February 13, 2006
In western Darfur, Sudan, the violent confrontations of 2004 have given way to a situation of chronic instability characterized by persistent violence affecting all those living in the province. For Doctors Without Borders/Médecins Sans Frontières (MSF), the challenge is to continue to provide medical assistance to people with ongoing and major needs, to remain responsive in the event of new emergencies and, despite the insecurity, to provide high-quality assistance. Dr. Pauline Horrill, MSF's program manager for Sudan, and Fabrice Weissman, head of MSF's projects in West Darfur, offer an update.
How would you characterize the current situation in West Darfur?
Since 2005, Darfur has no longer been the scene of major confrontations and massive violence that threw the region into a state of unrest in 2003 and 2004. As a result of those confrontations, hundreds of thousands of people were driven onto the roads from their looted and burned villages, having lost all their possessions and their crops. In some places, they were fleeing killings that left one person in 20 dead.1 Since last year, the situation is now more aptly described as one of chronic instability.
Dr. Pauline Horrill:
However, certain areas of West Darfur state, where we are working, are experiencing periodic resurgence of violence. These events are linked to the current situation near the border with Chad, to recurrent fighting among the militias, the government army and rebel groups, and to tensions among nomad clans that have degenerated into bloody confrontations. This chronic instability, punctuated by violent episodes, has a direct impact on the population and has led us to redefine and step up our activities.
What are the displaced persons' living conditions?
Almost all of them–totaling some 2 million, or one in three Darfur residents–continue to live at the sites where they sought refuge nearly two years ago. In these towns controlled by government forces–like garrison outposts–the living conditions, although improved, remain prison-like. The people living in these open-air jails still cannot–and do not want to–return home because of the continuing insecurity outside these sites. Few of the displaced persons venture outside the camps to find firewood, or forage for their personal needs, or to sell to earn some income and improve their situation. Some slightly better-off individuals have managed to buy plots of land on the outskirts, but working on them is still dangerous because of the violence experienced by people who venture outside the camps. The displaced persons continue to be crammed inside makeshift shelters, and this overcrowding is unhealthy. Finally, violence continues even within the camps. This is characteristic of every displaced persons' camp, where traditional structures have been shaken by flight and violence–including intra-family violence and prostitution undertaken for reasons of survival. Epidemiological indicators suggest that the health and nutritional situation is stable, but it remains fragile.
I last visited in December 2005 and, before that, in February 2005. I was struck by the fact that nothing had changed in 10 months even if, at first glance, everyday life seemed to have resumed. In Mornay, for example, children attend school and goods are traded in the market at the center of the camp. However, this activity masks considerable fragility, as revealed by our medical work, which continues at a high level. In Mornay, with its 5,000 inhabitants and still home to 74,000 displaced persons, nearly 5,900 patient visits are conducted every month and the major illnesses–respiratory infections, diarrhea, and a variety of physical ailments–are obvious signs of that fragility. We saw another sign of this instability in July, when the general food distribution had to be postponed after disturbances related to the displaced persons' registration process and the number of children suffering from "moderate" malnutrition then shot up. Simply reducing or delaying the supplies to a camp can almost immediately worsen families' nutritional status. But most importantly, there is a continued suffering that affects all the displaced persons in the camps: the lack of hope that their situation will change.
Is the Assistance Provided Adequate and Appropriate?
We continue to provide significant medical assistance, but living conditions remain unacceptable. And because we have reached the limit of our operational capacity, we cannot ensure that certain treatments are adequate; for example, care for women who are victims of sexual violence. As in other similar situations, women do not seek treatment easily because they are afraid of being ostracized or subjected to police repression. In addition, this issue is highly politicized–the authorities want to make the case that this form of violence does not exist or exists only marginally, while other organizations tend to exaggerate it, hoping to provoke the international community to take stronger action in Darfur.
Similarly, we have not set up mental health programs, although from what we hear from our Sudanese employees and patients, people are deeply traumatized by what happened to them in 2004.
In the end, keeping the population of the camps alive represents a real challenge–in human as well as financial terms. We are still talking about tens, even hundreds, of thousands of people who need water, medical care, and food. Humanitarian aid organizations have a significant presence in Darfur with 1,200 international volunteers. But what is more critical is the quality of the assistance and the ability to respond to emergencies that may arise, whether related to resurgence of violence or to epidemics, as the Darfur region is at great risk for epidemics of yellow fever, meningitis and malaria.
What are living conditions like outside the camps?
In the rebel-controlled areas–essentially in the Jebel Marra, the mountainous region in the center of Darfur–living conditions are markedly better than those in the displaced persons' camps. However, they are still difficult because the army and the militias surround these regions, thus limiting people's opportunities to find food and seek medical care. The few health-care facilities that existed in this region no longer operate. The only way for the population to receive health care is to travel to towns held by government forces, but at the risk–particularly for men, who are systematically suspected of being rebel fighters–of arrest. Traveling also means crossing through areas of confrontation. In Niertiti, for example, at the foot of the Jebel Marra, where we work, people travel only on market days. That is why last July, we launched a mobile clinic, once and then twice weekly, for residents of Kutrum in the rebel zone, where 25,000 people still live. The long-term goal is to have an on-going presence so that we can provide high-quality care and improved referrals for those patients who require hospitalization.
Are the nomadic populations affected?
While the nomadic populations are less affected, they are not spared because rebel activities interfere with traditional migration routes. Confrontations among clans, which have continued over decades, are more frequent — and bloodier --today as a result of the high level of arms in the region. In mid-December in Zalingei, following clashes between two nomadic tribes, our teams treated 52 seriously wounded people in the hospital over three days. This fighting also resulted in the displacement of 3,600 people to Alamedia, one of the two displaced persons' camps near Zalingei. But these nomadic populations could not move into the camp because the other displaced persons believed them to be close to the Janjaweed militias. Their access to the range of services, and specifically to medical care, was thus limited.
What is the outlook for MSF's programs in West Darfur?
We have four programs in Western Darfur, covering some 300,000 people (displaced persons and others). Our team is made up of 27 international aid workers and more than 580 Sudanese, and have increased our budget for this state by nearly 20 percent from 2005, which reflects new activities (mobile clinics and additional activity in the Zalingei and El Geneina hospitals).
Our enhanced presence in the Zalingei hospital is a good example of the problems we face today. Built to meet the needs of a population of 30,000, it must now serve 90,000 people, following the influx of displaced persons. The hospital could not respond to the flow of wounded people in December and as a result, we became involved.
Although we have already made a significant commitment of human and financial resources to Darfur, we must also be prepared to react in the event of additional emergencies.
1 Violence and Mortality in West Darfur, Sudan (2003-2004) – epidemiological evidence from four surveys. Epicentre and Médecins Sans Frontières. Report published in The Lancet in October 2004.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)