South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER 5 YEARS OLD

LANKIEN AND TUT PAYAMS, NYIROL COUNTY

JONGLEI STATE

16TH AUGUST – 12TH SEPTEMBER 2007

Edward Kutondo- Survey Program Manager Imelda .V. Awino – Nutritionist

Simon Tut Gony- Program Assisstant

2

ACKNOWLEDGMENTS

ACF-USA acknowledges the support, commitment and cooperation of the following institutions and persons, who enabled the team to successfully actualize survey objectives:

Office of United States Foreign Disaster Assistance (OFDA) for funding the survey;

The Sudan Relief and Rehabilitation Commission (SSSRRC) Nyirol County for availing relevant data and ensuring smooth flow of activities;

The entire survey team for their hard work, team spirit, commitment and endurance despite the

difficult terrain;

South Sudan Ministry of Health in Jonglei State, MSF-OCA, Sudan Red Crescent, Cush Community Relief International for availing staff for capacity building;

Parents, caretakers and the local authority for their cooperation.

3

TABLE OF CONTENTS

.I. EXECUTIVE SUMMARY................................................................................................................................4 .II. INTRODUCTION .........................................................................................................................................10 .III. OBJECTIVES .............................................................................................................................................11 .IV. METHODOLOGY.......................................................................................................................................11

.IV.1. Type of Survey and Sample Size .......................................................................................................11

.IV.2. Sampling Methodology .......................................................................................................................11

.IV.3. Data Collection....................................................................................................................................12

.IV.4. Indicators, Guidelines, and Formula’s Used.......................................................................................13 .IV.4.1. Acute Malnutrition........................................................................................................................13 .IV.4.2. Mortality .......................................................................................................................................13

.IV.5. Field Work...........................................................................................................................................14

.IV.6. Data Analysis ......................................................................................................................................15 .V. RESULTS OF THE QUALITATIVE ASSESSMENT ..................................................................................15

.V.1. Socio- demographic Characteristics of the Respondents....................................................................15

.V.2. Food Security.......................................................................................................................................17

.V.3. Health...................................................................................................................................................20

.V.4. Water and Sanitation ...........................................................................................................................22

.V.5. Maternal and Child care practices .......................................................................................................24

.V.6. Education .............................................................................................................................................24

.V.7. Actions Taken by NGO’s and other partners .......................................................................................25 .VI. RESULTS OF THE ANTHROPOMETRIC SURVEY.................................................................................26

.VI.1. Distribution by Age and Sex................................................................................................................26

.VI.2. Anthropometrics Analysis ...................................................................................................................27 .VI.2.1. Acute Malnutrition, Children 0-59 months of Age........................................................................27 .VI.2.2. Risk of Mortality: Children’s MUAC .............................................................................................28

.VI.3. Measles Vaccination Coverage ..........................................................................................................29

.VI.4. Household Status................................................................................................................................29

.VI.5. Composition of the Households..........................................................................................................29 .VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY..............................................................29

.VII.1. Mortality Rate.....................................................................................................................................29 .VIII. CONCLUSION .........................................................................................................................................30 .IX. RECOMMENDATIONS..............................................................................................................................31 .X. APPENDIX ..................................................................................................................................................32

.X.1. Sample Size and Cluster Determination..............................................................................................32

.X.2. Anthropometric Survey Questionnaire.................................................................................................33

.X.3. Household enumeration data collection form for a death rate calculation survey (one sheet/household)..........................................................................................................................................34 .X.4. Enumeration data collection form for a death rate calculation survey (one sheet/cluster) ..................35 .X.5. Calendar of events in Lankien and Tut payams, Nyirol County, Jonglei State....................................36 .X.6. Food market prices- Lankien and Tut payams, Nyirol County.............................................................37 .X.7. The map of Lankien and Tut payams, Nyirol County ..........................................................................38

4

.I. EXECUTIVE SUMMARY

Introduction Nyirol County in Northern Jonglei State borders Akobo County to the South East, Wuror County to the South, Ayod County to the West and Khorfulus- Atar County to the North West. It is composed of 8 payams namely Lankien, Tut, Pultruk, Waat, Nyanbor, Chuil, Pading and Keeth. The county’s population is estimated at 108,9541. The main denizens of the Nyirol County are the Lou Nuer of the Goatbal clan sub divided into two main sub clans namely the Cienglang and Ciengnyarkuach2. Their main source of livelihood is agro-pastoralism, though crop farming, employment and petty trade are gaining prominence. Lankien and Tut payams, locally referred to as ”Thol payams” are characterized by a low lying flat terrain. The area, classified under Eastern flood plain zone, is covered by clay soil with portions of sandy soil. This topography predisposes the area to flooding during the rain season. The vegetative cover comprises of thorny trees such as Acacia senegali and Desert dates species. The seasonal streams like Thol cut across the payams during the rain season. There are no permanent rivers in the area. According to FEWSNET April 2007, the hunger gap season was likely to be severe in some livelihood zones such as the northern parts of the Western Flood Plains and the Eastern Flood Plains (Nyirol, amongst other counties in Jonglei State) where structural food deficits are normally acute. Food security in Nyirol County is further weighed down by the poor harvest caused by floods and civil insecurity due to disarmament in the year 2006. Flooding was reported in most parts of Upper Nile and Jonglei states between June and July 2007. Such was the case in Nyirol County where the local authority reported flooding and displacement of 9,4533 persons within the county. This was reported to have worsened in July 2007 when people were displaced, farms destroyed and market access cut prompting the local authority to seek for help from the government, national and international agencies4. ACF-USA undertook a nutritional survey in Nyirol County in Lankien and Pultruk payams in July 2002. Above emergency GAM and SAM rates of 28.4% [24.3% - 33.0%] and 4.3% [2.7% - 6.8%] respectively (expressed in z-scores, NCHS reference, with 95% of confidence interval) were unveiled. No nutritional survey was since implemented. In view of potential food insecurity, negative effects of floods and civil insecurity impact on livelihoods, ACF-USA deemed it necessary to undertake a nutrition survey in Nyirol County. Objectives

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

community; To build the capacity of MOH and National NGOs in detection of malnutrition.

Methodology SMART5 methodology was utilised in the training, planning, collection and analysis of both anthropometric and mortality data.

1 Source: SSRRC Supervisor Nyirol County 2 Source: SSRRC Supervisor Nyirol County 3 Source: SSRRC Supervisor Nyirol County 4 Local Authority; Nyirol County 5 Standardised Monitoring and Assessment In relief and Transition

5

Information gathered from reliable resource persons; SSRRC supervisor Nyirol, SSRRC secretary Lankien, surveyors as well as a map of the area was used in determining the relatively accessible villages. The population of the accessible villages was estimated at 24,468. In the anthropometric survey, each village with a total population of more than 5,000 was broken down in proportion to the respective sub-village sizes. The children under five years old, estimated at 20% of the population, were the target population. Thereafter the target population (4,894), malnutrition prevalence (33.0%), precision (4.6%) and design effect (2) were keyed into Nutrisurvey software6 planning template for sample size calculation. The sample size obtained (742) was then increased by 5% to cater for any unforeseen eventualities; and divided by 207 to obtain the number of clusters required. A total of 39 clusters were obtained and randomly assigned for assessment. For the mortality survey; the total accessible population (24,468), crude mortality rate prevalence (1.0), precision (0.4), recall period (90 days) and design effect (2) were inputted into Nutrisurvey software August 2007 version to calculate the sample size (4772). This sample size was then divided by the total number of clusters (39) to obtain the targeted number of people present now per cluster (123). The EPI method was applied in the random selection of households during data collection. At first the centre of the clustered sub village was identified and thereafter a pen was spun to determine a starting direction so as to eliminate bias towards the centre. The survey team then moved along the pointed direction to the periphery of the village where the pen was re-spun and a starting point established using simple balloting. In some instances, due to the nature of the terrain and distance between households, a pen was spun once at the centre of the village to determine the starting direction and the first household was randomly selected through simple balloting. The next households were determined through proximity or to the right depending on household distribution in the villages. In the selected household, both the anthropometric and mortality questionnaires were administered. 20 children aged 6-59 months and 123 persons present now in the household were targeted per cluster for the anthropometric and mortality surveys respectively. Qualitative data was gathered alongside the aforementioned. A structured qualitative questionnaire and observation was used to collect secondary data in regard to Maternal and Child Health (MCH); Water, Sanitation and Hygiene (WASH); food security; availability and use of health facilities. The questionnaire was systematically administered in every fifth household in a sum of 5 households per cluster. Summary of Findings Nyirol County is composed of 8 payams namely; Lankien, Tut, Pultruk, Waat, Nyanbor, Chuil, Pading and Keeth. Lankien is currently the county headquarter. As of August 2007, the county’s populace was estimated at 108,954. The total population of Thol payams which were covered in the survey was estimated at 39,2738. Most of the inhabitants of Thol payams were residents (89.5%) with 4.5%, 1.9% and 4.1% being returnees, internally displaced and temporary residents respectively based on anthropometric status analysis. Approximately 9,4539 persons were displaced in Nyirol County by August 2007, due to floods reported to have worsened in July 2007. During the survey period, the security situation was tense. Disarmament exercise was reported to have been undertaken between June-July 2006. The fragile situation eventually led to the temporary evacuation of some international NGOs in the area on the 12th September 2007. However, the Nyirol County commissioner was quick to point out that the security situation in the area was normal and that the government was in the process of controlling firearms in the community through what he termed as “Community Policing”.

6 August 2007 Version 7 For ACF-USA: The number of children that can be measured accurately per day/ team. 8 Source: SSRRC Supervisor Nyirol County 9 Source: SSRRC Supervisor Nyirol County, August 2007.

6

Food security in the region was hampered by a number of factors such as floods, inaccessibility to markets, pests, birds and insecurity. During the survey period, most of the farms were observed to be flooded. The community largely consumed the green milking maize from the farms that were on the verge of depletion. This concurred with qualitative data findings indicating that the community’s main food source was private production (86.7%) and wild food collection (68.9%). The main wild foods collected were wor and nyakajang. A few of the households (11.1%) purchased food from the not so well stocked market. The market prices of commodities greatly fluctuated depending on demand and availability. A large proportion (86.7%) of community had cultivated crops in the previous growing season with land sizes ranging from 0.5-5 feddans10. However most (97.4%) of the harvests were below expectations because of floods, pests, diseases, insecurity and birds. Some of the crops planted were maize, sorghum, beans, vegetables, pumpkins, millet and groundnuts. Sale of livestock was the predominant source of income followed by firewood collection, petty trade and employment. Notably the number of livestock was reported to have declined in the past five years. This was ascribed to floods, livestock benefits such as sale as well as persistent raids from the Murle community of Pibor County. Generally households owned livestock such as cows and goats which were at home. Milk was a major gain from livestock and was mainly fed to the young children. Other livestock benefits in order of priority were sale, dowry and food on special occasion. Availability of fish was limited due to flooding, lack of fishing equipment and fish at fishing points. Qualitative findings indicated that WFP distributed food for recovery in the area in April 2007. Health services in the Thol payams are proffered solely by MSF-OCA11. The agency runs 1 Primary Health Care Centre in Lankien payam with the main programs being TB, Kala-azar and Basic Health Care. Laboratory services, Ante natal care as well as health education sessions were offered by MSF-OCA. Daily operations of the PHCC were managed by trained community health workers under the supervision of skilled international staff. The main causes of morbidity and mortality as reported by the MSF-OCA and revealed by qualitative analysis were diarrhoea, malaria, RTI, Kala-azar and fever. Majority of the community had to walk for more than one hour to access medical services which in most cases were sought late when the disease had progressed to severe stages. Distance to the health services was further increased by inaccessibility to most areas due to heavy rains. A measles outbreak was reported in April 2006. To curb the situation, MSF-OCA with the support from UNICEF responded through mass vaccination campaign. Since then, measles vaccination has been ongoing in the PHCC. A total of 675012 children less than 15 years of age had been vaccinated against measles between April and August 2007. Other than measles, no EPI services were being offered during the survey period. However the agency is enthusiastic that it will introduce EPI services in the coming months. There were approximately 5 functional boreholes in the region that could not meet adequately the water needs of the households. Given this fact, the community relied largely on surface run off (80.0%) and collected rain water (86.7%) for drinking and household uses. Boreholes were utilized by only 11.1% of the community. Water treatment methods were not up to date. (40.0%) of the households consumed untreated water while a few either used filtration (37.8%), or decantation (26.7%). No latrines were observed in all households assessed save for agencies. Human waste was therefore disposed off in the bush, open field or behind houses. The deplorable water and sanitation situation exposed the community to infections and diseases such as diarrhea, typhoid, malaria and guinea worm. Initiation of breastfeeding after birth was timely. Most (94.7%) mothers breastfed their children immediately after birth with breastfeeding done on demand by 73.7%. Weaning and complimentary foods included

10 Unit of land measurement equivalent to approximately 4200 sq meters 11 Médecins Sans Frontières- Operation Centre Amsterdam. 12 MSF-OCA statistics August 2007

7

cow/goat milk, porridge, wild vegetables such as wor and cereals like green maize. The young children were fed twice a day. A number of agencies were operational in the area in various sectors as follows: Médecins Sans Frontières Operation Centre Amsterdam (MSF-OCA): An International NGO proffering health services. MSF-OCA main programs in the area are Tuberculosis, Kalazaar and Basic Health Care (Feeding programme). The agency operates 1 PHCC in Lankien and 2 PHCU’s in Riang and Pultruk payams. Surgical referrals are sent to the MSF-H Leer facility. Norwegian People Aid (NPA): The agency runs an agricultural program in the county targeting three payams namely; Waat, Lankien and Pading. 300 farmers have been targeted in the entire county. Currently the agency is undertaking trainings in the various payams in phases on issues such as land preparation, planting, weeding, harvesting and storage. 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 Lankien, Pultruk, Pading, Nyanbor and Waat payams. The main activities include; case finding, case management and health education. The agency also runs a preventive Trachoma control program. Cush Community Relief International (CCRI): A national agency operating in Waat payam since 2006. CCRI supports 1 PHCC in Waat payam through quality assurance of drug prescriptions and treatment. It also provides outreach services in some parts of Waat.

8

Nutrition and Mortality Survey Results 794 children were assessed during the anthropometric survey but only 782 were included in the final analysis due to errors in 12 records. Table 1: Anthropometric and mortality summary results

INDEX INDICATOR RESULTS13

Global Acute Malnutrition W/H< -2 z and/or oedema

17.3% [13.7% -20.8%]

Z- scores

Severe Acute Malnutrition W/H < -3 z and/or oedema

0.8% [0.1% - 1.4%]

Global Acute Malnutrition W/H < 80% and/or oedema

6.1 % [4.3% - 8.0%]

NCHS(1977)

% Median Severe Acute Malnutrition W/H < 70% and/or oedema

0.3 % [0.0% - 0.7%]

Global Acute Malnutrition W/H< -2 z and/or oedema

18.3% [14.5% - 22.1%]

Z-scores

Severe Acute Malnutrition W/H < -3 z and/or oedema

2.2% [0.9% - 3.5%]

Global Acute Malnutrition W/H < 80% and/or oedema

3.8 % [2.1% -5.6%]

WHO(2005)

% Median Severe Acute Malnutrition W/H < 70% and/or oedema

0.3 % [0.0% - 0.7%]

Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day

1.24 [0.80 - 1.68] 0.12 [0.00 - 0.44]

Measles immunization coverage (N= 745 children ≥ 9months old)

By card According to caretaker14

Not immunized

31.5% 34.4% 34.1%

DISCUSSION In the July 2002 (hunger season), ACF-USA survey, GAM and SAM rates unveiled were 28.4% (24.3% - 33.0%) and 4.3% (2.7%-6.8%) respectively. The current survey conducted at the beginning of the harvesting season revealed lower GAM and SAM rates of 17.3% (13.7%-20.8%) and 0.8%(0.1%-1.4%) accordingly. Crude mortality rate of 1.24/10,000/day has also declined despite still being above the alert level. The current above emergency global acute malnutrition rate is attributed to the following factors: Inadequate food intake: More than half of the mothers fed the young children twice in a day on foods such as milk, green maize and wild vegetables. There were inadequate frequent energy dense feeds to meet the energy requirements of the growing children. Food diversity existed, however there was limited consumption of pulses and fruits. Disease incidences: Common causes of morbidity and mortality cited were diarrhea incidences, malaria, kalazaar as well as respiratory tract infections. These weakened the immune system, affected appetite and reduced food intake which eventually lead to malnutrition. Other than the long walking distances, accessibility to the health facilities was further weighed down by the numerous streams and swamps traversing the area, hence delaying medical assistance.

13 Results in bracket are at 95% confidence intervals. 14 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

9

Food insecurity: Destruction of past and current harvests by floods largely predisposed the community to food insecurity. Flooding is likely to prolong the hunger period among some households while in areas where crops were destroyed, hunger season could start early in 2008. Other than fresh milk and green maize that was mainly fed to the children, food availability was scarce. The IDP and returnee population increased pressure on limited food stocks among the host community. Livestock numbers had declined due to sale, raids and slaughter. Limited market access and high prices equally reduced food availability and access. Households adopted eating of immature crops, low quality foods and kinship support as coping strategies. Poor water and sanitation: Most water sources were prone to contamination due to the community’s activities such as bathing at water points, washing at water sources, human waste disposal and guinea worm infestation. Almost half of the households consumed untreated water whereas a few used filtration and decantation which could not eliminate microorganisms. Water was observed to be collected in dirty containers and left uncovered enhancing contamination during collection and storage. The users faced the risk of water borne infections such as diarrhea. The average daily consumption of water per household depended on household size, distance to water points, availability of water containers as well as household chores. Poor maternal and child health care practices: No specialized meals were given to pregnant and lactating mothers despite the increased physiological demands. Children were mostly fed to two meals per day that were not adequate in quality and quantity. In some cases the children were either weaned early or late. Early marriages as well as lack of adequate and diversified meals further compound maternal and child health, thence the high GAM rates. Security: The security situation in the area had been tense, limiting the community’s time for participation in productive activities. The insecurity was attributed to disarmament exercise, alcoholism, family differences and general lawlessness. Cattle raiding are still a threat to livelihoods in Jonglei pastoralist areas such as Pibor County and surrounding areas. The insecurity affects availability of milk and animal products at the household level. RECOMMENDATIONS ACF-USA recommends the following within an integrated approach in order to reduce malnutrition rates and contribute to improved health and nutrition: Food Security • To monitor the impact of floods and displacement on harvests and overall food security situation in

October and there after in order to mitigate the negative effects and promote utilisation of positive flood effects.

• To initiate strategies that increase household food production, availability and access. This could involve flood control, wet land cultivation, promotion of short term maturing crops, crop diversification, fishing, agricultural extension services, income generating activities, Food for Agriculture and Food for Recovery.

Health • To increase coverage of primary health care services through capacity building, active participation of

MOH in collaboration with NGOs and outreach services. • To forge ahead and incorporate EPI services, nutrition surveillance and treatment of malnutrition cases

as part of integrated management of childhood illnesses. Water, Sanitation and hygiene • To look into the feasibility of construction and protection of safe water sources bearing in mind the fact

that the area is guinea worm endemic and water contamination is likely due to poor waste disposal. • To undertake health education on vital issues such as safe water use, latrine construction and use,

good health seeking practices as well as appropriate waste disposal Maternal and Child Care: To sensitize mothers and care takers on appropriate maternal child care that includes weaning and complimentary foods as well as antenatal and post natal care.

10

.II. INTRODUCTION

Nyirol County in Northern Jonglei State borders Akobo County to the South East, Wuror County to the South, Ayod County to the West and Khorfulus- Atar County to the North West (see the map on the left side). The county is composed of 8 payams namely Lankien, Tut, Pultruk, Waat, Nyanbor, Chuil, Pading and Keeth whose populace is estimated at 108,95415. The population of Thol (Lankien and Tut) payams where the survey covered was projected at 39,27316. The main denizens of the Nyirol County are the Lou Nuer of the Goatbal clan sub divided into two main sub clans namely the Cienglang and Ciengnyarkuach17. Their main source of livelihood is agro-pastoralism, though crop farming, employment and petty trade are gaining prominence.

Lankien and Tut payams, locally referred to as ”Thol payams” are characterized by a low lying flat terrain. The area, classified under Eastern flood plain zone, is covered by clay soil with portions of sandy soil. This topography predisposes the area to flooding during the rain season. The vegetative cover comprises of thorny trees such as Acacia senegali and Desert dates species. The seasonal streams like Thol cut across the payams during the rain season. There are no permanent rivers in the area. During the survey period, the security situation was tense. Disarmament exercise was reported to have been undertaken between June-July 2006. The fragile situation eventually led to the temporary evacuation of some international NGOs in the area on the 12th September 2007. However, the Nyirol County commissioner was quick to point out that the security situation in the area was normal and that the government was in the process of controlling firearms in the community through what he termed as “Community Policing”. According to FEWSNET April 2007, the hunger gap season was likely to be severe in some livelihood zones such as the northern parts of the Western Flood Plains and the Eastern Flood Plains (Nyirol, amongst other counties in Jonglei State) where structural food deficits are normally acute. Food security in Nyirol County is further weighed down by the poor harvest caused by floods and civil insecurity due to disarmament in the year 2006. Flooding was reported in most parts of Upper Nile and Jonglei states between June and July 2007. Such was the case in Nyirol County where the local authority reported flooding and displacement of 9,45318 persons within the county. This was reported to have worsened in July 2007 when people were displaced, farms destroyed and market access cut prompting the local authority to seek for help from the government, national and international agencies19.

15 Source: SSRRC Supervisor Nyirol County 16 Source: SSRRC Supervisor Nyirol County 17 Source: SSRRC Supervisor Nyirol County 18 Source: SSRRC Supervisor Nyirol County 19 Local Authority; Nyirol County

11

ACF-USA undertook a nutritional survey in Nyirol County in Lankien and Pultruk payams in July 2002. Above emergency GAM and SAM rates of 28.4% [24.3% - 33.0%] and 4.3% [2.7% - 6.8%] respectively (expressed in z-scores, NCHS reference, with 95% of confidence interval) were unveiled. No nutritional survey was since implemented. In view of potential food insecurity, negative effects of floods and civil insecurity impact on livelihoods, ACF-USA deemed it necessary to undertake a nutrition survey in Nyirol County.

.III. OBJECTIVES

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

community; To build the capacity of MOH and National NGOs in detection of malnutrition.

.IV. METHODOLOGY

.IV.1. Type of Survey and Sample Size

The anthropometric and mortality data was gathered using SMART20 methodology. Information gathered from various reliable resource persons as well as secondary data was instrumental in triangulating population figures of the area. A map of the location was used to determine the relatively accessible villages whose inhabitants were estimated at 24,468 (Appendix X.7). Qualitative data was simultaneously gathered through a structured qualitative questionnaire21 and observation. Key issues queried were Maternal and Child Health (MCH), Water Sanitation and Hygiene (WASH), food security, availability and use of health facilities.

.IV.2. Sampling Methodology

A two-stage cluster sampling method was used:

• Cluster selection: The anthropometric and mortality sample sizes were calculated in Nutrisurvey Software August 2007 version. For the anthropometric survey, the target population (4,894), malnutrition prevalence (33.0%), precision (4.6%) and design effect (2) were keyed into Nutrisurvey software planning template for sample size calculation. The malnutrition prevalence was based on the previous survey in the year 2002 whose GAM rate was 28.4% [24.3% - 33.0%]. The sample size obtained (742) was then increased by 5% to cater for any unforeseen eventualities; and divided by 2022 to obtain the number of clusters. A total of 39 clusters were obtained and randomly assigned for assessment (Appendix X.1). For the mortality survey; the total accessible population (24,468), CMR prevalence (1.0), precision (0.4), recall period (90 days) and design effect (2) were inputted into Nutrisurvey software August 2007 version to calculate the sample size (4,772). This sample size was then divided by the total number of clusters (39) to obtain the targeted number of people present now per cluster (123).

20 Standardized Monitoring and Assessment in Relief and Transition 21 Administered systematically in every 5th household in a sum of 5 HH per selected clusters 22 For ACF-USA: The number of children (6-59 months) that can be measured accurately per day per cluster.

12

• Household and children selection: EPI method was used to randomly select households in the field. At first the centre of the clustered sub village was identified and thereafter a pen was spun to determine a starting direction to eliminate bias towards the centre. The survey team then moved along the pointed direction to the edge of the village where the pen was re-spun and a starting point established using simple balloting. In some instances, due to the nature of the terrain and distance between households, a pen was spun once to determine the starting direction. Simple balloting procedure was then used to select the first household. In the selected household, both the anthropometric and mortality questionnaires were administered. The next households were determined through proximity or to the right depending on household distribution in the villages. This was done till the target of 2023 and 12324 per cluster was achieved for the anthropometric and mortality surveys respectively.

.IV.3. Data Collection

The enumerators underwent a 4 day training (anthropometric, mortality, qualitative, standardization and pilot test) facilitated by ACF-USA staff. The actual data collection was undertaken in a spun of 12 days by a team of 2 ACF-USA staff, 10 enumerators, 4 MSF-OCA national staff, and 3 capacity building staff each from CCRI25, SRC26 and MOH. The anthropometric, mortality and qualitative data was gathered in the clustered villages as per the methodology. In every household the anthropometric questionnaire was administered to all eligible children till the target of 20 children per cluster was obtained. Households that had no eligible children remained a part of the “sample” that contributed zero children to the nutritional part of the survey. These households were recorded on the nutritional data sheet as having no eligible children and the status noted. The mortality questionnaire was administered in all households irrespective of whether it had eligible anthropometric children or not. 123 persons present per household were targeted. Household numbers in the anthropometric questionnaire tallied those of the mortality survey. Alongside the anthropometric and mortality data, qualitative data was gathered systematically. Children aged 6-59 months were targeted in the anthropometric survey. An anthropometric questionnaire (See appendix X: 2) with the following variables was used to gather data:

Age: Recorded with the help of a local calendar of events (See appendix X: 5). Gender: Male or female Weight: Children were weighed without clothes using a SALTER balance of 25kg (precision of

100g). Height: Children were measured on a measuring board (precision of 0.1cm). Children less than

85cm were measured lying down, while those greater than or equal to 85cm were measured standing up.

Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1cm) using ACF-USA MUAC tape. In special cases, MUAC measurements of children with deformities on the left hand were taken on the right.

Bilateral oedema: Assessed by the application of normal thumb pressure for at least 3 seconds to both feet.

Measles vaccination: Assessed by checking for measles vaccination on EPI cards and asking caretakers.

Household status: All surveyed households were questioned on the duration of stay in that area to determine whether they were permanent residents, displaced, returnees or temporarily in the area.

23 For the anthropometric survey: Children aged 6-59 months 24 For the mortality survey: Total persons present now per cluster 25 Cush Community Relief International 26 Sudan Red Crescent

13

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

.IV.4.1. Acute Malnutrition

Weight for Height Index Acute malnutrition rates were estimated from the weight for height (W/H) index values combined with the presence of oedema. These indices were compared to the NCHS 27 references and WHO28 standards 2005. The results of the Weight for Height (W/H) index were then expressed in both Z-scores and percentage of the median. The expression in Z scores has true statistical meaning and allows inter study comparisons. The percentage of the median on the other hand estimates weight deficits more accurately and is commonly used in determining eligible children in feeding programs. With the above facts in mind; the following guidelines are used in expressing results in Z-score and percentage of the median. Guidelines for the results expressed in Z-score:

• Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the child’s lower limbs.

• Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema.

Guidelines for the results expressed in percentage of median:

• Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the child’s lower limbs.

• Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema

Children’s Mid-Upper Arm Circumference (MUAC)

Accurate and rapid screening tools are essential in emergency assessments. MUAC is one such tool that is quite useful for rapid screening of children under five years of age. Taken accurately, MUAC readings are a good predictor of mortality. This tool 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 <75cm, >=75cm - < 90cm 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 utilised in mortality data collection over a 90 days recall period. The data obtained was then used to calculate the crude mortality rate (See Appendix .X.3 and .X.4 for mortality questionnaires). ENA by SMART Software (August 2007 version) was used in these calculations. To obtain the CMR the formula below was applied. 27 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 28 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.

14

Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where:

a = Number of recall days (90) 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 follows29: 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

Prior to undertaking the actual survey, a number of meetings were held with the local authority, prospective enumerators and NGO’s to elucidate the survey objectives. Thereafter; a total of 14 enumerators and 3 capacity building staff were comprehensively trained for 4 days. Both standardization and pilot tests were undertaken during the training. The entire survey lasted 28 days. The actual survey was undertaken by 4 teams. The anthropometric and mortality data collection team composed of 2 ACF-USA staff, 10 enumerators, 4 MSF-OCA national staff, and 3 capacity building staff each from CCRI, SRC30 and MOH. Qualitative data was collected alternately by one team leader with the assistance of the qualitative data supervisor who acted as a translator. Capacity building is one of the survey objectives that aim at strengthening the nutrition surveillance capacity of MOH and National NGOs. This approach is relevant as the region transits from conflict, early recovery and positions itself for recovery and development. During the Nyirol survey, 3 staffs each from CCRI, SRC and MOH were capacity built on detection of malnutrition using SMART methodology. Key topics covered during the capacity building process included: Selection and training of enumerators; collection of accurate anthropometric, mortality and qualitative data; undertaking field level editing and analysis; team briefing and problem solving skills. The MOH being a key health player is considered in nutrition surveillance and treatment capacity building in order to enhance its capacity in integrating nutrition in primary health care services. It is upon this basis that an MOH staff from Waat participated in the training and data collection. SRC and CCRI are both National NGOs operating health related programs in Upper Nile and Jonglei States respectively. SRC intervenes in emergencies through assessments, supplementary feeding, provision of NFIs and public sanitation activities. CCRI supports 1 PHCC in Waat payam through quality assurance of drug prescriptions and treatment. It also provides outreach services in some parts of Waat. Their participation in nutrition surveys enhances their skills in detection of malnutrition and promotes integration of nutrition activities in their programs. MSF-OCA is an International agency running health programs in Upper Nile and Jonglei States. To MSF-OCA, the capacity building initiative is relevant in detecting and planning nutrition treatment programs as part of integrated management of childhood illnesses.

29 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95. 30 Sudan Red Crescent

15

.IV.6. Data Analysis

Anthropometric and mortality data was analyzed using ENA by SMART August 2007 version. SPSS31 version 10.0 was used in the qualitative data analysis. Other data analysis such as MUAC, measles immunization coverage and household status were done using Microsoft Office Excel 2003 version.

.V. RESULTS OF THE QUALITATIVE ASSESSMENT

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

Nyirol County is composed of 8 payams. These are Lankien, Tut, Waat, Pultruk, Nyanbor, Pading, Chuil and Keeth payams whose populace was estimated at 108,954. Notably about 30,00032 returns are expected in Nyirol county as from October 2007. Thus, there is need to plan for their return, rehabilitation and reintegration. Nyirol County lies in the Eastern flood plain zone and is characterized by savannah grassland, acacia trees and clay soil. Savannah grassland and botanical species (Desert dates and Acacia senegalis) were the predominant vegetative cover in Lankien and Tut payams The terrain is also covered with sandy soil segments. Numerous seasonal streams and swamps such as Thol stream traversed the area as observed. No permanent rivers or lakes exist in the area. The area had a flat low lying topography such that when it rained; most residential areas and foot paths were flooded except for a few raised parts. The survey covered Lankien and Tut (Thol payams) consisting of about 39,273 persons. Out of this; Residents, Internally displaced persons, temporary residents and returnees formed 86.7%, 2.2%, 2.2% and 8.9% respectively among the households included in the qualitative assessment. This is depicted in figure 1 below. Approximately 9,45333 persons were displaced in Nyirol County by August 2007, due to floods reported to have worsened in July 2007. Generally most households were sparsely distributed except those living in Lankien centre.

HOUSEHOLD STATUS

Residents87%

IDPs2%

Returnees9%

Temporary residents

2%

Figure 1: Status of households. 31 Statistical Package for Social Sciences 32 Source: Nyirol County Commissioner, 31st August 2007. 33 Source: SSRRC Supervisor Nyirol County, August 2007.

16

The major denizens of the region are the Lou Nuer of the Goatbal clan. The clan is sub divided into two main sub clans namely the Cienglang and Ciengnyarkuach who are natively pastoralists. However with the floods and persistent raids from the Murle, the community is gradually embarking on other livelihood sources for sustenance such as agro-pastoralism (71.1%), crop farming (17.8%), employment (4.4%) and petty trade (2.2%). Other (4.4%) sources of livelihood included kinship and reliance of relief food from international agencies more so by the returnees. Seasonally, the community starts moving to the cattle camps in search of food and pasture between January-February; and return back to their homes as from April so as to commence land preparation. A lot of movement was eminent during the survey period. Mortality data analysis indicates that 233 and 246 persons either left or joined the households three months to the survey. This was attributed to first, heavy rains in the area that was reported to have worsened in July 2007 and displaced part of the community to drier grounds. Secondly, lack of food in the market necessitated some of the household members, especially the males to walk for about 3 days to Malakal or Bor town to purchase commodities. It was the males who went for such long journeys due to the magnitude of challenges experienced on the way such as increased water level, some degree of insecurity on the way and weight of commodities purchased since human labor was the only mode of transport then. This probably explains why female respondents (88.9%) were mostly found in the homes compared to the male (11.1%) counterparts.

44.4%

31.1%

11.1%8.8%

28.9%

Sale of livestock Petty trade Sale of crops Labour Sale of firewood

SOURCES OF INCOME

Figure 2: Sources of Income, Lankien and Tut payams; Nyirol County.

Sources of income to this community were limited with majority (44.4%) relying on selling the already declining livestock thus weakening the food security asset base. Other sources of income included petty trade (31.1%), sale of charcoal/firewood (28.9%), sale of crops (11.1%) and labor (8.8%). Sale of the local brew “seko” was the main form of petty trade. The women were seen to start brewing alcohol very early in the morning. In the long run alcohol brewing not only depleted the already limited food stocks but also utilized a lot of time that could be used on more productive activities. The community’s mobile nature due to natural calamities such as floods, seasonal movement as well as insecurity threats predisposed the community to above emergency malnutrition levels as unveiled by the survey findings.

17

.V.2. Food Security

Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food for a healthy and active life. This includes food safety right from production, storage to consumption. However, in Lankien and Tut payams of Nyirol County such was not the case. According to FEWSNET April 2007, the hunger season was likely to be severe in some livelihood zones such as the Eastern Flood Plains (Nyirol, amongst other counties in Jonglei State) where structural food deficits are normally acute. Food security in Nyirol County is further weighed down by the poor harvest caused by floods, population returns and civil insecurity due to disarmament in the year 2006. The Lou Nuer’s main source of livelihood was agro-pastoralism, though crop farming, employment and petty trade were gaining prominence. As the survey was undertaken during the harvesting season (August and September), the main food source was private production as reported by most (86.7%) households. Observations concurrently indicated that the community largely depended on the green maize from the farms that was on the brink of depletion. Sorghum, okra amongst other food crops such as pumpkins were not ready. Thus to meet their additional food demands, the community resorted to eating the sorghum stalks (rwany) as a source of energy and wild food collection. Other food sources included buying (11.1%), food aid (4.4%), wild food production (68.9%), and gifts (2.2%) amongst others (2.2%) as depicted in figure 3 below. Food aid was a major source of food to the returnees who had received food rations in April 2007. Wild food collection was second to private production. Since most of other farm produce was not ready and commodity prices had increased, a relatively high (68.9%) of the community resorted to consumption of wild foods such as wor, nyakajang and raw tamarind (koat).

FOOD SOURCE

Wild food collection; 39.3%

Food Aid ; 2.5%

Buying ; 6.3% Private production ; 49.4%

Other; 1.3%

Gifts; 1.3%

Figure 3: Sources of food.

A large proportion (86.7%) of the community had cultivated various crops in the previous (2006) growing season. These included maize (97.4%), sorghum (97.4%), vegetable (12.8%), and beans (5.1%) amongst others (10.3%) such as millet, groundnuts and pumpkins. Most land sizes averagely ranged from 0-5 feddans (57.8 %) with 28.9% cultivating farms sizes of at least one feddan34. However the farm output was way below expectations as reported by 97.4% of assessed households. The aforesaid probably explain why some households had already depleted their food stocks and relied on buying, consumption of green maize and wild food collection as observed during assessment. The minimal harvests reported were attributed to floods (100.0%), birds (82.1%), diseases (56.4%), insects (30.8%) as well as other (17.9%) shocks such as

34 Unit of land measurement equivalent to approximately 4200 sq meters

18

lack of labor. Generally, the community reckons that provision of early maturing seeds (91.1%), tools (95.6%), education (64.4%) as well as others (11.1%) such as food aid (FFR and FFW) could significantly improve harvests. It is important to note that rains started exceptionally late in the current year resulting in delayed land preparation and sowing. As a result, harvests were delayed to September and would most likely move through to October. Given the aforementioned facts; and uni modal cropping and anticipated high population returns; the food security situation is bound to deteriorate further. This situation could further be worsened by the fact that the current harvests are bound to be negligible again due to flooding, birds, pests and diseases as was observed during assessment. All the households that did not cultivate crops in the previous cropping season cited lack of seed as the main challenge. Other reasons noted for not planting included lack of allocated land (83.3%) and equipment (16.7%). Qualitative analysis findings unveiled that food availability in most households varied. Whereas some households had food stocks to last them up to six months (8.9%), three months (44.4%) and a month (24.4%); 22.2% had diminished food stocks. Hence to meet their food demands, this portion resorted to wild food and vegetable collection (30.0%), kinship (20.0%) and sale of firewood/charcoal (10.0%). The sell of livestock was within the normal coping and income source strategies. Due to the changing context in South Sudan from emergency to post crisis/development, sustainable modes of food distribution such as Food for Work (FFW and FFR) are preferred to the general food distribution (GFD). During the survey period, despite the fact that WFP distributes food in the location, no households had received any food rations three months prior to the survey. This is probably because WFP had distributed Food for Returnees (FFR), Food for Education (FFE) and Food for Institutions (FFI) around April 2007. Norwegian People’s Aid has been running an agricultural program in Nyirol County since 2006 August in Waat, Lankien and Pading payams. The agency has targeted 300 farmers in the county; equally distributed in the three target payams. Its’ core activities include training and distribution of agricultural input. In Lankien, the agency has distributed agricultural inputs such as hoes, sickles, axes and assorted seeds to 1500 households. Similarly trainings on ox plough framing and crop husbandry have been undertaken. So far, 28 day training has been achieved on topics such as land preparation. Subsequent trainings are thereafter undertaken on monthly basis till all key components of crop husbandry are completed. Additionally 5 agricultural extension staffs have been trained and three more (3) sent to Yei Agricultural Training Institute for specialized courses35. Heavy rains in the region reduced market access to parts such as Bor and Malakal. Human labor was thus the main mode of transport. The community therefore had to succumb to high levels of water and long distances to get the food to the markets. Even though all households reported market presence with various foods being sold as depicted in Figure 4 below, the purchases of carbohydrates was limited. Food availability and prices varied daily with majority (77.8%) having to walk for more than an hour to the markets. For example 1 kilogram of meat that would normally go for 2 Sudanese pounds was sold between 5 and 8 pounds on four subsequent days. Foodstuffs purchased by the community in order of priority included oil (94.6%), other foods (56.8%) such as meat, salt and onions; milk (27.0%), sugar (24.3%), sorghum (13.5%), rice (13.5%), wheat (5.4%) and maize (2.7%).

35 Source: NPA Field Officer- Nyirol County.

19

FOODS SOLD VS PURCHASES

0%

20%

40%

60%

80%

100%

120%

Sor

ghum O

il

Suga

r

Whe

at

Ric

e

Oth

ers

Milk

Mai

ze

Vege

tabl

e

Fish

FOOD

PER

CEN

TAG

E

SOLD

PURCHASED

Figure 4: Foods sold in the market vs. food purchased.

73.3% of the community owned livestock such as cows (90.9%) and goats (18.2%) all of which were at home. Unfortunately the quantities of livestock were reported to be on the decline (97.0%) in the past five years. According to key informants, unrelenting cattle raids, floods, diseases as well as certain livestock benefits such as sale were the main causes of the reduction in numbers. Livestock benefits varied from one household to the other. Milk was a main livestock derivative in all households. Other livestock benefits included sale (87.9%), dowry (42.4%) as well as food on special occasions (15.2%).On average per day, livestock produced 0-2 liters with the most (39.4%) producing 0.5 liters. Despite the availability of numerous streams and swamps that were otherwise a source of fish, fishing was not practiced by this community. This was because of over flooding (71.8%), lack of fishing equipment (51.3%) and lack of enough fish in the fishing points (2.6%). A balanced diet is essential for good nutrition and health. This is not only limited to adequate food quantity and quality, but also it encompasses variety and frequency. Households’ current meals mainly comprised of maize (51.1%), milk (66.7%), meat (42.2%), wild fruits and vegetables (55.5%). Frequency of meals consumed varied too as illustrated in figure 5 below:

0%

20%

40%

60%

80%

100%

PER

CEN

TAG

E

Meat Cereal PulsesVegetables Fruits Fish Poultry Milk

FOOD

FREQUENCY OF FOOD CONS UM P TI ON

Daily Weekly Monthly Not at all

Figure 5: Frequency of meal consumption.

20

The previous year poor yields as well as the anticipated low harvests, increased population returns, flooding, poor market access, reduction in livestock numbers and food stocks in some households as well as low variety and frequency in meal consumption could probably have contributed to the above emergency malnutrition rates. To survive, the community resorted to wild fruits and vegetable collection, kinship support, sale of livestock and crops and consumption of “raw” farm produce.

.V.3. Health

Health services in the Lankien and Tut payams were proffered solely by MSF-OCA. The agency runs 1 PHCC in Lankien and 2 PHCUs in Riang and Pultruk payams. During the survey period, most (93.3%) households reported availability of health facilities. The main health facility was Lankien PHCC. The PHCC which targets 60,000(Nyirol County: 56,532: NIDS 2004), of which 12,000 are <5 years and 1000 are pregnant and lactating mothers offered both preventive and curative services to the community36. These services included Outpatients(OPD), In-patient(IPD), Antenatal Care (ANC), Tuberculosis (TB), HBF (Home Based Feeding), Sexually Transmitted Diseases (STD) as well as Kalazaar (KA). MSF-H Leer facility took care of surgical referrals. The PHCU on the other hand offered Outpatients (OPD), Antenatal Care (ANC) and HBF (Home Based Feeding). These health facilities were run by trained community health workers (CHW) distributed as follows: 6 in Lankien and 1 in Pultruk. Supervision of service provision was done by qualified trained doctors. To become a CHW, the staff starts of as an auxiliary nurse for 2 years after which a competency test is done to determine promotion to health worker level. Thereafter the health worker is trained for 9 months. Drug supply in the health facilities was reported to be good. Drug dispensation at the pharmacy was undertaken by MSF-trained senior dispenser. Thus population near the centres had access to consistent supply of essential drugs through a standardized drug management system that follows accepted guidelines. To enhance treatment, most laboratory services were offered by the agencies. Services were offered by a qualified expert laboratory technician alongside 4 staffs trained by MSF-OCA (2 senior and 2 junior laboratory technicians). Majority (91.1%) of the community reported to first seek medical attention at the public clinic. However care was sought at disease critical stages. Key resource persons reported that conventional treatment from traditional healers or own treatment with renowned herbs was initially preferred. Between January and August 2007, the average consultations per month in Lankien PHCC and Pultuk PHCU were 3,300 and 613 patients37.

36 MSF-OCA Acting Project Coordinator, Lankien payam. 37 Statistics -MSF-OCA (Acting Project Coordinator, Lankien payam)

21

35.6%

31.1%

33.3%

30 MIN - 1 HR

1 - 2 HRS

> 2 HRS

TIM

EDISTANCE TO HEALTH FACILITIES

Figure 6: Distance to health facilities The health facilities were generally far away from the community. All the respondents had to walk for more than thirty minutes as illustrated in the figure 6 above. This distance was further worsened by the heavy rains limiting accessibility. ACF-USA undertook a nutrition survey in Nyirol County in Lankien and Pultruk payams in July 2002. Above emergency GAM and SAM rates of 28.4% [24.3% - 33.0%] and 4.3% [2.7% - 6.8%] respectively expressed in z-score at 95% C.I were unveiled. No nutrition surveys were undertaken between 2003 and 2006. The current survey indicated slightly above emergency GAM and SAM rates of 17.3% [13.7% -20.8%] and 0.8% [0.1% - 1.4%] Different mortality rates have been unveiled by surveys carried out in the area in 2002 (ACF-USA), 2005(MSF-H) and 2007 (ACF-USA) as illustrated in the figure 7 below.

MORTALITY TRENDS

7.22

0.120.9

0.002.004.006.008.00

10.0012.0014.0016.00

Jul-02 Nov-05 Sep-07

TIME

CM

R

0.001.002.003.004.005.006.007.008.00

< 5

YRS

CMR <5 YRS

Figure 7: Mortality trends; Nyirol County The 2007 survey findings indicated a CDR of 1.24 (0.80 – 1.68)/ 10,000 persons /day which is above the alert levels in emergency situations. Of the 54 deaths, 36 of them were reported to be as a result of prolonged diarrhoea incidences. Generally the children may not affected compared to adults due to relatively

22

better feeding, drinking safe water and early medical care. An average mortality rate of 4.7% was reported at MSF-OCA Lankien PHCC between January and August 200738. MSF-OCA reports diarrhea incidences, malaria, respiratory tract infections and kalazaar to be the most common causes of morbidity and mortality. This concurs with qualitative findings indicating malaria (97.8%), diarrhea (71.1%), RTI (44.4%) amongst others (42.2%) such as kalazaar as the main causes of morbidity. The malaria incidences could be attributed to stagnant water that provided breeding ground for mosquitoes. As observed, most households did not have mosquito nets to protect them from mosquito bites in the night. The diarrhea incidences on the other hand could be attributed to diseases as well as consumption of contaminated water. Measles, a viral childhood disease has a link to malnutrition. Other than measles, no EPI services were being offered during the survey period. A measles outbreak was reported in April 2006. To curb the situation, UNICEF supported MSF-OCA to undertake a mass vaccination campaign for children below 15 years. Since then, measles vaccination has been ongoing in the PHCC. A total of 675039 children less than 15 years of age had been vaccinated against measles between April and August 2007. Survey findings indicated that 65.9% of children (6-59 months of age) had been vaccinated against measles according to the mass measles campaign cards/ road to health cards and caretaker. 34.1% of the children had not been vaccinated against measles. The low measles coverage could be due to poor health seeking behavior and unavailability of EPI services outside the centre. MSF-OCA reported that it would soon begin to offer EPI services. Due to the tensions existing in the area, MSF-OCA had temporarily evacuated the area. Even though, medical services were still on going and were being offered by the trained CHW. Nyirol County is endemic to guinea worm infection. Carter center, whose main objective is to eradicate guinea worm in south Sudan by the year 2009 runs a community based guinea worm eradication program. The program covers 5 payams of Nyirol County namely Lankien, Pultruk, Waat, Pading and Nyanbor with the main activities being case finding, case management and health education. A total of 17 cases were found and managed between June and August 2007.40 The agency also runs a Trachoma control program where only preventive services were offered such as health education. According the MSF-OCA, some of the challenges faced by the health sector are the transient/semi-nomadic population who tend not to stay for long in a given place. This hinders appropriate planning. Other factors include cultural misunderstandings as well as an unstable climate which at times limits access to food, water, shelter and the health facility. These along with the poor health seeking behavior and the increased distances to health services contribute to the high GAM rates unveiled.

.V.4. Water and Sanitation

Everyone has the right to water as recognized in the international legal instruments. This right provides for sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic use. Additionally, an adequate amount of safe water is necessary to prevent death from dehydration, to reduce the risk of water-related diseases and to provide for consumption, cooking, personal and domestic hygienic requirements41. There were approximately 5 functional boreholes in the region that could not adequately meet households’ water needs. Given that the total population of Thol payams was estimated at 39,273, the estimated number of persons per boreholes is about 7,855 persons. This falls short of SPHERE 2004 minimum standards on

38 Statistics -MSF-OCA (Acting Project Coordinator, Lankien payam) 39 MSF-OCA statistics August 2007 40 Carter Center, Nyirol County Technical Advisor 41 SPHERE Project; Humanitarian Charter and Minimum Standards in Disaster response; 2004 Edition: Minimum Standards in Water supply, Sanitation and Hygiene; Page 55.

23

water supply42 which recommends approximately 500 people per hand pump with flow rate of 16.6 liters/minute.

Owing to this fact, the community greatly relied on surface run off (80.0%); collected rain water (86.7%) and swamps (8.9%) for domestic use yet more than often these sources are prone to contamination (see picture on the left side). Algae, long grass and water lilies were seen on top of water surfaces. Flooding and community practices such as bathing at water collection points, washing clothes as well as livestock drinking and pasture increased contamination risks. These predisposed the community to water borne illness such as diarrhea, guinea worm and typhoid. Notably of all the 54 deaths noted, 36 were due to diarrhoeal incidences. Boreholes were utilized by only 11.1% of the community. Increased consumption of unprotected surface water is an indication of insufficient water availability. Most (53.3%) households walked for 30 minutes to one hour to and from the water sources . 35.6%, 2.2% and 8.9% had to walk for less than 30 minutes, 1-2 hours and more than 2 hours respectively. Distance to water sources was further increased by

the inaccessible terrain. Water treatment methods were not up to date. Prior to consumption, nothing was done to the water other than sieving or decanting. (40.0%) of the households consumed untreated water while a few either used filtration (37.8%), or decantation (26.7%). These methods do not effectively eliminate microorganisms and hence the user faced the risk of water borne infections. Water was observed to be collected in dirty containers and left uncovered enhancing contamination during collection and storage. The average daily consumption of water per household depended on household size, distance to water points, availability of water containers as well as household chores. Nyirol County is guinea worm endemic. Stagnant rain water due to the low lying topography as well as consumption of untreated water posed additional risk. Women and children were seen walking into stagnant water sources in order to draw water. Assuming that either the women or the children fetching water had hanging guinea worms, the larvae would have been released into the water. Consumption of this water without subjecting it to appropriate treatment predisposed the individuals to infection. Carter Center’s community based guinea worm eradication program in the region is timely. The agency strives to actualize its objective through active case finding, case management and health education. In endemic areas worms are contained through application of Abat in stagnant water. Abat is a drug applied in stagnant or infected water to kill guinea worm cyclops. The drug is applied every 28 days in endemic areas. It is commendable to note that hand washing was practiced by all households before and after meals. However the quality of water used was poor and could not guarantee safety. Latrine usage was nil as there were no latrines in the area. Only agencies and government institutions had such facilities. Thus, human waste was disposed off in unhygienic conditions either in the bush or left on the ground. Maximum hygienic standards should be exercised in the disposal of children’s waste, which are believed to be more dangerous than those of adults. This is because of two main reasons. First of all infants lack antibiotics and secondly the level of excreta-related infection among children is frequently higher than that of adults. However this was not the case during the survey period. Waste for children aged 0-3 years was disposed off in the bush (66.7%), thrown in the yard (51.1%) or left on the ground (11.1%). With the prevailing rains the area, the waste was swept off into water sources further predisposing the community to infections.

42 SPHERE Project; Humanitarian Charter and Minimum Standards in Disaster response; 2004 Edition: (2004) Water and Supply standard 1: Access and water quantity; Guidance Note 6(Page 65)

24

Generally the water and sanitation situation in Lankien and Tut payams was wanting. Water sources were prone to contamination with human waste indiscriminately disposed. The synergistic relationship between poor water and sanitation, diseases and malnutrition could probably explain the above emergency GAM rates.

.V.5. Maternal and Child care practices

Proper antenatal and post natal care is vital. Expectant, lactating and children below five years are vulnerable groups and thus need small frequent meals to meet their increased nutrient demands. During the survey period, no specialized meals were fed to the expectant and lactating mothers. These mothers were seen to engage in tedious chores such as grinding of sorghum or maize (mantap), tending to the children, fetching water, brewing alcohol (seko) and walking long distances to take ill children to health units. MSF-OCA recognizes the need for appropriate antenatal care and in a bid to enhance maternal and child health, the agency offers an antenatal health package. Other than antenatal visits and health education, an antenatal delivery kit was given to the mothers. This kit comprised of plastic sheet, cotton cloth, blanket, two examination gloves, non sterile gauze, soap, razor blade and two umbilical cord 30cm piece. It was commendable to note that initiation of breast feeding after delivery was timely. Most (94.7%) mothers breastfed their infants immediately after birth with (5.3%) portion commencing breastfeeding within a day after birth mainly due to delivery complications. Breastfeeding on demand was practiced by 73.7% of the respondents. However, 26.3% of the respondents, breastfed at their own time due to many chores and limited time. This prompted early weaning in some instances, a practice that predisposes infants to infection and malnutrition. Qualitative findings unveiled that most (81.6%) mothers initiated weaning from 4-6 months. 13.2% and 5.3% commenced weaning at less than 4 months and more than six months respectively. Children were fed on foods such as cow/goat milk, fresh maize ad wild vegetables such as wor and nyakajang. The livestock were at home and thus the milk produced was plenty and available to the young children. Energy dense complimentary foods are essential to meet an infants increased nutrient needs for growth and development. Porridge and vitamins (vegetables) were accessible in very small portions. Lack of adequate vitamins and carbohydrates predisposes the child to weak immunity as well as various forms of malnutrition. Hence, there is need to provide health education to mothers and caretakers on appropriate and timely weaning/ complementary foods. Frequency of feeding varied depending on food availability and presence of caretakers at home during meal times with most children being fed twice a day. The children were normally seen to be fed at least twice a day with in between meals despite limited food available. This concurs with qualitative analysis findings indicating that majority (66.7%) of the mothers fed their children twice in a day. Other children were either fed once (2.2%), thrice (26.7%) or more than four times (4.4%). The high malnutrition rates unveiled could be attributed to poor water and sanitation practices. Drinking water was in most cases not treated. Children waste was thrown off in the bush or left on the ground and latrine use was very limited. Despite mothers reporting to wash hands before handling food, the water used was dirty further predisposing children to infections. The early weaning, late weaning, inadequate energy dense complimentary foods and infrequent meals compromised the nutritional needs of children. Infections cause diseases which eventually lead to malnutrition. However the availability and accessibility to cow milk helped to improve the nutritional status of children.

.V.6. Education

The Ministry of Education oversees learning activities in this area. Both formal and informal education was offered in Nyirol County through schools and kin relations. For example, it was the duty of the older members of the household, more so the grandparents to instill morals to the young children.

25

There were few functional primary schools in Lankien and Tut payam though the exact number could not be established by the end of the survey. The New Sudan and partly the Kenyan syllabus were reported to be used in the primary schools. Challenges to education were reported and observed to be lack of adequate teachers, classrooms, scholastic materials and rains that destroyed classrooms and hampered access to schools. Other than UN agencies that provided Food for Education in the region around April 2007, no agency was undertaking education activities in the region. In a bid to empower the community on various health initiatives, MSF-OCA sponsors CHW training. This training is provided to staffs that have satisfactorily worked with the agency as auxiliary nurses for two years and have passed the competency test.

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

Medicines San Frontiers Operation Centre Amsterdam (MSF-OCA): An International NGO proffering health services in the area. MSF-OCA main programs in the area are Tuberculosis, Kalazaar and Basic Health Care (Feeding programme). The agency operates 1 PHCC in Lankien and 2 PHCU’s in Riang and Pultruk payams. Services offered in the PHCC included Outpatients(OPD), In-patient(IPD), Antenatal Care (ANC), Tuberculosis (TB), HBF (Home Based Feeding), Sexually Transmitted Diseases (STD) as well as Kalazaar (KA). The PHCU on the other hand offered Outpatients (OPD), Antenatal Care (ANC) and HBF (Home Based Feeding). Surgical referrals were sent to the MSF-H Leer facility. An up to date laboratory was present in Lankien PHCC where all tests were done as well as blood transfusion if need be. Other than measles, no EPI services were offered. The MSF-H health facilities were managed by trained CHWs under close supervision of expert doctors. Staffing capacity was as follows:

6 CHWs at the Lankien PHCC and 2 CHWs each at Pultruk and Riang PHCU 4 drug dispensers 4 laboratory technicians (2 senior and 2 junior)

Norwegian People Aid (NPA): The agency runs an agricultural program in the county targeting three payams namely; Waat, Lankien and Pading. 300 farmers have been targeted in the entire county. Currently the agency is undertaking trainings in the various payams in phases on issues such as land preparation, planting, weeding, harvesting and storage. 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 Lankien, Pultruk, Pading, Nyanbor and Waat payams. The main activities include; case finding, case management and health education. The agency also runs a preventive Trachoma control program. Cush Community Relief International (CCRI): A national agency operating in Waat payam since 2006. CCRI supports 1 PHCC in Waat payam through quality assurance of drug prescriptions and treatment. It also provides outreach services in some parts of Waat. Plans are underway by the agency to expand the scope of its activities to cover water and education.

26

.VI. RESULTS OF THE ANTHROPOMETRIC SURVEY

A total of 794 children were assessed during the anthropometric survey. However, only 782 were included in the final analysis due to errors in 12 datasets.

.VI.1. Distribution by Age and Sex

Table 2: Distribution by Age and Sex

BOYS GIRLS TOTAL AGE (In months) N % N % N %

Sex Ratio

06 – 17 95 48.5 101 51.5 196 25.1 0.9 18 – 29 70 47.9 76 52.1 146 18.7 0.9 30 – 41 76 52.4 69 47.6 145 18.5 1.1 42 – 53 83 48.3 89 51.7 172 22.0 0.9 54 – 59 63 51.2 60 48.8 123 15.7 1.0 Total 387 49.5 395 50.5 782 100.0 1.0

A local calendar of events was used to determine the ages of the children. In cases where the mother could not recall the events, height was used as a proxy. There was some over representation in the 54-59 months age group and slight under representation in the 18-29 and 30-41 months age groups. This effect is linked to recall bias. However, the overall sex ratio of 1.0 indicates that the sample was representative.

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

6-17

18-29

30-41

42-53

54-59

Age

gro

up in

mon

ths

BOYS

GIRLS

Figure 8 : Distribution by Age and Sex

27

.VI.2. Anthropometrics Analysis

.VI.2.1. Acute Malnutrition, Children 0-59 months of Age

Distribution of Acute Malnutrition in Z-Scores Table 3: Weight for Height distribution by age in Z-score and /or oedema (NCHS Reference)

< -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD Oedema Age group

(In months) N N % N % N % N %

06-17 196 0 0.0 45 23.0 151 77.0 0 0.0 18-29 146 1 0.7 21 14.4 123 84.2 1 0.7 30-41 145 1 0.7 13 9.0 131 90.3 0 0.0 42-53 172 1 0.6 24 14.0 146 84.9 1 0.6 54-59 123 1 0.8 26 21.1 96 78.0 0 0.0

TOTAL 782 4 0.5 129 16.5 647 82.7 2 0.3 Table 4: Weight for height vs. Oedema in z-scores (NCHS Reference)

Weight for height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor 0 (0.0 %)

Kwashiorkor 2 (0.3 %) Oedema

NO Marasmus 133 (17.0%)

No malnutrition 647 (82.7%)

Of the sample population, 17.0% and 0.3% were marasmic or had kwashiorkor respectively.

Figure 9: Weight-for-Height Z-scores distribution, Lankien and Tut payams; Nyirol County-2007

The sample population curve has significant dislodgement (mean=-1.13) to the left indicating a poor nutritional status. The weight for height (W/H) standard deviation (SD) of 0.8543 indicates a representative sample.

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

28

Table 5: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references

NCHS Reference WHO Reference

Global Acute Malnutrition 17.3% (13.7% - 20.8%)

18.3% (14.5% - 22.1%)

Severe Acute Malnutrition 0.8% (0.1% - 1.4%)

2.2% (0.9 % - 3.5%)

Distribution of Malnutrition in Percentage of the Median

Table 6: Distribution of Weight/Height by age in percentage of the median and oedema (NCHS Reference)

< 70% ≥ 70% & < 80% ≥ 80% Oedema Age (In months)

N N % N % N % N %

06-17 196 0 0.0 19 9.7 177 90.3 0 0.0 18-29 146 0 0.0 5 3.4 140 95.9 1 0.7 30-41 145 0 0.0 5 3.4 140 96.6 0 0.0 42-53 172 0 0.0 6 3.5 165 95.9 1 0.6 54-59 123 0 0.0 11 8.9 112 91.1 0 0.0

TOTAL 782 0 0.0 46 5.9 734 93.9 2 0.3

Table 7: Weight for height vs. oedema in percentage of median (NCHS Reference)

Weight for height < 80% ≥ 80%

YES Marasmus/Kwashiorkor 0 0.0 %

Kwashiorkor 2 0.3% Oedema

NO Marasmus 46 5.9 %

No malnutrition 734 93.9 %

Table 8: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median

NCHS Reference WHO Reference

Global Acute Malnutrition 6.1 % [4.3% - 8.0%]

3.8 % [2.1% -5.6%]

Severe Acute Malnutrition 0.3 % [0.0% - 0.7%]

0.3 % [0.0% - 0.7%]

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

Taken accurately, MUAC measurements can be used as a good predictor of mortality.

Table 9: MUAC Distribution

< 75 cm height >=75 – < 90 cm Height ≥ 90 cm height Total MUAC (mm)

N % N % N % N % < 110 or oedema 0 0.0 1 0.5 1 0.2 2 0.2 ≥110 MUAC<120 4 2.8 3 1.4 0 0.0 7 0.9 ≥120 MUAC<125 23 16.2 9 4.2 3 0.7 35 4.5 ≥125 MUAC <135 42 29.6 54 25.0 44 10.4 140 17.9

MUAC ≥ 135 73 51.4 149 69.0 376 88.7 598 76.5 TOTAL 142 18.2 216 27.6 424 54.2 782 100.0

29

0.2% and 0.9% of the children were severely and moderately malnourished according to MUAC/oedema criterion.

.VI.3. Measles Vaccination Coverage

Table 10: Measles Vaccination Coverage

Measles vaccination N % Proved by Card 235 31.5 According to the mother/caretaker 256 34.4 Not immunized 254 34.1 Total 745 100.0

.VI.4. Household Status

Table 11: Household status

Status N % Residents 459 89.5 Internally Displaced 10 1.9 Temporary Residents (on transit) 21 4.1 Returnee 23 4.5 Total 513 100.0

.VI.5. Composition of the Households

650 households were assessed during the nutrition and mortality survey and their composition is shown in the table below. Table 12: Household Composition

Age group N % Average per household Under 5 years 969 19.9 1.5

Adults 3902 80.1 6.0

Total 4871 100.0 7.5

.VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

.VII.1. Mortality Rate

Population movement, births and deaths noted in the 650 households assessed were as follows: 4871 persons were present on the survey day, 969 of them being children below five years of age 246 people had joined the households, 7 of them being children under five years of age 233 persons had left the households; 13 being children below 5 years of age 85 births 54 deaths were reported; only one of them being a child below 5 years of age

The above data was then used to calculate the mortality rates. Findings were as follows The crude mortality rate – 1.24 [0.80 – 1.68] /10,000/day The under five mortality – 0.12 [0.00 – 0.44] /10,000/day

A lot of population movement was noted during the survey period due to floods which caused the community to move to drier grounds. These reduced market access, and households were forced to walk long distances, mostly to Malakal to purchase commodities. The unveiled Crude Mortality rate was above alert levels of 1/10,000/day in emergency situation. Most adult deaths were attributed to diarrhoeal incidences.

30

.VIII. CONCLUSION

The two nutrition surveys undertaken in Lankien and Tut payams, both unveiled above emergency GAM rates. In the July (hunger season) 2002 survey, GAM and SAM rates were 28.4% (24.3% - 33.0%) and 4.3% (2.7%-6.8%) respectively. The current survey conducted at the beginning of harvesting season unveiled lower GAM and SAM rates of 17.3% (13.7%-20.8%) and 0.8%(0.1%-1.4%) accordingly. Crude mortality rate of 1.24/10,000/day has also declined despite still being above the alert level. The current above emergency global acute malnutrition rate is attributed to the following factors: Inadequate food intake: More than half of the mothers fed the young children twice in a day on foods such as milk, green maize and wild vegetables. There were inadequate frequent energy dense feeds to meet the energy requirements of the growing children. Food diversity existed, however there was limited consumption of pulses and fruits. Disease incidences: Common causes of morbidity and mortality cited were diarrhea incidences, malaria, kalazaar as well as respiratory tract infections. These weakened the immune system, affected appetite and reduced food intake which eventually lead to malnutrition. Other than the long walking distances, accessibility to the health facilities was further weighed down by the numerous streams and swamps traversing the area, hence delaying medical assistance. Food insecurity: Destruction of past and current harvests by floods largely predisposed the community to food insecurity. Flooding is likely to prolong the hunger period among some households while in areas where crops were destroyed, hunger season could start early in 2008. Other than fresh milk and green maize that was mainly fed to the children, food availability was scarce. The IDP and returnee population increased pressure on limited food stocks among the host community. Livestock numbers had declined due to sale, raids and slaughter. Limited market access and high prices equally reduced food availability and access. Households adopted eating of immature crops, low quality foods and kinship support as coping strategies. Poor water and sanitation: Most water sources were prone to contamination due to the community’s activities such as bathing at water points, washing at water sources, human waste disposal and guinea worm infestation. Almost half of the households consumed untreated water whereas a few used filtration and decantation which could not eliminate microorganisms. Water was observed to be collected in dirty containers and left uncovered enhancing contamination during collection and storage. The users faced the risk of water borne infections such as diarrhea. The average daily consumption of water per household depended on household size, distance to water points, availability of water containers as well as household chores. Poor maternal and child health care practices: No specialized meals were given to pregnant and lactating mothers despite the increased physiological demands. Children were mostly fed to two meals per day that were not adequate in quality and quantity. In some cases the children were either weaned early or late. Early marriages as well as lack of adequate and diversified meals further compound maternal and child health, thence the high GAM rates. Security: The security situation in the area had been tense, limiting the community’s time for participation in productive activities. The insecurity was attributed to disarmament exercise, alcoholism, family differences and general lawlessness. Cattle raiding are still a threat to livelihoods in Jonglei pastoralist areas such as Pibor County and surrounding areas. The insecurity affects availability of milk and animal products at the household level.

31

.IX. RECOMMENDATIONS

ACF-USA recommends the following within an integrated approach in order to reduce malnutrition rates and contribute to improved health and nutrition: Food Security • To monitor the impact of floods and displacement on harvests and overall food security situation in

October and there after in order to mitigate the negative effects and promote utilisation of positive flood effects.

• To initiate strategies that increase household food production, availability and access. This could involve flood control, wet land cultivation, promotion of short term maturing crops, crop diversification, fishing, agricultural extension services, income generating activities, Food for Agriculture and Food for Recovery.

Health • To increase coverage of primary health care services through capacity building, active participation of

MOH in collaboration with NGOs and outreach services. • To forge ahead and incorporate EPI services, nutrition surveillance and treatment of malnutrition cases

as part of integrated management of childhood illnesses. Water, Sanitation and hygiene • To look into the feasibility of construction and protection of safe water sources bearing in mind the fact

that the area is guinea worm endemic and water contamination is likely due to poor waste disposal. • To undertake health education on vital issues such as safe water use, latrine construction and use,

good health seeking practices as well as appropriate waste disposal Maternal and Child Care: To sensitize mothers and care takers on appropriate maternal child care that includes weaning and complimentary foods as well as antenatal and post natal care.

32

.X. APPENDIX

.X.1. Sample Size and Cluster Determination

Geographical unit (Village) Population size Actual walking distances in hours

Assigned cluster

1. Dardar 1245 2 hours 1,2 2. Jiop Bang 1436 4 hours 3,4 3. Khot Luay 1003 1 hour 30 minutes 5,6 4. Nyal 1943 4 hours 7,8,9 5. Mangeer 578 3 hours 10 6. Kurwhy 456 1 hour 7. Piethchiengkertut 674 1 hour 30 minutes 11 8. Kapnack 1002 1 hour 30 minutes 12,13 9. Wicjutni 647 1 hour 45 minutes 14 10. Lankien 2354 30 minutes 15,16,17,18 11. Kuem Dhol 1425 1 hour 19,20 12. Khot 556 1 hour 21 13. Wuiyot 1542 1 hour 30 minutes 22,23 14. Weikuoth 1620 2 hours 24,25,26 15. Muk piny 2987 1 hour 27,28,29,30,31 16. Pubor 1624 2 hours 32,33 17. Wunkir 1251 2 hours 34,35 18. Tut 2125 6 hours 36,37,38,39

TOTAL 24,468

33

.X.2. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No:

N°. Family N°.

Status (1)

Age Mths

Sex M/F

Weight Kg

Height Cm

Sitting Height cm(2)

Oedema Y/N

MUAC

Cm

Measles C/M/N

(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. Sitting Height is optional. To apply for ACF-USA survey. This data is for research. 3. Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles.

34

.X.3. 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

ID HH member

Present now

Present at beginning of recall (include those not present now

and indicate which members were not present at the start of the

recall period )

Sex

Date of birth/or age in years

Born during recall

period?

Died during the

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

Current HH member

Current HH members who

arrived during recall (exclude births)

Past HH members who left during

recall (exclude deaths)

Deaths during recall N

Total < 5 Total <5 Total < 5

Births during recall

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

35

.X.4. Enumeration data collection form for a death rate calculation survey (one sheet/cluster)

Survey Payam: Village: Cluster number: HH number: Date: Team number:

.X.5. Calendar of events in Lankien and Tut payams, Nyirol County, Jonglei State

MONTHS SEASONS 2002 2003 2004 2005 2006 200755 42 30 18 6

JANUARY PAYKEL

YOUNG PEOPLE MOVE WITH CATTLE TO THE

CATTLE CAMP Signing Of The CPA

54 41 29 17 5 FEBRUARY

PAYREW

THE OLDER PEOPLE JOIN THE YOUTH AT THE

CATTLE CAMP

53 40 28 16 4 MARCH

PAYDIAK

PEOPLE STILL AT THE CATTLE CAMP

Acute Watery Diarrhoea Outbreak

52 39 27 15 3APRIL

PAYNGUAN

THE ELDERLY COME BACK FROM CATTLE

CAMP CLEARING LAND

Disarmament In Nyirol County

Measles Outbreak

51 38 26 14 2 MAY

PAYDHIECH

RAIN BEGINS PLANTING OF CROPS

Disarmament In Nyirol

County

50 37 25 13 1JUNE PAYBAKEL WEEDING OF CROPS

Disarmament In Nyirol

County

49 36 24 12 0 JULY

PAYBARROW WEEDING OF CROPS

Death Of Dr .J. Garang Disarmament In Nyirol

County

47 35 23 11AUGUST PAYBADAK

YIELDING OF FIRST HARVEST, LOTS OF

GREEN MAIZE Burial ceremony of the

late Dr. J. Garang

59 46 34 22 10SEPTEMBER PAYBANGUAN

HARVESTING STARTS

58 45 33 21 9 OCTOBER PAYWAL CLEARING OF FARMS

57 44 32 20 8 NOVEMBER

PAYWALKEL

RAIN STOPS

56 43 31 19 7

DECEMBER PAYWALREW

CHRISTMAS CELEBRATION

37

.X.6. Food market prices- Lankien and Tut payams, Nyirol County

Prices in Sudanese POUNDS COMMODITIES

QUANTITY

AUGUST 2007 SEPTEMBER 2007

Crops/vegetables Sorghum 1 kg 6 8 Onions 2 small pieces 2 3 Maize 3 large fresh pieces 1 2 Tomato paste 1 small sachet (75

grams) 2 2

Animal products Goat 1 small size 60 65 Milk 500ml 2 2 Beef 1 kg 6 9 Others Sugar 1 kg 18 20 Salt 100g 2 5 Rice 1 kg 8 10 Oil 500 ml 4 5 Firewood 1 small bunch 8 9

EXCHANGE RATES

• 1 US Dollar = 2 Sudanese pounds • 1 Sudanese pound = 40 Kenya shillings

38

.X.7. The map of Lankien and Tut payams, Nyirol County