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Congo Republic: A Forgotten War Rages

Fighting between government forces and rebel militias in Brazzaville, the capital of Congo Republic, has generated massive atrocities against civilian populations, including executions, mutilations, rapes, and disappearances. More than 250,000 people—nearly 10 percent of the country’s population—fled the capital of this Central African nation at the end of 1998 to seek refuge in tropical forests south of the city, only to find themselves caught in the middle of the fighting. Since May 1999, more than 200,000 people have returned to Brazzaville. In May, MSF volunteers in Brazzaville reported an enormous medical and nutritional crisis: 60 percent of children under five suffered from severe or moderate malnutrition, new returnees faced a lack of hygiene and medical assistance, and many spoke of "epidemics of swollen feet" (a symptom of kwashiorkor, a very serious form of malnutrition). Many said that while in the forests they had been used as human shields, and women and children were systematically raped. From May to October 1999, more than 500 women and children receiving care at the Makelekele Hospital and at a transit center for the displaced reported having been raped on the road back to Brazzaville.

Afghanistan: War Enters Twentieth Year; Toll on Civilians Escalates

Afghanistan’s health care system is in ruins as it faces its twentieth year of war. This nation—which has sent 2.6 million refugees—the world’s largest refugee population—fleeing to Iran and Pakistan, suffers from a critical "brain drain," as most medical staff have departed. In 1999, several international organizations also left Afghanistan due to lack of funding, and U.N. sanctions established in October 1999 have restricted the ability of those remaining to move supplies into the country. Afghanistan continues to have the world’s poorest health statistics including the highest maternal mortality rate. Irrigation canals have been mined, making it impossible for people to grow crops. As a result, there is chronic malnutrition, and children’s physical and mental development is stunted throughout the country. From June to August 1999, the Taliban movement undertook a large offensive on the Panshir Valley—one of the few remaining parts of the country not in its control. Although it did not succeed, 40,000 to 60,000 people were displaced in the process. The Taliban implemented a scorched-earth policy—razing crops, destroying irrigation systems, and burning houses—as they withdrew. Although the government has shown some moderation in its policies restricting women’s access to health care, such access is still heavily constrained. Working throughout the country, MSF has provided female medical staff, as well as substantial primary care and nutritional aid.

Angola: Displacement, Landmines, Hunger Threaten War Victims

Since a breakdown of the 1994 "Lusaka Protocol" reignited Angola’s 30-year civil war in December 1998, civilians have been facing new dangers. Rich in natural resources, Angola could be one of the wealthiest countries in Africa, but it has become one of the poorest. Displacement of 1.6 million people (more than 800,000 since December 1998), has put severe strains on public health, food, and water infrastructures. In Kuito, where MSF runs a surgical program, the organization treated 354 cases of landmine wounds in the first six months of 1999—a 27-fold increase from the same period last year. Humanitarian agencies face numerous challenges in trying to improve conditions: from landmine danger and direct threats, to outright denial of access. MSF was denied access to the besieged city of Malange, for example, from March to June 1999. When MSF returned, they discovered tens of thousands of internally displaced people without food, clothes, medicines, or fuel. Fifteen percent suffered from severe malnutrition. MSF immediately implemented an emergency feeding program.

Millions Die from Lack of Access to Medicines

Treatable communicable diseases such as tuberculosis, meningitis, and pneumonia are still the leading causes of death in the developing world. Little research is being carried out on tropical and other infectious diseases like malaria and sleeping sickness that largely affect people in poor nations, because drugs for such illnesses are not profitable for pharmaceutical companies. Moreover, even when effective treatments exist, as they do for diseases like multidrug-resistant tuberculosis and many AIDS-related infections, patent protection keeps them out of the financial reach of people in the world’s poorer countries. MSF doctors are consistently frustrated by their inability to treat their patients for diseases that would not be fatal to their patients in North America or Europe. To address this far-reaching problem, MSF has launched the Access to Essential Medicines Campaign, a project to improve the availability of high-quality medicines worldwide. The project will pursue increased use of world trade regulations that allow countries to produce affordable, generic copies of patented drugs, and will seek innovative ways to spur research and production of affordable new formulas.

Democratic Republic of Congo: Health Care System in Ruins

Following 30 years of "kleptocracy," the Congolese must now contend with a regional conflict being played out on their soil. The country is effectively cut in two by fighting between government forces based in the western capital of Kinshasa and rebel factions in the east, both of which are heavily supported by neighboring countries’ governments and opposition movements. Although the frontline has been stable for six months following an August 1999 peace treaty, fighting continues in some areas. In eastern Congo, which is cut off by destroyed roads, the major city Kisangani is without medicines or salt. Despite the nation’s rich resources, the only functioning health structures are those supported by foreign agencies, including MSF. Without a national primary health care system, epidemics like plague, cholera, measles, meningitis, and hemorrhaegic fevers break out frequently. There are 830,000 internally displaced persons within the country as well as more than 250,000 Congolese refugees living in neighboring countries. High rates of malnutrition exist even in the capital—a city of 6 million—where more than a tenth of the population is malnourished, and among displaced populations throughout the country. Each year there are 50,000 new cases of sleeping sickness—a deadly disease that was nearly eradicated in the 1960s.

Colombia: Danger and Threats Plague Medical Staff and Aid Workers

Gaining access to health care becomes more difficult each day for the people of Colombia. Health services in the zones most affected by the armed conflict suffer from a lack of infrastructure and personnel. Few medical staff will work in the most dangerous areas where the need is greatest. Health posts and entire towns have been destroyed, and indigenous populations in the most remote regions are particularly cut off from health care. Public perception of the conflict in Colombia is that it is drug-related, affecting only those directly involved in trafficking. However, the problem is a much larger, undeclared civil war between the government and guerrilla forces, and most victims are civilians. Hundreds of medical staff have been attacked, and, in many cases, killed. In addition, violence has spread to the cities, where slum dwellers face great danger. MSF programs provide medical and psychological assistance to young victims of violence in Agua Blanca, Cali’s largest slum, as well as primary care in the slums of both Cali and Bogota. The organization also brings mobile health clinics to isolated communities in northern Colombia, where guerrilla warfare has waged for 30 years, and to the victims of the January 1999 earthquake in Armenia.

Mozambique: Cholera Epidemic Strikes

One of Africa’s largest cholera epidemics of recent decades struck Mozambique in December 1998, and by mid-May 1999 had infected 62,263 people, with 2,063 deaths. The epidemic was particularly severe and difficult to manage, because, unlike epidemics that take place in confined areas where water resources can be quickly purified, it spread from village to village, over large distances. Almost all of Mozambique’s provinces were affected—even tiny and remote villages—and the bacteria was particularly resilient. In a nation that is still recovering from civil war, with very limited health resources, an epidemic like this creates a huge strain on the health system and interferes with the ability to address other diseases, like malaria, AIDS, and tuberculosis. Working with the Ministry of Health, 90 MSF volunteers opened 180 cholera treatment centers, and brought more than 500,000 liters of rehydration solution to isolated parts of the country. The organization also made available five tons of drinking water, tanks, bladders, and pipes.

Sri Lanka: Civil War Intensifies

The fighting between Sri Lanka’s government forces and the Liberation Tigers of Tamil Ealam (LTTE), has intensified since November 1999, creating havoc for civilians in the northern and eastern provinces. MSF volunteers have provided medical treatment for numerous civilians who have been victims of shelling and bombings, including the bombing of a church in Madhu that was serving as a safe haven for 3,000 civilians. By November 10, 60,000 residents of Vavuniya had heeded LTTE warnings to flee their homes in preparation for an assault. But the government prevented those already living in displaced camps from leaving because they did not possess appropriate travel documents—in flagrant violation of international law. In Batticaloa district, where MSF has worked since 1987, the organization has been refused permission by the government to bring mobile clinics to populations completely without health care. Medical teams in Mallavi and Puthukkuydiyiruppu, cut off from the south of the country, fear imminent supply shortages. Transporting medical supplies and staff to the northern and eastern part of the country has been an ongoing challenge throughout this 16-year civil war.

Burundi: War and Displacement Leave Civilians Without Health Care

A humanitarian crisis has prevailed in Burundi since a civil war broke out following the 1993 assassination of the elected president. About one-sixth of the population—or 800,000 people—have been either voluntarily or forcibly displaced by the government in its effort to control rebel activities. One immediate effect of removing people from their farmland has been to further impoverish a country that has never been rich. Tensions increased last summer with the return of Burundian rebels who had fought in neighboring Democractic Republic of Congo. Fearing rebel attacks, authorities moved approximately 300,000 people living in the province of Bujumbura Rural into 50 regroupment camps. Conditions in these camps are dire, and on November 18, 1999, MSF announced that it was suspending its operations in the camps to draw attention to this man-made disaster. Only 19 of the sites had been accessible to aid agencies for security reasons, and limits on movement did not permit effective assistance and prevention of epidemics and malnutrition. In other parts of the country, such as Karusi, in the center of the country, MSF has seen sharp increases in the number of children receiving emergency feeding in its therapeutic feeding centers.

Somalia: Civilians Face the World’s Neglect

For nearly a decade, the people of Somalia have lived in a state of emergency due to civil war, and health care is currently at the lowest levels since 1991. There are constant epidemics and food shortages due to the persistent destruction of property, displacement, drought, and flooding. A drought has killed a large portion of the country’s livestock, and an animal hemorrhagic fever outbreak in 1998 caused greater economic collapse. Somalia’s infant and maternal mortality rates are ranked in the top ten percent worldwide. Cholera is endemic and affects thousands of people each year, particularly in urban areas in the center and south of the country. In Galkayo, MSF is currently fighting cholera and meningitis epidemics, and the collapse of immunization has also led to measles outbreaks. Although MSF and other international agencies provide medical services and epidemiological monitoring throughout the country, the unstable situation makes lasting improvements unlikely. Amid such desperate circumstances, the commitment of the international community is decreasing. Donor funds for relief assistance are in short supply, and only a handful of relief agencies are working in southern and central Somalia, the most affected regions.

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