

5.3 million people. The-survey originally was to include samples from the area thought to be most affected by the drought, specifically any area receiving food relief. However, because of the large physical area, the availability of only one survey team, and the lack of interest and help generated by local U.S. and Malian officials, the sample frame was restricted to the cercles of Kayes, Yellimane, Nioro du Sahel (Kayes

Region) and Nara (Bamako Region) in the western part of the country and

Gao, Ansongo, and Gourma-Rharous (Gao Region) in the eastern part.' The survey sample was then drawn from a universe composed of about 654,000 people (based on 1961 estimates, which at the time of -sampliig were the only available data) and located between 14 and 16 degrees north latitude.

Initially, 35 clusters were included in the survey based on relative populations of the areas, but because of logistical problems, gasoline shortages, time, limitations, and mechanical problems, only 25 clusters were sampled (Table 9 and Figure III). The survey was performed between

May 17, 1974 and June 29, 1974.

Anthropometric Data

Overall 625 rural sedentary children were measured and weighed

(Table 9). Sixty-seven or 10.7% *ere below 807. of the median weight for height level derived from the Stuart-Meredity reference popula­ tion, i.e., below the Acute Malnutrition Threshold (AMT). Of those children under 85 centimeters, 21.5% (40 of 186) were under the 34-

AHT, while of those over 85 centimeters, only 6.2% (27 of 439) were under

the AMT. The difference is significant (pc.001). The mean percent of

median (MPH) for all sedentary children studied was 90.2.

In the two refugee camps surveyed, located at Gao and Ansongo in the

east, 32 of 150 children were below the AMT. Again, 20 of 49 younger

children were below the AMT while only 12 of 101 older children were below

the AMT.

While there was no apparent difference between the cercles studied,

a difference was noted between the sample clusters in the eastern region

of Gao and the sample clusters in the western regions of Kayes and

Bamako (Table 10). The percent of eastern sedentary children (16% - 40

of Z50) below the AMT was considerably greater than the percent.of western

sedentary children (7.2% - 27 of 375) below that threshold.. A difference

was also noted between the proportion of wasted children in sedentary

communities compared to the children of the camps of Gao and Ansongo.

However, this difference, which indicated less malnutritibn in the seden­

tarists, is evident primarily because of the-more well-nourished western

part of the country, because when the camp children of Gao and Ansongo

were compared to the sedentary children of Gao Region, no difference was

noted. These interpretations are based on numbers which are.too small to

make statistically valid comparisons. The epidemiologist performing this

survey, however, was also impressed by the differences between the eastern

and western sections.

Anecdotal Information

No children with kwashiorkor were seen, but four or five children with 35 marasmus were seen in the camps and three children with marasmus were seen in the rural sedentary population. Although many cases of dry, scaly dermatosis were seen, they could not be ascribed definitely to

Vitamin A deficiency, as other signs of this deficiency (e.g. night blindness, xerophthalmia, keratomalacia, Bitot's sp6ts) were not ob­ served. Similarly, although poor dental hygiene and periodontal disease was common, gingival hemorrhages and hemorrhages into the skin sugges­ tive of Vitamin C deficiency were not noted. No cases of beri beri were observed.

In the western regions studied, measles was encountered only in yellimane, whereas in the east, measles was prevalent in all the cercles surveyed despite reports that a measles vaccination team had been to some of these areas in February. Many of the deaths which occurred in the month or two before the survey were attributed to measles.

According to data provided by Service D'Hygiene, Ministere de la

Sante, Government of Mali, there were 27,496 cases of measles with 1,522

(5.5%) deaths in 1973. Whereas the absolute number of cases was greatest in Mopti, Bamako, Gao, and Segou, death to case ratios were highest in

Gao (129 per 1,000 cases) followed by Mopti (70 per 1,000 cases) and

Kayes (52 per 1,000 cases) (See Figures IV and V). Thus the death to case ratio appears to have been highest in areas thought to have the worst drought conditions and the severest levels of undernutrition.

Measles data were available for only 3 months of 1974, in which period ld,332 cases (vs. 7,422 in first 3 months of 1973) were reported- The reported death to case ratio has climbed from 27 per 1,000 in 1973 to 36

37 per 1,000 in 1974, largely because of the very large increases in Gao and Mopti. Data collection is not standardized and reporting is poor, so that the ostensible differences between regions with regard to number of cases and number of deaths may be an artifact of reporting differences.

Food distribution is under control of the Ministry of Defense, which sells-approximately half the donated grain to defray transportation ex­ penses. Since 1973, food relief has ranged from free monthly distribu­ tion, to monthly distribution for a fee* (usually people are allotted anywhere from 2-6 kilograms per person per month), to no relief at all.

On the whole, food seemed to be available monthly, but often-in less than the quantities needed.

In May 1974, the refugee camp population (there are about 30 camps located in Gao Region)"was said to be about 50,000. By July it had increased to approximately 80,000. The largest camp is at Gao, which had 25,491 people, of whom about 13,000 were children. The doctor at the

camp reported that there was a current measles epidemic despite require­ ments that~all incoming people be vaccinated against smallpox, measles, and cholera. He-reported about 2-3 deaths and about 1,200 visitors to

the dispensary daily. Each family is given a week's ration of grain and small children are fed powdered milk and CSM under the eyes of camp officials.

The Ansongo camp had about 5,000 residents and was increasing in population at a rate of about 50 per week. About 20 people died during

"Money to buy food is obtained by making straw mats (used to make houses and to sleep on) which are sold in Bamako, and from family working in cities. 37 May, according to the Infirmier, but no measles was present. (A measles epidemic ended in December.) The greatest health problem there is felt to be diarrhea secondary to malnutrition. Children in the camp are given meat once a week, fish twice a week, and CSM daily. Table 9.. Identification of Villages Containing the Sampled Clusters 38 in Mali May - June 1974

No. of Children Region Cercle No. Villagea "ExAmined Kayes e 1 Tichy-Gansoye 25 (Populatign- 2 Bougoutrou 25­ 151,000) - 3 Hamdallye (Peuhlis) "25

A Aouruc c B Kakoulou C Balkinkarec Yellimane 4 Diongaga 25 (Population- 5 Sambaga (Sanakole) 25 67,000)b 6 Kirane 25 Nioro 7 Fosse-Faarta 25 (Population- 8 Maouni-Peuhls 25 202,000)b 9 Alahina-Bangassi 25 10 Kamatingue 25 11 Bana 25 12 Sirakoro 25 D Foulanguedou c E Arifounda-Alandc Bamako Nara 13 Bourdiadje 25.- (Population- 14 Kabida-Bambara 25 11g,000 )b 15 Koli 25 F Mourdiah c G Dilly c H Ballec Gao Gao 16 Magna Doue 25 (PopulAtion- 17 Forgo-Sonraii 25 971000)b 18 Kossiakari "2.5

- 119 - Gargouna 25 Ansongo 20 Badji-Gourma 25 (Population- 21 Badji-Hausa 25 67,000)b I Ouatagounac Courma Rharousd 22 Tourchawane 25 (Population- 23 Ghourma-Rharous 25 .72,000)b 24 Gaberi 25 25 Sahamar 25 Total - Sedentary T25* *67 were below the AMTe

Total - Refugee Camps 150** **32 were below the AMT

a - All villages listed are rural sedentary. b - 1971 estimates from Service Statistique, Koulaba. c - Places were inaccessible or, when reached, abandoned. d - Because the cercle of Dire, where 2 clusters were to be studied, could not be reached, I extra cluster was chosen in Gourma-Rharous. e - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart- Meredith reference population. t N FIGURE flI. ' - Location of villages in nutrition survey sample in MALI, 1974. 37 35 36 Numbers correspond to villages listed in Gourma Table 9. Letters correspond to those villages- 34 lharous .originally selected but not reached. Sampling Frame from which clusters- were chosen is- ', Gao (Camp 1) located within heavily odtlined MURrTANIA .areas. N•

I7 P 7 , 33/L... e 21 28 -- Ansngo (Camp 2)

9° 1

GUNA 1 24 NIGER ,L31

KAE1,aes SKSS 4 Yaflil MOPTI 26 N'aoukeG,. ounda 3. Njro 16 Kol-Unea 28 MOpti 6 Bue

BAM KO7.Naa 1. ounta 4. nsng

0. oioro 12 Kngab . 2. To i 19 13. D~o20 23. Macm-a8o

KAYES9. Baaaye . IKS 22. SeafhluOT 6 lfuk A 4 ona 11. Bamaola e 24. Sa s 9 lnn 7 ia 12Kan2aba 2 Teoii.in2.

13. 24 UPan 40

Table 10. Number of children examined and Number below AMT in East and West Malia May - June 1974

Number Location Studied No. (AMT.b

Clusters in the Regions of Kayes and Bamako 375 27

Clusters in the Region of Gao 250 40

Total 625 67

a - The figures for the east and west parts of Mali are not statistically representative of the respective parts of the country. On the contrary, they are groupings of clusters which were chosen to represent the whole. of Mali. b - AMT - TheAcute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart-Meredith reference population. 41

- FIGURE IV, NUMBER OF CASES OF MEASLES IN MALI BY REGION, 1973" 8000­

7000­

6000-

5000­

LC

u0 4000 ­ uJ

300 0.

20000 -

1000-

Kayes Bamako Sikasso "Segou mopti "Gao- REGIONS

Figures reported by The Service Nationale des Grandes Enderles. 42

FIGURE V. NUMBER OF DEATHS PER CASES OF MEASLES IN MALI BY REGION, 1973*

150

140 ­

130

120

,oo_ 1OQ­

- o go (n uJ L 80 ci 0

60­ a. so­ 0, 40- Lu

30;

20­

10­

0

Kayes Bamako Sikasso Segou "-MoptiGao

REGIONS

*Flgures reported by the Service Nationale des Grandes Endemies. 43 Mauritania.

Based on a 1965 census and on population trends prior to the drought, the total population of Mauritania was estimated to be 1.2 million people.

Thiscl6sely corresponds to the mid-year 1972 estimate in the U. N. Demo­ graphic Yearbook - 1972. From this data, a sample frame was established which excluded the city of Nouakchott (population about 120,000) and Region

VIII (total population of 28,000 people, 75% of whom live in one city).

Within this sampling frame the number of clusters per region was determined according to the population proportional method already described. The

CDC investigator then went to the regions to be studied and obtained the names of all villages which-could be reached, given the poor road system,

the onset of the rainy season, and the severe limitation of gasoline. In

this way, 35 clusters, based on the population proportional method, were

drawn from 7 of the 8 regions in Mauritania. The villages from which

these clusters were taken were located between 160 and 200 north latitude.

They were surveyed between May 21, 1974, and July 23, 1974 (Figure VI).

The clusters drawn in Mauritania were classified as nomad, sedentary,

or functionary, based on several criteria. A cluster was considered nomadic (N) if the inhabitants did not engage in farming or agriculture,

if camel or cattle herds were presently or previously tended by the in­

habitants and if the inhabitants were either living in tents 6r had changed

encampment at least once in the last 5 years. A cluster was considered

sedentary (S) if inhabitants engaged in no active herding of cattle (pre­

sently or previously), if the inhabitants primarily lived on agricultural 44 existence (i.e., actively participated in farming) and if they either had

pot changed encampment in the last 5 years or now lived in permanent stone houses or semi-permanent mud strawbrick huts. Functionaries (F) were presently employed by the government or employed in the service connected

or modern sector (e.g., shopkeepers, carpenters, masons, truck drivers,

mechanics, etc.). Eighteen clusters were classified nomad, 16 sedentary,

and 3 functionary.

Anthropometric Data

In total, 875 children were examined of whom 87 or 9.9% were below

the Acute Malnutrition Threshold (AMT) (Table 11). The mean percent of

median for these children was 89.7. Further analysis reveals that 41 of

375 sedentarists, 9 of 75 functionaries, and 37 of 425 nomads were below

the AMT. Again, the small number of children studied precludes statis­

tical comparisons within the country. As noted in other countries, those

children less than 85 cm bore the major brunt of the food shortage in

Mauritania. Whereas only 4.2% (24 of 572 children) of the older children were below the AMT, 20.8% (63 of 303) of the younger children were below

the AMT. The large number of undernourished younger children (when com­

pared to the older children) was also seen when nomads, sedentarists,

and functionaries were examined as separate groups.

Anecdotal Information

Only a few children with marasmus were seen, and no edema or other

evidence of kwashiorkor was found, despite rare reports of the latter near 45 the Senegal River. The chief of the hospital at Nouakchott attributed the lack of kwashiorkor to the nomads' high protein diet of goat milk and meat when it is available. Indeed, although the residents around

Nouakchott have lost almost all their cattle, a large number,of goats remains.

There was little clinical evidence of avitaminosis in children (6 out of 953 examined), and reports of vitamin deficiencies from interviewers, doctors, and dispensaries were very rare. The diagnosis of avitaminosis

A, especially in adults, based solely on a history of night blindness, was the most commonly reported vitamin deficiency. Vitamin B and C deficiencies were less frequently reported.

There have been fewer cases of measles this year compared with 1973.

Regions I, 11, VI, and VII have reported, however, a high seasonal in­ cidence of chickenpox. Other alleged health problems include cholera, hepatitis, meningitis, malaria, tuberculosis, diarrhea, endemic syphilis, schistosomiasis, and pneumonia. The reported numbers of some of these diseases can be-found in Table 12. According to a report by Theodore

R. Flournoy, American Peace Corps Volunteer, who worked with the CDC investigator during the survey and gathered additiohal information on his own, mobile vaccination and medical teams have been active throughout

the country, especially with regard to the care of misplaced nomads. The

exceptions to these active health care teams were found in Akjoujt (Region

VII) where there was inactivity because of lack of nomads and in Kaedi

(Region IV) where there was inactivity because of the lack of gasoline.

Mr. Flournoy further states that according to the directors of the various 46 mobile health teams, and nurses and doctors throughout the country, most regions did not have sufficient medical supplies to last through the rainy season, which ends around the first of October. It seems that Atar

(Region VII) was the only region which seemed to have enough supplies to last through the rainy season.

Food relief varied from adequate weekly rations in Nouakchott, to inadequate relief every 2-4 months or so in the majority of areas. Most areas in Regions I, II, and IV have received no relief since September-

October 1973. The attempt .to locate by region those villages which have­ not received food relief is only an indication of the food relief situa­ tion, i.e., some villages have apparently adequate food relief, although located in regions where food relief had generally been less than adequate.

Food is distributed to the head of a family or tribe based on relevant information, including the number in his family and amount of food needed, contained on a "carte pour vivre," which is essentially a ration card.

Each ihdividual is entitled to five kilograms of food at a cost of 3 UM per kilogram, but those who are unable to pay receive the food at no cost.

According to Mr. Flournoy, most regions (exceptions being III and VII) re­ ceive much less food than they need. He believes that insufficient supply at the regional level is probably due to a number of factors including inadequate gasoline, poor roads, and insufficient food supplies.

Although the CDC investigator had the impression that improved nutri­ tional status seemed to be correlated with food distribution, in fact anthropometric evidence of wasting in those villages which had received 47 aid in 1974 and those which had not received food relief since September-

October 1973 (especially in Regions I, II, and IV) was similar. Relief is sporadic in most villages, and many places which had received relief in 1974 had received only one shipment of food, often some months before the survey. 48 Table 11. Identification of Villages Containing the Sampled Clusters in Mauritania May - July 1974

No. of Children Region Letter Village Typea Examined

VI b A Zum-Zum N 25 (Populatipn-267,000) B Tignairjue N Z5 C Ain Salama N '25 D Tegramane N 25 E Kra Lahmer N 25 P Jedrel Mlhguein S 25 G Tiguent N 25 H Akjoujt N 25 Ib I Oulata F .25 (Population-188,000)b J Nwandar N 25 K Nema F 25 L Bireh N 25 M Timbedra S 25 N Takha N 25 II 0 Aloun S 25 (Population-100,000)b P Benamene N 25 R Salkha N. 25 V1I S Ksar Torchane S 25 (P6 pulationu90,000)b T Tezgrez S 25 U Teyarett S 25

- V Lareiga S 25 (Vopulation-183,000 )b W Botlena S 25 X Seys Becaye S 25 Y Kouroujel S 25 Z Garalla S 25 AA Kankossa N 25 IV BB Mbout Chorfa S 25 (Population~9l,000)b CC Kaedi N 25 V DD Toulde N 25 (Population-217,0O)b HE Thialgoa S 25 FF Sae S 25 GO Tantane S 25 UH Bouhadidea N 25' II Aleg N 25 JJ Aleg F 25 Total 875* (Population-1,136,000)b *87 were below the AMre a - Villages are designated: F-Functionary; S-Sedentary; U-Nomad, according to rationale in text. b - Population estimates are based on the 1965 Mauritanian census and population trends prior to the drought. c - AMT - The Acute Malnutrition Threshold has been designated as '807 of the median weight for height values derived from the Stuart-Meredith reference population. 49

FIGURE VI.

Location of villages in nutrition survey sample in MAURITANIA, 1974.

Letters correspond to villages listed in Table 11.

Sample Frame from whick clusters were chosen is located within

-- heavily outlined areas.

SPANISH SAHARA S FT. GOURAUD MALI

PORT ETIENNE 8 ATAR

ATLANTIC/ OCEAN ; Region 6

ROS GHJALGIOUN O 0 D I FP 0R . 0 NEMA ,fv%- Region 2 L. J!

SENEGAL MALI 50

Table 12. Number of Cases Reported for Specific Diseases Mauritania: 1971-1973

1971 1972 1973

Cholera 1,448 141 150

Pertussis 3,231 4,281 4,992

Hepatitis - - 2,207

Measles 4,903 8,997 15,091

Meningitis 154 18 369

Source: Ministry of Health, Mauritania '51

Niger

The latest available data estimates the 1973 population of Niger to be about 4.3 million people, of whom about 3.5 million are rural seden­ tarists. The sampling frame, from which the clusters were drawn, encompasses an area between 13 and 23 degrees north latitude, and includes the Departments of Niamey, Dosso, Tahoua, Maradi, Zinder, and a portion of

Agadez (Table 13, Figure VII). The Diffa Department and the Bilma and Arlit Arrondissements of the Agadez Department were excluded because of the tremen­ dous transportation problems encountered there during the rainy season.

These excluded areas account for only 3% of the total sedentary population.

The survey was conducted between June 21, 1974, and July 26, 1974.

Anthropometric Data

Overall, 11.4% (88 of 774) of the rural sedentary children evaluated were below the Acute Malnutrition Threshold (AMT) (Table 13). Of 303

-children less than 85 centimeters, 20.8% (63) were below the AMT while of 471 children greater than 85 centimeters, only 5.3% (25) were below the AMT

(Table 3). The difference is significant (p <.001).

The mean percent of median weight for height for all rural sedentary children examined was 89.9. Additionally, 134 nomad children* were examined and 18 were found to be below the AMT. Of the younger nomad children, 10 of 44 were below the AMT, while of the older children, only

8-of 90 were below the AMT. The mean percent of median for nomads was 89.5.

*Nomad children--children of herdsman who had not been sedentarized for 1 year in the place where measurements were taken and who did not intend to remain there. 52

Anecdotal Information

All children who were weighed and measured were briefly examined for physical signs of vitamin deficiency and protein calorie malnutrition.

Four of 774 sedentary children examined and 1 of the 134 nomads had edema.

No children with marasmus were seen. In the four children who had gingival bleeding, Vitamin C deficiency (scurvy) may have been the etiological factor.

However, associated signs and symptoms of scurvy (e.g., hemorrhages into the skin, subcutaneous bruising or bleeding) were not found in these children, making that diagnosis presumptive. Reports of night blindness (especially in adults) were plentiful, but only I child, approximately 18 months old, reportedly had night blindness associated with xerosis. This combination is suggestive of Vitamin A deficiency. In most individuals night blindness was not associated with any other manifestations of Vitamin A deficiency, and definitive diagnoses of this deficiency could not be made with any degree of precision. No other signs or symptoms of specific avitaminosis were detected.

- Measles cases in the past year were reported in 16 of the 35 villages examined, but except for 1 village in Niamey, 2 villages in Maradi, and 1 village in Zinder, these cases occurred 2 or more months before the survey.

No large outbreaks of other diseases were reported but in individual villages there were reports of hepatitis, dysentery, pertussis, conjunctivitis, meningitis, fever, and cough.

For the past 2 or 3 years, and in some areas for the past 7 years, the villages in Maradi, Zinder, and the northern arrondissements in Niamey and

Tahoua have had poor harvests. Consequently, these villages are very

'dependent upon Government of Niger relief supplies. Many of these villages 53 had been unable to save seed for planting this year, and except for wealthy families, food reserves were generally limited to a 1 week supply at most. In fact, food was often secured on a day-to-day basis.

Food availability in the Niamey and Dosso Departments was somewhat better than in Tahoua, Maradi, and Zinder, perhaps one of the reasons why last year's millet was still available in Niamey and Dosso. Active markets existed in all arrondissements especially in larger villages. Some of the smaller markets which were some distance from food distribution centers had

closed.

Emergency foods, generally anza (a wild, pod-covered, seed-like fruit which must be diced and then soaked for 5 to 10 days prior to eating) were gathered in all of the Maradi villages and in most of the Zinder and Tahoua villages. This was also true in Dogondoutchi, Dosso Department, where some of these villages further away from food distribution centers also relied heavily upon anza to supplement their diets.

Throughout the country, millet was expensive when sold at the markets and rice was difficult to obtain at any price. U.S. sorghum was generally

available, either from individual merchants or from supplies designated for sale by the Government of Niger. A certain amount of donated food is

authorized for sale by the Government of Niger in order to pay for adminis­ trative and logistical support of food distribution. Abuse of this system at the local level was not encountered by our teams. In the river areas, a wide assortment of fruits (citrus, mango, banana), grains (millet, sorghum, rice), peanuts, and flocks of poultry were observed. Away from the river, the foods were more restricted, consisting mainly of millet, sorghum, and 54 in the southern regions, peanuts. Goats were plentiful and chickens, though limited, were laying eggs. Cattle were few, but appeared well fed.

The Government of Niger is responsible for the distribution of foods* to the administrative capital of each sous-prefecture. Then government vehicles assigned to each sous-prefect distribute the food to the food distribution areas in each arrondissement, This distribution system is dependent upon available supplies, available transportation and petrol, and niotorable roads (especially during the rainy season). Because of these obstacles, distribution is generally inconsistent. The typical village which requires relief supplies usually does not receive them on any fixed schedule. Indeed, many villages (especially in Zinder and

Maradi) which had received aid within the 2 months before the survey had not received any additional aid before or since that one shipment.

Types of food distributed by Government of Niger:

- U.S. sorghum (a large proportion of total) - French powdered milk - Seed (beans, peanuts, sesame) 55 Table 13. Identification of Villages Containing the Sampled Clusters in Niger June - August 1974

No. of Children Department Arrondissement Letter Villagea Examined Niamey Tera A Teraville 25 (Population- Tera B Firniare 25 828,000)b Tillaberi C Lossa Kadot 25 Quallam D Tinzaou 24 Quallam E Quallam Ville 25 Filingue F Hollo 25 Niamey G Koguiri Bani Koara 25 Niamey H Yeuri 25 Say I Addare 25 Dosso Bobogi J Irrah 25 opulation- Dosso K Tamo Koara 25 582,000) b Loga L Falouel 25 Gaya M Tanda 25 Dogondoutchi N Issakitchi 25 Dogondoutchi 0 Jikata 25 Tahoua Tahoua P Amalloulc (Population- Illela R Azao0 6471000) b Birni N'Konni S Sab6ngaC Madaoua T Arzazori 25 Bouza U Guidan Tabi 25 Keita V Labanda Ic Maradi Dakoro W Guidan Barmo 25 (P-ojulation- Dakoro X Guidan Allo 25 641$000) Guidan Rounji Y Garin Ganaou 25 Madarounta Z Na Ounfana 25 Mayah AA Tchiake 25 Aigue BB Rafa 25 Tessaoua CC Massirida 25 Zinder Matameye DD Dangoudao 25 (Population- Magaria EE Kouara 25 65 6 ,000)b Magaria FF Dogoual Samia 25 Mirria GG Garin Gambo 25 Mirria H{ Hamdara 1 25 Tanout II Tchinboragen 25 Goure JJ Soukounadi 25 Total - Sedentary 774* *88 were below the AMTd

Total - Nomad 134* **18 were below the AMT a - All villages listed are rural sedentary. b - Population based on data from H. Weisler, 1973. Refers to rural sedentary population only. c - Villages selected in sample but not accessible. d - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart- Meredith reference population. FIGURE VII.

Location of villages in nutrition survey sample in NIGER, 1974. L

Letters correspond to villages listed in Table 13. Circled letters were villages selected but not accessible.

Sampling Frame from which clusters were chosen is located within heavily outlined areas.

o032

180 CHAD•

1 9 N7 13XA2.291 5

UPPER 0 NIGERIA VOLTA DAHOMEY ! 141 57

LEGEND

DEPARTEMENTS ARRONDISSEMENTS

NIAMEY I.Tera 2. Tillabed 3. Ouallan 4. Filingue 5. Niamey 6.Say

D0O 7. Bimi N'Gaoure S. Dosso 9. Log 10. Gaya 11. Dogondoutchi

TAHOUA 12. Tahoua 13. Illela 14. Birni N'Konni 15. Madaoua 16. 'Bouza 17. Keita 18. Tchin Tabaraden

MARADI 19. Dakoro 20. Maradi 21. Mayahi 22. Tessaoua

ZINDER 23. Matameye 24., Magaria 25. Myrria 26. Tanout 27. Goure

DIFFA 2. Maine-Soroa 29. N'Guigmi 30. Diffa

AGADEZ 31. Agadez 32. Bilma 58

Upper Volta

According to the latest available census data, the total population

of Upper Volta is 5.5 million. Because the northern part of the country is thought to be the most severely stricken by drought and undernutrition,

the universe from which the sample clusters were chosen was limited to

five northern cercles from Medical Sectors IV, VIII, and IX. The total

population of the sample universe is estimated to be 532,600. The cercles

chosen, approximately located between 13 and 14 degrees north latitude,

included Djibo in Sector IV, Barsologho and Kongoussi in Sector VIII, and

Dori and Ouadalan in Sector IX (Figure VIII). Based on the total popula­

tion of this area, a-population proportional sample of 35 clusters was

drawn (Table 14). The survey was conducted between June 2, 1974' and

June 21, 1974.

Anthropometric Data

overall, 80 of 875 (9.1%) rural sedentary children measured were found

to be below 80/h of median weight for height, the previously defined Acute

Malnutrition Threshold (ANT) (Table 14). When these children were

separated into those less than 85 cm in height and those greater than 85 cm

in height, it was found that 19.9% (60 of 302) of the younger children were

-below the AXT while only 3.5% (20 of 573) of the older children were below

the A1T (Table 3). This difference is statistically significant (p <'.001).

The overall mean percent of median (MP4)weight for height was 90.6%. 59 Anecdotal Information

No children with edema or other evidence of kwashiorkor were seen, but marasmus was noted in three children. In these cases the mothers of these children had been ill and were unable to produce sufficient milk for the nursing infants. The mothers do not share their milk in this culture, and apparently goat's milk was not utilized.

One refugee camp (Bella) was visited but only 14 children were examined. Of these, four were below the AMT. No evidence of kwashiorkor or marasmus was observed.

Generally, an excessive number of deaths were not noted this past year. However, in one village in Dori, 45 children and adults had died in the past few months among the 23 households visited. Fever and a rash (perhaps measles) were implicated in many cases but the precise etiology could not be determined.

No definitivecases of avitaminoses were detected. Measles was­ present in only two of the villages. The most common childhood disease this year was whooping cough (pertussis) which reached epidemic propor­ tions in several villages and reportedly resulted in several deaths.

Malaria was also common, and 164 of 566 children examined (29%) had splenomagaly. Tuberculosis and leprosy were present in most villages.

The food supply varied from large amounts of stored millet in the southern villages to none in the northern areas. In some of the northern villages, people bought food daily and many families were totally depen­ dent on foreign aid. In Kongoussi, 3 of the 11 villages had a poor food 60

supply and were beginning to eat "lamboya," a green, starchy berry only

eaten during periods when normal food stuffs are not available. Some of

the remaining villageshad sufficient millet for planting, but not for

eating, while four to five villages had sufficient millet stored for eating

and planting. In Ouadalan all villages had been receiving monthly aid-

American sorghum and French corn. One of the four villages in Ouadalan

had planted millet, none had millet in storage, and all planned to subsist

entirely on relief food until harvest. In Barsologho, most families had

sufficient millet stored for both eating and planting. Each village al­

legedly obtained American millet, 10 kilograms per person per month, from

the collective in the city of Barsologho. In Dori, one of the nine vil­

lages had a small amount of millet in storage and two of the villages had

completed planting. The remaining villages had no millet in storage and bought their food daily. According to reports money for food was obtained

by selling blankets or goats. Four or five of these villages allegedly

were completely dependent on foreign aid, which amounted to 50.kg of millet

per four people per month. In Djibo, 50 kg of millet were given per 2

people every 2 months. In half of these villages millet remained inthe

homes. The people in the rest of the villages, despite only nominal food

reserves, considered themselves better off than last year because of the

potentially good harvest.

In general, the cattle this year seemed healthy, in contrast to last

year when over half of the cattle died. This probably reflects the marked

decrease in the number of cows since last year, and the concomitant increase

of grazing land and food per animal. Table 14. Identification of Villages Containing the Sampled Clusters 61 in Upper Volta June - July 1974

No. of Medical Children Sector Cercle No. Villapea Examined VIII Kongoussi 1 Namssiguian 25 (Population- 2 Alga 25 174 000) b 3 Robssere 25 4 Kangare 25 5 Sampalo 25 6 Mogo Konkin & Loa 25 7 Gonee & Bodingo 25 8 Ylou 25 9 Hore 25 10 Rouko 25 11 Yoba 25 Barsologho 12 Korko 25 (Population- 13 Zongo 25 55,000)b 14 Dablo-Bangene 25 IX Dori 15 Tieka Liedji 25 (-Population- 16 Bambira 25 127 ,000)b 17 Kabchirga 25 18 Boderigel 25 19 Niagassi 25 20 Kodiolaye 25 21 Tonka 25 22 Diobou 25 23 Dori 25 0uadalan 24 Dembam 25 (Population- 25 Kissi 25 609000)b 26 Ouanare 25 27 Gaigu 25 IV Djibo . 28 Bangaharia 25 (Populatign- 29 Firguindi 25 117,000) 30 Xathe 25 31 Serguissome 25 32 Kelbo 25 33 Kobauoa 25 34 Djiko ,25 35 Arabinia 25 Total 875* *80 were below the AMT0 IV-Ribo: Bella Refugee Camp 14** **4 were below the AMT

a - All villages listed are rural sedentary. b - Adjusted 1972 population estimates based on previous census. c - AMT - The Acute Malnutrition Threshold has been designated as 80% of the median weight for height values derived from the Stuart-Meredith reference population. FIGURE VIII.

Location of villages in tbe.nutrition survey, sample in UPPER VOLTA, 1974. 38 -Vf

Numbers correspond to villages listed in Table 14. 15 NIGER

° Sampling Frame from which clusters 3 A is located within, l8 9 were bhosen 31 37 heavily outlined areas.

2' 36 7

24 20 6

31 29 4 S 13 43 DAHOMEY

TOGO GHANA 28 1

CdTE DVIVOI R E 63 LEGEND

SECTEUR CERCLE 1. Bousse 2. Kombissiri 3. Ouagadougou 4.Sapone 5. Ziniare 6. Zorgo 7. Bogande 8. Diapaga 9. Fada N'Gourma 10. Garango 11. Koupela 12. Tenkodogo IIl 13. Diebougou 14. Gaoua

IV - 15. Djibo 16, Ouahigouya 17. Seguenega 18. Titao V ' 19. Boromo 20. Koudougou 21. Leo 22. Reo '23. Tensdo V; 24. Dedougou 25. Nouna 26. Tomea 27. Tougan VII 28. Banfora 29. Bobo Dioulasso 30. Hounde 31. Orodar VIII 32. Barsologho 33. Boulea 34. Kaya 35. Kongoussi 36. Pissila IX 37. Dori 38. Ouadalan X 39. Gourcy 40. Yako XI 41. Manga 42. Po 43. Tiebele' 44. Zabre BIBLIOGRAPHY 64

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