Emergency Response Team: Summary Report Health, Nutrition and WASH Assessment Duk County

Jonglei state

Specific Activity

 To assess and prioritize multi-sector needs using the Initial Rapid Needs Assessment tool (IRNA) in accessible Payams of Duk County where there is a concentration of IDPs  To assess the accessibility to safe water, sanitation and knowledge of good hygiene among the targeted population  To determine the support required to facilitate health and nutrition programming in payams where needs are identified

Specific locations Region Airstrips

Poktap, Ageer Payam Duk County, Panyagor Airstrip (Twic East) Ayueldit, Duk Padiet Payam 7°11'01"N 31°24'50"E Poktap Airstrip (Duk) 7°27.725’N, 31°24.886’E Duk Payuel Airstrip 7°35’54”N, 31°27’03”E Duk Padiet Airstrip 7°44’29”N, 31°23’58”E

Dates of activity

2/4/2015-9/4/2015

Demographic Data

STATE COUNTY PAYAM POPULATION

Jonglei Duk Poktap 12,314

Ayueldit 21,102

TOTAL 33,416 Source: RRC/CRS Office (CRS continues with ongoing registration of new arrivals (IDPs & Returnees)in both locations)

The population figures indicated above are based on the on-going registration of individuals in both locations. However, in Poktop, the population is concentrated in the camp, and the team estimated the population seen to be approximately 6,000 to 8,000 people. In Ayueldit, on assessment there were very few people seen in Ayueldit center as the populations are scattered into neighboring villages, most of which are not accessible due to reported insecurity. The JDF team reported that Dorok (2 hours North from Ayueldit), which neighbors county, is one village with a reported population of approximately 6,000 people. On travel from Poktap to Ayueldit; the bordering villages: Payuel, Mareang, and Padiet are all deserted as residents have fled.

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Medair team Counterparts Others

Christine Muthoni, ERT Nutrition Daniel Pisegna – Executive Jacob Akech Deng- Team Leader Director, John Dau Commissioner Duk County Foundation (JDF) Alicia Morcombe, ERT Health Deng Sam Mabok - RRC Manager Peter Lim - Nutrition Officer, Coordinator Duk County JDF Stephen Cressey, ERT WASH Deng Mayom Deng – Executive Manager Joh Deng – Manager, JDF Director, Sudan Medical Care (SMC) Marcello Jerfasio, ERT WASH John Deng - Field Supervisor, Technician SMC

James Jok – Program Officer, SMC

Taban George – LWF Acting Area Coordinator

Lotari Cyprian Peter – LWF WASH Project Coordinator

Summary of Objectives Outputs Achieved

General  Meet with the Duk County Commissioner, The assessment team met with the Duk County Duk County SSRRC, County Health Commissioner and the RRC in Poktap to explain Director for Duk County and local the purpose of the assessment and to find out the authorities in Duk County to explain the current priorities for intervention in the county. Full purpose of the Health and Nutrition cooperation was given to the team for conducting assessment and keep them updated on the assessment. progress and changes

 Gather security information and Security accessibility of various payams where Security information was gathered through UNDSS IDPs are concentrated and the NGO security forum prior to the visit. The team met with the Commissioner and RRC in Panyagor upon arrival to gather information on security and IDP movement in Duk County The RRC in Poktap provided a security update and the team was given a security briefing from CARE and JDF on arrival in Panyagor. The security situation remained stable in the areas assessed throughout the team’s visit.

Access The roads are poor quality throughout and in the dry season most vehicles drive inside the dry canal rather than use the adjacent road. In the wet season it is said that the roads become un- navigable by motor vehicle. Travel time in the dry season is:  Panyagor to Poktap – 1 to 1.5 hours  Poktap to Ayueldit centre – 1.5 to 2 hours  Ayueldit centre to Amiel village – 20 minutes

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Summary of Objectives Outputs Achieved Vehicle & Equipment Rental There are no vehicles for rental in Poktap. Vehicle hire in Panyagor is based on a transport rate of 200 SSP/person to travel to Ayueldit in the absence of public transport, i.e. 2800 SSP/day based on 14 passengers.

Health & Nutrition  Meet with the CHD, JDF, Sudan Medical The team met with the JDF and SMC teams on Care and other partners on ground to ground and visited the accessible health facilities discuss health and nutrition needs in with them. accessible payams, including IDP locations JDF is the lead nutrition partner for treatment of SAM through OTP services in Duk county and currently are operational in 2 locations - Poktap and Ayueldit. There is no partner implementing TSFP for treatment of MAM in Duk county.

SMC is the designated health partner for Duk County and is currently supporting two health facilities, Poktap PHCC and Ayueldit PHCU. Their primary concern is lack of PHCC inpatient capacity and the structures of the PHCC and PHCU. They plan to recruit a midwife or TBA to start ANC services in Ayueldit PHCU. JDF are running ANC services in Poktop.

Both agencies expressed concern at the lack of a referral centre and means of transportation, especially in anticipation of the upcoming rainy season and the impact it will have on road accessibility. Since the burning of the PHCC in Panyagor (8 hours walk) the nearest referral centre is in Bor, a 3 hour drive from Panyagor.

 Assess access to Primary Health Care and Poktap PHCC;supported by SMC nutrition services for the affected population  The only PHCC in Duk County, easily including distances travelled, services accessible for surrounding population, located provided and staff availability in the centre of IDP settlement  Acts as referral centre for outlying villages,  Visit Poktap and Ayueldit health facilities to including Ayeuldit (7 hour walk) assess health and nutrition needs using the  Referrals from Poktop –closest surgical IRNA tool referral facility 3-4 hour drive to Bor for obstetric emergency  One of two health care facilities and the only PHCC in Duk County  1-2 months stock of all essential medications present. Planned delivery of next 3 months supply before rainy season (SMC/CHD)  Functioning out of a small mud building with five rooms  There is a functioning incinerator for waste management  12 staff including 1 Clinical Officer, 1 CHW, 2 lab Assistants, 1 Pharmacy Assistant, 2 EPI vaccinators, 1 Cold Chain Manager, 1 Clerk, 3 support staff

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Summary of Objectives Outputs Achieved  Only MSF Guidelines available at PHCC others reported stolen  Health services include; OPD consultation, 2 bed capacity inpatient room for observations and IV therapy, EPI, basic laboratory services to test for Malaria  EPI services began in March following cold chain installation; 103 children have received measles, pentavalent and BCG vaccinations  Static EPI services provided on Mondays and Fridays. TT vaccine not available  Fridge, no freezer available therefore no EPI outreach  30-50 patients seen per day  SMC staff provide supervision from Panagor 2-3 times per week to collect reports and toprovide training

Poktap Health and Nutrition Services; by JDF  Laboratory with 1 technician (able to diagnose malaria, pregnancy, Kala-azar, Hb)  ANC provided by midwife, functions from tent across from PHCC. Ultrasound available and midwife trained ultrasound technician. Automatic BP, weighing scales, essential RH emergency obstetric drugs available Stored in the EPI fridge. ANC opened in Jan, since then total 103 ANC visits (29 ANC2, 3 ANC3), 11 deliveries  OTP functioning and services provided under a tree Monday through Friday. JDF in process of relocation and planning infrastructure for the nutrition services.  Therapeutic foods are stored in a lockable container and a stabilisation centre (SC) tent has been set up.  Nutrition staff include: 1 Nutrition Officer, 2 Nutrition Assistants, 1 SC nurse, 1 data manager  Weekly house to house MUAC screening of children and PLW is done to identify new arrivals in the camp. SAM cases are referred for admission to the OTP, however MAM cases are not referred as there is no TSFP  IYCF messaging—during the weekly house to house screenings JDF staff conduct IYCF messages to the households..  During the MUAC screening on the assessment week: 129 males, 137 females were reached with IYCF messages.  No IYCF at the community level. Did not see IYCF at OTP, however upon suggestion by team, nutrition staff began IYCF messaging with the caregivers and children on the spot.No partner on ground implementing Therapeutic Supplementary Feeding Program (TSFP) for the treatment and management of

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Summary of Objectives Outputs Achieved the moderate acute malnourished (MAM) cases

Ayueldit PHCU; supported by SMC  Ayueldit has a small population, the PHCU and school both operate out of the school building. Tents for NFIs (CRS) and PHCU supplies are available  Only other health facility in Duk County  No access to any form of communication. Without SMC supervisory visits, no report mechanism for routine HIS, emergency referrals or outbreaks  Beneficiaries travel from nearby villages (between 30 min– 2 hr walk)  Referral option - 7 hours walk to Poktop, for surgical intervention nearest facility Bor, 6 hour drive  Services provided; OPD consultation, basic ANC, consisting of ferrous sulphate and folic acid, Fansidar distribution and early referral when able, no family planning or condoms available for distribution, pharmacy, malaria RDT, minor wound care all in 1 room  Facility not secure, no lockable door  5 staff include; 2 CHWs, 1 pharmacy assistant, 1 EPI vaccinator, 1 guard1-2 months stock of all essential medications present. Planned delivery of next 3 months supply before rainy season (SMC/CHD)  No visible guidelines for staff reference  Functioning pit incinerator for waste disposal  No cold chain functioning, therefore no EPI  SMC completed measles campaign Oct 2014, polio 2015  No skilled delivery available  ANC supplies provided by CHW, IPT, ferrous sulphate, folic acid, clan delivery kit  Average 30-40 consultations/day  Reporting managed with weekly SMC supervision in dry season

Ayueldit Nutrition services; by JDF  OTP running next to the PHCU under a tree and available Monday through Friday. JDF in process of setting up tents for nutrition services  Nutrition staff: 2 nutrition assistants  No partner on ground implementing TSFP for MAM  No IYCF at the community level and was not being done at the facility level

Morbidity and Mortality  The main morbidities seen in both health facilities are acute watery diarrhoea, malaria

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Summary of Objectives Outputs Achieved and respiratory tract infections for both children <5yrs and >5yrs  Poktop, 2 suspected measles cases identified in February but feedback on samples not provided. SMC implemented measles vaccination in response to the outbreak.  No deaths recorded in either facility for February and March. During the assessment period 1 death occurred at each health facility, a 39 year old man suffering from 2 months of fever, headache, and a 9 year old child suffering from a week of constipation, abdominal pain, distention and a day of vomiting blood.

Gather data on numbers of children admitted in JDF is implementing the Outpatient Therapeutic nutrition programs and availability of essential program (OTP) for severely malnourished children supplies. in both Poktop and Ayueldit. Currently, the program reports an active caseload of 50 children age 6-59 months in the program (total for both locations). Team unable to verify the exact caseloads as there was inadequate stationary and

some data was missing from the registrars and

admission cards. During visit team observed staff filling out the admission cards correctly and staff knew the correct admission and discharge criteria by weight (however, not the new amended CMAM guidelines).

There are 295 cartons of Ready to Use Therapeutic Food (RUTF) prepositioned in Poktap to run till January 2016. The expiry date for the RUTF is 07/2016. JDF expects more consignment of RUTF supplies from UNICEF to be prepositioned based on their PCA. There is also 1 carton of F75 and F100 each expiring 04/2016.

There are some nutritional supplies lacking on ground including stationary, routine medications and Resomal for SC and OTP.

 Conduct a rapid nutrition assessment with Poktap IDP camp exhaustive or non-convenient sampling An exhaustive rapid MUAC assessment for MUAC screening of children aged 6-59 children 6-59 months and PLW was conducted at months and PLW in accessible clinic Poktap IDP camp. The nutrition status catchment areas and where possible in classification based on the MUAC and checking for locations identified as having IDPs but oedema are as follows; without access to nutrition services Nutrition M F Total Proxy Status % (MUAC) GAM Red (<11.5cm) 6 5 11 1.0% Yellow (>11.5- 74 75 149 13.6% 12.5cm) Green 503 433 936 85.4% (>12.5cm) Total 583 513 1,096

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Summary of Objectives Outputs Achieved

1,096 children were screened in Poktap with 11 (1%) children identified and classified with Severe acute Malnutrition (SAM) (these children were referred for admission to JDF’s OTP), 149 (13.6%) children were classififed as Moderate Acute Malnutrition (MAM) and 936 (85.4%) children were well-nourished.No cases of oedema were identified. Overall the Proxy GAM is 14.6%

508 PLW were also screened and 449 women were well nourished, 62 (12.2%) women are ‘at risk’ with MUAC between >21 to <23cm. 7 (1.4%) women were identified and classified with acute malnutrition and a MUAC cut-off <21cm.

Ayueldit population In Ayueldit, screening was done at the PHCU due to inaccessibility of the villages due to far distances and time constraint of assessment. The populations were mobilized and assembled at the nutrition centre. The population access health and nutrition services only at Ayueldit PHCU.

Nutrition M F Total Proxy Status %GAM (MUAC) Red (<11.5cm) 1 2 3 2.0% Yellow (>11.5- 4 10 14 9.3% 12.5cm) Green 75 58 133 88.7% (>12.5cm) Total 80 70 150

150 children 6-59 months were screened in Ayueldit, 3 (2%) children were identified and classified as SAM (they were admitted to the OTP), 14 (9.3%) were MAM and 133 (88.7%) children are well nourished. No oedema cases were identified.Overall the proxy GAM is 11.3%

22 PLWs were also screened and 14 women were well nourished, 7 (31.8%) are ‘at risk’ with MUAC between >21 to <23cm. 1 (4.5%) woman was identified and classified with acute malnutrition and a MUAC cut-off <21cm.

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Summary of Objectives Outputs Achieved  Provide training for nutrition staff on Prior to the assessment, JDF requested a general collection of nutrition data and reporting nutrition training on: quality data collection and programming. The training was also tailored to the requests of the nutrition staff and to cover identified gaps (such as following new admission criteria and treatment protocols). The training was conducted for the JDF nutrition staff (9 males). The team comprised of: 1 Nutrition Officer, 3 Nutrition Assistants, 1 Stabilization Centre (SC) Nurse, 2 Data Managers and 2 senior management staffs. The staff are working in both nutrition sites (Poktap and Ayueldit)

The training covered the following:  Revision of the new Outpatient Therapeutic program (OTP) /Targeted Supplementary Feeding Program (TSFP) admission and discharge criteria for children 6-59 months and PLW  Treatment protocols for SAM and MAM children (including routine medications)  Screening and data collection  Weekly and monthly nutrition cluster reporting  Importance of nutrition education (IYCF-E messaging) at the facility level and for children admitted to the program

 Determine technical and logistic support Nutrition technical gaps seen in nutrition include: required (including storage facility and lack of SC training for the staff and the need for supply route) to facilitate health and nutrition basic start up materials to enable it to offer programming in payams identified and adequate services. prioritized as needing support The OTP programme though running will need registrars and admission cards (working tools) for good reporting and data collection and management.

Provision of routine medications for the treatment and management of children with SAM. For the establishment of the SC—Resomal, SC equipment for milk preparation, working tools such as cards are required.

The closest medical referral facility from Ayueldit is Poktap, a 7 hour walk away (38.7 km). Poktap to Panyagor is an 8 hours walk. There is no reliable means of transport on ground and in the rainy season no accessibility by car to Ayueldit. For surgical, complex and antenatal complications; patients can then be referred to Bor which is a further 3 hours’ drive from Panyagor.

There is no vehicle or communication access outside weekly supervisory visits from SMC and JDF (based in Panyagor). These are only possible during the dry season.

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Summary of Objectives Outputs Achieved

WASH  Meet with the local government water The team met with Gabriel Mapiou, the Duk department to discuss their priorities in Duk County Director of Water & Sanitation, who County identified 9 boreholes in Poktap. Only one of these was broken, and this recently. The priorities identified were latrine construction in Poktap IDP camp.  Locate and assess water points in the  There are 8 functioning hand pumps in Poktap vicinity of Poktap and Ayueldit and identify and 1 broken pump. The quantity of water requirements to rehabilitate. points is technically sufficient (ie: enough for 15 l/p/d), although most of the IDPs use 2 hand pumps that are centrally located in the camp.  Several hand pump aprons are cracked/ damaged and all drainage channels/soak aways are insufficient.  The most commonly used borehole in Poktap was tested positive for presence of bacteriological contamination.  There are reportedly 23 hand pumps in Ayueldit boma, 10 of which are broken, although most of these are thought to be around the unoccupied areas of Duk Padiet.  Of the 4 hand pumps observed, 2 had broken aprons and drainage was poor.  Assess options for providing new water  Although there are some surface water sources points based upon the existing water in Poktap, these are on the eastern side of the sources in the areas assessed. canal and very remote from the IDP community.  The only viable options for more water points would be drilling new boreholes or installing a submersible pump in one of the boreholes and creating a water yard.  Road access to Poktap is very poor and likely prohibitive for getting a drilling rig to the area. Some fuel is available but it is unlikely that a generator could be sustainably supported so any electric pumps would probably require solar power.

 Assess suitability of different types of latrine  The geography is flat, black cotton soil, suitable construction within the IDP community of for latrine construction, although liners and Poktap. raised platforms would be required for the coming rainy season.  There are existing latrines at the old school which are no longer used. These are constructed with raised concrete superstructure platforms.  The IDP community reported some knowledge of latrine usage. Fear of snakes especially in the wet season are the main issues identified with open defecation. HHP would be required to encourage usage of any latrines.

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Summary of Objectives Outputs Achieved  Conduct household surveys in the villages  Community members were interviewed in around Ayueldit to determine likely barriers Ayueldit centre and Amiel village. In all to latrine usage. cases, hygiene knowledge was very limited and although the benefits of soap were known, people were not willing to buy it.  Knowledge of latrines and usage in the past was very low. There are some latrines constructed at schools in the boma but no household latrines.

Summary of Findings Recommendations Follow up

Health Inadequate infrastructure at both Construct/extend new SMC facilities, need for increased inpatient buildings for Ayueldit and beds in Poktap PHCC and a secure Poktap health facilities building for the Ayueldit PHCU

Limited RH services, lack of skilled birth As discussed and in SMC attendant in Ayueldit process by SMC, recruit a midwife or TBA for Ayueldit PHCU. Provide RH training for clinic staff to provide ANC and for early referral of complications or danger signs to JDF Poktap ANC

No cold chain or EPI services are in Establish cold chain in MoH/SMC /JDF Ayueldit Ayueldit or equip Poktap with outreach capacity through JDF freezer

Lack of referral mechanism for obstetric Explore alternative SMC/ CRS/ JDF and surgical emergencies transport options, Liaise with NGO partners in order to use their vehicles for patient referrals

Lack of equipment including autoclave for Supply Poktap PHCC with SMC/ CHD sterilising surgical equipment sterile surgical equipment and autoclave for minor surgical procedures

There is a lack of communication means Supply the PHCU with a SMC/ CHD in Ayueldit. radio or other communication means

Food& Nutrition No TSFP is operational in either Poktap Initiate TSFP services for WFP/JAM or Ayueldit for the treatment and the treatment and management of children and PLW with management of children moderate acute malnutrition and PLW identified with MAM to prevent further deterioration of nutrition . status before the rains start

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JDF has a tent set up for an SC in Poktap Advocate to UNICEF or a UNICEF/JDF/Nutrition but services are not yet being offered nutrition partner with partner because the staff require SC training on capacity to conduct the SC SAM management with complications. training on treatment and management of SAM with complications.

Basic equipping of the SC (milk Provide basic SC start-up UNICEF preparation and feeding equipments, kit stationary, medications) are needed so as to have the facility functional

The SC will be the only facility for treatment and management of SAM with complications in Duk County IYCF: Community Level Roll out IYCF-E messaging JAM/JDF/UNICEF There is no partner on the ground at the community level by implementing IYCF in either Poktop or the responsible partner Ayueldit. In Poktop, JDF is conducting early before the rains start. IYCF messaging during weekly house to house MUAC screenings so as to fill in the gap

IYCF: Facility level Provide IYCF counselling Medair/JDF In both Poktop and Ayueldit, nutrition staff card set to each facility are not trained on IYCF and are lacking the IYCF training cards for teaching. Provide IYCF training to UNICEF nutrition staff

In Poktop there is a small market with items from Panyagor, however, in Ayueldit there is no market. The populations rely primarily on wild game hunting, fishing and dried fish

WFP/ CRS are responsible for the Continued registration and CRS/WFP General Food Distribution (GFD) in both dry food ration provision to locations. This has greatly helped avert the new arrivals and serious malnutrition levels among the households with need internally displaced (IDPs) and returnees populations in Duk County

Water, Sanitation and Hygiene (WASH) Water supply is generally acceptable in Emergency latrine Medair to follow up with both Poktap and Ayueldit, although in construction in Poktap LWF/NCA about timescales both cases the locations of the before the wet season for response and whether communities is sometimes remote from commences in earnest Medair support would available water sources. assist them in completing sanitation programming Latrine construction and usage is very Hygiene education and before onset of rainy low, with open defecation almost at 100%. latrine use promotion in season. Poktap.

Hygiene awareness is low in all areas. Hygiene promotion in Ayueldit

LWF are planning new water points, latrines and hygiene awareness across the two locations.

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Report Written by: Date written Results ERT Assessment  A multi sectorial Health, Nutrition and WASH Team assessment was conducted in the 2 locations in Alicia Morcombe Report written Duk County (Ayueldit and Poktap) hosting internally Christine Muthoni on: displaced and host populations. Stephen Cressey 11/04/2015  1,246 (663 males, 583 females) children were MUAC screened for acute malnutrition  530 PLWs MUAC screened for acute malnutrition  Nutrition training for 9 JDF nutrition staff

Recommendations  Follow up with partners (LWF and NCA) regarding sanitation programming in Poktap IDP camp  Establishment of TSFP and community level IYCF activities is needed  Technical support needed for JDF Nutrition staff for the continued treatment and management of SAM with complications  Health needs and service gaps can be filled by existing partners

Note: Permission granted to utilize report information without request provided that Medair is identified as source.

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Appendix 1 - Images

Tent for Ayueldit clinic, however, due to heat Actual location of Ayueldit Clinic – in one patients are seen in one of the rooms of the room in the local school local schools

The hospital in Panyagor - completely burnt when a fuel powered fridge caught on fire during the night at the end of March 2015

ANC tent in Poktap Driving in the Jonglei Canal from Panyagor to Poktap

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Appendix 2 – Map and Satellite Images

Source: REACH Project – with locations of Poktap and Ayueldit added by Medair

Poktap Town & IDP Camp* 1km line (for reference)

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* Note: Poktap town largely destroyed during conflict. Satellite imagery from June 2013 does not reflect current situation

Poktap IDP Camp – approximate inhabited areas and household numbers

250HH 15HH

30HH

40HH

50HH

20HH 300HH

Ayueldit boma – Location of visited hand pumps

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Appendix 3 – Boreholes Visited

# Location Coords Condition 1 Poktap 7°27.386’N PID: 36m Stiff but working. Marshy run off. 31°24.774’E

2 Poktap 7°27.467’N PID: 39m Working but within CRS/military compound 31°24.811’E

3 Poktap 7°27.467’N Redundant borehole (missing head & pump assembly) in same location as #2 31°24.811’E 4 Poktap 7°27.504’N PID: 42m Working 31°24.720’E

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5 Poktap 7°27.607’N TD: 50m, PID: unknown 31°24.431’E Broken – likely pipe is broken. Only recently stopped working

6 Poktap 7°27.319’N PID: 33m 31°24.519’E Working. Apron is worn out and run off is marshy. Busy – queue of 15 containers at 11.45am

7 Poktap 7°27.240’N PID: 42m 31°24.526’E Working. Run off ground is marshy. Queues observed at 11.55am

Page 17 of 19 8 Poktap 7°27.080’N PID: 36m 31°24.544’E Stiff but working. Run off is marshy & with animals drinking. Small queue at 12 noon

9 Poktap 7°27.793’N TD: 60m; PID: 36m Working. Run off channel damaged & marshy ground. 31°24.685’E

10 Poktap 7°27.174’N PID: 36m Working. Apron wearing out and run off is marshy. 31°24.738’E

11 Ayueldit 7°43.456’’N Working centre No photo 31°19.963’E

www.medair.org 12 Ayueldit 7°42.854’N Working boma 31°18.853’E

13 Ayueldit 7°42.646’N Working boma 31°18.531’E

14 Amiel 7°41.816’N Working village 31°16.597’E

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