November 1, 2004
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 â€“ 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 â€“ almost entirely in those over 5 years of age (95.5% of all deaths in those aged 18 â€“ 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 â€“ 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 â€“ 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.
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.
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.
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.
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.
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.
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.
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.
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.
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 â€“ 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,â€¦) are alarmingly high and, in most locations, the needs are still not adequately met.
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.
The extremely low grade of shelter has major implications for the health of the displaced populations â€“ particularly during the recent rainy season (June â€“ 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 seasonâ€¦” 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.
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.
Erratic general food distributions started in February 2004 but became more regular only in May-September 2004 â€“ 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.
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.
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 â€“ dependent on international food aid.
* 30 days recall period
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.
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 â€“ 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.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)