Refugees and sanitation in the Eastern Region of Sudan - El Baghir Nasr Dafalla and Bakri Yassin Taha

1. Introduction

Sudan is among the poorest 25 countries in the world (LDCs). Its population is estimated as 22 million (1983 census) with a growth rate of 2.5% and a per capita income of Sudanese £400 (World Bank, 1983). The infant mortality rate is 140-150/1000 (Ministry of Health Annual Report - 1984).

Sudan is surrounded by eight African countries, four of which (Ethiopia, Chad, Zaire and Uganda) have suffered from internal political instability, causing their nationals to seek asylum in Sudan.

The majority of refugees who cross the border settle in the Eastern Region of Sudan. The first influx to be offered official recognition arrived in Sudan in 1967, with a total number of 30 000. The second influx arrived in 1970 (24 000) and after 1975 the influx of refugees into the country became a daily occurrence, reaching the current total of 740 000, apart from those who settled in the west and south of the country (220 000). More than 90% of refugees are illiterate. There are both homogeneous communities composed of different tribes and several small ethnic minorities. Muslims and Christians comprise the majority. Most of the refugees are of rural, agricultural, nomadic or semi-nomadic background. Urban refugees are fewer, with diverse skills and educational levels. Their health education background is very poor. They are not accustomed to latrines, but prefer to defaecate in the fields.

2. Refugee settlements

Of the 740 000 refugees settled in the Eastern Region, only 277 312 have been accommodated in settlements or reception centres. Children under five constitute 12.6% of the total (34 989). Settlements can be classified as follows:

(1) Land settlements	(for families with a previous background of agricultural activities)
(2) Wage-earning settlements	(situated near the National Agricultural Schemes to provide labour)
(3) Urban settlements	(for those who were urban dwellers in their home country)
(4) Reception centres	(for newly arrived refugees)

The total number of settlements and reception centres in the Eastern Region is 32. Their population varies from 3000 to 20 000 per settlement or reception centre. Some reception centres, e.g. W. Sherefe, even accommodate more than 40 000 refugees.

The greatest remaining portion of refugees integrate in the main towns and villages of the Region and share the existing health facilities with the local population. This is exemplified by the pressure on hospitals: 66% of the outpatients in Kassala Hospital are refugees, while in Gedaref Hospital they account for more than 50%.

3. Refugees’ future

The future of the refugees in Sudan is not known. Some, who entered Sudan in 1967, are still there, with no sign of returning to their countries of origin. Unless the causes of their being refugees are resolved, they are likely to remain in Sudan indefinitely.

4. Sanitation programme objectives

In order that the sanitation programmes in refugee settlements and reception centres may fulfil their purpose, the following objectives have been clearly set in the relevant agreements:

(a) To ensure the removal and disposal of human excreta and other waste.

(b) To control insects and rodents in order to minimize the incidence and spread of communicable diseases.

(c) To improve the general health conditions of the refugees in all settlements and reception centres.

The following indices provide means of evaluating whether these objectives are being achieved.

1. The number of satisfactorily constructed latrines.

2. The utilization of latrines by refugees.

3. The number and frequency of vector control measures undertaken.

4. Number of staff present on site to collect refuse, spray and disinfect settlement sanitary facilities, conduct educational activities, construct and maintain latrines and report on activities.

5. The average monthly mortality rate.

6. The incidence of vector-borne diseases among refugees compared to that among the local population.

7. The frequency of garbage collection.

5. Sanitation systems applied in refugee settlements and reception centres in the Eastern Region of Sudan

There are two stages in implementing sanitation systems for refugees. In the first stage of an emergency, when a new influx of refugees starts crossing international borders to enter the country, they are usually accommodated in reception centres where the main priorities for sanitation include:

5.1 Proper control of human excreta disposal

This is achieved through a combined system of demarcated defaecation areas and trench latrines. Experience has shown that refugees prefer defaecation in fields to using latrines, particularly trenches or communals. For this system to serve its purpose, enough manpower has to be provided for collection and burial of human excreta on a routine daily basis, and funds made available for local purchase of equipment, periodic insecticidal operations and fly control, which are all of vital importance. The system seems to work well during the rainy season. It is to be noted that refugee communities hardly participate in this process.

5.2 Solid waste disposal

Solid waste disposal is carried out through the employment of some refugee workers and participation of the community. Refuse is collected in some demarcated communal places from where it is loaded on to tractors and off-loaded at the final disposal site, which is situated one or two kilometres from the reception centre. Incineration of dry refuse is the most common means of final disposal.

In addition, dumping of broken glass, tyres, tins, etc., is carried out. Hospital pathogenic waste is burnt in small barrels kept at the comers of the clinic areas or specially transported and dealt with immediately at the disposal site.

6. Supervision of water supply and protection of sources

In the next stage of an emergency, efforts concentrate on the protection of water sources and availability of enough water supply. Sources of water include:

6.1 Surface water (rivers)

Refugees consume raw water directly taken from rivers. The applicable protective measures are the division of rivers into three parts: the upper stream for drinking water, the middle part for washing and bathing, and downstream for animals (these measures were applied in 1985 in Wad-Kawli Reception Centre on the Atbara River). The second protective measure is the selection of sites for refugee reception centres within a walking distance of not less than five kilometres from any river (Shagarab Reception Centres). This measure is taken to protect river water from contamination, since most of the local population live in towns and small villages along these rivers and depend entirely on this water for domestic use. Local regulations for the protection and organization of such water sources are applicable in all such villages and towns.

6.2 Temporary system for piped water

This system is also applied in reception centres sited along rivers. Although the systems supply refugees with enough water, the quality of water is not guaranteed (e.g., the Oxfam system in Safawa Reception Centre, and the German one in Shagarab Centres). Pumps are installed on river banks to pump water to storage tanks from which water is distributed into a system of standpoints for refugees to use. Special care is taken with wastewater; it is important to construct a platform with proper slopes for drainage purposes.

6.3 Vector control

This activity depends principally upon the elimination of breeding sites, i.e., control of excreta disposal, refuse, waste and rainwater drainage. Periodic insecticidal operations are adopted whenever vector population density is beyond control and there is an indication of a rise in the number of cases of some specific disease related to a particular vector. Malathion powder 50% is used for malaria control, Agna-Reslin for fly control (ULV - machines) and Abate for the control of the aquatic stage of mosquitoes.

Delousing activities are well implemented to eliminate body, head and pubic lice. Other methods include boiling of clothes and shaving of hair. Propoxur 1% is used in refugee emergency situations for delousing activities.

6.4 Health education activities

Due to the low standard of personal hygiene and the poor background of health education among the new arrivals, a system of community outreach has been adopted within the guidelines of health services in general. A number of home visitors is to be employed, under intensive daily training, to carry out the following responsibilities:

(a) Educate refugees to use the defaecation areas and trenches rather than practising indiscriminate defaecation.

(b) Educate refugees to practise handwashing immediately after defaecation.

(c) Educate refugees to assist in the control of diarrhoeal diseases through:

- ORS usage and the role of mothers or child-carers in this
- Control of stools using the “cat” system.

(d) Check on bedridden patients and explain the importance of consulting a doctor.

(e) Follow up tuberculosis patients and malnourished children.

6.5 Food supervision

This activity is carried out to ensure that locally purchased food, as well as food internationally procured, is fit for human consumption and complies with the National Act of Food Supervision and Quality Control 1973.

7. Sanitation activities in permanent settlements

Sanitation activities in permanent settlements are very similar to those applied in emergency situations, except that some programmes, such as that for the disposal of human excreta, are incorporated into the annual budgets for development work. Such activities include:

(1) Construction of permanent family VIP (ventilated improved pit) latrines in all refugee settlements. The idea behind this programme is to assist radically in solving and controlling indiscriminate defaecation in and around the settlements. Also the programme anticipates a period of stay for refugees of many years. It is therefore assisting in controlling some of the environmental factors that lead to the spread of diarrhoeal and related diseases.

For this programme to be successful, there are two major components. The first is the contribution of UNHCR in the procurement of some building materials such as cement, iron bars, chicken wire and wood. The second is the contribution of refugees in the digging of pits and the building of superstructures: thus refugees contribute in the reduction of the overall cost and fulfil the objective of community participation.

(2) The construction of slaughterhouses, as well as butchers’ and vegetable sheds is also of a developmental nature. It can also contribute to the control of food quality and make supervision much easier: taeniasis is one of the prevailing diseases, particularly among Ethiopian refugees.

(3) Emphasis on the construction of permanent reliable water sources which will ensure enough water supply of good quality, is well adhered to in permanent settlements. For settlements sited near rivers or irrigated schemes, slow sand filtration systems are in use, while deep boreholes supply the rest of the settlements.

Both systems are connected to overhead tanks and hence to a distribution system whereby water is collected by refugees from standpoints.

8. Constraints affecting the sanitation programme in Eastern Sudan

In spite of the above-mentioned objective and the designated programme activities for both settlements and reception centres, sanitation has been subject to some constraints which have affected the flow of services and the maintenance of the programme. These constraints include the following:

8.1 Labour force reduction

Due to a financial crisis UNHCR decided in October 1989 to reduce manpower as well as funds allocated for the running of services in all programmes designed for refugees in Eastern Sudan. Sanitation is one of the areas affected. The labour force originally employed to undertake sanitation activities was drastically cut. This reduction amounted in some areas to 90% and in others it varied from 20% to 80%. (See Appendix 1.)

8.2 Reduction of budget allocations

The budget allocations for sanitation programmes have been subject to drastic cuts in 1989 and 1990. An arbitrarily allocated fund of Sudanese pounds 2000 for different settlements and reception centres was approved by UNHCR. These funds are specifically allocated for the purchase of local equipment and other materials necessary for sanitation activities. They are in fact set arbitrarily, regardless of actual needs, camp population or the volume of work to be done.

This has resulted in the non-fulfilment of the requirements in materials necessary for the running of the sanitation services. Funds allocated by UNHCR meet only 2.5% to 4% of real needs. (See Appendix 2.)

Failure to properly collect and dispose of human excreta resulted in very unpleasant living conditions with a large fly population and breeding sites. The Wad Sherefe and Safawa Reception Centres were the most affected. After official visits paid to these areas by the regional authorities (March 1990), a request was made for immediate intervention to alleviate such problems. This indicated the dissatisfaction of the region with the sanitation programme, especially in these reception centres, which are considered as entry points for refugees crossing the borders into the country. In such centres a high standard of sanitary provision is required to counteract possible outbreaks of gastrointestinal diseases or any other disease of public health importance.

8.3 Delay in receiving internationally procured insecticides

It is well documented that insecticides for the control of vector-borne diseases are always received late. In Sudan, these insecticides are supposed to be received in March every fiscal year and distributed by June just before the season of malaria transmission. In 1989 and 1990 insecticides were received in October.

Malaria is a disease of high prevalence among refugees. Its proper control is closely linked with early preparation and organization of programme resources at the correct, scheduled time.

Refugees suffered a major malaria epidemic in 1988. Dr C.A. Malcolm, consultant entomologist, stated in his report (TSS 58/77): “The high malaria rate in 1988 among refugees compared to the preceding year was almost universally blamed on a shortage of insecticides”. He added that there were other contributing factors such as the amount of rainfall that year and the actual definition used for cases of malaria.

8.4 Cessation by UNHCR of the construction programme of VIP latrines in refugee settlements

The above programme was stopped in 1989. It was assumed by UNHCR that VIP latrines were not being used by refugees. However, in 1984, prior to the implementation of this programme, a pilot project for family latrines in two settlements (Tenedba and Mafaza) was agreed upon by both UNHCR and the Sudanese Commissioner for Refugees. The experiment included 65 families in each settlement, for whom family latrines were constructed. The project was assessed after one year (1985). All indicators showed that it was a success. Since then the programme of construction was included in the annual budget in all refugee settlements. It was intended to attain total coverage with family latrines by 1990-1991.

Due to financial reasons, as well as delays in the international procurement of some building materials, progress was somewhat slow. The highest coverage reached in the settlements was 59% while the lowest was 3.7%.

The programme is still half completed. It is to be stressed that the problem of human excreta disposal may remain unsolved as long as refugees remain in Sudan. (See Appendix 3.)

The incidence of diarrhoeal diseases, hepatitis, parasitic worms and schistosomiasis in refugees camps in 1989 is shown in Appendix 4. No doubt several interrelated factors prompted the prevalence of such diseases, but the most likely contributing factors include poor sanitation and inadequate water and food.

8.5 The adoption of a water fee collection strategy in refugee settlements

As a long-term objective UNHCR and the Office of the Sudanese Commissioner for Refugees agreed in 1988 that a water fee collection strategy be adopted and implemented in refugee settlements as from 1989-1990. The revenue collected would be used for:

(1) Payment of salaries of the water project staff.
(2) Assisting in the purchase of fuel, lubricants, spare parts of pumps and water systems.
(3) Covering any unforeseen expenses related to the water project.

This new strategy may have had some negative impact on refugees’ health. In settlements sited near the irrigation schemes and rivers, refugees tend to avoid payment of fees by taking their drinking water directly from canals or rivers, rather than using the already established distribution points for reliable drinking water in their settlements.

A report prepared by Dr Alex Mercer, a biostatistician in the Refugee Health Unit, suggested that the incidence of four major diseases could have been affected by the end of 1989. Diarrhoeal diseases, schistosomiasis, hepatitis and parasitic worms could all be transmitted in this way, although there are other interrelated factors that might account for the high prevalence in camps situated near canals or rivers.

Appendix 1

Labour reduction

Appendix 2

Breakdown of equipment needed/year/camp

Appendix 3

Availability of latrines

Camps	Total of population end of 1989	Approximate number of families	Number of latrines constructed	Number of latrines collapsed	Number of latrines operative	% of families covered
W/Sherefe	42 932	8 585	317	17	300	3.5
Shagarab 1	21 161	4 232	469	23	446	10.5
Shagarab 2	12 466	1 247	714	0	714	57.3
Shagarab 3	13 642	2 728	250	18	232	8.5
Safawa	25 905	5 181	76	0	76	1.5
Reception	116 106	23 221	1 826	68	1 768	7.6
Fau 5	3 999	800	-	-	-	-
Kilo 5	2 325	465	97	5	92	19.8
A/Sid	2 670	670	75	0	75	14.6
Kilo 7	1 846	369	47	0	47	12.7
K/Helew	9 154	1 831	182	10	172	9.4
Umrakuba	14 127	2 825	550	67	483	17.1
K/Girba	10 912	2 182	160	0	160	7.3
Karkora	12 246	2 449	767	10	757	30.9
Kilo 26	11 643	2 329	225	10	315	9.2
Tawawa	15 753	3 151	1 392	0	1399	44.4
A/Rakham	3 658	732	334	-	334	43.8
Tenedba	2 534	507	295	-	295	52.8
K/Awad	1 911	382	148	-	148	54.0
Kafaza	3 280	650	298	-	298	43.8
Hawata	4 135	827	327	-	327	59.6
Umgurgur	7 894	1 579	780	10	770	48.8
Umgulja	5 464	1 095	238	0	238	21.8
Abuda	5 006	1 001	167	0	167	16.7
Ukali	2 695	539	118	0	118	21.9
Salkin	6 990	1 399	58	0	58	4.1
Adingpar	4 540	906	-	-	-	-
Umbrush	5 560	1 112	40	0	40	3.6
Umzuzur	4 720	944	-	-	-	-
Dehama	5 950	1 190	-	-	-
Um Sagata	7 516	1 503	93	0	95	6.2
Settlements	156 428	31 286	6 398	112	5 286	20.1
All Camps	272 534	54 507	8 224	270	8 054	14.8

Appendix 4

Incidence of water-related diseases by camp: 1989

1. Four of the categories of disease under which morbidity is recorded in the monthly health surveillance reports from the camps can be classed as water-related. Bilharzia [schistosomiasis] is the most specifically water-borne disease whereas the other three categories - worms, hepatitis and diarrhoeal disease - may involve a large component of food-borne infection.

2. The type of worm infestation is not recorded, in the monthly reports for example, so there is no indication of the proportion of cases which may be linked with contamination of water supplies. Similarly, the type of hepatitis is not specified, and even if hepatitis A is largely responsible, food-borne transmission may be involved. Many cases of diarrhoea may reflect contamination of food rather than of water, while among young children the symptoms may be a secondary complication of some specific childhood epidemic infection such as measles.

3. Despite the limitations of the data, incidence rates for these four diseases provide some indication of which camps may have the most problems with contamination of standing water and drinking water. In fact, two camps clearly stand out as being the worst for water-related diseases - Kilo 7 and Awad Sid.

4. Kilo 7 had the highest incidence rate for worms in 1989 and the second highest incidence rate for the other three diseases. Using an index obtained by adding the rankings for each of the four diseases, Kilo 7 was the worst camp.

5. Awad Sid had by far the highest incidence rate for bilharzia, and nearly half the cases recorded in the settlements were in this relatively small camp. The camp also recorded the highest incidence rate for diarrhoeal disease and the second highest for worms, and it ranked second-worst on the index of all four diseases despite the relatively low incidence of hepatitis.

6. Mafaza and Umburosh had high incidence rates for hepatitis in 1989, but relatively low incidence rates for the other three diseases.

7. About 4% of all the cases of worms were recorded in two camps, Safawa and Umrakuba, which had the highest incidence rates after Kilo 7 and Awad Sid. Umrakuba was in fact the third worst camp on the index of all four diseases combined, but Safawa had relatively low incidence rates for the other three water-related diseases.

8. Kilo 5 and Towawa ranked fourth and fifth worst on the index of all four diseases. Both camps had relatively high incidence rates for bilharzia, worms and hepatitis, though not for diarrhoeal disease.

Alex Mercer
Biostatistician
Refugee Health Unit

30 April 1990