A Pandora's box to malnutrition, epidemics and illness opens in the Central African Republic

© Ton Koene Since late 2005, an increase in violence committed by pro- and anti-government forces in northern Central African Republic (CAR) has caused massive displacement of the population. Civilians there, suspected of supporting one side or the other, are systematically targeted by violence or caught in the crossfire. Many villages along the roads have been attacked, looted or burnt, forcing their inhabitants to flee. At the same time, bandits take advantage of the general lawlessness that prevails in the area to inflict further violent attacks on civilians.

In December 2006, MSF teams counted 36 villages partially or totally burnt on the road between Kabo-Batangafo and Kabo-Dékoa. What is life like for the local population?

"Violence in the area, mainly the systematic burning of houses on both axes, meant that many people have fled to the bush. We do not realize what does the word bush means, but testimonies from people we met give a clear idea: 'We are living like savages.' 'We have lost our dignity.' 'We are eating the same as the animals.'

In a conflict setting, access has to be gained and negotiated every day. In the Central African Republic, we have to do it every hour.

"What is happening here constitutes a humanitarian crisis. The people we see were caught first in the crossfire and now they are trapped between accusations of being pro-rebel (so they cannot move to the main villages around and access health services or even come back to their own houses in order to rebuild them), or the demands of rebel soldiers (who steal their minimal food stocks or take the few assets they do have).

"Still when MSF teams arrive at the previously fixed appointments for the mobile clinics, we see food or bicycles abandoned on the road. They belong to civilians who thought we were the army coming to attack them again. The number of ghost villages has now increased on the axes. This is right now the Kingdom of Fear. These people really live between a rock and a hard place, in a constant spiral of violence that is pushing them to the limit."

A lack of food distributions in the past, little or no freedom of movement, an absence of any form of commercial transport and many other factors has led to a considerably vulnerable food security situation.

In that area, the number of villages burnt by armed groups and the CAR army has increased in the last months, forcing several thousands people fleeing in the bush. What are their most urgent needs?

"After several months surviving in the harshest conditions, people's coping mechanisms are starting to collapse. For example, we already know that food stocks, which families usually hide so that they can cope with violence-related episodes, have already been finished or stolen by armed people.

"Though we still don't know exact malnutrition figures, we have seen a slight increase in the number of moderate and acutely malnourished children. A lack of food distributions in the past, little or no freedom of movement, an absence of any form of commercial transport and many other factors has led to a considerably vulnerable food security situation.

"This has been worsened by the overwhelming presence of malaria: almost 70% of children under the age of five. Almost 40% of adults suffer from this disease which, when coupled with malnutrition, poses a real threat to their lives.

"Illnesses derived from the current living conditions in the forest are recurrent: respiratory infections, parasites and diarrhoeas are consequences of the lack of shelter, proper quality water consumption or extremely harsh living conditions.

"MSF finished a distribution of basic living materials early on January. By no means is this enough and more mosquito nets, hygiene kits and plastic sheeting are urgently needed. Last but not least, such a scenario is the perfect environment for an epidemic outbreak. A meningitis outbreak, which has a three-year cycle, is a potential risk. Measles is another example. We are currently following up some cases of bloody diarrhoea which we discovered during our last mobile clinics."

MSF teams are confronted with security problems and often they can't get to the people in need or run mobile clinics. Can you explain what kind of difficulties you face and their impact on the people you are trying to assist?

The levels of violence make this part of CAR a no-go area for most humanitarian organisations.

"When talking about thousands of displaced people living in sub-human conditions, access for independent evaluation of needs and immediate response remain the priorities. In a conflict setting, access has to be gained and negotiated every day. In the CAR, we have to do it every hour.

"Over the last month, we were forced to cancel more than six mobile clinics in three different axes (Batangafo - Kabo, Kabo - Ouandago and Kaga Bandoro - Oundago) when the military authorities in the area did not give us security clearance to go into rural areas, or when our risk analysis showed a threat to our security. However, over the last two weeks access has improved considerably. All our mobile clinics are running again [eight per week] and we were even able to expand activities, starting a new mobile clinic and opening up a new axe [Batangafo - Kaga Bandoro].

"The levels of violence make this part of CAR a no-go area for most humanitarian organisations. To reopen previously functional health centres in the rural area axes is very difficult in this climate of violence. The only option is to implement a regular circuit of mobile clinics as MSF is doing.

"Composed of several doctors and nurses, the mobile clinics are the only way to offer health care assistance on the spot to a population that, as stated before, can neither access health centres in the villages, as they are accused of being pro-rebels, nor use the previously existing health system, as it has been completely destroyed.

"Our mobile clinics have an average of 150 consultations per day, and most of the people we treat are in extremely vulnerable situation. Just as an example, more than 500 wound-dressings were done over the last month, the majority of injuries being related to these severe living conditions."

Have you witnessed a story, an episode that can explain the situation of violence the civilians are facing?

H.J. outlined his fears about the future: "I am very worried about the next few months as we could not work our fields and we do not have any more food available....Right now, we just eat honey and wild fruit."

"Yes, it is the story of H. J. Teacher at one of the small villages that was completely burned in late December 2006. He started by deploring the fact that 'this year's academic course has been lost'.

"He remained professional even in the most difficult situation: his clothes were dirty and falling apart. He continued saying 'I cannot understand why nobody is doing anything for our children here'.

"He is the one who showed me the real meaning of the word 'bush' as I was saying above. He told me, 'We live as animals, as savages. Look at my clothes: I have lost my dignity".

"H.J. is one of the community leaders. As he was talking to me he looked around at the other eight members that represent the village 'We live in the bush, in family groups. When fear comes to us, we even regroup in clusters of 20, even 40 persons, lying down in the soil.'

"It was very delicate and this is why I asked him about when this fear is coming from, after the meeting is finished.

"'Before we only feared the FACA - the military army, but we learnt when, where and how they were coming to our areas, so we avoid them. Now it is difficult because it is not only FACA but also rebel groups who come to our places and demand what little food stocks or money we have. If you do not give them what they want, they beat you. And each time they beat you harder.'

"H.J. outlined his fears about the future: 'I am very worried about the next few months as we could not work our fields and we do not have any more food available....Right now, we just eat honey and wild fruit.'

H.J. has eight children between six months and nine years old.

"'Last month, 15 people died in my village, several of them because of diarrhoea. You can come with me to count the graves, if you want to.'"

What was your first thought when you saw a burnt and empty village?

"At first you cannot understand what you are looking at. You think it has been the choice of the community to go, to change their living-place. When you come to know that this is the result of direct violence aimed at these people, you cannot process this as something acceptable, even if you've been in other conflict scenarios.

"You never get used to it.

"We're talking about small villages, usually less than 300 persons, perfectly integrated with their environment, with an extremely poor but functional way of life. And suddenly everything disappears and is transformed into fire and fleeing, opening the Pandora's Box to malnutrition, epidemics and health illness."