Summary
Since war broke out in South Sudan, there has been an influx of refugees into Uganda. Subsequently new camps, Bidibidi being one of them, were created to accommodate the numbers since the old ones had been overpopulated. This assessment sought to assess the health status of refugees in Bidibidi Refugee Settlement; identify health needs with regard to food, water, shelter and other non-food items; and assess the health services available for refugees in the camp. We employed the modified cluster sampling technique to select samples for a household survey and randomly selected 10 health facilities for the facility survey. Other data collection methods included focus group discussions, visual observation, review of secondary records and key informant interviews. We found that the emergency is not in a critical phase, but the population nutrition status is poor. Malaria is the leading cause of morbidity and mortality. We also found that there is less water and food available than is recommended. Poor food security with no coping strategy predisposes the refugee population to poverty and its antecedent effects. We recommend strengthening preventive efforts for better health outcomes, local food production to enhance food security; water extension and equitable distribution of relief items.
Introduction
Since 2013 when war broke out in South Sudan, the United Nations High Commissioner for Refugees (UNHCR) reported that over 1.5million people had fled the country. Most of these came to Uganda, consequently increasing the population of South Sudanese refugees in the country threefold, totaling about 800,000 in Uganda (1). Bidibidi Refugee Camp was opened in August, 2016 to accommodate the influx of refugees which had caused overcrowding in the pre-existing settlement camps.
The settlement camp is situated in Yumbe district, West Nile sub-region. The settlement is spread across 5 sub-counties in the district, and has a population of over 272,000. Yumbe District population is estimated at 534,300 (2). Refugees in such emergency settings face enormous challenges, which often impact negatively on their health. The challenges include inadequate living space; shortage of food and clean water, which results in poor sanitation; inadequate security and integration into the host community.
The sudden rise in population stresses the available resources. All these predispose refugees to a heightened risk of disease outbreaks and increased morbidity and mortality. In March, 2017 a team comprising of two Public Health Fellowship Program, Ministry of Health Fellows and a Supervisor, conducted a rapid health assessment to ascertain the health status of the refugee population; identify their health needs in regard to water, food, shelter and other non-food items; and assess availability of health services.
Methods
Using the modified cluster sampling method (3), we selected 210 households, and randomly selected 10 health facilities for the survey. We collected information using standardized questionnaires. For the household survey, we collected data on the demographics of the household head, household size, distance to water collection and food distribution points (both estimated by self-reported time taken walking from home to the respective points), time taken in a queue before they pick water, capacity of water storage container and occupation. We also collected data on ownership (and number) of mosquito nets. For the health facilities survey, we collected data on level of facility, services offered, as well as physical and financial access. We reviewed medical records for the major causes of morbidity and mortality, mortality rates and nutritional indices. Two focus group discussions in each of the 5 zones with community leaders and community health workers were also conduct- Along with observation, the focus group discussions helped in triangulation of information got from the interviews. Daily food per capita was computed using NutVal 4.0.
Results
The median age of household survey respondents was 31 years (IQR: 26-41). 117 (56%) were women and 7 (3.5%) were less than 18 years of age. The median household size was 7 persons (IQR: 5-10). 44 (21%) of households had at least a pregnant woman and 117 (56%) had at least one breastfeeding mother. We found the daily water per capita to be 3.6litres and daily food per capita was 1703 Kcal. 46 (22%) respondents reportedly walking for half an hour to a water collection; 122 (58%) report- ed lining up in the queue at the water source for over 30 minutes. The average water storage capacity per household is 38 litres. 136 (65%) households did not have any food stock and 136 (65%) household heads interviewed did not have any gainful employment.
Observed communities had no gardens for local food production. Global acute malnutrition was at 5.6%. 28% of households did not have a mosquito net with the average mosquito net per household at 0.2 mosquito nets. All health facilities selected were level 3 facilities and they all offer outpatient department with limited inpatient services. They were all physically accessible and services were free of charge. From the Health Information System (HIS) records reviewed between October 2016 and February 2017, the leading cause of morbidity and mortality at the camp was malaria. Among children <5years, malaria contributed 19,932 (36%) of 55,574 facility visits and 25 (32%) of 78 deaths, while in the ≥5-year population it led to 47,170 (33%) of 142,089 facility visits and 14 (32%) of 44 deaths.
The other causes of morbidity among children <5years were upper respira causes of morbidity among children <5years were upper respiratory tract infection (URTI) (12,782; 23%), watery diarrhea (8,892; 16%) and acute malnutrition (3,890; 7%). Among the ≥5-year population, the other causes of morbidity are URTI (26,997; 19%), watery diarrhea (14,209; 10%) and skin diseases (9,946; 7%). For mortality, the other causes among <5 year old children are anemia (18; 23%), acute malnutrition (7; 9%), lower respiratory tract infection (LRTI) (5; 6%) and neonatal death (5; 6%). Among those at least 5years old, the other causes are chronic diseases (8; 18%), watery diarrhea (3; 7%) and LRTI (3; 7%). Overall crude mortality rate at the camp was 0.04 per 10,000population per day. Death among children <5 was 0.7 per 10,000 population per day.
Discussion
Our findings are consistent with that from a similar study that concluded that the leading causes of morbidity and mortality in refugee settlements are malaria, acute respiratory infections, malnutrition and measles (4). The high rates of malaria in Bidibidi may be attributed to the flat terrain, which facilitates water logging, and therefore providing breeding sites for mosquitoes.
Furthermore, the low percentage of mosquito net ownership may facilitate the transmission of malaria. In the focus group discussions, we also learnt that mosquito net utilization for its intended purpose was low, with men using them as building mate- rials instead.
The high incidence of malaria may also have contributed to anemia among children, though intestinal worms may have played a role too. Acute malnutrition prevalence may be attributed to irregular supply of food and in insufficient quantities; according to Brennan (5), food scar- city and underlying illnesses e.g. diarrhea, may be causative factors.
Moreover, without gainful employment and gardens, majority of the refugee community is very food insecure, with no clear coping strategy. This may predispose them to starvation and other related dangers. Haile (6) emphasizes the importance of humanitarian food relief in the absence of such coping mechanism, especially in helping them manage their limited resources. The distance from water points and time taken in the queue indicate a water-stressed community.
Conclusions and Recommendations
The crude mortality rate is not indicative of a critical emergency (less than 1/10000/day), though the global acute malnutrition (GAM) rate shows a poor nutrition state of the population (a GAM prevalence of 5-9 is an indication of poor population nutrition status). Water and food available per person per day was inadequate. Water distribution was sub-optimal.
We recommend UNICEF to extend water sources closer to the population; appropriate and adequate water storage facilities should be provided to boost daily water per capita. Community health services should be strengthened by Real Medicine Foundation, International Rescue Committee and Medicine Sans Frontier (MSF) to step up prevention efforts. Primary food production should be encouraged to enhance food security and local storage capacities should be explored.
References
- http://www.unhcr.org/news/stories/2017/2/589dba9f4/number-refugees-fleeing- south-sudan-tops-15-million.html
- Uganda Bureau of Statistics, 2016 estimate got from www.citypopulation.de/ php/uganda-admin.php?adm2id=053
- Henderson R. H. and Sundaresen T, 1982. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. BUN. Wld Hlth Org. 60, 253-260,.
- Alan J. Magill, Edward T. Ryan, David Hill, Tom Solomon, 2012: Hunter’s Tropical Medicine and Emergency Infectious Disease-9th
- RJ Brennan and R Nandy, 2001: Complex humanitarian emergencies: A major global health challenge; Emer- gency Medicine (2001) 13, 147-156
- Menghestab Haile, 2005: Weather patterns, food security and humanitarian response in Sub-Saharan Africa; The Royal Society: DOI: 10. 1098/rstb.2005.1746