In Karamoja, in northeastern Uganda, malnutrition is cyclical and chronic. However, the poor rains last year and late rains this year mean that there is little or no harvest. Only now are people planting their peanuts and sorghum. Inflated food and fuel prices are exacerbating the situation, resulting in clear pockets of malnutrition.

Médecins Sans Frontières (MSF) was undertaking an assessment in the Karamoja area in north-eastern Uganda, when in February 2007, an assessment by the World Food Programme (WFP) in the same area revealed that 20 percent of those surveyed were suffering from acute malnutrition.

In response to these findings, MSF opened an ambulatory therapeutic and supplementary feeding programme for children under five in the worst-affected district: Kaabong in the north of Karamoja. MSF staff currently run ten ambulatory clinics - where both severely and moderately malnourished children come for check-ups and to receive food rations - and one stabilisation centre at the district hospital, where severe cases and those with complications are admitted.

Between January and June 2008, 593 severely malnourished and 1,846 moderately malnourished children were admitted into the programme and a further 390 children were admitted to the stabilisation centre. An MSF nutritional survey in November 2007, and a World Food Program (WFP) nutritional survey in February 2008 in the north of Karamoja, indicated that the situation is improving. In November, the MSF survey showed a rate of 15.3 percent global acute malnutrition (GAM), while the WFP survey showed a rate of 9.1 percent.

However, the situation in the south of Karamoja has deteriorated, prompting MSF teams to launch nutritional interventions in June 2008 in Moroto and Nakapiripirit districts. More than 13,500 children were screened in 20 different sites across the two districts, with 1,400 admitted into the feeding programme so far. In some areas, 60-90 percent of the kids also have malaria.

Tackling disease outbreaks

In November 2007, the first cases of Hepatitis E were diagnosed in Kitgum. Hepatitis E is a viral infection caused by drinking contaminated water. There is no cure or vaccine - all that can be done is to relieve the symptoms by methods such as rehydration. If the patient survives the infection, the virus disappears and the liver recovers.

MSF teams in Kitgum have focused on trying to prevent any further spread by constructing latrines, chlorinating water and through public health promotion. By June 2008, MSF had treated 1,290 Hepatitis E patients and recorded only 34 deaths.

At the end of 2007, MSF responded to an outbreak of Ebola haemorrhagic fever in western Uganda. MSF teams constructed isolation facilities in the two key areas of Bundibugyo and Kikyo using a team of highly experienced international personnel. The team provided specialised care to patients, psychological attention, plus safe water and sanitation services to reduce further infection. MSF also assisted the community with safe burial teams, community education and awareness campaigns, which allowed the team to contain the epidemic. The intervention ended in January 2008.

Between January and April 2008, MSF treated 845 patients during a cholera outbreak in Arua district. At the height of the outbreak, up to 40 patients were admitted each day to the cholera treatment centre (CTC) in the Oli neighbourhood of Arua town. MSF also worked to expand access to safe drinking water in three of the sub-counties where the highest number of cholera cases were recorded, providing 4,232 cubic metres of water between March 21 and April 14. In addition, MSF assisted with chlorination at hand pumps and various city water points in badly affected areas.

Refocusing activities in camps for displaced people

In many parts of northern Uganda the humanitarian situation has improved. Better security has led tens of thousands of people who were displaced by the conflict to move back to 'satellite camps'. However, hundreds of thousands continue to stay in the larger camps and the situation remains precarious. In the absence of a peace agreement many people continue living in fear of renewed attacks.

Nevertheless, the improvements in local security in recent years have resulted in an increase in the capacity of the Ministry of Health (MoH), although adequate staffing and drug supply continue to remain a problem. Throughout 2007 and early 2008, MSF handed over most of its basic health care activities in the larger camps to the MoH.

In some areas, such as Kitgum and Gulu, MSF teams have refocused their activities on secondary care and HIV/AIDS care. In Gulu district MSF handed over two health clinics in Awere and Awoo camps, in April and June respectively. MSF teams are currently upgrading the health centre in Lalogi, about 35km south east of Gulu town, in order to provide comprehensive secondary health care, including maternity, inpatient care, ambulatory assistance and HIV/AIDS-TB care.

Between January and June 2008, a total of 30,896 consultations were carried out in these three sites, out of which 982 were patients admitted to the Lalogi clinic's inpatient department.

Caring for people living with HIV/AIDS

According to the World Health Organization (WHO) and UNAIDS, there are more than one million adults and children living with HIV/AIDS in Uganda. Approximately 220,000 of these are thought to clinically require anti-retroviral therapy (ART).

MSF has been providing HIV/AIDS care in Arua since 2001. By the end of December 2007, 11,618 people were enrolled in the programme, with 4,090 of them on ART. The programme includes treatment for TB/HIV co-infection, nutritional support for malnourished adults and children living with HIV/AIDS, in addition to a programme to provide prenatal care and prevent the transmission of HIV from pregnant women to their unborn children (PMTCT).

As of June 2008, 782 people had been treated in the nutrition programme. Between January and June 2008, 231 women were enrolled in the PMTCT programme.

The number of children under 15 years of age on ART has increased in the past year, with a focus on case finding and sensitisation from the medical team and people living with HIV/AIDS support groups. These groups provide health talks and group discussions, lead awareness raising sessions in their communities and provide volunteers to look after children and adult patients without caretakers.

In the northern district of Kitgum the HIV prevalence is estimated to be 10 percent. However, only one missionary hospital was providing ART until MSF established HIV testing and treatment in a MoH clinic in Madi Opei in 2007. The MSF team also worked on training local staff, supporting the in-patient ward and extending reproductive healthcare.

As of the end of June 2008, 288 HIV positive patients had been enrolled into the programme, with 55 of them receiving ART. Every month around 2,000 outpatient consultations are provided and 100 patients are admitted to clinic.