Weak states in Africa - Angola MSF statement to US Senate Subcommittee

Our medical presence alongside the Angolan population, all directly affected by the war, provides us with a clear understanding of the scale of the humanitarian crisis in Angola, its causes, and what must be done to assure the medical well-being of the Angolan people.
We want to thank the Senators of the Committee on Foreign Relations, especially Senator Feingold, for this opportunity to report on the recent and current humanitarian situation in Angola. At the hearing we hope to bring to your attention what we believe are the major humanitarian issues that require urgent consideration. Medecins Sans Frontieres (MSF) is an international, independent emergency medical aid organization that has been working in Angola since 1983. Since then MSF has worked in 15 of the 18 provinces, running primary health care services in displaced camps, nutritional programs and emergency feeding programs, supporting hospitals and other health structures and running surgical, sleeping sickness and tuberculosis programs. Our medical presence alongside the Angolan population, all directly affected by the war, provides us with a clear understanding of the scale of the humanitarian crisis in Angola, its causes, and what must be done to assure the medical well-being of the Angolan people. It is premature to think that the post-conflict situation in Angola has become normalized. A large number of Angolans are still in a precarious situation. This testimony will address the continuing nutritional crisis; food insecurity; MSF's concerns about the resettlement of displaced people; and the lack of access to health care for many Angolans. Background The end of the fighting in April revealed a humanitarian crisis previously hidden during Angola's three decade long war. Hundreds of thousands of starving civilians emerged from rural areas to which MSF and other agencies had been denied access by both the Angolan Armed Forces (FAA) and UNITA. Our teams recorded mortality figures nearly four times greater than what is internationally accepted as the threshold for an emergency. Rapid assessments found moderate malnutrition rates as high as 50% and severe acute malnutrition higher than 20%. These people were starving not because of natural disaster, drought or crop failure, but as a direct result of how the war was fought. Peace may have silenced the guns, but it did not bring relief: thousands of Angolans who had survived the horrors of the war, and who could have been saved, died needlessly. For example, in Malange province, MSF found in May that 17% of the women whose children were receiving emergency nutritional care said they had lost children since the beginning of 2002.
War tactics pursued by both parties directly caused the pockets of famine MSF encountered immediately after the cease fire. In willful violation of international humanitarian law, both warring parties cut civilians off from humanitarian assistance for years. From 1998-2002, sanctions against UNITA, compounded by UNITA's own strategies, prevented agencies to operate under areas they controlled. The Government of Angola restricted aid agencies to provincial capitals and, even in these government-held regions, the neglect of the health system led to a near complete failure of health services. Peace may have silenced the guns, but it did not bring relief: thousands of Angolans who had survived the horrors of the war, and who could have been saved, died needlessly. For example, in Malange province, MSF found in May that 17% of the women whose children were receiving emergency nutritional care said they had lost children since the beginning of 2002. Consistent with these urgent needs, MSF mobilized its largest worldwide operation, with 175 international volunteers and 2,200 national staff working or monitoring activities in 15 of Angola's 18 provinces. Unfortunately, the slow humanitarian response to this immense crisis by the Government of Angola, aid agencies and the UN, as well as serious logistical constraints, prolonged the crisis throughout the summer. So far MSF has treated more than 16,000 children at our therapeutic feeding centers (TFCs). In June, we were treating 3,600 children in more than 20 intensive feeding centers throughout the country, and provided supplementary feeding to more than 10,400. A preliminary retrospective mortality survey showed death rates of 3.3/10,000 per day for children under 5 years of age. The current situation "My husband received half a cup of rice. We, the family, received half a cup of rice and one tin of sardines. That was one month ago. Since then no one has given us anything.... We haven't eaten anything for four days." Current nutritional crisis Today, Angola presents a mixed picture. Across the country, we are treating 1,400 children at 14 centers for acute severe malnutrition. While the acute emergency has eased in most parts of the country, localized emergencies persist, particularly in Mavinga and Bailundo. The worst nutritional crisis is unfolding in the southeastern town of Mavinga. In this pocket of dramatic famine, we are treating 250 children in our Therapeutic Feeding Center (TFC); we are supplying 10,000 children and vulnerable adults with weekly food rations there and in two nearby Reception Areas with a combined population of 70,000. Families walked through the bush for weeks to reach Mavinga, abandoning their homes and fields, and had no means to provide for themselves. Some people starved after arriving. A recent shigella outbreak (bloody dysentery) affected 392 patients, and 100 people remain in an isolation ward. When General Food Distribution to the area was halted in August because mines were discovered on the landing strip, an estimated 10,000 people went to Mavinga in search of food, overwhelming the town and our feeding facilities. Our medical teams even report that children treated in our TFCs during the summer have been readmitted in the past few weeks with the same deadly symptoms of acute malnutrition. Conditions are serious in Huambo Province as well, where MSF is currently treating 350 children in therapeutic feeding centers in Bailundo alone. This is certainly an improvement over the past 2 months, when we were treating more than 600. But we receive 90 new patients each week. MSF continues to gain access to some previously cut-off regions, finding high levels of malnutrition. The survivors of today are in an unsteady state, and it will not take much to disrupt such a fragile balance.
From famine to food insecurity "We don't have food or clothing because we didn't get anything when we arrived. The people from the WFP came by two weeks ago to register the population, but they haven't been back since. They say they want to give us food for two weeks so that we have enough time to return to damba Queio, but we don't know when the government is going to decide on our return. For the moment to get food to eat, the women work in nearby fields. One day of work equals one basket of manioc. People who have family in Menongue are getting help from them. " There should be no sense of false security. Even though the people we treat successfully may be strong enough to leave intensive care, they are still in the process of recovering from horrific conditions. MSF continues to gain access to some previously cut-off regions, finding high levels of malnutrition. The survivors of today are in an unsteady state, and it will not take much to disrupt such a fragile balance. Lack of resources Several categories of displaced people each received different levels of attention. The 85,000 former UNITA combatants along with 350,000 family members regrouped at 38 Reception Areas (RAs), "new" IDP population of those who were trapped in isolated areas during years of conflict, and the approximately 335,000 Internally Displaced People receiving food aid prior to the April 4th ceasefire agreement. There were also those in the "newly accessible areas" immobilized by illness or the threat of mines. WFP integrated all of these groups into one caseload, increasing their estimate of people requiring food aid from 1.5 to 1.9 million. The WFP estimates these nearly 2 million people will need food aid for their daily survival until well into 2003. These people are extremely vulnerable to inconsistencies in food supplies, and their nutritional status could quickly deteriorate if confronted with prolonged interruptions in aid deliveries. Agencies involved in food supply already operate under several constraints. As of early October, WFP's budget for Angola was 74% under-funded, and cereal supplies are predicted to run out in January. Even now, the WFP is delivering one month's worth of food every six weeks in Mavinga, further weakening food security. Donor countries need to insure such interruptions do not occur. The rainy season, in full force by the end of October, poses a dual threat to access. The already deteriorated roads will become impossible... Intense rains also expose buried landmines and set them in motion. This combination of a destroyed road network, the presence of mines, and the lack of long term funding commitments compromises the food security of this vulnerable population.
Logistical constraints Food distribution is severely hampered by logistical constraints, by the ever-present threat of mines, and by damaged roads and collapsed bridges. For example WFP General Food Distributions have been suspended in large parts of Huambo, Cuanza Sul and Cuando Cubango Provinces because they do not have enough heavy-duty vehicles needed to transport cargo across rough terrain, they have difficulty identifying Implementing Partners who manage on site general food distributions, cannot ensure the security of field staff because of the presence of landmines. One of the major humanitarian priorities will be demining. Provisions must be made to expand and accelerate demining activities. In spite of investments in demining programs and increases in demining teams, mines remain a significant threat throughout the country, particularly on those routes that have not been traveled for decades. For example, the detonation in August of two anti-tank mines in the Cuango area led to the suspension of all aid to Xa-Muteba RA for several weeks. Further such incidents, complicating the delivery of aid, should be expected. The scale of the problem demands far greater resources. The network of roads has not been maintained for years and bridges spanning key rivers are down, posing a constant challenge to access. Travel from Malange to the quartering area in Xa-Muteba, Lunda Norte Province, a distance of about 150 miles, can take three to four days because a bridge is destroyed and up to a hundred trucks queue at a river ford waiting to be hauled across. The journey from Luanda to Mussende in Cuanza Sul Province should take less than a day. It took MSF three days last month, traveling roads that had not seen traffic since before the war and crossing bridges only designed for pedestrians. Mussende RA with 10,700 residents has still received no food aid. The rainy season, in full force by the end of October, poses a dual threat to access. The already deteriorated roads will become impossible as torrential rains erode the unpaved stretches, undermine weakened pavement, and turn the powdery dry clay into deep bogs that few vehicles can negotiate. Intense rains also expose buried landmines and set them in motion. Areas previously thought safe will suddenly and tragically prove otherwise. Just outside the city of Malange last week, thirteen people were killed when their van swerved just off the main road to avoid a pothole and hit an antitank mine that was probably placed years before at a long-since forgotten checkpoint. It is likely that recent heavy rains had eroded previously compacted earth above this mine to render this stretch of road lethal once again. This combination of a destroyed road network, the presence of mines, and the lack of long term funding commitments compromises the food security of this vulnerable population. Massive population movements over recent months, as well as further anticipated movements, threaten to affect food security adversely. MSF is seriously concerned that the resettlement process is not proceeding according to international standards or national laws. Between 6,000 and 10,000 people per day were spontaneously returning to their place of origin. Up to 80% of these people were returning to areas that were considered unsuitable for resettlement.
Lack of access to health care "The government does nothing for the people of Angola. They just take the money for the school and hospital and put it in their pockets. It doesn't matter to them, because if their child is sick they just send them to Namibia or South Africa and they just send their children to school to be educated outside Angola. This is the way it is here in Angola." As the malnutrition emergency recedes, lack of general healthcare comes more into focus. The health care infrastructure in Angola was not only destroyed by war. Years of neglect have left most Angolans with inadequate basic services. The problem is especially acute in the areas to which people are returning. Before the ceasefire MSF was present in 11 of the 18 provinces of Angola, operating feeding centers and supporting hospitals with medical personnel and drugs. We continue to support hospitals and health posts in nine areas in addition to operating feeding centers. Outside the former security cordons, extending around provincial capitals, we see little improvement in the provision of healthcare. Preventative healthcare is rarely provided, and curative care at the primary level is either non-existent or limited to infrequent and inadequate supplies of drugs. Referral services are similarly not in evidence. In a recent assessment to Lunda Norte province, we found that the hospital had been destroyed during the war. The health post had been without medical supplies since July, and the four person nursing staff had not been paid for months. This is the only health facility serving an area that, when last surveyed, had a population of 147,000. Reports of measles outbreaks continue to confirm the poor vaccination coverage countrywide. MSF has reported measles outbreaks in Saurimo, Jumenge-Cameia and Lago Dilolo municipalities in Moxico, and in Cuanza Sul and Lunda Sul Provinces. Sometimes reported outbreaks prompt authorities to carry out vaccination campaigns, and MSF itself has vaccinated more than 50,000 children against this deadly disease. Return and resettlement "We all want to go back to living like we did before, in 1978 and 1979. The public servants could stay herein the town. The ordinary people could go back to their fields and take responsibility for themselves again. We know that all this will take time, but we have hope, hope that everything will turn out alright. " Massive population movements over recent months, as well as further anticipated movements, threaten to affect food security adversely. MSF is seriously concerned that the resettlement process is not proceeding according to international standards or national laws. Resettlement must be voluntary and returnees well-informed, and only in places that have minimum necessary access to drinking water, food, shelter health services, seeds and tools, healthcare assistance and government administration. MSF has observed acute food shortages and inadequate sanitary conditions among the 430,000 people living in RAs. These camps cannot be closed without providing the mechanisms necessary for resettlement. Where resettlement for hundreds of thousands of displaced Angolans has already occurred, it has been hasty and haphazard. The UN estimated that during August and September, between 6,000 and 10,000 people per day were spontaneously returning to their place of origin. Up to 80% of these people were returning to areas that were considered unsuitable for resettlement. Population movements also seem to have occurred through pressure. MSF discovered how local authorities in Catata told the people living in displaced camps that they were obliged to return to return to their village of origin, and that their huts would be destroyed. MSF notified those responsible that any return had to be voluntary, and in the end, people were allowed to stay. An earlier example of this is the departure in May of about 12,900 displaced people from camps surrounding Kuito in Bie Province. This movement followed administration assurances that there would be no more aid for them in Kuito and that food and materials would be distributed in Trumba, 30 km away. Aid agencies were not informed of the administration's decision and, on a subsequent visit to Trumba, MSF found that there was little provision of assistance. Spontaneous movements or an accelerated resettlement process jeopardizes the safety and health status of returnees. Any return should be voluntary, well informed and in accordance with international standards and norms. Only then will these people receive even a measure of the dignity that has been denied them for so long. Conclusions and recommendations Emergency nutritional needs must be met in the isolated pockets of dramatic famine that persist. And nutritional assessments must continue to areas that are still cut off from assistance. Sufficient food stocks and their delivery must be guaranteed to ensure that food reaches the nearly two million people estimated by WFP who will require such assistance well into 2003. Donor commitments must be met. Access to isolated populations is seriously hampered by a severely deteriorated road network and destroyed bridges spanning major rivers. De-mining operations must be accelerated to support food distribution programs, the provision of health services and the resettlement process. People must be provided with adequate basic health care, with a focus on training, primary health care, and basic referral systems. Resettlement must be voluntary and returnees well informed. The process must be implemented in compliance with international standards as well as the government of Angola's Norms on the Resettlement of Displaced Populations. This includes: The adequate assessment of resettlement areas to ensure security, access to health care, and proper sanitation. The prevention of forced and coerced resettlement. Meaningful protection for returnees. The distribution of food, non-food items, seeds and farming tools to provide returnees with food and shelter while they resume farming activities to become food self-sufficient.