Mortality among displaced former UNITA members and their families in Angola
WHAT IS ALREADY KNOWN ON THIS TOPIC
In Angola a tentative ceasefire was signed in 2002, bringing 27 years of civil war to an end After the ceasefire, health assessments conducted among previously inaccessible displaced populations suggested a severe humanitarian crisis
WHAT THIS STORY ADDS
This retrospective survey, conducted among former members of UNITA and their families living in resettlement camps, documents the effects of violence, isolation, and a food crisis on a large Angolan displaced population.
The population experienced high mortality both before and after the ceasefire, mainly due to violence in 2001 and malnutrition in 2002; child mortality was particularly alarming.
Military and political considerations should not prevent the delivery of adequate and timely humanitarian assistance to populations in need.
In Angola, 27 years of civil war between the ruling Movimento Popular de Libertação de Angola (MPLA) and the União Nacional para a Independência Total de Angola (UNITA) movement were tentatively ended by a ceasefire signed on 4 April 2002. The last phase of the war (1998-2002), characterised by Ã?â?¦gscorched earthÃ?â?¦h military strategies and an international embargo imposed on areas held by UNITA, rendered large areas of Angola inaccessible to international relief organisations.
After the ceasefire, three million people were estimated to be in need of immediate aid.1 Several health assessments conducted among previously isolated populations showed alarming prevalences of malnutrition (32% in Cuando Cubango province and 52% in Huila), with crude mortality reaching 2.3 deaths/10,000/day in Huambo and 3.6/10,000/day in Moxico,2 far in excess of normal mortality in developing countries, estimated at 0.3-0.6/10,000/day.3 These data, along with observations of relief workers, strongly suggested that, among the inaccessible populations of Angola, a largely undocumented humanitarian disaster had unfolded.
Between April and August 2002, as part of the post-ceasefire demobilisation, about 81,000 former members of UNITA and 230,000 of their family members assembled in 35 resettlement camps countrywide.
The medical relief organisation M&eaccute;decins Sans Frontières launched nutritional and healthcare programmes in several of these. In this report, we document the findings of a retrospective mortality survey conducted in several former UNITA camps as part of an effort to document the effect of war on Angola's populations.4
The survey covered 14 months (June 2001 to August 2002), most of which was before the ceasefire. The main objectives were to measure crude mortality and mortality in children aged under 5 years, to identify major causes of death, and to describe the demographic evolution of the population.
Participants and methods The study included all 11 camps of former UNITA members in the four provinces of Bi&eaccute;, Cuando Cubango, Huila, and Malange. Covering a registered population of 149,106, the survey thus included 38% of the total estimated former UNITA population in 35 camps countrywide. All camps in the survey were administered by UNITA, and relied on external assistance for food and health care. Camp population varied from 4,800 to 42,000 people.
Objective: To measure retrospectively mortality among a previously inaccessible population of former UNITA members and their families displaced within Angola, before and after their arrival in resettlement camps after ceasefire of 4 April 2002.
Design: Three stage cluster sampling for interviews. Recall period for mortality assessment was from 21 June 2001 to 15-31 August 2002.
Setting: Eleven resettlement camps over four provinces of Angola (Bi&eaccute;, Cuando Cubango, Huila, and Malange) housing 149,000 former UNITA members and their families.
Participants: 900 consenting family heads of households, or most senior household members, corresponding to an intended sample size of 4500 individuals.
Main outcome measures: Crude mortality and proportional mortality, overall and by period (monthly, and before and after arrival in camps).
Results: Final sample included 6,599 people. The 390 deaths reported during the recall period corresponded to an average crude mortality of 1.5/10,000/day (95% confidence interval 1.3 to 1.8), and, among children under 5 years old, to 4.1/10,000/day (3.3 to 5.2). Monthly crude mortality rose gradually to a peak in March 2002 and remained above emergency thresholds thereafter. Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%). Most war victims and people who had disappeared were women and children.
Conclusions: This population of displaced Angolans experienced global and child mortality greatly in excess of normal levels, both before and after the 2002 ceasefire. Malnutrition deaths reflect the extent of the food crisis affecting this population. Timely humanitarian assistance must be made available to all populations in such conflicts.
Causes of death
Malnutrition, fever or malaria, and war or violence were the three most frequently reported causes of death (table 2). Malnutrition was among the three top causes of death in all age groups, but children aged under 15 were disproportionately affected. Of the 69 war related deaths, 38 occurred among adult men, 13 among adult women, and 18 among children aged under 15. Overall, war or violence was the leading cause of death in 2001 (43/126 (34%)) but was supplanted by malnutrition in 2002 (89/264 (34%)).
Proportionate mortality from malnutrition rose steadily from 15% in June-September 2001 to 33% in January-March 2002 and 39% in April-June 2002.
Fever or malaria remained the second most important cause of death throughout the recall period. Differences in proportionate mortality before and after arrival in the camps essentially concerned war or violence (decreasing from 66/280 (24%) before to 3/110 (3%) after) and diarrhoea (increasing from 21/280 (8%) before to 21/110 (19%) after).
In total, 42 disappearances were reported during the study period. Of these, 23 occurred among children aged under 15, 11 among women aged 15 and above, and 10 after arrival in the camp. Counting all 42 disappearances as deaths (that is, total number of deaths = 432) increases the crude mortality for the whole recall period to 1.7/10,000/day (1.3 to 1.8).
This retrospective survey provides country level mortality data representative of a large population of former UNITA members and their families displaced within four provinces of Angola. During the 14 months from June 2001 to August 2002, both crude mortality and mortality in children aged under 5 years remained above emergency levels. Mortality among children under 5 was some four times higher than normal, with nearly a quarter of all babies born during the recall period dying before the survey.
Implications of results
In this population, violence was the dominant cause of death up to December 2001. Nearly half of those killed and the vast majority of those who had disappeared were women and children. Our survey results thus confirm reports that civilians were often direct victims of the war in Angola.16
Overall, however, malnutrition was the main killer in the study population, an observation mirrored throughout Angola during the 2002 crisis (among adults, it is possible that deaths such as from HIV infection and AIDS and from tuberculosis might have been misreported as malnutrition, but reliable information is lacking on the burden of these infections on the study population).
The nutritional emergency peaked between January and June 2002, when hunger was responsible for almost half of reported deaths. Indeed, crude mortality trends run parallel to malnutrition deaths, which show a steady increase from June 2001 to March 2002.
The food crisis was aggravated by the surveyed population being inaccessible to relief organisations because of military operations and an embargo on UNITA held areas. The observed crude mortality before the ceasefire is more than double normal levels. Had humanitarian assistance been available, this excess mortality might have been partially limited.
Crude mortality remained high after the ceasefire, when the study population emerged from isolation and settled into camps. Populations tend to have long recovery periods after complex emergencies, particularly after nutritional crises.17, 18
A follow up survey conducted in camps of former UNITA members in Cuando Cubango province showed that crude mortality remained at 1.1/10,000/day up to October 2002.19 Taken together, our post-ceasefire data suggest that, at least for the first four months of demobilisation in Angola, medical and nutritional assistance to the former UNITA population was insufficient to restore mortality to normal levels.
The scarcity and delay in general food distributions after the camps' establishment were probably important factors contributing to the high crude mortality (and correspondingly high proportionate mortality from malnutrition).
After 4 April former UNITA populations, already struggling from years of isolation and months of an acute food crisis, were told to assemble rapidly into camps located far from the main roads and urban centres, often surrounded by mined territory, with inadequate water sources and little available means of developing coping strategies such as farming. At the same time, United Nations consolidated appeals for Angola were vastly underfunded, reflecting a general unwillingness on the part of donor agencies to commit to relief programmes during this crisis.20
While needs assessments were limited in this context, it seems clear to us that, in the assistance of this displaced population, minimum standards in emergency response were not met.21
This survey documents the impact of war, isolation, and a resulting food crisis on a large population displaced within Angola. Excess mortality of the extent shown here is a constant feature of armed conflicts currently affecting large areas of Africa.22 Military and political considerations must not come in the way of effective and timely humanitarian access to populations rendered isolated by such conflicts.