For 18 years, people in northern Uganda have endured a brutal conflict with consequences that are nearly invisible to the outside world. More than 1.6 million people – 80 percent of northern Uganda’s entire population – have been displaced and now live in squalid conditions. Civilians have been attacked and killed by the Lord’s Resistance Army (LRA) in their villages, as well as in the camps where they have sought refuge. The LRA has abducted tens of thousands of children, forcing them into combat and sexual slavery, a fear that causes up to 50,000 children to stream into city or camp centers across the north every night from as far as 10 miles away in search of a safe place to sleep. The Ugandan army has moved hundreds of thousands of civilians against their will into “protected villages” that offer little security and hardly any assistance, and has victimized ordinary people with brutal raids against suspected LRA militants. While the death toll from direct violence reaches into the tens of thousands, chronic food and water shortages in the 200 makeshift settlements throughout the north have also exacted a heavy price. In November 2004 alone, MSF recorded staggering death rates in six camps in Lira and Pader districts, with many dying from preventable diseases like malaria, respiratory disease, and diarrhea. Recent peace overtures from both the LRA and the government have not led to a noticeable improvement of the situation for people living in deplorable conditions and in constant fear.
Civilians were once again besieged in the eastern DRC when fighting erupted in North Kivu this past December. Nearly 150,000 people fled for their lives from Kayna, Kanyabayonga, and Kirumba just a few weeks after thousands of others fled fighting in the Mitwaba region. These were just the latest chapters in a decade-long war that has cost an estimated three million people their lives and reduced an already impoverished country’s limited infrastructure to ruins. Towns like Bunia, in Ituri province, still bear scars from last year’s fighting, and rape is widespread. Political divisions often erupt along ethnic lines, affecting entire areas of a country the size of Western Europe, where many Congolese cannot meet even their most basic needs. Local militias and government troops prey on civilians throughout the east. In Katanga province, armed groups have burnt down health structures, and unpaid militaries harass, loot, and exploit people. Medical services are woefully inadequate in the entire country, if they exist at all. Measles vaccination coverage in the country is barely above 50 percent, while Doctors Without Borders/Médecins Sans Frontières (MSF) responds to frequent outbreaks of cholera and typhoid fever because of poor sanitation and lack of potable water. A peace accord signed by seven warring factions in December 2002 led to a transition government and a UN peacekeeping force in the east, but the situation remains grim. Even with elections scheduled for June 2005, much remains to be done before any sense of security or hope is restored to people ravaged by a war with no end in sight.
Forgotten by much of the world, Colombia’s enduring conflict continues to inflict great misery on civilians. More than three million people have been displaced within the country, usually to vast shantytowns on the outskirts of major cities, and violence is still the leading cause of death. While control over coca, oil, timber, and other resources fuels the decades-long conflict, half of Colombians live in poverty. In many areas, it is nearly impossible for people to stay outside the conflict, as both government and anti-government forces consider everyone a potential informer or collaborator. In areas where control changes hands, civilians caught in the middle can be threatened, attacked, or killed. Various armed factions fight for control inside the shanty towns, making violence and intimidation a part of people’s daily lives. Medical personnel are threatened, patients have been forcibly removed from ambulances and executed, and health structures are repeatedly looted. Even medical supplies have become a strategic objective. Diagnostic tools and treatments for cutaneous leishmaniasis are heavily controlled because the disease, which primarily affects people in rural areas, is viewed as a marker for possible rebels or their supporters. Living in a state of continuous fear has taken a predictable toll on people’s mental health, as well. Some patients walk for hours to a clinic seeking treatment for headaches, when medicines are available in their villages. Subsequent consultations often lead to discussions with mental health personnel that reveal the terrifying conditions of life in Colombia.
Tuberculosis (TB) kills one person every 15 seconds, thus claiming millions of lives every year even though it is a curable disease. While the risk of TB is relatively low in wealthy countries, the disease is making a comeback throughout the developing world: one-third of the world’s population is infected with the TB bacilli and eight million people annually develop active TB. Unfortunately, most TB is diagnosed by sputum microscopy, a diagnostic test developed in 1882, and the only available medicines for treatment were invented up to 60 years ago. TB treatment takes a minimum of six months and nearly two years for multi-drug resistant (MDR-TB) strains. The AIDS pandemic has lead to an explosion of HIV/TB co-infection, as TB is the most common opportunistic infection for those living with HIV/AIDS. This further increases TB’s appalling human toll. There is an urgent need for serious improvements in the way TB is tackled globally, from research and development of new medicines and diagnostic tests that detect all forms of TB in all patients, especially children and people living with HIV/AIDS, to innovative treatment programs that go beyond Directly Observed Therapy – Short-course (DOTS). “It’s time to openly admit we’ll never be able to ‘control TB’ by prescribing more of the same,” said Dr. Francine Matthys, TB advisor for MSF’s Campaign for Access to Essential Medicines, at the 35th Union World Conference on Lung Health in October 2004. “Massive investment is needed now, so that we can effectively diagnose and treat all those with TB in the shortest possible time.”
Fourteen years of violence have dramatically affected Somalia’s population of nine million, with approximately two million people displaced or killed since civil war erupted in 1990 and close to five million people estimated to be without access to clean water or health care. The collapse of the health-care system, along with most other state services, have hit women and children particularly hard: one in sixteen women dies during childbirth; one in seven children dies before their first birthday; and one in five children dies before the age of five. Natural disasters like flooding in the lower Juba and Shabelle valleys have only worsened the human catastrophe, causing high rates of chronic malnutrition and preventable disease. Even though a recently selected central government offers a glimmer of hope, violence still shatters people’s lives as predatory militias and warlords wield power for financial profit. From January to November in Galcayo, in one of the more stable parts of Somalia, MSF treated nearly 1,000 people for violence-related traumas, including 262 gunshot victims. The continuing insecurity in many areas and a lack of international attention has resulted in a dearth of meaningful emergency assistance, leaving many desperate segments of society abandoned and all but forgotten.
A decade of intense conflict continues to devastate people in and around Chechnya. Despite repeated claims from officials that the situation is ‘normalizing,’ Chechnya is far from peaceful and stable. Even so, since 2003, Russian and Ingush authorities have put considerable pressure on internally displaced people (IDPs) in Ingushetia to return to the war-wreaked region. By the end of 2004, only 45,000 people who fled the conflict, out of an original 260,000, remain in Ingushetia and are living in terrible conditions, while those pressured to return to Chechnya have been placed in “Temporary Accommodation Centers,” where conditions are not much better. Almost all of the 539 people interviewed for a study by MSF in 2004 had been exposed to crossfire, aerial bombardments, and mortar fire. More than one in five had seen killings, and nearly half had seen family members assaulted. About 90 percent of people in the Chechen camps and 80 percent in Ingushetia had had someone close to them die from war-related violence, while more than a third of people in Ingushetia and two-thirds in Chechnya felt unsafe. It is common for friends and neighbors to be arrested or simply “disappear” on both sides of the border. As authorities look poised to continue their policy of moving people against their will, from one inadequate and insecure location to another, the plight of people trapped in this nightmare remains largely ignored.
In Burundi, a country struggling to emerge from a decade-long civil war, a user-fee, or cost-recovery, system has become the cornerstone of health-care financing. As a result, the country’s most impoverished are paying a catastrophic price. A recent medical survey by MSF found mortality rates double the emergency threshold, and little or no health care for those who could not pay. In regions covered by the user-fee system, malaria deaths were twice as high as in areas adopting a low flat fee. One in five people interviewed said they didn’t visit health centers even when they are sick because they couldn’t afford it – not surprising in a country where nearly 99 percent of the people live on $1 a day and a staggering 85-90 percent survive on $1 a week. For many, even a simple consultation costs an average of 12 days’ worth of income. To access lifesaving care, the sick risk further impoverishment by selling off all of their tools and livestock or by borrowing sums of money that can take years to repay. Hospitals have even held patients in confinement until the family finds money for treatment. Deficient state funding and international donor priorities only reinforce the system, even though there is no evidence that cost-recovery contributes to either the sustainability or efficiency of health-care delivery. In the end, it is the health of the war-affected country’s poorest citizens that suffers most from the failed policy.
A man-made cataclysm continues to rage in North Korea, where people struggle against violent repression and massive deprivation in a country that is almost entirely sealed-off from the outside world. In the late 1990s, an estimated two to three million people starved, and recent stories from refugees reveal that the food and health situation is still dire. Even though huge amounts of international assistance pours into the country, there is no way of knowing if it reaches those most in need and many suspect that the bulk of aid is simply diverted by the military regime. Economic reforms, introduced in July 2002, have exacerbated problems, resulting in runaway inflation that undermines people’s ability to afford basic food items. For many desperate North Koreans, even fleeing the country does not end their anguish. Considered economic immigrants by Chinese authorities, most live in hiding because they fear arrest and forced repatriation to North Korea, where they are subject to imprisonment and brutal treatment. Humanitarian aid workers who try to assist refugees face reprisals from Chinese authorities, who deem such assistance a criminal offense. The UN High Commission for Refugees (UNHCR) has not visited the border region for years even though China is a signatory to the 1951 Refugee Convention. While most international interest continues to focus on North Korea’s nuclear weapons program, little attention is paid to the intense suffering endured by North Koreans, both inside and outside the country, who have little access to the basic services and security they need to survive.
More than 10 percent of children do not survive their first year of life in Ethiopia. Scarce farmland in the overpopulated arid highlands leaves an estimated five million of Ethiopia’s 69 million people to face chronic food shortages. Severe droughts in 1999 and 2001 compounded the situation. While some recent rains have provided a little respite, the lack of substantial rainfall since early 2003 has led to the deaths of an estimated 50 percent of people’s livestock. To address this persistent food insecurity, the government is in the process of a multi-year effort to voluntarily resettle more than two million people to the country’s more fertile lowlands. Actual assistance in the program has fallen short of government promises, while resettlement has proven deadly for some communities by exposing people to malaria-endemic regions for the first time. Ethiopian doctors struggle with few resources to fight infectious diseases like HIV/AIDS, malaria, TB, and kala azar for which treatment is expensive and often inaccessible. Malaria has become particularly deadly because drug resistance has rendered the most common anti-malarial treatment practically useless. The government has changed its national malaria protocol to use the more effective artemisinin-based combination therapy (ACT), but international supplies of ACT are facing a huge shortfall. Ethiopia is considered an important partner in the US-led “war on terror,” and the US military has carried out some assistance activities alongside its intelligence and training missions in regions bordering Somalia. MSF has already warned against a possible confusion between soldiers trying to win “hearts and minds” and humanitarian aid workers providing needs-based assistance, and raised concerns that the security of its teams could deteriorate.
Intense fighting during the summer of 2003 in Liberia’s capital, Monrovia, cost more than 2,000 people their lives. More than a year after this debilitating 15-year civil war ended, though, Liberians are still living in a state of crisis. Little of the country’s demolished infrastructure remains, leaving most people without basic services like water and sanitation. More than 300,000 people are still displaced within the country while 300,000 refugees wait to return from neighboring countries. Health care, already scarce in the main cities, hardly exists at all in remote areas of the country. Today, there are only 30 Liberian physicians working in a country with more than three million people. In Bong County, MSF provides 7,000 consultations a month for 60,000 displaced people. Some families are returning to Lofa County, but virtually nothing by way of essential services has been prepared for them. The return of refugees to Nimba County, where MSF provides 5,600 consultations a month, could exacerbate ethnic tensions. Women continue to be victimized by sexual violence, as well – from October 2003 to July 2004 alone, more than 800 people came to MSF for treatment from camps housing 35,000 displaced people north of Monrovia. Against this awful backdrop, instability in neighboring countries, an incomplete disarmament process, and general discontent threatens Liberia’s fragile peace. During three days of riots in Monrovia in October 2004, nearly 400 people were wounded and 15 killed.