NEWS UPDATE

Introduction
There is a war in the West of Sudan, with two rebel movements (the Sudanese Liberation Army (SLA) and Justice and Equality Movement (JEM)) having launched an insurgency against the rule of Khartoum. After dramatic attacks in April of 2003, the Government of Sudan countered with a decisive military response as well as arming and organizing tribal militias to launch a campaign of violence and forced displacement against the civil population (presumed to support the rebel insurrection). Mass violence against civilians in Darfur began with a wave of attacks against villages in February 2003 and escalated in summer 2003.

For over a year, the people of Darfur have endured a vicious campaign of violence and terror which has led to huge numbers of deaths and forced more than a million people to flee from their destroyed villages in search of safety. Over a year after their escape from their villages and after countless promises from the Government of Sudan and world leaders, safety has still not been found. The victims of violence were forced out of their homes; their homes were destroyed; they were pursued during their flight; harassed and violated during flight and they have continued to be persecuted and intimidated as they seek shelter in crowded and miserable displaced settlements. The pervasiveness of the violence against civilians in Darfur, as well as its duration over time represents a crime of enormous magnitude. The failure to stop the violence against civilians in Darfur was matched with an equally staggering failure to provide the necessary assistance for these devastated communities in the first year of the conflict.

Patients in MSF clinics in Darfur and in neighboring Chad have repeatedly recounted to us how armed militia attacked their villages, killing and raping the inhabitants. These people saw not only their homes destroyed, but also the militia purposefully destroyed their crops and water sources, ensuring that their way of life was torched along with their houses. Almost 1.8 million people were forced to flee their homes, including 200,000 Darfurians who crossed the border to seek refuge in neighboring Chad. Very few of them envisage how and when they can return and take up their lives.

Humanitarianism is based on the notion that people have the right to find safety and support amidst the violence of war. In Darfur the villagers fleeing violence and persecution have found little of either, as the violence and intimidation continued in their places of refuge. Rape and killings have been commonplace in the towns and camps where over a million displaced Darfurians now huddle.

The scale and impact of violence has been documented in a series of nutritional and retrospective mortality studies, which MSF conducted through the spring and summer of 2004 . The results of these surveys reflect the pervasiveness of the violence and appalling consequences of the atrocities committed against people in Darfur, but also the failure of the response to aid the victims of this violence.

In all surveys conducted by MSF, the leading cause of death for those over the age of 5 years was violence rather than disease or malnutrition. In one study in Wade Saleh district in West Darfur, 60% of the deaths in people above 5 years of age were due to violence. Surveys completed by MSF in September 2004 showed that the leading cause of death (32.5%) suffered by displaced people living in Kalma camp over the previous seven months was violence and this figure was a staggering 78% of those aged 18 – 49 years. Among the displaced population in Muhajaria and Shariya, who had not been exposed to violence in the first part of the year, mortality was relatively low. But mortality recently surged due to new fighting and recent displacement – almost entirely in those over 5 years of age (95.5% of all deaths in those aged 18 – 49 years was due to violence in the previous 30 days prior to survey).

While men seemed to be the primary target, women and children were also killed in large numbers. Studies in the large displaced camp of Murnei in West Darfur showed that 75% of the deaths of adult women resulted from violence. In the villages around Murnei, which had been torched in the campaign of terror, an average of 5 percent of the total population was killed. Those who survived told MSF staff of people being locked in houses as they were set afire. MSF staff saw clear signs of torture evident amongst some of the survivors.

The camps of refuge have been turned into congregations of fear, in which people claim they live under the guard of some of the same armed men who burned their villages and killed their families. The displaced are too scared to go home and yet frightened to remain where they are. In several camps, people were too scared to transport wounded children to a hospital, fearing to be attacked on the road. Although the Government of Sudan has claimed that the violence has been brought under control, the displaced still face violence and intimidation.

The massive violence against civil populations resulted in elevated mortality, destruction of livelihoods and flight. The terrified populations that crammed into towns and villages across Darfur, seeking relative safety then suffered a second calamity. These terrified populations faced suffering and death due to a massive public health crisis induced by deprivation during their ordeals and lack of shelter, water, food, an adequate sanitary environment and access to essential health care. The aid program was one year late and remains inadequate.

Even in the easily accessible Kalma camp, located 30 minutes from the major urban centre of Nyala, 3.2% of children still suffered from severe malnutrition in September 2004. For many months, the 75,000 people in Murnei camp were forced to survive on less then 1,000 kilo calories per day - less than half of what is minimally required to sustain a human being. Less than a third of the families in the large camps in Kass owned any soap – essential to avoiding diarrheal and skin diseases.

The lack of assistance has forced people into desperate measures and dangerous survival mechanisms. In the displaced settlements, people are forced to search for firewood to exchange for food even though it means running the risk of rape for women, of execution for the men. Some told MSF that they were so desperate and so scared they would send the children out in the hours before dawn to search for wood – in the hope they would be less subject to attacks.

In the following pages, MSF seeks to convey what has happened to the health of people in Darfur based on data emerging from our clinics and surveys. We do this in order to create some understanding of the magnitude and depth of the suffering and the failure to address these problems. We try to combine this with a human perspective gathered from the conversations and laments of the thousands who came to our clinics for assistance but who themselves were unable to remain silent about the atrocities committed against them and their families.

While this picture of suffering, which has left hundreds of thousands of broken lives amidst the burned-out houses and villages of Darfur is a reflection of what has happened, we have to remind ourselves that this violence and suffering has still not ended. The people of Darfur continue to live in fear of violence and intimidation, even while an assistance effort goes on around them.

Methodology
This report is based on a series of cross-sectional nutrition and mortality surveys carried out in conjunction with Epicentre in 6 locations of Darfur - as well as face-to-face encounters with displaced people and patients, reported by the teams working in West, South, and North Darfur since the beginning of the year 2004.

MSF presence
MSF currently has over 200 international aid workers and over 2,000 national staff working throughout the three States (West, North and South Darfur) and an additional 30 international staff and 160 national staff caring for Darfurian refugees in Chad. MSF medical teams in 26 locations in Darfur conduct medical consultations, treat victims of violence, care for severely and moderately malnourished children, improve water and sanitation conditions, and provide blanket feeding and other essential items for more than 700,000 displaced people in Darfur. Since the beginning of its operations, MSF has born witness to the extent and the nature of the violence against people in Darfur and its impact on the health and nutritional status of the population.

1. Flight From Home
One of the most striking features of the crisis in Darfur has been the sheer volume of people who were forced to flee their homes. 200,000 Darfurians have crossed the border to seek refuge in neighboring Chad and roughly 1.4 million people fled their homes but remain displaced inside Darfur. Direct and systematic attacks against civilians provoked this mass displacement. For example, in a survey carried out in Kebkabya village in North Darfur in August 2004, 98% of the people interviewed said they had to flee their village of origin because of violence.

	“The attack on my village happened early in the morning. The Janjaweed and the Government soldiers were divided into three groups and each group had a different task. The first group took every man between the age of 18 and 40. They put them on trucks. Another group looted our huts. And the last group took the cattle. The Janjaweed told us [the women] that they would bring our men to Deleig. When we arrived in Deleig two days later, we saw the dead bodies of our men laying on the ground in the streets.” Female IDP, 30, Deleig (West Darfur)

The displaced and refugees uniformly describe the perpetrators of these acts of violence as soldiers, Janjaweed or Arab men on horses and camels. People paint a horrifying picture of the massive flight from their homes.

1.1. Violence
MSF often works in conflict areas, where there is ongoing war and civil populations suffering the impacts of violence and deprivation. In most such circumstances, violence is an indirect killer – leading to massive public health crises with diseases and malnutrition responsible for most of the excess mortality. Darfur does not fit this scenario. Retrospective mortality surveys show that a huge number of people have died due to direct violence. In a study among 893 displaced families in Kalma, South Darfur, carried out in September 2004, nearly half of the 104 deaths (50) reported over a seven-month period for people over 5 years of age was due to violence. All but three of these deaths had occurred in people's home villages. Among displaced families in another camp in South Darfur, Kass, 59% of deaths in the previous 4 months in the age group 18 – 49 years was due to violence.

In Murnei camp in West Darfur, where 80 000 displaced people had fled from 111 different villages between September 2003 and February 2004, one in every 20 people or 5% of the original population of those villages were killed in violent attacks. Men accounted for three out of every four deaths, but women and children were also killed, with more than 75% of the deaths among women and 50% of the deaths among children reported due to violence.

	“I was in my house with my wife and children, when we suddenly heard some shooting. So we went outside. There were Janjaweed all around. They shot at me, in the chest, but I survived. But they killed my 3-year-old son, right in front of my eyes.” Male IDP, 45, Deleig (West Darfur)

The consequences of this violence have not been felt equally by all population groups in Darfur. MSF works indiscriminately, and on an impartial basis, providing help to all people only according to need, yet the reality is that the majority of patients treated in MSF clinics and feeding centers are of Fur, Massaleit, and Zaghawa tribal origin.

1.2. Pattern of attacks
Repeatedly people have described to MSF how the Janjaweed encircled their villages and fired guns at random to draw people out of their homes. Once people were outside their huts, the shooting was more targeted and people who tried to escape or defend themselves were killed. There was hardly any time to bury the dead with dignity as surviving family members had to flee for their own lives. Attacks are continuing in certain areas in North Darfur provoking similar mass displacement.

	“The Arabs attacked on 12 December 2003, at around 8 a.m. They came on camels and horses. They left their camels and horses at distance and walked toward the village. They shot first blindly at the crowd and then in my direction. My brother who was standing next to me fell down when the shot hit him. We took his body to bury him in Al Geneina. But it was too unsafe to reach the city so we buried him on the road on our way to Chad.” Refugee woman, 30, Mileta village (Chad)

	“During the attack on my village, my husband got killed in front of me. While everybody ran away, I stayed with his dead body during 3 days. There was nobody to help me to bury the body. I covered his body with a piece of cloth and left.” Female IDP, 40, Deleig (West Darfur)

Attacks were also launched from the air. People described how Antonov planes began bombing villages, schools, mosques, and health centers. As people tried to flee, the Janjaweed on the ground moved in to destroy the villages. On other occasions, the latter conducted ground attacks with support from land cruisers and powerful weapons.

	“My father, brother and uncle were killed in my village by helicopter shots. While we were escaping the attack, on the road, the Janjaweed came with land cruisers and weapons.” Female IDP, 15, Kalma camp (South Darfur)

1.3. Rape and sexual violence
Because of the sensitivity of this issue, the number of women reporting sexual violence in MSF clinics is thought to under represent the scale of the problem. In many reported cases the rape happened several months ago and women and young girls had not dared to visit a health facility earlier to seek treatment and undoubtedly the majority will not have sought treatment at all.

Rape and the fear caused by rape is a prominent feature of the crisis in Darfur. MSF's medical activities have uncovered a high incidence of sexual violence. In a survey in Murnei camp, West Darfur, for example, nearly 14% of the 132 victims of violence treated by MSF medical teams from MSF from April to June 2004 were victims of sexual violence.

Most of the cases of sexual violence, which have come to MSF's attention, occurred during the original attacks on villages. Over a two-month period (August and September 2004), in South Darfur, MSF treated 123 victims of rape. At least 100 of these cases happened during the attacks on the victim's home villages. According to patients, in all cases the assailants were armed men who forced their victims at gunpoint. Gang rapes and abductions have also been reported. Among the cases MSF treated, five women told how armed men detained them for a few days, during which time they were raped several times and mistreated.

A 23-year-old woman described how a group of Janjaweed raped her during the attack of her village in January 2004. They asked her to take her clothes off but she refused and ran to the mosque. They followed her and raped and beat her in the mosque. She was left unconscious with wounds on her body and head due to the beating. Scars visible on her body supported this account.

	“The Janjaweed want to show that they are in control and hope that everybody will move away from the land. The rapes are a sign of provocation against Fur men/rebels: “if you're a man, you cannot let this happen to your wives; so come and fight against us”. Then women are afraid to tell their husbands they have been raped since they don't want them to go and fight. They only say they have been beaten. But men are fully aware that their wives are raped…” Female IDP, 20, Garsila (West Darfur)

1.4. Stripping the population
The attacks on the villages forced people to flee with nothing. The attackers stole or destroyed almost everything during the attacks on villages leaving people to try and survive in Darfur's hostile environment. Groups of distressed people were then continually harassed, beaten, raped and looted as they moved, to keep them in a state of fear and to ensure they left the area.

People recounted that the Janjaweed and the Government soldiers cut access to water sources and made holes in people's jerrycans to prevent them from bringing water with them as they fled the violence. There are reports that many people, especially the most vulnerable ones (children and the elderly) died of thirst during the escape.

	“Some Government soldiers and Janjaweed encircled our village, Artala. They stopped us from going to the wells to take water and stole all our resources (food and belongings). They were all around the wells and they looted our huts. They also blocked the roads. The only road they left open was the road to Kubum.” Male IDP, 40, Kubum IDP site (West Darfur)

People fled, violence continued. Controlling most of the main roads and present in the fields, the Janjaweed continued to assault and rob the people as they fled their villages. Very often, the few belongings the displaced managed to bring along with them were stolen during raids along the roads. Villages and surrounding fields were literally burnt to the ground. It is obvious when driving through the burnt villages that the destruction included not only the demolition of huts and food stocks, but also the devastation of fruit trees, irrigation, and people's fields. There is nothing to sustain the survivors of the attacks should they desire to return to their villages.

2. The Search For Refuge
Although the people driven from their villages have gathered in “sites” which they believe to be safer, there is no real refuge for this traumatized population. People continue to be the target of different forms of violence and intimidation: murders, assaults, and rapes. In the MSF survey of 900 families carried out in Kass in South Darfur in September 2004, violence was the second most important reported cause of death in persons over 5 years of age in the previous 4 months. 53% of these deaths had occurred since arrival in the place of “refuge”.

The situation in Darfur perverts the very idea of refuge. People escape the attackers once, yet they cannot find real safety. Constant insecurity and harassment, as well as lack of basic essentials for survival, mean that many displaced people are continuously on the move, abandoning one place and trying desperately to establish a place of safety in another. Over the last seven months, the great majority of displaced people have been displaced several times, often within a short period. People walk for hours from one village to another to find a place where they can settle. But neither the roads nor the places of settlement are safe. Although the level of violence is not the same in the places of refuge as it was in the places of origin, there are still an unacceptable number of incidents occurring in many places where the displaced have sought shelter. This general climate of insecurity generates further displacement and aggravates the vulnerability of the population. In general, people create their own relative security by gathering in certain locations, mainly major urban centers, where sudden surges in population numbers and density completely outstrips the local capacity leading to a host of medical concerns.

In Kalma camp for instance, the estimated population in June 2004 was around 26,000 people. Over a two-week period, the camp doubled in size due to a population influx mainly from West Darfur . In September 2004, the population figure was 66,000 people. Those newly arrived had left their villages of origin several months before and stopped in several locations before they reached the camp. After such prolonged distress migration without access to assistance, the health and nutritional status of the newcomers on arrival is disastrous. The constant increasing of camp population numbers has lead to a sustained inability for the insufficient aid programming to control the health crisis and continuing high levels of malnutrition and disease.

2.1. Conditions of life
The displaced families are in the most fragile of situations; often sheltering under sheets of plastic and patched pieces of cloth stretched over branches, they have not had enough food to keep their families alive and are prey to various diseases.

	“This attack on our village was after the harvest. A plane bombed the village and we left Artala with nothing but our clothes and our children.” Male IDP, 35, Kubum IDP site of gathering (West Darfur)

They lost most of their productive assets in the systematic looting and destruction of property, which took place during the attacks on the villages. Most commonly and dramatically the people have lost their land and their cattle. The fragile environment has further been attacked – cutting down fruit trees and devastating local forests, while denying the displaced population the possibility of going to the bush to collect wood and wild foods to allow them to survive. The displaced are in a dramatic economic situation; their needs for food and basic non-food items (jerrycans, soap, blankets,…) are alarmingly high and, in most locations, the needs are still not adequately met.

     a) Shelter
On arrival in the sites, the displaced build minimal shelters with basic material such as wood, plastic sheeting and pieces of cloth or blankets. In the worst cases, the new arrivals do not even have enough materials to build such shelters and settle under trees with the few belongings they have.

In Kalma camp (South Darfur), the Epicentre survey revealed that among an estimated population of 66,000 in the camp, around 11,220 did not have an adequate roof to protect them from the rain. As a consequence, these people are highly vulnerable to preventable diseases such as acute respiratory infections and malaria. More than 7,200 did not receive plastic sheeting from aid agency distributions. In Kebkabya, there are still 1 out of 14 households , which did not have appropriate shelter to protect against the rain, despite a large distribution of plastic sheeting just before the rainy season started. The most vulnerable are undoubtedly the new arrivals in the camp, since they are left out of the general distributions of non-food items for days or weeks until they are formally registered. Aid distributions are irregular and insufficiently well targeted to cover the needs of the whole population.

Even the displaced people who have been settled for a few months in their sites of gathering are not able to collect or buy enough wood to build a decent quality shelter which will protect them from the rain or the mosquitoes and will allow them to house all their family members.

	“My husband and I fled after the attack on our home village. We first went to Nyala but life is too expensive there. So we moved to Kalma camp. But we still don't have anything in our hands. No money to build a shelter and no money to buy food.” Female IDP, 33, Kalma camp (South Darfur)

The extremely low grade of shelter has major implications for the health of the displaced populations – particularly during the recent rainy season (June – October). The population are largely living in crowded damp and dirty mud huts with insufficient protection from the rain and the wind or dust storms and without screening from mosquitoes.

The interiors of huts are damp or wet leaving the thin mats people sleep on humid and dirty. “If you want to see the real scale of our suffering, come and see us during the rainy season…” an old woman says to an MSF worker as she is sitting in front of her small shelter and shelling peanuts to sell in the market.

The number of blankets is also insufficient in many households. Around one quarter of the camp populations do not possess any blanket at all. The rest of the population (77%) interviewed have one or more blankets for a family of six or seven people . The cold and damp severely impact on the health of the children and elderly.

     b) Water and sanitation
Water and sanitation related diseases - mainly diarrheal diseases - are very common and have had a disastrous effect on the population. People have regrouped around existing villages or towns, massively overburdening the water resources available. In Muhajaria (South Darfur) for instance, hand pumps are the only protected water sources. There is currently only one hand pump for 2,700 people (while the recommended standard is one for 500 people). The water sources in the destroyed villages, if they have not been destroyed themselves, are inaccessible because of the risk of attacks. Commonly, people take drinking water from puddles on the ground and from open unprotected wells. In most of the settings the population does not have enough water and the water is not clean enough to drink. Even where there is sufficient water – quality remains unacceptable. A quarter of the reported deaths in the camps are caused by diarrhea . The percentage is even higher among children under 5, where it accounts for more than a third of deaths. More than a quarter of MSF consultations relate to diarrheal diseases caused by the lack of clean water and bad hygiene. There has also been a major increase in cases of jaundice, much of it thought to be attributable to the fecal-oral transmission of Hepatitis E, an unusual disease that is particularly dangerous for pregnant women.

The international aid community has been very slow to respond to and improve the water and sanitation conditions of the populations, especially in the camps. For instance, in Kalma camp, MSF water and sanitation technicians report that an estimated amount of 7 liters per person per day of water is distributed when the recommended minimum is 15 liters per person per day. Water is of vital importance for drinking, cooking food and washing and such a small amount cannot meet these needs. In addition, many people are lacking essential items to improve their hygiene practices such as soap and jerrycans. The first consistent distributions of non-food items started only in May 2004. In three locations in South Darfur (Kalma, Kass and Muhajaria), only a third of the displaced population own soap.

Access to latrines and washing areas is dramatically lacking and has hardly been improved by humanitarian aid. In Kalma camp, a camp that has received international assistance for over seven months, there is still only an estimation of one latrine per 70 people, when the recommended minimum during emergencies is one latrine per 50 people and the target is often considered at one latrine per 20 people. In other areas, like in Um Kher, a village in West Darfur, less than 10% of the displaced population have access to a latrine or a washing area. The United Nations estimates that 60% of the needs throughout Darfur with regards to water and sanitation are still not met.

     c) Nutritional status of the population
Many displaced people demonstrate greatest concern and anger over food shortages and the destruction of their food stocks. People claim they will be attacked if they return to their fields. There was almost no planting in May and so even if there were good rains there will be virtually no harvest in many conflict effected areas in November this year. Food aid does not cover all the needs to fill this gap. The displaced and host populations had to wait nine months after their arrival until the first food aid was distributed. When MSF first arrived in Darfur, the number of people (especially the children) close to starvation was staggering. For instance, on the first day the MSF therapeutic feeding centre in Kalma opened, 112 children were admitted.

Erratic general food distributions started in February 2004 but became more regular only in May-September 2004 – and then only in the main camps along major roads and around large towns. The food distributions to date have not completely addressed the high levels of mortality among starving children, but have for now prevented a looming famine. However, the distributions still only cover half of the assessed needs of the displaced population . Many areas are still unassessed and pockets of displaced are still not receiving food, mainly in the rebel-controlled areas. People cannot buy food because their belongings have been stolen, they have no income and food prices have increased. Many populations in Darfur have been reduced to full dependency on aid. The numbers dependent on food aid are only likely to increase next year with the failure of the November harvest.

	“We are depending so much on the food rations distributed by the organizations. We have no source of income, as there is no work available in Deleig. The only option is to collect wood and to sell it in the market. But it becomes too dangerous only 1 or 2 kms far from Deleig.” Female IDP, 24, Deleig (West Darfur)

	“I have two children and I don't have anything to eat at home. My husband was killed last February (2004) and I have no other relatives here. I have no wood and no money to build a shelter so I live at somebody's place. I can't go outside to get some wood because one of my children is sick [severely malnourished child admitted in MSF feeding centre]. I'm also very hungry.” Female IDP, 19, Kalma camp (South Darfur)

Although the nutritional crisis in the major sites in West Darfur has been stabilized after May 2004, it remains very fragile for host and displaced populations. Any interruption of assistance would result in an immediate and drastic deterioration of their nutritional status.

In the camps in South Darfur, the situation is still cause for particular concern, as shown by the table below.

Table 1: Malnutrition rates (W/H Z-Scores), South Darfur, September 2004

Based on MSF statistics , malnutrition is reported to be the second cause of death, after diarrheal diseases. Different nutritional surveys highlight that malnutrition is the direct result of lack of food shortages and not due to environmental factors.

In early July 2004, when Kalma camp received a major population influx, the number of new admissions of children under 5 in the feeding centers grew exponentially. Among the new admissions, almost 40% of children were from displaced families who had arrived very recently in the camp (less than two weeks before) . But the majority of children newly admitted remained among children already in the camps for some months. This situation is a worrying indicator of the critical nutritional conditions of both the new arrivals and those who have been longer in the camp.

Some women explained that the delivery of food relieves them from going outside the towns and therefore they are less exposed to beatings and rapes. Food distributions and therapeutic nutritional support cover some of the immediate needs of the population. According to the UN, still 49% of the food needs are uncovered. The displaced are either exposed to risk or confined in a state of semi-starvation – dependent on international food aid.

     d) Health status of the population
Mass displacement and food shortages have a serious impact on the health status of the population. The very precarious living conditions of the displaced have favored the development and spread of preventable diseases. The main reported causes of deaths are diarrheal diseases, respiratory infections and malaria. Almost 45% of MSF consultations are for diarrheal diseases and acute respiratory infections, while malaria cases, particularly acute during the rainy season, represent the third main disease seen during consultations. The high incidences of all three diseases can be traced to people's lack of adequate shelter and appalling water and sanitation conditions in the camps.

Table 2: Crude mortality rates – South Darfur, September 2004

The crude mortality rates remain above the emergency thresholds, which are one per 10,000 per day for all ages and two per 10,000 per day for children under 5.

Table 3: Reported causes of death – South Darfur, September 2004

Mortality rates are alarming. In Kalma camp (66,000 people ), in South Darfur, the retrospective mortality survey from September 2004 showed that in the past seven months, approximately 2,500 people have died, of which 1,100 were children under 5. In other words, around 20 children have been dying every day in the past seven months. These figures are far above the emergency thresholds. Estimates over August do not show any appreciable improvement, despite increased access to health resources in Kalma camp (due to lack of food and water and new influxes of severely affected people).

Measles has been a major killer of malnourished children in the past months. UNICEF supported the Ministry of Health to vaccinate – but coverage was so low that the epidemics continued with disastrous effect. MSF has repeatedly asked to carry out measles vaccination campaigns but the Ministry would not allow NGOs to vaccinate as they claimed they had already done the job.

2.2. Ongoing violence in and around the places of refuge
The number of deaths caused by violence is still at a shockingly high level. In Kalma and Kass, most of the violence occurred before arrival in the place of refuge. Since April this year there has been a cease-fire. But people in the camps are still reporting deaths due to violent attacks.

From March to August 2004, MSF treated 355 cases of violent trauma, in nine different project locations. Children under 5 are not spared the violence (20.3% of all violent trauma cases occurred among children under 5). These traumas include bullet wounds and people who had been severely beaten or flayed. In addition, brutal assaults inside and outside towns, acts of intimidation and sexual abuses are a daily reality in the places of refuge.

	“In the village of Dogodussa, the Janjaweed constantly harass us on the road when we go and collect some wood. Every time I go, they throw stones at me. Some other time, they lash me with a whip. If I have a new dress on me, they take it off and I come back home naked.” Female IDP, 27, Dogodussa village (West Darfur)

Although there are probably fewer acts of violence today in most places of refuge compared with when the displaced arrived, the fear of further violence is very much present. The number of attacks occurring outside of the towns certainly fuels this fear.

     a) Outside town
Almost all of the displaced people MSF spoke to have a story of a recent incident that happened when they were collecting wood in the fields. Wood is crucial, as it is needed to build a shelter, for cooking fuel or as a marketable item. But since the Janjaweed have taken control over many of the rural areas, it is dangerous to venture even one or two kilometers from towns or villages to collect this valuable resource. Men are at greater risk of being killed or severely beaten, as they might be considered as rebels. Therefore, women venture forth more often and, as a result, are the main targets of such assaults. Among many reported cases, the following one illustrates a very common pattern of assaults outside town. On 8 July 2004, two women in their twenties had their wounds dressed in the MSF clinic in Mukjar after they had been assaulted by two “Arab men on foot”, two kilometers from a village near Mukjar. The men fired guns at them. The women fell as they attempted to run away, and were badly beaten with sticks, leaving them with lacerations and abrasions to the eyes, the back of the head and lower legs as well as multiple bruising.

In the MSF clinic in Mukjar, the medical team treated 15 women in the first week of July 2004 for serious injuries sustained in 8 separate incidents. In two of these incidents, beatings were followed by rape. This represents over one incident per day. The clinical diagnosis of their wounds showed the intensity of the trauma. The message to all IDP women is clear: do not venture outside the camps.

In Muhajaria in the last week of September 2004, the MSF team treated a woman who received three gunshot wounds when she was in the field, harvesting. She explained that her husband was shot in front of her and as she was trying to escape, the Janjaweed shot her in the back. She had three bullet wounds in the back, in the left arm and in the leg.

     b) Inside town
Violence also continues inside the settlements and the sense of fear is always present. In early July 2004, MSF treated a twenty-two-year-old woman who had an open wound and difficulty breathing due to bruised ribs after she had been severely beaten by police or military in her home. These forces were reportedly looking for her husband who was suspected of being a rebel but was not present at home.

In March 2004 in Dabba, a district of Garsila in West Darfur mainly populated with displaced people who sought refuge there after the attacks on their villages, the Janjaweed brutally attacked part of the displaced population living in the edge of town. A woman, who came to the MSF clinic in Garsila described the event. The Janjaweed surrounded one area and sectioned it off from the rest of the district. The inhabitants were forced into the middle of a circle, and the men were severely beaten. The Janjaweed then fired their weapons into the ground and told everybody to go back into their houses and stay there.

Violence is concentrated in certain areas. The village of Mukjar in West Darfur recorded a high number of violent injuries, with 203 cases from February to August 2004. In Muhajaria, a rebel controlled territory in South Darfur, almost half of the reported deaths are due to violence for the months of August and September 2004. Whilst direct conflict and open attacks on villages have declined in most parts of Darfur, fighting between rebels and Janjaweed is beginning again in the eastern part of South Darfur, where villages continue to be burnt.

2.3. Intimidation

	“When you have been bitten by a snake, you are afraid of the rope you see on the ground”, IDP man, 40, Kass town (South Darfur)

Intimidation methods have been and are still systematically used by the armed groups. Violence touches people at an individual level and the fear of violence is omnipresent. To improve their sense of security, the displaced tend to gather in larger urban centers, where they hope to find safety in numbers.

     a) Presence of armed men
The number of Janjaweed and armed men both in towns (especially on market days) and in rural areas is very high, and that their very presence spreads fear among the population. While patrolling in the rural areas, the Janjaweed frequently shoot in the air around population gatherings to intimidate people. People recognize some of them as “unpunished criminals” who were the main actors in the attacks and who continue to rob the displaced of their most valuable assets such as beds, wood or jerrycans.

     b) Taxation practices
People also tell MSF that the armed groups controlling the remaining villages request the populations in certain areas to pay “protection money”. The Janjaweed threaten people with assaults if they do not pay this fee. People say that they have to give any goods that they have in their houses if they are not able to pay the amount of money.

	“In a village near Deleig, there is a checkpoint at the entrance of the town guarded by Janjaweed. They told us that if we want to be protected, we have to pay them a “fee”. We have to give them food: some people prepare breakfast and others prepare dinner. And we have to do it everyday.” Female IDP, 30, Deleig

2.4. Ongoing sexual violence in the places of refuge
After arrival in the places of refuge, women are still subject to sexual abuses. Presently most of the rapes occur when women go outside towns. In the present context, women have a leading role in the household management since men have great security concerns when they go outside. It is a terrible choice forced on women that they have to continue pursuing basic activities outside town, like collecting wood, fetching water or working in the fields, to support the household given the risks they face as soon as they are outside towns or villages.

	“In the last week of April 2004, a group of 40 women went to collect wood only 1 km far from Mukjar. Six armed Janjaweed on horses attacked the group. Another woman and I were badly beaten. The other woman was held down on the ground, beaten and raped by four of the Janjaweed.” Female IDP, 30, Mukjar (West Darfur)

In certain areas, rapes also occur inside town. Women reported that armed men enter their houses, force their husbands to leave for few hours and abuse the women in the meantime.

	“Yesterday evening [22 April 2004], some Janjaweed entered a hut, ordered the man of the family to leave the hut and when he came back, he found that his wife had been raped.” Male resident, 35, Bindisi (West Darfur)

Women also reported that they are victims of other types of sexual assaults, which cause great humiliation and psychological distress. In rare cases, women have reported rape to the authorities although the latter rarely investigate the complaints nor take steps to prevent recurrence. A police report may however be required in the local clinics for women to receive adequate treatment. In August and September 2004, MSF gave medical treatment to twelve raped women, sometimes as young as 12 or 13 years old. Often the women and the young girls had been harshly beaten with clinical examinations revealing severe signs of laceration and bruising. If the incidence of rape is lower in the places of refuge than during the attacks, fear of rape remains extremely present among the female population. The psychological trauma, which has resulted from intimidation tactics and terror campaigns, is clearly visible. In most settings where MSF is active, women and children who come to health care facilities find a space where they feel protected and safe. However, in Darfur women and children are visibly afraid even within the clinic walls.

2.5. Impact on access to health care
In general, access to assistance for the population is hampered by the violence to which they are subject. This violence and fear also prevent them from reaching health care facilities. People living in smaller villages have to travel long distances to reach a clinic where they can receive treatment and therefore expose themselves to attacks along the way. And we have reports that some people might be detained when trying to cross front lines between government and rebel held areas (women and children as well as men).

3. Going Home
There have been various attempts where the Government officials have reassured the displaced populations in the major camps they should feel safe and go home. Such pressure provoked in the larger camps (Kass and Kalma) angry demonstrations from the displaced. To make matters worse, on several occasions, most notably in South Darfur (Kass town and Kalma camp) and West Darfur (Murnei and Ardamata camps), the Sudanese authorities have pressured the leaders of some communities to return to their villages of origin in order to “solve” the problem. Only very few households have resettled in their home villages. High risks of assaults in the rural areas in combination with the absence of any means of survival mean that the displaced cannot return to a sustainable life. Some villages have attempted to go home to collect wood and food from the fields only to be beaten and return to the displaced camps with nothing.

According to a survey conducted in Habilah in the southern part of West Darfur, over 95% of the heads of family interviewed said that they did not wish to go back home under the current situation. Among those who did not wish to return, 85% answered that a security related issue was the main reason for staying in their current place of refuge.

In fact, rather than going home, the displaced keep arriving in the main camps from smaller congregations of displacement all over Darfur, seeking greater security and assistance.

4. CONCLUSION
In response to a rebel insurrection in Darfur in early to mid-2003, the Government of Sudan launched a military counter insurgency. This involved an intensive military response including arming, organizing, and encouraging tribal militias to wage a campaign of unrestrained violence against certain sectors of the population of Darfur: perceived to be African, sedentary and supporters/sympathizers of the rebellion.

Whatever the origins of the conflict – it is clear that the use of violence has been massive, indiscriminate (largely targeting civilians), and disproportionate. There has been massive loss of life due to direct violence (mainly amongst men aged 15 – 50). Around 1.6 million people have been displaced, settling in ad-hoc displacement sites in major towns and villages throughout Darfur. An additional 200,000 people have sought refuge in Chad. It can be safely concluded that a prime objective of the violence was to move certain sectors of the population out of the areas in which they were living.

During their exodus those affected experienced ongoing attacks, harassment and looting along routes of flight. For those who sought sanctuary and protection in camps in Chad or around towns in Darfur it was to be a further 9 months of fear, misery and death before any international assistance was delivered on a meaningful scale. Outside the areas of displacement, they faced attacks from tribal militia still roaming Darfur. Inside these areas, inadequate shelter, food supplies, access to water and health care and terrible living conditions compounded the effects of the violence and migration and led to a massive public health crisis. There have been high rates of acute malnutrition and epidemics of water-born and infectious diseases raging throughout the crowded and unsanitary camp environments.

The international community has pledged to help the victims of this crisis. So far it has not provided adequate aid and assistance, nor has the Government of Sudan responded to the needs of the people in any meaningful manner. More importantly, neither the international community nor the Government of Sudan have taken effective measures to ensure the cessation of violence against civilians.

The aid response has been late and has been delayed further by bureaucratic barriers by the Government of Sudan during the first months of 2004. Even now, aid remains grossly inadequate and of insufficient quality. Whilst the increased numbers of actors and volumes of aid now present in Darfur have stabilized the public health crisis in the major camps and around the main towns, many gaps remain in shelter, water and sanitation, nutrition and health. These are particularly damaging for new arrivals to the camps already weakened through their displacement. And as well as the camps, there are many smaller pockets of displaced people, who may have chosen to stay away from the camps to be near their land. Their needs generally remain unassessed and unmet. The assistance program is not effectively meeting the needs of those in camps, let alone being rolled out to these many pockets of victims, host and displaced alike, suffering deprivation.

Violence, by now well documented and discussed in international fora, continues to be a daily threat for the displaced population of Darfur. Families, in order to sustain themselves, have to continue collecting wood, fetching water or working their fields. In doing so, they make a terrible choice, putting a family member at great risk of assault or worse as soon as they are outside the camps, towns or villages. Even if they were to choose to stay within the camps or towns, risking shortages for their families, they have no guarantee of safety.

The climate of fear that still exists in Darfur is all-pervasive. Camps of refuge are anything but; displaced Darfurians tell MSF that they are living under the guard of some of the same armed men that burned their villages and killed their families. They are too scared to go home and yet frightened to remain where they are.

The situation in Darfur perverts the very idea of refuge. People escape the attackers once, yet they cannot find real safety. In this, the Government of Sudan and the international community have completely failed them.

To redress the situation the people of Darfur must have:

• expanded assistance in terms of quality and quantity
• delivery of aid wherever they have chosen to seek refuge
• freedom from the threat of violence, the fundamental cause of this crisis

© 2004 Doctors Without Borders/Médecins Sans Frontières (MSF)