yx!T×ùÃ -@Â L¥T m{ÿT
THE ETHIOPIAN
JOURNAL
OF
HEALTH
DEVELOPMENT
The Ethiopian Journal of Health Development
EDITORIAL BOARD
Editor-in-Chief: Asfaw Desta
Associate Editor-in-Chief: Derege Kebede
Berhanu Abegaz
Gebre-Emanuel Teka
Hailu Yeneneh
Tesfaye Bulto
David Zakus
Elias Gebre-Egziabher
Hailegnaw Eshete
Mehari Woldeab
Tigest Ketsela
Zewdie Wolde-Gebriel
Publication officer: Simon Tekle-Haimanot
Secretary: Manyaheleshal Kebede
________________________________________________
Jointly Sponsored
by
The Ethiopian Public Health Association & The Addis Ababa University
The Editorial Office of the Ethiopian Journal of Health Development
is the Department of Community Health, Faculty of Medicine, Addis Ababa University.
The Ethiopian Journal of Health Development P.O.Box 32812, Addis Ababa, Ethiopia.
Telephone: 157701 or 518999 ext.7, FAX: (251-1) 517701
Addis Ababa University
Faculty of Medicine
Department of Community Health
ANNOUNCEMENT
The Department of Community Health in the Faculty of Medicine of Addis Ababa University wants
interested individuals to be aware of the Master of Public Health Degree Program which will welcome a new
class of students in September 1992.
The program includes basic postgraduate courses in Management, Epidemiology, Biostatistics, Maternal
and Child Health, Health Education, Environmental Health and Nutrition. Another vital part of the curriculum is
the Community Health Residency in an Awraja Health Department or its equivalent.
The candidate's individual interests and career plans can be pursued in an area of concentration and thesis
research. The applied research project is carried out during the second year, usually in the location of the
Community Health Residency.
The program continues for 22 months from September 1992 until July 1994. Application forms are
available at the Registrar's Office in the Sidist Kilo Campus of the University. All documents must be submitted
to the Registrar's Office between March and May 1992. Equally important is obtaining letters of support from
institutions which plan to utilize the new knowledge and skills acquired by the trainee. Most candidates are
sponsored by the Ministry of Health. The Department encourages other institutions to do likewise.
Prospective students must have at least a baccalaureate degree, previous training in a health or related
professions, and at least two years' experience in health or related services. Other academic requirements are as
specified in the application form of the School of Graduate Studies of the University.
If you have inquiries please forward them to Dr.Derege Kebede, Head, Dept. of Community Health,
Faculty of Medicine, P.O.Box 1176, Addis Ababa.
Fax: 251-1-51-77-01
-----------------------
INFORMATION FOR CONTRIBUTORS
1. The Ethiopian Journal of Health Development is a multi-disciplinary publication concerned with the broad field of health development. The Journal
publishes analytical, descriptive and methodological papers, as well as original research, on public health problems, management of health services, health
care needs and socio-economic and political factors related to health and development. Book reviews, letters to the editor, news items and short
communication are also acceptable. Articles which support the goals of "Health for All by the Year 2000" through the primary health care approach are
particularly welcome. Contributions from and/or about developing countries in general and African countries in particular will be given priority. The
following is a representative, but not exhaustive, list of subjects of interest to the Journal: health policy and health politics, health planning, monitoring and
evaluation, health administration, organization of health services, hospital administration, health manpower, including training, health statistics/health
information systems, maternal and child health and family planning, environmental health and water, food and nutrition, communicable diseases, health
education, epidemiology, community involvement, intersectoral activities, health economics/financing of health department, health technology, drug supply
and distribution, international health organizations/technical cooperation among developing countries.
2. All manuscripts should be submitted to the Editor of the Journal. Manuscripts will be considered for publication on the understanding that they have not
been previously published and are not simultaneously submitted or published elsewhere. This does not refer to papers presented orally at symposia or other
proceedings. Each manuscript will be assessed by at least two reviewers knowledgeable in the relevant subject. Manuscripts that are accepted for publication
become the property of the Journal; rejected manuscripts will be returned to the author.
3. Manuscripts should be submitted in triplicate, typewritten on one side of quarto or A4 paper with double spacing and liberal margins. There should be a
single separate title page containing the title, each author's full name, with the senior author listed first, organization or institution where the work was done,
each author's present address if different and the name and full postal address of the author to whom correspondence should be addressed.
Acknowledgements of those making substantive contributions to the paper, and any relevant informations such as if the paper was presented at a meeting or
is part of a large study should be noted at the end of the manuscript. A short summary or abstract should be included on a separate page.
4. The language of the Journal is English. Articles of national importance written in Amharic might be accepted for special issues.
5. References should be cited in the text as consecutive, bracketed numbers. Those appearing for the first time in tables or figures must be numbered in
sequence with those cited in the text. References in numerical sequence should be listed on a separate sheet, double-spaced, at the end of the manuscript. It is
the author's responsibility to verify that all references are accurate and complete. Titles of journals should be cited in full. References should give the full
facts of publication. For a book, these are; full name of the author(s) or editor(s); year of publication; full title of the series, if any, and volume number;
publisher's name and city of publication; page number(s) of the citation. For an article in a journal: author's full name; title of the document; information
identifying the source and location, date; Ph.D. dissertation (include department and institution), paper presented at a workshop (include name, location,
month and year of workshop), mimeo or photocopy (include department and institution). References to personal communications should be placed in
brackets in the text, giving the full name and date. Ethiopian names should be referred to in accordance with national usage, e.g. Taye Daniel as Taye Daniel
but will be cross-referenced in indexes as, e.g. Daniel, Taye. 6. Tables should supplement not duplicate the text, unnecessary and lengthy tables are
discouraged. Each table should be typed (double-spaced) in triplicate, on a separate sheet, numbered and given a suitable title. The approximate place in the
text should be indicated. Place explanatory material in footnotes. Figures and illustrations should be submitted in triplicate. They should be unmounted,
black and white glossy prints of line drawings or photographs; do not send original art work or negatives. Each figure or illustration should be given a
number, the author's name lightly marked in pencil on the back and a brief caption, double-spaced, should be typed on a separate sheet. If it is not possible to
provide glossy prints of figure, they should be accurately drawn in black ink on good quality white paper and the numbers and wording should be typed on an
overly of tracing paper, not on the figure itself. Coloured illustrations will be reproduced at the author's expense.
7. Miscellaneous. The generic names of drugs should be used; if necessary, the proprietary name may be placed in parenthesis after the generic name. When
percentages are used in case studies, the actual numbers should be indicated as well. e.g. 39/75, (52%). The first time an abbreviation or acronym is used it
should be preceded by the full name for which it stands.
8. Twenty reprints will be supplied free to the senior author. Additional reprints may be ordered and paid for in advance.
9. The Editorial Board reserves the right of final acceptance, rejection and editorial correction of papers submitted. Authors are responsible for all statements
made in their work including changes made by the copy editor. Priority and time of publication are governed by the Editorial Board's decision.
ANNUAL SUBSCRIPTION RATES
Ethiopian Journal of Health Development, P.O.Box 32812, Addis Ababa, Ethiopia. The Journal will publish at least two issues a year.
Ethiopia (in Birr) institutional 18 (annual) & 10 (single), individual 12 (annual) & 7 (single), student 8 (annual) & 5 (single). Africa (in U.S$) institutional 18
(annual) & 10 (single), individual 12 (annula) & 7 (single), student 8 (annual) & 5 (single). Overseas (in U.S$) institutional 25 (annual) & 15 (single),
individual 18 (annual) & 10 (single), student 12 (annual) & 7 (single). All prices include postage (airmail outside if Ethiopia). Checks should be made out to:
Chairman, Dept. of Community Health, Addis Ababa University.
EDITORIAL
Asfaw Desta*
The Ethiopian Journal of Health Development has come a long way since its first appearance in 1984. With
the support that it has enjoyed from many institutions, groups and individuals, it is growing in strength and
reputation. Its objective of promoting the primary health care approach is being fulfilled. In the words of a
former Minister of Health of Ethiopia "the Journal is one of the few that has managed to reach the health
professionals ...at the periphery where it is most needed." We expressed "our hope that our Journal will enjoy
the full support of, and close association with, the Ethiopian Public Health Association (EPHA)" for which it
has now come to be the "official organ". Addis Ababa University (AAU) has also included the Journal in its
list of "reputable journals". By a memorandum of understanding recently signed between the EPHA and
AAU, our Journal is promised continued support as a joint publication of the two institutions. All these are
encouraging developments of which all members of the Editorial Board and Editorial Consultants are proud,
and for which we are grateful to all sponsoring organizations, authors of articles, reviewers and subscribers
for their contributions to help
us reach this stage. We are hopeful that all this will continue with the help of everyone who has been with us
and with those who will join in the future.
It is to be remembered that the EJHD and its Editorial Board and Editorial Consultants were established by
the National Health Development Network (NHDN) Committee which ceased functioning in 1986, although
its ideals are still the guiding principles of the Journal. For the first time since the establishment of the
Journal, an election of the Editorial Board members has been carried out by the outgoing members, bringing
in the 12 newly elected members whose names appear in this issue. This is done in accordance with the
provision of the memorandum of understanding between AAU and the EPHA mentioned above. It was found
necessary to have elections because it proved difficult for the members to continue to work together. Some
have left the country. Among those in the country some, for reasons beyond their control, could not continue
to participate in' the frequent meetings of the Board. For others, the additional responsibilities they have
assumed could not enable them to continue as actively as they used to. We know they still support the
Journal -their Journal -and we are sure to enjoy their continued contributions. Unfortunately, the new list of
Editorial Consultants does not appear in this issue because we were not ready with the complete list by the
time of printing. Again some of the old members are out of the country. One of them, Desta Shamebo, we
lost by death (see Obituaries). We also wish to enlarge the membership of the Editorial Consultants and we
could not publish their names before we obtained their consent. We hope to come up with the complete list of
names in the next issue. Wish us good luck and, please, join us to continue with the excellent work that
previous members of the Editorial Board and Editorial Consultants, authors, reviewers, subscribers and
sponsors have accomplished. It is your Ethiopian Journal of Health Development.
____________________________________________________________
*Department of Community Health, Faculty of Medicine, Addis Ababa University
OBITUARIES
It is with a great sense of loss that we report the unexpected and untimely deaths of three young health
professionals who were very closely associated with the Ethiopian Journal of Health Development. The sad
news was all the more shocking because all of them occurred during a short span of four months in 1992.
Ato Desta Shamebo died on July 24, 1992 at the age of 47. He graduated from the former Gondar Public
Health College with a BSc and then got his MPH degree in Biostatistics from the University of California
(Berkeley). He pursued his studies for the PhD and was to receive his doctorial degree from the University of
Umea (Sweden) in August 1992, since he had finished all the requirements. Ato Desta served in Addis Ababa
University for over 20 years during which he attained the rank of Associate Professor. Administratively, he
served as Head of the Department of Community Health and as Associate Dean of the Medical Faculty. He
had done extensive research work in many areas with the "Butajira Health Project" as the most notable one
since he was the founder of it. He had published papers in several journals including in our journal of which
he was also a member of Editorial Consultants from the beginning. Ato Desta is survived by his wife and
four children.
Dr. Haile Selassie Tesfaye died in June, 1992, at the age of 46. He graduated with a BSc in Biology from the
then Haile Selassie I University. He later worked for higher degrees and got his MSc in Microbiology (USA)
and his PhD degree in Molecular Biology from the University of Kansas, USA. He has served as a high
school teacher for three years and for 14 years at the National Research Institute of Health, where he was
head of the Departments of Clinical Bacteriology and Vector Biology and Deputy General Manager of the
Institute, when he died. He had done a lot of research work much of which was published in several journals.
He had contributed papers to our journal where he also served as a member of the Editorial Board. He was
also the chairman of the Ethiopian Public Health Association. Dr. Haile Selassie was unmarried.
Dr. Areworki Gebre- Yohannes died on April 24, 1992, at the age of 49. Dr. Afeworki got his BA degree
from Hamilton College (USA) in Biology. After he obtained his MSc, also in Biology , he worked and later
earned his PhD degree in Microbiology from the London School of Hygiene and Tropical Medicine. Dr.
Afeworki served in the National Research Institute of Health (NRIH) for about 25 years during which time
he did a lot of research and published scientific papers in several journals, including our journal, the EJHD.
Administratively, he had served as head of the Department of Clinical Bacteriology and Vaccine Quality
Control. It was just after he was appointed as General Manager of NRIH that his unfortunate death occurred.
Dr. Afeworki is survived by his wife and two children.
These three young scientists rendered a tremendous amount of service in their respective fields for the good
of their country .Their deaths have deprived the country and the health profession the contributions they
could have continued to make with the kind of education and experience they had acquired in professional
and managerial work. They led exemplary professional lives for which they will always be remembered.
We wish to express our gratitude for what they have done and offer our condolences to their families.
ISOLA TION OF ENTERIC PATHOGENS AND COLIFORM
BACTERIA FROM INFANT FEEDING BOTTLE CONTENT IN
ADDIS ABABA, ETHOIPIA
Zeleke wrrensay*,BSc,MSc, & Haile Selassie Tesfaye**,BSc, MSc, PhD
ABSTRACT: Gastro-enteritis causing bacterial pathogens were studied in infant feeding bottle-contents
collected from 244 feeding bottles which were brought to 5 clinics and 2 hospitals from January 1989 to
November 1989 in Addis Ababa, Ethiopia.
The most frequent bacterial isolates were coliform which included Enterobacter spp. ,Klebsiella spp.,
faecal E.coli and Cotrobacter spp. Enteric pathogens like enteropathogenic E. coli (EPEC), Shigella spp., and
Staph. aureus, constituted respectively (3.3%), 1 (0.01 %),9 (2.2%) of the total isolates.
Although the percent of isolation of enteric pathogens in this study is low, the frequent isolation of
Coliform from samples of bottle-contents suggests that the bottle-feeding serves as a vehicle in transmission
of the enteric pathogens in the studied population.
Bottle-feeding mothers should be constantly taught on proper handling of feedingutensils and feeds.
Above all the superior quality of breast milk needs to be emphasized to nursing mothers. Moreover, further
and well controlled studies are also recommended to reduce diarrhoeal diseases in infant and young children.
INTRODUCTION
Many studies (1,2,3) have demonstrated an association between infant feeding practice and infant health. The
majority of these works indicated that infant morbidity and mortality are influenced by the mode of infant
feeding practice.
Artificial feeding of infants is a method which for success relies upon maintenance of high degree of hygiene
in the home. In developed countries with good sanitation, nutrition and medical care, bottle-feeding is less
risky than in the set up of the developing countries (2,4). Since the standard of personal hygiene and public
sanitation is low in many communities of developing nations, contamination of infant feeds with pathogenic
micro-organisms may be an important source of infectious diarrhoea (5). Bacteriological survey of feeds and
feeding bottles from Africa and other countries (6,7) have shown gross contamination of feeding utensils and
feeds.
In Ethiopia, gastro-enteritis has been a major disease problem among infants and young children (8,9,10).
Studies from Ethiopia (II), South Africa (12) and from other countries (13) on paediatrics diarrhoea indicate
that enterotoxigenic coliform such as Klebsiella, Entero-bacter, and Citrobacter are putative casual organisms
in addition to known enteric pathogens. Although gastro-enteritis is a major cause of morbidity and mortality
in infants and young children, bacteriological studies of infant food and feeding utensils and its influence on
the health of bottle-fed babies in Ethiopia are very scarce. Therefore, the aim of the present study is to
investigate the importance of infant feeding bottle-contents as a vehicle of bacterial enteric pathogens in
Addis Ababa, Ethiopia. The specitic objective of the study is to isolate and identify enteric pathogens. The
study does not attempt to isolate pathogens which have special isolation requirements such as Campylo
bacter jejuni, Yersinia enterocolitica, or diarhoeagenic E. coli other than Enteropathogenic E. coli (EPEC).
______________________________________________
*Jimma Institute of Health Science, Jimma, Ethiopia
**National Research Institute of Health, Addis Ababa, Ethiopia
MATERIAIS AND METHODS
Feeding bottle-contents of 244 babies who were brought to five clinics and two hospitals in Addis Ababa
were included in the study from January 1989 to November 1989. The babies had 'varying complaints such
as fever, cough and diarrhoea, while some were brought for clinical checkup and routine immunization.
After thorough shaking, about 10ml of the bottle-contents were transferred into sterile screw-capped
container. The samples were transported to the bacteriology laboratory in the National Research Institute of
Health, Addis Ababa, within 1-2 hours of time.
In the laboratory the bottle-contents were inoculated on to Mac-Conkey, Salmonella Shigella, Mannitol Salt
and Sheep Blood Agar prepared from Difco Powders. The cultured plates were then incubated for 24-48
hours at 37°C aerobically. Furthermore, 2.5ml volume of the bottle-contents were removed from the original
samples with sterile pipettes and passed into lactose broth as suggested by Isom (18) for pre-enrichment of
Salmonella species. After an over night incubation at 30C, 2.5ml volume of the pre-enriched culture were
transferred into Tetrathionate enrichment broth.
Tryptone soya yeast (TSY) enrichment broth was used for enrichment of other pathogens. The broth cultures
were incubated at 37°C for 48-72 hours, after which inocula were taken with sterile pasteur pipettes and
inoculated into Mac-Conkey, Salmonella-Shigella, Mannitol Salt and Blood Agars. Bacterial colonies on
Mac-Conkey and/or Salmonella-Shigella agars were differentiated on the bases of fermentation reactions as
lactose fermenting or non-lactose fermenting colonies. The standard biochemical techniques suggested by
Cheesbrough (19) were used for identification of Salmonella, Shigella and other Enterobacteriacae.
Salmonella, Shigella species, and entero-pathogenic E. coli (EPEC) were further confirmed serologically
with respective antisera for these organisms, obtained from Difco laboratories. Gram positive bacteria such
as Staphylococcus species and Bacillus species were looked for, on blood and mannitol salt agars and
identified with combination of Gram stain, Catalase and Coagulase test, and whenever necessary by using
appropriate biochemical tests described by Cowan and Steel (20).
RESULTS
Table I shows the types of bottle-contents (feeds) analyzed. Table 2 shows the various bacterial species
isolated from different bottle-contents. As can be seen from Table 2, 270 bacterial isolates were recovered
from a total of 244 samples of bottle-contents. A total of 26 bacterial strains were recovered from 17 samples
of cereal blends. Fresh cow's milk samples yielded 165 different bacterial isolates. Some samples of the
bottle-contents yielded more than one bacterial species. Of the 270 bacterial isolates, 63 (23.3%) were E.coli
and of these E.coli isolates, 9 (14.2% ) were the classically recognized serotype of entero-pathogenic E. coli
(EPEC). Shigella species was isolated from only one sample.
Table 1. Type of bottle-contents (feeds) analyzed Bottle-content (feeds) analyzed
Bottle-content
Number
%
Cow's milk
151
61.9
Cereal blend
17
6.9
Coomercial milk powder
33
13.5
Mixture of cereal & cow's milk
28
11.5
Others (tea, water, etc.)
15
6.1
Total
244
100
Staphylococcus aureus consisted 9 (3.3%) of the total bacterial isolates. Of the 9, Staph. aureus isolate 5
(55.5%) were detected from fresh cow's milk. No Salmonella or Vibrio species were isolated from any of the
bottle- contents. The predominant isolates were the coliform bacteria which included Enterobacter spp. 66
(22.4%), Klebsiella spp. 50 (18.55%), and Citrobacterspp. 31 (11.5%).
Table 2. Bacterial isolates fraIl different samples of bottle-contents.
Bacterial isolates
Enteropathogenic E.coil
E.coil type I
Other E.coil...
Shigella flexneri
Staphyloccous aureus
Bacillus spp.
Enterobacter spp.
Citrobacter spp.
Klebisella spp.
Proteus spp.
Acineto bacter spp.
Pseudomonas spp.
Streptococcus spp.
Other
organisms(Yeasts,
unidentified spp.)
Total
NB.
Fresh cow's
milk (151)
No
%
5
3.0
30
18.8
5
3.0
1
0.01
5
3.0
6
3.6
29
17.6
25
15.5
35
21.1
2
1.2
12
7.2
2
1.2
4
2.4
4
2.4
Commercial
milk (33)
No %
4
11.4
4
11.4
0
0
0
0
1
2.8
0
0
12
34.2
1
2.8
6
17.1
0
0
3
8.5
2
5.7
1
2.8
1
2.8
Cereal (17)
No
0
5
1
0
1
0
11
2
1
0
1
0
2
2
165
35
26
100
100
Others (15)
Total
%
0
19.2
3.8
0
3.8
0
42.3
7.6
3.8
0
3.8
0
7.6
7.6
Cow's milk +
cereal (28)
No
%
0
0
5
17.8
3
10.7
0
0
1
3.6
0
0
7
25.0
3
10.7
6
21.4
0
1
1
3.5
0
0
1
7.1
0
0
No
0
1
0
0
1
0
7
0
2
1
1
0
0
3
%
0
6.3
0
0
6.3
0
43.0
0
12.5
6.3
6.3
0
0
18.8
No
9
45
9
1
9
6
66
31
50
3
18
4
9
10
%
3.3
16.7
3.3
<0.01
3.3
2.2
24.2
11.5
18.5
1.1
6.6
1.4
3.3
3.7
100
28
16
100
270
100
100
. Powder milk formula milk or formula, "Tea, water, Oral rehydration solution etc.,
... Biochemically conform to E.Coil but serologically different from EPEC.
DISCUSSION
The present study has some limitations such as inability to test toxigenicity of S. aureus and the coliform
bacteria. Despite these limitations the study has attempted to investigate the bacteriological contamination of
infant feeding bottle contents. The predominant bacterial isolates from samples of bottle-contents were
coliform such as Enterobacter spp., Klebsiella spp., Citrobacter spp. and E. coli. Contamination of household
utensils, foods, water, etc. by coliform group of bacteria has been reported from many countries (14,15).
These bacteria have also been reported previously from Ethiopian infants with diarrhoea (11) and from food
and water (17). Although the present study has not shown that the coliform organisms are toxigenic, previous
studies (11, 13) demonstrated that some of these bacteria are toxicogenic and could cause diarrhoeal disease
in infants and young children. Earlier study on diarrhoeal etiology (16) analyzed 49 feeding bottle samples
from Addis Ababa and the results showed that 15 (13%) of their samples yielded coliform.
In the present study enteric pathogens such as entropathogenic E. coli (EPEC), Shigella spp. and S. aureus
have been detected from a small number of samples. The total yields of9 (3.3%) EPEC from bottle-contents
in this study is comparable to the isolation rate reported by Habte et aI (16). The frequency of isolation of
EPEC in the present work is by far lower than the rate reported from Zaria, Nigeria (2). EPEC constituted 29
(58% ) of the isolates in the above report. The recovery of S. aureus in the present study is comparable to
what was reported from Zaria, Niger in a similar study (2). Isolation rate of Shigella spp. from bottle-contents
in the present study is very low. Literature review on a similar studies does not show a better recovery rate of
Shigella from feeds and feeding utensils. For instance, no Shigella spp. has been recorded in the reports from
Nigeria (2), Uganda (21) and Indonesia (7).
All different types of bottle-contents in this study were found to be contaminated with coliform bacteria.
However, there are slight difference in tile degree of contamination. This observation agrees with what have
been noted by workers in other co\mtries (5, 22).
CONCLUSION AND RECOMMENDATION
This study can only measure what is happening at a single point in time. It is, however, reasonable to suppose
that antecedent and successive feeds will be similarly contaminated and the degree of contamination may
vary from time to time. The result of the study shows that all classes of bottle contents (bottle feeds) are
potential vectors of enteric pathogens. Hence infants and young children in the studied population often
ingest contaminated feeds whether they develop recurrent diarrhoea or not.
Breast milk is free of potential hazards associated with bottle-feeding and superior in its protective value
(16). Therefore, breast-feeding should be constantly emphasized to mothers. On the other hand, bottlefeeding mothers should be taught on proper handling of feeding utensils and feeds. The teaching of mothers
who practice bottle feeding must be accompanied by regular home visit to observe both feeding utensils and
home environment. Furthermore, well controlled community based longitudinal studies are needed if we are
to reduce gastro-enteritis in babies as the result of using feeding bottles.
REFERENCES
1. Jelliffe, D.B. and Jelliffe E.F. Feeding utensils and infant diarrhoea in less developed countries. Am. J.
Vis. a.ild. 1982; 136: 167.
2. Cherian, A. and Lawande R.V. Recovery of potential pathogens from feeding bottle-contents and teats in
Zaria, Nigeria. Trans. R. Soc. Trap. Med. Hyg. 1985; 79: 840-842.
3. Anderson, J.A.D. and Gatherer, A. Hygiene of infant feeding utensils, practice and stsnd.rd in the home.
Br. Med. J. 1970; 2: 20-23.
4. Kovar, M.F. Serdela, M.K., MarksJ.S., FraBer, D.W. Review of the epidemiologic evidence for an
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5. Black, R.E., Romano, G.L., Brown, K.H., Bravo, N., Bazalar, O.G., and Kanoshiro, H.C. Incidence and
etiology of infantile diarrhoea and major routes of transmission in Huscar, Peru. Am. J. Epidemial. 1989;
129: 785-799. 6. Drejer, G.F. Bottle feeding in Doulala, Cameroons. J. Trap. Pedialr. 1980; 26: 24-35.
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feeding bottles. I. Trop. Pedialr. 1980; 26: 58-61.
8. Frij, L. Observation on parasitic and bacterial infections of the intestine among paediatric out-patients in
Addis Ababa, Ethiopia. Eth. Med. I. 1973; II: 13-24.
9. Stintzing, G., Tufvesson, B. Habte, D., Back, E., Johnson, T . and Wadstrom, T. Etiology of acute
diarrhoeal disease in infancy and childhood during the peak seasons, in Addis Ababa. A preliminary report.
Eth. Med. I. 1977; 15: 141-146.
10. Thoren, A., Stintzing, G., Tufvesson, B., Walder, M. and Habte, D. Etiology and clinical features of
severe infantile diarrhoea in Addis Ababa. Eth. Med. I. Trop. 1982; 28: 127-131.
11. Wadstrom, T., Aust-Kettis, A.S., Habte, D., Holmgren, J.,Meevwisse, G. Enterotoxin producing bacteria
and parasites in stools of Ethiopian children. Arch. Dis. a.ild. 1976; 15: 865-870.
12. Schub, B.D., Greeff, A.S., Lecatsas, G., Prozesky, O.O.W., Hay, J.T., Prinsloo, J.G. and Ballard, R.C. A
Microbiological investigation of acute summer gastroenteritis in black South African infants. I. Hyg. Cambridge. 1977; 78: 377-385.
13. Guarino, A., Campano, G., Malamisura, B., Alessio, M., Guandalin and Rubino, A. Production of
Escherichia coli Sts -like Heat Stable entertoxin by Cilrobacler freundii isolated from humans. I. Clin.
Microbiol. 1987; 25: 110-114.
14. Steenbergh, W.U., Mossel, D.A., Akusia, J.A. and Jansen, A.A.J. Machakos project studies: Agents
affecting health of mother and child in a rural area of Kenya. Trop. Geog. Med. 1983; 35: 193-197.
15. Pickering, H. Social and environmental factors associated with diarrhoea and growth in young children:
Child health in urban Africa. Soc. Sci. Med. 1985;21: 121-127.
16. Habte, D. and Debesai A. Etiology of infantile gastro-enteritis. Eth. Med. I. 1964; 3: 191-24.
17. Jiwa, S.F.H., Krovcek, K. and Wadstrom, T. Entero-toxigenic bacteria in food and water from an
Ethiopian community. App. Environ. Microbiol. 1981; 41: 1010-1019.
18. lsom, B.G. Compedium of methods for the microbiolo2icalexamination of foods. Ist. ed. American Public
Health Association, Washington D.C. 1976.
19. Cheesbrough, M. Medical laboratorv manual for Tropical countries II, Microbiology. Ist ed. F.L.M.L.S.
Tech. R.M.S. 1984.
20. Cowan, S.T. and Steel, K.J. Manual for the identification of medical Bactoria. 2nd ed. Cambridge
University Press, Cambridge.1974.
21. Philip, 1., Lwanga, S.K., Lore, W. and Wasawa, D. Methods and hygiene of infant feeding in urban area
of Uganda. I. Trop. Pedialr. 1969; 15: 167-171.
22. Hibbert, J.M. and Gorden, M.H.N. What is the weanling dilemma? Dietsry faecal Bacterial ingestion of
normal children in Jamaica. I. 1i-op. Padialr. 1981; 27: 225-258.
AN INVESTGATION OF DIARRHOEAL DISEASE OUTBREAK
AT DILATE MILITARY TRAINING CENTRE
Makonnen Admassu*, MD & Abera Geyid**, MSc
ABSTRACT: This study was conducted to investigate a reported diarrhoeal diseaseboutbreak among higher
education students recruits in Bilate Military Training Centre, Sidamo Administrative Region, Out of the
total patients of 5,248 who visited at the out-patient department 1,616 (30.1% ) were patients with diarrhoea.
There were 99 patients admitted to the hospital out of which 27 (27.2 % ) were diarrhoeal patients. There ere
no deaths reported. A total of 965 (75.6%) were treated with antimicrobial, mainly Tetracyclines,
Chloramphenicol, Metronidazole and Chloroquine. Only 114 (8.9% ) were treated with Oral Rehydration
Salts (ORS) while 86 (7.11 % ) with Anti-diarrhoeal (Charcoal) and ORS. There was no proper excreta
disposal and the water source was found to be bacteriologically non-potable. Among the 34 stool specimens
collected for culture and sensitivity tests, the genus Shigella was isolated in 6 patients; where 4 were
higellaflexneri (Group B) and 2 were Shigella dysenteriae (Group A) one type 1 (Shiga's Bacillus) and the
other type 2 (Schmittz's Bacillus). Shigella dysenteriae serogroups 1 and 2 showed resistance to eight and
seven drugs including Trimethoprim Sulpha-Methoxazole (TSM) respectively. This study highlights the
importance of safe water and improvement of general hygiene and environmental sanitation for prevention
and control of epidemics and indicates the importance of continuous surveillance of drug resistant Shigella
for the control of outbreaks of Shigellosis.
INTRODUCTION
Diarrhoea is a major cause of morbidity and mortality in all age groups in developing countries. Vibrio
cholerae, genus Shigella and other entero-pathogens are endemic in tropical and sub-tropical regions.
Shigella is capable to cause widespread epidemics distinguished by high case fatality and extreme debility in
survivors (1,2). The 1968 Shigella epidemic in Central America affected half a million people and killed
20,000. In India (West Bengal) caused morbidity and mortality in 350,000 and 3,800 people, respectively
(1,3,4,5). In Maldives and Burundi it took the lives of 2,000 people in 1981 and 1982 (1,2). Shigella still
causes endless human suffering and catastrophes in Bangladesh and other Asian, Latin America and African
countries (1,2,6).
Ethiopia, as a tropical and developing country, is frequently subjected to outbreaks of Shigellosis. Hararge in
1978, Omo Region in 1979, Gondar in 1980, Illubabor in 1981 (7,8). Keffa, Wellega, Bale and Sidamo are
other regions with high prevalence (7,8,9). The problem of Shigellosis is specially acute where general
hygiene and environmental sanitation are poor and where there is inadequate supply of safe water (10, II).
High virulence, low infective dose (10-100 bacteria), large load of excreted organisms (106-108/gram of
stool) and rapid development of resistance to many antimicrobial are the agent factors that contribute to the
widespread of the outbreak and put heavy tasks on the control of Shigellosis (12-15). Lack of laboratory
facilities in many health units, wrong diagnosis of bacillary dysentery as amoebiasis, failures in early case
detection and incorrect use of antibiotics, not only pose a problem in control activities but also make
treatment ineffective (1,2,15).
The aim of this paper is to disclose the reported diarrhoeal disease outbreak which occurred in Bilate Military
Training Centre and discuss the control measures which need to be undertaken in order to prevent further
epidemics.
___________________________________________
*National Control of Diarrhoeal Diseases Programme, Ministry of Health, Addis Ababa, Ethiopia
**National Research Institute of Health, Addis Ababa, Ethiopia
BACKGROUND
Bilate Military Training Centre (BMTC) is located in Sidamo Administrative Region, 90km away from A
was sa and 395 km south of Addis Ababa. Previously it was a state farm. It is a low land area found in the
great rift valley 1000- 1400 meters above sea level with two distinct seasons: hot and dry in summer, rainy
and humid in winter. It is endemic for malaria. Various unpublished data from RHDs suggest that outbreaks
of Typhoid fever associated with Shigellosis also occur frequently. The recruits were students of higher
education from allover the country. There were about 10,000 trainees in the centre out of whom 1,000 were
females. Their age distribution ranged between 18-22 years. They were divided into 6 brigades, and females
were in the 3rd brigade. At the time of this study, there was one hospital and six brigade clinics. There were
five physicians, six nurses, 47 health assistance and one laboratory technician.
PATIENTS AND METHODS
The diarrhoea outbreak started on 5th of March, 1991 and reported to the CDD-MOH office on the 18th of
March. Most patients presented with complaints of loss of appetite, weakness, fever, cramp abdominal pain
and diarrhoea with blood and mucus. Acutely sick looking appearance with some signs of dehydration were
the most frequent findings in the majority of patients. Few had high temperature (up to 4OOC) and very low
blood pressure.
Review of the clinical records of patients in each brigade clinics and in the hospital was done. Personal
communications with the physicians, and hospital administration staff as well as with those in Sidamo
Regional Health Department was performed.
Living quarters, dining halls, recreational places, kitchens, bakery, showering places and latrines were all
inspected. Water sources, deep wells, reservoirs and daily use tankers were checked for damage and the pipe
lines were inspected for leakage.
Water samples were collected from the main reservoirs and daily use tankers: within the tankers, inlet pipes
leading to the tankers, outlet pipes and faucets. Sterile containers in cold ice-box were used to transport the
water samples to the National Research Institute of Health (NRIH) for examination.
In the laboratory, each water sample was immediately prepared and incubated at 37°C for 24 to 48 hours and
examined for the presumptive coliform counts, by the multiple tube fermentation method using Mackonkey
broth tube (16). A Iml amount undiluted and a I: 10 saline diluted portion of each water sample was also
pour-plated with molten normal agar for total plate counts. From a positive Mackonkey broth tube further
subculture and identification method was performed to examine the presence of Escherichia Coli type I by
incubating it at 44°C for 24 hours. The E. Coli is present and/or presumptive coliform counts is higher than
10 organisms/lOOml of water for unchlorinated piped water or 50 organisms/ 100ml of water for
unchlorinated spring water, river or water from deep wells and/or the total plate count is over 106 CFU
(colony formation unit) per l00ml of water (16).
Thirty four stool samples were collected from patients and healthy food handlers in small sterile plastic vials.
Patients were selected among those with diarrhoea and no antibiotics treatment during the last 14 days prior
to collection. Cary- Blair transport media was Used to transport faecal specimen to NRIH. In the laboratory,
swabs were immediately inoculated on Mackonkey agar and Salmonella-Shigella agar and Thiosulfate citrate
bile sucrose agar media, as well in to enrichment broth media like Kauffmann and alkaline peptone water. All
the plates and broth tubes were incubated at 37°C aerobically for 24 to 48 hours and examined for enteric
pathogens like Shigella, Salmonella, EPEC and V. Cholerae.
Biochemical and serological identifications were done according to the standard methods Edwards and
Ewing (17). Drug susceptibility test for each Shigella isolated were done according to the standards agar-disk
diffusion method (18). Sensitivity disks used included the following drugs: Cephalothin (Ct), Polymixin (Pb),
Tetracyclines (f), Streptomycin (S), Ampicillin (A), Chloramphenicol (C), Carbenicillin (Cb), Kanamycin
(K), Gentamicin (Gm), Trimethoprim-sulfamethoxazol ( TSM or Sxt), Nalidixic acid (Na), Sulfadiazine (Su).
RESULTS
As Table 1 shows, 5,248 patients visited the six brigade clinics during the outbreak, from March 5th to 22nd
1991, 1,616 (13.8%) were patients with diarrhoea.
Table 1. Total nulber (X) of patients with diarrhoea seen at the different brigade clinics fr001
March 5 to 22, 1991 in Bilate Military Training
Centre
Clinics
Total Patients
Brigade 1
Brigade2
Brigade 3
Brigade 4
Brigade5
Brigade6
Total
524
347
911
1,345
1,060
1,011
248
With diarrhoea
No. (X)
72 (13.7)
74 (21.3)
117 (12.8)
845 (62.8)
176 (16.6)
332 (32.8)
1,616 (30.8)
Table 2 shows the type of treatment given in the brigade clinics. Among 1,616 patients, 148 (11.6% ) were
treated with Chloramphenicol and 185 (14.5%) with Chloramphenicol and ORS. Tetracyclines was given for
198 (15.5%) and 103 (8.1% ) were treated with Tetracyclines and ORS. Metronidazole alone was given for
122 (9.7% ) and for 107 (8.4% ) in combination with ORS. Only 114 (8.9% ) were treated with ORS alone.
Anti-diarrhoeal drugs particularly charcoal were being used to treat 86 (6.8%) patients while 43 (3.4%) were
referred to hospitals for further medical care.
In the hospital medical OPD, among the 817 patients seen during the 17-days outbreak, 113 (13.8%) came
with diarrhoeal illness. Laboratory investigations were done for few
Table 2. Type of treatlfent given at Brigade clinics. 1991
Type of treatment
Number (%)
Chloramphenicol
148 (11.6)
Tetracyclines
198 (15.5)
Chloroquine
81 ( 6.4)
Ampicillin
11 (0.9)
Metronidazole
122 (9.7)
P. Penicillin
10 (0.8)
Chlora~enicol & ORS
185 (14.5)
Tetracyclines & ORS
103 (8.1)
Metronidazole & ORS
107 (8.4)
ORS
114 (8.9)
Charcoal
23 (1.8)
Charcoal & ORS
63 (5.0)
Others
68 (5.3)
Referred to hospital
43 (3.4)
Total
1,276*(100)
*Clinical records of 340 patients were not available
patients. The treatment given was similar to the one in the brigade clinic.
There were 99 patients admitted to the medical ward out of which 27 (27.2%) were diarrhoeal patients with
moderate to severe degree of dehydration. They were rehydrated intravenously and one or two types of
antibiotics were given. There was no death and the average hospital stay was 3 days. Table 3 shows the
results of the laboratory investigations done in the hospital. Direct microscopy was the only laboratory
investigation performed. Among the 186 stool specimen examined, Trophozoite of amoeba and giardia were
found in 50 (26.9% ), many pus cells and RBC were seen in 19 (9.7% ) and 76 (40.9% ) were negative for
ova or parasite.
Bacteriological analysis of the 10 water samples, 3 from reservoirs and 7 from the daily use tankers, showed
that all but one sample were bacteriologically non-potable. Out of the thirty four stool specimens, 7 from
Table 3. Laboratory result of faecal specimens at BMTC 1991
Findings
Giardia L. Trophoz.
E. Hystolytica Troph.
Many pus & RBC cells
Others
No ova or parasites
Total
Number(%)
32 (17.2)
18 (9.9)
19 (9.7)
41 (22.3)
76 (40.9)
186 (100)
patients and 2 from kitchen workers, total 9 showed bacterial growth. The genus Shigella was isolated in 6
patients, and Salmonella Para B strains were identified, one from a patient and two from healthy kitchen
workers. Further serogrouping and serotyping for species differentiation, identified 2 Shigella dysenteriae
(Group A), one type 1 strain and the other type 2 strains and 4 Shigellaflexneri (Group B).
The anti-biogram results indicate that S. dysenteriae type 1 strain was resistant to 8 drugs (TCACbKSSxtSu),
and susceptible to Cf, Gm, Na, Pb. S. dysenteriae type 2 strain was resistant to 7 drugs (TCACbSPbSxt) and
sensitive to Cf, K, Gm, Na and Su. S. flexneri species showed 3 types of resistance pattern, TCASSu, TCAS,
and TCACbS but were all sensitive to Sxt, Cf, K, G. One strain was sensitive to all antibiotics and 3 strains
were sensitive to Su.
DISCUSSION
Out of 160 countries worldwide and 58 Afri can countries, 150 & 56 countries, respectively, listed shigellosis
as one of the primary causes for morbidity and mortality (19). As many as 25% of all diarrhoeal related
deaths can be associated with Shigella (2). Anecdotal evidence showed that shigellosis is a major health
problem in Ethiopia. The commonest way of transmission of shigellosis is person to person contact through
contaminated food items, utensils, etc. particularly in over crowded populations with little or no sanitary
facilities. In our study, though, contaminated water sources, as possible cause of the outbreak cannot be ruled
out. This type of transmission was also found in other studies (10,11).
Since antimicrobial treatment were given prior to laboratory investigations, sufficient numbers of stool
specimens could not be collected. This problem was observed in most studies conducted in various
developing countries. In Bangladesh during 1979 and 1988, and in Thailand during 1986 and 1991 (2).
The genus Shigella is the most probable cause for the outbreak. Shigella group A and B were the only
serogroups isolated in this study. Predominance of these species were observed in two studies done
previously on the prevalence of shigellosis in Ethiopia (7,8,20).
Out of the 4 Shigellajlexneri isolated only one was found to be sensitive to the commonly used antibiotics:
Tetracyclines, Chloramphenicol and Ampicillin. The others showed 3 types of resistance patterns (TCACbS),
(TCAS), (TCACbSSu). Multiple drug resistance to as many as 6 drugs (TCACbSSu) was reported in
Ethiopia (20,21) and in other countries (22,23). Few TSM resistant Shigella jlexneri strains were isolated in
Ethiopia (21,24) but, in this study, these species were uniformly sensitive to TSM.
Shigella dysenteriae type 1 (Shiga bacillus) showed resistance to 8 drugs (TCACbKSSxtSu) in this study.
Similarly resistance to 6 (TCACbSSu) and, one strain, to 7 (TCACbKSSu) drugs was observed in Ethiopia
(20,25,26). One TSM resistant strain (Gimira strain) was recovered in Gimira Awraja, Keffa Administrative
region in the 1984 outbreak of Shigellosis (9,27). In other countries like Bangladesh, TSM resistant type 1
exceeds 25% (2). In Thailand 42-43.8% and in the USA 7% TSM resistant Shigella dysenteriae type 1 were
recovered (28-31).
It was reported previously that Shigella dysenteriae type 2 was sensitive to the commonly used antibiotics
(20,26). But, unlike the previous reports, the strain isolated in this outbreak showed resistance to 7 drugs
(TCACbSPbSxt) including TSM. Perhaps this is an unusual finding in this study. Nevertheless, it should be
supported by subsequent studies in the future.
The appearance of multiple drug resistant Shigella dysenteriae in the outbreak of Shigellosis will be an
immense health hazard in Ethiopia.
Regarding the treatment given to these patients, 3 problems were observed.
a) Anti-diarrhoeal drugs were used: 83 (6.7% ) patients were treated with charcoal.
b) Bacillary dysentery was wrongly diagnosed as amoebic dysentery and 229 (18.0%) patients were given
Metronidazole.
c) 840 (65.8%) patients were treated with Tetracyclines, Chloramphenicol and Ampicillin. The antibiotics
used are not recommended for the treatment of Shigellosis, in fact, all isolated Shigella species were found to
be resistant to all of them.
Although antibiotic treatment can be initiated solely on clinical grounds, it is recommended to collect 5-10
stool specimens to be sent to the laboratory for sensitivity tests (I). Enactment of essential drug policies
might curb the indiscriminate use of antibiotics and anti-diarrhoeal.
1) Anti-diarrhoeal drugs: Hydroxy diphenoxylate Atropine Sulphate, Loperamide and'activated charcoal
should be omitted from the national drug list (32).
2) Shigellosis outbreaks usually occur in rural areas (7,8). Health centres and health stations are the main
health units found in the rural part of Ethiopia (33). Since TSM is the only common antibiotic effective
against Shigella it should be available at least in health centres and should be strictly used either for proved
cases or for severe cases of bacillary dysentery .
3) Drugs sale policy should be defined. TSM should be handled by pharmacists in pharmacies only (not in
drug shops or vendors) and must be sold on prescription only.
Early case detection in the control of Shigellosis is crucial. Proper case registration and efficient reporting
system is mandatory. It calls for immediate interventions, arrangements for stool examinations and other
appropriate control measures can be taken at the right time. Early case detection in outbreaks highly
minimizes the bias of treatment given based on clinical grounds only.
Continuous surveillance of drug resistance of Shigella dysenteriae is recommended. If labora.tory support is
not readily available, cases can be managed on the basis of the sensitivity results of recently isolated
organisms in the country or of organisms isolated in nearby regions (2).
Finally, antibiotic treatment per se is not a solution in the control of Shigellosis. Public Health measures,
such as improved personal and domestic hygiene (hand washing and avoiding house flies), availability of
proper sewage and excretal disposal, provision of clean and safe water should be implemented.
On national level, the Diarrhoeal Diseases Control Programme needs to study pattern of antibiotic use,
investigate resistance of Shigella strains to drugs in different regions, develop treatment schemes appropriate
to local conditions and train health workers in correct case management of dysentery.
Usually, reports concerning investigation of outbreaks do not appear in journals or any medical publication
and remain in the files of Departments archives. Instead, they should be published to improve control
activities and contribute baseline data for epidemiological research purposes.
ACKNOWLEDGEMENT
We thank Ato Asheber Yergu and Ato Abebe for data collection and compilation. We greatly appreciate the
assistance of Dr. Tigest Ketsela and Dr. Renato Correggia of the National Control of Diarrhoeal Diseases
Programme for reviewing the manuscript. We also thank W/o Berhan Redda for her assistance in typing the
manuscript.
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MATERNAL EDUCATION AND CHILD SURVIVAL
IN ADDIS ABABA
Yohanne. Kinfu**
ABSTRACT: Maternal education is found to be positively associated with child survival and its impact was
generally more critical in the step from primary to secondary schooling than from the illiterate to literate
group. Although once income/wealth is controlled, differences in maternal education resulted relatively little
variation on child survival. The result also demonstrated that given the level of maternal education its
proportionate effect on child survival improved as one ascends from the lowest to the highest income/wealth
category. The findings have important implications for policy and further research.
INTRODUCTION
Developing countries in general and African states in particular have been experiencing a very high mortality
rate. The persistence of high mortality rate in these countries has been a subject of thought to researchers who
have been searching for the possible causes of high mortality while governments have been striving to
allocate their meagre resources to implement policies geared towards reducing mortality to a "reasonable
level". Nonetheless, after World War II significant decline in mortality have been observed in all parts of the
world, but have occurred at different rates in different areas. The sheer value of life aside, reducing infant
mortality or enhancing child survival has high priority for developing countries because children are major
sources for both poor families and the nation, and because decrease in infant mortality or enhancing child
survival usually lead to reductions in fertility. Consequently, third world governments would like to find
means of reducing infant mortality even more. To do so, they need to know exactly what changes have
contributed to this decline and what factors are more important.
A number of factors attributed to child survival, ranging from an exogenous technological diffusion,
particularly of medical, technology to an endogenously induced factor like socio-economic development.
However, there is a growing consensus that mortality levels and particularly of infant and childhood
mortality are highly and significantly related to socio-economic status of the child's parent, which forms the
immediate environment to the child.
In line with this, several studies on determinants of infant and child survival underscored that child survival
in the less developed countries in highly and positively associated with maternal education, more than with
any other socio-economic variables. Data from Latin America Behm, 1976-78; Haines and Avery, 1978,
Africa Caldwell, 1979 Fara and Preston 1982 and Asia Cochrane, et al. 1980; Caldwell and McDonald, 1981
all show a positive and significant relationship between the extent of maternal education and the chances of
child survival, although the magnitude and nature of its effect varies in different settings.
It is with this background that the study seeks to examine the association between the mother's years of
schooling and child survival in Addis Ababa. In order to shed light on the mechanisms through which
education operates, the discussion considers whether the strength of the maternal education -child survival
relationship is altered by variations in household income/wealth level which is measured in the study in terms
of house-ownership and rent level paid.
_____________________________________________
*This paper is extracted from the author's dissertation in partial fulfillment of the M.A. degree in population studies, "Correlates of
Infants and Child Mortality in Addis Ababa", 1990
**Population and Development Planning Unit, ONCCP, Addis Ababa, Ethiopia
SOURCE AND NATURE OF DATA
The major source of data for the study was the Population and Housing Census of Addis Ababa which W3S
carried out in May 1984 as part of the National Population and Housing Census.
Considering the advantage of sampling and limited available time for the study during the preparation of the
original thesis, it was decided to take probability sample of persons rather than work on the entire data set in
the area. Thus, a systematic sampling procedure with a random start was adopted to select the units of
sampling in this case, the enumeration areas.
The sample drawn consisted of 36 enumeration areas with a total population of 34,618 of which 9,201 are
females in reproductive age group. The analysis, therefore, is based on these 9,201 women whose age is
between 15 and 49 inclusive.
In the 1984 census, data on education was collected in two ways. One was for those who were still attending
up to the census night and the other was about the highest level or grade completed. The latter information is
used for the purpose of this study. For analysis purpose three sub-groups, namely; Never been to school, 1 to
6 years of schooling and 7 years and over were identified among which child survival differences are
compared.
Although the census did not collect information on direct measurements of income and wealth in a
household, in an attempt t) uncover the relationship between income and child survival and also to take the
maximum advantage of the relatively available little information, two variables are selected and assumed to
measure the economic status of a household. These include type of house-tenure and rent level paid by the
respondent.
In the 1984 census, the type of house tenure was categorized in to self-owned, rented from Kebele office,
rented from agency for the Administration of Rented Houses, those who are paying difference in rents and
rent free houses.
Due to smallness of the cases in the sample the category of those who are paying differences in rents is
omitted from the analysis. Thus, for analysis purpose house-tenure system was sub-grouped in to the
following three sub-groups - self-owned, rented (includes rented from Kebele office and from the Agency for
the Administration of Rented Houses) and rent free households.
In this study the assumption is made that those households who live in self-owned flats were likely to be
better off in terms of their income than those households who live in rented premises who in turn are
assumed to he living in comfort more than those who do not pay rents.
Such assumptions are likely to he thought with problems, since there were no clear standards to be followed
in putting up houses in the city. However, on the average the study feels that the assumption might not be
violated and also reflect income differentials among the stipulated groups.
The census also collected information on the monthly rent paid by residents who lived in rented premises.
This information is also used to reflect the income difterentials among households. For our purpose the rent
level is divided into two broad sub-groups. Those who pay monthly rent of less than 50 birr and those who
pay more than 50 birr. Once again it is assumed that those households who pay a monthly rent more than 50
birr are likely to be better off in terms of their economic status (i.e. income/ wealth level) and their housing
facilities which in fact has a more direct impact on chances of child survival.
A note is needed that since the goal of this analysis is to examine factors impinging on the survival of
children, it is assumed that the proxy measures (i.e. house ownership and rent level paid) serve as indicators
of children's consumption of goods and services that affect their health and hence their survival status
including, among others calories and nutrient intake, clothing and shelter, sanitary facilities, and use of
medical systems. It is obviously reasonable to expect that, ceteris paribus, a higher income household should
experience higher chances of child survival. This expectation presumes that children in higher income capita
will consume more health enhancing goods and services per capita than children in lower income
households.
CONCEPTUAL HYPOTHESIS
The factors that are related to child survival are multi-dimensional in their nature (social, economic,
demographic, biomedical and environmental). It also requires a multi-disciplinary approach in its research
strategy (socio-economic, demographic and epidemiological research). This is why several
analytical/conceptual framework have been developed by researchers of all kind concerned to this particular
problem. Most of these frameworks give due emphasis to what they refer to as the intervening variables that
are more proximate to the event of death. Unfortunately, the available data provide no information on these
intervening variables; the data available relate mainly to socio-economic variables. Therefore, due to this
problem and also since our prime survival and maternal education, one factor from the list of child survival
determinants, we are unable to use these elaborated frameworks. Consequently, we have framed a conceptual
hypothesis which is expected to show how maternal education and increased income affect child survival.
In the framework outlined in Fig. I the effect of maternal education on child survival is expected to operate in
two directions, namely; through awareness creation and increased opportunity. In the model it is also
assumed that education promotes participation in the modern sector that higher education enables a woman to
acquire better occupation and hence a higher income/wealth level.
The basic hypothesis of this framework and the study in general is that higher maternal education and/or
higher household income/-
Fig.1 Simplified schematic representation of the effect of maternal education and income/wealth on child
survival
of maternal education and income/wealth on child survival wealth level enhances child survival through the
mechanisms stated below. It is hypothesized that maternal education through its " Awareness creation" effect
influences the attitudes of mother's towards traditional norms and beliefs including traditional child raising
practices, fatalism about illness and ritualistic disease prevention practices which have an impact on the
child's health and survival. An educated mother is most probably less fatalistic, better able to deal with
modern medical facilities and all available resources and also more aware of simple hygienic measures. More
impontantly because of her responsibility of her own care during pregnancy and the care of her child through
the most vulnerable stages of its life, her educational level can affect child survival by influencing her
reproductive behaviour and also increasing her skills in health care practices related to contraception use,
nutrition, hygiene, preventive care and disease treatment. On the other hand, it may be hypothesized that
higher education leads to better occupation with a higher income or it may also increase chance of marrying a
man in a higher occupation group and/or with a higher income, which guarantee increased opportunity or
greater capability to provide a variety of goods, services and assets at the household level which in turn
enhances child health and survival. Below are some major ways in which income influences child health.
Increased opportunity will guarantee a household to provide children with a sufficient amount of nutrious
food, it also provides a means to pay for preventive services including for physicians, hospitalization, drugs
and also maternity care during child birth. Moreover, since both size and quality of housing facilities are
correlated with household income/wealth level those with, better income enjoy better facilities and hence
reduce the chance of environmental exposure of their children to infectious agents.
Generally, it is believed that those households with a better economic status have the opportunity to provide
more health enhancing goods and services that affect child health and survival through increasing per capita
calories and nutrients, clothing and shelter, sanitary facilities, use of medical facilities and adult supervision
than the lower income households. This hypothesis assumes that children in a higher economic group will
consume more health enhancing goods and services per capita than their counterparts.
METHOD OF ANALYSIS
The procedure used for studying the differentials in infant and child survival among the different educational
sub-groups is adapted from a method originally developed and tested by Trussell and Preston in 1982 used in
analyzing mortality differentials among different socio- economic groups of which education is one.
The basis of the method was to construct an index of infant and child mortality for women of a certain socioeconomic category in this case education and proxy measures of income/wealth and compare the values of
the index among different sub-groups of women in the same category. The group who had a lower index
among the category is the one who has a better enhance of child survival. Simply put, the higher the index
the heavier the mortality of the group and vise versa. Note that the index as it stands is not a measure of child
survival or mortality level rather it is an index of comparison of chances of child survival or mortality level
among the groups.
The index of infant and child mortality for women of a certain sub-group of a given socio-economic category
is constructed as a ratio of the actual number of children who have died to the expected number of an
"average" women in the population of the same age group. This latter quantity is derived by multiplying
children ever born (CEB) by the expected proportion of children dead. This expected proportion dead in turn
is based upon general mortality conditions in the population as well as upon the distribution of exposure
times of their children to the risk of mortality, as measures by the mother's age.
For each sub-group, I, of a certain socioeconomic category the index is formed as follows.
M (1) =
CDJ (i)
CEBJ (i) SPD (i)
=
Observed dead
Expected dead
Where: M (1) is the index of child survival of sub-group I (where 1=3 in the case of maternal education, 1=3
in the case of house ownership and 1=2 in the case of tent level paid). CDJ (i) is the actual number of dead
children to women of age group i (where i=15-19, 20-24, ...45-49) in the Jth sub-group of a certain socioeconomic category.
CEBJ (i) is the total number of children ever born to women of age group i (where i= 15-19, 20-24, ...45-59)
in the Jtb sub-group ofa certain socio-economic category. SPD (i) is a standard expected proportion dead to
an average women of age group i (where i= 15-29, 20-24, ...45-59) in the population. This standard expected
proportion is based on the relationship between proportions dead and qj (probabilities of dying between exact
age 0 and j) originally established by Brass (For a detailed exposition of the technique, the original papers
may be consulted). The "standard" values chosen for this purpose was Coale-Demeny "East" model life table
at level 17.5, which is the estimated level for all Addis Ababa.
RESULTS
There is abundant evidence both from the developed and the developing countries of the world that maternal
education exerts a very significant and independent positive impact on the levels of child survival, although
the mechanism through which it operates still remains inconclusive. In this study maternal education is used
to test the common hypothesis that the higher the level of maternal education, the higher the chance of child
survival. The following table presents the child survival variations among the sub-groups of educational
category.
Table 1. Effect of maternal education on child survival, Addis Ababa, 1984
Variable of analysis
Index of child survival
Maternal education
Never been to school
1.520
1-6 years of schooling
0.024
7 years or more
0.630
An examination of the index by maternal education in Table 1 reveal that the expected pattern also hold in
the area. Clearly, child survival of those mothers who had higher educa-tion (7 years or more) is higher than
those mothers who had lower education (I to 6 years of schooling and never been to school). Once again a
note is needed that the group who had a lower index among the sub-group is the one who has a better chance
of child survival. Consequently, children whose mothers had 7 years or more of schooling experienced 141
% higher chance of survival than their counterparts born to illiterate mothers.
As outlined in the conceptual hypothesis this variation might be due to the "teaching" or "awareness creation"
effect of the subjects taught in the schools. Most teaching materials in the country include lessons on topic
like nutrition, primary health care, hygiene and sanitation, etc. which are expected to have a positive
influence on student's attitude towards personal hygiene, disease causation (germ theory of disease as a cause
of illness), basic preventive and curative procedures, choice of therapies and practitioners. Because of this
experience, therefore, after they leave school such information are expected to transform their preference for
health care practices so as to significantly improve child survival, often without investment of additional
economic resources.
If education affects child survival through the "teaching" effect alone one would expect a comparable or
proportionate improvement in child survival status when one moves from the illiterate to primary and from
primary to 7 years or more group. However, unlike the expectation the data from the same table revealed that
the move from primary to 7 years or above exert somewhat more influence on child survival than the step
from no education to primary education (1-6 years of schooling). For instance, a step from I to 6 years of
schooling to 7 years or more enhance child survival by 63% as compared to 48% by a move from no
education to 1 to 6 years of schooling. This finding suggests that the observed difference could be attributed
to the "increased opportunity" effect of education which favours those in a higher educational category. In
other words, those who have longer years of schooling (7 years or more). have increased opportunities to
move in to more modern and better occupations and to earn more money. Thus, higher income will enable
those in a higher educational category to buy more health enhancing goods and services which in fact has an
enhancing effect on status of child survival.
Therefore, in order to see the behaviour of maternal education in the presence of proxy measures for
income/wealth the index is cross tabulated by maternal education against house ownership and rent level paid
by the household. A glance at the observed relationship in Table 2 depicts that within each category of
income/wealth, child survival situation has increased as education of mother increased. For instance, for the
same level of income/wealth, say those who reside in "self-owned" flats, those with 7 years or more of
schooling still continue to experience higher chance of child survival than the illiterates and those with 1 to 6
years of
Table 2. Cross tabulation of the index of child survival by maternal education, house ownership and
rent level, Addis Ababa, 1984
Background variables
Maternal Education
House ownership
Rent-free
Rented
Self-owned
Rent-level
Up to 50 Birr
over 50 Birr
Never been to school
1 to 6 years
7 yrs. or more
1.620
1.575
1.426
1.146
1.104
0.900
0.792
0.749
0.523
1.608
1.334
1.156
0.900
0.915
-
schooling, although the magnitude of difference became lesser once income/wealth level is controlled. A
similar observation can be made for all proxy measures. This is due to the reason that more highly educated
women, other things being equal, are more aware of the importance of investment and tend to spend a higher
share of their income on health-related activities.
Furthermore, it seems reasonable to expert that education increases the efficiency of mbility spent on health
due to better knowledge about effective health care measures. For both reasons the income elasticity of child
survival could be expected to be greater among the better-educated. It seems that a proportionate increase in
income among the highly and lower educated group would bring better chance of survival among the highly
educated than the latter group. On the other hand the same table shows that within each category of
education, child survival increases as income/wealth increases. For example, considering only those who are
living in rent-free houses, the step from never been to school to primary and then to 7 years or more reduced
mortality by 41.4% and 44.7% respectively; while if we consider those who are residing in self-owned house
the step from never been to school to primary and then to 7 years or more reduced mortality by 58% and
72.1% respectively. Similarly, taking same rent level say up to 50 birr, the move from never been to school to
primary reduced mortality level by 39% while the same step reduced mortality by 48% in the case of rent
level over 50 birr. The general conclusion that comes out of the income maternal education relationship is
that the proportionate influence of income/wealth on child survival is much more higher in higher
educational categories, although maternal education has relatively little effect on child survival differences
within categories of income/wealth.
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
The objective of the study is to examine the relationship between child survival and maternal education. In an
attempt to carry out its objective, a sample of 920 1 women is drawn from the 1984 census result of Addis
Ababa. The sample design is a systematic sample without replacement. The unit of selection is an
enumeration area.
Following the method developed by Trussell and Preston the chances of child survival of different
educational categories are compared. The findings are that: mothers with higher education experienced better
chance of child survival and the impact of maternal on child survival was more critical in the step from
primary to secondary schooling than from the illiterate to literate group. However, the proportionate
influence of maternal education on child survival is much more higher in higher income group this implying
that the effect of maternal education on child survival may operate indirectly through income.
The most relevant and obvious conclusion is the need to undertake specific studies designed to this particular
end to allow a deeper analysis of relations between child survival and socio-economic, demographic and
epidemiological factors.
From the study two clear policy implications and a number of silent policy issues have emerged.
-The finding that longer years of maternal education is strongly and positively associated with child survival
obviously calls the attention of policy makers to encourage women to go to school for longer period of time.
This of course can not be done in isolation without changes in the attitude of parents towards keeping
females in school for longer number of years. In this regard, an inter-sectoral population information and
education programme constitute a vital component to promote awareness and understanding of the broad
field of population issues with the purpose of developing responsible attitudes and behaviour toward that
issue.
-Secondly, as it is observed the impact of maternal education on child survival would be much more
effective with the enhancement of the economic-status of the mother suggesting policy makers to create
opportunity for women in financially gainful activities. In sum, policy makers should give attention in
promoting the role of women through removing institutional and cultural barriers which hinder women from
access to education, employment, etc.
Scarcity of data is one of the hindrance for detailed analysis and restricts the domain of analytical tools.
Therefore, efforts should be made to generate, collect, analyze and disseminate adequate and reliable
population data on a continuous basis.
BIBLIOGRAPHY
I. Behm, H. Final report on the research project on infant and childhood mortality in the Third World. Infant
and child Mortality in the Third World, Paris. 1983.
2. Behm, H. et al. Socio-economic detenninants of mortality in Latin America. Pop. Bull. U.N. New York.
1980; 13.
3. Caldwell, J.C. Education as a factor in mortality decline: An examinalionof Nigerian data. Population
studies. 1979.
4. Caldwell, J.C. and McDonald, P. Influence of maternal education on infant and child mortality in
International Population Conference Manila, Liege, International Union for the Scientific Study of
Population. 1981; 2.
5. Cochrane, S.H., O'Hara, D.J. and Leslie, L. The effects of education on health. Working Bank Worlcing
papers, Washington, D.C. 1980; 405.
6. Fara, A.A. and Peterson, S.A. Child mortality differentials in Sudan. African Demography program
worlcing paper. August 1981; 7.
7. Haines, R. and Avery, R.C. Differential infant and child mortality in Costa Rica: 1968-1973. J. Pop. Stud.
December 1974; 31 (3).
8. United Nation. socio-economic deferential in child mortality in developing countries, Department of
International Economic and Social Affairs, New York. 1985.
9. Kinfu, Yohannes. Correlates of infant and child mortality in Addis Ababa. Dissertation submitted for the
Award of M.A. degree in population studies, University of Ghana, Legon. Septenlher 1990.
IMMUNOGENICITY OF PLASMA DERIVED V ACCINE
IN ETHIOPIAN HOSPITAL PERSONNEL
Hailu Kefenie.,MD, Bekure Des!A. & Almaz Abebe..,MSc
ABSTRACT: To study the immunogenicity of plasma derived hepatitis B vaccine, serological markers
(HBsAg, anti HBc and anti HBs) were determined in 432 hospital employees by the Hepanostika
microenzyme linked immunoassay method (ELISA) using kits obtained from Organon Technika
Laboratories (Holland). Three doses of Pasteur plasma derived vaccine (Hevac B), containing 5 mcg of
HBsAg, were administered intramuscularly at one month intervals to 80 of the l02 marker negatives. A
booster dose was given at one year. Hepatitis B markers (HBsAg, anti HBc and anti HBs) were determined at
4, 12, 13 and 24 months by the ELISA method. Titration for anti HBs were pertormed at T 4, T 12, and T 13
by the radio-immunoassay method. Of 80 vaccinees, 2 discontinued after the first injection. Sero-conversion
to anti HBs occurred at 4 months in 57 of 80 (71.3% ); at 12 months in 64 of 73 tested (87.7%) and at months
13 and 24 in 66 of 69 tested (95.6%). Protective levels of anti HBs were achieved in titrated sera collected
from sero-converters in 89%, 88.5% and 100% at months,4, 12 and 13 respectively. No vaccinee developed
any evidence of hepatitis B infection during the two years of follow up. A female developed generalized skin
rash and a pregnant woman aborted, both following the first injection. We conclude that plasma derive<!
hepatitis B vaccine administered to adult Ethiopian hospital personnel is highly immunogenic and protective
with minimal side effects.
INTRODUCTION
Hepatitis B is a disease of worldwide dis tribution. Morbidity and mortality are due to both the acute disease
and chronic sequelae, i.e. chronic hepatitis, cirrhosis and hepatocellular carcinoma. The extent of the
infection varies with the geographic location; being the highest in Sub-Sahara Africa, China and South-East
Asia (1,2).
Measures such as screening of blood for hepatitis B surface antigen (HBsAg) before transfusion, the use of
hepatitis B immunoglobulin following cutaneous or mucosal exposure to blood containing hepatitis B virus
and similar preventive steps had only a small contribution to the overall control of hepatitis B infection. This
leaves vaccination strategy as the single most important method of preventing hepatitis B infection.
Most sero-surveys conducted earlier have documented HBsAg carrier rate of more than 10% and an overall
infection rate of greater than 70% in the adult population of Ethiopia (3,4,-5,6) even though some studies
have reported lower rates among certain population groups (7,8). This clearly places it among the countries
with the highest prevalence. With this background knowledge it is obvious that only nationwide vaccination
of all newborns will have a significant impact on the control of hepatitis B infection in this country.
However, it also appears beneficial, even in hyper endemic to vaccinate target groups with an increased risk
of infection among the adult population. Health care workers have been shown to belong to this group (5).
Even though several studies have shown the immunogenicity, efficacy and safety of both the plasma derived
and recombinant DNA hepatitis B vaccines (9-17) we feel it is important to document at least its
immunogenic potential in Ethiopians before embarking on a large scale vaccination programme. It is with
this in mind that we initiated this study in order to determine primarily the immunogenicity and
simultaneously the tolerance of plasma derived vaccine among our hospital personnel.
_________________________________
.Armed Forces General hospital, Addis Ababa, Ethiopia
..National Research Institute of Health, Addis Ababa, Ethiopia
SUBJECTS AND METHODS
Participants
In September 1987, all employees of the Armed Forces General Hospital were invited to take part in the
study. However, due to lack of diagnostics kits only the first 432 were selected and screened for HBsAg,
antibody to coreantigen (anti-HBc) and antibody to surfaceantigen (anti HBs) by the Hepanostika
microenzyme linked immunoassay method (ELISA) using commercially available kits obtained from
Organon Technika Laboratories. One hundred and two marker negatives were eligible but 20 were unable to
participate for various reasons and only 82 were enroled in the study. There were 24 males and 56 females
with a mean age of 30. ) (range 17-50) years.
Conduct of the study
Three doses of Hevac B Pasteur were administered intramuscularly into the deltoid muscle, at one month
intervals, starting from the time of initial screening for hepatitis B viral markers (months, To, Ti, and TJ. A
booster dose was given at 12 months (f IJ from the first injection. Before vaccine administration, verbal
consent was obtained after explaining to each participant the possible side effects of the vaccine and the right
to withdraw at any time of the study.
The vaccine is prepared from the plasma of healthy carriers of HBsAg and contains a highly purified and
inactivated suspension of the sub-types "ad" and "ay" absorbed on to aluminium hydroxide. It also contained
the preS protein which is the outermost epitome on the hepatitis B viral envelope. The vaccine is in a ready to
use syringe containing 5mcg of HBsAg/ml and was kept at 2°C to 8°C until administration.
Seven ml of venous blood was obtained from each participant at T 4' T 12' T 13 and T 24 and the serum sent
to the National Research Institute of Health for the determination of HBsAg, antiHBc and anti HBs. Sera
obtained at To was sent to "Pasteur Vaccines" for the determination of hepatitis B markers (HBsAg anti HBc,
anti HBs) while that of T 4' T 12 and T 13 were for the titration of anti HBs and anti PreS. Radioimmunoassay (RIA) was used for anti HBs and the ELISA method for anti preS titer determination. The
results of anti HBs titration were expressed in international milli-units per millilitre (mIU/ml). Titers above 2
rnlU/ml were considered sero-conversion where as levels more than 10 mIU/ml were taken as protective.
Anti preS values of 30 rnlU/ml or more were regarded as significant.
All sera were frozen and stored at 20°C before testing. In order to verify laboratory reliability 63 masked
replicates of sera from T4 were sent to "Pasteur Vaccines", Paris, for the analysis of hepatitis B markers.In
order to monitor the tolerance of the vaccine each participant was instructed to contact the principal
investigator for any side effect and were also questioned about side effects every time they came for blood
drawing.
Statistical Methods: Chi-square and Z-tests are used for differences between proportions.
RESULTS
Out of the 82 participants enroled in the study 80 received three doses of vaccine and 73 took the booster
dose. Two subjects withdrew from the study after the first injection due to presumed side effects.
Sero-conversion to anti HBs occurred at 4 months in 57 of 80 (71.3%), at l2 months in 64 of73 tested
(87.7%) and at 13 months in 66 of 69 tested (95.6%). At 2 years the anti HBs positivity rate remained
unchanged in the 69 participants tested. This is shown in figure 1. Seven participants at T 12, 11 at T13 and T
24 were not available for testing. Three women followed for 2 years failed to sero-convert. Analysis for
Table 1. Sero-conversion rate by Age
Age bracket
Sero-conversion rate different months from first injection
T4
T12
No
%
No
%
< 20
(3/4)
75
(3/3)
100
21-30
(34/46)
73.9
(38/40)
95
31-40
(17/24)
70.8
(19/24)
79.17
41-50
(3/6)
50
(4/6)
66.66
Total
(58/80)
71.3
(64/73)
87.67
T13
No
(3/3)
(39/40)
(19/20)
(5/6)
(66/69)
%
100
97.5
95
83.33
95.65
anti preS has been left out because most of the sera sent to "Pasteur Vaccines" were said to be inadequate for
antibody determination. There is no statistically significant difference in sero-conversion rate between the
different age brackets and the sexes (X2 and Z tests respectively). This is seen in tables 1 and 2.
Table 2. Sero-conversion rate by sex.
Months after first
Male
injection
No
%
T4
17/24
70.8
T12
19/21
90.5
T13
20/20
100
Female
No
40/56
45/52
46/49
%
71.4
86.5
93
Total
No
57/80
64/73
66/69
%
71.3
87.7
95.5
In the sero-converters titrated for anti HBs, a protective level was reached jn89%, 88.5% and 100% at
months 4, 12 and 13 respectively. Statistical analysis using the Z-test did not show significant difference
between the sexes in attaining this level of antibody, as shown in table 3.
The distribution of antibody titers in sero-converters, at the different time intervals is depicted in table 2. It is
worth noting that there is a large increase in the levels of antibody titers
Table 3. Anti HBs above protective level in sero-converters titrated at different time intervals and distribution
by sex
Months
after
first injection
T4
T12
T13
No. titrated
M
11
12
8
No. with protective level of anti HBs & % protected of titrated
F
34
40
37
Total
45
52
45
M
10(91)
9(75)
8(100)
F
30(88)
37(93)
37(100)
Total
40(89)
46(89)
45(100)
following the booster dose. Geometric mean titer (GMT) in sero-converters were 14.64 at 4 months, 23.24 at
12 months and 1036.5 mIU/ml at 13 months.
No vaccinee came up with hepatitis B viral markers suggestive of acute hepatitis during the 24 months of
observation. During the two years of follow up no side effects were reported except in the two women who
discontinued the vaccination programme after the first injection. One developed a generalized macular skin
rash, headache and fever on the same day as the vaccination and the other women aborted at 6 weeks of
pregnancy, seven days after the injection.
There was complete agreement between the results obtained from the same sera tested both locally and at
"Pasteur Vaccines" indicating reliability of the two laboratories.
DISCUSSION
This study demonstrates that plasma derived Pasteur Vaccine is highly immunogenic in a sample of adult
Ethiopian health care workers. The 95.6% sero-conversion rate obtained one month after the booster dose is
similar to results obtained by other investigators among different population groups, following varK>us
vaccination protocols (10,12,14,16). It is worth noting that out of the 432 hospital employees screened only
102 had no evidence of hepatitis B infection. This has an important bearing on future strategies of
vaccination programme in this country. In line with Gebreselassie's study (18) the most reasonable approach
in an hyperendemic area, like Ethiopia, would be to vaccinate all new-borns within the framework of the
expanded programme of immunization. With the current reduced cost of the vaccine it seems appropriate
to vaccinate even the adult population without screening for viral makers whenever vaccination is deemed
necessary .
The presence of pre-S proteins in the vaccine is thought to enhance the immunogenicity of the vaccine. These
pre-S antigenic determinants being the outermost epitomes on the hepatitis B virus envelope are said to
induce virus neutralizing antibodies before antibodies to the S-proteins develop and may provide early
protection by blocking the attachment of HBV to liver cells (19). Even though these claims cannot be substantiated from our study the good level of antibody obtained with the relatively low antigenic dose used in
this vaccine may suggest the augmentative role of pre-S protein.
Currently it is believed that anti HBs levels above 10 mIU/ml are protective against hepatitis B infection
(20). In our study this level is surpassed by 100% of the 45 seroconverters titrated at T 13. This indicated that
the potential of the vaccine to protect against infection is high among our study population, similar to
observations by others (10,12,14,16).
Even though previous studies have given inconsistent results (11,12,15) we found no statistically significant
difference in sero-conversion rate between the sexes. However, there were 3 obese females who failed to
develop anti HBs during the whole period of follow up. This is in agreement with observations made by other
investigators (21). It is speculated that the presence of large amounts of fat tissue inhibits the interfacing of
the vaccine and antigen recognizing lymphocytes (22). However, others have come up with evidence of a
genetic prediliction for non response to hepatitis B vaccine (23). The relatively low vaccine dose used in our
study may also contribute to the poor antibody response in these obese participants.
Our study also showed no significant difference in vaccine response between the different age brackets.
However, there is a trend of inverse relation between antibody titer and age. The lack of a more definite
relationship may be due to the small number of vaccinees above the age of 41.
Antibody persistence following vaccination is said to be directly related to the peak GMT of antibody. Even
though there was an impressive increase in antibody titer one month after the booster dose, the peak GMT
documented in this study is lower than reported by some investigators (11,12,22). The reason for this is not
obvious but the low dose utilized in this trial may have a role. This has been shown to be the case by rug et
al. in which they documented a lower GMT with the 5 mcg of HBsAg compared to the 10 and 20 mcg (22).
The issue of antibody persistence is important in relation to the need and timing of a booster dose (24).
Nevertheless, the Centre for Disease Control in Atlanta Georgia, currently recommends that no routine
booster dose be given in adults and children with normal immune status within 7 years after vaccination (25).
Skin rash and fever as a side effect of hepatitis B vaccine has been documented by other as well (10,12).
However, from the review of the available literature abortion has not been reported in vaccine recipients.
Even though this could have been just a coincidence, caution should be exercised when pregnant women are
considered for vaccination. Sore arm is the most frequent side effect reported in other studies
(10,12,14).However, none of the participants in this study complained of it even after direct questioning. We
conclude that plasma derived Pasteur Vaccine administered to adult Ethiopian hospital personnel is high
immunogenic, with minimal adverse effects.
REFERENCES
I. Beasley, R.P., el al. Geographic dislribution of HBs Ag carriers in China. Hepalology. 1982; 2: 553-556.
2. Szmuness, W., el al. The epidemiology ofhepalilis B infection in Africa: Resulls of a pilot study in the
Republic of Senegal. Am. I. Epidemiol. 1973; 98: 104-110.
3. Hai1u Kefenie, el al. Ethiopian nalional hepalilis B sludy. I. Med. Vir. 1988; 29: 75-83.
4. Edomariam Tsega, el al. Hepalilis A, B, and delta infection in Ethiopis: A serologic survey with
demographic data. Am. I. Epidemiol. 1986; 123 (2): 344-350.
5. Hailu Kofenie, el al.PrevaJence of hepalilis B infeclion among hospital personnel in Addis Ababa
(Ethiopia). Eur. J Epidemiol. 1989; 5: 462-467.
6. Gebreselassie, L. Prevalence of specific markers of viral hepatitis A and B among an Ethiopian population.
Bull. WHO. 1983; 61 (6): 991-996.
7. Gebreselasaie, L. Occurrence of hepatitis B surface antigen and its antibody in Ethiopian blood donors.
Elh. Med. J. 1983; 21: 205-208.
8. Gebreselasaie, L. Occurrence of hepatitis B surface antigen in various population groups in Ethiopia. Elh.
Med. J. 1986; 24: 63-67.
9. Brown, Se., et al. Antibody responses to recombinant and plasma derived hepatitis B vaccines. BMJ. 1986;
292: 159-161.
10. Coutinho, R.A., et al. Efficacy of a heat inactivated hepatitis B vaccine in male homosexuals: Out-come
of a placebo controlled double blind trial. BMJ. 1983; 286: 1305- 1308.
11. Jilg, W., et al. Clinical evaluation of a recombinant hepatitis B vaccine. Lancet. 1984; 1174-1175.
12. Dienstag, J.L., et al. Hepatitis B vaccine in health care personnel: Safety, immunogenicity and indicators
of efficacy. Ann. Inter. Med. 1984; 101: 34-40.
13. Sciknik, H.M., et al. Clinical evaluation in healthy adults of a hepatitis B vaccine made by recombinant
DNA. JAMA. 1984; 251 (21): 2812-2815.
14. Szmnesa, W., et al. Hepatitis B vaccine: Demonstration of efficacy in a controlled clinical trial in a high
risk population in the United States. N. Engl. J. Med. 1980; 303: 833-841.
15. Stevena, C.H., et al. Hepatitis B vaccine: immune responses in hemodialysis patients. Lancet. 1211-1213.
16. Xu, Z- y ., et al. and United States -China cooperative study group on hepatitis B. Prevention of perinatal
acquisition of hepatitis B vinls carriage using vaccine: Preliminary report of 8 randomized double blind,
Placebo controlled and comparative trial. Pedialrics. 1985; 76 (5): 7i3-718.
17; Report of the Centera for Disease Control mulicenter efficacy trial among homosexual men. The
prevention of, hepatitis B with vaccine. Ann. Intern Med. 1982; 97: 362-366.
18. Gebreselassie, L. Seroepidemiologicalstudy of HBV infection in Ethiopia reveals the prime age
ofheaptitis B vaccination to early childhood. Proceedings of 8 symposium on progress in hepatitis B
immunization (eds.) Couraagetand M.I. Tong. Colloque Insenn. 1989; 194-536.
19.Deinhardt, F., and W. Jilg. Vaccines against hepatitis. Ann. Inst. PasleurlVirol. 1986; 137 E: 79-95.
20. Pasteur Vaccins. Hevac B Pasteur; Pre-S protein; New implications in hepatitis B immunization. 1986; 130.
21. Weber, D.I., et 81. Impaired immunogenicity of hepatitis B vaccine in obese persons. N. Engl. J. Med.
1986; 314 (21): 1393.
22. Grady, G.F. The here and now of hepatitis B immunization. N. Engl. J. Med. 1986; 315 (4): 250-251.
23. Alper, C.A., et al. Genetic prediction of non re,sponse to hepatitis B vaccine. N. Engl. J. Med. 1989; 321
(ii): 708-712.
24. Jilg, W ., et a1. Peraistance of specific antibodies after hepatitis B vsccination.J. ofHepatology. 1988; 6:
201-207.
25. Center for Diseases Control. Protection against viral hepatitis: Recommendation a of the Immunization
Practices Advisory Committee (AC1P). MMWR. 1990; 39 (S-2): 1-26.
AN OUTBREAK OF ACUTE TOXICITY CAUSED BY
EATING FOOD CONTAMINATED WITH DATURA STRAMONIUM
Aaefa Aga*,BSc (PH) & Aberra Geyid**,BSc,MSc
ABSTRACT: We report methods used to characterize an outbreak of food-borne acute toxicity among the
labour force of a cotton plantation in Middle Awash Agricultural Development Enterprise in July and August
1984. Among 1492 patients seen at the Enterprise and Ministry of Health clinics during this period, 688
(46.1% ) exhibited unusual sign and symptoms. Thirty three patients required hospitalization for intensive
medical care while nine patients were reported to have died due to this condition. Contamination of corn
flour with pesticides was initially suspected and laboratory animal tests were carried out which failed to show
any signs of acute toxicity. Investigation of the source of the corn and its processing was simultaneously
conducted and revealed the contamination of the corn with seeds of an indigenous plant identified as
Daturastramoniwn, an antimuscarinic alkaloid. These alkaloids contain hyoscine and hyoscyamine which is
known to have toxic effect on the exocrine glands, heart, and the autonomic nervous system in man. Signs
and symptoms observed in the patients and preventive measures implemented are discussed.
INTRODUCTION
Middle Awash Agricultural Development Enterprise is located in western Hararghe region, eastern Ethiopia
about 255 km away from Addis Ababa. The Enterprise is mainly engaged in cotton plantation in a wide area
of Middle Awash plains. The work force of the Enterprise reaches about 20,000 during cotton picking and
weeding seasons. Food to the workers is supplied by the Enterprise in a form of ration mainly comprising
corn flour, rarely wheat flour, when supplied in excess is sold to the local town people and merchants who in
turn export to the places in the neighbouring regions.
In August 1984, the Awash Agricultural Development Corporation who manages the Middle Awash
Agricultural Development Enterprise requested the Ministry of Health to take measure on an illness afflicting
the labour force of the Enterprise for which no description was given except suspecting food-borne toxicity.
Samples of corn flour were sent to the National Research Institute of Health laboratory for food toxicity
testing but all of them were reported negative. The Ministry of Health took initiative to investigate and
control this illness with no further description.
Case Definition. The team which was formed by the Ministry of Health arrived at Middle A wash
Agricultural Development Enterprise on August 10, 1984. The team observed few cases and went through
the registers of 5 health units. After this observation, cases commonly showed dryness of mouth and throat,
blurred vision, dry and flushed skin, and some neurologic abnormalities such as restlessness, confusion,
talkativeness, delirium, etc. after ingestion of bread and 'tella' prepared from corn flour distributed few days
ago by the Enterprise. Hence a case was defined as the occurrence of one or more of the following
symptoms-dryness of mouth and throat; difficulty in swallowing; hot, dry, and flushed skin; blurred vision within 30 minutes after the consumption of food or 'tella' prepared from corn flour distributed by the Middle
Awash Agricultural Development Enterprise between July 18 and August 5, 1984, or at least one of the
following neurologic symptoms or signs within 24 hours after the consumption of the corn flour -mania,
talkativeness, restlessness, confusion, delirium, or other serious signs or symptoms such as seizures or coma.
This report of illness was clearly different from intoxication with food contaminated with pesticides, ergot
fungus, and lathyrus peas that have occurred in Ethiopia in the past (13,14).
The team of investigators immediately started its function with the following objectives:
_______________________________
*.Jimma Institute of Health Sciences, Jimma, Ethiopia
.**National Research Institute of Health, Addis Ababa, Ethiopia
1) to characterize the illness under question and possibly find the etiologic agent,
2) to recommend methods of preventing future occurrence of such illness.
CASE FINDING, MATERIAIS AND METHODS
The immediate task of the investigators was to suspend the distribution of corn flour originated from the
same source (main store of the Enterprise at Nazareth) and advise the Enterprise management to find other
sources for their regular ration supply to the labour force. The next task was to establish a committee
composed of various professions with responsibility to the local administration. The main duty of the
committee was to help trace the source of the suspected corn flour. The third task was to disseminate the
available information of the acute toxicity to the health authorities, storekeepers, bakery owners, farm
management, cereal retailers, and the labour force.
To identify the potential cases, health records were reviewed from July 17 to August 10, 1984 for all persons
who met our case definition. In addition, fifty postcases were interviewed to determine the interval between
ingestion of the suspected corn flour and onset of the illness.
To confirm the outbreak was due to eight samples of the suspected corn flour obtained from stores of the
Enterprise and labelled from F-loo to F-107. Part of the samples were to be fed to a batch of mice and to be
observed for at least 15 days. The rest of the samples were to be tested for potential toxic agents including
bacteria, fungus, yeasts, chemical residues and indigenous plants. The assay was considered positive for
toxin if the mice demonstrated restlessness within 30 minutes of feeding except that the period of observation
was extended to 15 days to determine the prolonged effect. All these were performed at the Central
Laboratory and Research Institute (now called National Research Institute of Health), Addis Ababa. Tests
were performed using thin-layer chromatography (TLC) for both identification and quantification of toxin.
Each sample was analyzed and quantified according to the methods recommended by the British
Pharamacopia (15) for known indigenous plants. Test for possible contamination with pesticides was
performed using UV spectrophotometer. Bacteriologic examination was carried out for possible pathogenic
organisms as recommended else-where by the standard methods used by the Bacteriology Division of the
Institute.
RESULTS
Source of corn consumed by patients
After thorough and arduous investigation of the source of the suspected corn, the committee came up with
the following report. The corn was cultivated by the southern Agricultural Development Corporation,
Awassa branch, and sold to the Awash Agricultural Development Corporation few months before the
outbreak. The purchased corn contained impurities such as seeds of stramonium (locally known as 'atse
faris'). The corn was stored at the central store of the Enterprise, Nazareth, from where it has to go to two
flour mills who have contactual relationship with the Enterprise. Owners of the flour mills have agreement to
sieve any impurities found in any cereal they powder. Grain stores are occasionally fumigated with malathion
by unskilled persons. The indigenous plant which was later identified as Datura stramonium, naturally grows
in the cultivation fields. Harvesting was performed with combiners mixing the plant's seeds and leaves with
the grain. The corn was sold without further processing. The committee, however, could not confirm whether
sieving was regularly performed or not at the flour mills.
Description of cases
The reviewed cases (1942) and 9 deaths from registers and charts of the health units participated in the
management of the outbreak showed that 688 patients met our case definition. The rest of the cased failed to
include any symptoms presented other than food intoxication as the diagnosis. The majority of cases were
from Amibara and Gewane farm units (538 of 688). Almost all patients complained dryness of the mouth and
throat and difficulty in wallowing (647 and 688 respectively). Eighty eight percent of the patients (609 of
688) complained blurred vision. Flushed face and dry skin were among the chief complaints (426 of 688).
Mania, talkativeness were more frequent neurologic symptoms (table 1).
Table 1. Symptoms of illness among 668 patients after consultation of the suspected corn-flour,
Sign & symptoms
Present
No. (688)
%
Dryness of mouth & throat*
647
94.04
Blurred vision with or with609
88.62
out loss of accommodation**
Difficulty in swallowing**
605
87.94
Abdominal distention/discanfort
187
26.45
Vomitting
27
3.92
Dry and flushed skin**
426
61.92
Palpitation**
495
71.95
Mania**
144
20.93
Talkativeness**
323
46.95
Restlessness**
344
50.00
Deliriun**
371
53.92
Depression**
14
2.03
Exhaustion**
19
2.96
Coma**
11
1.59
* Source: Registers & charts of 3 hospitals, 4 health centres and 5 health stations.
** Criterion for inclusion as a case.
Exhaustion, depression and coma were symptoms observed relatively in only few cases, this shows that the
illness was dose dependent as there was variation of dose among the cases. The most affected age group was
15-39 for both sexes which may be due to the domination of this age group in the labour force. The sex ratio
was 3.3:1 which again may be due to the large number of males in the work force. The average interval
between distribution of the suspected corn flour and onset of the outbreak was about 3 and a half days (table
4) whereas the average interval between consumption of the suspected flour and onset illness for the fifty
postcases was about 30 minutes (data not shown). The case fatality rate was 1.31% in the cases reviewed.
Table 2. Age & sex distribution among 688 persons affected by food contaminated with Datura stramonium,
Middle Awash, July-August, 1984.
Age in year
5
5-14
15-24
25-34
35-39
40-44
45-49
50-54
55+
Total
Male
No.
3
94
223
158
29
13
8
528
%
0.57
17.80
42.23
29.92
5.49
2.46
1.53
100
Female
No.
1
32
115
12
160
%
0.63
20.00
71.87
7.50
100
Total
No.
4
126
338
170
29
13
8
688
%
0.58
18.31
49.13
24.71
4.21
1.89
1.16
100
Among the 33 cases referred to hospitals, Addis Ababa and Metahara, the diagnosis of only 3 was known as
postintoxication hysteria (Dejazmatch Balcha Soviet Red Cross Hospital). The postmortem examination
performed at Menilik II Hospital did not indicate the etiology but asphyxia was recorded as the pathological
finding which could be due to respiratory depression.
Laboratory Studies
After observation of presence of seeds of stramonium in the suspected corn, the laboratory investigation was
geared towards identifying and analyzing the toxic content of the indigenous plant. The standard solution was
prepared from the wildly growing Datura stramonium seeds collected alongside the road near Middle Awash.
The extraction performed revealed 0.3% total alkaloids, hyoscyamine, hyoscine, and traces of atropine in 6 of
8 samples (table 3). The amount of stramonium in each sample ranged from 30 to 200 mg/kg flour which
means 0.09 to 0.06 gm alkaloid/kg flour (table 3).
Table 3. Estimated content of alkaloid in eight samples of corn-flour by place of collection during the
outbreak of acute food intoxication.
Samples
Content of
Content of
Content of
Place of store where
stramonium in alkaloid in
alkaloid in
samples were
mg/kg flour
gm/kg flour
mg/150 gm
collected
bread
F-100
200
0.60
90.00
Amibara I
F-101
150
0.45
67.50
Amibara II
F-102
50
0.15
22.50
Melka Werer I
F-103
Amibara I*
F-104
30
0.09
13.50
Mekla Werer II
F-105
100
0.30
45.00
Gewane
F-106
40
0.12
18.00
Nazareth flourmill
F-107
Dophen- Bolhaboo**
* This sample of flour was wheat in nature, purchased from Debre Zeit Flour Mill Factory and was used as
control.
**This farm unit has its won flour mill, did not share the corn-flour distributed during the outbreak. This was
also used as a control sample.
The laboratory studies for bacterial, yeast and fungal contamination revealed presence of spoilage bacteria,
mould, and yeast in 6 of 8 samples. However, the bioassay failed to indicate presence of any acute toxicity
even after feeding several batches of mice with the sample flour for 15 days. Traces of pesticide, malathion
was detected in all samples.
Estimates of total alkaloid ingested by the patients was found difficult to quantify due to lack of information
on the amount of alkaloid ingested. However, we based our estimation on rationing information given by the
torekeepers. Thus, single bread was assumed to contain about 150 gm corn flour. Taking this assumption into
consideration, the amount of alkaloid ingested per meal ranges between 13 and 90 mg per person, an
extremely high dose for human.
When extracts of stramonium at the dose of 75 mg per kg body weight was injected into mice, restlessness
was observed after l5 minutes; the mice recovered in 24 hours.
DISCUSSION
This report describes an outbreak of poisoning characterized by dryness of mucus membranes, flushed and
dry skin, blurred vision, and neurological manifestations. Severely affected patients had signs of severe
neurological manifestations-seizures, depression, and coma
.
Epidemiological and environmental investigations indicated that the illness followed the consumption of corn
cultivated near Awassa, Sidamo Region. The corn flour was found to contain Datura stramonium, an
indigenous plant that wildly grows in cereal cultivation fields. Datura stramonium is a solanaceous plant
containing alkaloids; hyoscyamine, hyoscine, and atropine, the sympatholytic compounds mainly affecting
the exocrine glands, heart, and the autonomic nervous system (1,2,6). The marked neurologic changes
observed in this outbreak were cognitive and transient except in the terminal cases.
The evidence seems to support the hypothesis that the poisoning was caused by consumption of corn flour
contaminated with stramonium seeds. Hyoscine and hyoscyamine are the only toxins found in a proportion
above the normal dose for therapeutic use of these compounds.
Another factor in favour of hyoscyamine and hyoscine as the responsible agents is the observation that
patient's signs and symptoms were compatible with their pharmacological properties. Hyoscyamine or
hyoscine (scopolamine) have similar properties of atropine. If given above clinical doses, they cause dryness
of mouth and throat, thirst, blurred vision, dry and flushed skin, disturbed speech, ataxia, restless-ness,
hallucinations, delirium, depression, and coma (1,3,4,10).
Extracts of stramonium has long been used as mydriatic drops. Finely powdered leaf of the plant has been
used in tobaccos for relief of respiratory symptoms (2,3,9). In old days, the plant was used in arrow heads by
primitive societies to poison their preys (8).
In Ethiopia, leaves of stramonium has been frequently used by priest school students who
Table 4: Pattern distribution of the suspected corn-flour and illness among 688 patients, middle Awash, July
and August, 1984
Farm unit
Date of
distribution
Qty.
Distribut
ed
No. of
persons
received
Date of
illness/ingestion
No. of
cases
Gewane
Amibara
Melka Werer
Melka Sadi*
Dophen-Bolhabo
Metahara Sugar Factory
18.7.84
1.8.84
5.8.84
7
119
179
104
7
595
895
520
7
23.7.84
4.8.84
5.8.84
19.8.84
2.8.84
207
331
16
10
124
No.
of
deat
hs
3
6
-
A.H.
6
3
24
* No official distribution was made but history of drinking home-made beer 'tella' was confirmed. Source: Distribution slis of Middle Awash store.
* Home-made bread was eaten prior to illness, patients were anKlng the labour force of the Sugar Cane Plantation & Factory. The flour was purchased from
an open market smuggled from Middle Awash Cotton Plantation. Source* Metahara Hospital.
A.H. = Admission to Hospital.
believed that when the juice of the plant is taken it makes them brilliant at their oral education, a medication
known as 'abisho' in Amharic. Users of this plant turn to be maniac after ingestion of alcohol even in a small
quantity (Bedru, 1990).
Recent occasional poisoning due to accidental ingestion of stramonium seeds or leaves especially in children
have been reported (1,4,5), how-ever, no massive outbreak similar to the one we are reporting is so far
reported.
Several authors have proved that rodents and marsupials are very tolerant to these alkaloids.In white rats,
small doses (13 mg/kg body weight) is slightly sedative and analgetic, but never hypnotic. Doses between 65
and 130 mg per kg body weight were purely excitant (5). The mechanism of tolerance has been described by
several authors long ago. The levoisomers the potent form of these alkaloids is rapidly hydrolysed by an
esterase found in sera of rabbits and rodents (3,4,5). The liver in situ in cats, rats, and rabbits rapidly
inactivates large amount of atropine, scopolamine, and hyoscya-mine. The toxicity of atropine in rats is
increased by injuring the licer with carbon tetrachloride (3,4,5). We thus assumed that the quantity of
alkaloids found in the incriminated corn flour samples was too small to show acute toxicity in the laboratory
mice. However, we suggest further investigation to confIrm this association.
It has been described elsewhere that seeds of Datura stramonium contains 0.16 to 0.5% total alkaloids
whereas the leaf contains 0.2 to 0.7% which is similar to our fInding (0.3%) (2,9).
There are several limitations to our study. As in other explosive outbreaks with important public health
implications, we chose not to undertake an analytic study to confirm our primary hypothesis -that corn flour
was the source of the illness observed. The unusual nature of the illness its explosiveness, the high number of
population at risk, and the fact that cases spread to different regions through smuggled corn flour, and that
patients shared no common exposure other than the consumption of corn flour, and the result of tests on
stramonium extracts persuaded us of this. We thus chose to undertake immediate control measures and to
investigate the mechanism by which corn flour caused the epidemic. Moreover, failure of the attending health
workers to record the presenting symptoms of most of the cases was the cause for eliminating 1254 cases
which could have most probably been true cases. The desperate conditions observed during the management
of the outbreak must have contributed to the failure. In this context, the investigation of cases could not be
completed in a rigorous fashion for all reported illnesses.
Another fact is that some of the health workers who participated in the outbreak management prior to the
arrival of the investigators administered atropine as an antidote for suspected food intoxication. This might
have further complicated the situation.
One of the most important outcomes of this study was that without epidemiological and clinical description
of an outbreak of illnesses, laboratory tests alone may not help in finding the etiology. This has been proved
by certifying the corn flour samples as negative for acute toxicity by the same laboratory we used for our
study.
In Middle Awash and regions afflicted with the outbreak, steps have been taken to prevent recurrence of
poisoning due to Datura stramonium. Tons of corn flour contaminated with this plant were dumped and
another tons of unpowdered corn mixed with the plant were advised to be sieved before powdering into flour.
Weeding away the plant from the corn cultivation field is advised. Treatment of cases with atropine as an
antidote to be discouraged, physostigmine to be used instead to reverse the to action of the alkaloids. Finally,
we suggest further laboratory study on extracts of stramonium leaves and seeds on animal models to
determine the cause of tolerance. No new outbreak of stramonium poisoning due to consumption of corn
flour have been reported in Middle Awash since August 1984.
REFERENCES
1. Oowdy, I.M. Stramonium into'.;calion: Review of symptomatology in 212 cases. JAMA. 1972; 221: 585587.
2. Trease, G.E. and W.C. Evans. Alarmacognosy, 12dt ed. English Language Book Society/Bailire Tindal.
1983.; 548-556.
3. Sollman, T. (ed.) A manual of pharmacology. 8dt ed, W.B. Sanunden Co., Ailladelphia. 1957; 394-398.
4. Eger, E.I. Atropine, Scopalamine, and related compounds. Anaslhesi010gy. 1962; 23: 365.
5. Gndeux, I., and Tonnesen. Atropine. ActQ Pharacol. el Taricol. 1949; 5: 95.
6. Oilman, A.G., et ai.(eda.) The pharmacological basia of therapeutics. 7dt ed. Macmillan Publishing
Company, New York. 1985; 131-138.
7. Thienea, C.H. and T J. Hley. Clinical Toxiology Lea & Febiger Ailladelphia. 1955; 19-22.
8. Mcnally, W.D. Toxicok>lY. Industrial Medicine. Chicago 1937; 472-482. 9. Lewis, W.H., W.P.F. Elvien
Lewla. Medical Botany. Plants affecting man's health. A Wiley-lnterscience Publication, John Wiley & Sons,
Inc. 1977; 423-425.
10. Richman, S. Adverse effect of atropine during myocardial infarction Enhancement of ischemia foUowing
interavenous administered atropine.JAMA. 1974; 228: 1414- 1416.
11. Hayea, A.H. Jr., et &1. Effects of large intramuscular doses of atropine on cardiacmythm. Clinic.
Pharmacol 11Ier. 1971; 12: 482-486.
12. Brand, J.J. and P. Whitlingham. Intramuscular hyoscine in control of motion sickness. Lancet. 1970; 2:
232-234.
13. Teshome Demeke, et &1. Ergotism- a rcport on an epidemic, 1977-78. Eth. Med. J. 1979; 17: 107-113.
14. Zewde Gebre-ab, et &1. Neurolathyriam- a review and a report of an epidemic. Eth. Med. J. 1978; 16: III.
15. British Alarmacopia, 1980 ed. 512-513.
16. Bednl Huasein. Pcraonal communication. National Research Institute of Health, Addis Ababa. 1990.
A COMPARAIVE STUDY OF THE NUTRIENT COMPOSITION
OF SOME COMMON NIGERIAN SOUPS
0.0. Keobinro*, MSc,PhD and C.O. Azuoru
1.0.
ABSTRACT: Ten common types of Nigerian soup combinations were collected and analyzed both within
urban and rural areas. They were analyzed for their nutrient contents and evaluated for their contributions to
the daily nutrient requirements. Soups are consumed about twice a day with an average consumption of
approximately 150 gms per person. The percentage contribution to the daily requirement ranges from 24.941% calories, 14.4- 28.7% protein, 39- 94.7% fat. The mineral contribution ranges from 5.6- 21.5% calcium,
9.4- 48.8% phosphorus, 30- 119.6% iron and 3.9 - 21.6% zinc. The vitamin contribution ranges from 1 -7.7%
riboflavin and 3.7 -7.6% ascorbic acid. It was also found that variations in the recipe, the preparatory
procedure and the length of cooking period have direct effect on the ultimate value of the nutrient quality.
INTRODUCTION
Soup and stew have often been perceived as identical as they are both made from a mixture of meat or fish
and vegetables. The only difference is that soups are cooked with a more intensive heat and for a shorter
period as compared with stews which are cooked under a reduced heat intensity and for a longer time. The
ingredients that make up soups/stews allover the world are influenced by many factors, ethnicity and culture,
availability of raw materials, and the economic power of the individual. For Caucasians, soups are served at
the beginning of meals in which two or more courses follow. Such soups may be clear or thick (1). This is
unlike the non-Caucasians, whose meal pattern entails just the main course and the soup serves as an
accompaniment usually eaten along with the staple.
On the whole, soups are supposed to stimulate the apetite and aid the acceptability of some other food
materials particularly the carbohydrates (2). The amount of soup served at a sitting varies from about onequarter to one-half pint (4). Except for soups that are thickened with flour or whose basic ingredient contains
appreciable amounts of carbohydrate plus fat and protein foods, the caloric value is negligible. There are
hundreds of different soups and they are classified into a few distinct groups. A few examples are broths,
clear soups, puree thickened soups, cream soups, peppery soups, etc. In Nigeria, any food cooked in oil or
water into which fish, meat and other ingredients are added is called soup, the basic ingredients and the
quantity varied according to tradition. In typical African soup, the basic ingredients that form the soup-base
are onions, tomatoes, peppers, melon seeds, cow pea, locust beans, red palm oil and a variety of vegetables.
The variety of ingredients makes the soups a very rich source of minerals and some vitamins. Hence, soups
are likely to contribute appreciably to the daily nutrient requirement of people consuming considerable
quantities and good quality soups. Oyenuga (3) showed an average consumption of vegetable soup to be
100.4 .:t. 14.24 gm per adult. A standard diet in the tropics is bulky and it is principally made up of die stable
which is high in carbohydrates but low in other major nutrients (2). These starchy staples are usually eaten
with soups. The nutrient qualities of such soups need to be examined since die supply of such nutrients from
die soup will determine die quality of die food consumed.
METHODOLOGY
A representative sample of the ten commonest soups was collected from randomly selected households
during die two major seasons of die year (i.e. wet and dry seasons), from three different localities each with
an urban and rural area in Oyo State. The rural areas represent die place of production of most food materials
and die urban areas are die major consumer. Hence, food is cheaper and within easier reach of the rural than
the urban inhabitants.
____________________________
.Dept. of Human Nutrition, College of Medicine,
University of Ibadan, Nigeria
The soup samples were collected as eaten from households at each season and were analyzed in triplicate for
their nutrient contents. Nutrients tested for included: energy value using the Gallenkamp Ballistic Bomb
Calorimeter; and total starch value which is determined as % glucose using die AOAC (5) procedure. Fat
extraction was by using ether and ethanol, while the crude protein value was by using the Kjeldhal method
estimating die nitrogen content as in AOAC (5). Similarly, the ash and mineral contents were determined by
die Lanthanum method, ascorbic acid by die titration method, and riboflavin by die fluorometric method as in
AOAC (5). A recovery test was done to evaluate the mineral content of a representative sample of each food
material for die purposes of dependency on die analytical method which is rated at between 90-96% .A
questionnaire was also designed to establish die recipe of these soups in both die rural and urban areas. These
ten soups are as follows:
Soup 1: Mixture off okra, artichoke (Ewedu) and melon seed soup. (Hibiscus esculentus linn, Cochorus
Olintorus linn and Citrullus wlgaris schard).
Soup 2: Cow pea soup (Gbegiri). (Vignaunguiculata subsp). .
Soup 3: Okra soup. (Hibiscusesculentus linn).
Soup 4: Okara with melon seed soup. (Hibiscus esculentus linn with citrullus vulgaris schrad).
Soup 5: Green leaf vegetable soup. (Celosia agentia linn).
Soup 6: W~-leaf (Gbure) with melon seed soup. (falinum triangulare wild with Citrullus Vulgaris Schrad).
Soup 7: Artichoke (Ew~u) soup. (Cochorus olintorus linn).
Soup 8: Okra with artichoke soup. (Hibiscus esculentus linn with Cochorus olitorus linn).
Soup 9: Artichoke with melon seed soup. (Cochorus olintorus linn with citrullus vulgaris schrad).
Soup 10: Plain melon seed. (Citrullus vulgaris schrad).
RESULTS
The recipes of the basic food materials of the soup from the different areas were similar although the quantity
of ingredients differ, resulting in the rural soups have a higher fat content while the urban soups having a
higher protein content.
The Nutrient Content of Rural Soups
In Table 1, the moisture content of rural soup ranged from 68.2-90%, in cowpea soup (unguiculata) and pure
artichoke soup (Corchorus Qti1Qw), respectively. Bean soup is the highest in energy content with 787 kilo
calories/l00 gm. This is the result of the fat used in making the soup plus the high fat content of beans. The
fat contents are, therefore, influence by the recipe. The crude protein is also determined by the quantity and
quality of the ingredients used in the individual soup. Soups with melon seed, which is a rich vegetable
protein source, have high crude protein content. Soup 9 has the highest with 20.93%.
Vitamins
The only two vitamins determined were vitamin B2 (riboflavin) and vitamin C (ascorbic acid). All the soups
were poor sources of these vitamins. Despite the abundance of vitamin C in fresh vegetable (1,3), the
preparatory procedure of these soups account~ for the low content of these vitamins, (table 1). The highest
riboflavin level was found in Soup 2 (plain bean soup) with 0.17 mg /l00 gm. The highest recorded level of
ascorbic acid is 3.9 mg 1100 gm in artichoke soup (Soup 7).
With an average daily consumption of soup being about 150 gm, Table 2 shows the mean nutrient content of
the mixture of soups from urban and rural dwellers. The caloric contribution to the daily recommendation
ranged from24.9% to 41.0%, while the protein contribution ranged from 14.4% to 28.7%, and the fat
contribution ranged from 39.0% to 94.7%.
The mineral contribution to the daily recommendation ranged from 9.4%-48.8% for calcium, phosphorus
ranged from 30.0%-119.6%, and iron contributed from 1.0%-7.7%.
The vitamin contribution to daily recommendation ranged from 3.7%-7.6% for ascorbic acid and 1.0%-7.7%
for riboflavin.
Minerals
Calcium, phosphorus, iron, zinc and cooper were the minerals evaluated. Calcium was the highest in Soup 5
(spinach variety soup) with 95gm. Phosphorus, zinc and iron were the highest in Soup 10 (plain melon seed)
with 454.26mgll00 gm, 1.90 mg/l00 gm and 6.2 mg/l00gm, respectively.
Urban Soup Nutrient Content
In Table 2, the moisture content of urban soups ranged from 66.6% in Soup 10 (plain melon seed) to 92% in
Soup 3 (okra soup). The energy value ranged from 357 kcal in Soup 3 (okra soup) to 871 kcal in the melon
seed soup. The crude protein was the highest in Soup 1(okra and artichoke and melon soup)
with20.3Ig1100gm and the fat content is highest in Soup 10 (plain melon seed) with 62g1100gm. The
carbohydrate content ranged from 0.23gm in Soup 1 to 9.3gmll00gm in Soup 8 (okra/ artichoke soup).
Mineral Content
Calcium was the highest in Soups 1 and 5 with 135mg/100gm. The phosphorus content was the highest in
water-leaf soup (Soup 6) with 294.8 mg/100gm. Iron was the highest in the okra/artichoke soup (Soup 8)
with 20.8mg/- 100gm. Zinc value was the highest in soup 10 with 1.18mg/100 gm, (table 2)
DISCUSSION
From the questionnaire, it was observed that there are variations in the recipe (i.e., the quantity of the
ingredients) and even innovations in preparing these soups, especially in the urban areas. Comparing the
soups themselves, some are richer in some nutrients than others. On the whole, all soups containing melon
seed and artichokes are found to be rich in all nutrients analyzed. The low values in the others can in part be
attributed to the method of preparation, or length of cooking period, or the type of heat treatment and cooking
utensils. Other reasons that can be considered are the quantity of the ingredients, the volume of water used
during cooking and probably the chemical reactions between reducing sugars and amino acids when foods
are cooked.
The moisture content of the soups from both the rural and urban areas showed very little difference. This can
be attributed to the cultural patterns of accepted thickness of soup within the community.
However, it may be difficult to change the preparatory methods and the quantity of soup consumed so as to
reflect an appreciable nutrient increase. Also incorporating many ingredients into the recipe of the soups will
further increase the nutrient quantity of the soups. The addition of melon seeds into nearly all the soups
should be encouraged. This will be beneficial to the young children, especially during weaning.
Table 1. Nutrient composition of soups from osegere village (rural)
Nutrient
Moisture %
Ash %
Energy kcal %
Carbohydrate gm%
Fat gm %
Crude protein gm %
Calcium mg/100 gm
Phosphorum mg/100
gm
Iron mg/100 mg
Zinc mg/100 gm
Copper mg/100gm
Ribflavin mg/100gm
Ascrobic acid mg/100
gm
Amount consumed/head
Soup 1
88.2
+ 9.1
6.0
+ 0.4
719.4
+ 31.9
1.16
+0.0
36.00
+1.0
8.04
+0.9
90.00
+5.1
97.02
+7.3
0.60
+0.0
0.40
+0.0
0
+0
0.40
+0
1.63
+0
161.59
Soup 2
68.2
+6.6
1.0
+0.0
787.40
+16.2
4.30
+0.1
46.33
+0.9
8.9
+0.9
17.80
+2.0
82.00
+5.4
0.40
+0.0
0.26
+0.0
0
+0
0.089
+0
1.18
+0
130.37
Soup 3
87.8
+10.8
5.0
+0.6
605.12
+21.3
4.88
+0.0
37.50
+1.7
9.06
+1.0
23.00
+0.9
39.94
+0.9
1.20
+0.0
0.50
+0.0
0
+0
0.052
+0
2.54
+0
149.66
Soup 4
82.2
+5.8
5.0
+0.3
766.32
+40.0
5.58
+0.1
45.00
+1.7
12.62
+0.8
60.00
+2.2
144.06
+11.9
2.40
+0.0
1.02
+0.0
0
+0
0.385
+0
2.99
+0
160.46
Soup 5
73.0
+7.3
2.0
+0.0
911.40
+51.2
2.91
+0.0
63.20
+5.2
8.90
+1.1
95.00
+2.7
70.76
+5.7
2.00
+0.0
0.42
+0.0
0
+0
0.010
+0
3.45
+0
120.98
Soup 6
77.0
+9.1
7.0
+0.7
834.52
+23.7
1.74
+0.0
53.67
+4.9
14.18
+1.9
45.00
+1.3
237.18
+41.7
1.20
+0.0
0.76
+0.0
0.10
+0
0.109
+0
3.17
+0
103.50
Soup 7
89.4
+11.1
8.0
+1.0
617.52
+18.7
9.54
+0.3
36.50
+2.8
15.28
+1.0
60.00
+2.0
60.98
+3.9
17.00
+1.2
0.50
+0.0
0
+0
0.077
+0
3.45
+0
188.17
Soup 8
90.0
+5.0
9.0
+1.1
620.00
+23.5
3.49
+0.0
20.50
+1.8
12.68
+0.9
60.00
+2.1
113.64
+7.5
1.20
+0.0
0.28
+0.0
0
+0
0.049
+0
2.99
+0
217.37
Soup 9
85.8
+3.3
5.0
+0.0
781.20
+19.4
3.26
+0.0
46.50
+3.6
20.93
+1.9
75.00
+3.1
180.90
+10.1
1.00
+0.0
0.58
+0.0
0
+0
0.0388
+0
1.63
+0
160.78
Soup 10
68.6
+5.2
6.0
+0.2
828.32
+27.3
2.33
+0.0
57.60
+4.4
15.62
+1.7
45.00
+2.6
454.26
+50.5
6.20
+0.0
1.90
+0.0
0.26
+0
0.040
+0
1.18
+0
63.68
Table 2. Nutrient composition of soups from Osegere village (rural)
Nutrient
Moisture %
Ash %
Energy kcal %
Carbohydrate gm%
Crude protein gm %
Fat gm %
Calcium mg/100 gm
Phosphorum mg/100
gm
Iron mg/100 mg
Zinc mg/100 gm
Copper mg/100gm
Ribflavin mg/100gm
Ascrobic acid mg/100
gm
Amount consumed/head
Soup 1
85.6
+4.1
3.5
+0.0
613.80
+19.0
0.23
+0.0
20.31
+2.1
30.67
+3.1
135.00
+10.2
216.06
+11.0
1.0
+0
0.32
+0
0
+0
0.071
+0
2.09
+0
127.24
Soup 2
74.0
+4.7
2.0
+0.0
679.52
+26.3
4.77
+0.7
16.56
+2.0
33.00
+2.7
85.00
+5.8
122.62+
12.2
2.00
+0
0.38
+0
0
+0
0.166
+0
1.18
+0
106.00
Soup 3
92.0
+3.3
5.5
+0.2
357.12
+11.9
5.23
+1.0
8.50
+0.9
21.00
+1.3
25.80
+1.3
113.24
+9.8
3.20
+0
0.38
+0
0
+0
0.090
+0
2.09
+0
112.02
Soup 4
87.8
+5.8
2.5
+0.0
558.0
+41.3
3.72
+0.0
15.31
+1.9
33.67
+4.6
115.00
+9.2
147.4
+10.3
9.80
+0
0.56
+0
0
+0
0.046
+0
2.54
+0
115.59
Soup 5
74.0
+4.4
5.0
0+.2
716.72
+50.1
3.49
+0.0
9.09
+1.7
56.33
+9.9
135.00
+9.9
91.12
+7.1
5.2
+0
0.54
+0
0
+0
0.022
+0
2.72
+0
119.54
Soup 6
75.2
+3.9
3.0
+0.0
750.20
+28.7
1.15
+0.0
19.53
+3.6
48.00
+4.0
115.00
+7.3
294.80
+22.8
2.00
+0
0.68
+0
0
+0
0.054
+0
2.27
+0
108.37
Soup 7
86.2
+4.9
5.5
+0.9
791.12
+30.3
6.05
+0.2
13.04
+1.1
53.00
+4.3
22.0
+1.1
37.52
+3.1
7.80
+0
0.48
+0
0
+0
0.082
+0
3.90
+0
114.17
Soup 8
90.8
+5.1
13.0
+1.2
536.92
+11.7
9.30
+1.0
10.00
+1.0
23.67
+1.3
22.80
+2.1
46.24
+2.9
20.80
+0
0.52
+0
0.16
+0
0.063
+0
2.54
+0
109.15
Soup 9
80.0
+4.4
3.5
+0.0
722.92
+30.8
2.91
+1.9
17.57
+1.9
45.67
+4.6
95.00
+6.3
237.86
+13.8
3.20
+0
0.68
+0
0
+0
0.065
+0
1.81
+0
125.33
Soup 10
66.6
+3.8
2.5
+0.0
871.72
+41.1
2.33
+1.7
13.62
+1.7
62.00
+5.5
17.80
+1.1
159.46
+8.9
10.40
+0
1.18
+0.2
0
+0
0.060
+0
2.09
+0
127.85
Table 3. Mean nutrient content of soups according to a daily consumption of approximately 150 gm/day
Soup
No.
1
2
3
4
5
6
7
8
9
10
Caloric
Protein (gm)
Fat (gm)
Calcium (gm)
850+20
874+ 33
672+19
819+29
1064+34
981+28
844+30
744+15
942+33
1106+32
18.4+1.1
17.4+1.0
10.8+0.8
18.5+1.1
11.1+0.6
19.9+1.0
16.3+0.9
15.0+0.8
21.5+1.2
19.2+1.1
45.3+3.7
42.8+4.0
44.6+3.2
44.5+3.0
77.7+6.1
61.1+5.0
56.3+4.1
31.2+3.0
55.9+4.0
75.8+6.0
172.3+10.0
48.2+5.5
25.7+3.1
112.1+6.6
104.9+5.8
89.3+4.0
61.1+6.0
73.8+5.2
114.2+6.8
44.8+3.0
Phosphorus
(gm)
230.3+10.0
125.5+9.0
75.3+5.1
164.7+10.1
90.0+7.2
271.9+10.3
83.2+5.8
118.4+9.9
242.1+10.2
390.7+12.1
Iron (gm)
3.0+0.1
4.3+0.0
3.1+0.0
7.2+0.9
6.0+0.9
5.8+0.7
13.0+1.0
12.0+1.1
10.2+0.9
8.4+0.8
Zinc
(gm)
0.6+0.0
0.7+0.0
0.8+0.0
1.0+0.2
0.7+0.0
1.1+0.1
0.7+0.0
0.6+0.0
1.3+0.1
1.9+0.0
Riboflavin
(gm)
0.07+0.00
0.12+0.01
0.10+0.01
0.21+0.01
0.02+0.00
0.09+0.00
0.10+0.00
0.07+0.00
0.61+0.00
0.06+0.00
Ascrobic
Acid (gm)
2.2+0.1
2.2+0.0
3.4+0.1
3.7+0.0
4. +60.1
3.1+0.0
4.9+0.5
3.4+0.1
2.7+0.0
2.4+0.0
Table 4. % nutrient contribution to the daily requirement with the consumption of 150 gm of ten common
soups.
Type of
soup
1
2
3
4
5
6
7
8
9
10
Caloric
Caloric
value
value
800
874
672
819
1064
981
844
744
942
1106
Fato (gm)
Crude Protein
RDA*
% of RDA
Met
Crude Protein
value
RDA*
% of RDA
Met
Fate
value
RDA*
%of RDA
Met
2700
2700
2700
2700
2700
2700
2700
2700
2700
2700
31.5
32.3
24.9
30.3
39.4
36.4
31.2
27.6
34.9
41.0
18.4
17.4
10.8
18.5
11.1
19.9
16.3
15.0
21.5
19.2
75
75
75
75
75
75
75
75
75
75
24.5
23.2
14.4
24.6
14.8
26.8
21.7
20.2
28.7
25.6
45.3
42.8
44.6
44.5
77.7
61.1
56.3
31.2
55.9
75.8
80
80
80
80
80
80
80
80
80
80
56.5
53.5
55.8
55.6
97.2
76.3
70.3
39.0
70.0
94.7
* Source: USA, NRC (1980) (6) oSource: USA, NRC (1980) (7)
Table 5. % mineral contribution to the daily requirement with the consumption of 150 mg of ten common
soups.
Soup
No.
Calcium (mg)
1
2
3
4
5
6
7
8
9
10
Phosphorus (mg)
Iron (mg)
Zinc (mg)
Calcium
Value
RDA*
% Met
Phosphorus
value
RDA*
% of RDA
Met
Iron
value
RDA*
%of
RDA
met
Zinc
value
RDA*
% of
RDA
Met
172.3
48.2
25.7
112.1
104.9
89.3
61.1
73.8
114.2
44.8
800
800
800
800
800
800
800
800
800
800
21.5
6.0
3.2
14.0
13.1
11.2
7.6
9.2
14.3
5.6
230.3
125.5
75.3
164.7
90.0
271.9
83.2
118.4
242.1
310.7
800
800
800
800
800
800
800
800
800
800
28.8
15.7
9.4
20.6
11.3
34.0
10.4
14.8
30.3
48.8
3.0
4.3
3.1
7.2
6.0
5.8
13.0
12.0
10.2
8.5
10
10
10
10
10
10
10
10
10
10
30.0
43.2
30.8
72.3
59.8
58.2
130.4
119.6
102.2
87.7
0.6
0.7
0.8
1.0
0.7
1.1
0.7
0.6
1.3
1.9
15
15
15
15
15
15
15
15
15
15
3.9
4.3
5.2
6.6
4.7
7.4
5.0
4.1
8.7
21.6
*Source: USA NRC (1980) (6)
Table 6. % vitamin contribution to the daily requirement with the consumption of 150 gm of ten common
soups
Soup
No.
1
12
3
4
5
6
7
8
9
10
Riboflavin (mg)
Ascrobic Acid (mg)
Riboflavin value
RDA*
%Met
0.07
0.12
0.10
0.21
0.02
0.09
0.10
0.07
0.61
0.06
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
4.5
7.7
6.1
13.3
1.0
5.4
5.9
4.5
3.8
3.5
Ascrobic Acid
vcalue
2.2
2.2
3.4
3.7
4.6
3.1
4.9
3.4
2.7
2.4
RDA*
%Met
60
60
60
60
60
60
60
60
60
60
3.7
3.7
5.6
6.2
7.6
5.2
8.1
5.7
4.4
4.0
*Source: USA NRC (1980) (6)
REFERENCES
1. Kesbinro, 0.0. The effect of cookin2 on ascrobic acid content of some Nigerian food stuffs and their
contribution to vitamin C status of consumers. A Ph.D. Thesis, Department of Human Nutrition,
University of Ibadan. 1980,
2. Omo1o1u, A. "Food famine and Health. Inaugural lecture 1973/74 session. University of Ibadan Press.
1974.
3. Oyenuga, V .A. Nigeria's food and feeding stuffs University of Ibadan Pre... 1968.
4. Oke, O.L. Ascotilic acid content of some Nigerian food stuffs. West African Phamac 1966; 8 (5): 92.
5. A.O.A.C. Official method of analysis of the Association of Official Agricultural Chemist. (1955) and
the Association of Official Analytical Chemists (1970). 1970.
6. Food and Nutrition Board RDA Publication No.1146, Notional Academy of Sciences, National
Reseorch Council.U.S.A. (1964).
7. --Revised (1980).
THE NOMINAL GROUP PROCESS IN THE IDENTIFICATION OF
THE HEALTH INTEREST OF ETHIOPIAN SECONDARY
SCHOOL STUDENTS
Zein Ahmed Zein*, BSc, MPH, Dr. Med.
ABSTRACT: The health interest of 114 Ethiopian students and 28 teachers in a secondary school in an
Ethiopian town was studied by nominal group process. Accordingly, the leading topics of interest to the
students were mental health, endemic infectious diseases, sexually transmitted diseases, skin diseases and
cancer. Contrary to their pupils, teachers ranked liver diseases and endemic infectious diseases as their
priority of health interest, but ranked mental health lowest. Gender differences in the choice of health
topics were apparent among the students. To a certain extent, the health concerns of the students reflect
the health problems prevalent in their community. As a technique, the study confirms the utility of the
nominal group process institutions where simple and rapid methods of identification of health interest are
sought.
INTRODUCTION
In Ethiopia, over 4 million students are enroled in primary and secondary schools (1). Health education is
not taught as a separate subject, but is integrated in the basic sciences curriculum, as is the case in several
countries (2,3). Local health care institutions are expected to conduct school health education
programmes, but health workers often have difficulties in deciding relevant topics for health instruction.
The aim of this survey is to report on a method of identifying the health interest of the students in a
situation
where
health
education
curriculum
is
absent
or
obsolete.
MATERIALS AND METHODS
The survey setting is the community of Addis Zemen, a roadside town of 8, 741 people (1) in the Gondar
region of northwestern Ethiopia. Because of the existence of a health center in the town, the Department
of Community Health of the Gondar College of Medical Sciences has been running public health
programmes in Addis Zemen as part of the undergraduate training of physicians in community health. In
November 1986, a team of senior medical students conducted the survey in the secondary school (grades
9-12). Five of the thirteen sections (average section size = 22 students) with an age range 5-18 years were
selected by means of a simple random sampling. A total of 114 students and all teachers (28) were
included in the study.
The study technique used in identifying health interest and educational needs is the Nominal Group
Process originally developed in the 1960's by NASA in the USA (5). The modification of the original
technique to suit school health education situations in Brazil by Candeias and Marcondes (6) is adopted
in this study because of its simplicity relative to the original techniques.
Accordingly, the students were requested to generate, in silence, two questions on their health interests
and to write them on a card designed and provided for the purpose. After ten minutes, the questions were
written on a blackboard and during the next half an hour they reviewed, clarified or proposed any items.
Each student then voted on five items he/she considered most important according to his/her interest.
He/she entered the votes according to priority in the space provided on the survey card. These were
further tabulated by class and sex, and the summation of points was obtained. The latter were converted
into ranks. The same procedure was repeated for teachers.
____________________________
Dept. of Community health, Gondar College of Medical
Science college, Gondar, Ethiopia
RESULT
Table 1 shows comparison of the fist five-health interests of students and their teachers. The five health
interest preferences of students according to their order of ranking were epilepsy and fainting, endemic
infectious diseases,
Table 1. Comparison of the first five health interest of students and teachers.
Health interest preferences
9
1
2
3
4
5
-
Epilepsy & fainting
Endemic infectious diseases
STDs
Skin diseases
Cancer
Asthma
Nervous tension
Tuberculosis
Heart diseases
Liver diseases
10
2
3
1
4
5
-
11
1
3
2
5
4
-
Rank order
Grades
12
1
4
5
2
3
-
Teachers
5
2
3
-
sexually transmitted diseases (STDs), skin diseases and cancer. In contrast to students the leading health
interest topics of teachers were liver diseases and infectious diseases (malaria, typhus, dysentery, etc.),
but teachers ranked epilepsy lowest. Table 2 indicates that concern for mental health was reported more
frequently by girls than boys. With regard to endemic infectious diseases and sexually transmitted
diseases, their ranks were unaltered when data was analyzed by gender indicating concern for these
health problems by both students and their teachers. The analysis of data by gender had also provided
further categories of health interests, namely, gastritis, eye diseases, diabetes and haemorrhoids.
Table 2. Comparison of the first five health interests of students and teachers by sex.
Health interest
preferences
Rank Order
9
Epilepsy & fainting
Endemic infectious
diseases
STDs
Skin diseases
Asthma
Nervous tension
Tuberculosis
Heart diseases
Gastritis
Eye diseases
Diabetes
Haemorrhoide
M
1
1
F
3
4
M
1
2
10
F
5
3
2
5
4
-
2
3
5
-
4
1
3
-
4
2
5
5
M
4
3
Grade/Sex
11
F
4
3
M
2
-
F
1
-
M
5
3
Teachers
F
5
5
2
1
5
2
3
1
5
2
3
5
4
-
2
1
3
-
2
4
2
3
5
-
4
-
12
DISCUSSION
The Nominal Group Process has been quite acceptable to students and their teachers. However, we had to
contend with several indigenous and descriptive terms for some of the health interest items and their
medical equivalents. The health interest items identified in this survey to a certain extent correspond to
health problems observed in the community of Addis Zemen. For instance, in a study on the perceived
morbidity of the inhabitants of Addis Zemen during a four-week recall period Zein etal (7) identified eye
diseases and sexually transmitted diseases as the top-ten leading causes of morbidity in that community.
Furthermore, these authors found congruence between morbidity rates as detected by the interview
method and clinical diagnoses by health center staff. This confirmed the findings of Luttywama (2) and .
Shamma & Lorfing (3) in which Ugandan and Lebanese school children not only asked questions that
reflected the health problems prevalent in their respective communities, but also ranked health interests
similar to their British counter-parts.
While the pattern of ranking of infectious diseases by school children as first or second priority health
interest item has been reported in both developed and developing countries, unlike Addis Zemen school
children, mental health is ranked lowest (2,3). The reason for ranking mental health by Ethiopian school
children, particularly by girls is not apparent. The prevalence of epilepsy in the Ethiopian population is 5
and 8 per thousand in urban and rural communities respectively and constitutes an important medical and
social problem in Ethiopia (8).
It is interesting to note that such popular topics as cigarette smoking, human sexuality, drug and alcohol
abuse which are frequently cited by school children in the countries are not mentioned in Addis Zemen.
Also, as this survey antedates the extensive world-wide media campaigns against AIDS, Addis Zemen
children nor their teachers could not possibly have mentioned those new diseases.
The difference between teachers and children in ranking health concerns is probably due to differences in
age as well as cultural back-grounds. In Ethiopia, teachers are recruited and assigned to schools by the
central government, and do not necessarily teach in the regions from which they originate.
The observation (5) that the nominal group process (individual silent effort in a group setting) facilitates
the generation of a large number of relevant dimensions than conventional interacting groups
(spontaneous group discussion) is also borne out in this study.
As well as enabling the health team to decide on relevant topics for school health education, there was
also a sudden interest in health matters in the school in Addis Zemen.
ACKNOWLEDGEMENTS
I am indebted to Drs. Abraham Assefa and Stuart Gillesepe for their assistance in the conducting of the
survey. The assistance of the secondary school administration in Addis Zemen, the health center team and
members of the Department of Community Health is appreciated.
REFERENCES
I. Ethiopia: Central Statistical Office. Population and Housing Census Preliminary Report. Addis Ababa.
Central Statistical Office. 1984.
2. Luttywama, J.S. A guide to predicting the health interests of school children. Int.J. Hlth. Educ. 1967;
14: 90-99.
3. Shamma, A.C. & I.M. Lorfing. A survey on health interest among Beirut school children. Int. J.. Hlth.
Educ. 1973; 16: 167-174.
4. Ethiopia: Central Statistical Office. Ethiopia: Abstract. Addis Ababa, Central Statistical Office. 1986.
5. Van de Ven, A.H. & A.L. Delbecq. The Nominal Group as a Research Instrument for Exploratory
Health Studies. Am. I. Publ. Hllh. 1972.
6. Candeias, N.M.F. & R.S. Marcondes. Identifying educational needs of school children in a secondary
school in Sao Paulo. lm. I. Hlth. Educ. 1980; 23: 42-48.
7. Zein Ahmed Zein, et .1. The prevalence of perceived morbidity in Addis Zemen town, north-western
Ethiopia. 1987.
8. Redda T.Haimanot. The pattern of epilepsy in Ethiopia. Eth. Med. I. 1984; 22: 113-118.
ERRATA'
E J H D. Vol.5, No.1 June 1991:
-Table of Content and P43: Melake Berhan Demena
should be read Melake Oemena.
-Editorial: Dr. Melake Berhan Oemena Should be
read Or. Melake Berhan Oagne.
SUPPLEMENT
WORKSHOP ON
HEALTH ASPECTS OF REPATRIATION IN ETHIOPIA
Organized by
The Ethiopian Public Health Association
Addis Ababa, Ethiopia
March 5, 1992
The Ethiopian Public Health Association
Executive Members
1. Tewabech Bishaw................. Chairperson
2. Haile Selassie Tesfaye.......... Secretary
3. Seyoum Taticheff................... Members affairs
4. Hailegnaw Eshete................... Research/Publications coordinator
5. Derege Kebede .......................
"
"
"
6. Ali Beyene ............................. Business Officer
7. Hanna Neka Tibeb................. Treasurer
Organizing Committee
1. Hailegnaw Eshete.................... National Research Institute of Health
2. Derege Kebede ........................Dept. of Community Health, Faculty of Medicine
3. Joyce Pickering .......................McGill-Ethiopia Community Health Project
4. Ali Beyene ...............................Ministry of Health
WORKSHOP ON
HEALTH ASPECTS OF REPATRIATION IN ETHIOPIA
Programme
Date: Thursday March 15, 1992
Venue: Ethiopian Red Cross Training Center
8:00
Registration
Workshop program review
8:30
8:40
Ato Hailegnaw Eshete
Chair, Workshop Organizing Committee
Welcoming remarks
Dr. Haile Selassie Tesfaye
A/Chairperson, Ethiopian Public Health
Association
Opening address
Dr. Adanetch Kidane Mariam
Ministry of Health
Session 1: Health aspects of repatriation of ex-soldiers
Speaker: Dr. Getachew Gizaw, Ethiopian Red Cross Society
Chairperson:, Prof. Jemal Abdulkadir
Rapporteur: Dr. Shabbir Ismael
10:10
10:40
Break
Session 2: Health aspects of repatriation of Ethiopian & non-Ethiopian refugees
Speaker: Dr. Ephraim Assefa, Administration for Refugee-returnee Affairs
Chairperson: Dr. Charles Larson
Rapporteur: Dr. Mesfin Kahssay
12:10
LUNCH
1:40
Session 3: Health aspects of repatriation of displaced civilian populations
Speaker: Dr. Tamirat Retta, Relief & Rehabilitation Commission
Chairperson: Dr. Hailu Kefenie
Rapporteur: Dr. Yemane Berhan
3:10
Break
3:40
Concluding remarks
Dr. Joyce Pickering
Dr. Haile Selassie Tesfaye
WORKSHOP PROGRAMME REVIEW
Hailegnaw Eahete*,BSc,MS,MPH
-Your Excellency Dr. Adanetch Kidane Mariam, Minister of Health,
-Your Excellencies Higher Ranking Authorities of the Transitional Government of Ethiopia,
-Distinguished guests from governmental and non-governmental organizations,
-Dear EPHA members,
-Ladies and gentlemen.
On behalf of the organizing committee, I am honored first of all to welcome you all to our workshop
discussion on an important and timely issue of the health aspects of repatriation in Ethiopia.
As stated in the constitution of the Ethiopian Public Health Association (EPHA), one of the major
responsibilities of the secretariat for enhancing the profession is to organize forums where its members
discuss relevant topics and forward feasible and beneficial recommendations to the government for the
necessary actions.
To this effect the EPHA had actively been involved in the past in coordinating the first and second annual
scientific conferences and similarly the necessary preparatory work is under way for the third annual
scientific conference to be held in August 1992.
In addition to the scientific conferences, our association has for the first time (in collaboration with the
Department of Community Health (DCH), Faculty of Medicine, Addis Ababa University) organized a
continuing education program to be held on March 6, 1992, on Health Research Methods. It is hopped
that a great deal of knowledge and beneficial experiences will be obtained from the Programme.
With the aim of expanding study and research, these and other activities of the association are conducted
with the help of concerned government and public organizations. We are privileged indeed to organize
the present workshop, with assistance from the McGill-Ethiopia Community Health Project, on a very
important topic, which I think may concern not only health professionals but a number of governmental
and non-governmental organizations. Prior to selecting this topic a number of other areas were suggested
for consideration and were discussed by the executive committee of the EPHA.
However, considering the living conditions and standard of living of the vast majority of the Ethiopian
population and the ongoing transmigration process throughout the country, the executive committee of
EPHA felt "health aspects of repatriation in Ethiopia" would be an appropriate topic to address and
perhaps would become an increasingly important issue even in the future. This is because population
movement and transmigration, in general, have been observed to affect the Epidemiology of many
diseases. A number of studies, particularly on the impact of human population, the transmission of
tropical diseases, dynamics of socio-economic and environmental conditions and there distribution
patterns of diseases in transmigration population (along with the problems of drug resistances) have been
well documented.
Finally, the Organizing Committee expresses its gratefulness to the McGill-Ethiopia Community Health
Project for its financial and technical assistance, which enables us to run this workshop smoothly and
efficiently. The active participation of the Department of Community Health in providing the workshop
with secretarial assistance and office facilities have also been appreciated.
May I, on behalf of the EPHA, thank the chairperson, the speakers, rapporteur and invited guests for
accepting our invitations without hesitation to participate in these deliberations.
Thank you very much.
______________
*National Research Institute of Health, Addis, Ababa, Ethiopia.
WELCOMING REMARKS
Haile Selassie Tesfaye*8Sc.MSc,A1D
-Your Excellency Dr. Adanetch Kidane Mariam, Minister of Health
-Dear EPHA members and invited guests, Ladies and gentlemen.
It has been among the duties and responsibilities of the Executive Committee of the Ethiopian Public
Health Association to organize forums for discussions on various issues of public health through
conferences, seminars, distribution of publications, newsletters and workshops. Today's workshop on
"Health Aspects of Repatriation in Ethiopia" is, there- fore, the first of its kind for EPHA. The objective
of this workshop, organized by the EPHA in collaboration with the Department of Community Health
and the McGill-Ethiopia Community Health Project, is to exchange experiences on health aspects of
repatriation in Ethiopia among those institutions and individuals involved in the process. From this
workshop, I hope, appropriate and feasible recommendations will be forwarded to the Ministry of Health.
I would like to thank, on behalf of the Association, the Department of Community Health and the
McGill-Ethiopia Community Health Project for their technical and financial assistance, respectively.
I would also like to thank the Coordinating Committee for its continuous effort in maintaining and
promoting the research activities of the Association.
May I now call upon your Excellency Dr. Adanetch Kidane Mariam, to open this workshop, please.
Thank you.
______________________
National Research Institute of Health, Addis Ababa, Ethiopia
HEALTH ASPECTS OF REPATRIATION OF EX-SOLDIERS
Getachew Gizaw*, BSc, PhD
1. INTRODUCTION
In May 1991 the Ethiopian People's Revolutionary Democratic Front (EPRDF) forces defeated the
military force of the previous government. These defeated soldiers were found scattered allover the
country with a higher concentration in the northern part, mainly in the regions of Eritrea, Tigrai, Gondar,
Gojam and Wollo. The scenario of the situation just after the war was that the vanquished soldiers were
left stranded in different areas; some on the move to the nearest towns on foot in large groups, and others
confined to certain areas under captivity. It is to these military forces of the previous government that the
reference is made as ex-soldiers.
In June 1991, the International Committee of the Red Cross Society (ICRC) and the Ethiopian Red Cross
Society (ERCS) engaged themselves in the repatriation process of the ex-soldiers. With the permission
and assistance of the EPRDF, the work of repatriation started in June 1991. In the repatriation, the staffs
of the Ministry of Health, ERCS and ICRC were involved actively, while the involvement of the Red
Cross youth volunteers is also worth mentioning. By December 231991, a total of 222,373 ex-service
men had been repatriated by the joint operations (Annex).
2. POPULATION MOVEMENT AND ITS IMPACT ON HEALTH
The patterns of population movement have been identified as one of the important social factors affecting
both the transmission and control of tropical diseases(7,9). The relationship between migration and health
outcomes has been studied by many researchers (9).
It is useful to note that population movement can also lead to changes in the biological factors affecting
the transmission of tropical diseases; by increasing the exposure of population, to vectors, by importing
new effective vectors into a new area, and by expanding the vector breeding sites (5,11).
The demographic and individual characteristics, and the environmental characteristics of the place of
origin and destination should be noted in the population movement. Such information should be derived
from the migrant population and places prior to the operation and be seriously considered in the planning
phase (7,8).
Population movements can be internal and external (across borders of countries). In both types, the
movement can be from rural to urban areas or vice versa. In the developing countries, the patterns of
migration, which have impact on the transmission, and control of infectious diseases include movements
in relation to economic development activities, social unrest, seasonal farming activities, etc. In affluent
countries, international exchanges by means of travel for business and tourism are becoming important
epidemiological factors in the spread of diseases. Such variations of population movements and the
differential impact on the transmission and control of diseases have been recorded by different
researchers (2,6).
Population movements have been linked with an increase in the incidence of specific tropical diseases
such as malaria, schistosomiasis, filariasis, trypanosomiasis, etc. According to PAHO, the geographical
spread of malaria in the Americas has significantly increased within the last 20 years (1,4,9).
_____________________
*Ethiopian Red Cross Society, Addis Ababa, Ethiopia
The same facts have also been noted by Beltran and Sawyer in 1981 in Mexico and the Amazon regions
(1).
In relation to population movement the data of epidemiological significance include: -Demographic information including population density;
-Group behaviour (water contact and excretion habits);
-Type and pattern of movement;
-The types of incidence and prevalence of infectious diseases in the place of origin and destination;
-The sanitation of the micro environment (transit centers);
-Water supply;
-The nutritional status of the migrants;
-The health status of the migrants;
-The mode of transportation;
-The duration of stay in the movement process;
-The socio-economic characteristics of the migrant population.
Migrants can influence the transmission of infectious diseases either by being active transmitters (in a
new host setting) or by being passive acquirers, i.e., contracting the disease in the course of movement or
at a place of destination or both (10).
In the control of infectious diseases during a situation of outbreaks or epidemic, the identification of the
focus or foci of the transmission is an important aspect for the control process.
However, if the mobility of the population is higher then the non-focal pattern of transmission can occur
and this can create problems in the control effort (9).
3. REPATRIATION OF THE EX-SOLDIERS
3.1. General
The repatriation work was an ERCS/ICRC joint operation and was started in June 1991. The interim
period between the end of the war and the beginning of the repatriation operation was very short. Thus,
the planning and resource mobilization for the operation were completed within the available time frame.
The initial planning envisaged a relatively short operation period for the repatriation, but experiences
proved the need for a longer operation.
The population movement in relation to the ex-service men had internal and international aspects. The
internal movements focused on repatriating the groups within the country, i.e., transporting them from
one region to another, while the international one dealt with repatriating the soldiers from the Sudan to
different regions in Ethiopia.
In relation to mode of transportation, the soldiers from different areas in large and sporadic groups
walked to the nearest shelter camps in unorganized fashion. All transportation was carried out using
vehicles from the main shelters to the transit camps and to the areas of destination.
The Kessela groups were transported by planes to different transit. Centers and thereafter by vehicles.
The repatriation activities mentioned in this paper are those in which ERCS and ICRC had direct and
active participation. The organizational set-up developed for the repatriation included the creation of
main transit shelters or camps in different sites within the regions where high concentrations of exsoldiers were found. Also, final transit centers were established where, during the short stay, about two
days, essential documents used for getting the ration distribution in the respective ERCS branch offices
were issued. All preliminary screening from a health point of view were planned to beeffected in the
main shelter camps.
3.2. Shelter Sites and Living Conditions
The main shelters under the ERCS/ICRC operation were organized in:
-Mekele and Adigrat (in Tigrai region);
-Azezo and Alem Zaga (in Godnar region);
-Bahir Oar (in Gojam region);
-Hayk, Kombolcha, Haruba, Chorisa & Kedida I (in Wollo region).
The location of the main shelters were chosen by taking into consideration the density of ex- I soldier
population in the northern part of Ethiopia. In Nazareth the main transit center was also organized. Some
of the shelter camps were organized in the outskirts of the towns while others were established a few
kilometers away from the towns but along the main highways.
All shelters were not initially meant to harbor such a large group at one time, and thus, there were not
enough toilet facilities, water points, sleeping places and cooking facilities. As a result, the use of open
fields for defecation was commonly noticed at the initial stages.
The influx of the ex-soldiers and the unexpected long stay of the groups in the camps demanded
expansion of the service-giving facilities. The inadequacy of water supply at Bahir Dar shelter was
noticed right from the start. Thus, more water points were added using collapsible water tanks. Additional
trench latrines were also constructed.
In relation to die environmental characteristics of the areas where die shelters were located, warm and
temperate climatic conditions were prevalent.
3.3. Demographic Characteristics and Group
Behaviour
Homogenicity has been noted in the age and sex distribution of the migrant population, i.e., all were men
within the age range of 18 to 50 years. Hetrogenicity was recorded with regard to their previous
occupations and educational standards, i.e. the men had previously been students, factory workers,
peasants, etc. However, as soldiers, all shared common group behaviour. In relation to excretion habits
significant individuals tended to use the open field rather than the trench latrines.
Distribution or Shelter Camps in Ethiopia
3.4. Characteristics of the Places of Origin and Destination
Most of the ex-soldiers, who were gathered in the main shelter camps, were previously located in Eritrea,
Gondar, Gojam, Wollo and in some parts of Tigrai where they were exposed to diseases prevalent in the
lowlands and temperate areas. Diseases of public health importance, such as relapsing fever, malaria,
schistosomiasis, menin-gococcal meningitis, infectious hepatitis, typhus, typhoid fever, shigellosis, etc., are
known to be endemic in these areas.
The destinations of the soldiers were highly divergent and covered different areas in all administrative
regions both in rural and urban set-ups. Thus, it is difficult to describe the
Characteristics.
3.5. Health Aspects of the Soldiers
The general condition of the soldiers upon arrival at the shelter camps was poor. The post war conditions and
physical exhaustion resulting from the movements had created a state of stress in most of the groups. Poor
nutritional status was also noticed. Those who were suffering from war wounds were not few in number. In
those groups who came from Kessela (Sudan), severe adult malnutrition was clearly observed.
Most of the soldiers were poorly dressed with poor personal hygiene and high body lice infestation. The
health problems identified during their stay in the camps included; shigellosis, relapsing fever, malaria,
SODS, skin infections and war wounds. The types and magnitudes of diseases diagnosed differed from camp
to camp. Relapsing fever, shigellosis and malaria did occur at the outbreak in epidemic proportions.
However, all were contained in time with a negligible case fatality rate. It has not been possible to make
correct epidemiological analysis as pertinent data have not been found, recorded or compiled. Most of the
information obtained were narratives.
However, some data on certain diseases have been available showing the activities of the first three months
in Mekele and Bahir Dar shelters. Based on these, some analyses have been done. The population .of the
shelters within the first. three months ranged from 13,338 to 33,700 in Mekele camp and from 1,600 to
65,000 in Bahir Dar with an average of 20,000 and 20,942 for the mentioned towns, respectively.
Quarterly incidence of commonly observed diseases in Mekele shelter 12 July - 19 October, 1991
Disease
No. of cases
incidence rate/1000
Shigellosis
1702
85
Relapsing fever
8480
424
SODS
851
43
*Source - ICRC
Death rate for all causes during the quarter was 12 per 1000.
NB All diagnoses are clinical
Blood films totalling 1335 were collected from relapsing fever and malaria suspected febrile cases. The
laboratory analyses showed 50.3% and 0.3% positivity for relapsing fever and malaria, respectively. Thus,
the high incidence rate for relapsing fever based on clinical findings seems justified and the occurrence of
relapsing fever was surely at epidemic proportions.
Quarterly incidence of commonly observed diseases in Bahir Dar shelter 23 July - 25 October, 1991
Disease
No. of cases
incidence rate/1000
Shigellosis
7037
336
Relapsing fever
6471
309
Malaria
3119
149
SODS
1356
65
*Source - ICRC
Death rate for all causes during the quarter was 11 per 1000.
NB All diagnoses are clinical
Blood films totalling 175 were randomly collected from febrile cases and the laboratory analyses showed
38% and 1% positivity for relapsing fever and malaria respectively. Thus, relapsing fever was at an outbreak
proportion. Public health measures taken included; boiling clothes, delousing, and mass treatment with
500mg tetracyclines. The adequate provision of water helped to improve the camp populations personal
hygiene, and there was a positive impact on the incidence of diarrhoea. In some ~shelters, cases of active
pulmonary tuberculosis were identified. About 80 cases were identified in Mekele shelter alone, and all were
without treatment. Later on such causes were transferred to hospitals under the Ministry of Health.
3.6. Evacuation System
In the main shelters some soldiers stayed for about two months. However, the average duration of time was
one month. Two evacuations by buses and trucks, i.e. done in July, and September/October 1991, have been
recorded.
During the first evacuation no screening of febrile cases was realized. In the second evacuation a trial was
made to screen those cases with possible infection diseases.
4. IMPACT OF THE EX-SOLDIERS MOVEMENT ON THE TRANSMISSION AND CONTROL OF
DISEASES
It is not easy to visualize the delayed effect of the population movement on the health of the community and
the migrant population. However, in relation to the immediate effects some observations have been recorded.
The soldiers in the camps were allowed to move freely to the nearest villages and towns. These urban-rural
contacts did favor the transmission of certain diseases to the communities. An increase in the incidence of
relapsing fever in Bahir Dar and Mekele towns was observed. The soldiers sold the blankets provided to
them to the persons residing in the nearby villages and towns thereby mediating the transmission of infected
vectors (body lice) to the community.
The free movement of the soldiers also exposed them to the endemic diseases of the surrounding areas as
evidenced by the increase of malaria cases among the camp population in Harbu shelter. As proper screening
for acute febrile diseases was not done during evacuations from the shelters, the possibility of transmitting
diseases in the place of destination could not be ruled out.
As defecation in the Open field was commonly observed in the adjacent areas of some shelters, the rainy
season definitely promoted the faecal contamination of the water points of some villages thereby causing
transmission of water-borne diseases.
The long stay of active pulmonary tuberculosis cases with an interruption of the treatment might have
favored the spread of the bacilli within the camp population. The possibility of resistant strain development
and its spread could not also be ruled out. 5.
5.RECOMMENDATIONS
Generally speaking the repatriations of the ex-soldiers have been realized with minor health problems but
with success, and the encountered acute health problems were contained in time. Diseases of explosive
epidemic potentiality. Such as meningococcal menlngitis are endemic in the north western part of Ethiopia.
This problem did not occur; most probably because of the seasonal influence and the high probability that the
soldiers had been vaccinated during recruitment. However, vaccination against meningococcal meningitis
could have been planned for the groups at their arrival in the camps for precaution. It is also the opinion of
the author that the mobility of the soldiers outside their shelter areas should have been limited.
In the chain of transmission of any communicable disease, the reservoir of the agent is an important element
for the control of the disease. With respect to the ex-service men grouped in the shelter camps, little effort
was exerted in health screening both during admission and evacuation. In such captured groups there seems
to be better conditions to conduct screening and take appropriate measures. In the future, under-takings of
these facts have to be seriously considered.
ACKNOWLEDGMENT
I would like to thank Dr. Antje Van Roeden, who is the medical coordinator of the International Committee
of the Red Cross, for her assistance in the compilation and provision of the medical data. My thanks also
goes to Ato Afework Teshome, of the Ethiopian Red Cross Society, for his assistance in the compilation of
different information.
REFERENCES
1. Beltran-Hemandez, F. La ..Iud et al Medio Tropical. La. migracione. intens. en Chiapa., Mexico. Paper
presented at the seminsrio oobre migracione. Humans. y Malaria OMS/OPS, Brazilia, Brazil. 1981.
2. Gedde., A.M. and P.M. Gully. The Returning Traveller. Royal CoUege of Physicia1lS of London. 1981;
15: No.2, 124-127.
3. Kloo., H., et al. Haematobuim Shistomiasis among seminomadic .nd .gricultural Afar in Ethiopia. Tropical
Geography ...ed. 1977; 29: 399-406.
4. PAHO. Malaria in the U.S.A., 1978. Epidemiological Bull, PA HO. 1980; I: 7-9.
5. PAHO. Report of the advisory committee on Medical Research Working group on Social Science Health
Research. PAHO/ACMR, 1982; 21/5.
6. ProIhero, R.M. population movements and problems of malaria eradication in Africa. WHO Bull. 1961;
24: 405-425.
7. Prolhero, R.M. Diseases and mobility: A neglected factor in epidemiology International Journal of
epidemiology. 1977; 6: 259-267.
8. Reid, D.D. The future of migrant studies. Israel Journal of Medical Science. 1971; 7: No.12, 15921595.Prolhero (1977).
9. Roaenfield, P.L., et al. Social and economic research in UNDP/World Bank/WHO special program for
Research and Training in Tropical Diseases. Sac. Sci. Ned. 1981; 15A: 529-538.
10. We-n, A.F. The role of migrant studies in epidemiological research. Israel J. J. of Med. Science. 1971;
1584-1591.
11. WHO Expert Committee on Malaria. Seventh report, WHO Technical Report Series 640, Geneva. 1979.
ANNEX
Total Number of Ex-service Men Transported to Different Regions as of December 1991
To: Addis Ababa
35,654
Sidamo
18,943
IIlubabor
14,328
West Shoa
12,217
Arsi
11,892
South Wollo -c
11,860
Wollega
11,137
North Gondar jlC,
9,497
East Gojam
9,334
West Gojam
8,901
South Shoa
9,284
North Omo
8,587
East Shoa
8,208
East Hararge
8,180
Bale
8,140
North Shoa
6,201
Keffa
4,403
West Hararge
4,473
Borena
2,624
Tigrai c
5,052
South Gondar
2, 711
Gambella
2,234
Dire Dawa
1,404
South Omo
1,097
Ougaden
892
North Wollo
419
Metekel
60
Assab
115
Eritrea
31
Total
222,373
 Source -ERCS -Activity implementation reports December 1991 -Relief Dept.
DISCUSSION
Chairperson -Prof. Jemal Abdulkadir
Speaker -Dr. Getachew Gizaw, ERC
Rapporteur -Dr. Shabbir Ismail, DCH, AAU
Prof. Jemal invited the speaker after giving a brief introductory remark about the background of Dr.
Getachew.
Then Dr. Getachew took the floor and started with introductory remarks on the effects of the defeat of the
Military Force of the previous government by the EPRDF. As a result all the defeated soldiers were found
scattered all over the country, mainly in the northern parts of the country, i.e., Eritrea, Tigrai, Gondar,
Gojjam and Wollo. These abandoned soldiers made different movements, either in an organized or scattered
manner to the near by towns. Therefore, in June 1991, the JCRC and ERCS in close assistance with the
EPRDF engaged in repatriation of these soldiers to their homelands. Accordingly, as of December 23, 1991 a
total of 222,373 ex-soldiers were repatriated by the joint operation. Dr. Getachew then went on discussing the
population movement and its impact on health, referring to pertinent literature. The discussion mainly
focused on migration and its social as well as medical outcomes. It was noted that transmission of tropical
diseases by the introduction of moving susceptible population to specially disease-endemic areas was
stressed. Types of the population, the internal as well the international, were also described.
REPATRIATION
Problems encountered were inadequate planning and very short time for preparation. Soldiers were
repatriated both from those within the country as well as those who came from abroad, mainly the Sudan.
Means of transport used for the repatriation process were walking, by vehicles and airplanes. The
organizational setups of the concentration of the soldiers were in main and transit shelter camps.
SHELTER SITS AND LIVING CONDITIONS
Ten camps in four different northern regions were erected. There were some disparities between expectations
and the actual happenings. These were lack of space and place for waste disposal, long duration of stay at the
camps and shortage of water supply.
DEMOGRAPHIC CHARACTERISTICS
Homogeneity among the soldiers was noted by age and sex as well as open-field habit of defecation.
Heterogeneity was seen on their previous occupational and educational status.
CHARACTERISTICS OF THE PLACES OF
ORIGIN AND DESTINATION
Most of the ex-soldiers who were gathered in the main shelter camps were previously located in Eritrea,
Gondar, Gojjam, Wollo and in some parts of Tigrai. They were exposed to diseases prevalent in the lowland
and temperate areas. Endemic diseases in these areas are reported to be relapsing fever, malaria,
schistosomiasis, meningococcal meningitis, infectious hepatitis, typhus, typhoid fever shigellosis, etc. The
destinations of soldiers were highly divergent, i.e., to all administrative regions of the country both to the
urban as well as to the rural settings. Hence, description of the characteristics is difficult.
HEALTH ASPECTS OF EX-SOLDIERS
Health problems encountered during the admission to the camps were: poor health status, physical
exhaustion, stress, poor nutritional status leading to severe adult malnutrition, war wounds, poor dressing,
poor personal hygiene and high body louse infestation.
FURTHER DISCUSSION
Professor Jemal summarized the main areas and highlights of the talk given by Dr. Getachew and opened the
floor for further discussion. Comment Dr. Melakeberhane Dagnew shared his experience at Gondar during
the crisis time. All the above-mentioned facts were also observed in Gondar , and especially at the Gondar
College of Medical Sciences Hospital.
Q. Why were soldiers repatriated to Addis? What are the health effects on Addis? Are they being followed
now? Are they being followed in other regions?
A. The mandate of ICRC and ERCS is only to repatriate and the follow-up is the activity of the MOH.
Appropriate recommendations are already given. Addis served as a by-pass to other areas. The same effect of
movement and migration can be seen in Addis too.
Q. Did you do any health education activities in the camps?
A. A lot of health education was being done but in general it was not very productive. The main reasons
were: lack of interest on the side of the soldiers, aggressive behaviour of the soldiers and the stress situation
in the camps. Comment (Dr. Tamirat)- All ERCS executives should have shifted to the settlement sites to
work on-site as much disaster has occurred but has not been reported. Preparation was less in transportation
between camps such as from Adigrate to Mekele. GCMS could have handled a lot, but instead ERCS
officials did not even appropriately consult the GCMS. Crime and killings had increased. Evacuation was
low.
Q. How do you assess your preparedness for such disasters? What were the shortcomings? What lessons
were learned?
A. Concerning the preparedness, this was an unusual situation and hence it was not well planned and
prepared, thus crisis-oriented management was used. It was not anticipated at all and not enough time for
planning was present. We did only what we could do, for instance, the airlifting of drugs was done whenever
possible. The other fact was that the aggressive and non- cooperative nature of the soldiers hindered even
some of the attempted activities. In general the work done was good.
Lessons learned were that .the mobility of the soldiers was directly related to the extent of the spread of some
diseases like relapsing fever. It is always good to delouse earlier and to have an adequate supply of water to
contain epidemics. The other lesson learned was that all camps should receive equal attention. In this
operation ICRC and ERCS did little in Dessie and Hayke camps compared to the one in Mekele.
Comment (the UNICEF representative) -felt that ERC/ICRC were quite well prepared. The joint activity by
the MOH, Malaria Control Program, ICRC and ERC was successful. The relapsing fever epidemics were
also contained in time and with less cost of life. Health education was being given, though in a wave and not
in the classic ways, but she felt that the attempt had been made. A joint effort by all parties concerned should
take place immediately, as happened in Mekele camp.
Comment (Dr. Getachew) -Mekele camp was better organized later but not initially. In general,
organizational capability of ERCS and the financial capacity of ICRC led to successful repatriation. The
ICRC should be appreciated for its less bureaucratic work and airlifting procedures.
Comment (the Malaria Control Representative) - Malaria was a problem in Harbu camp. He gave the extent
of relapsing fever in the different camps. He added that relapsing fever is becoming a problem, and attention
should be paid.
Q. How was the mass, treatment of relapsing fever with tetracyclines, regarding the J .H. reaction?
A. Major problems were not encountered. This may have been underestimated due to the situation, and it
may not have been followed properly.
Professor Jemal added that it should be studied anyway.
MIGRATION AND HEALTH
(Refugees and Returnees in Ethiopia)
Ephrem Assefa* MD
1 INTRODUCTION
There are in the world today more than 30million refugees and internally displaced persons within the
borders of their own countries, most of whom are currently dependent on international relief assistance for
their survival. Conflicts and famine are among the most frequent causes of these forced mass population
movements. These are people who have not only lost everything, but in addition, must struggle for survival
simply to recover their dignity as human beings.
With its more than five million refugees and about two million displaced people, Africa is the continent
today most affected by the consequences of conflict or natural disaster. During recent years wars have
increased in number, causing an entire population of completely destitute people to leave their houses
Drought has affected all the countries of the Sahel as well as extensive regions in east and southern Africa
emptying the countryside and villages of their residents.
Undoubtedly, however, human distress throughout the last decade has been the most severe in the Horn of
Africa, particularly in Ethiopia and the Sudan. The United Nations High Commissioner for Refugees and the
entire international community have been mobilized to provide the necessary assistance to hundreds of
thousands of victims without delay and despite tremendous logistical problems.
The Horn of Africa has experienced major socio-political upheavals, which have triggered mass refugee
displacements and migrations. Situated at the core of this volatile region, Ethiopia in the past decade has
witnessed the steady influx of hundreds of thousands of refugees and returnees from neighboring Sudan
and Somalia. In fact, while Ethiopia has pursued a generous policy of hospitality to refugees throughout the
ages, it has at no time in its history been inundated with such a huge caseload of refugees as in the past
decade.
Ethiopia has been home for all system seekers irrespective of their nationality, race, religion or sex since time
immemorial:
-The Jews in the first half of the 2nd century B.C.;
-The followers of Islam in the 2nd half of the 7th century A.D.;
-The Armenian Christians in the 2nd half of the 19th century A.D.
Ethiopia acceded to the 1951 UN convention and its 1967 protocol relating to the status of refugees in 1969,
and to the OAU convention governing the specific aspects of refugee problems in Africa in the year 1973.
The first refugee influx of the current caseload started coming into ltang, Gambella Administrative Region in
southwest Ethiopia from south Sudan in mid-1983 and the Somali refugees into East Hararge in mid-1988.
The refugee population in Ethiopia has been escalating at a very alarming rate as evidenced by the increase
from 40,000 by the end of 1983 to 1,062,000 Sudanese and Somali refugees by the middle of 1991. At
present, as of February 1992, there are 495,472 Somali and 10,000 Sudanese refugees in the country , as well
as 500 urban refugees in Addis Ababa who come from different parts of the world.
The situation in Somalia has also caused the sudden and spontaneous flight of about 250,000 Ethiopian
returnees since the beginning of 1991.
The refugees are exposed to many factors, which put both their physical and mental health at risk. The flight
into exile brings its own hardships: a long journey, often on foot, over difficult terrain and in conditions of
great insecurity.
______________________
*Administration Refugee-Returnee Affairs Addis Ababa. Ethiopia.
Fleeing with the few goods and possessions they can carry, most of the refugees arrive in a severely
debilitated state. These refugees have moved into the remote and inaccessible area." of the country, where
relief programmes are difficult to organize. Hence Ethiopia, which finds it difficult to provide the basic needs
of its own people, is struggling to bear the burden imposed by hundreds and thousands of refugees.
Assistance to the refugees and returnees in Ethiopia is provided through the cooperative and complementary
efforts of the government of Ethiopia (principally the Administration for Refugee-Returnee Affairs and the
Ministry of Health), the UNHCR, other members of the UN family (especially the World Food Programme),
and a number of non-governmental organizations.
Budgeted at $61 million dollars for 1991, the UNHCR/Ethiopia Programme is the largest one in dollar terms
in the world. This is due to the nearly full dependence of the refugees on international assistance, to the high
costs of distributing water and food, and to the fact that as an extremely poor country itself, Ethiopia cannot
afford to cover the administrative costs of the refugee Programme.
2. INTERNATIONAL LAW AND COUNTRY POLICY TOWARDS REFUGEES
AND RETURNEES.
2.1. International Law
A brief account is given below of refugee law and humanitarian law. Reference is also made to human rights
as they apply to the situation of any person, including displaced individuals. It will be seen that a substantial
corpus of international law has been developed over the last 40 years, essentially within the framework of the
United Nations system or in the form of regional agreements.
A. Refugee Law
The universally accepted definition of a refugee is that of a person who finds himself outside his country of
origin or habitual residence owing to a well-founded fear of persecution on account of his race, religion,
nationality, membership of a particular social group, or political opinion. (1951 UN convention on Refugees
and 1967 Protocol).
The 1969 OAU Convention Governing the Specific Aspects of Refugee Problems in Africa:
Taking into consideration the specific political and social circumstances in Africa, refugees are also defined
as those persons who flee from external aggression, occupation, foreign domination or events seriously
disturbing public order.
Regional legal instruments with broader concepts of the term "refugee" also exist in Central America and
Asia.
B. International Humanitarian Law
The Geneva convention of 1949, in particular article 3 and the fourth convention, offer a basic protection to
the civilian population in armed conflict situations.
C. Human Rights Instruments
The 1948 United Nations Universal Declaration of Human Rights offers the basis for a "Standard of
Humanity" which must apply in all situations, at least in regard to the so-called group of inalienable human
rights.
2.2. Policy Towards Refugees/Returnees
Ethiopia's policy towards refugees has always been governed by an innately humanitarian compassion for the
suffering, and hence, is marked by the generous provision of asylum, protection and assistance to all those
who come to seek refugee in its territories without ethnic, religious and/or other biases. In fact, it is a country
which pursues an open-door policy towards refugees and an equally open-door policy with regard to
returnees. It thus promotes the policy of voluntary repatriation as the most durable global solution to the
refugee problem be it in terms of receiving its own citizens living in exile or refugees in Ethiopia who seek to
return to their respective countries of origin.
In strictly legal terms, Ethiopia's policy towards refugees and returnees per se is governed by the principles
and tenets enshrined in the 1952 UN convention relating to the status of refugees and its 1967 protocol to
which it acceded in 1969, as well as the organization of African Unity (OAU) convention governing the
specific aspects of refugee problems in Africa which it ratified in 1973.
Furthermore, with regard to services in all aspects of its programmes to refugees, the country strictly adheres
to UNHCR's policy "that refugees are to be neither more nor less privileged than the host population".
This approach serves to avoid the tensions and jealousies that would result from providing a higher level of
care to refugees.
3. REFUGEE IN ETHIOPIA
The refugee programmes in Ethiopia can be classified into three broad categories:
-Care and maintenance Programme for Sudanese refugees in the west;
-Care and maintenance Programme for Somali refugees in the east;
-Emergency refugee Programme.
3.1. Sudanese Refugee
Though the history of Sudanese refugees in Ethiopia dates back to the 1970's and even earlier, their numbers
were not so significant as to attract the attention of the international community. Since 1983, however, the
influx of Sudanese refugees has been growing at a rather alarming rate to reach a total of over 400,000
around the end of April, 1991. The Ethiopian government with UNHCR established four camps to shelter
these refugees. These are Itang (June 1983), Dima (August 1986), Assosa (May1987) and Fugnido
(December 1987).
The refugees are coming from the Eastern Equatorial, Lower Upper Nile, and Bahar ElGhazal regions of the
Sudan. The dominant groups are the Dinka and Nuer with the rest made up of Shilluk, Anuak, Murle,
Toposa, Didinga, Uduk and Latuka peoples.
Though most are agro-pastoralist from the rural areas, there are a number of urban southern Sudanese who
form the bulk of the teachers and health workers. A noticeable feature of these camps is the disproportionate
numbers of males and unaccompanied young boys.
The areas where these camps are situated, i.e., within 70-80 miles of the Sudan border, are comprised of low
tropical forest and savannah land criss-crossed by rivers originating in the high plateau of western Ethiopia.
Each camp is situated near perennial rivers that constitute the main source of water for the refugees. The Gilo
(Fungido) and Baro (Itang) rivers flood annually during the main rains in July through September. This
flooding is particularly acute in Itang where it poses a major health hazard. The supply of potable water to
refugees in the Sudanese camps is only satisfactory in Dima, where a system has been installed in which the
river water is pumped and sedimentation filtration and chlorination take place. An average of 7.7 liters per
person per day is provided.
May 1991 was marked by dramatic events and significant political development. This was also a period
during which peace and stability was disrupted in the country temporarily. Hence, out of a sense of
insecurity, the vast majority of the Sudanese refugees evacuated their camps so that there are now only some
10,000 or so Sudanese refugees remaining.
Yearly and cumulative influxes of Sudanese refugees in Ethiopia (1983-1992).
Year end
1983
1984
1985
1986
1987
1988
1989
1990
Apr. 30, 1991
February 1992
itang
40000
65433
85303
121042
146948
221101
239394
280611
280783
10000
Pugnido
19065
45003
69703
85081
86188
-
Dimma
10986
33167
35243
33243
35091
35127
-
Assosa
22142
29978
41279
-
Total
40000
65433
85303
132010
221322
331325
385619
400783
402098
10000
Demographic composition of south Sudanese refugees in Ethiopia as of April 30,1991
Age group
0-5
6-15
16-45
46
Total
Percentage
Male
24542
70851
185003
8138
288534
72%
Female
24137
34711
54127
1589
113564
28%
Total
47679
105562
239130
9727
402098
100%
Percentage
12
26
60
2
100%
3.2. Somali Refugee
While the influx of Somali refugees into Ethiopia initially started in mid-1987, when the refugees were
settled in Harshin, the most massive influx actually occurred in 1988. UNHCR assistance to the refugees
started in May, 1988 and the refugees in Harshin were transferred to Hartisheik, currently the largest Somali
refugee camp in the country .The other camps, namely Camaboker (July 1988), Rabasso (August 1988) and
Daror (August 1988), were simultaneously established in the Aware region to accommodate the increasing
number of Somali refugees.
August 1989 saw another influx of Somali refugees into Biyo Gurgur Aisha camp (October1989) in the Dire
Dawa region. The escalation of the conflict situation in Somalia around February 1991 resulted in yet another
additional influx of some 275,000 refugees along different entry points across the border; Teferi Ber and
Derwonani in East Hararge, Arabi in Dire Dawa, Dolo Odo and Melka Suftu in Borena and Kelafo; Mustahil
and Gode in the Ogaden region. New refugee camps had to be subsequently established in most of the areas
up to mid-May 1991.
The refugees are coming from the northwest of Somalia. The dominant groups are the ISAAKs with the rest
being ISSAs, Gadabursi, Hawiya and many other small clans.
Most of the refugees are nomads, and semi- nomads. However there are a lot of city dwellers from Hargeisa
and Burao. This urban group comprises the elite of northern Somali. Most of the health workers in the camps
are from this group.
The areas of these camps are arid and devoid of water and vegetation. An average of 800,000 liters of water
per day is transported from Jijiga town and Jerrer valley by water tankers to Hartisheik, Teferi Ber and
Derwonaji camps. The Aware camps depend on earth darns for their water supply, which frequently dry up
during the dry season.
Due to the recent political development in the country and especially the disruption of law and order in the
meanwhile, the smooth conduct of refugee operations in east Ethiopia was temporarily disrupted much the
same as in western Ethiopia.
However, the situation of Somali refugees has not changed as drastically as is the case with the Sudanese
refugees. A considerable number of no less than 480,000 Somali refugees are still residing in the various
camps and remarkable reductions in population figures is noted only in Daror.
Number of Somali refugees in Ethiopia as of February 1992.
1. Hartisheik ...........246,522
2. Camaboker ..........66,615
3. Rabasso ...............26,181
4. Daror ...................31,622
5. Teferi Ber ............50,000
6. Derwonaji ............45,000
7. Aisha ...................19,362
8. Arabi ...................10,170
Total.............495.472
3.3. Care and Maintenance Programmes for Refugees
Basically, the refugee care and maintenance programmes constitute a standard survival package of food,
shelter, water, health and other social services as well as fundamental logistical and delivery support systems.
UNHCR is the foremost agency of concern providing emergency care and maintenance assistance to the
refugee populations in the country with full support from the government and material contributions from
selected NGO's. "This multi-sect oral assistance is primarily intended to ensure a minimally acceptable living
standard in terms of food, water, shelter and health services. Although other essential social services, such as
education, community welfare, and social counseling are rendered, these are not as developed as required.
FOOD: The food ration for refugees consists of the following:
Cereals
500 gm (person/day)
Pulses
50 gm
"
"
Oil
30 gm
"
"
Sugar
20 gm
"
"
CSM/FAFA
30 gm
"
"
Salt
5 gm
"
"
Food distribution has been regular with most commodities available except for shortages in oil and blended
food.
WATER: The unsatisfactory water situation in all the camps (except Dima) is the major threat to the health of
the refugee population. The daily average water supply ranged from 2-3 liters per person, which is far below
the recommended requirement.
3.4. Health Services to Refugees
Health services to the refugees is based on a four-tier system linked by referral and supervisory arrangement
and is consistent with the policy of the Ministry of Health (MOH).
Level One: Community-based health services, using CHA and TBA. (CHA: 1000 and, TBA:2500)
Level Two: Satellite clinics staffed by nurses and health assistants; one satellite clinic services 10-30,000
refugees and is responsible for the supervision of 10-30 CHA's working under its catchment area.
Level Three: Health centers and/or field hospitals depending on the number of satellite clinics; staffed by
medical doctors, nurses, health assistants, sanitarians, pharmacy and laboratory technicians. The health center
is responsible for the supervision of the satellite clinics under its zone.
Level Four: Regional and central MOH hospitals: where patients requiring further investigation and
treatment are referred. The basic operation of the health delivery system relies more on community-based
health service programmes. The preventive services are based on:
-Appropriate vector control (malaria); fully implemented by the malaria control of the MOH.,
-Health and nutritional screening of new arrivals coupled with mass vaccination for measles and vitamin A
prophylaxis;
-Maternal Child Health (MCH) clinics integrated with: growth monitoring, BPI, ORT corners, supplementary
feeding programmes for under-fives, pregnant and lactating women, pre and post-natal check ups, delivery
services;
-A camp sanitation Programme: camp cleaning on a weekly basis, building pit-latrines and refuse disposals,
health education, vital statistics via grave watchers and TBA's;
-Active surveillance for epidemic potential diseases from the community up to the hospital level (Annex 1);
-Curative services with OPD and in-patient facilities (1 hospital bed per 2000 refugees);
-Standard treatment protocols with essential drug lists in place.
3.5. Health Status of the Refugees.
As with all refugee populations, the health Status has to be compared with the levels Achieved before
immigration and also with those of the neighboring host population.
The health and nutritional status of the refugees under the care and maintenance Programme, both in the east
and westb1eon- the whole and at least comparable to, if not better than, that of the local population. This is
manifested by the low CDR (Crude Death Rate) and malnutrition prevalence rates.
The CDR in all the camps is, on average, below 20/1000/year and the malnutrition prevalence rate is below
10% less than 80% WFH (Weight For Height) (excluding the camp of Teferi Ber which is 18% less than
80% WFH).
Comparison of CMR in various refugee and host country non-refugee population
Refugees
Refugees Pop.
Period
Somali ( Ali Matan)
Eth.
60000
Aug-1980
Sudan 8 Eastern
"
220000
Jan.-Mar.1985
Campus
Ethiopia Hartisheik
Somali
1700000
Feb-Apr. 1989
Somalia
Displaced Ethiopia
100000
Oct.-Dec. 1984
Korem
Shoa (famine victims in
380000
Feb.-Oct.1985
villages)
Refugees
30.4
16.2
Country
1.8
1.7
6.6
1.9
60-90
2
8.2
2
Out-patient statistics indicate the most common diseases treated are malaria, acute respiratory infections,
tropical ulcers, diarrhoeal diseases, eye infections and intestinal parasites. Furthermore, the most common
causes of death are diarrhoeal diseases, malaria, respiratory tract infections (including tuberculosis) and
trauma.
4. RETURNEES IN ETHIOPIA
Durable solutions to the refugee problem have traditionally centered on voluntary repatriation, local
settlement and third-country resettlement of these three, voluntary repatriation is considered the preferred
solution.
Two categories of returnees are distinguished: Spontaneous and Organized returnees. Very little is known
about the spontaneous returnees but most observers expect their number vastly to exceed that of the
organized returnees.
4.1 Historical Background
Spontaneous and organized repatriations have occurred since as far back as 1983.
Information on the spontaneous returnees is scanty. However, it is recorded that there were:
a) Spontaneous returnees from the Sudan into Eritrea in 1983, and these were assisted by the League of Red
Cross and RRC;
b) Spontaneous returnees from Somalia into the Ogaden in 1983-5, and these were assisted by WUSC and
RRC. The population of these returnees is estimated around 400,000.
Organized repatriation programmes have been concluded since 1984. These include:
a) 33,000 Ethiopian refugees who were repatriated from the Republic of Djibouti in 1984, via Shinile;
b) 15,400 Ethiopian refugees who were repatriated from Somalia from December 1986-1990,via Dollo;
c) 4,501 Ethiopian refugees who were repatriated from northwest Somalia in 1991, via Teferi Ber.
4.2 Current Returnee
Further to the organized repatriations mentioned above, a plan of action was worked out to repatriate some
160,000 Ethiopian refugees from Somalia as per the provisions of the Tripartite agreement concluded in
December 1989 between Ethiopia, Somalia and the UNHCR. Unfortunately, however, the escalation of the
conflict situation in Somalia since February 19911ed to an abortion in the organized repatriation. Since then,
over 370,000 spontaneous returnees have entered the country along different entry points. These returnees
are currently found in Kelafo, Kebridehar, Gode, and Mustahil in the Ogaden region, Arabi in Dire Dawa,
Kebribeyah, Derwonaji, Teferi Ber and Babile in Eastern, - Hararge, Dolo, Qdo, Melak Suftu and Moyale.
4.3. Assistance to Returnees
-Food distribution
-Travel and rehabilitation cash payment
-Follow-up in reintegration area
A. Food
The returnees are entitled to food rations for one year .The food distribution standard is the same as for
refugees.
B. Travel grant
Two adults from one family are entitled to 100 Birr each. All registered dependents are given 50 Birr/person.
C. Rehabilitation grant
Two adults from one family are entitled to 240 birr each. Registered dependents are entitled to120 Birr each.
4.4. Health Services to Returnees
Unlike the refugee health service, the returnee health service is mainly geared to:
a) First-aid on their way from the border to the reception center;
b) Health and nutrition screening in the reception center (15 days duration);
c) Referral of the severely ill patients.
Returnee operation areas in Ethiopia 1991
A. Eastern operation (Hararge)
I. Arabi
3,000
2. Habile
21,000
3. Teferi Her
27,500
4. Dernowaji
58,000
5. Degehabour
18,500
6. Kebribeyah
30,000
Total
150,000
B. South Eastern operation (Ogaden)
1. Kelafo
25,088
2. Kebridehar
22,631
3. Gode
13,753
4. Mustahil
13,402
5. Hurkur
5,560
6. Shilabo
2,510
7. Warder
2,532
8. Debe Wayne
3,003
Total
88,479
C. South operation (borena)
I. Dolo-Odo
104,674
2. Suftu
29,217
Total
133,891
Grand total 372,370
4.5. Health Status or the Returnees
As outlined above, the main activities of the health sector is geared to screening, and as the returnees are
reintegrated into their area of origin, it is quite difficult to mention the health status of the returnees.
However, in those unfortunate instances where returnees are kept in camps their mortality and malnutrition
rates are very high. For instance the CDR among returnees is57.6/1000/year in Teferi Ber with a malnutrition
rate of 25% < 80% WFH. In Dernowaji the CDR and malnutrition rates are 55.6/1000/yearand 28% < 80%
WFH respectively. Crude death rate and malnutrition rates in Kebribeyahare 58/1000/year and 60% .In Dolo
and Suftu CDR and malnutrition rates are recorded to be93.6/1000/year and 60% < 80% WFH.
4.6. Potential Returnees
Currently there are over 800,000 Ethiopian refugees in the Sudan.
Host Country
Sudan
Sudan
Years of influx
1976-1984
1984-1985
Origin
Eritrea (Ethiopia)
Ethiopia
population
500000
340000
5. HEALTH CONSEQUENCES OF MIGRATION
Acute movements of large populations into areas with insufficient resources have precipitated health crises
that have demanded prompt, well-targeted responses. On too many occasions, mortality -much of it
preventable -has been exceedingly high during the early phases of relief operations.
Migration facilitates the transmission of disease by spreading causative agents and/or by changing the
environment. Migrants may have lowered resistance to diseases and/or may be exposed to new diseases. In
certain circum-stances, diseases may actually cause migration Diseases in refugee camps can be broadly
classified into the following categories: Endemic disease in country of origin;-diseases encountered at time of transit;
-Endemic disease in host country;
-Diseases that is likely to arise due to over-crowding and living conditions in the camps.
When refugees flee to developing countries that are characterized by low income and poor health indicators,
they exert an additional burden on the frail health delivery system precipitating a health emergency.
In a refugee situation the "emergency" phase is the period during which mortality rates are higher than those
experienced prior to displacement. This phase varies from 1-12 months. The emergency phase is considered
to be over when CMR (Crude Mortality Rate) drops to less than 1 per 10,000 per day.
In the post emergency phase, mortality rates generally return to that of the surrounding population.
Most mortality in refugee populations has been caused by measles, diarrhoeal diseases, under-nutrition, acute
lower respiratory infections and malaria, the same diseases that affect non-refugee populations. Although
outbreaks of cholera, meningitis and typhus are potentially serious, they have not caused many deaths. Thus,
it is not the type of illness but rather the incidence and high mortality rates that makes these populations
remarkable; this vulnerability being explained by under-nutrition and nutrient deficiency. Other factors, such
as crowding, poor water supply, personal hygiene, physical trauma and psychological stress may also
contribute to the mortality rate in these situations. Although complex social, political, and economic issues
affect the well being of refugees, implementation of the following might help them survive the acute phase of
their displacement.
1. Provision of food rations containing adequate calories, protein, and essential micronutrient. Although
supplementary feeding programmes are often popular with relief agencies, their effectiveness in refugee
camps in the absence of adequate general food rations is questioned.
2. Provision of clean and adequate water. The provision of adequate quantities of clean water bas resulted in
the reduction of diarrhoeal disease morbidity.
3. Implementation of appropriate interventions for the prevention of specific communicable diseases;
-Immunization of children against measles;
-Malaria control;
-Prompt identification and treatment of symptomatic individuals by health screening.
4. Institution of appropriate curative programmes with adequate population coverage, with standardized
treatment protocols and an essential drugs list. Proper management of diarrhoeal diseases, URTI, etc.
5. Establishing a simple but effective health information system with active surveillance for mortality,
nutritional status and important epidemic diseases such as measles and cholera. Furthermore, health services
for refugees should be integrated, as much as possible, within health programs for host country nationals.
6. IMPACT OF REFUGEE/RETURNEEPRESENCE
The refugee hosting areas in Ethiopia, be they in the east or west, are located in very remote peripheries
which lack the most basic infrastructure and natural resources.
The impact of refugee/returnee presence in these areas can be summarized as follows. (This list is not
complete but is intended to arouse discussion and to show that it is multi-dimensional.)
6.1. Environment and Eco-system
The increased caseload of humans and cattle will affect:
-Wild-life in proportion to increased population,(i.e. hunting);
-Forests in proportion to increased demand for firewood and construction of houses;
-Grazing land in proportion to the increased number of cattle, (i.e. the graze land will be over loaded).
6.2. Economy
-Shortage of commodities in proportion to increased demand;
-Decrease in 'l>rice of agricultural products in proportion to refugees selling their rations.
6.3. Health
-Shortage of health manpower in proportion to the deployment of staff to the refugee camps;
-Increased case loads in referral hospitals in proportion to the referral of refugees.
6.4. Roads
-Dilapidation of roads in proportion to heavy traffic to and from the refugee camps.
7. PROGRAMM~ OF MUTUAL BENEFIT TO REFUGE~ AND NATIONALS HEALTH
HEALTH
7.1 The health services rendered to the refugees are equally shared with nationals living around the refugee
camps. This also includes medical care, feeding programmes, EPI, etc.
7.2. There are two projects currently underway to upgrade the hospitals of Jijiga and Gambella to render
more surgical services to the referred refugees and nationals. These projects are funded by the European
Economic Commission (EEC) and are implemented by MSF. There is also a plan to upgrade Mizan Hospital
surgical services.
7.3. A health center is to be built and handed over to the MOH in Kebribeyah, which is mainly to assist the
reintegration of returnees.
REFERENCES
1. Report on Ute Round-Table on "The Movement of People, New Developmenla" International organization
for Migration, May 1990.
2. ToIle, M.J. and R.J. Waldman. "Prevention of Excess Mortality and Refugee and Displaced Populations".
JAMA. June 27, 1990; 263 (24).
3. Toole, M.J. and R.J. Waldman. "An Analysis of Mortality Trend. Among Refugee Populations in Somalia,
Ute Sudan and Thailand". Bull. WHO. 1988; 66 (2): 237-247.
4. Moore, P.S., et .1. "Surveillance and Control of Meningococcal Meningitis Epidemic. in Refugee
Populations". Bull. WHO. 1990; 68(5): 587-596.
5. "Review of Health and Nutrition Programme for Western Ethiopia Refugee Camps". TSS Mission Report
90/08, Geneva.
6. "Review of Health and Nutrition Programme for Eastern Ethiopia Refugee Camps". TSS Consultancy
Report 89/40, Geneva.
7. "Health and Nutrition Programme Review". TSS Consultancy Mission Report 90/27, Geneva. 8. "Report
of Ute Multi-donor Technical Mission on Refugee. and Returnees", Feb. 1991.
9. "Profile for Refugee Emergency-prone Countries -Sudan". Office of Ute UNHCR, Nov. 1987.
10. "Somalia -An Emergency Preparedness Profile". Office of Ute UNHCR, Oct. 1987.
11. "Profile for Refugee Emergency-prone Countries -Ethiopia" . Office of Ute UNHCR, June 1985.
ANNEX I
ADMINISTRATION FOR REFUGEE AFFAIRS
MONIH: ........................
WEEK: I II IV
DATE .........TO..............
WEEKLY NOIFIABLE DIEASES
RADIO REPORT
1. Measles
2. Relapsing Fever
3. Suspected Meningitis
4. Suspected Yellow fever
5. Suspected Cholera
6. Suspected Typhoid fever
7. Suspected Hepatitis `
CASES
<5YRS
>5YRS
(A)
(B)
DEATHS
<5YRS
>5YRS
(C)
(D)
______
______
______
______
______
______
______
_______
_______
_______
_______
_______
_______
_______
______
______
______
______
______
______
______
N.B: All reported cases should be based on Physician's opinion.
______
______
______
______
______
______
______
DISCUSSION
Chairoperson: Dr. Charles Larson.
Speaker: Dr. Ephrem Assefa, Administration
for Refugee-Returnee Affairs.
1. INTRODUCTION
There are in the world today more than 30 million refugees and internally displaced persons within the border
of their own countries. Conflicts and famine are among the most frequent causes of these forced mass
population movements. The Horn of Africa has experienced major socio-political upheavals which have
triggered mass refugee displacements and migrations. The refugee population in Ethiopia has been escalating
at a very alarming rate, as evidenced by the increase from 40,000 by the end of 1983 to 1,062,000 Sudanese
and Somali refugees by the middle of 1991. The situation in Somalia has also caused the sudden and
spontaneous flight of about 250,000 Ethiopian returnees since the beginning of 1991.
2. LAW AND POLICY
Ethiopia's policy towards refugees and returnees is governed by the principles and tenets enshrined in the
1952 UN convention relating to the status of refugees and the OAU convention governing the specific
aspects of refugee problems in Africa which it ratified in 1973.
3. REFUGEE IN ETHIOPIA
The refugee programmes in Ethiopia can be classified into three broad categories: -care and maintenance
programme for Sudanese refugees in the west;
-care and maintenance programme for Somali refugees in the east;
-emergency refugee programme.
3.1. Sudanese Refugee
Although the history of Sudanese refugees in Ethiopia dates back to the 1970's, it was in 1983 that there was
the beginning of an alarming influx which reached a total of 400,000 refugees around the end of April, 1991.
The Ethiopian government with UNHCR established four camps to shelter these refugees. These are Itang
(Iune 1983), Dima (August 1986), Assosa (1987) and Fugnido (December 1987). Each area is situated near
perennial rivers that constitute the main source of water for the refugees. Flooding is particularly acute in
Itang where it poses a major health hazard during the rainy seasons.
A noticeable feature of these camps is the disproportionate numbers of males and unaccompanied young
boys. Most of the refugees are agro-pastoralists from the rural areas. Currently, there are only about 10,000
Sudanese refugees remaining in Ethiopia, the vast majority of them having evacuated their camps after the
May 1991 political development in Ethiopia.
3.2. Somali Rerfugee
While the influx of Somali refugees into Ethiopia initially started in mid-1987, the most massive influx
actually occurred in 1988. August 1989, and the escalation of the conflict in Somalia around February 1991,
resulted in an additional influx of 250,000 refugees. Most of the refugees are nomads and semi-nomads. The
camp areas are arid, devoid of water and vegetation. An average of 800,000Iitres of water per day is
transported to these camps. A considerable number of no less than 480,000 refugees are still residing in the
various camps.
3.3. Care and Maintenance Programme for Refugee
This programme constitutes a standard survival package of food, shelter, water, health and other social
services and fundamental logistical and delivery support systems. Food distribution has been regular with
most commodities available except for shortages in oil and blended food. The unsatisfactory water situation
in all the camps (except Dima) is the major threat to the refugee population.
The daily average water supply ranges from two to three litres per person, which is far below
the recommended requirement.
3.4 Health Services to Refugees
Health services to the refugees is based on a four-tier system linked by referral and supervisory arrangement
and is consistent with the policy of the MOH. The four-tier system includes community-based health
services, satellite clinics, health centres and regional or central referral hospitals. The basic delivery of the
health system relies more on community-based health services pro- grammes. The preventive services are
based on appropriate vector control (malaria), health and nutrition screening of new arrivals coupled with
mass vaccination for measles and vitamin A prophylaxis, integrated MCH clinics, a camp sanitation
programme, active surveillance for epidemic potential diseases and curative services with OPD and in-patient
facilities.
3.5. Health Status of the Refugee
The health and nutritional status of the refugees under the care and maintenance programme, both in the east
and the west, is quite stable on the whole and at least comparable to, if not better than, that of the local
population. This is manifested by the low CDR malnutrition prevalence rate which is below 10% less than
80% WFH (Weight For Height).
Out-patient statistics indicate that the most common diseases treated are malaria, acute respiratory infections,
tropical ulcers, diarrhoeal diseases, eye infections and intestinal parasitosis. Furthermore, the most common
causes of death are diarrhoeal diseases, malaria, respiratory infections (including tuberculosis) and trauma.
4. REfURNE~ IN ETJDOPIA
Two categories of returnees are distinguished: spontaneous and organized returnees. Spontaneous and
organized repatriations have occurred as far back as 1983. Spontaneous returnees from Sudan and Somalia in
1983-1985 were estimated to be more than 400,000. Three organized repatriation programmes were
concluded in 1984 from Djibouti and Somalia, and the number of returnees was estimated to be 53,000. A
plan of action was worked out to repatriate some 160,000 Ethiopian refugees from Somalia. However, the
escalation of the conflict situation in Somalia since February 1991100 to an abortion of the organized
repatriation resulting in over 370,000 spontaneous returnees entering the country .The returnees are entitled
to food rations for one year , a travel grant of 50 birr/person and a rehabilitation grant of 120 birr for each
registered dependent. Health services to the returnees are mainly geared to first-aid on their way from the
border to the reception centre, health and nutrition screening in the reception centre and referral of the
severely ill patients.
4.1. Health Status or the Returnees As the returnees are reintegrated into their area of origin it is quite
difficult to mention the health status of the returnees .However, in those unfortunate instances where
returnees were kept in camps their mortality and malnutrition rates were very high. The CDR ranged from
55.6 - 93.6/1000/year and malnutrition rates ranged from 25%-60% < 80% WFH. Currently there are
800,000 potential returnees who are refugees in the Sudan.
5. HEALTH CONSEQUENCES OF MIGRATION
Migration into areas with insufficient resources has precipitated health crises that have demanded prompt,
well targeted responses. It facilitates the transmission of diseases by spreading the causative agent and/or by
changing the II environment. Migrants may have lowered resistance to diseases and/or may be exposed to
new diseases. Thus, a high incidence of disease and mortality rates makes these populations remarkable. Part
of this vulnerability is explained by under-nutrition, and other factors such as crowding, poor water supply
and personal hygiene, physical trauma and psychological stress. When refugees flee to developing countries
that are characterized by low income and poor health indicators, they exert an additional burden on the 184
frail health delivery system precipitating a health of emergency. Among the major impacts of a
refugee/returnee to the host country are increased population, increased depletion of ilia. forest, shortage of
commodities and increase burden to the health situation.
FURTHER DISCUSSION
Q. How often are you able to recruit health workers including CHWs from among yourrefugees?
A. It depends on the occupation of the refugees.Some health workers are recruited from the
refugees.
Q. Do you pay the CHWs -it will influence thesustainability of community health services -or
is there any material incentive?A. Because of the high rate of absence we havestarted paying the CHWs.
Their salary is 103 birr per month.
Q. You have mentioned that the reports from the CHWs were more valid than the health center report -what
about the quality of the reports of the CHWs?
A. This was mentioned in relation to the incidence of diseases. Since the CHWs did house-to-house visits the
report of incidence of diseases was more valid. The health centre report is a passive report and did not
include all new cases in the community.
Q. What kind of reproductive health service did you provide? How did you follow the vital statistics?
A. I. No family planning service is provided at present. This is because of a lack of acceptability of family
planning in the "Somalia camp". In the "Sudanese camp" there were more males and we found that it was not
acceptable by the refugees.
A. 2. Vital statistics is reported by TTBAs and "grave watchers". The TTBAs report births and the "grave
watchers" report deaths. The reports from the "grave watchers" is checked by the health workers. The
refugees are afraid to report deaths because rations will be decreased. They tend to report more births to
increase the amount of rations they receive.
Q. Do physicians report the weekly notifiable diseases? A. We insist on physicians' opinions and they do
report.
Q. Was the recruitment of CHWs related to refugees or returnees?
A. Refugees.
Q. Is there any change in the policy of UNHCR to development programmes particularly in relation to longterm assistance? A. Refugees are not permanent residents, hence, it is difficult to build long-term projects.
The other problem is there are no sufficient funds to initiate and maintain development programmes.
Resources are mainly directed to the care and maintenance programmes of the refugees. Comment: Yes, we
are doing something in development programmes. In Gambella Hospital we have built the MCH block and
extended the operation theatre; we intend to improve the sewerage system. Similar projects are carried out
in Jijiga. While we have no direct responsibility to provide permanent development projects, some measures
have been taken in limited areas. With regard to development projects for both local people and refugees, we
are only catalysts of community-based activities.
Comment: To compensate for the work load in Gambella Hospital some instruments were provided by the
UNHCR, but these were taken back by the refugees. We need more instruments than mentioned.
A. We will provide.
Q. Did you see yellow fever?
A. No.
Q. How is the flow of the health information system?
A. We have a link with the MOH and data is accessible to the MOH through the health institutions.
Comment: The regional health department did not get reports from your health institutions. Please send the
reports regularly.
A. Well taken. We will send the reports regular-
HEALTH ASPECTS OF DIE REPATRIATON OF DISPLACED
CIVILIAN POPULATION IN WAR AND
DROUGHT-AFFECTED AREAS OF ETHIOPIA
Tamirat Reua*, M.D.
INTRODUCTION
A historical perspective of draught and famine in Ethiopia, "The Challenge of Draught - Ethiopia's Decade of
Struggle in Relief and Rehabilitation" , gives an account of the different episodes that the country has had to
suffer from this type of natural calamity. After reviewing the medieval situation, it progressively reaches to
the great famine of the period from 1988-1992.
The review includes in its analysis the situation in the highlands and also the situation in pastoralist areas of
the country where, according to the observations, such incidents happen, in a cyclical manner every ten
years.
S.P. Petrides, in "The Boundary Questions between Ethiopia and Somalia , gives an account of how many
major conflicts the country had to face between 1932 and 1935/6. The impressive list includes not less than
34 major conflicts involving at one time or the other; the west and north-west, the north, the east and the
southern parts of the country. This list excludes the internal conflicts which were numerous, according to
Tekle Tsadik Mekuria the well known Ethiopian historian.
REPATRIATION
The narrow and strict definition of repatriation, in the present presentation, is being enlarged to also include:
-those displaced within the boundaries of the country;
-those displaced within the limit of their respective administrative regionslawraja (sub-districts);
-those people to be moved to settlement/- resettlement areas.
Repatriation can be subdivided into three phases:
A) CENTRIPETAL Phase;
B) JOURNEY Phase with single/multiple stop overs;
C) CENTRIFUGAL Phase.
While phase (B), the journey phase, may have its own inherent difficulties (organization, logistics,
administration, distance between stopovers, length of the travel, etc.), its medical implications are within the
reach of middle level medical staff, unless there is a vehicle accident or explosion on the line. The other two
phases are of a different nature. Although the medical action in both is to keep the displaced person in good
health, success in either case varies due to the fundamental differences of their respective outcomes. These
include: span of life, geographical distribution, interaction with the surroundings, concentration of means and
delegation of power in problem- solving, political benefits as well as the focus of the nation, the political
leadership at their different echelons, and by way of extension, the focus of international attention.
CENTRIPETAL PHASE
It is a well known fact that draught victims only leave their localities when there are no more resources for
survival available. They are in absolute necessities to leave to search for the means of survival. Victims who
are displaced due to armed conflicts, on the other hand, are out of their homes sometimes in a matter of a few
hours. When natural and man-made disasters are allied, as our country has often experience in
___________________________________________
.Relief and Rehabilitation Commission. Addis Ababa, Ethiopia
the last few decades, then the condition of survival has even a bleaker outlook for those stricken in this
situation. It is simply a nightmare.
The movement of these victims generally leads them to the main communication roads, regular market
locations or the boundary gates, where the displaced have a stopover to rest and wait for those behind. Soon
small groups are formed to exchange the ways and means for solving their immediate and life-threatening
situation.
Some determinants (traffic load, existence of water source, availability of firewood, etc.) invite the travellers
to remain where they are, and they end up by attracting the attention of the concerned authorities.
It is here and in the given conditions then, that the authorities have to cater to and assist the displaced
population by: erecting shelters; providing food, water, and logistical facilities; creating storage space and
health facilities (including nutrition and sanitary components); setting up the needed administrative structure;
and ensuring the essential linkages with the concerned authorities.
These operations are executed under hectic and dramatic conditions. In general, the dominant feeling in these
precarious shelters is of a dehumanized atmosphere:
-the assisted people are the colour of the soil and this in turn creates in them the feeling that they are "dirt"
and have lost their identity;
-there is an absence of protection against the morbid curiosity of the outside world;
-people are pushed and pulled with no regard, or consideration;
-there is a total disruption of traditional respect and regard among themselves;
-signs of belonging and affection to their loved ones are suppressed;
-they are denied the care and support to alleviate the burden of their disabilities or handicaps (i.e. blindness,
polio, rickets, extensive burns etc.).
In sum, they are handled as an entity with no soul or desire.
The shelter population, helped by promiscuity, becomes gradually acculturated to its new cohort loosening
the traditional prevailing inter-relation-ships now governed by cultural breaks. This leads to behavioral
changes mainly characterized by a loss of dignity.
It is against this background that the health service delivery system for the displaced is evolving. This
includes the handling of common findings, for instance, that communicable diseases ( which account for the
major part of the medical problems and are the leading causes of mortality and morbidity) worsen in the
appalling conditions of daily shelter life.
People in shelters feel lonely among the masses and are unoccupied).. Over-crowding worsens the overall
condition of this human dramatic venture and sentences dozens of innocent victims daily with no appeal.
(Tables 1, 2, 3, and 4).
The Magnitude of the Problem Between 1977 and 1992 some 9.5 million civilians were displaced, excluding
refugees and returnees, due to draught/famine. and armed conflicts (fables 5a and 5b).
Displacement was also due to settlement schemes. To cite but one example, from November 17 to September
5, 1985, some 604,905 people were moved from five administrative regions to six other administrative
regions (fables 6a, 6b, 6c, 7a and 7b). As of February 27th, 1992, some 90,092 people were displaced in
Sidamo alone due t\1 inter-ethnical conflicts (Table. 8a, 8b and 8c). As elsewhere, however, massive
population movements in Ethiopia do not go without heavy losses in human lives. According to the records
of the Relief Department of the Relief and Rehabilitation Commission (RRC), some 72,055 deaths occurred
in the three fiscal years of 1984, 1985 and 1986, and out of these, at least 44.7% were under 15 years of age
(fables 9a, 9b and 9c).
According to further reports of the Information Centre of the RRC, the situation in the shelters is a
nightmare:
-from 2.18.84 to 9.11.84,1,218 children under 15 years of age died, and of these, 73% were below six years
of age;
-in the same period (2.10.84-9.11.84) the total number of deaths was 545 for the three sites, (i.e., in the
shelters, feeding centre and in the town of Korem), and of these, children from 0-6
[ years of age represented 39.26% (fables 8a, 8b and 8c)
It is recorded in the reports forwarded from the branch offices of the RRC for three consecutive years (1985,
1986, and 1987) that the country also lost some 1 ,344,628 domestic animals (cattle, goats, camels, horses,
mules and donkeys) (fable 10).
INVOLVEMENT OF PUBLIC HEALTH IN CATERING TO THE DISPLACED POPULATION
Health manpower is an obligatory component of all activities catering to the displaced population.
It is the single most important activity for those members who are living under permanent stress, stretched to
the maximum through endurance and hardship. Unfortunately, the displaced population are often failed by
extreme shortages of drug and medical equipment supplies. The tools forwarded to the medical manpower
in this type of undertaking have, in my experience, fallen far short of the needs. Operational expenses, in
particular for an effective medical intervention, have been very low and difficult to obtain (fables 5a, 5b, and
14). The following points are the highlights in which the field medical professionals were involved.
Setting up a shelter
-locations are not always adequate nor are they always chosen with the knowledge of health professionals the
few exceptions are Bete in Northern Shoa, Kobo, and Alamata);
-participation in their design is to allow for an easy flow of people and goods.
2.setting a medical activities quarter within the generation sheltercomprising:
-an OPD (out-Patient Department)
-inpatient area with due consideration to aeration, light, etc.
3. Providing isolation areas, for patients with:
-measles; whooping cough; hepatitis; diarrhoeal diseases; TB. Also orphans may require a separate facility as
does a feeding centre (the size depending on the under-five population) with its different components, in
particular the therapeutical (super internal, intensive, supplementary, etc.), feeding (Table 11).
4. Providing for delousing:
-steaming of clothes;
-mass treatment for scabies;
-shaving (Table 12).
5. Select auxiliaries (youth, boy scouts), to:
-search for sick people within and outside the shelter premises;
-search for defaulters;
-distribute drugs;
-register patients;
-translate;
-spray DDT, etc.
6. Providing for the adjustment of medical personnel to the demand (an extreme fluctuation in the shelter
setting was a known trend, hence the need for a radio network.)
-In Ibenat, at the end of April 1985, the number of people was around 48,000 people.
-From 29.4.85 to 2.5.85 the number increased to 60,000 people, and in early June 1985, the.population
reached 125,000.
-At the end of June 1985 the population decreased to 20,000. In Korem, 600 patients were admitted in
August 1984, while in September 1984 the number was 1,263 of this increase necessitated that a third ward
be opened at this time).
In Debre Berhan on February 9, 1985 the estimated number of draught victims in the camp was 3,000 people.
Some 1500 people had found shelter in the rooms and in the eight tents supplied by the Kebeles. The
remaining people were sleeping outside; their thin clothing inadequate to protect them from the cold nights of
the highlands. The number of new arrivals averaged 150 per day.
From the 17th of November 1985 to the 26th of December 1985, the RRC used Debre Berhan camp as a
transit camp where drought victims from northern areas would spend one night on their journey by bus to
settlements in the south. Some 41 transit operations occurred during the aforementioned period involving
some 109,500 people on their way to settlement areas. (Tables 8a and 8c).
7 .Developing a water supply
8. Providing sanitation:
-during the dry season there was no problem;
-during the rainy season latrines were filled up very quickly, the ground water level rose, and new latrines
had to be dug on a continual bases.
9 .Providing clothing
In Ibenat from January to March 1985 there were some 48,000 people living outside the shelter in 200 tiny
huts and 50 tents. "These 48,000 were living under dreadful conditions in tiny huts made from sticks, straw
and maize stalks."
The same observation was made for those displaced people living around the shelters in Korem, Harbu,
Debre Berhan, etc.
10. Providing energy:
-kerosene burners with a supply of kerosene were provided when possible;
-firewood was also provided (out of RRC's experience it is calculated at the rate of 1m 3 for 500 people in a
shelter situation).
11. Providing a grinding mill
In Korem during October 1984, the rate of in-patient admission was 50 to 70 per day. The report during that
period states that most of the people ate the grain obtained from the dry ration distribution directly without
grinding it. Naturally one would not expect the grain to be absorbed.
12. Protecting the minor from Psychological
What are the Problems encountered generally and the activities Performed in shelter situations?
a) People suffer from communicable diseases
b) Outbreaks of epidemics occur
c) Malnutrition increases
d) Vaccination programmes are needed
e) Prophylactic treatment (RF -Malaria) is given
f) Deliveries are performed
g) Cooperation between agencies is straightened
What are the shortcoming
a) Insufficient health manpower
b) Failure of the flow of food supply for drivers due to:
-the unavailability of food;
-the inaccessibility of the areas to be assisted;
-a shortage of vehicles;
-food spoiled by rain;
-misunderstandings creating an imbroglio between donors and the RRC;
-security problems, be they inter-ethnic group conflicts in the shelter or conflicts between the
shelter population and local people;
-obligations to change shelter locations; for example from Ibenat to Addis-Zemen in January
1985 because the road from Addis Zemen to Gondar was closed for several weeks in January
1985.
In general, when displacement is caused by an armed conflict the shelters become attractive for the enemy.
Therefore, the displaced population may sustain more casualties than a dispersed population because of the
concentration of people. On the other hand, there is always a risk that conflicting parties will spoil the
already heavy atmosphere of shelters by open or undercover operations and activities sweating their goals.
c) Shortage or lack of funds for medical activities and operational expenses (i.e. per diem, vehicle, fuel, etc.)
d) Shortage of drug and medical equipment
e) Overlapping of resources -generally an existing health structure in the vicinity of shelters is not requested
to close down temporarily to transfer all its supplies in the shelter set-up.
f) Shortage of water supply and supplies for individual hygiene (i.e. soap, clothing, etc.)
g) Total lack of social/occupational activities
-rehabilitation, in principle, should start as soon as people are in the shelters
h) Outbreak of epidemics.
In IBENAT alone, the following outbreaks were witnessed:
-in March 1985 an epidemic of measles accounted for the majority of the 243 deaths which occurred;
-in June 1985 there was another epidemic and 3568 children were vaccinated;
-from August to September 1985 an outbreak of meningococcal meningitis resulted in 22 cases and five
deaths.
In Harbu from 5.l1.84 to 27.12.84100 of the 1848 deaths which occurred were due to hepatitis (1.11.84 to
14.12.84).
Inconsistency in the calculation of rate individual ration rates (Table 13):
-during 1982-1983:
-grain: -700 gm/day/person for pastoralist adults, 500 gm/day/person for other adults, 125 gm/day/person for
children below 10 years, 250 gm/day/person for children 10-14 years;
-supplementary: -100 gm/day/person for children below 10 years;
-vegetable/butter oil: -10 gm/day/person for all adults, 5 gm/day/person for children below 10 years, 10
gm/day/person for children 10-14 years.
-in 1984 at Harbu:
-grain: -15 kg/person/month for all adults, 7 1/2 kg/person/month for children 6-15 years;
-supplementary: -100 gm for children 0-14 years;
-vegetable/butter oil: -20 gm only for adults.
The EWS and Planning Department of the RRC acknowledged this fact in the operation implementation
review of 1986 and expressed their preoccupation as follows:
..." A problem of which the RRC has been aware for some time and which can be noted clearly from the
voluntary agencies response during this latest planning exercise is the widely differing daily ration
distribution rate used from agency to agency.
Such an occurrence may lead to an insufficient use of resources, misunderstandings amongst beneficiaries
living in the same area receiving different rations and, in some cases, basic survival rations not being
covered.
The RRC will be studying this problem and with the relevant expert advice, will be proposing a National
Standard Ration Rate which will be followed in all dry rations distribution programmes throughout the
country. "
On the other hand there are different type of combinations, as for example:
-premix;
-family ration;
-individual ration, etc.
CENTRIFUGAL PHASE
This phase starts with the official evacuation of the displaced people from the shelters where they had been
cared for up to that time. The alternatives in this kind of operation are as follows.
1. Those for whom the vicious circle is perpetuated
The displaced people in Dessie shelter from 1974 to 1984 (originally 30,000 people) were evacuated to other
shelters in Korem after they had already experienced ten years of shelter life.
2. Those displaced returning to their original residential areas
In Mekele and Quiha camps 45,817 people were evacuated to their respective awraja at the end of 1985 EC
(Ethiopian Calendar); In the Ogaden 15,956 people were evacuated from Kebri Dehar and Kelafo camps, in
1984 EC.
3.. Those displaced people having migrated to neighbouring administrative regions
In Ibenat, Gondar Administrative Region, ill July 1985 EC some 166,127 people were repatriated. Their
composition was: 58% from Wollo Administrative Region, 1% from Tigrai Administrative Region, and 41 %
from Gondar Administrative Region.
The logistical needs to repatriate the displaced was complex and the condition was worsened by the
inaccessibility of some areas of repatriation. By foot the shortest distance for those displaced from Wollo was
a three day journey. The returnee needed to have at least a one month ration of grain when they left the
shelter (15kg/-person/month). The evacuation of Debre Berhan camp on 17 March, 1985 involved some
8,510 people originating from Tigrai, Wollo, Gondar and Shoa.
4. Those displaced moving to settlement areas include the following:
Examples of displaced people moving from highlands to lowlands.
-910 people were moved by helicopter from Ibenat to Metema (both in Gondar administrative region) on the
26th, 27th and 28th of April, 1985;
-the settlers from Sidamo were moved to Metekel (Gojjam administrative region);
-around 13,000 displaced highlanders of Wollo moved to Bale after three months of stopover in the
Denakillowlands between 1985-1986. For people moved to settlement areas the journey was generally long,
and varied between 10 to 15 days.
Expected Medical Participation in the Course of Evacuating Shelters
In spite of a general evacuation there are always displaced people who remain in the shelters. These are:
-handicapped people, crippled, elderly patients;
-children under therapeutic nutrition rehabilitation;
-unaccompanied and orphaned children.
For example there were 3,616 people still in Mekele and Quiha in August 1985 and 5,982 people still in
Ibenat in July 1985.
Thus, medical care has to continue for those left behind in the shelters. Medical care was also offered during
the journey and stopover with some cases referred to health facilities on the way.
Those better off as far as the immediate medical care is concerned, from all those repatriated are the settlers
for evident politico-economical reasons and impacts.
Behavior or Local Population at Destination
A feeling of encouragement and/or resentment can be felt as substantiated by the ICARA II mission in the
Ogaden (1987), with the settlers in Gode.
Settlers in conventional settlements cause a narrowing of the available arable land from the local farmers thus
decreasing their potential income. This is an underlying reason for the resentment of the local population
against the newcomers as substantiated by the research of Alemneh Dejene ("Peasants, Agrarian Socialism
and Rural Development in Ethiopia, 1987)
When settlers are moved, all the needed necessary public health majors are not taken into account. For
example:
-prophylactic treatment; vaccinations before departure, etc. ;
-preventive measures at the final destination point, i.e. spraying DDT in malaria endemic zones, protecting
water sources, etc.
SUMMARY
Medical experience in handling displaced people in Ethiopia is far-reaching. A solution to the lack in the
flow of information flow, however, should be found particularly when displaced people are called to be
moved from their normal ecological areas to newer ones.
Since its inception in 1974, the Relief and Rehabilitation Commission (RRC) has catered to several hundred
thousand displaced civilians in conjunction with the Ministry of Health (MOH) and the donors' community.
In fact, its actions have covered all administrative regions at one time or another in its 18 years of existence.
Repatriation of displaced civilians has and still is one of the major tasks and responsibilities of the RRC in
collaboration with other authorities and collaborating agencies concerned.
The health field in these endeavour has played and continues to playa prominent role. The general condition
and the degree of dependency of displaced civilians calls attention to the medical profession to come up with
tangible and affordable solutions to mitigate the degree of casualties on the basis of sound retro- spective and
prospective analysis. This in turn will help to alleviate the forcible causes of morbidity and mortality related
to civilian population movements, including their repatriation.
This presentation is an invitation to medical professionals to move towards retrospective analysis, as they are
aware of the scarcity of published materials in this area. Yet a wealth of information is lying unused in the
archives of many institutions in the country.
It is also an invitation for thorough epidemiological studies along with possible unusual clinical and/or social
manifestations of diseases, since the present population movements are likely to be one of the challenges for
health professionals for the coming decades. What will be needed, in an ever increasing way, is their utmost
methodological analyses with particular exigence in the flow of information with respect to their findings and
observations.
My plea goes to the liberation fronts, political party leaders as well as the Transitional Government
authorities, to help the health professionals perform and achieve their duties by allowing them to reach those
in need presently found in different parts of the country.
We will never be able to have an accurate estimate of the lives lost and the number of cases of malnutrition
with its devastating effect on the population, had we been provided with safe access to mitigate the
casualties.
To the teaching institutions my plea is to insist on the fact that research papers should also focus on health
matters related to repatriation aspects. Lastly, my plea is also addressed to the donors' community, that along
with their generous interventions in other fields of support for the Country, they also help our health
manpower capability building by sponsoring research undertakings including those studies of research
related to repatriation.
REFERENCES
I. Relief and Rehabilitation Commission. The Challenges of Draught: Ethiopia's Decade of Struggle in Relief
and Rehabilitation. H. & L. Communication UK., London, 1985.
2. S.P. Petrides. The Boundary Question Between Ethiopia and Somalia. People's Publishing House, New
Delhi, March 1983.
3. Zein Ahmed Zein. The Ecology of Health and Disease in Ethiopia. Ministry of Health, Addis Ababa, 1988.
4. Alemneh Dejene. Peasanta, Agrarian Socialism, and Rural Development in Ethiopia. West Review Presa,
June 1987.
5. Relief Department. of the RRC (unpublished). Years 1984, 1985 and 1986.
6. National Appeal Documents of the RRC (unpublished). Yeara 1981 through 1992 {yearly).
7. Haile Mariam Seifu, et al. Special report on repatriation of IBENAT. Relief Department of the RRC
(unpublished), 1985.
8. Haile Mariam Seifu, et al. Special report on repatriation of Mekele and Quiba. Relief Department. of the
RRC (unpublished), 1985.
9. Haile Mariam Seifu, et al. Special report on repatriation of Kelafo, Gode and Mustahil. Relief Department
of the RRC (unpublished), 1984.
10. I.C.A.R.A. II Misaion Report, 1987. 11. Christian Relief and Development Asaociation, Medical
Report, Debre Berhan, 1985.
12. Irish Concern, Medical Report (Wollo and Gondar Administrative Regiona), 1985 and 1986.
13. Medecina Sans Frontiere -France (MSF-F), Medical Report (Wollo Administrative Region), 1984 and
1985.
14. Relief and Rehabilitation Commission, Health Division, Medical Reports of 1984, 1985, 1986 and 1987.
15. Relief and Rehabilitation Commission, Settlement Department, Settlement Report, 1975 through 1987.
16. Dawit Wolde Giorgis. Red Teara: War, Famine and Revolution in Ethiopia. The Red Sea Press, Inc.,
January 1989.
17. Information Centre in the Early Warning System of the RRC, Daily compilation of radio network
messages, 1984, 1985 and 1986.
Table 1. Inquiry commission findings 24/7/1965-28/1965 EC (Ethiopian Calendar)
Sub-district
Wadla Delanta (Wollo)
Werehimenu (Wollo)
Borena Saint (Wollo)
Yejju
Total
Displaced
3317
866
4420
3743
12343
Ill
1500
2373
3068
6941
Dead
29
66
19
144
Table 2. Displaced people assisted in Shelter (Fiscal Year 1984)
Adm. Regions
0-6
6-15
Eritrea
59
100
Tigrai
346
577
Wollo
771
1345
>15
7464
2938
5188
Gondar
47
79
762
Hararge
Total
2713
3644
4260
5874
8983
21959
Ser.
No.
Regions
1
2
3
4
5
6
7
8
9
10
11
Eritrea
Tigrai
Wollo
Assab
Gondar
Shoa
Hararghe
Sidamo
Gamo Gofa
Bale
Gojjam
Total
Total
7623
3861
5188
6012
11200
888
4163
5051
15956
43961
0-6
M
F
6-15
M
F
>15
M
F
Total
M
F
133596
133628
272991
8499
25125
33122
52080
31444
10720
14774
98
716077
150059
152120
218451
8861
33142
34285
51674
32867
11482
19015
140
711881
165476
172441
260703
8861
38550
105368
70455
57520
28012
13870
120
921376
169011
184210
278015
8420
32705
100044
66572
50656
24372
16165
128
930298
381836
36369144
686479
14622
71495
213157
111245
107944
38686
35214
257
2030079
354894
435334
763514
15962
62050
219269
112032
99527
38957
44296
346
2146181
680908
675213
1120173
31982
135170
351687
233780
196908
77418
63858
475
3567572
673964
771664
1259980
33028
127897
353598
230278
183050
74811
79476
614
3788360
Table 4. People assisted in different Administrative Regions (1977 report, Relief Dept. Page 2)
No.
Adm. regions
Dry rations
Shelter
Total
1
Eritrea
1354877
2179
1357051
2
Tigrai
1446877
108528
1555405
3
Wollo
2380153
102559
2482712
4
Assab
65010
5
Gondar
263067
5046
268113
6
Shoa
705285
3855
709140
7
Hararghe
464058
646058
8
Sidamo
379958
379958
9
Gamo Gofa
152220
152220
10
Bale
143334
143334
11
Gojjam
1089
1089
Total
7355932
222167
7578099
Grand
Total
M&F
1354872
1446877
2380153
65010
263067
705285
464051
379958
152229
143334
1089
7355925
Table 5. (a)
Year
Distribution
and number
of
displaced
people
Bale
Sidamo
Harar
Eritrea
Gondar
Arsi
1977-1978
600000
250000
1200000
458000
1980
in several
Adm.
Regions
2400000
1982
in several
Adm.
Regions
1651000
1983
in several
Adm.
Regions
410000
1984
in several
Adm.
Regions
100000
1985
in several
Adm.
Regions
63700
1986
No shelter
Total
Ogaden
Tigrai
Wollo
Diredawa
Gondar
Shoa
Wellefa
Assosa
Addis
Ababa
1991
1571794
350000
83970
12930
2964
299350
52210
5510
14860
750000
1992
845637
152
43366
100784
88915
100000
115989
431150
18689
Gambella
17688
Total
sidamo
North Omo
W.Gojjam/
Metekel
Borena
22842
500
8210
136504
Medical assistance requirement
1982
1984
Drug and
2084 who kit (per
equipment worth
kit US $ 7,225 =
3294640
US $ 15056900
Drugs worth
1985
5 mobile med.
team
1986
Drug worth Birr
5,000,000
1991
147 Expatriate specialists
221 different med. equip.
106 types of drugs
1992
4,072 WHO Kit (per kit =
US $ 7,225)
=US $ 33971950
8,920,000
1986
309 Med. staff
Drugs worth Birr 16300000 worth drug
Fire wood: (1984)
91,728 m3 of fire wood
At a cost of Birr 20 [m3= Birr 1,834,560/1m3 for 500 people in a shelter for 1 year]
Table 5 (b). Assistance requirement different areas.
Year
1992
1991
1988
1987
1986
1985
1984
1983
1982
Population in need of
5,584,197
5,594,756
7,472,612
5,214,400
2,500,000
6,500,000
6,323,100
6,372,180
5,264,298
5,464,430
4,709,500
Food assistances requirement
Grain
Supplementary
967,748
165,046
-
Veg./Butt./Oil
32,991
-
1,264,759
1,002,149
938,529
367,248
1,080,000
1,124,876
1,127,300
4,561,462
872,380
402,479
19,898
7,874
23,420
37,984
27,344
106,009
14,645
10,758
1,046,719
409,203
1,243,777
1,260,855
1,248,620
505,200
878,087
701,296
88,229
34,081
116,000
97,984
93,980
384,530
65,809
-
Total
Table 6 (b) Settlers movement from November 17/84 to September 5/85
Settlers
regional
destination
Illubabor
Wellega
Keffa
Gojjam
Shoa
Gondar
Total
Origin of settlers
Wollo
Heads of
household
Dependent
s
25509
69489
19418
10981
125397
46717
151147
32313
18858
249035
Total
Tigrai
Heads of
household
Depende
nts
72226
220636
51731
29839
374432
21343
12472
7576
41391
24372
8895
15058
48325
Total
Shoa
Heads of
household
Dependents
Total
Gojjam
Heads of
household
Depende
nts
Total
45715
21367
22634
89716
8907
3648
2977
15332
2505
33369
19368
7631
3692
36526
3644
73861
28275
11279
6669
54858
6149
107230
3344
3344
13081
13081
16425
16425
Gondar
Heads of
househo
ld
2183
2183
Depe
ndent
s
Total
4204
4204
6387
6387
Depe
ndent
s
Total
Total
Heads of
household
Depende
nts
Total
55759
85609
29971
29657
2505
2183
205684
90457
167673
51063
71465
3644
4204
388506
146216
253282
81034
101122
6149
6387
594190
Total
Heads of
household
Depende
nts
Total
48587
85609
21567
22244
2505
2183
182695
79455
167673
40086
58184
3644
4204
35
128042
253282
61653
80428
6149
6387
535941
Table 6 (b) Settlers movement from November 17/84 to September 5/85
Settlers
regional
destination
Illubabor
Wellega
Keffa
Gojjam
Shoa
Gondar
Total
Origin of settlers
Wollo
Heads of
household
Dependent
s
19715
67489
11682
3610
104496
37110
151147
21457
5654
215368
Total
Tigrai
Heads of
household
Depende
nts
56825
220636
33139
9264
319864
20332
12472
7027
39831
23657
8895
14955
47507
Total
Shoa
Heads of
household
Dependents
Total
Gojjam
Heads of
household
Depende
nts
Total
43989
21367
21982
87338
8540
3648
2858
15290
2505
32841
18688
7631
3656
37449
3644
73068
27228
11279
6514
54739
6149
105909
333441
333441
13081
13081
16425
16425
Gondar
Heads of
househo
ld
2183
2183
4204
4204
6387
6387
Table 6(c) settlers movement from December 25/87 to May 25/88.
Settlers
Origin of settlers
regional
Wollo
Gondar
destination
heads of
Dependents Total
Head of
household
household
Gojjam
2501
2851
5352
Gondar
1764
Total
2501
2851
5352
1764
Dependents
Total
3599
3599
5363
5363
Total
Heads of
household
2501
1764
4265
Dependent
Total
2851
3599
6450
5352
5363
10715
Table 7 (a).
Year of
selection
1967
1968
1972
1975
Original residence Adm. Reg.
Previous Occupation
Shoa
Keffa
Wollo
Keffa
Shoa
Wellega
Arsi
Wollo
Hararge
Sidamo
Gamo Gofa
Keffa
Illubabor
Wellega
Shoa
Tigrai
Gondar
Gondar
Jobless
Farmers
Nomads
Number of head family
Male
Female
6968
Jobless
Farmers
7200
Farmers
4949
300
Farmers
480
2
Table 7 (b)
Location of settlement
Anderacha, Lemu, Dedessa, Gojeb, Kiche, Djeweha, Tedele,
Z/W, Asaita
Limu, Dedessa, Gojeb, Wesen-Kerke
Negesso, Awara melka Abderba, Addis Ketema, Meki, Dedessa,
Kersa, Waleme, Techmerei-Betcha, golgota, Dubti, Shenile,
Dama Arota, Tchano, Degra
Anderacha, Gambella, Angrutine, Assosa
Humera
Table 8 (a). Need for radio network
Regions
Figures of the National Appeal
Nov.-Dec. 1991
Wollo
43,366
Gondar
115,989
Gojjam
8,210
Hararge
85,915
Wellega
18,689
Sidamo
22,842
Gambela
17,688
Shoa
312,699
Total
Justification
To Create jobs for jobless people who have left Wollo and are looking for
jobs in other localities. Those who have had problems of arable land to
gather nomads
To assemble jobless people displaced because of a lack of arable land
Those farmers whose land has been taken over by state farms to gather
nomads
To gather those affected by drought and man-made disasters and those
unable to find arable land
To gather minorities populations and help them to organize themselves
To assemble those drought victims (from Gaint Awraja)
As of 27/2/92
87,804
210,075
9,110
179,151
15,239
90,092
22,905
31,899
646,275
Table 8(b). One month rations complied from daily radio transmissions.
Regions
Eritrea
Tigrai
Date E.C.
1-30/5/78
1-30/10/78
5/78-10/78
Wollo
5/78-10/78
Pop.
4779
592
55141
13675
128800
40971
Gr. Food
56.08
16.06
454.32
459.41
3504.00
3849.30
Supp.
2.01
0.75
467.64
81.12
223.53
292.12
Oil
21.14
0.73
36.63
32.38
71.37
102.14
Total
82.23
17.54
958.59
572.91
3798.95
4243.58
NB. 1) Quantity is in quintals
2) Quantities computed for an administrative region are generally lower than the actual figures because radio transmission may lag behind the
actual state of food distribution because of power interruption. (e.g. shortage of fuel)
3,500 Ethiopian returness
- in Ogaden
83,970
-in Tigirai
12,930
-in Wollo
2,964
-in Diredawa
299,350 -in Gondar
52,210
-in Shoa
5,510
-in Wellega
14,860
-in Asossa
750,000 -in Addis Ababa
1,571,794-in Total
Tigrai
S. Wollo
E.Hararge
Diredawa
Ogaden
N.Gondar
Addis Ababa
Wellega/Assosa
Gambella
Sidamo
N.Omo
W.Gojjam/Metekel
Borena
Total
43,366
115.98
43,150
18,689
17,688
22,842
500
8,210
270,434
100,784
100,000
136,504
337,288
Table 9. (a). Deaths reported from regional office as victims of draught and re;ated diseases.
Adm. Regions
Sub-district
<15
>15
Wollo
Waga
1824
916
Lasta
171
240
Wadladelanta
5
51
Ambassel
15
33
Rayana Kobo
17
30
Kalu
23
Total
2035
1266
Shoa
Merabete
7
10
Yererna Kereyu
Menzna Geshe
1
2
Total
8
12
Sidamo
Welayta
Hararge
Warder
8
13
Kebri-Dahar
6
2
Total
14
15
Table 9. (b). Deaths from natural calamities (1985)
Adm. Regions
0-15
M
F
Eritrea
37
46
Wollo
1116
971
Gondar
406
158
Tigrai
642
42
Shoa
Hararge
Sidamo
-
>15
M
63
1308
164
2
-
152,000
85,915
237,915
(1984 fiscal year/8.7.83-7.7.84)
Total
2746
411
56
48
47
23
3331
17
6
3
36
326
21
8
29
F
49
1391
133
94
-
Total
M&F
195
4786
861
1165
2169
9
132
8/7/4986-7/7/7987 (1987 Fiscal Year)
Adm. Regions
0-6
M
North Gondar
Eritrea
Shoa
3
Hararge
8
F
9
6-15
M
9
F
5
3
2
52
>15
M&F
5
3
5
69
Table 10. Domestic animals victims of draught (1985 and 1997)
TYPE
1977
GONDAR
WOLLO
HARARGE
ASSAB
SHEWA
SIDAMO
CATTLE
1977
21492
1978
78
1979
3004
1977
89
1978
538
1979
6
1977
121072
1978
150
1979
-
1977
61517
1978
140
1979
11950
1977
-
1978
-
1979
-
1977
23945
1978
-
HOURSE
, MULE
MONKEY
(PACK
ANIMAL)
GOAT
14394
33
21
-
635
10
33843
-
-
4061
49
400
-
-
-
77356
-
-
-
-
-
-
-
90677
-
-
110084
300
500
3000
-
-
31391
-
3692
-
-
8402
-
SHEEP
AND
GOAT
SHEEP
-
-
8
-
-
25
-
-
-
-
-
27400
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
236763
-
-
94427
-
200
3000
-
-
14875
-
2944
-
-
266
-
CAMEL
10
-
-
-
-
-
-
-
-
15931
-
5780
-
-
-
1819
-
682
-
-
-
800
COMBIN
ATION
187192
698
-
-
1130
-
-
-
-
-
-
77366
-
-
-
14
-
-
-
-
-
-
1979
1977
35539
1978
-
1979
-
GAMO
GOFA
1977
10237
2640
-
-
100
BALE
10
1977
3000
TOTAL
292754
97,584
248050
133192
44397
27433
248050
82683
352475
27433
3144
25022
352475
117491
265702
25072
8340
265702
88567
Table 11 From 7/7/84 to 8/7/85 Feeding center beneficaries (only selected shelters).
Mothers
Children <5 years
Wollo
Bati
916
2261
Korem
818
23962
Habru
675
2245
Gondar
Ibnat
3104
12260
Eritrea
Hamassen
624
15518
Others
1708
1922
3027
3084
87
Total
4485
26702
5947
18448
16229
Measurements
Sites
60%
Korem
3734
724
1642
1365
60-79%
>80%
Gondar
111
2
46
63
Enderta Tigrai
8082
408
3181
4463
Gamo-Gofa
2821
38
441
2342
Table 12.
Date
shaving
14.5.84 to
14.6.84
1 to
30.7.84
8.8.84 to
8.9.84
6.9.84 to
30.9.84
2816
scabies
treated
1594
7420
1807
8451(6869
new 157)
4890
(shaved
942)
2995
1970
1320
14
12
2414
844
53
7
shaving
4890
Steaming
1234
Saving
7098
steaming
933
1.10.84 to
30.9.84
1.10.84 to
30.11.84
1.12.84 to
8.1.85
Health
educ.
1892
Delivery
Abortion
Death
OPD
Injection
Dressing
15
4
95
21
111
28
111
4483
1948
3318
4442
1441
3219
1441
123
230
2354
72
347
1943
3257
2127
5843
5
551
12
21
3949
82
4961
Table 13. Rate of ration distributions in different years.
Year
Grain
Adult
Pastoralist
others
Under 10-14
10 yrs
yrs
1982/83 700gr
500gr
125gr
250gr
1984
700gr
700gr
4 to 14 350gr
1986
1987
1988
-
Measles
Hepatitis
366
Inpatient
1441
123
433
77
579
1319
2437
215
709
315
1263
707
41
4871
3534
593
2290
153
40
477
10455
5636
1101
2915
432
11918
10734
1171
2534
16
Supplementary
Veg. Butter oil
under 14
yrs
100gr
100gr
10-14
yrs
10gr
-
under 14
yrs
5gr
-
Adult
-
10-14
yrs
100gr
500gr
500gr
500gr
100gr
100gr
100gr
100gr
100gr
100gr
-
-
20gr
20gr
20gr
All
Table 14. Drug and medical equipment distributed of different administrative region.
Ser Date
No. of
Total
Bale
Wollo
Tigrai
Addis
no
sites
Ababa
1
1/11/74
8
413230.78
65302.24 35222.29 3397.00 19458.35
2
1/2/7541
290921.78
7573.80
5297.67
30/4/75
3
25/4/7568
203540.00
433.39
16594.50 3859.20 9.99
20/7/75
4
21/7/7528
447013.14
80748.43 29304.64 18699.11
20/9/75
5
1/11/76in 13 adm. 5134000.72 30/10/77 reg.
+ 2937 box
6
1/5/78in 18 adm. 11750.54
3138
33219.83
18/7/80
reg.
N.B. US $1=2.07Eth birr
Typhus
30
deaths
10gr
20gr
Gondar
Keffa
Wellega
Hararge
-
14958.61
-
23370.29
-
20524.75
10981.95
28708.80
1278.56
14797.82
2352.74
35031.41
22189.22
155542.63
17284.47
-
-
-
-
15307.90
-
67429.15
12397.96
DISCUSSION
Chairperson -Dr. Hailu Kefenie
Speaker -Dr. Tamirat Retta
Rapporteur -Dr. Yemane Berhane
The speaker started his presentation by reminding the audience that displacement and repatriation are not
new to Ethiopia. He explained that the Ethiopian people have suffered from armed conflicts and natural
calamities for a long time.
Repatriation in this presentation included those displaced within the boundaries of the country, those
displaced within the limit of their respective administrative regions/awrajas (sub-districts) and those people
to be moved to settlement or resettlement areas. The repatriation process was explained to have three phases:
a) Centripetal Phase - the time victims leave their localities when no more resources are available for their
survival;
b) Journey Phase - the movement of displaced people with single or multiple stopovers;
c) Centrifugal Phase -thee start of an official evacuation of displaced people from the temporary shelters
where tltey received emergency care to places where they can be assisted better, for example to settlement
areas.
The medical problems associated with the journey phase are determined by the length of the journey, the
distance between the stopovers and the availability of basic infrastructure in the area. Generally, medical
problems occurring in this phase were handled by mid-level medical staff, unless vehicle or explosive
accidents occurred on the line.
CENTRIPET AL PHASE
The victims of either war or drought leave their localities when no more resources are available for survival.
They mostly move following main communication roads, regular market locations or main boundary gates.
On the road, victims form small groups to help each other . The journey usually ends in places where victims
find some means for survival or in places which enable them to attract the attention of the concerned
authorities. In such places the crowd quickly gets bigger and the authorities in the vicinity are forced to erect
shelters and to provide food, water and other essential care, including medical care. These operations, most
of the time, are executed under hectic and dramatic conditions with no respect and regard to the victims.
Although communicable diseases are known to be the leading cause of morbidity and mortality in the
shelters, the cultural, social and psychological breaks caused by the shelter life are beyond imagination.
Unfortunately, these do not receive enough attention by the care providers in the shelters. Displacement in
Ethiopia in the last two decades was mainly due to drought, war, settlement schemes and inter-ethnical
conflicts.
Between 1977 and 1992 some 9.5 million civilians were displaced in this country , excluding refugees and
returnees. It was also mentioned that in only three years (1976-78 EC) some 72,055 deaths were recorded by
the relief department of the RRC. Of these, about 44.7% were children under 15 years of age. Other
specific events were also discussed in greater detail.
The health professionals who are stretched to their maximum capability to provide care to the displaced
people are living under permanent stress. No information is provided to them or nor are they consulted until
an overt medical problem prevails in the shelters. Most often the health service providers fail to alleviate the
health problems and their consequences due to an extreme shortage of supplies, insufficient manpower, or
lack. of operational expenses.
The major health problems encountered in the shelters of the displaced people were communicable diseases,
with outbreaks of epidemics and malnutrition. To alleviate these problems vaccination, prophylactic
treatment, particularly for relapsing fever and malaria, basic medical care at the outpatient and in-patient
level, provision of water and sanitary facilities and food distribution were undertaken with some success.
Shortcomings of the shelter health service delivery:
1. Insufficient health manpower .
2. Failure of flow of food supply due to:
-unavailability of food
-problems in food distribution operations
-lack of infrastructure
-security problems
-inconsistent allocation of rations for individuals.
3. Shortage or lack of fund for medical expenses; i.e., supplies, drugs and operational expenses .
4. Shortage of water supply and supplies for individual hygiene, like soap.
5. Total lack of social/occupational support.
6. Outbreaks of epidemics -measles and meningococcal meningitis outbreaks were the major ones causing
considerable human suffering and death.
CENTRIFUGAL PHASE
This phase marks the official evacuation of the displaced people from the shelters. The alternatives in this
kind of operation were discussed as follows:
1. Those for whom the vicious cycle is perpetuated.
-these are people who are moved from one shelter to another shelter [i.e. from shelter life to another shelter
life].
2. Displaced people in the shelter returning to their original residential areas.
3. Displaced people in the shelter moved to settlement areas.
Complex logistic requirement and inaccessibility of some areas of repatriation are the main problems in this
phase. The journey to repatriate the displaced people is usually long varying from three days to 15 days, with
multiple stop-overs. The returnee must have at least one month of rations when they leave the shelter (15
kg/person/month). In spite of the general evacuation operation, there are always displaced people who will
remain in the shelters. These are handicapped, elderly people, and children who are either sick or
unaccompanied. Therefore, medical care had to continue for those left behind in the shelters. Of all the
repatriated, settlers are assumed to receive better immediate medical care for obvious political reasons. Still,
these people suffer from endemic diseases like malaria for simple lack of prophylactic treatment and
preventive measures before and at the final destination. The behaviour of the local people at the destination
point has also caused considerable psychological damage to the settlers.
In general, the speaker emphasized that medical experience in handling displaced people in Ethiopia is rich.
But, he mentioned that a lack of the floe of information has blocked the wide-spread use of those rich
experiences. Therefore, he invited medical professionals to retrospectively analyze the information lying
unused in the archives of many institutions to further enrich the knowledge in this area since the problems
associated with displacement and repatriation are still among the major problems of the country. Lastly the
speaker requested:
-liberation fronts, political parties and the Transitional Government authorities to help the health
professionals to perform and achieve our duties by allowing us to reach those in need presently in different
parts of the country;
-teaching institutions to focus on health matters related to repatriation in their research works;
-the donor's community to support our manpower capability building by sponsoring research undertakings
including studies of research related to repatriation.
FURTHER DISCUSSION
At the end of the presentation the following comments and questions were entertained. Two people from the
audience expressed their appreciation to the speaker for presenting the situation so nicely and for the effort
done so far to help the displaced people. They also expressed their feeling about the need to develop early
warning systems and suggested that the report of this workshop be sent to the concerned government
authorities.
The other comment emphasized the complexity of the health impact of population movements, dealing only
with emergency situations. Starting from now we have to divert our attention from crisis management to
planned management of such situations. It was also mentioned that we have to expect problems associated
with diseases with a long incubation period, which may not yet have exerted their effect on the society.
Another comment was focused on the concept of self-reliance. It was explained that as we have become
perpetual beggars, donors seem to be tired of us. Therefore, effort must be consolidated to try to contain the
problems ourselves as far as possible.
Q. What has been done in the past and what is the plan in regard to disaster prevention/early warning?
A. We believe that prevention is better than a cure. So, to mention some, a detailed report was submitted to
the central government before the disaster of 1984, but due to the prevailing other priorities, there was no
reply. The same year (March, 1984) the RRC applied to the international donor community but resources
appeared only after five months. This disaster was aggravated by cheap apathy and politicization. In the
future, since the problem is multifaceted and not the domain of only medical people, our appeal is to the
Transitional Government and to political organizations to let us do our job and help us with the rest.
Q. Can you elaborate on the relationship between the Ministry of Health (MOH), the Ethiopian RRC Cross
society and the RRC? A. The medical department is one of the main departments in the RRC, and its
activities are well coordinated with the MOD and other health related organizations. There are about 47
NGOs working with the RRC with the permission of the MOD.
A. Regarding the emergency situations, we have no problem because our policy is clear. We also have tried
to support the MOH even in its planned activities.
Q. What is the RRC involvement in capacity building (rehabilitation) of displaced people? Do you deal with
the psychosocial problems?
A. We mainly deal with emergency situations because of the limited resources we have. Nevertheless, we
have tried to help the displaced people by providing farming tools and seeds, and by helping in irrigation and
land protection activities. The unfortunate thing is what little we have done and the considerable number of
health infrastructure that has been destroyed by the war .
Finally, the moderator closed the session by suggesting to the organizers of the workshop that they pass the
knowledge gained in this workshop to the concerned authorities and institutions. He also emphasized that
such matter cannot be fully tackled at once, and therefore needs follow-up.
Participating Organizations
1. Department/Regional Heads, Institutes, Ministry of Health
2. Ethiopian Public Health Association
3. Department of Community Health, Faculty of Medicine, AAU
4. McGill-Ethiopia Community Health Project
5. Ethiopian Red Cross Society
6. United Nations High Commission for Refugees (UNHCR)
7. Relief and Rehabilitation Commission (RRC)
8. Christian Relief Development Agency (CRDA)
9. Ministry of Interior
10. The Commission for the Rehabilitation of Members of the Former Army & Disabled War Veterans
11. United Nations Development Program (UNDP)
12. World Bank
13. All Africa Leprosy Training Center (ALERT)
14. National Research Institute of Health (NRIH)
15. Ethiopian Nutrition Institute (ENI)
16. International Red Cross Society
17. World Health Organization (WHO)
18. Food Agriculture Organization (FAO)
19. World Food Program (WFP)
20. UNICEF
WORKSHOP ATTENDANCE
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
4
46
47
48
49
50
51
52
Name
Dr. George Olwit
Dr./Mesfin Kassaye
Dr. Meaza Demissie
Dr. Yemane Berhane
Dr. Adem Ibrahim
Dr. Girma Kebede
Dr. Filimona Bisrat
Dr. Shabbir Ismael
Mr. Ali Beyene
Dr. Madeline Fletcher
Ato Gabre-Emannuel Teka
Dr. Charles Larson
Dr. David Zakus
Dr. John Tabayi
Dr. Fisseha HaileMeskal
Haddis T/Medhin
Ephrem Assefa
Dr. Adane Makonne
Dr. Assefa Amenu
Mr. Masresha Zenebe
Birarra Gambella
Asnakew Yigzaw
Tizazu Tiruye
Shimelis Bekele
Gebre Madebo
Tesfaye Shiferaw
Abebe G.Mariam
Dr. Fikreab Kebede
Joyce Pikering
Jemal Abdulkadir
Dr. Kassahun Mitikie
Getachew Gizaw
Begna Bekele
Gebissa Tolossa
Roma Hein
Bekure Hawaz
Tamirat Retta
Yirdaw
Mirian K.Wge
Hailu Kefenie
Mulugeta Ersumo
Tadele Tedla
Befekadu Girma
Gebre Medhin Kidane
Teshome Desta
Eyoel Jarsa
Ashenafi Mamo
Dr. Degefu
Dr. Seid Mohammed
Elias Lemma
Solomon Endale
Belachew Degene
Name of Organization
McGill-Ethiopia Community Health Project (MECHP
Dept. of Community Health, Addis Ababa University
"
"
"
"
"
"
"
"
Ministry of Health, Bale RHD
Wollo RHD
Dept. of Community Health, Addis Ababa University
"
"
"
"
Ministry of Health, PPD
Dept. of Community Health, Addis Ababa University
"
"
"
"
McGill-Ethiopia Community Health Project (MECHP)
"
"
"
"
UNHCR
National Research Institute of Health (NRIH)
Ministryof-Health (MOH)
ARRA
MRHD
MRHD
Ministry of Information
RHD
S.Gondar RHD
W.Gojjam RHD
S.Hararge RHD
Sidamo RHD
Jimma Institute of Health Sciences (JIHS)
E.Gojjam RHD
E.Shoa RHD
McGill-Ethiopia Community Health Project (MECHP)
Medical Faculty, AAU
N.Gondar RHD
Ethiopian Red Cross Society(ERCS)
Ministry of Health, EHD
Arsi RHD
UNICEF
Ministry of Health
Relief & Rehabilitation Commission, RRC
Ministry of Health, Public Relation
World Health Organization(WHO)
Armed Forces General Hospital
N.Omo RHD
Ministry of Health
A.A. RHD
Malaria Control Organization
Ministry of Health
"
" "
ARA
PH
Illubabor RHD
ETV
ETV
ETV
No.
53
54
55
56
57
58
59
Name
Melake Berhan
Saba Wolde Michael
Teferi Asfaw
Hailegnaw Eshete
Derege Kebede
Haile Selassie Tesfaye
Seyoum Taticheff
Name of Organization
Gondar College of Medical science (GCMS)
Dept. of Community Health, AAU
On behalf of the commissioner, Relief & Rehabilitation Commission (RRC)
National Research Institute of Health (NRIH)
Dept. of Community Health, AAU
National Research Institute of Health (NRIH)
"
"
"
Publication of this issue was financially supported by Addis Ababa University,
the Ethiopian Science and Technology Commission (SAREC),
and the McGill-Ethiopia Community Health Project.