Central African Republic: Pressing health needs in the country

By Dr Unni Karunakara, International President, Médecins Sans Frontières

The Central African Republic (CAR) is a country largely forgotten by the world and to a large extent neglected by the international humanitarian community.  Surrounded by Sudan, Chad and Congo where more high-profile crises are taking place, CAR’s dire and desperate health situation – in which few people have access to health care and many die of easily treatable diseases – has received little attention and even less assistance. A significant effort needs to be mounted by the government and the international community to address pressing health needs in the country.

I have just returned from CAR where Médecins Sans Frontières (MSF) has a very significant commitment. We manage nine hospitals and 36 health centres and health posts. I was able to visit one of these hospitals, in Paoua, in the country’s north-west, which is managed in partnership by MSF and the government. Last year, we treated 610,000 people as outpatients in CAR and had a budget of roughly €20 million. Other humanitarian agencies also have significant presence in the country. And yet these efforts are not nearly focussed or effective enough to make a dent in the huge health needs.

Two years ago, worried by the severe health problems we were seeing each day in our clinics and hospitals, but lacking strong data on what was actually going on, MSF conducted five separate retrospective mortality surveys in different parts of the country. These showed death rates that indicate a very serious, indeed crisis, situation. In the worst case, in the western town of Carnot, we found death rates higher than those among Somali refugees fleeing the famine in that country in 2011, or among displaced people during the worst of the violence in Darfur in 2005 - crises that attracted enormous interest and action.

MSF’s newest mortality survey, carried out this spring in northwest CAR, shows children urgently need better access to healthcare: of those children who died before their fifth birthday, 60 per cent were found to have died at home, while 13 per cent died on the journey to hospital.

It should not be this way. This should be a hopeful moment for the country – by all accounts, the country is on the path to stabilisation. But what I heard, from everyone I spoke to, was that there the healthcare system is nearly non-existent and no-one believes that any of the health-related Millennium Development Goals will be met before 2015. Little is being done to confront the spread of HIV, or vaccine-preventable childhood diseases like measles or malaria.

It is malaria that is most frightening. It is “holoendemic” in CAR – meaning, essentially, that every single person gets infected with it at least once each year. It is the major cause of illness – in our own facilities, it accounts for just under half of all consultations. And it is the single greatest cause of death, especially among young children.

It angers me that this can be the case when we have all the necessary means at our disposal to prevent infection altogether. There are rapid diagnostic tests allowing the disease to be spotted quickly and easily, there are medicines which are effective, easy to take and relatively inexpensive, and there are bednets treated with long-lasting insecticide.  We also know that an approach using local people living in the community to diagnose and treat the disease could offer a cure even in the remotest village.

And yet, in the month before I arrived, there was a near-total rupture in medicines. The government had absolutely no anti-malaria medicines available in any of its facilities. Even worse, this happened in the middle of the malaria season, when caseloads increase by at least 50%, and despite the involvement of the Ministry of Health, the Global Fund, and UN and other humanitarian agencies.

The international community – donor countries, United Nations and other multilateral agencies, humanitarian and development agencies – needs to be more effectively involved in the setting of health priorities and supporting the delivery of health care in CAR.  If this situation was occurring anywhere else in the world, you would surely have mobilised by now. Instead, and scandalously, what we have found is that, in CAR, funding for health has fallen over the last five years.

While in the Central African Republic, I called on the country’s president, François Bozizé, as well as his Minister of Health, Jean-Michel Mandaba, the Special Representative of the Secretary-General of the UN Margaret Vogt, and officials from the various United Nations health agencies in the country. I discussed the health situation in the country and asked them to lead the fight against malaria.   

The mobilisation for CAR should start here and now with malaria. Rather than trying to do everything at once, there has to be greater prioritisation, to focus efforts and resources. The President and the Minister of Health should designate combating malaria the number one priority. Donor governments, UN agencies and the Global Fund should sit together with the government, help them prioritise and help turn those plans into reality. They should also offer more predictable and sustainable funding, rather than year-to-year funding which hampers longer-term efforts. An États-Generaux de la Santé, an all-party conference for health in CAR, or a President’s Commission for Malaria might be ways to mobilise such support and help focus common efforts.

On malaria in CAR we can have a serious impact: we can save the lives of many, mostly children; we can build up the health system while doing so. We can also treat a pervasive and perverse fatalism, that the situation is hopeless and that no more can be done. It is this fatalism, as much as the conflicts, the diseases, the health system failings, which kills in the Central African Republic.

First published in The Standard, 17 August, 2012