VZCZCXRO6745
PP RUEHGI RUEHMA RUEHROV
DE RUEHKH #1771/01 3190750
ZNR UUUUU ZZH
P 150750Z NOV 07
FM AMEMBASSY KHARTOUM
TO RUEHC/SECSTATE WASHDC PRIORITY 9161
INFO RUCNFUR/DARFUR COLLECTIVE PRIORITY
RUEHRN/USMISSION UN ROME

UNCLAS SECTION 01 OF 04 KHARTOUM 001771 
 
SIPDIS 
 
AIDAC 
SIPDIS 
 
STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W 
USAID FOR DCHA SUDAN TEAM, AFR/SP 
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS 
GENEVA FOR NKYLOH 
NAIROBI FOR SFO 
NSC FOR PMARCHAM, MMAGAN, AND TSHORTLEY 
ADDIS ABABA FOR USAU 
USUN FOR TMALY 
BRUSSELS FOR PBROWN 
 
E.O. 12958:  N/A 
TAGS: EAID PREF PGOV PHUM SOCI UN SU
SUBJECT:  DARFUR - USAID NUTRITION UPDATE 
 
REFS: A) KHARTOUM 1297 B) KHARTOUM 1018 
 
KHARTOUM 00001771  001.2 OF 004 
 
 
------- 
Summary 
------- 
 
¶1.  Recent nutrition surveys in pockets of Darfur reveal that the 
nutrition status of children under five has deteriorated since May 
2007 to levels approaching those recorded in 2004 -- the beginning 
of the Darfur humanitarian response when the nutritional situation 
was at its worst.  From September 15 to 25, a USAID and U.S. Centers 
for Disease Control (CDC) team rapidly assessed the nutrition 
situation in all three Darfur states.  The team discussed nutrition 
trends with UN agencies, non-governmental organizations (NGOs), and 
state ministries of health.  The causes for the high malnutrition 
rates are not easy to pinpoint and include a variety of factors. 
Given the protracted nature of the Darfur conflict, the humanitarian 
community needs to find creative ways to address acute malnutrition, 
including transitioning to longer-term preventive approaches while 
continuing to ensure appropriate and timely emergency nutrition 
interventions.  End Summary. 
 
¶2.  A USAID Office of U.S. Foreign Disaster Assistance (USAID/OFDA) 
public health advisor and a CDC epidemiologist traveled to Khartoum 
and Darfur to review the nutrition situation and make technical 
recommendations for the nutrition programs supported by USAID/OFDA. 
This cable summarizes the team's findings. 
 
-------------- 
Trend Analysis 
-------------- 
 
¶3. In early 2007, with the exception of Ed Daein, nutrition surveys 
from camp and non-camp areas reported global acute malnutrition 
(GAM) rates below the 15 percent emergency threshold.  Since May 
2007, GAM rates have increased, ranging from 15.9 percent to 30.4 
percent, approaching rates reported in 2004 in the same areas.  The 
USAID team notes that severe acute malnutrition (SAM) remains below 
2004 levels and mortality levels remain below the emergency 
threshold. 
 
¶4. Data from routine nutrition surveillance and feeding centers 
support these trends, for the most part.    Therapeutic feeding 
center (TFC) and supplementary feeding center (SFC) admissions 
follow a seasonal trend.  From January to July 2007, SFC admissions 
rose and then leveled off but remained below 2006 levels.  TFC 
admissions for the same time period increased steadily, exceeding 
2006 levels.  Transfer rates from SFC to TFC, signifying 
deterioration in nutritional status, increased from 4.3 percent in 
April to 8.5 percent in June. 
 
¶5. Key areas of concern are internally displaced person (IDP) camps 
and settlements such as Abu Shouk, As Salaam, Ed Daein, and Kalma. 
These IDP areas have humanitarian challenges that include 
overcrowding in camps, public health problems particularly during 
the rainy season, and the precarious physical condition of 
individuals resulting from limited access to diversified diets 
either through their own production or market mechanisms.  The 
nutrition assessment team reported that possible causes for the 
increase in malnutrition rates include deteriorating security and 
subsequent limited access to populations; seasonal deterioration of 
nutrition during the rainy season; care and feeding practices for 
children and pregnant women; appropriateness of supplementary 
feeding products; effectiveness of nutrition programs; and lack of 
communities' understanding of treatment modalities for malnourished 
children leading to high default (drop out) rates from supplementary 
feeding programs. 
 
¶6. Consistently since 2004, young children (6 to 29 months) continue 
to be most at risk of acute malnutrition compared to children 30 to 
59 months.  This trend is a clear indicator that infant and young 
child feeding is a major problem that humanitarian interventions 
have not adequately addressed. 
 
¶7. Access to clean water has remained at minimally acceptable levels 
in IDP camps, but seasonal deterioration in sanitation has been 
reported in all nutrition surveys in the larger camps.  In addition, 
new influxes of IDPs increase the need for additional water, 
latrines, and hygiene promotion activities. 
 
¶8. Since March 2007, the prevalence of easily preventable and 
 
KHARTOUM 00001771  002.2 OF 004 
 
 
treatable diseases has steadily increased.  A number of surveys have 
shown strong correlation between diarrhea and acute malnutrition, 
and acute respiratory infections and acute malnutrition.  The 
surveys also demonstrate, although to a lesser extent, a correlation 
between fever/malaria and acute malnutrition.  Vaccination rates 
remain below Sphere guidelines.  For example, the measles 
vaccination rates reported in camp surveys do not exceed 55 percent. 
 The surveys demonstrate a clear correlation between measles and 
increased malnutrition and mortality rates. 
 
¶9. Nutrition coverage of current programs remains limited and 
inadequate, only reaching between 6.7 to 53 percent of children who 
should be enrolled in feeding programs. (Note: This data is mostly 
from camp settings. End Note.)  According to Sphere standards, 
coverage of supplementary and therapeutic feeding programs should 
reach more than 90 percent of the population in a camp setting, more 
than 70 percent in urban areas, and more than 50 percent in rural 
areas. 
 
¶10. Another indicator of the quality of programs is the number of 
children who drop out from the programs.  In Darfur, this rate 
exceeds the Sphere standards of less than 15 percent. 
 
¶11. Although nutrition programs in Darfur have shifted from strictly 
center-based treatment of malnutrition to a community-based model, 
the shift has not resulted in the high coverage rate the 
community-based model was intended to have.  The team reported a 
visible integration of the community management of acute 
malnutrition into the health care system at the expense of community 
outreach, a critical component in reaching high coverage rates and 
treating more than 90 percent of malnourished children.  The 
community-based approach needs to be linked to the health system and 
also reach out to the community in order to identify children in 
need of these services. 
 
--------------------------------------------- -------- 
Constraints to Improving Nutritional Status in Darfur 
--------------------------------------------- -------- 
 
¶12. USAID staff attended a two-day nutrition meeting in Khartoum 
hosted by the UN Children's Fund (UNICEF) and the Ministry of Health 
to analyze the nutrition situation in Darfur based on inter-sectoral 
information.  The participants also reviewed the current nutrition 
interventions, identified gaps in coverage and program areas, and 
refined the nutrition strategy in order to better address the short- 
and medium-term nutritional needs in Darfur.  The discussions in the 
meeting and at the field-level corroborate USAID's understanding of 
some of the possible underlying causes of malnutrition.  The 
findings are summarized below. 
 
--POOR BREASTFEEDING PRACTICES:  Exclusive breastfeeding for the 
first six months of life is not practiced in Darfur.  Although 
relief organizations have implemented nutrition education, including 
the promotion of exclusive breastfeeding, in many nutrition programs 
during the last four years, the response has lacked systematic 
effort and innovative approaches to change breastfeeding practices. 
 
 
--LACK OF APPROPRIATE COMPLEMENTARY FOODS:  In Darfur, there is a 
lack of appropriate complementary and weaning foods for infants and 
young children, as well as a lack of knowledge about appropriate 
feeding practices.  Mothers are not familiar with best practices for 
introducing solid food and are introducing them too early.  Within 
the general food distribution there are few options for weaning 
foods and a relative lack of dietary diversity.  Although not 
intended as a weaning food, a six month old child would need to 
consume a large quantity of corn-soya blend (CSB), which is included 
in the general food ration, in order to meet the daily nutritional 
requirements.  Preparation of CSB as a weaning food is time 
consuming for mothers. 
 
--CARE PRACTICES AND EMPLOYMENT OPPORTUNITIES: 
Relief organizations consistently identified child care practices as 
a significant factor contributing to the poor nutritional status of 
children.  Mothers leave their infants in the care of older children 
for more than eight hours a day while they seek employment 
opportunities outside of camps.  While this is a common cultural 
practice in Darfur, aid workers are observing that child care 
responsibilities are now passed down to even younger children than 
before.  As a result, relief agencies believe that the young 
children are insufficiently fed during the day, as caretaker 
 
KHARTOUM 00001771  003.2 OF 004 
 
 
children are not capable of preparing CSB.  In addition, 
breastfeeding ceases during the hours when the mother is outside of 
the house, further compounding the problem. 
 
--LACK OF KNOWLEDGE ABOUT MODERATE MALNUTRITION:  Many organizations 
identified the lack of recognition of moderate malnutrition as a 
significant issue.  Many parents do not perceive a moderately 
malnourished child as malnourished because that child still appears 
healthy, possibly impacting the effectiveness of supplementary 
feeding programs and contributing to the high default rates.  The 
workshop participants noted a need for strong educational activities 
that communicate the seriousness of moderate malnutrition. 
 
--QUALITY OF SUPPLEMENTARY FEEDING PROGRAMS (SFPs) AND PRODUCTS:  UN 
and NGOs questioned the effectiveness of SFPs and the acceptability 
of CSB.  Performance indicators from feeding programs are below the 
Sphere standards as previously noted.  Some aid agencies claim CSB 
is not accepted by the population because it is a maize-based 
product and the taste of soy is strong and not liked by the 
population. (Note:  Reports of the unacceptability of CSB have 
mainly been anecdotal, without data to support the claims.  In an 
effort to gain a more concrete understanding of the issue, WFP and 
its nutrition NGO partners have recently completed post-distribution 
monitoring surveys to gauge acceptability of CSB in all three states 
of Darfur.  Data analysis is underway, with results expected soon. 
End Note.) 
 
--CAPACITY:  Capacity was highlighted as a significant gap impacting 
the nutrition situation.  Several NGOs do not have the technical 
capacity for specific nutritional interventions, such as therapeutic 
feeding.  Also, relief agencies have a hard time recruiting staff to 
work in Darfur.  Additionally, capacity among local staff and state 
ministries in nutrition prevention and treatment is limited and 
needs improvement.  The state ministries of health are unable to 
properly take on nutrition programs handed over to them by nutrition 
partners.  As the nutritional situation stabilized in 2005 and 2006, 
many agencies downsized their staff and programs.  For example, 
UNICEF had 12 implementing partners in 2005 in South Darfur and only 
four in 2007.  The lack of partners significantly limits the 
activities and program coverage that UNICEF is capable of supporting 
and the ability to scale-up in response to a nutrition crisis. 
 
--COORDINATION:  Participants noted a general lack of coordination 
at both the Khartoum and state level, except in West Darfur.  Aid 
agencies report good coordination within each sector, but very 
little cross-sectoral interaction.  Since malnutrition is a 
cross-sectoral issue, strong coordination between sectors is 
required to improve the nutrition situation. 
 
--CHRONIC SITUATION NEEDS NEW APPROACH:  The chronic nature of the 
conflict now requires nutrition interventions to prioritize 
preventive activities, including behavior modification, in addition 
to treatment.  A stronger focus on capacity building of national 
staff and ministries is also needed. 
 
--INSECURITY:  Security incidents frequently impede access to 
programs and beneficiaries.  Limited access to populations and the 
disruption of services have impacted the effectiveness of programs. 
Additionally, some populations are completely without access to 
services or humanitarian aid.  Insecurity can prevent vulnerable 
populations from accessing existing services, particularly if the 
programs are facility-based and not community-based. 
 
--REPEATED DISPLACEMENT:  A lack of stability and constant movement 
among much of the conflict-affected population may be a major 
contributing factor to the spike in malnutrition.  Populations do 
not have access to their land, impacting their food security.  Also, 
repeated displacement impedes the ability of humanitarian aid 
agencies to access the vulnerable populations.  When displaced 
populations finally reach an official camp, the IDPs' nutritional 
and health status is often significantly deteriorated. 
 
--EXHAUSTION OF COPING STRATEGIES:  Partners also identified the 
exhaustion of coping strategies as a contributing factor.  In the 
beginning of the conflict, people fled with some assets, such as 
livestock or household items.  After four years of conflict, these 
assets have been depleted and families are left without coping 
strategies.  As a result, minimal shocks -- even seasonal changes -- 
may have a larger impact on the nutritional status of the 
population. 
 
 
KHARTOUM 00001771  004.2 OF 004 
 
 
----------------------------------- 
Responding to the Current Situation 
----------------------------------- 
 
¶13. In response to the recent nutrition findings, UNICEF, state 
ministries of health, and NGOs quickly mobilized resources to 
support nutrition interventions in Mukjar in West Darfur, in Abu 
Shouk camp in El Fasher, in Kalma camp near Nyala, and in Ed Daein 
in South Darfur.  To better understand child care practices, UNICEF 
and the Ministry of Health conducted a household survey across 
Sudan, including Darfur, which gathered data on infant and young 
child feeding.  Further surveys and research on the underlying 
causes of malnutrition are currently underway in Darfur.  The UN 
World Food Program (WFP) is conductingQ monitoring survey to 
address the CSB issue. 
 
----------- 
Conclusions 
----------- 
 
¶14. Due to the protracted nature of the humanitarian crisis in 
Darfur, the assessment team determined that the quality and scope of 
nutrition interventions need an overhaul in order to remain 
effective within the current Darfur context.  USAID staff will work 
with USAID-funded partners to review nutrition strategies and 
develop and implement new approaches to improve nutrition programs 
in Darfur, in an attempt to keep malnutrition rates below emergency 
threshold levels.  USAID will closely monitor the nutritional status 
in Darfur paying close attention to the short- and long-term impact 
that insecurity, exhaustion of coping mechanisms, and repeated 
displacement has on the nutritional status of the population. 
 
FERNANDEZ