10. Uganda

IDPs in North Uganda

In the North, particularly in Gulu and Kitgum districts, twelve years of violence by the rebel group, the Lord's Resistance Army (LRA) has forced over 200,000 people from their homes. A further 22,000 are estimated to have been abducted, including 6,000 children according to UNICEF estimates. These people have either congregated in "protected villages", moved in with host families, or have found shelter in public buildings. The instability and relocation has prevented farming in many cases and has resulted in a food shortage amongst the displaced, although some are able to cultivate in their new location. WFP is currently providing food assistance to approximately 318,000 IDPs in both Gulu and Kitgum districts. WFP has covered a pipeline shortfall of cereals for the displaced by a loan from another emergency operation in Uganda (CRS - 11/05/99; IRIN - 27/05/99, 18/06/99; WFP - 03/05/99, 26/05/99).

Gulu District

Insecurity between 1996 and 1998 led to displacement of much of the population. Security improved from November 1997, and since December 1998 better access to land meant some IDPs were able to harvest crops at the end of last year (ACF - 06/99).

Figure

ACF-USA undertook a nutritional survey in the accessible IDP camps in Gulu district in March 1999 (see Annex). The prevalence of wasting and oedema had fallen to relatively low levels as compared with the same period in 1998 (see graph below) - as would be expected with an improvement in the security situation and an increase in agricultural activities. Improvements in the nutritional situation were apparent in camps with and without health facilities, which indicates that the decrease in malnutrition was more likely to be food related, and not disease related. The prevalence of severe wasting and/or oedema however, did not decrease in the camps with medical facilities indicating that there were some new cases of severe undernutrition. Levels of stunting (height-for-age) among children remained high in both camps; in camps with health facilities 39.0% were moderately stunted, 16.9% of these severely so. In the camps without health facilities 41.8% were stunted, and 17.4% severely so.

The Prevalence of wasting and/or oedema in IDP camps with and without health facilities in Gulu district

Other indicators examined included measles vaccination, under-five mortality and the coverage of feeding programmes (see table below). Under-five mortality had decreased since the previous year in both types of camps. The feeding programme coverage had actually decreased in the camps with health facilities, although it had increased in the other camps. The measles vaccination rate as confirmed by card was low in both camps.

	Camps with health facilities		Camps without health facilities
	1998	1999	1998	1999
Under - five mortality	2.2/10,000/day	1.4/10,000/day	2.2/10,000/day	1.3/10,000/day
Feeding programme coverage	39.2%	32.6%	0.1%	29.4%
Measles vaccination	32.6%	38.3%	18.6%	33.7%

Kitgum District

ACF-USA also undertook a survey in Kitgum district in March 1999. Agriculture is traditionally the largest source of income for this population and many farmers now suffer from extreme poverty as a consequence of the insecurity and the loss of their cattle in raids. As a result of a massacre a large proportion of the population (around 25%) was displaced from the west of the country to six IDP camps in January 1997. These people are largely dependent on food distributions for their needs as they have difficulties in accessing their land. Since January 1999 the security situation has improved and many of the displaced have had more access to their land and have been able to harvest their crops.

The prevalence of wasting and/or oedema in IDP camps and villages in Kitgum District

This survey compared the nutritional status of IDPs and residents in the area (see graph). The prevalence of acute wasting and/or oedema was similar in both groups, although the villagers had slightly higher levels of severe wasting and/or oedema. 39.3% of IDP children were stunted, 12.7% severely so. The table below shows the distribution of other indicators collected. The main difference seen is that the feeding programme coverage in the IDP camp is much higher than that of the villages.

	IDP camps	Villages
Under - five mortality	0.6/10,000/day	1.1/10,000/day
Feeding programme coverage	37.2%	5.6%
Measles vaccination	29.0%	32.5%

Bundibugyo District

The security situation continues to deteriorate in the Western district of Bundibugyo. Aid agencies and government officials estimate that 50,000-70,000 have been recently displaced from their homes. Reports indicate that Ugandan rebels crossing over from the Rwenzori mountain area of DRC have been attacking villages, killing people and burning houses before returning to the DRC. Similar attacks took place throughout much of 1998, although security had improved sufficiently to allow families to return home by September. WFP and other agencies were forced to temporarily suspend their activities in the area but have restarted delivering food very recently to 146,000 displaced people in eight camps in and around Bungibugyo town (IRIN - 06/04/99, 12/05/99, 20/05/99, WFP - 23/04/99; 03/06/99)

A nutritional survey was conducted by Epicentre amongst IDPs in Bundibugyo town in February (see Annex). Insecurity prohibited surveys outside of the town. The IDP population at this time was estimated to be approximately 12,000 people and the resident population was estimated at 9,000. The IDPs were not found in separate camps (except in one location where 2,149 were clustered) but were living amongst the resident population's houses. The prevalence of acute wasting was estimated at 5.7% and severe wasting at 1.5%. Oedema was found in 0.7% of the survey population.

CMR was recorded at 1.37/10,000/day and the under five mortality rate was 1.68/10,000/day. The main causes of death amongst the under fives were malaria (67%), diarrhoea (13.3%) and measles (13.3%). In the population aged over five injuries accounted for 39% of deaths; diarrhoea and malaria were responsible for 45% of deaths. The attack rate (the cummulative incidence rate) of watery diarrhoea varied between 0.5-2.8% (mean 1.0%) in the two weeks prior to interview. Those of bloody diarrhoea from 0-0.6% (mean 0.2%). The very high proportion of deaths caused by injuries indicates how insecure the area is; it may also explain the reported sex ratio of 0.9 males to females. Measles vaccination coverage confirmed by card was low at 24.4% although from interviews with mothers it was estimated that 77.0% of the children aged 6-59 months had been immunised.

Bundibugyo district is facing a major public health crisis according to this report. This is caused by; the constant influx of newcomers, severe overcrowding, restricted amounts of water of unknown quality (3.0 litres/day of water) and few latrines (which were shared between 25 and 534 people). The high number of deaths due to diarrhoea were a direct result of the overcrowding and poor sanitary conditions. Although the absolute prevalence of wasting and/or oedema was not exceptionally high, the current situation will be exacerbated by the increasing number of IDPs and the approaching rainy season. Also, with insecurity increasing the population was less likely to go to their farms and collect food, hence it was predicted that the food security and hence the nutritional situation were likely to deteriorate.

Sudanese Refugees

A new influx of refugees has been expected because of the recent inter-ethnic fighting in Southern Sudan and also the continuing insecurity in north-eastern DRC. WFP has set-up a contingency plan to provide food assistance in this instance. To date, however, only a small number (372) have sought protection and assistance (UNHCR - 17/06/99; WFP - 16/04/99).

The number of Sudanese refugees assisted by WFP in Uganda currently stands at 161,100. A joint Food Needs Assessment was undertaken in the refugee camps in June. The mission recommended that food distributions from WFP should be phased out completely by June 2001, with gradual reductions to be effected through the two year period. In many of the camps only partial rations are currently provided as the refugees have access to agricultural land. The refugees in Palorinya and Pakelle camp were assessed as self-reliant at the time of the mission and hence will have their rations phased out from next month (WFP - 21/06/99).

An ACF-USA survey was undertaken in Kiryandongo camp (approximately 14,700 refugees) in April 1999 (see Annex). These results were compared to surveys in this camp in May and November 1998 (see graph). The nutritional situation has remained stable since November - there has been a significant decrease in the prevalence of acute wasting and/or oedema since May 1998 (particularly in the younger age groups). Feeding programme coverage for the camp was still low at 22.2% and had fallen from 31.3% in November. The measles vaccination coverage was also low at 40% according to card, although this figure was increased to 74.2% after interview with the children's parents.

The prevalence of wasting and/or oedema in Kiryandongo camp

The official WFP caseload for the Rwandese, Burundians, Congolese and Somalis in the camps in southern Uganda stands at 17,577 (WFP - 03/06/99). The nutritional situation of the refugees in these other camps was also reported to be adequate in the last RNIS; no new information has been received since this time.

Overall, the population most at risk is that in the western district of Bundibugyo, where there is a public health crisis as a result of displacement caused by insecurity (category IIa). The nutritional situation among the IDPs in Gulu and Kitgum, and has improved, but remains precarious (category IIb). The situation among the refugees is not critical (category IIc).

Priorities and recommendations:

Recommendations from the epicentre survey in Bundibugyo include:

· The local authorities must resettle the IDP population in Bundibugyo town in peripheral camps. These camps must be secure as otherwise the people will not remain there

· Collect mortality and morbidity data in all camps.

· Implement a mass vaccination campaign against measles. This should include the resident population.

· Provide this population with food assistance.

· Provide an adequate supply of safe water and sufficient numbers of latrines are essential to avert further public health crises.

The surveys from Kitgum, Gulu and Kiryandongo all recommend the following:

· Continue to regularly monitor the nutritional situation in the camps.

· Establish a referral system for nutrition within the health structure of the area. Facilitate home visits in order to identify and refer malnourished children to feeding centres.

· Strengthen the education programme, focusing on child care and nutrition

· Strengthen the measles vaccination coverage programme

In addition the surveys in Kitgum and Gulu also recommend:

· Design more appropriate programmes aimed at aiding the self-sufficiency of the displaced populations if security remains stable.