Population-Based Mortality Assessment -- Baidoa and Afgoi, Somalia, 1992

Since 1990, Somalia has been the site of an intense civil war that has disrupted health-care services and food delivery to a substantial part of the country. A regional drought, in combination with the ongoing civil disturbances, has further resulted in widespread famine. Multiple international government- and nongovernment-aid agencies are involved in the relief effort for Somalia. However, security problems in most areas of Somalia have prevented recent, systematic population-based assessments of the health and nutritional status of local Somali populations for use in directing relief efforts. To characterize the mortality of various Somali populations and to provide data on major population centers outside of the capital (Mogadishu), CDC, in collaboration with the United Nations Children's Fund (UNICEF) and the U.S. Agency for International Development, conducted a survey (1) of urban populations in a central region of Somalia (Figure 1). This report describes two pilot assessments performed during November 20-25 and December 5-6, 1992, in the towns of Baidoa and Afgoi. Baidoa

Baidoa is a regional center of the Bay Region of Somalia. Formal census data on this city were not available, and population estimates were provided by nongovernment-aid agencies. In early August 1992, the estimated population of Baidoa was 37,000 persons; by November 20, the town population had decreased to an estimated 21,000. On November 20, based on hut counts, the displaced population at two major camps for displaced persons (DPs) in Baidoa was approximately 5200 persons. An additional unknown number of DPs resided in the town itself.

For this mortality assessment, the DP-camp population was divided into seven areas of approximately equal populations (i.e., clusters), and survey starting points were randomly chosen in each of the seven areas. From the random starting point, residents in approximately seven consecutive huts in each cluster were selected to be interviewed. Interviewees were asked questions regarding deaths that occurred in the family (i.e., parents, spouse, or children) from the first day following the Moslem holiday Ramadan (April 3, 1992) to the day of the interview and deaths that occurred during the 30 days preceding the interview.

Mortality data were collected for 349 DPs who were alive on April 3 (Table 1). From April 3 through November 21, 137 (39%) persons were reported to have died, resulting in an average daily crude mortality rate (CMR) of 16.9 deaths per 10,000 population. Among 63 displaced children aged less than 5 years, 44 (70%) died from April 3 through November 21 (aged less than 5 years mortality rate {less than 5MR}=30.1 deaths daily per 10,000 population aged less than 5 years). For all age groups, the most common reported causes of death based on a structured verbal autopsy were diarrhea (56% {9.4 deaths daily per 10,000}) and measles (23% {3.8 deaths daily per 10,000}). During the 30 days preceding the survey, 16 (7%) of 228 persons died (average CMR=23.4 deaths daily per 10,000), and among children aged less than 5 years, five (21%) of 24 died (less than 5MR=69.4 deaths daily per 10,000). Of the sample population alive on November 20, 9% were children aged less than 5 years.

To measure mortality for the entire town of Baidoa, mortality surveillance data collected by the International Committee of the Red Cross and the Somali Red Crescent Society were used. Each morning, dead persons found in the city were counted after they were transported by truck for burial. From August 9 through November 14, 12,255 dead persons were transported for burial (37% of the estimated August 9 Baidoa population). During this period, an additional 3700 (10%) persons may have emigrated or have died and been buried without being counted. Deaths peaked in early September during concurrent epidemics of measles and multidrug-resistant Shigella dysenteriae (Figure 2). Afgoi

Afgoi is a town of approximately 35,000 persons that straddles the Shabelle River 19 miles (30 km) west of Mogadishu. To characterize health and mortality patterns in this town, 19 cluster survey starting points were randomly chosen. On November 24-25 and December 5-6, eight consecutive huts or houses were visited in each cluster. However, this survey was curtailed before the target number of clusters were visited because of security concerns.

Mortality data were collected from 152 households for 1004 persons who were alive on April 3. Of the 767 long-term residents of Afgoi and 237 persons displaced from other areas who were included in the sample, 94 (9%) persons died from April 3 through December 6 (average CMR=4.0 deaths daily per 10,000). The most commonly reported causes of death based on a structured verbal autopsy were measles (28% {1.1 deaths daily per 10,000}) and diarrhea (22% {0.9 deaths daily per 10,000}).

DPs were more than 1.5 times as likely to die than were residents during this period (DP average CMR=5.5 deaths daily per 10,000; resident average CMR=3.5 deaths daily per 10,000). As in Baidoa, children aged less than 5 years were at highest risk for death (less than 5MR=9.4 deaths daily per 10,000); moreover, during this period, mortality rates for displaced children aged less than 5 years reached 12.8 deaths daily per 10,000.

CMRs during the 30 days preceding the survey remained elevated (DPs=6.3 deaths daily per 10,000; residents=3.7 deaths daily per 10,000) compared with the average daily CMRs for the preceding 7 months (DPs=5.6 deaths daily per 10,000; residents=3.5 deaths daily per 10,000) (Table 1). Reported by: United Nations Children's Fund, Mogadishu, Somalia. Disaster Assistance Response Team, US Agency for International Development, Nairobi, Kenya. Div of Field Epidemiology, Epidemiology Program Office; Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases; Div of Environmental Hazards and Health Effects, National Center for Environmental Health; International Health Program Office, CDC.

Editorial Note

Editorial Note: Extreme mortality rates commonly occur in famine-affected, internally displaced, and refugee populations (1). During the 1984-85 famine in the Horn of Africa, average CMRs exceeded 20 deaths daily per 10,000 persons (1). By comparison, the reported annual CMRs in the Horn of Africa during nonfamine times ranged from 20 to 24 deaths per 1000, which is equivalent to daily CMRs of 0.55-0.65 deaths per 10,000 persons (2). The findings in these investigations of mortality among DPs in Baidoa and both displaced and resident populations in Afgoi suggest that health conditions are considerably worse in Somalia than they were during peak mortality periods of the 1984-85 famine in Ethiopia and Sudan. The CMRs reported in these villages in Somalia are among the highest ever documented by a population survey among famine-affected civilians.

Because of two important limitations in these studies, the findings cannot be generalized to the entire population of Somalia. First, although these studies were designed as cluster sample-population surveys to assess nutritional status and vaccination coverage among children aged 6-59 months, too few children were present in the sampled households to permit precise estimates of the prevalence of malnutrition in these populations. Second, the Baidoa survey characterized the mortality history only of displaced persons, and the Afgoi survey results may not have characterized all sections of the town because the survey was interrupted.

Despite these limitations, these findings are a measure of the magnitude of the famine-related disaster in Somalia. These findings are also consistent with assessments of previous emergencies that have documented that children aged less than 5 years and DPs are at highest risk for dying. One indicator of the intensity of this disaster is that only 9% of the sample population in the Baidoa study were aged less than 5 years compared with 20%-25% for most developing-nation populations.

Although the surveillance data based on body counts in Baidoa suggest a gradual improvement in mortality rates, the mortality rates derived from surveys of Afgoi and DPs in Baidoa may not have decreased during the 30 days preceding the survey, despite the massive relief efforts. The CMR in Afgoi is more than two times higher than the rate recorded for the nearby towns of Merca and Qorioley from April 1991 through April 1992 (3). Anecdotal reports from other regions of Somalia (e.g., Bardera and Saco Uen) suggest that local mortality rates may be higher than in Baidoa or Afgoi.

Measles, diarrhea, dysentery, acute respiratory infections, and malaria are common but preventable causes of mortality among famine-affected populations. Feeding programs are critical for reducing protein-energy malnutrition; however, community health programs that focus on the prevention of these infections can also have a major impact on mortality. Community-based measles vaccination and oral rehydration programs should be given high priority during famine-related emergencies. In addition, routine vitamin A supplementation for all children aged less than 5 years (and older children if malnutrition rates are high in older age groups) may also reduce child mortality, especially measles-related mortality (4). Surveillance efforts should include monitoring of trends in morbidity and mortality and evaluation of relief efforts.

References

1. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41(no. RR-13).

2. United Nations Children's Fund. State of the World's Children, 1991. New York: United Nations Children's Fund, 1992.

3. Manoncourt S, Doppler P, Enten F, et al. Public health consequences of the civil war in Somalia, April 1992. Lancet 1992;340:176-7.

4. Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988;66:689-97.

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