War or health: Humanitarian crisis worsens in war-torn Congo

Of 16 admissions into the clinic yesterday, the doctor tells us, five children had lost one or both parents.

This is but one example of the grim reality facing millions living in today's war-torn Democratic Republic of Congo (DRC), a country in the grip of a devastating war spanning decades, in which death and violence is endemic.

We meet eight-year-old Zarie, now the only one of her family left to take care of her malnourished baby sister. The baby lies asleep, tied onto her back, as she awaits her turn in the feeding queue. Five other children have also arrived at the clinic today with their sick mother, who is suffering from deep grenade wounds to both her legs. The family fled fighting in their village, and spent days and nights in the forest too scared to return and seek medical help. Their father was killed outright as the first bombs dropped on their house. Stories of such human tragedy are commonplace in the DRC; everyone is affected.

Table 1.
Exposure to violence, Basankusu (1998-2000)
Type of violence n (%)
Exposure to violence (n = 912) 771 (84.5)
Theft 596 (77.3)
Destruction of house/field 362 (47.0)
Physical assault 160 (20.8)
Imprisonment 85 (11.0)
Torture 118 (15.3)
Sexual abuse 103 (13.4)
Mines 3 (0.4)
Bullet wound 41 (5.3)
Knife/machete wounds 34 (4.4)
Forced recruitment 82 (10.6)

Populations living in eastern parts of the country, witnesses to ongoing heavy fighting between armies, rebel factions, and proxy militia, are particularly affected.1 Physical assaults, torture, sexual abuse, theft, and destruction of property occur with frightening regularity.2 Thousands live in a state of perpetual terror and motion.

This year, violence has once again escalated around the town of Bunia, Ituri province, near the Ugandan border, following the withdrawal of Ugandan forces. In May, more than 100 000 residents fled in fear of militia wielding machetes, spears, and guns.3 Massacres and indiscriminate killings were carried out with total impunity. The corpses of men, women, and children lay rotting in Bunia's streets, with aid agencies unable to move securely throughout much of the area to respond to the mounting health and humanitarian needs. Forty thousand people arrived in neighbouring Beni after a two-week journey by foot through the forest, while tens of thousands remain as yet unaccounted for.

The likelihood of a major massacre taking place in Bunia in the near future is increasing; the killing continues throughout Ituri at this time. After repeated calls for the presence of an international peace-keeping force, with a mandate to stop the ongoing violence, a rapid-reaction force of French-led UN troops was deployed in June. However, its work is currently restricted to Bunia, initially for three months.

In 2001, Médecins Sans Frontières (MSF) carried out a survey to assess the population's exposure to violence in western and central DRC. In Basankusu,2 a ceasefire zone occupied by the military, it was found that, between 1998 and 2000, 85% of households had a family member who had experienced violence; nearly 90% had been obliged to flee or were displaced during that time (see Table 1).

Existing health services have long since been unable to respond to the escalating needs. Infectious and diarrhoeal illnesses, malaria, and malnutrition — a pattern of disease typical in such emergencies4 — remain common causes of death throughout the country at this time, both in and out of areas of direct fighting.

The DRC now ranks 179 out of 191 countries surveyed by the World Health Organization,5 and remains one of the world's least developed countries.6 Years of mismanagement and corruption have left health services throughout the country in crisis.

Violence and population displacement on a massive scale compounds the situation further still. The withdrawal of multilateral and bilateral aid initiatives since 1992 has left the health system in the sole hands of non-governmental organisations and independent groups. The WHO estimates that up to 75% of the population may have no access to formal health care.7 The result is high mortality and chronic ill health throughout the country.

MSF has been providing medical assistance in the DRC since 1981. Activities include supervising and training health staff, vaccinations, antenatal care, epidemiological surveillance, and water and sanitation improvement. MSF is working at a grass roots level to ensure continuous provision of drug supplies into the regions in which it works. The destruction of roads and bridges has severely damaged trade networks throughout the interior of the DRC, and thus health centres throughout the country lack basic supplies. Where they do exist, a shortage of paper money in a country whose economy has totally collapsed means that few have any means of buying them.

More than two-thirds of people in Basankusu, for example, reported not seeking consultation when they fell ill because they had no money to pay for doctors or medicines.2 Perpetual insecurity hinders the initiation of long-term health initiatives. A sustainable approach remains out of the question in a country with neither centralised control nor a functioning economy. Instead, acute needs must be addressed with the urgency they have long since required.

In Bunia, MSF is currently carrying out 15 to 20 surgical interventions a day, mainly for injuries from gunshots or machete wounds, and up to 120 medical consultations. Monitoring of the 100,000 displaced people living in two camps in Bunia is ongoing, with measures being put in place to contain a possible cholera outbreak. No access to the thousands who fled to forest areas around Bunia, and who are cut off from food supplies and health care, is possible at this time.

In other areas, public authorities sent to maintain law and order abuse civilians with impunity as well, presenting as great a threat to the civilian population as the previous military groups. The MSF team in Yahuma, in Oriental Province, has recently witnessed such abuses. Aside from general looting, villagers are used as 'slaves' by the newly established police force. Resistance has led to physical retribution and indefinite detention.

In other more stable parts of the country, infectious disease control and treatment are a priority. Death among children is particularly high throughout the DRC; a collapsed health service means that many are left unprotected from vaccinepreventable diseases, such as measles and tuberculosis.

Francine, who presented at the MSF clinic this morning, is one of thousands affected. Skeleton thin, she lies in the examining room groaning and coughing in acute pain as the doctor checks her abdomen. She has not been to a clinic before, she explains, because she had no money to pay. The doctor's diagnosis is advanced disseminated tuberculosis, from which she will almost certainly die. A cruel and unjust end for a child of 12 years.

In recent months, the health and humanitarian situation in the DRC has gone from bad to catastrophic. Continued violence and displacement means that thousands cannot be reached with vital humanitarian assistance. International organisations, falling over each other in Iraq at this time, are notably absent in this forgotten corner of the globe, despite obvious and acute needs. Western governments, who have long since brushed this crisis under the carpet, must stop declaring the situation too tangled to resolve, and act to provide a massive increase in assistance countrywide.

Initiatives that will guarantee the security and protection of the civilian population, and allow improved access of humanitarian aid into areas in and around Bunia, should be encouraged and initiated by the international community and local leaders. It is crucial that humanitarian organisations are allowed free and independent access to assess the scale of unmet need at this time.

This brutal conflict remains, without doubt, one of today's greatest international humanitarian emergencies. Without immediate assistance, the cycle of human misery will continue unabated and the health of the population decline further still.


1. Médecins Sans Frontières. 'The war was following me': ten years of conflict, violence, and chaos in the eastern DRC. Amsterdam: MSF, 2002.

2. van Herp M, Parque V, Rackley E, Ford N. Mortality and lack of access to health care in the Democratic Republic of Congo. Disasters 2003; 27: 141-153.

3. Left S. Fighting in Congo. The Guardian, 27 May 2003.

4. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Ann Rev Pub Health 2001; 18: 283-312.

5. World Health Organization. World Health Report, 2000. Geneva: WHO, 2000.

6. United Nations Development Programme. Human Development Report. New York: UNDP, 2001.

7. World Health Organization.