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Grandesso F, Sanderson F, Kruijt J, Koene T, Brown V. Mortality and Malnutrition Among Populations Living in South Darfur, SudanResults of 3 Surveys, September 2004. JAMA. 2005;293(12):1490–1494. doi:10.1001/jama.293.12.1490
Context Mass violence against civilians in the west of Sudan has resulted in
the displacement of more than 1.5 million people (25% of the population of
the Darfur region). Most of these people are camped in 142 settlements. There
has been increasing international concern about the health status of the displaced
Objective To perform rapid epidemiological assessments of mortality and nutritional
status at 3 sites in South Darfur for relief efforts.
Design, Setting, and Participants In August and September 2004, mortality surveys were conducted among
137 000 internally displaced persons (IDPs) in 3 sites in South Darfur
(Kass [n = 900 households], Kalma [n = 893 households],
and Muhajiria [n = 900 households]). A nutritional survey was performed
concomitantly among children aged 6 to 59 months using weight for height as
an index of acute malnutrition (Kass [n = 894], Kalma [n = 888],
and Muhajiria [n = 896]). A questionnaire detailing access to food
and basic services was administered to a subset of households (n = 210
in each site).
Main Outcome Measures Crude and under 5-year mortality rates and nutritional status of IDPs
in Kass, Kalma, and Muhajiria, South Darfur.
Results Crude mortality rates, expressed as deaths per 10 000 per day,
were 3.2 (95% confidence interval [CI], 2.2-4.1) in Kass, 2.0 (95% CI, 1.3-2.7)
in Kalma, and 2.3 (95% CI, 1.2-3.4) in Muhajiria. Under 5-year mortality rates
were 5.9 (95% CI, 3.8-8.0) in Kass, 3.5 (95% CI, 1.5-5.7) in Kalma, and 1.0
(95% CI, 0.03-1.9) in Muhajiria. During the period of displacement covered
by our survey in Muhajiria, violence was reported to be responsible for 72%
of deaths, mainly among young men. Diarrheal disease was reported to cause
between 25% and 47% of deaths in camp residents and mainly affected the youngest
and oldest age groups. Acute malnutrition was common, affecting 14.1% of the
target population in Kass, 23.6% in Kalma, and 10.7% in Muhajiria.
Conclusion This study provides epidemiological evidence of the high rates of mortality
and malnutrition among the displaced population in South Darfur and reinforces
the need to mount appropriate and timely humanitarian responses.
In early 2003, 2 rebel movements (the Sudanese Liberation Army and the
Justice and Equality Movement) launched an insurgency against the rule of
Khartoum and the government of Sudan, and Janjaweed tribal
militias have responded with decisive counteroffensives. Militia attacks have
been blamed by refugees and internally displaced persons (IDPs) for indiscriminate
killings, rape, abduction, cattle and property looting, and razing of villages.
More than 1.5 million people (25% of the population of the region) are now
scattered in 127 encampments in Darfur and 15 in neighboring Chad.
Humanitarian assistance arrived late, having been limited initially
by severe government restrictions and low institutional donor interest; and
also by insecurity, which is ongoing. Médecins Sans Frontières
(MSF) began work in West Darfur in December 2003, and operations in South
Darfur, including feeding centers and primary care clinics, opened in May
2004 and have been centered on 3 sites (Figure
1). Kass is a busy market town where 50 000 IDPs arrived mainly
in November 2003 and now live both within the compounds of the 30 000
residents and in distinct encampments in school grounds and waste areas. Kalma,
which in January 2004 was a small village on the main railway line running
east of the regional capital Nyala, is the largest single IDP settlement in
South Darfur and in August 2004 had 66 000 inhabitants; it has continued
to grow. Muhajiria is in relatively inaccessible rebel-held territory east
of Nyala and has had 2 major influxes of new arrivals, one in October 2003
and another in August 2004. The 3 surveys reported herein were part of site-specific
assessments of health and nutritional status designed to inform the delivery
of relief activities in the region.
We performed 2-stage household-based cluster surveys in 3 sites in South
Darfur (Figure 2). In 2 of these (Kass
and Muhajiria), residents were considered by aid agencies to be as vulnerable
as IDPs; therefore, both groups were surveyed. Sectors were defined by the
Sudanese authorities for local resident populations; for IDP camps, the sector
boundaries used were those recognized by IDPs (populations) and their community
leaders and were mainly distinct geographical landmarks. Sector-specific populations
were estimated at each site using a combination of local government census
(for residents), the reports of community leaders (for IDPs), health worker
censuses, World Food Program data, and shelter counts.
Households, defined as groups of people eating together, were selected
on the basis of the standard World Health Organization/Expanded Program of
Immunization method.1 For the first stage of
sample selection, we allocated numbers of clusters to camp or town sectors
proportionally to the population.2 For the
second stage, the first dwelling within each cluster was selected either by
walking in a random direction from the center to the perimeter, counting the
number of households (n) and randomly selecting a
number between 1 and n, or, where dwellings were
arranged on a grid, by randomly selecting a global positioning system coordinate.
Subsequent households were selected by proximity.
At each site, general household status, crude and under 5-year mortality,
and nutritional and vaccination status of children aged 6 to 59 months were
assessed simultaneously within the same survey design. Within any 1 cluster,
the general household questionnaire was administered to the first 7 households
and the mortality questionnaire to the first 30 households. Anthropometric
data were collected on all children residing within selected households and
aged 6 to 59 months until data had been obtained on a total of 30 children.
Sample size calculations were performed prior to the survey. Nine hundred
households (30 clusters × 30) or 4500 people (assuming a mean household
size of 5 people) would have been sufficient to estimate a crude mortality
rate of 2.0 per 10 000 per day with a 95% confidence interval (CI) of
1.0 to 3.0, a recall period of 30 days, and a design effect (loss of variance
due to intracluster homogeneity) of 2. Similarly, with an expected prevalence
of malnutrition of 10%, 900 children would give a 95% CI of 7.5% to 13.3%.
For access to items and services, 210 households give adequate precision,
assuming a prevalence of 50% for the main outcomes.
Each survey team included a community health worker, a local person
who spoke Arabic and English, and a member of the expatriate or Khartoum-based
MSF staff who acted as supervisor. Training at each site was performed over
3 days by 2 authors (F.G. and F.S.) and included pilot testing of the questionnaires.
Questionnaires were forward- and back-translated into Arabic before they were
issued, and were delivered orally. The majority of questions required simple
yes or no answers or a choice from a list of up to 7 items. We asked the help
of neighbors to trace absentees and revisited empty households and households
in which children were temporarily absent. Each cluster was completed in 1
Médecins Sans Frontières and Epicentre do not routinely
subject individual standard rapid assessment surveys to formal ethical scrutiny;
however, both organizations subscribe to the ethical principles outlined in
the Declaration of Helsinki.3 In addition,
the conduct of the study and the content of the questionnaires were reviewed
and approved by the local Sudanese authorities (Humanitarian Aid Commission)
and were described to IDP community leaders who agreed to and in many cases
facilitated the survey. No incentives were offered to participants or officials.
The interviewee was the most senior adult household member, who gave oral
informed consent to participate in the study. For children aged 6 to 59 months,
consent to anthropometric measurement was obtained from a parent or guardian.
No names were obtained or recorded except when respondents agreed to the referral
of malnourished children or sick individuals to the relevant MSF clinics.
Ages of children were not recalled reliably, and thus the target age
range of 6 to 59 months was defined by a height of at least 65 cm and less
than 110 cm. A standard United Nations Children's Fund (UNICEF) height
board was used and children with a height of less than 85 cm were measured
lying down. Weight was determined with a 25-kg Salter scale (UNICEF kit) that
was calibrated daily. Acute malnutrition was said to be present in a child
with a weight-for-height ratio z score of less than
−2 compared with the reference population median or if there was pedal
Measles vaccination cards were scarce and vaccination status was based
on verbal report by the parents. Access to clean water was defined as the
last collection of drinking water having come from a protected well, tap,
water bladder, or other chlorinated container. There was a reluctance to show
food distribution cards and ownership was assessed by verbal report. Respondents
were asked whether they generally used a latrine for defecation. Soap was
reported as present by the interviewee or observed by the survey team.
It is customary for mortality data to be collected using a well-defined
date to mark the beginning of the recall period. For Kass, the celebration
of the birth of the prophet Mohammed on April 30, 2004 (a national holiday
in Sudan), was chosen and gave a recall period of 121 days. For Kalma and
Muhajiria, a shorter recall period (30 days) was dictated by the priorities
of the operational teams. Following a death in Sudan, the custom is to mourn
the deceased for a period of 40 days. This period is punctuated by ceremonies
of remembrance and the days following a death are reliably counted by the
family of the deceased. For each death, we noted the age of the person who
died and coded the reported cause as violence, diarrhea, or other (includes
multiple other causes of death, such as pneumonia, measles, injuries, and
tumors). For diarrhea, we used the standard definition of 3 or more loose
stools per 24 hours. Interviewees were asked to report household size and
the number of children younger than 5 years; this information was used to
determine the denominator for mortality calculations.
We entered data into EpiData version 3.0 (EpiData Association, Odense,
Denmark). Analyses were performed using EpiNut (EpiInfo version 6.04; Centers
for Disease Control and Prevention, Atlanta, Ga) and Stata version 7.0 (StataCorp,
College Station, Tex). Ninety-five percent CIs were calculated and adjusted
for the design effect.
Surveys were performed from August 26-30, 2004, in Kass; September 2-6,
2004, in Kalma; and September 11-15, 2004, in Muhajiria. There were no recorded
cases of refusal to take part in the survey. The main characteristics of the
surveyed population are described in Table 1.
Two hundred seventeen deaths were reported over the previous 121 days in Kass;
and in Kalma and Muhajiria, there were 30 and 36 deaths over the 30 days prior
to the survey. The crude mortality rates at all 3 sites were considerably
higher than the 1 per 10 000 per day that is recognized internationally
as defining an emergency situation4,5 and
4 to 6 times the expected rate in sub-Saharan populations (crude mortality
rate, 0.5). In both Kass and Kalma, the under 5-year mortality rates exceeded
the 2 per 10 000 per day used as the emergency benchmark.
Deaths from medical causes predominated in Kass and Kalma (80% and 90%
of deaths, respectively). Diarrheal diseases were responsible for 25% and
47% of all deaths in these 2 sites, affecting mainly children younger than
5 years and adults older than 50 years. Violence was the major cause of death
in Muhajiria (72%), with all but 1 of the 25 violent deaths in men. Most violent
deaths had occurred during the fighting prior to displacement and were the
major factor in determining the excess mortality. In Kass, 18% of deaths were
due to violence, and violence was ongoing; in Kalma, 2 (7%) of 30 deaths were
The prevalence of acute malnutrition was high, particularly in Kalma
where nearly 24% of children younger than 5 years were affected (Table 2). Reported measles vaccination coverage
ranged from 46% to 70%. Between 25% and 71% of people reported regularly using
latrines; only in Kalma did a high proportion have access to clean drinking
water; soap was scarce. In Muhajiria, where 13 000 displaced people had
arrived in the previous month, there had as yet been no distribution of food
or essential household items, such as plastic sheeting.
The 3 surveys, all performed under difficult and insecure field conditions,
represent 190 000 people, including 47% of the 289 000 IDPs estimated
to be residents in South Darfur in September 2004.6 Despite
relief efforts in Kass and Kalma, both crude and under 5-year mortality rates
were well above the benchmark emergency thresholds and a high proportion of
deaths were reported to be from diarrhea. In Muhajiria, adult mortality was
high and the majority of the deaths were violent. Acute childhood malnutrition
at all 3 sites was equal to or more than the 10% defined as “serious”.5 A large proportion of households had access to food
and nonfood items but many still lacked access to safe water and sanitation.
We used a 2-stage cluster design for the surveys. Although this increases
the sample size required, it is the most practical solution in the absence
of a nominative list of refugees that would have allowed for random sampling.
The studies were designed with a large sample size to account for the anticipated
heterogeneity between clusters (design effect of 2) and met the 5 criteria
for validity and precision previously described for nutritional assessments
conducted during complex emergencies.7
Surveys such as these have important and well-defined limitations.8 Our survey could not include households in which all
members died, which may underestimate the mortality rate. As food distribution
relates to the size of the family, we cannot exclude that some interviewees
may have exaggerated the size of the household or underreported the number
of deaths. However, field teams were specifically trained not to count deaths
that occurred before the study period, and the short recall periods used for
both Kalma and Muhajiria should have minimized recall bias.
Mortality rates in refugee situations are commonly compared with the
emergency threshold, which is calculated as twice the normal mortality rate
for the region (in this case sub-Saharan Africa); hence, the reason for using
1 per 10 000 per day in our analyses. An alternative might be to compare
our rates with background rates in Darfur. A region-wide survey undertaken
by Save the Children Fund-United Kingdom in 20019 estimated
the crude mortality rate of residents and IDPs to be 1.0 and 1.4, respectively.
Compared with these data, our estimates are high.
Children younger than 5 years are more likely to die of communicable
diseases, and these deaths are inextricably linked with their underlying nutritional
status. In Muhajiria, childhood mortality and the incidence of malnutrition
were both relatively low and likely reflect the recent displacement of many
of the families interviewed, with childhood health still close to predisplacement
levels. In Kalma, malnutrition was well above even the “critical”
threshold of 15%.5 In this case, IDPs had no
access to cultivated land or to food other than that provided in the general
food distributions performed by international aid agencies. Although 98% of
residents had registration cards at the time of the survey, distributions
in the area had been sporadic.
Deaths from diarrhea are likely to reflect inadequate environmental
sanitation. This is supported by the reports of poor access to safe water
and latrines and low ownership of soap in our surveys as well as direct observation
by the field teams of conditions in IDP settlements. In Kass, a measles outbreak
documented by MSF in June 2004 may have contributed to the high under 5-year
mortality rate at this site and prompted a measles campaign run by UNICEF.
Low background levels of measles vaccination have been documented in Darfur9; inadequate coverage in the June 2004 measles campaign
in Kass and the huge growth of Kalma camp since the June 2004 campaign may
account for the low vaccination coverage reported herein. Muhajiria is in
rebel-held territory and was not included in the measles campaign. Inadequate
primary health care, which was not directly evaluated by our survey, is also
likely to contribute to deaths from medical causes.
In September 2004 in 3 of the major IDP settlements in South Darfur,
living conditions for people affected by the conflict were still precarious
and clearly met the criteria for a humanitarian emergency. Very similar situations
were documented in West Darfur in June and July 2004.10 Although
food distributions in the main centers and at least in 2 sites (Kass and Kalma)
were improved as a result of this and other surveys, the recent news from
South Darfur is not encouraging. Regular measles catch-up campaigns are not
favored by local authorities who advocate that regular Expanded Program of
Immunization schedules should be sufficient, and there is serious risk of
measles outbreaks in IDP settlements. Security is deteriorating and there
are constant new arrivals of IDPs to the camps. As of February 2005, the World
Food Program food registration data for the population of Kalma stood at 150 000.
After recent violence in the region, the population of Muhajiria has scattered
throughout the surrounding area. Violent attacks are reported frequently by
those individuals who stray from the camps to farm or collect fire wood. Additional
efforts from humanitarian and governmental actors are urgently needed to guarantee
acceptable living standards for these populations.
Corresponding Author: Frances Sanderson,
MD, PhD, Department of Infection, Charing Cross Hospital, London W6 8RF, England
Dr Sanderson had full access to all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Grandesso, Sanderson,
Acquisition of data: Grandesso, Sanderson,
Analysis and interpretation of data: Grandesso,
Drafting of the manuscript: Grandesso, Sanderson.
Critical revision of the manuscript for important
intellectual content: Sanderson, Kruijt, Koene, Brown.
Statistical analysis: Grandesso, Sanderson.
Obtained funding: Brown.
Administrative, technical, or material support:
Study supervision: Sanderson, Brown.
Financial Disclosures: None reported.
Funding/Support: This study was supported by
Médecins Sans Frontières, Amsterdam, the Netherlands. Nutrition
kits used for height and weight assessment were donated by the United Nations
Role of the Sponsor: Médecins Sans Frontières
was involved in the design and conduct of the study and the review of the
manuscript. Médecins Sans Frontières did not participate in
the collection, management, analysis, and interpretation of the data, or the
preparation and approval of the manuscript.
Acknowledgment: We thank the Médecins
Sans Frontières staff and all the dedicated Sudanese field workers
and translators who assisted with this project.