BBAAKKOOLL RREEGGIIOONN,, SSOOMMAALLIIAA NNUUTTRRIITTIIOONN SSUURRVVEEYYSS && AANNAALLYYSSIISS

APRIL 2000

FINAL

Nutrition surveys in Hoddur, Wajid and Rabdure were undertaken by UNICEF. Food security contextual data, and analysis and interpretation of nutrition data were undertaken by FSAU with contributions from SACB Nutrition Working Group. Final document was produced by FSAU. Bakol. Nutrition Assessments and Analysis. 2000

SUMMARY

Bakol is recognised as one of the most food insecure regions of Somalia. Events in recent years such as successive crop failures and insecurity have demonstrated that the population is an extremely vulnerable one. Health and welfare as well as livelihoods have suffered. One of the more easily measured indicators, nutritional status, has demonstrated this decline most vividly. The community that offers to provide humanitarian assistance to this region faces many challenges. Some of these challenges lie within Somalia. Many other challenges lie within the responsible organisations themselves.

Bakol region has become a focus of attention in recent months due to the steadily worsening food security situation that has resulted in much population movement and continues to threaten the livelihood of around 104,000 people in the region. This paper attempts to review both recent and historical nutrition data from the region and to interpret both the trend and the current situation using information from all accessible sources.

Over the course of six months, during which the food security situation deteriorated steadily (with the exception of some minor relief during the rains in November), three nutrition surveys were undertaken in the region. All surveys demonstrated extremely high rates of global malnutrition with the highest being in Rabdhure with a rate of 30% and the lowest in Wajid at 21%. Hoddur had a global malnutrition rate of 22.7%.

During normal times, malnutrition levels in Bakol region have been within levels considered acceptable for the environment. Malnutrition levels recorded during the three recent surveys in Bakol region have been between twenty and thirty per cent. Many organisations plan an emergency intervention when rates of 15% are seen. Other organisations use 20% as the cut off point. With the exception of one food-aid organisation in Somalia, no organisation questions the seriousness of these levels of malnutrition. By any standards, these levels are unacceptably high and would normally indicate that an emergency response is indicated. An emergency response should consist of general food aid, supplementary feeding, therapeutic feeding and other non-food interventions like health and water programmes.

Since last September, the demand for information on nutrition in Bakol has been high. In the absence of efficient nutrition surveillance systems, this information has largely relied on nutrition surveys. Following the circulation of the ‘Famine alert’ in January, the demand for surveys grew and UNICEF undertook two further surveys in Wajid and Rabdhure. The results were not surprising to those who had recorded the steadily worsening food security situation during the preceding months. The nutrition surveys did not answer the question ‘How bad is the situation in Bakol?’ because this was already known. These nutrition surveys were a reply to anyone who wanted to know ‘What is the extent of the damage already done to children in the region?’

The lack of capacity (caused by time constraints, lack of interest, other overriding influences on decision making) among organisations to understand, digest and critically analyse all available information has led to a tendency to deny or refute reports without attempting to interpret their relevance. The implementation of timely and appropriate interventions has therefore been hampered not only by insecurity and logistical constraints but also by weaknesses in decision making by humanitarian organisations.

This paper does not suggest that food-aid should be the first or only response to such a crisis. It is widely acknowledged those non-food inputs such as water, health services and support for agriculture and animal health are equally critical. However there comes a point when the health and nutritional status of a population is under threat, coping mechanisms are stretched to the point of failure and people are entering a state of destitution from which individuals and families may never emerge. Emergency food and non-food interventions are then required to save both livelihoods and lives.

The paper recommends that we (members of the humanitarian community in Somalia) evaluate events in Bakol, and responses to them in order to identify reasons why serious malnutrition was not prevented. We need to examine reasons for the failure of the humanitarian aid community to understand and interpret early warning systems and food security information. Regional intersectoral co-ordination of activities among

Page 2 of 2 Bakol. Nutrition Assessments and Analysis. 2000 implementing organisations needs to be strengthened. In this situation, donors are the only ones who can demand accountability from humanitarian organisations and this responsibility has to be taken seriously.

Information systems on food security in Somalia are advanced and efficient in comparison to information systems in other sectors – like health. Understanding this information should lead to more efficient and effective programming, but in the case of Bakol, this has not happened. We, the members of the humanitarian aid organisations have a responsibility to ensure that basic minimum standards are maintained in the delivery of services. In the case of Bakol, where lives and livelihoods have been lost and immeasurable suffering has occurred due to malnutrition, illness and displacement, we have to ask if this is really the best we can do. The consequences of such a crisis on the population cannot be measured and yet the hidden costs in terms of lost and damaged lives and livelihoods have to be acknowledged.

Page 3 of 3 Bakol. Nutrition Assessments and Analysis. 2000

Introduction

When it comes to convincing the humanitarian aid community that a serious problem exists, it seems that BBC is still more powerful than early warning systems and nutrition surveys combined. During a recent meeting of humanitarian organisations in Nairobi, the information that a nutrition survey in Rabdhure town had shown a global malnutrition rate of 30% was presented. The representative of one prominent organisation responded, with a shrug of the shoulders, that this was ‘normal’. Many people consider the sound of gunfire normal in Somalia too. Such abnormal and inappropriate responses need to be examined and explained. Difficulties in planning and implementing appropriate actions should be acknowledged, but we cannot continue to deny the existence of problems. Furthermore, a poor response to early warning systems and the demand for evidence in the form of malnourished children, when the problem has already impacted people’s health, demonstrates a continuing weakness in the management and planning of many programmes.

Information systems on food security in Somalia are advanced and efficient in comparison to information systems in other sectors – like health. Understanding this information should lead to more efficient and effective programming, but in the case of Bakol, this has not happened. We, the members of the humanitarian aid organisations have a responsibility to ensure that basic minimum standards are maintained in the delivery of services. In the case of Bakol, where lives and livelihoods have been lost and immeasurable suffering has occurred due to malnutrition, illness and displacement, we have to ask if this is really the best we can do?

Bakol region has become a focus of attention in recent months due to the steadily worsening food security situation that has already resulted in much population movement and continues to threaten the livelihood of approximately 104,161 people in the region. This paper attempts to review both recent and historical nutrition data from the region and to interpret both the trend and the current situation using information from all accessible sources.

Understanding the issues influencing nutrition in Somalia’s most chronically food insecure areas continues to present challenges to those concerned with planning and implementing humanitarian interventions in the country. The challenge includes determining the reality of nutrition status of populations that are often not easily accessed and attempting an interpretation of the results, usually in the absence of even the most basic epidemiological data. Historical information is often available in the reports of ad-hoc assessments that have been undertaken in times of previous crises. Interruptions in humanitarian projects are caused by insecurity and funding gaps/delays.

Background

Bakol region covers an area of approximately 26,000 sq. km. and consists of five districts, Hoddur, the headquarters of the region, Wajid, Tieglow, El-Berde and Rabdhure.1 There are two main food economy groups in the region2, (i) agro-pastoralists, who make up 70-80% of the Bakol population and are predominantly located in Hoddur, Wajid and Tieglow districts with a small proportion found in Rabdhure district and (ii) pastoralists, who make up 20-30% of the population and are mainly located in Rabdhure and ElBerde districts. The urban population (those not involved in crop or livestock production) in this region is negligible, between 0 and 1%.

Accurate population figures are difficult to determine. In August 1995, UNDOS estimated the population of Bakol region was 245,000. UNDOS/WHO/UNICEF estimated the population at 210,000 in 1998. The population size estimated during last year’s polio immunisation campaign was 255,980. Population movement into and out of the region is strongly influenced by food security factors and civil insecurity. With the neighbouring Bay region, Bakol region was the worst hit during a decade of armed conflict. The general

1 UNDOS. Report of the mission to Bay and Bakol Regions. January 2000. UNDP/UNOPS, Nairobi. 2 SCF UK-FSAU. Bakol – The agro pastoral food economy group. Part 1: Background Information. May 1998.

Page 4 of 4 Bakol. Nutrition Assessments and Analysis. 2000 impact has been ‘an extraordinary destruction of infrastructure and little opportunity for economic development, let alone humanitarian assistance’.3

Month Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Season Deyr Jilaal Gu Hagai Deyr

Rain long dry long rains short dry short rains season season

Food Production Sorghum harvest harvest Beans harvest harvest Early maize/beans consume green consume green donkey watermelon

Honey honey - limited honey honey - limited honey domestic wild bees domestic wild bees bees bees Milk camels near farms camels near farms increases availability increases availability of milk milk availability of milk increases Ghee small increase peak season for reduces moderate ghee with availability ghee production production of fodder as lot of milk from crops

Food purchases and market prices Cereal Prices fall Prices rise Prices fall Prices rise following prior to the following prior to the harvest Gu harvest harvest Deyr harvest Livestock Prices increase and peak just before the Haj

Figure 1 ‘The seasonal calendar of food availability’, Bakol - The agro-pastoral food economy group. Part 1: Background Information, May 1998. SCFUK-FSAU.

Chronology of events related to Bakol

Up to September 1999 Bakol region has experienced seven successive below normal harvests with the last three being very acute4. The 1998 gu crop production was the lowest this decade and this was followed by an extremely poor gu harvest in 1999. (The gu harvest usually accounts for 75% of annual cereal production in the region.) The 1999 gu crop failure was not uniform throughout the region, rather crop production deteriorated westwards from Tieglow, with areas of Hoddur and Wajid most severely affected.

September 1999 The interagency assessment in September concluded that the situation would progress from one of chronic to acute vulnerability that could not be relieved until the next gu rains (April to June 2000 forecast to be below average5) and resulting harvest (July/August 2000). The intermediate deyr rains and resulting harvest had the potential to alleviate the situation somewhat. The assessment report concluded that immediate food assistance was required for 76,000 people in the region. FSAU estimated that emergency food needs from September to December at 2,472 MT.

A nutrition survey undertaken in Hoddur by UNICEF, using the standard survey methodology as approved by the SACB showed a global malnutrition rate of 22.7%. This included an extremely high level of severe malnutrition of 7.2%.

October 1999 Most of the region experienced scattered showers, but insufficient rainfall for seed germination. Serious water shortages along the Ethiopian border caused pastoralists to cross the border, particularly in El-Berde district where one drum (200 litres) costs 9,000 Som.Shillings. Food security

3 Interagency assessment. Bay and Bakol. September 1999. 4 FSAU. The Emergency in Bakol. Internal Discussion paper. March 8 2000. 5 FSAU

Page 5 of 5 Bakol. Nutrition Assessments and Analysis. 2000

at household level was below normal, but coping mechanisms still functioned. Locally produced cereal was not available in the markets.

November 1999 Little rain was received during the month of November. The short-term showers slightly improved the livestock condition (except for cattle) in the pastoral zone, but the situation in the agro-pastoral zone deteriorated significantly. Significant water shortages were reported throughout the region, particularly in El-Berde, along the Ethiopian border. An above normal, unseasonal, population movement, particularly from areas experiencing both water shortage and crop failure, started towards the main villages and district centres. Unlike previous population movements, the number of non-Bantu households was very high, indicating that the situation was more serious both in agropastoral and pastoral regions of Bakol.

December 1999 No rains were received during the month of December. Significant water shortages were reported throughout the region, particularly in Hoddur, Wajid, Rabdhure and El-Berde, along the Ethiopian border. Unseasonal, above normal, population movements toward the main villages continued. IDPs were reported to be very weak, and deaths of children were confirmed. A growing number of people were unable to meet their consumption needs, lost their assets and became destitute. Cattle condition was below normal. No crops were reported to be standing. UNICEF installed hand pumps to public shallow wells in Hoddur. The region was relatively calm and stable. Roads were accessible, with the exception of roads in remote areas, where mines are believed to have been buried during the previous conflict. One important road was de-mined by Somali volunteers and experts from neighbouring countries.

January 2000 People and livestock movement (particularly cattle) remained above normal everywhere in the region. Most cattle had been evacuated to other regions. Some camels and goats remained. Food aid distributed in Wajid on the 27th of January decreased the flow of people moving toward Bay and Gedo, except those who moved because of water shortages. Bad nutritional status was reported throughout the rural agro-pastoral villages in Bakol, as well as the cattle pastoral zones. Coping strategies were over stretched.

January 8-15 A rapid assessment was undertaken by senior food-security professionals from FSAU and FEWS after which a ‘Famine Alert’ was issued.

January 26 ‘Bakol Famine Alert’ was issued by FSAU and FEWS. The statement confirmed the deteriorating conditions in the region for the health, nutrition and general welfare of the population and the need for an appropriate and urgent response. Comments in reaction to this alert primarily questioned the validity and credibility of information from Somali sources.

February 1 The humanitarian community met to discuss the situation in Bakol, were unable to interpret the information already available and requested evidence of a problem in the form of malnourished children. UNICEF agreed to conduct nutrition surveys in Wajid and Rabdhure.

February 7-9 Officials from various organisations visited Hoddur and reported that no evidence of a critical situation was seen.6

6 It is generally appreciated among nutritionists that signs of malnutrition in the general population may not be evident to casual observers until the malnutrition rate is over 30%. It is also well understood that the severely malnourished

Page 6 of 6 Bakol. Nutrition Assessments and Analysis. 2000

February 2000 Once again cereal production failed in many of the sorghum growing areas in the region. By mid February 2000, all household food stocks in these areas were reported to be completely depleted and people were relying on food-aid.7. Serious water shortages were reported from the El Barde district, Elgaras and Biyoley sub-districts in Tieglo, and pastoral zones in general. In Wajid and Tieglo, food aid targeting improved. No food aid in El-Berde, Rabdhure and Hoddur. There were reports of a small harvest from ratoon areas, such as in Hoddur and Tieglo, and low harvest from areas planted in Wajid in deyr 1999/2000. The sorghum harvest was a virtual failure, as compared to historical data. No maize, cowpea and any non-cereal crops were harvested.

The nutrition survey undertaken by UNICEF in Rabdhure showed a global malnutrition rate of 30% including 6% severe malnutrition.

March 8 The UN Co-ordination Unit, FSAU and FEWS jointly developed and issued a document8 examining some of the issues arising out of the deterioration in humanitarian conditions in Bakol region, the ensuing early warning alerts issued by FSAU and FEWS, and the initial response of the international community.

March 2000 Food-aid distributions9 reduced internal non-seasonal population movements. Serious water shortages continued throughout the region. The drought in Ethiopia’s zone 5, particularly the Shabelle areas of Kalafe and Mustahil, had a negative impact on Bakol coping strategies. Many farmers engaged in dry sowing and preparing the land, hoping for rain in April. Some experienced lack of seeds, because of crop failures since 1997. Some young calves were slaughtered in order to prolong the lives of lactating cows. This critical intervention was reported from the region in 1974 and 1986 when a significant number of cattle died. Overall, the availability of food and its accessibility was reported to be in crisis in Bakol until the arrival of the gu harvest, which would occur at the end of June – if gu rainfall was adequate and sufficient seeds were planted.

The nutrition survey undertaken by UNICEF in Wajid showed a global malnutrition rate of 21% out of which 3% were severely malnourished.

Water

The UNICEF inventory of water sources in October 199910 stated that ‘the condition of most of the existing water sources with the exception of those recently rehabilitated is deplorable. The civil strife in 1988-1992, followed by rival militia occupation of the region between 1995 and April 1999 saw near total destruction with scorched earth policy applied with impunity in the region. Almost all the existing infrastructures and food production machinery were destroyed not to mention the looting and vandalism of borewells equipment. Borewells power and pumping units were ripped out and carried away or simply disabled, the casings were often filled with stones or in some cases filled with grenades.’

The UNICEF inventory revealed that of the 31 boreholes in the district, only three were functioning, two in Tieglow and one in Wajid. This has had a serious effect on animal health. Lack of water has forced many children, who might be easily recognised as such by the casual observer, will not be found playing in the streets. They will be at home, conserving their energy, in an attempt to stay alive. 7 FSAU & FEWS/Somalia. Deyr 1999/2000 Crop Harvest Assessment Report. FSAU. Nairobi, March 2000. 8 UNCU, FSAU, FEWS. The Emergency in Bakol. Crying Wolf, Early Warning or Normalisation of Emergency Conditions? 8 March 2000. 9 See food aid distribution charts at the end of the document. 10 UNICEF Somalia. Inventory of water sources in Bay and Bakol regions. October 1999. USSC, Nairobi.

Page 7 of 7 Bakol. Nutrition Assessments and Analysis. 2000 animal owners to take their animals out of the region. In the towns, populations depend on water from dug wells. The UNICEF inventory identified problems at many wells that increased the risk of poor sanitation and contamination of supply.

Following this inventory, UNICEF rehabilitated four boreholes in the region. Three of these; Gudo, Wasila and Karkor are situated between Hoddur and Tieglow and the fourth, Kulanjarer is situated between Hoddur and Wajid. Shallow wells were rehabilitated and upgraded in Hoddur and Rabdhure.

ADRA have some plans to improve water availability around ElBerde but at the time of completing this report, the project has not been commenced.

Health and nutrition services

UNICEF supports PHC and supplementary feeding programmes through Community Based Organisations (CBOs) in Hoddur, Wajid, Tieglow and Rabdhure. IMC supports health related activities in ElBerde and plan to resume support to health activities in El-Berde, Rabdhure and Wajid in the near future.

Hoddur Throughout a long period of insecurity period, UNICEF continued to support health and nutrition programme delivery through implementing partners, including community-based organisations. In 1997 the policy changes of UNICEF resulted in its withdrawal from direct implementation of the PHC and EPI programmes. UNICEF started to support the Hoddur Health Authority in November 1998, as the agency responsible for ensuring the effective delivery of essential health services in the town and district. HHA has worked closely with UNICEF during the past two years, in activities including support and supervision of MCH centres, static and mobile EPI services, and UNIMIX distribution.

In September, after community leaders and the RRA administration reported high malnutrition rates in Hoddur town and surrounding areas, subsequently confirmed by UN and INGO emergency assessments to that area, UNICEF undertook a nutrition survey in the town. In November 1999, after an improvement in the security situation in Hoddur town, UNICEF resumed full-scale programme and operational deliveries through the Baidoa Office, with an emphasis on response to emergencies in health and nutrition. Following the training of Hoddur Health Authority staff in Jowhar, a UNICEF needs assessment on provision of safe water and EPI activities with mobile teams was conducted.

Wajid During 1999 and to date UNICEF supports health services in Wajid district through Wajid Health Authority, a Community Based Organisation that runs the MCH in Wajid town, including provision of static and outreach immunisation services. UNICEF initiated supplementary feeding of UNIMIX and BP5 through the MCH centre at the beginning of August 1999 to 1,000 malnourished children under the age of five in Wajid town.

Rabdhure During 1999 UNICEF supported health services in Rabdhure district through IMC in provision of immunisation services through outreach teams. By the end of the year IMC had halted their programme in El-Berde and Rabdhure Districts, resulting in the PHC programme ceasing. As a result UNICEF initiated supplementary feeding of UNIMIX and BP5 through Rabdhure District Health Authority at the beginning of December 1999 to 1,000 malnourished children under the age of five in Rabdhure town and surrounding villages. A total of 90mt of general food was distributed by WFP in Rabdhure District in April 1999.

Food aid11

General food distribution October to December. Estimated needs: 1854MT. Actual deliveries: 305 MT (not including 260 MT that was misappropriated)

11 Please refer to the graphs in the appendix.

Page 8 of 8 Bakol. Nutrition Assessments and Analysis. 2000

Needs reaching target population: 16.5%. January to March: Estimated needs: 2532 MT Actual deliveries: 1186 MT Needs reaching target population 46.8%

Problems with general food aid delivery: November & December. Routes for food delivery to Wajid were inaccessible. November 1999. 340 MT designated for vulnerable groups in Hoddur misappropriated by local authorities. January 1999 Food destined for Tieglow. Convoy attacked three times en route and did not reach destination.

Supplementary food distribution. UNICEF, through local and international partners, has provided supplementary food to all regions during this period.

Problems with supplementary food distribution: The populations in which supplementary food is being distributed have inadequate household food supply and so supplementary rations are usually shared with other family members. The result of this is that the overall impact on malnutrition levels of the target group is minimal, if it exists at all.

Monitoring of supplementary food distribution has faced many challenges due to a lack of implementing partners in key locations.

Nutrition surveys in Bakol

Nutrition surveys 1987 to 1995. In Bakol region, the malnutrition rates evaluated during the pre-war period and especially during the 1987 drought period were relatively low compared to other areas.12 Malnutrition rates recorded in various surveys were as follows: in 1987, Bakol - 11.5% (CDC) and Wajid, Hoddur 6.7% in 1987 and 8.3% in 1998 (UNICEF, SRCS).

In 1992, the region experienced the most serious famine ever recorded. During 1993 and early 1994, surveys recorded malnutrition rates of 22% in Bakol (CPHNSS), 21.3% in Rabdhure and 33% in El-Berde (UNICEF). The effects of the good gu harvest in mid 1994 were reflected in a drop in malnutrition rates to 5% in Hoddur, 5.5% in Tieglow and 4.6% in Wajid during the last quarter of 1994 and early 1995.

1999-2000 Over a six-month period, UNICEF, one each in Hoddur, Wajid and Tieglow, has undertaken three nutrition surveys. Similar methodology and sampling technique was used in all. Surveys followed the SACB guidelines (consistent with WHO guidelines for nutrition assessments), which provided confidence limits of 95% plus or minus 5%.

UNICEF undertook these surveys in order to have a better understanding of the factors affecting the nutrition status of the populations to which they have provided varying levels of health services and supplementary food over a prolonged period. Cluster sampling methodology was used to select and assess children aged 6– 59 months or between the heights of 65 and 110cm. Caretakers were asked if children had received Vitamin A supplement or measles vaccination, or had suffered from diarrhoea or ARI diseases in the two weeks prior to the survey.

An accurate population census could not be undertaken in any of the areas prior to the surveys due to the time limit and lack of resources. The surveys in Hoddur and Rabdhure took place in the town area whereas in Wajid, 22 out of the total of 30 clusters were rural. Due to the low population in Rabdhure town, all children were measured.

12 Cambrezy C. Nutrition Surveys in Somalia 1980-1996. FSAU. Nairobi. February 1997.

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Hoddur nutrition survey 10th – 18th September 1999

Hoddur is the capital of Bakol region and is located 180 km north west of Baidoa and 90 km from the Ethiopian border. It has a population of approximately 10-12,000 people, representing approximately a quarter of the number that lived in the town before its capture by the SNA in January 1996. This incident resulted in displacement of population throughout the region and total collapse of social service deliveries in Bakol region. With the concerted efforts of international, national, local administration and community leaders in the zone, the humanitarian situation improved, in spite of continuing difficulties such as political changes and insecurity.

Hoddur town continues to be one of the urban centres most severely affected by the civil war and subsequent emergencies in Somalia. A UNICEF assessment visit in August 1999, followed by the interagency assessment mission at the beginning of September, indicated that Hoddur town and district may be categorised as a most vulnerable area, according to criteria measuring out-migration, asset loss, crop failure, market access and livestock production.13 Evidence of burned villages, loss of possessions and loss of livestock mean that people in the area have little ability to cope with low food production and high market prices in the near future.

A total of 910 children were screened during the survey. The results showed a global malnutrition rate of 22.7% below –2 Z-scores with 7.2% severely malnourished (5.7% less than –3 Z-scores, plus 1.5% with oedema).

Nineteen per cent of the families visited were female headed. Sixty two per cent of the families were returnees who had been displaced from Hoddur until the RRA recaptured the town, 4% were displaced families from surrounding villages while 34% were residents who had never moved.

Diarrhoeal disease during the two weeks prior to the survey were reported for 17.3% of the children and 38% had ARI during the same period. A total of 11% of assessed children were vaccinated against measles in the previous 6 months, 32% vaccinated against measles before 6 months and 57% were not vaccinated against measles at all. The results indicated very low coverage, due to inadequate EPI service delivery. Thirty eight per cent of the children had received Vitamin A supplements.

Wajid nutrition survey– 14th to 23rd February 2000

Wajid is located 90km Northwest of Baidoa town and 90km from the Somali border with Ethiopia. Around 80% of the population of Wajid District and its satellite villages are pastoralists, while 15% rely on rain fed farms and 5% on small-scale business.

Wajid is one of the districts worst affected by war and drought in Bakol region, resulting in a pre-war population of up to 80,000 people being reduced to approximately 30,000 people by February 2000. Most of the population currently residing in Wajid are internally displaced people from Wajid District and other parts of Bakol region suffering drought, as well as returnees who were displaced during the inter-clan fighting and SNA occupation in Bay and Bakol. At the time of the survey, the population residing in the District was around 30,000 of whom around 6,700 live in Wajid town.

A total of 909 children were screened during the survey. The results of the survey showed a global malnutrition rate of 21% below –2 Z-scores with 3% severely malnourished (2.5% less than –3 Z-scores, plus 0.5% with oedema).

The results showed that 21% of the children were vaccinated against measles in the previous 6 months, 5% were vaccinated before 6 months and 74% were not vaccinated, indicating very low EPI coverage in Wajid

13 UNICEF Somalia. Assessment Report to Bakol Region. August 1999 and Inter-Agency Assessment, Bay and Bakol Regions, September 1999

Page 10 of 10 Bakol. Nutrition Assessments and Analysis. 2000 districts. Cases of measles and whooping cough cases were seen in all rural villages in Wajid district except Wajid town.

Sixty seven percent of the children had been provided with Vitamin A during the six months prior to the survey. This was largely the result of the first and second round of the NID campaign conducted in Wajid district at the end of October and November 1999. The incidence of diarrhoea was 26%, and 17% of children had ARI during the two weeks before the survey.

In February 2000 the number of severely malnourished and kwashiorkor cases reported by the Wajid District Health Authority did not show significant change compared to the previous month of January 2000. A total of 1,000 registered malnourished children are provided with supplementary food on a monthly basis.

Rabdhure nutrition survey – 30th January to 4th February 2000.

Most of the population has been displaced from Rabdhure district and other parts of Bakol region suffering from drought. The pre-war population of Rabdhure was approximately 15,000 with approximately 2,000 remaining at the time of the survey. Since the beginning of December, UNICEF has supported a supplementary feeding programme for children under the age of five.

A total of 498 children between 6 and 59 months or between 65 and 110cm were screened during the survey. The results of the survey show a global malnutrition rate of 30% below –2 Z-scores with 6% (28 children) severely malnourished (4% less than –3 Z-scores, plus 2% with oedema).

Of the children surveyed, 43% had an episode of diarrhoea and 21% an episode of ARI in the two weeks before the survey. Twenty seven percent of children had been vaccinated against measles during the previous six months and 1% before that. Seventy percent had received vitamin A supplements during the previous six months.

Nutrition and health of children in the areas surveyed The nutrition survey Hoddur in September 1999 demonstrated a very high malnutrition rate already at that point. The survey team recommended that food-aid was urgently required and that supplementary feeding programmes should continue in the town and surrounding villages. Food aid needs for the district from October to December were estimated to be an average of 220 MT per month, rising to 293 MT per month for the January to March period. In November, the WFP consignment of 370 MT of food-aid destined for the vulnerable groups in Hoddur was misappropriated and up to the end of March, no further deliveries were made. UNICEF delivered a total of 17.5 MT of supplementary food in November. In the absence of any significant food aid interventions, the health and nutrition status of children remaining in the town can only have deteriorated significantly.

In Hoddur, supplementary feeding might have prolonged the lives of a small number of children but its overall impact was probably insignificant in a population faced with gross food shortage. At the time of the survey a high proportion children (7.2%) were severely malnourished. In a total population of 12,000, one fifth of whom are children under the age of five, this proportion accounts for approximately 173 children. It is difficult to imagine how these children could have made a recovery from this state without extra food and specialised management, neither of which was available in Hoddur in the intervening six months. There is little doubt that the majority of the 172 children, who were severely malnourished in September, if they remained in Hoddur, are now dead. It is also extremely likely that in the absence of an improvement in the food security situation, the condition of many of the children who were then moderately malnourished has worsened considerably. It seems likely that in the absence of food aid in Hoddur, many of the worst off families moved to towns such as Rabdhure where some assistance was available in February.

Following a preliminary review of the results of the nutrition survey in Rabdhure, the Nutrition Working Group (within the SACB) agreed that the malnutrition rates in Rabdhure were very alarming, especially the level of severe malnutrition (6%) which is indicative of the proportion of children facing a high risk of mortality. Despite being identified as a vulnerable population, no general food aid had been delivered to Rabdhure from December to January. Immediate food and non-food assistance was recommended, without

Page 11 of 11 Bakol. Nutrition Assessments and Analysis. 2000 which many children were likely to die. Management and prevention of malnutrition and disease were two high priorities. In February WFP delivered 158.8 MT of food aid. Supplementary feeding has continued in Rabdhure, with a total of 37.5 MT being distributed since November. Supplementary food distributed prior to the February food aid delivery is unlikely to have had a significant impact on the health or nutritional status of young children. Families with no other food will usually share anything that is available – it is unrealistic to expect that they will do otherwise. From February, supplementary food has probably helped in the rehabilitation of moderately malnourished children and some of the severely malnourished children who are not suffering from other medical conditions. The February food aid delivery was be sufficient for approximately two months. This food aid has to continue until the food security of the population improves.

At 21%, the malnutrition rate in Wajid is lower than that in Rabdhure and Hoddur. This lower level reflects the improved access to general food following WFP food distributions, some harvest in the last season in the east of Wajid District, increased access to health services, as well as relative proximity to the main town in the area, Baidoa. Diarrhoeal disease is probably lower in Wajid town due to the large number of shallow wells in the area, providing relatively good access to water. While this rate of 21% is better than the two other areas surveyed, the level still represents an unacceptably high malnutrition rate. Plans for continuing regular food aid and targeted supplementary feeding need to be in place.

The continuing absence of a health information system in Somalia makes interpretation of the influence of various illnesses on malnutrition extremely difficult. Little is known of the normal pattern of common diseases in the region.

UNICEF support to the rehabilitation of wells and other water points in urban areas is likely to have a positive impact on the incidence of diarrhoeal disease, although hygiene and care in the home of small children is equally important. Local health authorities and NGOs need to examine and address the particular factors contributing to diarrhoea in each area. The return of animals to the region as a result of availability of water in the newly rehabilitated borewells will increase access to animal products for families.

At the time of this report, effectively during a period of enormous stress for the population, the lack of implementing partners for UNICEF in the delivery of health services and reduced access to some areas because of insecurity was evident in the low immunisation coverage, inadequate nutrition and epidemiological data and low implementation capacity. IMC’s plans to return to the area are likely to have a positive impact here.

Discussion

Bakol is recognised as one of the most food insecure regions of Somalia. Events in recent years such as successive crop failures and insecurity have demonstrated that the population is an extremely vulnerable one. Health and welfare as well as livelihoods have suffered. One of the more easily measured indicators, nutritional status, has demonstrated this decline most vividly. The community that offers to provide humanitarian assistance to this region faces many challenges. Some of these challenges lie within Somalia. Many other challenges lie within the responsible organisations themselves.

Nutritional status During normal times, malnutrition levels in Bakol region are within levels considered acceptable for the environment. Malnutrition levels recorded during the three recent surveys in Bakol region have been between twenty and thirty per cent. Many organisations plan an emergency intervention when rates of 15% are seen. Other organisations use 20% as the cut off point. With the exception of one major organisation in Somalia, no organisation questions the seriousness of these levels of malnutrition. By any standards, these levels are unacceptably high and would normally indicate that an emergency response is indicated. An emergency response should consist of general food aid, supplementary feeding, therapeutic feeding and other non-food interventions like health and water programmes.

Since last September, the demand for information on nutrition in Bakol has been high. In the absence of efficient nutrition surveillance systems, this information has largely relied on nutrition surveys. Following the circulation of the ‘Famine alert’ in January, the demand for surveys grew and UNICEF undertook two

Page 12 of 12 Bakol. Nutrition Assessments and Analysis. 2000 further surveys in Wajid and Rabdhure. The results were not surprising to those who had recorded the steadily worsening food security situation during the preceding months. The nutrition surveys did not answer the question ‘How bad is the situation in Bakol?’ because this was already known. These nutrition surveys were a reply to anyone who wanted to know ‘What is the extent of the damage already done to children in the region?’

Population movement Population movement in the region is complex and needs to be better understood in order to plan appropriate responses. It is obvious that people from Bakol have moved within districts, within the region and certainly out of the region. We need to determine whether people on the move are the worst off or the better off, whether they are moving as families with children or if families are splitting up. Impact on the points of departure as well as on the point of arrival need to be understood.

Co-ordination and planning among organisations Poor co-ordination among organisations and delays in the processing of funding has caused problems with implementation of vital programmes in the areas of health and water.

Recommendations

1. Evaluate events in Bakol and responses to them in order to identify reasons why serious malnutrition could not be prevented. 2. Examine reasons for the failure of the humanitarian aid community to understand and interpret early warning systems and food security information. 3. Address weaknesses in the capacity of implementing organisations to develop contingency plans for potential crises. 4. In this situation, donors are the only ones who can demand accountability from humanitarian organisations. This responsibility has to be taken seriously. 5. The continued stalling of the process to implement a Health Information System in Somalia needs to be questioned. The ‘responsible’ organisation needs to be held accountable. 6. If good quality nutrition information is not taken seriously, the need for further investment in better nutrition surveillance in Somalia should be questioned. 7. No further resources should be wasted on nutrition surveys in Bakol until it has been demonstrated that a substantial change has occurred in the overall food security situation. No recovery can be expected in the vulnerable populations until this has occurred. 8. Regional co-ordination of activities among implementing organisations needs to be strengthened. 9. Intersectoral co-ordination and communication needs to be strengthened e.g. Water and sanitation committee needs to be represented at the Food Security and Rural Development Committee monthly meeting.

Page 13 of 13 Bakol. Nutrition Assessments and Analysis. 2000

BAKOOL REGION FOOD NEEDS -v- FOOD AID OCTOBER 1999 TO MARCH 2000

BAKOOL REGION - FOOD NEEDS vs FOOD AID (OCT 99 - APR 2000) El Barde - Actual Food Distribution

1000 200

900 180

800 160

700 140

ICRC 600 120 UNICEF ICRC CARE UNICEF

500 MT 100 CARE

MT WFP PROJECTION WFP NEEDS NEEDS 400 80

300 60

200 40

100 20

0 0 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Month Month

Hudur- Actual Food Distrbution Tieglo - Actual Food Distribution

450 300

400 250 350

300 200 WFP-looted ICRC ICRC 250 UNICEF UNICEF MT

MT 150 CARE CARE 200 WFP WFP NEEDS NEEDS 150 100

100

50 50

0 0 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Month Month

Rab Dure - Actual Food Distribution Wajid - Actual Food Distribution

300 180

160 250

140

120 200

ICRC ICRC 100 UNICEF UNICEF 150 CARE MT

MT CARE WFP 80 WFP NEEDS NEEDS

60 100

40

50 20

0 0 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Month Month

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