Fast track — ArticlesViolence and mortality in West Darfur, Sudan (2003–04): epidemiological evidence from four surveys
Introduction
The situation in Darfur, Sudan has drawn increasing international political and media attention.1 Although much interest is justifiably directed at relief needs, the violent events that brought about the humanitarian crisis have also come under scrutiny.
The present conflict in Darfur began in earnest in February, 2003, with the emergence of two anti-government rebel groups (the Sudan Liberation Army and the Justice and Equality Movement). The ensuing anti-rebel offensive, led by pro-government Janjaweed militia and Sudanese army units, resulted in the displacement of more than one million people within Darfur itself, and the flight of about 188 000 to neighbouring Chad up until August, 2004.2, 3 Militia attacks in particular were blamed by refugees and internally displaced people for indiscriminate killings, rape, abductions, cattle and property looting, and razing of villages.4
Available evidence on the extent of violence in Darfur largely relied on testimonies from refugees in Chad, or mostly non-quantitative assessments done when access was possible in selected sites within Darfur itself.5 Estimates of the number of people killed increased progressively from 3000 in January6 to 10 000 in April,7 reaching 30 000 to 50 000 in July, 2004.8 To our knowledge, however, these figures did not represent systematically gathered epidemiological evidence, mainly because of the dire absence of international relief organisations working on the ground within Darfur. Factors accounting for this lack of assistance included ongoing insecurity, severe governmental restrictions on the entry of international aid staff and material to Darfur, and low institutional donor interest.
Médecins Sans Frontières (MSF) was one of the first non-governmental relief organisations to obtain an authorisation to work in Darfur. Beginning in December, 2003, the French section of MSF gradually implemented nutritional, medical, and water and sanitation programmes in several sites for internally displaced people in West Darfur state. As part of comprehensive, site-specific assessments of the health and nutritional status of these populations, we retrospectively measured the extent and causes of mortality both before and after displacement to these sites. We also investigated the effect of the events on demographic structure.
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Methods
We did two-stage, household-based cluster surveys in four sites of West Darfur (Zalingei, Murnei, Niertiti, and El Geneina) after estimating numbers of internally displaced people through a combination of community health worker censuses, shelter counts, and area mapping (details not shown).9
Internally displaced people lived either in clearly identifiable camps (consisting mostly of minuscule thatch or cardboard structures crowded together without any evident spatial planning), or had mixed
Results
Surveys took place on 24–27 April (Zalingei), 3–8 May (Murnei), 22–26 June (Niertiti), and 26–29 June (El Geneina), 2004. No refusals to take part in the survey were reported. The main characteristics of surveyed populations are shown in Table 1. Among people present on the survey date, the proportions of people younger than 5 years were as expected for sub-Saharan Africa, but the overall male-to-female ratio showed a deficit in male people (Table 1). Age/sex pyramids were skewed (figure 2),
Discussion
The four surveys we present, which were done in difficult and insecure field conditions, are representative of about 215400 internally displaced people—43% of the total estimated population of 500800 internally displaced people in West Darfur in July, 2004·2 These findings provide data on demographic events affecting a large Darfurian population of internally displaced people in the periods before and after displacement, and clarify the contribution of violence to mortality in this population.
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