Increasing Malnutrition in the Rural Areas Even As Relief Poured In
A June 1998 OLS survey in several locations in rural Bahr El Ghazal, excluding the children who were so malnourished they were already in feeding centers, showed a 50 percent malnutrition rate for the under fives. The survey, which assessed over 4,000 children, found that the major reason for the high rate of child malnutrition was lack of food rather than disease.158
Strikingly, despite increasing deliveries of food, the high rate of malnutrition could not be brought under control, even among children receiving rations at feeding centers.
In relief work, there have been two ways to distribute food: general food rations (for the entire population), and selective feeding programs, which are used if the overall food needs of a population are adequately met but there are high degrees of malnutrition in certain vulnerable groups.
There are three kinds of selective feeding programs: therapeutic feeding programs (to reduce mortality by taking care of those vulnerable groups at greatest risk of dying from causes related to malnutrition), supplementary feeding programs (to prevent the moderately malnourished from becoming severely malnourished), and blanket supplementary feeding programs (in a situation of a grossly inadequate general food supply, for all members of the vulnerable groups, to prevent widespread malnutrition and mortality).159
Therapeutic feeding aside, feeding for supplementary feeding programs is of two forms: wet rations, which are prepared once or twice daily in the kitchen of a feeding center and consumed on site; and dry rations, distributed usually weekly to take home for preparation and consumption.160 Some in the relief community point out that use of selective feeding programs in the 1998 Bahr El Ghazal famine was an admission of failure. When general food rations are required in a famine but for logistical, financial, access, and other reasons there is not enough food to go around, agencies resort to selective feeding programs as a way to assist the most vulnerable, who are usually the under-five-year-old children. Among other things, the result is that children are brought back to health and discharged but soon reappear, malnourished, at the feeding center.
After the flight ban was lifted in April 1998, food distribution was made through feeding centers for the children under five determined by height and weight measurements to be malnourished.161 The mother would receive a ration for that child for a week. A U.N. study in early June 1998 found that in all three supplementary feeding centers it visited in rural Bahr El Ghazal, children receiving take-home rations were not gaining weight, and in fact, many were losing weight. This was in part because the entire family shared the ration, there being no other food for them, after wild fruits and leaves were eaten.162
To counter this, in Ajiep, located on the Jur River about forty kilometers (twenty-five miles) northeast of Wau, the relief agencies arranged for a general distribution of enough maize for a month's half ration for 24,000 people, regardless of age. The estimated population in need at Ajiep, however, had by then swollen to 70,000, as the feeding center, the only source of regular food, acted as a magnet for a desperate population still capable of walking days to get there. The population that had not so moved in search of food was found to be in worse state.163
Ajiep continued to be an epicenter of the famine, despite access, regular food deliveries, and feeding centers. Death rates began to soar there.164 The rate was eighteen people for every 10,000 daily in Ajiep in early July; ten days later, the rate quadrupled to nearly seventy per 10,000. AEvery day 120 people are dying in a total population of 17,500 within a radius of five kilometers (three miles),@ according to MSF, which operated a feeding center there. The rate among under fives went from under thirty-two per 10,000 to 133 per 10,000.165 A rate of two per 10,000 is considered disastrous by aid organizations.166
The severity of the famine was reflected in an NGO report from the field:
Everywhere adults and children are dying. The teams are keeping track of mortality rates. In Ajiep, there are at least four people responsible for counting the dead and reporting back each day. Doctors Without Borders has also organized a cemetery and for the dead to be picked up as many have no relatives or the relatives are too weak to do anything. Traditionally the Dinka dead are buried in their village compound so that the spirit rests with the family, but because these people have fled their homes and have no shelter, it is not possible for them to do this.167
Finally in late July, in Ajiep food was delivered to a wider area to encourage the 70,000 people bunched up to disperse.168 By late September, due to different measures taken by the agencies, this acute situation had eased: the mortality had declined from sixty-three/10,000/day in July to three/10,000/day in September, for a total of 48,000 beneficiaries.169 The trials of Ajiep were not over: in October Ajiep suffered heavy flooding when the River Jur burst its banks. Some 46,000 people in Ajiep were left with no shelter or land, and flooding made the airstrip unusable for four weeks, hindering relief deliveries.170
Meanwhile those children who weighed less than 60 percent of their normal body weight were admitted to the therapeutic feeding program. There they were directly fed meals several times a day, because they could not digest the foods (unground cereals, such as lentils, maize, and sorghum) that were airdropped.171 Therapeutic feeding is a last resort because it is staff-intensive and fosters dependency.172 It does, however, preclude anyone from taking the food from the intended beneficiary. At times the person taking the food away was not a stranger; family members were pitted against each other by the famine and inadequate relief food.173
158 OLS, Press Release, AOLS Survey Shows Child Malnutrition is Growing in Bahr El Ghazal,@ Nairobi/Khartoum, July 13, 1998.
159 Medecins Sans Frontiers, Nutrition Guidelines (Paris: Medecins Sans Frontiers, 1995) (1st ed.), pp. 31-33.
161 "Most standardized indicators of malnutrition in children are based on measurements of the body to see if growth has been adequate (anthropometry).@ Medecins Sans Frontiers, Nutrition Guidelines, p. 16. Weight for height (W/H) is an indicator of acute malnutrition that tells if a child is too thin for a given height (wasting). In emergencies, W/H is the best indicator because it is a good predictor of immediate mortality risk and it can be used to monitor the evolution of the nutritional status of the population, according to this medical NGO. Ibid.
162 In Panthou, Bahr El Ghazal, MSF-Belgium observed that out of concern for their other children, many mothers of children qualifying for therapeutic feeding declined the twenty-four hour residential therapeutic treatment and took home supplementary rations instead. These rations were not likely to go exclusively to the target child because there was not yet any general food distribution. WHO/UNICEF Mission: Feeding programs, Southern sector.
163 Martin Dawes, "New food fears in southern Sudan," BBC News, World: Africa, June 5, 1998.
164 George Mulala, ASudanese family perish outside jammed food center,@ Reuters, Ajiep, Sudan, July 30, 1998.
165 ADeaths quadruple in 10 days in Sudanese town: MSF,@ AFP, Nairobi, July 23, 1998.
166 Alessandro Abbonizio, AFamine worsens in southern Sudan,@ AFP, Ajiep, Sudan, July 19, 1998.
167 Samantha Bolton, International Press Officer for Doctors Without Borders, ASouth Sudan: Testimonies of a human tragedy,@ Nairobi, August 31, 1998.
168 WFP, Emergency Report No. 31 of 1998, July 31, 1998: Sudan.
169 WFP, Emergency Report No. 38 of 1998, September 25, 1998: Sudan.
170 '@Sudan famine victims struggle with rains - agency,@ Reuters, Nairobi, October 22, 1998. Bor, north of Juba on the White Nile, also was suffering its worst flooding in ten years, and some 80,000 were at risk there. Ibid.
171 Rosalind Russell, "Southern Sudan Fights Loosing Battle Against Hunger," Reuters, Ajiep, Southern Sudan, July 3, 1998.
172 When the famine was a few months old, a standardized criteria for admittance to the feeding programs in Sudan was suggested: all children below 70 percent weight for height were to receive therapeutic feeding, and those between 70 and 80 percent weight for height were to receive supplemental feeding. OLS (Southern Sector), Emergency Update No. 15, September 16, 1998.
173 Hugh Nevill, AIn southern Sudan, it's sister against sister,@ AFP, Agangrial, Sudan, July 22, 1998.