South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHIILDREN UNDER FIVE YEARS OF AGE

GOGRIAL WEST AND EAST COUNTIES WARRAP STATE

GOGRIAL WEST COUNTY: 30TH JANUARY TO 18TH FEBRUARY 2008 GOGRIAL EAST COUNTY: 14TH FEBRUARY TO 7TH MARCH 2008

Edward Kutondo - NSP Manager Imelda .V. Awino and Joseph Nganga - Nutritionists; Samuel Jikany, Simon Tut Gony, Victor Biar and Gabriel Biar -Program Assistants

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ACKNOWLEDGMENTS

ACF-USA South Sudan would like to express utmost appreciation to the following, without whom the survey objectives would not have been actualized.

™ European Commission Humanitarian Aid Office (ECHO) for the financial support;

™ World Vision International for accommodating the ACF-USA south Sudan team during the survey as well as providing all necessary logistical support;

™ World Vision staffs; Merab Opondo, Lois Miano and Joy Kiruntimi and the ACF-USA south Sudan survey team for ensuring actualization of survey objectives;

™ The Warrap state, Gogrial West and East County authorities for availing relevant planning information for survey implementation;

™ The team members (Measurers, Data recorders and Supervisors) involved in ensuring the survey obtained good quality data;

™ The parents and caretakers for providing valuable information by patiently taking there time to be interviewed and allowing their children to be measured.

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TABLE OF CONTENTS

.I. EXECUTIVE SUMMARY...... 4 .II. INTRODUCTION ...... 7 .III. OBJECTIVES ...... 8 .IV. METHODOLOGY...... 8 .IV.1. Type of Survey and Sample Size ...... 8 .IV.2. Sampling Methodology ...... 8 .IV.3. Data Collection...... 9 .IV.4. Indicators, Guidelines, and Formula’s Used...... 10 .IV.4.1. Acute Malnutrition...... 10 .IV.4.2. Mortality ...... 11 .IV.5. Field Work...... 11 .IV.6. Data Analysis ...... 12 .V. RESULTS OF THE QUALITATIVE ASSESSMENT ...... 12 .V.1. Socio- demographic Characteristics of the Respondents...... 12 .V.2. Food Security...... 14 .V.3. Health...... 17 .V.4. Water and Sanitation ...... 19 .V.5. Maternal and Child care practices ...... 21 .V.6. Education ...... 22 .V.7. Actions Taken by NGO’s and other partners...... 22 .VI. RESULTS OF THE ANTHROPOMETRIC SURVEY ...... 24 .VI.1. Distribution by Age and Sex...... 24 .VI.2. Anthropometrics Analysis ...... 24 .VI.2.1. Acute Malnutrition, Children 0-59 months of Age...... 24 .VI.2.2. Risk of Mortality: Children’s MUAC ...... 26 .VI.3. Measles Vaccination Coverage ...... 26 .VI.4. Household Status...... 26 .VI.5. Composition of the Households...... 26 .VI.6. Distribution by Age and Sex...... 27 .VI.7. Anthropometrics Analysis ...... 27 .VI.7.1. Acute Malnutrition, Children 0-59 months of Age...... 27 .VI.7.2. Risk of Mortality: Children’s MUAC ...... 29 .VI.8. Measles Vaccination Coverage ...... 29 .VI.9. Household Status...... 29 .VI.10. Composition of the Households...... 29 .VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ...... 30 .VIII. CONCLUSION ...... 30 .IX. RECOMMENDATIONS...... 31 .X. APPENDIX ...... 32 .X.1. Sample Size and Cluster Determination- GOGRIAL WEST COUNTY ...... 32 .X.2. Sample Size and Cluster Determination- GOGRIAL EAST COUNTY ...... 34 .X.3. Anthropometric Survey Questionnaire...... 36 .X.4. Household enumeration data collection form for a death rate calculation survey (one sheet/household)...... 37 .X.5. Enumeration data collection form for a death rate calculation survey (one sheet/cluster)...... 38 .X.6. Calendar of events- Gogrial West County – Warrap state; February 2008...... 39 .X.7. Calendar of events- Gogrial East County – Warrap state; February 2008...... 40 .X.8. Food market prices- Gogrial West and East County February/March 2008...... 41

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.I. EXECUTIVE SUMMARY

Introduction

Gogrial West County consists of 9 payams namely; Alek South, Alek North, Alek West, Gogrial, Kuac North, Kuac South, Riau, Akon North and Akon South. The county’s area coverage is estimated at 6400 km² with 643,9401 inhabitants. Gogrial East County is composed of 6 administrative payams namely; Pathuon East, Pathuon West, Toch East, Toch West, Toch North and Nyang Payams, and has a populace of about 216,1792.

The nutrition survey covered all the payams of Gogrial East County and 7 payams of Gogrial West namely; Alek West, Alek South, Gogrial, Alek North, Riau, Kuac North and Kuac South payams. Generally, the region has a flat low lying terrain. The soil is a mixture of sandy and loamy type with portions of clay soil (proportions varying with locality). This soil structure and the terrain predispose the area to flooding more so during the rainy season. Rivers Jur, Nyantit and Malualawein cut across the county and are good sources of livelihood to the community at certain times of the year. The Dinka are the major denizens of the area. Nevertheless the signing of the comprehensive peace agreement (CPA), improved road access and trade in the region has greatly enhanced coexistence with other communities such as Jurchuol, Nuer and traders from other places such as the Equatorial region and Uganda.

Heavy downpour in September – November 2007 led to increased water levels and over flowing of rivers Jur, Malualawen and Nyantit as well as flooding in particularly low lying areas. This consequently affected livelihoods of most households leading to population displacements in these areas. This calamity, coupled with increased population returns to the county is anticipated to greatly exert a lot of stress on the already meager food stocks.

Since 2004, ACF-USA has annually monitored the nutrition situation of this area (see figure 1 below on malnutrition trends reported from ACF-USA nutrition surveys).

GAM SAM 30%

25%

20%

15%

10%

5%

0% Dec-04 Feb- Mar 06 Jan- Feb 07

Figure 1: Malnutrition trends in Gogrial West County expressed in z-score at 95% C.I The analysis of the previous and current malnutrition rates shows a down ward trend. ACF-USA has since established a sentinel site in Gogrial West County (Alek south payam) to timely detect changes in trends for prompt action. The first round of data collected in December 2007 unveiled a GAM of 10.4% (4.1% - 16.7%, expressed in z-scores with 95% C.I.).

WVI conducted a nutrition survey in Gogrial East County in February 2006. Findings revealed GAM and SAM rates of 15.2% (CI: 13.0% -17.6%) and 3.2% (CI: 2.2% -4.6%) respectively expressed in z-scores using NCHS reference, with 95% confidence interval. Reports from WVI indicated that between May and

1 Source: Gogrial West County SSRRC secretary, January 2008 2 Source: Year 2006 figures, SSRRC Office, Gogrial East County 5

September 2007, there was cholera outbreak in the County. The location also experienced insecurity in which three persons lost life in the month preceding November. In view of the potential food insecurity linked to negative effects of flooding and insecurity as well as the need to monitor and augment baseline information, ACF-USA in collaboration with WVI planned to implement a nutrition survey in the two counties with the following specific objectives: ƒ To evaluate the nutritional status of children aged between 6 to 59 months; ƒ To estimate the measles immunization coverage of children aged 9 to 59 months; ƒ To estimate the crude mortality rate through a retrospective survey; ƒ To determine immediate, underlying and basic factors influencing the nutrition situation of the community.

Summary of findings

Gogrial West County

705 children were included in the final analysis after excluding 4 incoherent records.

INDEX INDICATOR RESULTS3 Global Acute Malnutrition 14.5% W/H< -2 z and/or oedema (11.1% -17.8%) Z- score Severe Acute Malnutrition 1.7% NCHS (1977) W/H < -3 z and/or oedema (0.5% - 2.9%) Global Acute Malnutrition 7.7 % W/H < 80% and/or oedema (5.0% - 10.3%) % Median Severe Acute Malnutrition 0.1 % W/H < 70% and/or oedema (0.0% - 0.4%) Global Acute Malnutrition 14.3% W/H< -2 z and/or oedema (10.7% -18.0%) Z-score Severe Acute Malnutrition 2.8% W/H < -3 z and/or oedema (1.5% - 4.2%) WHO (2005) Global Acute Malnutrition 4.0 % W/H < 80% and/or oedema (2.3% - 5.6%) % Median Severe Acute Malnutrition 0.1 % W/H < 70% and/or oedema (0.0 - 0.4%) Global Acute Malnutrition 3.0% (<120 mm) MUAC Height > 65cm Severe Acute Malnutrition 0.4% (<110 mm) Total crude retrospective mortality (last 3 months) /10,000/day 0.21 ( 0.00 – 0.44 ) Under five crude retrospective mortality /10,000/day 0.43 ( 0.00 – 1.18 ) By card4 8.3 % Measles immunization coverage According to caretaker5 50.5 % [N= 649 children>= 9 months old] Not immunized 41.1 %

Table 1: Gogrial West County Results

3 Results in bracket are at 95% confidence intervals. 4 The mass measles campaign card or the Road to health card was checked to verify measles immunization status of the child 5 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker 6

Gogrial East County

A total of 720 children were assessed during the anthropometric survey, however, only 706 were included in the final analysis due to errors in 14 records.

INDEX INDICATOR RESULTS6 Global Acute Malnutrition 13.5 % W/H< -2 z and/or oedema (10.5% - 16.5%) Z- score Severe Acute Malnutrition 0.8 % NCHS(1977) W/H < -3 z and/or oedema (0.2% - 1.5%) Global Acute Malnutrition 6.8 % W/H < 80% and/or oedema (4.9% - 8.7%) % Median Severe Acute Malnutrition 0.1 % W/H < 70% and/or oedema (0.0% - 0.4% ) Global Acute Malnutrition 14.6 % W/H< -2 z and/or oedema (11.3% - 17.9% Z-score Severe Acute Malnutrition 2.1 % WHO(2005) W/H < -3 z and/or oedema (1.0% - 3.2%) Global Acute Malnutrition 4.1 % W/H < 80% and/or oedema (2.4% - 5.8%) % Median Severe Acute Malnutrition 0.1 % W/H < 70% and/or oedema (0.0% - 0.4%) Global Acute Malnutrition 1.8% (<120 mm) MUAC Height >65 cm Severe Acute Malnutrition 0.7% ( <110 mm) Total crude retrospective mortality (last 3 months) /10,000/day 0.17 (0.02-0.31) Under five crude retrospective mortality /10,000/day 0.37 (0.00-0.84) By card7 13.8% Measles immunization coverage According to caretaker8 42.3% [N= 638 children>= 9 months old] Not immunized 43.9%

Table 2: Gogrial East County results

6 Results in bracket are at 95% confidence intervals. 7 The mass measles campaign card or the Road to health card was checked to verify measles immunization status of the child 8 When no EPI card was available for the child at the household, measles vaccination information which was collected according to the caretaker 7

.II. INTRODUCTION

Before signing the Comprehensive Peace Agreement (CPA), Gogrial East, Gogrial West and Twic County were referred to as greater Gogrial. In this report, Gogrial Counties will be used to refer to the areas covered by the survey in Gogrial West and East counties.

Situated in Warrap state, Gogrial Counties border a number of counties as illustrated in the map above. Kuajoc and Gogrial were the state and county headquarters’ respectively.

Gogrial West County consists of 9 payams namely; Alek South, Alek North, Alek West (Alek Payams), Gogrial, Kuac North, Kuac South (Kuac Payams), Riau, Akon North and Akon South (Akon Payams). The county’s area coverage was estimated at 6,400 km² with 643,940 inhabitants.

The total populace of Gogrial East County on the other hand was estimated at 216,1799 and it is composed of 6 administrative payams. These were Pathuon East, Pathuon West (Pathuan Payams), Toch East, Toch West, Toch North (Toch Payams) and Nyang Payams.

The Dinka Bahr el Ghazal clan- Aguok, Awan and Kuac sub clans were the main occupants in Gogrial West County. The major community in Gogrial East county is Dinka Apuk which is divided into Abok, Ador, Amouk, Nyarmung, Biong’, Abior, Bioyar, Apol and Jurmannganger clans.

Rivers Jur, Nyantit and Malualawein which cut across the county support various livelihoods of the community especially at certain times of the year.

The region’s flat terrain and soil structure predisposed it to flooding during the rainy spells as was the case in 2007. In Mid September 2007, flooding occurred in some lowland areas along rivers in the Western Flood Plains submerging homes and low lying crops such as groundnuts. The main rivers overflowed in late September, causing severe flooding in the nearby flatlands and swampy areas. Losses were expected to be grave in low lying areas especially along rivers10.

ACF-USA and WVI have undertaken several surveys in Gogrial West and East Counties so as to monitor the malnutrition trends. Even though the findings indicated a declining trend, all GAM rates unveiled were above emergency thresholds of 15%.

High malnutrition rates unveiled in the past, disease outbreaks, spontaneous returns and the need to evaluate program implementations and impact of floods on livelihoods prompted ACF-USA and WVI to undertake a nutrition survey in the area. Nutrition survey in Gogrial West County was implemented between 30th January and 18th February while that of Gogrial East was undertaken between 14th February and 7th March 2008 correspondingly.

9 Source: Year 2006 figures, SSRRC Office, Gogrial East County 10 FEWSNET September 2007 8

.III. OBJECTIVES

ƒ To evaluate the nutritional status of children aged between 6 to 59 months; ƒ To estimate the measles immunization coverage of children aged 9 to 59 months; ƒ To estimate the crude mortality rate through a retrospective survey; ƒ To determine immediate, underlying and basic factors influencing the nutrition situation of the community.

.IV. METHODOLOGY

.IV.1. Type of Survey and Sample Size

A nutrition survey was undertaken in 7 and 6 payams of Gogrial West and East Counties respectively using SMART methodology.

The local authorities, international agencies working in the area and the prospective surveyors were very instrumental in determining the accessible population. The supervision team’s movement to various areas was also helpful in ascertaining population presence in a few sampled areas. Only accessible areas were considered during planning.

The anthropometric survey targeted children aged 6-5911 months owing to their vulnerability to malnutrition. Thus, all eligible children in sampled households were assessed till a target of 20 was obtained.

Mortality and qualitative data was simultaneously gathered during the anthropometric survey.

.IV.2. Sampling Methodology

A two-stage cluster sampling method was used:

• Cluster selection: The anthropometric and mortality sample sizes were automatically calculated in Nutrisurvey Software October 2007 version after inputting relevant information as tabulated below.

Gogrial West County Gogrial East County Children below 5 yrs of age 73,766 37,781 Estimated prevalence % 22.7 17.6 ± Desired precision % 4.6 4.2 Design effect 2 2 Children to be included 634 626 Table 3: Anthropometric survey planning information

The anthropometric sample sizes were then increased by 10% and 5% respectively to cater for any unforeseen eventualities. Results obtained were then divided by 2012 to obtain the total number of clusters required for the survey. 35 and 33 clusters were sampled for assessment in Gogrial West and East accordingly (Appendix X.1 and X.2).

11 20% of the extrapolated accessible population was calculated to determine the target population 12 For ACF-USA South Sudan: The number of children that can accurately be measured per day per team. 9

Mortality survey planning:

In Gogrial West County, the 2007 January – February mortality survey results and total accessible population were considered during planning. The total accessible population (368,826), CMR13 prevalence (0.89), precision (0.4), recall period (90 days) and design effect (2) were inputted on the same planning template for sample size calculation. The sample size of (4681) was then divided by the total number of clusters (35) to obtain the required number of persons present now per cluster. 134 persons present now were targeted per cluster.

In Gogrial East County; the total accessible population of 188,905 was used in planning. An estimated prevalence rate of 0.8, desired precision (0.4), design effect of 2 and a 94 day recall period were keyed into the planning template. The target obtained (4301) was thereafter divided by the total number of clusters (33) to obtain the required number of persons present now per cluster. 122 persons present now were targeted per cluster.

The prevalence and precision were determined by highest figures that could be expected in these areas, usually guided by past nutrition survey results.

Selection of households and children:

Within a cluster: Only the sampled villages were assessed during data collection. In the clustered village, the EPI method was followed to the letter to determine the starting point. Somewhere near the centre of the village, a pen was spun to determine the starting direction. The team then moved to the periphery along the pointed direction. At the end of the village, the pen was re-spun and a direction obtained. Just like the first stage, the survey team moved along the pointed direction only this time counting all households in that direction to the edge. Simple balloting was used to determine the first household. Mortality and anthropometric questionnaires were administered accordingly and subsequent households determined through proximity or the right principle

Choosing children within the house: In every selected household, all eligible children were assessed till a target of 20 was obtained. In cases whereby the teams only needed one child to attain the target of 20, all eligible children in the next household were measured and not just one. A local calendar of events was used to determine the ages of children.

Formal and informal interviews, observation and structured questionnaires were used to obtain qualitative information so as to determine the immediate, underlying and basic causes of malnutrition within the location.

.IV.3. Data Collection

During this period, anthropometric, mortality and qualitative data was gathered under supervision. Training of prospective surveyors was undertaken so as to ensure quality of data. A lot of practical exercises were undertaken to ensure “hands on” experience on various procedures. Standardization and pilot tests formed part of the training.

The anthropometric questionnaire was administered to all eligible children till a target of 20 children per cluster was obtained. In instances where the anthropometric target was not achieved at the end of the village, the teams moved to the center of the clustered village to identify a second starting point and direction for assessment. If the entire village had been assessed then the next nearest non-clustered village was assessed to achieve the target. Additionally, in circumstances where the teams found eligible children who had just been circumcised, all the other variables were taken save for the weight and reason noted on the anthropometric form. Similarly, households without eligible children remained a part of the “sample” that contributed zero children to the nutritional part of the survey.

13 Crude Mortality Rate 10

The mortality questionnaire was administered in all households irrespective of whether they had eligible children or not. 134 and 122 persons present per household were targeted in Gogrial West and East Counties respectively. Anthropometric and mortality survey household numbers corresponded.

An anthropometric questionnaire (See appendix X: 3) was used to gather various data on the target population. Data gathered included: ª Age: Recorded with the help of a local calendar of events (See appendix IX: 6 and 7). ª Gender: Male or female ª Weight: Targeted children were weighed without clothes using a SALTER balance of 25 kg (precision of 100g). ª Height: Children were measured on a measuring board (precision of 0.1 cm). Children less than 85 cm were measured lying down, while those greater than or equal to 85 cm were measured standing up. ª Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1 cm) using ACF-USA or UNICEF MUAC tape. MUAC measurements of children with deformities were taken on the right hand. ª Bilateral oedema: Assessed by the application of normal thumb pressure for at least 3 seconds to both feet. ª Measles vaccination: Assessed by checking for measles vaccination on EPI cards and probing caretakers. ª Household status: Information was sought on the duration of stay in that area. This was used to determine whether households were residents, displaced, returnees or temporarily in the area.

.IV.4. Indicators, Guidelines, and Formula’s Used

.IV.4.1. Acute Malnutrition

¾ Weight for Height Index Acute malnutrition rates were estimated from the weight for height (W/H) index values and presence of bilateral oedema and compared to the NCHS 14 references and WHO15 standards. The Weight for Height (W/H) index results was then expressed in both Z-scores and percentage of the median.

The expression in Z score not only has a true statistical meaning but also expresses malnutrition rates more precisely. It also allows for inter study comparison. The percentage of the median on the other hand, estimates weight deficits more accurately and is commonly used in determining eligible children for targeted feeding programs.

The following guidelines were thus used in expression of results in Z-score and percentage of the median. Guidelines for results expressed in Z-score: ª Severe malnutrition: - WFH < -3 SD and/or existing bilateral oedema on the child’s lower limbs. ª Moderate malnutrition: - WFH < -2 SD and ≥ -3 SD and no oedema. ª Global acute malnutrition: - WFH < -2 SD and/or existing bilateral oedema. Guidelines for results expressed in percentage of median: ª Severe malnutrition: WFH < 70 % and/or existing bilateral oedema on the child’s lower limbs. ª Moderate malnutrition: WFH < 80 % and ≥ 70 % and no oedema. ª Global acute malnutrition: WFH <80% and/or existing bilateral oedema

¾ Children’s Mid-Upper Arm Circumference (MUAC) MUAC is a useful tool for rapid screening of children under five years of age. Taken accurately, MUAC measurements can be a good predictor of mortality.

14 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 15 WHO Child Growth Standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. Methods and development. Geneva, Switzerland: World Health Organization, 2006. 11

It is important to note that MUAC is a malnutrition indicator in children taller that 65 cm in some protocols, and children taller than 75 cm in others. Thus MUAC measurements of the surveyed children were presented in various height groups of <75 cm, ≥75 cm - < 90 cm and ≥90 cm. MUAC Guidelines MUAC < 110 m and/or oedema severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm Moderate malnutrition and risk of mortality MUAC ≥ 120 mm and <125 mm High risk of malnutrition MUAC ≥ 125 mm and <135 mm Moderate risk of malnutrition MUAC ≥ 135 Adequate’ nutritional status

.IV.4.2. Mortality

SMART methodology was utilized in mortality data collection. A 90 and 94 days recall period were used in Gogrial West and East Counties in that order.

In Gogrial West County, recall period was marked by the death of an intellectual (Martin Malueth) in the area at the beginning of November 2007 while in Lounyaker (Gogrial east) a man was shot to death in mid November 2007.

Obtained data was used to calculate the crude mortality rate (See Appendix .X.4 and .X.5 for mortality questionnaires). ENA16 by SMART Software (October 2007 version) was used in these calculations.

To obtain the CMR the formula below was applied.

Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days (9017/9418) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period

The result is expressed per 10,000 people / day. Thresholds are defined as follows19:

Total CMR: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

Under five CMR: Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

.IV.5. Field Work

The data collection exercise was undertaken under the general supervision of ACF-USA South Sudan team. The field work was undertaken in a number of phases as outlined below: ª Meeting of local authorities and agencies on ground so as to elaborate the teams’ mission in the area. ª Gathering of relevant data and moving to a few sampled villages to ascertain population presence.

16 Emergency Nutrition Assessment 17 Recall period in Gogrial West County 18 Recall period in Gogrial East County 19 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95. 12

ª Selection of prospective surveyors. ª Training of surveyors so as to ensure quality data. As a capacity building initiative due the transition from emergency to development, Sudanese nationals formed the entire enumeration team. The staffs were trained on timely detection of malnutrition. ª Anthropometric, mortality and qualitative data collection. ª Collection of secondary data from various agencies on ground, key resource persons and authority. ª Summation of the nutrition survey exercise.

As a capacity building initiative, Sudanese nationals inclusive of two Ministry of Health (MoH) staff formed the entire survey team. They were trained on SMART methodology as used in implementation of anthropometric and Mortality surveys, and on timely detection of malnutrition.

.IV.6. Data Analysis

The anthropometric and mortality data sets were analyzed in ENA by SMART October 2007 version. SPSS (Statistical Package for Social Scientists) version 10.0 and Microsoft Office Excel 2003 version were utilized for the qualitative data analysis.

.V. RESULTS OF THE QUALITATIVE ASSESSMENT

.V.1. Socio- demographic Characteristics of the Respondents

Gogrial West County consists of 9 payams namely; Alek South, Alek North, Alek West, Gogrial, Kuac North, Kuac South, Riau, Akon North and Akon South. The county’s area coverage was estimated at 6400 km² with 643,94020 inhabitants. Gogrial East County on the other hand has total populace estimated at 216,17921. It is composed of 6 administrative Payams. These were Pathuon East, Pathuon West, Toch East, Toch West, Toch North and Nyang Payams.

Generally, the region has a flat low lying terrain with some exceptionally lower areas that are susceptible to flooding. The soil is a mixture of sandy and loamy type with portions of clay soil (proportions varying with locality). This soil structure and the terrain contribute to severity of flooding due to water retention capacity more so during the rainy season. Rivers Jur, Nyantit and Malualawein cut across the county. These rivers act as good sources of livelihood to the community at certain times of the year.

In this years dry season, majority of the people living in Pathuon and Toch East Payam moved to Toch North, West and Nyang Payams. Areas that were reportedly flooded in the rainy season were Nyang, Toch North, West and East Payams. Organized returnees have been reported to be arriving from other countries through concerted efforts of GOSS, IOM and UNHCR while others have been spontaneous. Registered returnees were 21,897 persons in the year 200722.

The communities living in Gogrial East have had long standing conflict with those of Gogrial West brought about by pasture, land ownership and cattle rustling in general23. This has also incessantly happened with the neighbouring Nuers of Mayom County for similar reasons. The severest clash occurred in May 2007 where 5 persons were killed and 150 cattle taken during the conflict24. As a result of the clashes more than 80,000 persons were reported to have been displaced at that time.25 Peace mediation was initiated in January 2008 under auspices of governor of Warrap state and commissioners of Gogrial East and West. The objectives were to resolve cattle raids, prevent loss of human lives and determine compensation for those who died during the conflicts.

20 Source: Gogrial West County SSRRC secretary, January 2008 21 Source: Year 2006 figures, SSRRC Office, Gogrial East County 22 Source: SSRRC secretary , Gogrial East County 23 Source: SSRRC secretary , Gogrial East county 24 Source: SSRRC secretary , Gogrial East county 25 Source: SSRRC secretary , Gogrial East county 13

The Dinka are the major denizens of the area. Nevertheless the presence of peace, improved road access and trade in the region has to some extent enhanced coexistence with other communities such as Jurchuol, Nuer and traders from other places such as the Equatorial region and Uganda.

The Dinka’s who the major inhabitants of Gogrial West and East Counties are natively agro-pastoralists; cultivating and rearing cattle at the same time and/or cultivators of crops as illustrated in the figure 2 below.

80%

60%

40%

20%

0% Agro- Fishing Crop farming Employment Other

Series1 32.70% 3.60% 65.50% 9.10% 1.80% Livelihoods

Figure 2: Sources of livelihood, Gogrial East County At the time of assessment, however, most cattle had already been moved to the cattle camps (Toics) therefore, their major livelihood base was at risk of being greatly weakened and they had started to rely on other strategies such as petty trade, employment amongst others such as casual labor. Even though fishing was reported to be a source of livelihood to some community members, this was carried out in the swamps in low scale since fishing activities in rivers Nyantit, Jur and Malualawein had been restricted by the authorities till March. As depicted in the figure 3 on the left, 12% of the community had no income sources. Remittance 2% Other than those who

Sale of personal assets 2% relied on employment or casual labor, the better

e Permanent job 14% m part of the community co

n Casual labour 48% I

relied on activities that f Petty trade 4% posed a threat to their ce o r u

o sources of livelihood

S Sale of crops 10% such as sale of crops, No income 12% petty trade such as sale Sale of livestock 8% of the local brew and livestock

Figure 3: Sources of income, Gogrial west, February 2008 The aforementioned activities led to further reduction of the already meager food stocks in most households increasing susceptibility to malnutrition thence the poor nutrition status unveiled. 14

.V.2. Food Security

Food security refers to the availability and accessibility to adequate, nutritious and safe foods at all times that meets all the nutritional requirements of all household members at all times.

A number of factors greatly affected the livelihoods of this community in the past year. These included flooding, disease outbreaks and population returns in the course of the year.

Findings of a one-day inter-agency assessment mission in Warrap State to assess the livelihood conditions of 1,530 IDP households and 2,363 households of spontaneous returnees indicated an urgent need of food assistance. WFP plans to provide them with a three-month emergency food ration.26

The main food sources during the survey period were cultivated crop (previous harvests) (61.8%) wild food27 collection (52.7%) and buying (21.8%) in Gogrial East County. Most (74.0%) households in Gogrial West cultivated food crops such as sorghum (97.3%), maize (35.1%), millet (2.7%) and vegetables (2.7%) in the last growing season. Ground nuts and sismsim were also cultivated. Farm sizes cultivated were smaller in Gogrial West compared to Gogrial East. Smaller farm sizes coupled with the inadequate harvests reported put the community at risk of food insecurity. Reported factors which would be attributed to the poor harvests include floods (especially the low lying areas) (54.1%), insects (54.1%), disease/pest infestation (24.3%) and birds (16.2%) as well as severe winds in Gogrial West. There are members of the community who did not have seeds and worked on farms of the well-off to secure income to buy seeds. As such they delayed their planting when rains had long started and their crops were therefore, at risk of destruction by floods.

The community reckoned the need to provide seeds and equipment, food aid support, land fertilization, expansion of cultivation areas as well as agricultural training (14.0%) to improve food harvests. Introduction of crop varieties was also suggested.

61.8% 70% 60% 52.7% 50% 40% 21.8% 30% 5.5% 20% 3.6% 5.5% 10% 0%

k g ip tion in ing ion h a toc h t s v s uy ec n ti es B ll l iv Fi o Ki Cu L c food ild W Food sources

Figure 4: Sources of Food, Gogrial East County On the other hand, lack of seeds/equipment (53.8%), land (30.8%) among other (15.4%) reasons such as lack of labor were some of the major challenges cited by households (26.0%) that did not cultivate.

Due to the above mentioned facts that hindered adequate crop production, food stocks in most households had either diminished or were on the verge of decline. Survey findings unveil that majority (64.0%) of the assessed households had already completed there harvests with 12.0% having food stocks that would last less than a month in Gogrial West. This adds up to 72.0% of households being at risk of food shortage in the coming months before new harvests are realized.

26 Humanitarian Action In South Sudan, Weekly Bulletin; 26th February to 4th March 2008 27 Dessert dates (lallop) and tamarind (Chuei) and variety of other wild vegetables 15

The prevailing situation of inadequate harvests, food shortages and population returns is anticipated to predispose the community to risks of malnutrition more so as it approaches the hunger gap period when food availability is expected to dwindle as food prices rise. The resilience of livelihoods and people’s subsequent food security determine their health and nutrition in the short term and their future survival and well-being28. Those who did not cultivate in the past season such as returnees largely depended on the host community, food aid (WVI programs on FFR, FFW) and kinship support.

Food aid program had previously been implemented in the region by WVI and WFP through Food for Work (FFW), Food for Education (FFE), Food for Recovery (FFR) and Cash for Work (CFW) modules. In the year 2007, FFW in the area was designed for vulnerable households to participate in various light skilled work and correspondingly ameliorate acute effects of eroded livelihoods. However, constraints were experienced when some of the households could not participate in the program citing inadequate ration sizes which could not meet needs of all household members as opposed to four beneficiaries per household, whom the program has been designed to cater for29. Most of the modules had not yet begun within the county in the current year due to logistical challenges associated with delivery of food30. Most of the households interviewed in Gogrial East reported their current food sources to be foraged wild food (tamarind and lalop) and waning private production. Increasing food prices could also constrain access to adequate food within households.

During the survey period, Wild food collection, sale of firewood/charcoal, meals reduction, food aid, and kinship were the main coping mechanisms employed by the community in Gogrial County.

Gogrial West Gogrial East

Sell charcoal/firewood/grass

slaughter livestock

Sale of capital assets

Kinship

Food aid

Forage for wild fruits

Reduction of meals

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Figure 5: Household coping mechanism It is noteworthy that consumption of wild foods does not necessarily imply food insecurity31, however, when it is coupled with reduction in frequency of meals consumed within the households and is consumed as sole food devoid of variety as was happening in Gogrial west and East Counties; it would be a significant indicator of precarious food security. Similarly, most households were exposed to variety of hazards among them flooding in low lying semi arid plains and conflict especially among the communities that were living on counties’ borderlines. As such, their major livelihood of agro-pastoralism was greatly undermined.

A number of vibrant markets were present in Gogrial West and East Counties. They were vibrant especially after CPA implementation and also, due to good road access. In both counties more than 80% of assessed household had access to markets with most markets situated about an hour away. Households that claimed to have no markets were those who had to walk for long hours to the main market since the “small” markets lacked most necessities. As observed most well stocked markets were positioned along the main highway to Wau or Wunrok as well as major centres of Lounyaker and Liethnom. Food sold included cereals, milk and milk products, meat and offal, fish, oil/fat, sugar/honey and pulses/legumes.

28 SPHERE 2004:Minimum standards in Food security, Nutrition and Food Aid , page 108 29 WVI education sector office. 30 WFP assessment team, Gogrial East County 31 South Sudan Livelihood Profiles, A guide for Humanitarian and Development Planning, 2004 16

The presence of seasonal and permanent rivers provided appropriate fishing ground to the community at certain times of the year. Qualitative survey findings indicated that 60.0% and 80.0% of households in Gogrial west and East Counties respectively, had access to fishing grounds. However, of these households, only a mere 4% and 12.7% correspondingly undertook fishing activities mainly at the swamps. Cited challenges to fishing included government restriction, lack of equipment and lack of enough fish at the fishing point and inaccessibility to fishing grounds. Most of the interviewed households doing fishing were situated n low lands which had wet grounds as well as near the river.

Nets, hooks and spears were the main fishing equipment used by households that fished with drying being the predominant mode of fish preservation. To improve harvest, provision of fishing equipment and education were deemed important by the community.

84.8% 75.8%

36.4% 27.3%

6.1% 3.0% S Y K H E N RS L L R T O A ON I W MI HE SAL T ASI OD DO O WEAL C O SPEC C F O

Figure 6: Livestock derivatives- Gogrial West County Livestock such as cattle, goats and chicken were owned by most households. The livestock that were mainly reported to be at home were goats and chicken. The cattle were at the cattle camp. Figure 6 (Livestock derivatives) above summarizes the main benefits from livestock in the surveyed location. The situation in Gogrial East is similar to the above illustration.

Averagely, most households reported to receive 0.5 (25.0%), 1(42.9%) and 2 (14.3%) liters of milk per day. Livestock mainly (52.0%) were bought or sold at the local markets.

Purchasing power, food availability and accessibility had some impact on the frequency and type of foods consumed by households. Currently consumed meals composed of cereals (88.0%), meat and offals, fish, milk and milk products, and largely wild fruits and vegetables such as tamarind and dessert dates (Lallop) in that order.

WVI, FARM Africa, and ACF-USA South Sudan had programs in Gogrial West and East Counties that focused on food security. Activities centered on provision of basic seeds/tools, promotion of natural resource management/ agro-forestry.

At the time of assessment, the ACF-USA South Sudan Food security team was in the process of undertaking a floods assessment in Gogrial West which had a purpose of identifying the number of households affected and thereafter undertake appropriate needs interventions.

The food security situation of this community is at risk especially towards hunger period. This is mainly due to hazards like floods and conflict in some parts of the area besides attack by pests, and diseases. Floods led to population displacements and destruction of food harvests in the already small farms cultivated in relation to the large household sizes. As such, food harvests in most households were on the brink of completion or had diminished. Coupled with the fact that livestock were at the cattle camps limiting its 17

derivatives, the community is expected to face tough times as it approaches the hunger gap period. Nevertheless, the community relied on wild food collection, sale of firewood/charcoal and cutting of grass, meals reduction, food aid and kinship support for survival.

.V.3. Health

Provision of health services in Gogrial West and East Counties was undertaken by WVI, NCA, and world Relief in collaboration with the Ministry of Health. Impact on health organization operates under auspices of RRP.

NCA supports health services in Gogrial West County and runs 1 PHCC situated in Alek South Payam and 11 PHCUs each located in Keet, Atukuel, Mandeng, Malual Ajak, Mankuac, Anguoth, Panliet, Ayuang, Malualawien, Bau and Pakor villages. One hospital was run by the government in Kuajoc. WVI on the other hand supports 1 PHCC in Ajiep and 3 PHCUs in Thurnyor, Magai and Agei in Gogrial West County. Also, World Vision International (WVI) and world Relief international (WRI) provide primary health care in Pathuon and Toch Payams respectively in Gogrial East County. There are three PHCC; one in Lounyaker (run by WVI) and the other two in Liethnom and Panacier bomas (run by WR and WVI respectively). Additionally, there are more than 17 PHCUs spread in the six Payams of Gogrial East County. Impact on health partners with WVI in providing reproductive health, improves health facilities, by rehabilitating PHCC/Us.

Both preventive and curative health services were offered in the above mentioned health facilities such as EPI, health education, antenatal and post natal care.

Most community members first sought medical attention from the health facilities if they were proximate to them, while some, who were limited by access, sought medical attention from traditional healers. Interviews with key informants and households sampled indicated that distance to health facilities greatly impacted on the health seeking behavior of the community. This is because in instances where the facilities were far away the community first sought medical attention from traditional healers.

Compared to the Nutrition survey done in Gogrial West previous year32 (February 2007), the health seeking practices of Gogrial West community had relatively improved with slightly more than half (52.0%) seeking care from health facilities. A significant number of people (65.5%) sought medical attention from a health facility in Gogrial East County. However, 29.1% of interviewed households still sought treatment from a traditional healer and are mainly those who are far from these facilities.

Reported causes of morbidity of children less than five years were malaria, acute watery diarrhea and respiratory tract infections (RTI) with malaria and RTI’s being morbidity causes amongst adults33. These concur with qualitative findings unveiled by nutrition survey results in Gogrial West County; that diarrhea (86.0%), malaria (58.0%), skin diseases (28.0%) and respiratory tract infections (26.0%) were the common causes of morbidity. Diarrhea incidences could be attributed to unacceptable water and sanitation practices observed within most households. Few latrines were available amongst the community with open defecation practice being the norm. Presumed causes of mortality in the area were malaria and diarrhea infections.

Cholera outbreak was reported in some parts of Gogrial West and East counties, Warrap state in the course of last year. 28 cases and 14 deaths were registered then. The situation was brought under control through collaborative efforts of the State Ministry of health (SMoH) Warrap, NGOs operating on ground and a support team from the Ministry of health Government of southern Sudan (GOSS) 34.

Measles is an infectious and contagious viral disease that has a link to malnutrition. A measles outbreak was reported in the area last year. This prompted the undertaking of a mass measles campaign in March 2007 so

32 Nutritional anthropometric survey children under five years of age, Gogrial West County, February 2007 33 Health officer in charge, Alek and Lounyaker PHCC, March 2008. 34 WHO South Sudan Health Update July- August 2007 (Page 6) 18

as to contain the situation. Children below 15 years of age were targeted during the campaign. Previous surveys have indicated low measles immunization coverage of children aged 9-59 months. Current findings fall short of the SPHERE recommended standards of 90% in emergency situations. Nonetheless they indicate an improvement if past survey results is used as a baseline. (See tables 1 and 2 for rates of Measles immunization).This could be attributed to the mass measles campaign undertaken in the area to curb the measles outbreak as well as routine immunizations at some health facilities.

A number of nutrition surveys have been undertaken in Gogrial West since 2004 by WVI and ACF-USA and while one was conducted by WVI in Gogrial East County in February 2006. The survey findings of the past nutrition surveys are not directly comparable to the present one due to variation in methodology employed and geographical coverage. Nevertheless, findings of the nutrition surveys can be used as an indicator of the past. Analytically, the present results have indicated a downward trend as indicated on the figure below save for the SAM that has almost doubled since 2007. A factor that could probably be attributed to increased geographical coverage amongst others such as immediate, underlying and basic factors linked to malnutrition. These include disease, inadequate food intake, poor health seeking behavior and calamities such as floods.

GAM SAM

25.2% 23.9%

tes

a 19 . 0 % r n

o 14 . 5 % ti i nutr l a M 3.8% 4.2% 0.9% 1.7%

Dec-04 Feb-Mar 06 Jan- Feb 07 Jan- Feb 08 TIME

Figure 7: Malnutrition trends Gogrial West County ACF-USA South Sudan runs targeted feeding programs in Gogrial West County while WVI runs Supplementary feeding programs in both Gogrial West and East counties. WVI runs two supplementary feeding programs targeting 2 Payams namely Kuac South and North having 10 SFC centers. However one center, “Ayuang” from Gogrial payam is served from Ajiep in Kuac South Payam. In Gogrial East County, WVI has SFP distribution points in Pathuan and Toch areas with Pathuan area having Lounyaker, Yikadoor, Mayombiong, Angernger, Pinydit Matiel, Mayinrual and Mayonchol as distribution points and Liethnom area having Ajogo, Liethnom, Panacier and Thiekthou distribution points. Nutrition screening using MUAC and anthropometric measurements, and registration is ongoing. The agency’s statistics indicated that between March and December 2007, Kuajoc and Ajiep SFCs recorded 4806(2457<5yrs children and 2349 pregnant and lactating mothers) and 2437(1487 <5yrs children and 950 pregnant and lactating mothers) admissions respectively. Between the months of September and November 2007; 314, 6810, 540 were new admissions, treated and defaulters recorded in all the SFP centres respectively. WVI plans to implement community therapeutic feeding care, tailored towards expansive and timely coverage by the programs especially in Gogrial East County. 35

ACF-USA has also been running a targeted feeding program in the area since May 2006 with service provision shifting appropriately with trends so as to ensure appropriate and best care practices to all patients admitted in the program. It was with this in mind that ACF-USA opted to shift to Community Therapeutic Care that ensures service delivery at the grass roots while at the same time increasing coverage with one main advantage; identifying cases before the situation worsens. During the survey period, the agency still operated in Alek South, Alek North and Alek West Payams. The table below summarizes admissions in the OTP/TFC and SFC centers in Gogrial west as from March to December 2007.

35 Source: WVI Nutrition Officer, Gogrial West and East. 19

400 350

300

250

200

150

100

50

0 MAR APR MAY JUN JUL AUG SEP OCT NOV DEC OTP/TFC 21 40 66 18 7 20 7 23 14 7 SFC 36 241 384 133 264 238 163 219 257 85

Figure 8: ACF-USA OTP/TFC and SFC statistics March-December 2007; Gogrial West County The increased trend in admissions in relation to seasonal vulnerability, in the OTP/TFC and SFC programs is largely attributed to two main reasons; appropriate timing/ gradual opening of more feeding sites and increased community mobilization and nutritional screening by health workers.

SC/TFC OTP SFC New Admissions 1 8 134 Cured 0 2 117 Deaths 0 0 0 Defaulters 0 4 39

Transfers 1 2 0

Currently in charge 1 39 463

Table 4: Gogrial West County, TFC/OTP and SFP statistics summary as of January 2008 (ACF-USA) In a nutshell, disease, poor health seeking behavior worsened by the long distances to health facilities and limited staffing are some of the factors influencing the health sector in the region. Limited staffing and increased distances to health facilities minimizes chances of seeking appropriate care. This leads to late care seeking behavior when disease has progressed to severe stages. At this stage, management becomes difficult leading to various complications such as malnutrition with death being the ultimate.

.V.4. Water and Sanitation

Besides accessibility, the main objective of effective water supply and sanitation programs in an area would be to reduce the transmission of faeco-oral diseases and exposure to disease- bearing vectors through promotion of good hygiene practices, provision of safe drinking water and the reduction of environmental health risks36. This was not the case in the surveyed area as a significant number of people obtained their drinking water from unprotected wells and river which were regularly contaminated.

In 2007, ACF-USA undertook a nutrition survey in the area that indicated that the water and sanitation situation of the community was deplorable. A fact that was attributed to limited number of functional boreholes increasing queuing time at water points and lack of appropriate waste disposal facilities

36 Sphere charter, 2004, Water sanitation and Hygiene 20

During the survey period unprotected wells, boreholes, rivers and swamps were the community’s water sources for drinking and household consumption as shown in the picture on the left with various variations in the two counties as shown in the figure below.

River Borehole Unprotected well Swamp water

60%

50%

40%

30%

20%

10%

0% Gogrial East Gogrial West

Figure 9: Sources of Water in Gogrial East and west counties Distance was a key determinant in the kind of water source used by households. Most households therefore relied on water sources near their homesteads. Other than boreholes that are believed to be clean water sources if well maintained, swamps and unprotected wells are highly susceptible to contamination37. These pose a risk of water borne diseases if water is not well treated prior to consumption. Such was the case in the surveyed location. Water treatment methods employed by most households in Gogrial West were decantation, filtering, traditional methods, boiling and to a lesser extent use of chemicals. Among the households interviewed in Gogrial East County only 14.5% filtered or sieved water before drinking it, while the rest did nothing to water. Even if the methods were used in some households, as aforementioned, most of these methods employed were not effective in elimination of disease causing microorganisms. Realizing the need for community sensitization on guinea worm infestation, Carter Center was running a Guinea Worm Eradication Program in the area. The agency’s main activities included training the community on appropriate detection of infections, case finding and management.

According to findings of a KAP survey undertaken in November 2007, most households traveled more than the SPHERE 2004 recommended minimum standard of 500m to the water point. This in the long run led to reduced water usage at the household level to an average of 6.78 liters per day per person, far below the recommended SPHERE 2004 standard of 15 liters per person per day. Current survey findings portrayed a similar picture. Most (66.0%) households with a size of 6 reported to use an average of 40-60 liters per day. As observed, various agencies on ground such as ACF-USA, WVI and NCA were engaged in activities such as boreholes construction and rehabilitation, a move that is expected to improve community access to safe water.

Among the assessed households, a large number of them did not have access to latrines and consequently human waste was disposed off in the bush. Human waste was thus disposed off in the bushes (98.0%) while that of children aged 0-3 years was either buried (94.0%) or thrown (2.0%) outside the yard in Gogrial West. The situation was not any better in Gogrial East. The poor waste disposal mechanisms employed coupled with minimal measures to ensure safe water consumption could be a causal factor in the diarrhoea incidences amongst the under fives. Nevertheless, few latrines were observed in the region more so in local authority, NGO, health centre compounds and a few homes.

One of the most effective ways to break the faecal-oral route of disease transmission is correct and timely hand washing practice. As per the KAP survey undertaken in November 2007, hand washing behavior was strongly influenced by the presence or absence of a convenient source of water and soap. During the survey

37 Sphere charter, 2004, Water sanitation and Hygiene 21 period, it was quite commendable to note that all respondents affirmed to practice hand washing before eating or feeding the children. However majority of the respondents in Gogrial East County did not use soap.

ACF-USA began a health education program in the area in September 2007. The program strives to create awareness on various issues that directly or indirectly impacts on the health and nutrition status of the community. To achieve their goal, the agency undertakes various health education sessions at community level. In a bid to also enhance safe waste refuse disposal, advocacy on latrine construction is on going. Toilet slabs and hand washing kits are given once an individual meets defined criteria. ACF-USA was also in the process of constructing community latrines at public places with one being underway at Alek market. WVI under auspices of RRP, also, has ongoing health education activities in the community and integrated health education within the PHCC/Us where they offer primary health care. With intensive health education in the area this water and sanitation situation in the community is bound to gradually improve.

.V.5. Maternal and Child care practices

An infant requires adequate and nutritious meals for optimal growth and development. This not only entails the type of feeds given to the infant after birth but also appropriate timing of initiation. Initiation of breastfeeding was timely, a practice commendably done on demand by all sampled households.

Exclusive breastfeeding for the first four to six months of life was well practiced in some areas. Generally in South Sudan children are exclusively breastfed up to the age of 4 to 6 months. However, the practice of introducing infants to cattle milk early below four months of age was apparent in some sections of the populations at the time survey was being undertaken. This could be particularly observed in Pathuan areas and some sections of Toch areas. Mothers could be away from home to attend to some livelihood chores for the reason of acquiring food for their families and in their absence all the children within the households under her care would at one point be fed on cattle milk. Though breast milk has been proven to be sufficient for the newborn baby, it starts getting insufficient in some essential nutrients such as iron and Vitamin D beyond 4- 6 months of age. Thus the need to introduce energy dense foods to compliment the breast milk diet at appropriate age. During the survey period in Gogrial west, most (82.0%) households introduced complementary feeds between 4–6 months. Others respondents reported to initiate complementary feeds at less than 4 months (2.0%), more than 6 months (14.0%). The disparity with Gogrial East County is that complementary feeding was introduced to an important fraction of children below four months. (See figure 10 below) The various complementary feeds given to children in this region included cow/goat milk, porridge (sorghum) among other family foods such as ascida38 .These are summarized below as per age groups.

< 4 months >=4 to 6 months >=6 to 10months > 10 months No child <24 months

100% 80% 60% 40% 20% 0% Gogrial East Gogrial West Ages at initiation

Figure 10: Introduction of complementary feeds in Gogrial Counties

38 Meal prepared out of sorghum and water 22

Some of the children who were not in the households at the time of the survey could have been taken care of at Toch villages near the cattle camp. It is the place where significant number of children could have convenient access to cattle milk.

No special diets were fed to the pregnant and lactating mothers despite the increased physiological demands. These women engaged in various duties as per their cultural practices such as collection of grass and thatching the houses, fending for the children, cooking as well as collection of water from the various water sources.

Lack of appropriate and adequate waste disposal facilities in the areas could largely explain the diarrhea incidences amongst the children below five years of age. The fact that cattle were at the cattle camps and foods stock in most households had diminished negatively impacted on the practice of breastfeeding and type, frequency, quality and quantity of feeds given to the young children as discussed above. Thus, to meet food demands amidst the food shortages, most children were fed twice a day. A proportion that could not adequately meet the increased nutrient demands thence the poor nutritional status.

.V.6. Education

Norwegian Church Aid and Save the Children UK work hand in hand with the South Sudan Ministry of Education to support the education sector. This is mainly through provision of scholastic materials such as books and pens, classroom construction, school feeding programs as well as trainings.

Gogrial East County has approximately 40 primary and 2 secondary schools. Collectively primary schools have about 9,364 male and 3,321 female students39. Gogrial West County has a total of 84 primary schools and 3 secondary schools. The new Sudan syllabus was the current syllabus in use for P1 to P4 grades while East African syllabus was used for the upper primary classes. Two teacher training colleges were also functional in the area that offered a variety of vocational courses such as dress making. Vocational training centre planned to be set up in Pinydit to train livelihood skills on tailoring, carpentry, masonry and driving.

Also, UNICEF supported the education department with stationary while WFP in collaboration with WVI have supported school feeding in form of girl incentive to schools to encourage girl enrollment. The community has contributed mostly in establishment of learning centres in these areas. RRP supports education through expansion and improvement of learning environments, capacity building of Parents teachers Associations (PTAs) and institution of Gender and advocacy committees. Nevertheless, a number of factors challenges still continue to face the educational sector. These include: ƒ Poor infrastructure, ƒ High student teacher ratio ƒ Long distances to schools ƒ Lack of clean water and proper feeding in some schools ƒ Insecurity in some parts of Toch North and West payams

.V.7. Actions Taken by NGO’s and other partners

ACF-USA: The agency has been operational in the area since 2006 when it opened a targeted feeding program in response to above emergency malnutrition rates. Other programs such as Food security, Water and sanitation and health education were introduced in the area in the course of 2007 so as to boost the impact of the nutrition component by tackling the underlying causes of malnutrition.

39 Director of education office, Liethnom, Gogrial East County 23

FARM-Africa: In Warrap state, the agency runs Southern Sudan Livelihoods Recovery and Development project through partnership with the Ministry of Animal Resource and Fisheries (MARF), Ministry of Agriculture and Forestry (MAF) and SUPRAID (A national NGO). . This project aims to assist farming families rebuild and develop their rural livelihoods and reduce their reliance on food aid. Norwegian Church Aid (NCA) is a non-governmental and ecumenical organization that works to ensure the individual's basic rights. NCA co-operates with church organizations and other local organizations that are involved in emergency relief, long-term development assistance and building attitudes/ influencing decision- making. The agency focuses on health, education and water and sanitation activities in Gogrial West County. Save the children – UK: The agency mainly focuses on provision of education in the county.

World Vision International: The agency operates a number of activities in the area. These include health and nutrition, water and a multisectoral project with activities in food security, health education and livelihood and water project. The component of Education, Water and sanitation, Food security and livelihoods are implemented under the umbrella of Recovery and Rehabilitation Program (RRP). Carter Centre: The agency, whose objective is to eradicate guinea worm in South Sudan by 2009, operates a community based guinea worm eradication program in Gogrial West County. The main activities include; training of community to be able to effectively identify guinea worms, case finding, management and health education.

Recovery and rehabilitation Program (RRP): Brings together VSF Germany, WVI, Impact on Health Germany, CESVI (Cooperazione e Sviluppo Onlus, Italy), SEDA (Sudan Education and Development Agency), SUPRAID (Sudan Production Aid) and INFRAID (Indigenous Forest Resources Awareness in the improvement of Diet). The counterpart to RRP is Ministry of finance and Economic planning. The purpose of RRP is to reduce poverty and increase food security amongst conflict affected rural households. The executing agency is VSF-Germany which oversees Community-based Animal Health Support Programme; restocking of goats and improved small scale fishery. Other sectors are covered by the aforementioned agencies.

World Relief International (WRI): Primary health care services, Education, Water and sanitation.

ALARM (Africa Leadership and Reconciliation Ministries): It is a church evangelical ministry, founded to run programs on education, Gender empowerment training, water and sanitation and leadership. 24

.VI. RESULTS OF THE ANTHROPOMETRIC SURVEY

ANTHROPOMETRIC RESULTS - GOGRIAL WEST COUNTY Only 705 children were included in the final analysis due to 4 aberrant data sets.

.VI.1. Distribution by Age and Sex

AGE BOYS GIRLS TOTAL Sex (In months) N % N % N % Ratio 6-17 91 50.8 88 49.2 179 25.4 1.0 18-29 99 57.9 72 42.1 171 24.3 1.4 30-41 66 45.2 80 54.8 146 20.7 0.8 42-53 68 54.4 57 45.6 125 17.7 1.2 54-59 37 44.0 47 56.0 84 11.9 0.8 Total 361 51.2 344 48.8 705 100.0 1.0 Table 5: Distribution by Age and Sex The general sex ratio of 1.0 falls within the acceptable ranges of 0.8 – 1.2. Imbalances noted in some age groups like 42-53 months could be attributed to the use of a local calendar of events in determining ages.

BOYS GIRLS

54-59

42-53

30-41

18-29

6-17

-0.6 -0.4 -0.2 0 0.2 0.4 0.6

Figure 11 : Distribution by Age and Sex

.VI.2. Anthropometrics Analysis

.VI.2.1. Acute Malnutrition, Children 6-59 months of Age ¾ Distribution of Acute Malnutrition in Z-Scores ¾ Age group < -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD Oedema N (In months) N % N % N % N % 6-17 179 8 4.5 34 19.0 137 76.5 0 0.0 18-29 171 3 1.8 31 18.1 136 79.5 1 0.6 30-41 146 0 0.0 8 5.5 138 94.5 0 0.0 42-53 125 0 0.0 9 7.2 116 92.8 0 0.0 54-59 84 0 0.0 8 9.5 76 90.5 0 0.0 Total 705 11 1.6 90 12.8 603 85.5 1 0.1 Table 6: Weight for Height distribution by age in Z-score and /or oedema (NCHS Reference) 25

WEIGHT FOR HEIGHT < -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 1 (0.1 %) 0 (0.0%) OEDEMA Marasmus No malnutrition NO 101(14.3 %) 603 (85.5%) Table 7: Weight for height vs. Oedema in z-scores (NCHS Reference) 101 (14.3%) of the children were marasmic with only 1(0.1%) having kwashiorkor.

The sample curve is shifted to the left of the reference population curve indicating a poor nutrition status of the surveyed population. W/H standard deviation (SD) of 0.8640 within the normal range of 0.8 – 1.2 and hence the assessed sample is representative of the surveyed population

Figure 12: Weight-for-Height Z-scores distribution, Gogrial West County-2008

NCHS Reference WHO Reference

14.5% 14.3% Global Acute Malnutrition (11.1% -17.8%) (10.7% -18.0%) 1.7% 2.8% Severe Acute Malnutrition (0.5% - 2.9%) (1.5% - 4.2%)

Table 8: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references ¾ Distribution of Malnutrition in Percentage of the Median ¾ Age < 70% ≥ 70% & < 80% ≥ 80% Oedema (In months) N N % N % N % N % 6-17 179 0 0.0 29 16.2 150 83.8 0 0.0 18-29 171 0 0.0 13 7.6 157 91.8 1 0.6 30-41 146 0 0.0 4 2.7 142 97.3 0 0.0 42-53 125 0 0.0 4 3.2 121 96.8 0 0.0 54-59 84 0 0.0 3 3.6 81 96.4 0 0.0 Total 705 0 0.0 53 7.5 651 92.3 1 0.1 Table 9: Distribution of Weight/Height by age in percentage of the median and oedema (NCHS Reference)

Weight for height < 80% ≥ 80%

40 In a representative sample population, the Standard Deviation should lie between 0.8 and 1.2 26

Marasmus/Kwashiorkor Kwashiorkor YES 1 (0.1%) 0 (0.0%) Oedema Marasmus No malnutrition NO 53 (7.5%) 651(92.3%) Table 6: Weight for height vs. oedema in percentage of median (NCHS Reference)

NCHS Reference WHO Reference

7.7 % 4.0 % Global Acute Malnutrition (5.0% - 10.3%) (2.3% - 5.6%) 0.1 % 0.1 % Severe Acute Malnutrition (0.0% - 0.4%) (0.0 - 0.4%)

Table 7: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median

.VI.2.2. Risk of Mortality: Children’s MUAC

< 75 cm height 75 Total MUAC (mm) ≥ – < 90 cm ≥ 90 cm height N % N%N% N % < 110 or oedema 2 1.4 2 0.8 0 0.0 4 0.6 ≥110 MUAC<120 10 7.2 7 2.7 0 0.0 17 2.4 ≥120 MUAC<125 22 15.9 12 4.7 2 0.6 36 5.1 ≥125 MUAC <135 54 39.1 66 25.8 30 9.6 150 21.3 MUAC ≥ 135 50 36.2 169 66.0 279 89.7 498 70.6 TOTAL 138 19.6 256 36.3 311 44.1 705 100.0 Table 8: MUAC Distribution

.VI.3. Measles Vaccination Coverage

Measles vaccination N % Proved by Card 54 8.3 According to the mother/caretaker 328 50.5 Not immunized 267 41.1 Total 649 99.9 Table 9: Measles Vaccination Coverage

.VI.4. Household Status

Status N % Residents 463 95.1 Internally Displaced 5 1.0 Temporary Residents (on transit) 17 3.5 Returnee 2 0.4 Total 487 100.0 Table 10: Household status

.VI.5. Composition of the Households

652 households were assessed during the mortality survey

Age group N % Average per household Under 5 years 784 16.7 1.2 Adults 3914 83.3 6.0 Total 4698 100.0 7.2 Table 11: Household Composition

27

ANTHROPOMETRIC RESULTS: GOGRIAL EAST COUNTY

706 children were included in the final analysis after 14 erroneous data sets were deleted.

.VI.6. Distribution by Age and Sex

AGE BOYS GIRLS TOTAL Sex (In months) N % N % N % Ratio 6-17 86 48.6 91 51.4 177 25.1 0.9 18-29 62 47.7 68 52.3 130 18.4 0.9 30-41 77 48.1 83 51.9 160 22.7 0.9 42-53 63 45.3 76 54.7 139 19.7 0.8 54-59 60 60.0 40 40.0 100 14.2 1.5 Total 348 49.3 358 50.7 706 100.0 1.0 Table 12: Distribution by Age and Sex The overall sex ratio lies within the acceptable ranges of 0.8 – 1.2. Imbalances noted in age groups 54-59 months could largely be attributed to recall bias brought about by the use of a local calendar of events in age determination.

BOYS GIRLS

54-59

42-53

30-41

18-29

6-17

-60% -40% -20% 0% 20% 40% 60%

Figure 13 : Distribution by Age and Sex

.VI.7. Anthropometrics Analysis

.VI.7.1. Acute Malnutrition, Children 6-59 months of Age ¾ Distribution of Acute Malnutrition in Z-Scores ¾ Age group < -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD Oedema N (In months) N % N % N % N % 6-17 177 1 0.6 29 16.4 146 82.5 1 0.6 18-29 130 1 0.8 20 15.4 109 83.8 0 0.0 30-41 160 3 1.9 15 9.4 142 88.8 0 0.0 42-53 139 0 0.0 12 8.6 127 91.4 0 0.0 54-59 100 0 0.0 13 13.0 87 87.0 0 0.0 Total 706 5 0.7 89 12.6 611 86.5 1 0.1 Table 13: Weight for Height distribution by age in Z-score and /or oedema (NCHS Reference)

28

WEIGHT FOR HEIGHT < -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 1 (0.1 %) 0 (0.0%) OEDEMA Marasmus No malnutrition NO 94 (13.3 %) 611 (86.5 %)

Table 14: Weight for height vs. Oedema in z-scores (NCHS Reference)

Figure 14: Weight-for-Height Z-scores distribution, Gogrial East County 2008 In comparison to the reference curve, the sample curve indicates a left reposition indicating a poor nutrition situation of the surveyed population.

The W/H standard deviation (SD) of 0.8241 indicates representative ness in sample selection.

NCHS Reference WHO Reference Global Acute 13.5 % 14.6 % Malnutrition (10.5% - 16.5% ) (11.3% - 17.9%) Severe Acute 0.8 % 2.1 % Malnutrition (0.2% - 1.5%) (1.0% - 3.2%)

Table 19: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references ¾ Distribution of Malnutrition in Percentage of the Median

Age < 70% ≥ 70% & < 80% ≥ 80% Oedema (In months) N N % N % N % N % 6-17 177 0 0.0 18 10.2 158 89.3 1 0.6 18-29 130 0 0.0 13 10.0 117 90.0 0 0.0 30-41 160 0 0.0 8 5.0 152 95.0 0 0.0 42-53 139 0 0.0 4 2.9 135 97.1 0 0.0 54-59 100 0 0.0 4 4.0 96 96.0 0 0.0 Total 706 0 0.0 47 6.7 658 93.2 1 0.1 Table 150: Distribution of Weight/Height by age in percentage of the median and oedema (NCHS Reference)

41 In a representative sample population, the Standard Deviation should lie between 0.8 and 1.2 29

Weight for height < 80% ≥ 80% Marasmus/Kwashiorkor Kwashiorkor YES 1 (0.1%) 0 (0.0%) Oedema Marasmus No malnutrition NO 47 (6.7%) 658(93.2%) Table 21: Weight for height vs. oedema in percentage of median (NCHS Reference)

NCHS Reference WHO Reference Global Acute 6.8 % 4.1 % Malnutrition (4.9% - 8.7% ) (2.4% - 5.8%) Severe Acute 0.1 % 0.1 % Malnutrition (0.0% - 0.4% ) (0.0% - 0.4%) Table 16: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median

.VI.7.2. Risk of Mortality: Children’s MUAC

MUAC < 75 cm height ≥ 75 – < 90 cm Height ≥ 90 cm height Total (mm) N % N%N%N % < 110 or 5 4.2 0 0.0 0 0.0 5 0.7 ≥110 6 5.0 1 0.5 1 0.3 8 1.1 ≥120 10 8.3 8 3.7 3 0.8 21 3.0 ≥125 40 33.3 48 21.9 27 7.4 115 16.3 MUAC ≥ 59 49.2 162 74.0 336 91.6 557 78.9 TOTAL 120 17.0 219 31.0 367 52.0 706 100.0 Table 17: MUAC Distribution

.VI.8. Measles Vaccination Coverage

Measles vaccination N % Proved by Card 88 13.8 According to the mother/caretaker 270 42.3 Not immunized 280 43.9 Total 638 100.0

Table 18: Measles Vaccination Coverage

.VI.9. Household Status

Status N % Residents 552 98.6 Internally Displaced 2 0.4 Temporary Residents (on transit) 4 0.7 Returnee 2 0.4 Total 560 100.0 Table 19: Household status

.VI.10. Composition of the Households

Age group N % Average per household Under 5 years 865 20.0 1.4 Adults 3441 80.0 5.5 Total 4306 100.0 6.9 Table 20: Household Composition 30

.VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

Relevant data gathered retrospectively was summarized and analyzed in ENA SMART Nutrisurvey software.

Death of a Sudanese intellectual (Martin Malueth) was used as the recall event in Gogrial West County whereas the killing of a resident in Luanyaker marked the referral event in Gogrial East County.

Gogrial West Gogrial East County County Total >5 years Total >5 years Total number of HH 652 624 Number of current HH residents 4,698 784 4306 865 Number of people who joined the HH 51 7 70 17 Number of people who left the HH 217 18 391 35 Births 43 45 Deaths 9 3 7 3 Table 21: Demographic data The above data was analyzed and the mortality rates tabulated below were unveiled. All the mortality rates fall below alert and emergency thresholds.

Gogrial West County Gogrial East County Crude Death Rate 0.21 [0.00 – 0.44] /10,000/day 0.17 [0.02 – 0.31] /10,000/day

0-5 Death Rate 0.43 [0.00 – 1.18] /10,000/day 0.37 [0.00 – 0.84] /10,000/day

Table 22: Mortality Rates

.VIII. CONCLUSION

The Gogrial West County nutrition survey unveiled GAM and SAM rates of 14.5 %( 11.1%-17.8%) and 1.7 %( 0.5%-2.9%) respectively. In the case of Gogrial East the results were: GAM of 13.5 %( 10.5%-16.5%) and SAM of 0.8 %( 0.2%-1.5%). The GAM, SAM and mortality results were all below emergency levels. This improvement in the nutrition situation could be attributed to intervention by various agencies in collaboration with the government of South Sudan. The intervention covered sectors like Health, Nutrition, WASH, Food security and livelihoods just to mention but a few. The current malnutrition rates are however still high and are linked to the following factors:

Disease incidences and inadequate health practices There are still high incidences of vector borne and hygiene related diseases in the region. Long distances to health facilities, limited change in undesirable practices and inadequate staffing compromised the health seeking behaviour of the community causing some to first seek medical attention from traditional healers. The uncurbed diseases like malaria, diarrhea and outbreaks of measles still put many children at risk of malnutrition.

Food insecurity: Floods disrupted livelihood activities of most households especially in the lowlands. Food harvests were below expectations with food stocks in most households diminished. Poor crop performance is linked to insecurity, crop diseases and attacks from birds and insects. Limited access to staple foods prompted households to rely on wild food collection, sale of grass, buying, kinship and food aid in some instances for survival. Cattle were also at the cattle camp limiting availability of milk. Low incomes and pressure of returnees on resources also limit the purchasing power of households even where food is available on the markets.

31

Not up to date water and sanitation practices: Unsafe water was consumed in locations with few functional boreholes. There were more functional boreholes in Gogrial East than Gogrial West. This limited the amount of water consumed per person per day and at the same time fell below the recommended levels thus contributing to low sanitation levels. Similarly, appropriate waste disposal facilities like latrines were limited and hence waste was disposed off indiscriminately.

Unsatisfactory maternal and child health care practices: Most children were fed twice a day on a diet limited in diversity. Additionally, no special feeds were given to the pregnant and lactating mothers. The reduced meal frequency and lack of diversified feeds limited maximum nutrient intake to meet their increased dietary demands.

.IX. RECOMMENDATIONS

Food Security ƒ Incorporate programs to support returnees to get integrated into the society and build their livelihoods without untamed effect on the food security of the host community. ƒ Increased targeting of vulnerable households to improve accessibility to seeds and tools that will help increase acreage and production. ƒ To continue expansion of demonstration units /field schools in various parts of Gogrial to raise more awareness on new crop varieties and appropriate farming techniques. This would also encourage maximum utilization of land fertilization. ƒ To continue building the capacity of communities on fishing to encourage diversification of livelihood choices and to make optimum utilization of fishing opportunities. ƒ To continue Market development services initiative so as to monitor price trends and therefore, identify bottlenecks in food supplies and to minimize community vulnerability to food inaccessibility. ƒ It is necessary to have planning for emergency response, disaster mitigation and developmental planning to reduce the effects of reoccurring hazards of floods, crop attack by pests as well as conflict among feuding communities.

Health and nutrition ƒ To carry out a focused and targeted feeding program at the community level so as to be able to tap and manage malnourished cases before they slip to severity. ƒ Continued and intensified health education to mothers and caretakers on the importance of immunization, record keeping and prevention of vector borne and hygiene related diseases. ƒ To look into the feasibility of integrating EPI services into other activities such as the targeted feeding programs so as to further increase the coverage.

Water, Sanitation and hygiene ƒ To continue borehole construction, rehabilitation and exploration of alternative water sources so as to improve access to safe water. ƒ To target health education activities such as safe water use, latrine construction as well as appropriate waste disposal. The purpose is to enhance impact and thereafter encourage such practices in these counties. 32

.X. APPENDIX

.X.1. Sample Size and Cluster Determination- GOGRIAL WEST COUNTY

PAYAM BOMA MAIN VILLAGES POPULATION CLUSTER NO. Dhok 4976 Gaikou 3988 1 Atokngar 4254 Ngapathian Malualawien 4786 2

Areumac 2659 Kunyuk 4321 Keem 4925 3 Atukuel Amom 3911 Lur 3607 ALEK-SOUTH Marial 4675 4 Marial dit 3300 Alek Kuruec 3574 5 Bulic 4289 Amoth 3859 Alek 4765 6 Ariewmac 3671 Ameeth Dingkar 4532 7 Ngiik 4217 Rumamuk 3264 Panachier 3540 8 Dheng 4248 Malekngok Marialmajock 3832 Malek 4721 9 ALEK-NORTH Mayom(Runkuel) 4522

Mayom(Riangkoot) 3546 10 Mankuac Mangok 4966 Makuac 5000 11 Achol 4980 Achock 4789 Nyokthiang Nyokthiang 3423 12 ALEK-WEST Malualpabuor 4968 Alueth Mayen 4549 13 Ajieng 3639 Alueth 3638 Maluilajak Lolrual 4057 14 Agok 4654 Mandeng Wunriang 4988 15

GOGRIAL Mayenbainhom 3992 Wuntur 4860 16 Gogrial Manalom 4479 Malek 3888 Ayuang 4860 17 KUAC-NORTH Monyjoch Gumel 4447

Panrok 4136 18 Adet 4596 Mangar 3240 33

Maker Akajar 4397 19 Agem 2318 Wunachier 2758 Agei 4416 20 Anguoi Toktong 3974 Metic 3312

Wunteng 2650 21 Kuajok Malek 3955 Akac 4394 Apukthiep 2636 22 Marial Achom 4390 Mathiang Arop ral 2312 Gukyich 1509

Pach 2387 23 Muorauor 4149 Panreu 4068 Anyuat 3457 24 Majok 2766 Lukluk Ajiep(Rae) 3201

Ajiep(mathiang) 4509 25 Chumich 2309 Liet 3200 Ajiep(Ror Ayiel ) 3739 26 Wunpach 5000 Wunkueldit Agapakolawer 3739 Tharweng 3308 27 Malualwut 4509 Warko Adet 3200 Aguar 4830 28 KUAC-SOUTH Malith 2264 Thurnyor 4094 29 Dong Manyang 3396 Magai 3378 Yiithliet 2243 Lilthok 4200 30 Wunkuelthii Marial ngap 4323 Ader 4917 31 Manyiel 3917 Panliet Kootic 4321 Kunyuk 4923 32 Maluil 4534 Rangalei 4978 33 RIAU Thurakoon 4527 Kueec 4528 34 Anguoth Malek 4834 Acibut 4704 35 Motmot 3222 368826 34

.X.2. Sample Size and Cluster Determination- GOGRIAL EAST COUNTY

PAYAM BOMA MAIN VILLAGES POPULATION CLUSTERS Majakliet 600 Panacier Panror 900 Toc West Panacier 1200 1 Lonny 600 Pinydit Pinydit 1800 Mawithuo 1200 Yiik Adoor 1800 2 Nyuop Chol 900 Mamer 1200 Ajom 900 Maper 900 Anien 1200 Payer 900 3 Yiik Adoor Bong 540 Bulic 660 Nyanikigo 720 Atong Atuk 570 Miirdit 570 Bokdiang 510 Ror Kou 600 Anapriang 1500 4 Angernger 3452 Manyiik 1,198 Aker ador 1,560 5 Athau 1,500 Luil Akelic 1,330 Ayei Ding 1,420 Manyiel 1,400 6 Angon 1,110 Pathuon East Bulic Ador 1,300 Nyok Nyok 1,250 Luil Athian 1,302 Wutliet 1,180 7 Apiath 1,050 Ror Macar 700 Majur 500 Angernger Manding Biong 809 Mayen Dau Riny 1,012 Adhuth Baak 938 8 Taep Ker 1,002 Kuel Acoun 876 Jok Angau 728 Guol Wei 1,210 Maluk anei gai 802 Thok Yiep Aleum 798 9 Roun Weng 901 Pany 1,003 Mabior Pany 873 Ajok Biong 1231 Mayom Anei Anei 809 Cuei Bai Deng 546 Makuei Biong 905 10 Nyang Awutwut 3,800 Nyang Thuramon 2,700 11 Wur Abei 3,000 Toc North pantit 3,000 12 Ajogo 2,815 Panthou 3,015 13 Aman 3,085 Gelual 2,800 14 Manguol 2090 35

Chuei Agany 1,993 15 Adier Chien 2,500 Cuei Malual 2,510 Mangol 2,000 16 Akuac 1,500 Thiek Thou 1,700 Marial Ngap 1,100 17 War Abieyi 1,300 Majaknyuom 1,150 Thur Maker 2,500 Thur Agar 2,250 18 Lietnhom 4,200 19 Thuramuon 3,780 Wuncue 3,360 20 Bulic 2,940 Thuramuon Malith 2,100 21 Warweng 2,100 Agaigai 1,680 Toc East Buokabok 1,680 22 Aliny 3,780 Yarachot 3,360 23 Adet 2,520 Nyangdit Tap 1,680 24 Ruot 2100 Abiei 1,680 Muon 840 Anayer 3467 25 Luonyaker 4365 26 Malual Amouk 3,000 Dalaliek 3,000 27 Marolamouk 2,000 Luonyaker Tungakun 1,500 Dhouk 3,000 28 Amothic 2,500 Thongloc 3,000 29 Pathuon West Thieu 3,500 30 Malual Akuem 2,500 Achot 3,000 Matiel 3,000 31 Riangalek 2,000 Madingamel 2,000 32 Malualwut 2,000 Majok Lacdit 1,500 Anyuotthouk 500 Akot 1,000 33 Pannyial 1,000 Jak 2,000

36

.X.3. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No:

Measles Family Status Age Sex Weight Height Oedema N°. MUAC C/M/N N°. (1) (Mths) M/F Kg Cm Y/N Cm (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

1. Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family…), 4= Returnee. 2. Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles.

37

.X.4. Household enumeration data collection form for a death rate calculation survey (one sheet/household)

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

1 2 3 4 5 6 7 Present at beginning of recall Date of Born Died (include those not present now HH Present birth/or during during the ID and indicate which members were Sex member now age in recall recall not present at the start of the years period? period recall period ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tally (these data are entered into Nutrisurvey for each household):

Current HH members – total Current HH members - < 5 Current HH members who arrived during recall (exclude births) Current HH members who arrived during recall - <5 Past HH members who left during recall (exclude deaths) Past HH members who left during recall - < 5 Births during recall Total deaths Deaths < 5

38

.X.5. Enumeration data collection form for a death rate calculation survey (one sheet/cluster)

Survey Payam: Village: Cluster number:

HH number: Date: Team number: Current HH Past HH members Current HH members who who left during Births Deaths during recall N member arrived during recall recall during (exclude births) (exclude deaths) recall Total < 5 Total <5 Total < 5 Total < 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

39

.X.6. Calendar of events- Gogrial West County – Warrap state; February 2008

2007 2008 MONTHS SEASONS 2003 2004 2005 2006 Cattle take to Toics (cattle 49 37 25 13 1 JANUARY camps) James Lual raises New Sudan Signing g of Kuajoc becomes the ACF-USA A PANTOK/ Cut grass for thatching flag in Alek CPA state headquarter nutrition survey captain NYIETH Gogrial town shot open to all dead in people Kuajoc Winnowing sorghum for 48 36 24 12 0 FEBRUARY storage Spear master Mordit dies Beginning of NCA begins Meningitis out break Alek PENROW/ KOL Clearing farms fight between construction of in Warrap state market the Aguok PHCC in Alek burns and Apuk clans. Clearing new farms 59 47 35 23 11 MARCH continue PEN DIAK/ Construct tukuls AKANYDIT Movement to water points 58 46 34 22 10 Hunting NCA opens PHCC in Bau- Aweil Plane crashes ACF-USA conducts Measles Fishing starts Fight between Lou and Kongor Ajiep and in Aweil airstrip a nutrition survey in campaign begins Thatching tukuls begins in Gogrial West County Kuajoc Returnees the County. in Gogrial West APRIL Purchase of malodas Rain maker Lual Lual dies in markets burn brought from SC-UK opens a PEN NGUAN/ Harvest of cash crop seeds Kuac. Khartoum by training institute in AKANYTHI (T obacco) Selection of community leaders government. Panliet and Ajiep in Ajiep ACF -USA NCA opens a PHCC opens TFC IN in Alek Alek

Rains begins 57 45 33 21 9 MAY Cultivation of lands begins The late Dr Garang visited Alek MedAir SPLM political PEN DHIECH/ Cows brought back from Kuajok Community receive the moves into ACF-USA TFC campaign month ADUONG toics. first food drop in Lunyaker Ajiep reopens in Alek

JUNE Cultivation continues 56 44 32 20 8 PEN DETEM/ Weeding crops Relief food truck gets stuck in Death of First time for people Change of ALETHBOR Young men go for Ker river Malualawien Deng Kong to receive money sudanes dinar to Begin planting maize and from the government Sudanese pounds sorghum.

JULY Planting maize and 55 43 31 19 7 PEN DHOROW/ sorghum. Death of Commander Ayiang AKOLDIT End of Weeding season Kuec Mayar- dies Serious Hunger gap. the Executive Sale of cows chief

AUGUST Fattening competition 54 42 30 18 6 PEN BET/ BILDIT Weeding maize and Death of Dr. Fight between Aguok groundnuts John Garang and Apuk in Citou Eating green maize. Salva Kiir sworn CARE build primary

in school in Ajiep SEPTEMBER Harvesting season 53 41 29 17 5 PEN Court opens cases in every WVI open Cholera outbreak DHONGUAN/ payam PHCC in Ajiep in Alek North. BIELTHI Eating green sorghum. “Gornhom”- Marking of young boys

OCTOBER Harvesting continues 52 40 28 16 4 PEN THIAR/ LAL Tilling of new farms WVI TFC A plane crashes at H.E Salva Kiir opened in Ajiep Alek airstrip. visits Gogrial Lino (an West Commander intellectual) dies Aduk dies in in Nairobi and Malakal and taken to Alek for brought to Alek for burial burial NOVEMBER Rain stops 51 39 27 15 3 PEN THIARTOK/ Mudding tukuls Demobilization of child soldiers Spear Master ACF –USA TFC Civicon company Martin Malueth, HORBEKLAI Preparation for Christmas in Gogrial West by SPLA Aniek dies closes in Alek starts road an intellectual celebrations construction in dies Kuajoc

Christmas time 50 38 26 14 2 DECEMBER WVI nutrition survey World Aids Day PEN celebrated in THIARKUROU Kuajoc 40

.X.7. Calendar of events- Gogrial East County – Warrap state; February 2008

MONTH Seasons 2003 2004 2005 2006 2007 2008 JANUARY/ KOL 49 37 25 13 1 Measles outbreak in Signing of CPA in Kwajok was made Cattle taken to Toch. the community. Naivasha Warrap state head House mudding quarters FEBRUARY/ 48 36 24 12 AKOCDIT Clash between Dinka Aguok kills one boy and Cutting grass for and Nuer over cows girl in Parau at night Luonyaker market roofing the houses. and many people died Panacier market burnt burnt Threshing of Dura the toch. Nuer took a by Aguok and vandalise lot of cows WVI items MARCH/AKOCTHI 59 47 35 23 11 Severe drought that Meningitis outbreak. Meningitis caused death of cattle in Govenor Anei Kueidi outbreak. Large no. Clearing of field in Kongkor takes cattle the Toch visited Luonyaker. of Returnees from preparation for from Aguok. Aguok Wau to Luonyaker planting. Roofing of comes back to fight Cholera outbreak in the houses. Apuk. yiik ador and Anger nger, APRIL/ADUONG' 58 46 34 22 10 Mayenrual Market Commissioner Fishing. Burning of burnt by drunk man Gorgory calls bush to create new after quarrel conference btw Nuer There was mass land for cultivation. In & Apuk to avoid measles campaign. readiness for rain. killings and cattle Rain begins. raids. MAY/ALETHBOR 57 45 33 21 9 Planting Sim sim, Heavy rains caused Dinka brought back groundnuts, sorghum, flood and death of cattle. their cattle taken by

millet, Maize. Cattle Cattle diseases spread. Nuer to apuk brought from Toch. JUNE/AKOLDIT 56 44 32 20 8 Severe hunger in the Severe crop attack by Ngot Rinny dies in Fighting between Continue in planting community pest called Nyan Nairobi and body Aguok and Apuk at sorghum/Dura. brought back to Mangar resulting to Planting of maize Luonyaker many deaths. The begins. Weeding of government started first plants giving salary to staff JULY/BIELDIT 55 43 31 19 7 Hunger begins. Death of Dr. Garang Collection of wild in a plane crash. Aguok comes and attack fruits. Weeding Apuk in Majakliet and completed. Chasing burn \ajogo market birds from crop fields. AUGUST/BIELTHI 54 42 30 18 6 Begin eating green Salva Kiir swon in as Aguok attack cattle maize. Harvest of president in forces in panacier WVI opened a TFC in small groundnuts and Khartoum Luonyaker sim sim. Men fattening competition. SEPTEMBER/LAL 53 41 29 17 5 There was an outbreak Peace conference call Harvesting sorghum of scabies in the by commissioner of Mayenrual market begins. Preparation of community. Gogrial East and West to burnt by accident of Dura granaries make peace between Candle Apuk and Aguok OCTOBER/NYIETH 52 40 28 16 4 Harvesting Salvakiir held peace Salva kiir and governor sorghum/Dura conference in Mayen Anei Kueidit held a SPLA soldiers were completes. Initiation rual for 5 days and peace conference in withdrawn from of young men - visited Luonyaker Lietnhum. WVI TFC was Khatoum to Juba 'Gaarnom' closed NOVEMBER/KONPIU 51 39 27 15 3 Harvesting of bigger World Vision opened a variety of groundnuts TFC in Luonyaker and

and millet. Planting Panacier tobacco. Rain stops. DECEMBER/ 50 38 26 14 2 HORBEKLAI Measles outbreak in Apuk community Gogrial East. hold conference in Harvests and Luonyaker and Bol Christmas celebration Madut and Chief Cold season begins Justice Riiny thiik attends 41

.X.8. Food market prices- Gogrial West and East County February/March 2008

PRICES PRICES COMMODITIES QUANTITY INGOGRIAL WEST INGOGRIAL EAST COUNTY COUNTY

Sorghum 100 kgs 85 sp 150sp Rice 1 kg 2 sp 3.5sp Wheat flour 25 kgs 35 sp Not there Onion 1 kg 4 sp 4sp Simsim 1 kg 4 sp 4sp Beef 1 kg 3 sp 4sp Goat 1 medium 100 sp 90sp Cow 1 big 1200 sp 1200 Sugar 1 kg 2 sp 2.5sp Salt 1 kg 1 sp 2sp Oil 500 mls 5 sp 5sp Groundnut 1 kg 2 sp 3sp

N.B: Sorghum and lentils were not available on the markets in Gogrial East at the time of survey.

1USD = 2 Sudanese pounds (SP).