Years of political and military instability in Central African Republic (CAR) have left the country in a chronic state of humanitarian crisis, particularly as it pertains to public health. The situation has deteriorated considerably since a March 2013 coup d'état and the near anarchy that has followed. And it has only continued to get worse.
MSF has been active in CAR since 1997 and continues to work, adapting its activities and opening new projects to address growing and increasingly urgent needs. Fighting and insecurity has displaced hundreds of thousands of people who are now extremely vulnerable, exposed to malaria, malnutrition, and other epidemics. But with lawlessness prevailing, health care workers and aid actors are finding it very difficult to reach them.
Even in more peaceful times, mortality rates in CAR greatly exceeded the emergency thresholds that define a humanitarian crisis. Life expectancy in the country is only 48 years, one of the lowest in the world, but the current chaos has virtually wiped out what little health infrastructure had existed.
The Ministry of Health has almost no presence outside of Bangui, the capital, and very few health care facilities operate in the interior of the country. There are few health care providers, with just one doctor per 55,000 people and one nurse or midwife per 7,000 residents, according the United Nations, and most of those are in the capital.
As a result, access to basic care is limited or non-existent in certain regions. Many women die during pregnancy or childbirth and the World Health Organization reports that 129 out of every 1,000 children die before the age of 5, primarily from malaria, chronic malnutrition, diarrheal illnesses, measles, or meningitis.
The situation has worsened since December 2012, when a rebel coalition known as Séléka launched an offensive that ushered in even more troubles. Many health care facilities were looted or destroyed and most health care workers left their positions to flee towards Bangui.
Since that time, during the annual malaria spike, drugs, vaccines, and supplies have been blocked in the capital. Health care facilities have been unable to resume their activities and health monitoring and routine vaccination systems have been halted. As a result, CAR’s 4.4 million people lack medical care and are therefore increasingly vulnerable to the elements and disease.
Now, in Bangui and elsewhere in the country, additional armed groups have entered the fray. New clashes have erupted between so-called self-defense groups (the anti-Balaka) and former Séléka forces. Intercommunal, ethnic, and religious tensions simmer and occasional explode, particularly in the north and northwest.
Attacks on villages are reaching unprecedented levels of violence. Since spring 2013, raids, abuses, arbitrary arrests and detentions, and summary executions—including of health care and aid workers—have risen. All international NGOs working in CAR have had vehicles stolen, sometimes in armed robberies. Facilities, offices, and living quarters have been looted and robbed and personnel have been threatened.
In this context of fear and violence, nearly 400,000 people, by the UN’s count, have fled, often more than once. They are hiding in the bush without shelter, food, or drinking water, exposed to the weather and mosquitoes that carry malaria, the leading cause of death in the country.
The situation is no better in the resettlement sites. Crowding and poor living and health conditions promote the risk of epidemics. The UN has said that 1 million people lack adequate food and 1.6 million are in immediate need of humanitarian aid.
MSF has repeatedly sounded the alarm about the situation in CAR. The country’s authorities, such as they are, cannot meet growing and pressing needs, particularly medical needs. MSF is particularly concerned about the fate of populations living in certain "gray" areas that are inaccessible to aid actors, primarily in the eastern region of the country. The health and humanitarian situation in these regions is unknown.
Despite this tense and volatile security context, MSF remains a major health actor in CAR and continues its work, traveling within the country, conducting needs evaluations, launching new programs, and treating patients and the wounded, regardless of their affiliation and of the forces controlling the area where we are working.
MSF has been working in CAR since 1997 and is currently managing seven regular projects—in Batangafo, Boguila, Carnot, Kabo, Ndéle, Paoua, and Zémio—and three emergency projects in Bossangoa, Bouca, and Bria. In addition, a mobile emergency team is covering the areas of Bouar, Mbaiki, and Yaloké.
By the end of the year, MSF hopes to launch activities in Bangassou and Ouango. We currently offer free medical care to approximately 400,000 people and provide approximately 800 hospital beds. We are working in seven hospitals, two health centers, and 40 health posts. The teams are composed of more than 100 expatriate health care workers and around 1,100 staff from CAR.
Our teams understand the changing context and are responding to the changing situation and needs. While we have had to temporarily evacuate our staff from certain areas that have become too dangerous in several regions of the country—and may well have to do so again—MSF has adapted its current activities and has even opened new projects to meet the needs.
Words into Action
It’s a rare situation, but the crisis in Central African Republic (CAR) is now in the headlines. France acknowledges that the people of CAR are “in a dire situation” and is calling on the international community to “mobilize,” the US has expressed concern about the deteriorating situation, and the UN Security Council is meeting to adopt a new resolution on CAR.
But despite all the attention, for those working on the ground, it is clear that aid for the people of CAR remains far below what is urgently needed.
Since December 2012, MSF has repeatedly denounced the almost total absence of humanitarian assistance in CAR and has called on international organizations to deploy emergency relief as a matter of urgency. Even before that, MSF released a report called A State of Silent Crisis about the widespread, overlapping, and overlooked health emergencies in CAR.
While the UN declared its intention to increase assistance, today, our teams on the ground clearly see that the concrete deployment of aid by the UN outside the capital, Bangui, is still minimal.
“UN agencies, including UNICEF and the World Food Program, must finally take the decision to leave Bangui and invest more efforts in assisting vulnerable people throughout the country, thus fulfilling their mandate," says Marie-Noëlle Rodrigue, director of operations for MSF. “Donors must also mobilize so that other non-governmental organizations have the financial means to strengthen the emergency humanitarian response, which those organizations currently working on the ground cannot manage alone.”
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