CAR

CAR: Disaster, Ignored

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Relatives of patients wait outside an MSF facility. Central African Republic 2013 © Ton Koene

This article is part of the Summer 2013 issue of the MSF Alert newsletter.

Only in geographic terms does the Central African Republic live up to its name. It is indeed located in the middle of the continent, but in no other way is it “central”—certainly not when it comes to the attention of the international community.

Perhaps the name is too literal, sounding more like a description than an assignation. Perhaps it’s overshadowed by its larger, noisier neighbor, the Democratic Republic of Congo. Whatever the reason, Central African Republic, or CAR, is often overlooked, if not forgotten altogether.

From MSF’s perspective, this is deeply troubling because there are innumerable medical needs in the country. CAR ranks 180th out of 186 nations in the UN’s Human Development Index. In a country the size of France, there are few roads, there is little infrastructure, and the national health care system barely functions. Average life expectancy is only 49 years, the second shortest in the world. Malaria is holoendemic, meaning that it affects every single one of the country’s 4.57 million people. Malnutrition is rife, particularly during the annual “hunger gap” between harvests. HIV rates are high. Vaccination rates are low. And though the country has seen its share of conflict, and is now dealing with the aftermath of armed insurrection that toppled its government, a 2011 MSF survey found mortality rates well above the emergency threshold even in areas not affected by fighting.

That survey was highlighted by MSF’s report “The Silent Crisis,” part of an ongoing effort to sound the alarm about the situation in CAR. “A health system torn apart by years of political and military instability, major organizational problems, and a lack of security in the northern and eastern regions of the country have had a catastrophic effect on the health of the population,” said Olivier Aubry, MSF head of mission in CAR at the time.

FROM BAD TO WORSE

MSF has worked in CAR since 1997. In 2012, during which the organization spent upwards of $24 million on its programs in the country, some 1,300 staff members carried out nearly 600,000 consultations, treated more than 330,000 people for malaria, and provided numerous other general and specialized services in 7 hospitals and 38 health posts throughout the nation. MSF offices worldwide have also consistently raised the issue of CAR on both the communications and advocacy fronts. Little has changed, however. Last year, another survey found that half of the reported deaths in the country were children; only a quarter of them had reached a health facility before they died.

And it now seems that life in CAR has gotten even worse. This past December, a rebel coalition called Seleka launched an offensive against CAR’s government and took several towns from its national army. A ceasefire was signed but didn’t hold, and in March, Seleka moved on the capital, Bangui, and overthrew President Francois Bozize, installing one of their own in his place.

State security forces, including the police, abandoned their posts, and in the ensuing months, CAR has been in a state of near-anarchy. Large segments of the population fled into the bush, where many remain. Few who returned dare venture out, even when they need medical care. Looting and theft are rampant, and health facilities, including MSF’s, have been targeted, as have international aid groups. Longstanding feuds between farming communities and nomadic herders from Chad have erupted into deadly confrontations. Rivalries between different Seleka factions are festering as well. And supplies of staple goods—including medicines—have been interrupted.

While it’s not open warfare, the current situation is just as fraught. Several months ago, “at the height of the crisis,” says Serge St. Louis, an MSF head of mission in CAR, “confrontations, shootings, and abuses occurred daily. Today, tension and violence have subsided and we are now in a particularly delicate phase—a sort of false calm that is both fragile and potentially explosive.”

Direct violence is far from the only threat, however. People living with HIV/AIDS cannot get the drugs they need. Neither can TB patients. Given the dangers on the roads, particularly outside the capital, vaccination campaigns have been curtailed or canceled, as have ambitious (and necessary) efforts to distribute bed nets as part of a malaria prevention strategy. The rainy season has already begun, meaning that a population will struggle to access treatment for the main cause of death in the country at the precise time when they are most likely to contract it. “We are very concerned about the unmet needs among a population that was already very vulnerable,” says St. Louis.

The needs are not only great, but the ability of MSF or anyone else to meet them is proscribed by the reigning air of insecurity and the wholesale absence of functioning state institutions. It is, says Ellen van der Velden, who oversees a number of MSF’s CAR operations, “A crisis on top of a crisis.”

WORKING THROUGH THE CHAOS

During the fi ghting, MSF temporarily evacuated staff and scaled back programs and plans in some locations. At the same time, though, teams scaled up elsewhere. They continued working in Bangui’s Community Hospital, where most of those wounded in fi ghting in March and May were taken, and Castor Health Center, also in Bangui, which has maternity and surgery wards.

One of MSF’s patients in the capital was a 14-year-old named Jordan from the Miskine neighborhood. When the rebels entered the capital in late March, he stayed inside his home, protecting himself as best as he could from the fi ghting. A stray bullet nonetheless fl ew into his house and struck him in the leg. A local priest helped get Jordan to Community Hospital, where MSF ran the operating theater. “Now he’s getting better and I hope that he’ll be at home soon,” his mother said soon afterwards.

Staff continued working in Paoua, northwest of the capital, as well, diagnosing and treating more than 15,600 malaria cases between January and May. Projects likewise continue in various spots in the northeast—Kabo, Batangafo, and Ndélé—and in the southeast, in Zemio. Teams kept working in Boguila too, albeit with a skeleton staff , even after a vehicle was looted and facilities were robbed.

In early June, a newly opened emergency project in Bossangoa was conducting 300 outpatient consultations each day and mobile clinics were serving districts where people were still hiding out in the bush. The needs were evident: malaria, diarrheal diseases, and malnutrition were all more prevalent than they had been one year earlier—33 percent higher when it comes to malaria. In fact, more than half of all children seen in the outpatient department of the Bossangoa program were confi rmed with malaria, as were 50 percent of women receiving antenatal care.

Another priority was re-starting treatment for some 11,000 people with HIV whose care had been interrupted. MSF was also donating blood to make up for a shortfall in the country’s hospitals, along with diagnostic tests and treatment supplies in several locations.

A TOO-QUIET RESPONSE

The carry-on eff ects of the fi ghting on an already faltering health care system have been profound and wide-ranging, limiting people’s access to care, limiting the treatment options available to emergency organizations such as MSF, and interrupting treatment for those who’d been lucky enough to start it previously. Chury Baysa, an MSF medical coordinator in Bossangoa, described one case when these consequences came together in a way that would have cost a boy his life had he not fi nally gotten the care he needed: “We had a four-year-old boy come to us at the end of May suff ering from severe anemia and malaria. He was so sick we had to transfer him by car, along very bumpy roads, from Bossangoa to our hospital in Boguila, so that he could have a blood transfusion. We have seen a number of cases like this, with children falling very sick because of a lack of mosquito nets and malaria drugs.”

One of the most troubling aspects of all of this is the lack of support or attention from the international community. The agencies and organizations that were already in the country have, for the most part, withdrawn to Bangui due to the rampant insecurity. The new government, such as it is, has done next to nothing to re-establish security and the rule of the law, particularly beyond the capital. International groups like the United Nations and the European Union could do much more as well, even in the current situation. Only 31 percent of a funding request the UN sent out has been met, and only $2.8 million of that is going to the health sector, a fraction of what’s needed.

MSF will continue to run its programs and make the country’s woes prominent in its communications and advocacy eff orts. But at a very basic level, people need to make Central African Republic more central to their thinking, especially when it comes to public health, regardless of whether or not they know or cared about the country before.