The conflict underway in this region of Chad has forced more than 150,000 people to flee their villages. The displaced persons are living in extremely precarious conditions and the risk of an acute emergency situation developing in the coming months is high.

Médecins Sans Frontières (MSF) is already working at several sites in Dar Sila region and will strengthen its operations in the field. The international community and aid groups in the region must also expand their assistance immediately, before the rainy season begins.

"People here need water, food, and shelter," says Franck Joncret, MSF Head of Mission in Chad. "They have been weakened by precarious living conditions and when they fall ill, access to care is extremely limited. If nothing is done to improve the situation quickly, we could soon face an emergency and high loss of human life."

Joncret has every reason to worry. Since late 2005, a conflict between government forces and rebel groups has been raging in the eastern part of the country. In addition, Chad and Sudan wage war on each other through armed militias across the border. Villages have been attacked, livestock and other possessions seized and civilians have been killed.

Violence intensified during the second half of 2006 and continues, leading residents to flee. The number of internally-displaced villagers continues to climb, totaling 40,000 in June 2006 and close to 150,000 today.

In Dar Sila department, the region most affected by the conflict, more than half the population&#—124,000 people&#—has settled in unhealthy camps clustered around cities and villages, including Goz Beïda, Adé, Dogdoré and Koukou. On March 31, a deadly attack on the villages of Tioro and Marena - the ICRC reports 250 to 400 casualties -prompted residents to take to the road.

"Armed men attacked early in the morning. They killed my husband and burned everything. Almost all the donkeys were dead, so I left on foot."

This woman and her children walked for 40 kilometers to reach Koukou, where they and others set up a displaced persons' camp, the third built in the town. For lack of water, several died of dehydration along the way.

Settlement areas face considerable pressure on resources

The displaced persons are settling wherever and however they can around the villages where they have sought refuge. Makeshift huts of straw and branches have been assembled in local fields, which will undoubtedly create tensions with residents during planting season. These flimsy shelters do not protect against daytime high temperatures that can reach nearly 45 degrees Celcius in the shade and drop precipitously at night, against sand carried by the wind or against violent rainstorms that are beginning in the region.

In February, a World Food Programme survey estimated that only six per cent of families had received plastic sheeting to reinforce their shelters. Other distributions are scheduled but will not meet all the needs.

The towns hosting the displaced persons are unprepared to handle an influx on this scale. Goz Beïda has a population of 10,000, while more than 50,000 refugees have settled there. The gap is even wider in Dogdoré: 2,000 inhabitants and nearly 30,000 displaced persons.

In addition to the problem of cultivable land, water supplies are inadequate. Traditional wells are drying up and in the best case, provide only muddy water that is unfit to drink. Many of the wadis (rivers) are dry by now and any water remaining into the dry season is of poor quality. The systems that aid organizations have set up to provide additional water are also inadequate.

"Despite the presence of many aid organizations in Goz Beïda, the quantity of potable water is only three to eight liters per day and per person, while the minimum daily need is 20," Franck says.

The health system is not up to the job

However, primary concerns focus on food and access to health care. For the most part, the health centers and public hospitals are too small to address the needs of displaced persons and residents. The Goz Beïda hospital, with 40 beds, will not be able to serve the many patients that will come as soon as the rainy season starts, given living conditions in the surrounding camps.

"Diarrhea, respiratory illnesses and malaria are the most common illnesses here," said Alberto Kalume Otshudiongo, an MSF doctor in Dogdoré. "I am worried because the rains have started and we will soon see a sharp increase in malaria cases and acute respiratory infections, which are particularly dangerous for children."

The nutritional situation is worsening

Our teams in the field have already noticed an increase in the number of child malnutrition cases. The displaced persons often leave their villages abruptly and are unable to bring food with them. They struggle every day to feed their families.

"We go into the bush to gather bales of straw or bunches of sticks to sell at the market," said a displaced woman. Others work in brick factories to earn enough to buy a few kilos of millet and pay the miller to grind it into flour.

Distributions like those scheduled as part of the United Nations' three-month emergency plan, set up in early April in collaboration with the ICRC, supplement these survival strategies. However, because the total calories provided for are lower than the standard food aid ration and because the population of certain camps has been underestimated, the distributions will meet only around half the daily need.

In general, despite the presence of many aid organizations, assistance to displaced persons in eastern Chad remains inadequate, while the needs are enormous. To address this, Médecins Sans Frontières will strengthen its aid activities (see sidebar).

"We will increase our assistance to the displaced populations in four key areas: access to food, medical care and water and shelter improvements in anticipation of the rainy season," Franck explained.

Aid must get underway before the rainy season

"After a two-week visit to Chad, I think there is a significant risk of emergency in the coming months," Emmanuel Drouhin, MSF Program Manager for Chad, said. "In the east, aid is concentrated primarily on refugees from Darfur, ignoring the displaced persons. Today, organizations are starting to focus on them but enough assistance has yet to arrive. The international community must step up to its responsibilities and send more aid to eastern Chad quickly. In two months, the roads will be impassable because of the rains and it will become much more difficult to reach the displaced populations there."

Strengthening MSF's activities - four priorities: health care, food, water and shelters

MSF's activities are currently focused in Dogdoré.

"In June 2006, we created a health center and 28-bed hospital there and are providing around 15 liters of water per day to the displaced persons and residents," said Field Coordinator Corine Wagner.

Every Thursday, an outpatient center treats malnourished children enrolled in the program. They receive a medical check-up and additional supplies of Plumpy'nut. Only the most serious cases (those with a related illness) are hospitalized. The Dogdoré program was suspended on March 28 for security reasons but reopened on April 16.

A measles vaccination campaign targeting all children under-15 (approximately 13,000) is scheduled to begin within the next ten days. Simultaneously, all children under-5 (approximately 6,000) will receive a month's supply of Plumpy'nut packets to prevent their nutritional status from worsening.

Plumpy'nut is a ready-to-use therapeutic food made of peanut butter, enriched with vitamins and micronutrients. This operation, known as a blanket feeding, will be repeated until September. To increase water supplies, a drill to create new, or improve, water supplies will boost distribution to 20 liters per person per day.

To improve the displaced persons' living conditions, we will soon send 5,000 to 6,000 tents. We will build latrines in the camps to improve hygiene if no other organization is able to do so.

An emergency project was opened on April 2 in Koukou to assist the 8,000 displaced persons who fled the deadly attacks on Tioro and Marena. Thanks to a temporary health center, MSF was able to treat 200 patients. A pump system and cistern trucks are still supplying more than 75,000 liters of water per day, in addition to the 60,000 liters provided by another organization. MSF will continue providing these supplies and expect to set up a hospital and malnutrition treatment facility in June for four months in anticipation of the rainy season, which is the most critical.

MSF will also develop our activities in Goz Beïda, after an assessment of the situation in the camps around the town raised concerns. Authorisation has been obtained from local health authorities to open a 40-bed pediatric hospital.

Based on developments and the response from other aid groups, hospitalization may be extended to adults. The MSF pediatric department will allow staff to treat the most serious cases of malnutrition. Children suffering from malnutrition but who do not require hospitalization will be treated as outpatients.

For water, MSF will supply one or two of the camps that have been set up around the town via water trucking. To address food needs, MSF will position more than 1,000 tons of enriched flour and oil in Goz Beïda, distributing these foods to supplement the rations provided by the other organizations. These quantities will provide additional caloric support (500 kcal/day) to 60,000 people for three months.

MSF teams will also try, within the constraints of volatile security conditions, to evaluate the situation in isolated areas near the towns where MSF projects are based, and to provide medical and material assistance to the people still living there.

Last, MSF will remain ready to respond on an emergency basis (once again, subject to security conditions), whether to new upsurges in violence or epidemics, as we did in Koukou, following the attacks on the villages of Tioro and Marena.