Democratic Republic of Congo

International staff:

158

National staff:

1600

MSF has been working in DRC since 1981

On the dilapidated road between Beni and Mambasa, there is a constant flow of people, on foot or riding bicycles, transporting all kinds of bags, bundles and objects: onions and bananas, mattresses, saucepans, clothes, wood, jerry cans and children. An attack by armed rebels, the third in as many months, pushed residents from their homes in December 2002, emptying village after village along the road south from Mambasa. "We had to flee in the middle of the night," recounts 20-year-old Kasereka Kasemengo. "I had to carry two of the children, as well as the child I'm carrying inside. It was very hard. We suffered so much, and we still have nothing." The Democratic Republic of the Congo (DRC) is not yet on the road to "normalization," despite recent progress in the establishment of a transitional government to end the civil war. Peace is elusive: the country's ongoing conflict continues to be a complicated struggle, perpetuated in part by regional and international interests in the country's rich natural resources.

It is the Congolese people living near conflict areas who suffer most from the war, attacked by all sides, their fields burned, their houses destroyed, their lives undercut by violence. Surveys conducted by MSF have documented that near the front lines of the fighting one in four families has experienced beatings while one in seven has suffered rape, torture or forced recruitment. Some areas, such as Nord- and Sud-Kivu provinces and the Ituri region of Orientale province, have particularly high levels of violence. Years of war and neglect have caused the country's health system to collapse, leaving most people with no access to medical care. Armed conflict, poverty and lack of health care mean enormous medical needs: "Wherever we stop the car, we could open a project," states one MSF project coordinator. In an environment where insecurity, outright con. ict and population displacements are commonplace, evacuations of health teams are frequent and logistical problems routine. Despite these challenges, MSF teams work to restore the dignity of people they encounter through responding to epidemics and emergencies and providing basic care to those who have none.

Bunia

"I fled Bunia because of the war. My husband is dead and so are my two children… I was saved because I was in the bedroom when they killed my husband. heard the noise and when I saw what was happening I went back in the bedroom and jumped out of the window. I landed in the flowerbed I had planted and I stayed quiet. I was there trembling among the . owers for a long time. When I came out, I saw my husband's body." – a woman taking refuge in the town of Erengeti

Despite ceasefire agreements and attempts to negotiate peace, fighting has persisted in eastern DRC since 1998. MSF has medical aid projects in many parts of eastern DRC, including the provinces of Nord-Kivu, Sud-Kivu, Katanga, Equateur and Orientale, but it is events in the northeastern region of Ituri, in Orientale province, that dominated much of MSF's new activities in the last year, and particularly in spring 2003.

United Nations peacekeeping troops arrived in the city of Bunia, regional capital of Ituri, in May 2003. Despite the presence of these 600 United Nations Mission in the Democratic Republic of the Congo (MONUC) soldiers, the power vacuum left by withdrawing Ugandan forces (who pulled out of the area in April as part of a previous bilateral agreement) was quickly filled with various armed militias. Many were still tied to larger rebel groups or backed by outside powers vying for control in the region. Within days, the tension in Bunia erupted into the brutal massacre of several hundred civilians. In the wake of the violence, the city was emptied of three-fourths of its population, as 150,000 people fled, many hoping to reach Beni, nearly 145km to the southwest in Nord-Kivu; others tried to cross the border into Uganda or stayed in Ituri itself. MSF has been working to support health centers and internally displaced people in Beni since December 2002, and responded quickly to the new influx. As teams supplied medical care, water and shelter to thousands arriving in the area, they also listened to their stories of the escape from Bunia and the perilous journey to reach Beni.

"It was by the grace of God that some people from Bunia managed to get here because many of them didn't make it," said one Bunia resident after arriving in Beni. For those who fled, survival was difficult and fraught with dangers. The journey was exhausting; most people had no supplies and many carried children or elderly relatives in their arms or on their backs. "It was like a human tide along the roads," remembered one woman. "People showed us the way. You saw traces left by the people who had gone before." Dangerous armed groups preyed on civilians, stealing their possessions and money and inflicting senseless violence. "Along the road, four boys we knew well were walking behind us," said one woman. "They were friends of my son and often came to our house. We heard them cry out. They were being attacked with machetes." The protracted conflict in eastern DRC is particularly horrific because civilians, even children, are frequently targeted. "This is not a war between ethnic militias or between groups," explains Thomas Nierle, MSF Director of Operations in Geneva. "This is more like a war against civilians." In the words of survivors in Ituri, the suffering of the Congolese people becomes clear: "My two-year-old died on the road in my arms," stated one woman. "If you didn't pay at each roadblock, things were difficult. Difficult? They threatened you, beat you and killed you if they wanted to... I didn't have any more money. I was carrying my baby close to me. He had his arms around my neck. They killed my son to intimidate me. They did it intentionally."

Women and children with war wounds

As teams in Beni helped those able to reach them, other MSF staff responded in Bunia. The first MSF team started work in Bunia at the end of April, supporting surgical activities at the hospital. MSF withdrew for several days when fighting flared up in town in early May. When the team arrived back in Bunia, the hospital was no longer accessible, so the team quickly set up a clinic in an old warehouse. Dubbed the "Bon Marché" clinic, the 70-bed facility began treating war-wounded people in mid-May and has since conducted an average of 300 consultations each day, and nearly 80 surgical interventions and more than 100 hospitalizations each week. Many of those with war injuries were civilians, often women and children, and to make matters worse the wounded seemed to have been isolated from any medical care for some time. "Fighters are brought in with fresh war wounds. But civilians have war wounds that are often more than three weeks old. It is very difficult to help them. These people must have suffered," comments MSF surgeon Birgit Neudecker.

With protection like this...

Violence and insecurity continued even after the arrival of 1,500 soldiers from the Unauthorized Interim Emergency Multinational Force (IEMF). The mandate of the IEMF was limited to Bunia town; villages in Ituri were still facing attacks by armed groups. Desperate for protection, residents began to return to Bunia, many gathering . rst near the MONUC positions; as their numbers grew, they were moved to a camp on the western edge of town. "Bunia is becoming like a partly surrounded refuge where people from the surrounding areas seek safety," commented MSF Head of Mission Nicolas Louis. But Bunia was far from safe. Security improved during the day, but at night militias entered Bunia to loot, kill and terrorize civilians. MSF continued activities at the Bon Marché clinic and began providing health services to the thousands gathering in the camp, adjacent to the clinic. From their patients, teams heard firsthand about the continued violence. Stories of rapes and disappearances were common; the displaced people were easy targets for armed perpetrators.

Inadequate humanitarian aid and no formal registration in the camp also meant that many people lacked minimal supplies and were going hungry. Arriving with nothing after traveling for weeks, many were forced to wait several days for any assistance. Those fortunate enough to receive food rations were given only 700 kilocalories a day, one-third of an adult's daily nutritional needs. With the new in. ux of people, MSF began medical screenings at the entrance of the city. With more than 1,000 new people arriving in Bunia daily in early July, MSF spoke out about the dangerous conditions faced by the more than 18,000 displaced people crowding into the camp. In July, MSF sent four cargo planes to Bunia to help address the massive needs and opened a new therapeutic feeding center to combat growing malnutrition. MSF staff also began a blanket feeding program to provide nutritional support to 17,000 children in the area of Beni.

Dangerous expectations

In July 2003, MSF released the report Ituri: Unkept promises? A pretense of protection and inadequate assistance. The report reemphasized the direct and indirect responsibility of neighboring states and various armed groups in fueling the ongoing con. ict in Ituri. Through the testimonies of the Congolese people themselves, the report documented the lack of basic assistance and continuing violence in Bunia and in the entire Ituri region. It also showed that, while protection inside the town did improve slightly, civilians' growing perception that safety could be found in Bunia, stimulated by the presence of UN and IEMF peacekeepers, was not always equaled by enough security. At the same time, massacres continued outside of town. It is impossible to forget the brutal massacres of civilians who believed they were being protected by United Nations peacekeepers in Bosnia and Rwanda. In Unkept promises, MSF called on the United Nations Security Council to avoid giving an illusory sense of security to the people of Ituri – and to instead provide them with real protection. Around the same time, MSF also expressed concern about the imminent withdrawal of the IEMF, slated for September 2003.

The fighting in Ituri has left thousands of people out of the reach of emergency assistance. With only small areas secured in and around the peacekeepers' compounds, the majority of those who used to live in Bunia are still displaced, with no access to emergency health care. MSF teams often receive patients who have been in hiding for weeks, and who arrive in very poor condition. That they have somehow found their way to the clinic means they are the lucky ones, the few who will receive medical care and food for their children. The people who are beyond a few kilometers from the city are still very vulnerable, and very exposed, and these are the people whom MSF, and other humanitarian actors, are unable to reach.

Many ways to die in DRC

Far away from the daily terror and intense con. ict in Ituri and other troubled areas of eastern DRC, forgotten ills – malnutrition, disease epidemics and lack of basic health care – silently claim thousands of lives. It seems unthinkable that children in Congo die every day from preventable and treatable diseases. But in a country like DRC, where most people do not receive medical care, the unthinkable has become common. Unfortunately, there are many ways to die in DRC.

In a letter home from a basic health care project in Mbandaka, Equateur province, MSF mission administrator Danielle Courtin writes, "Words fail to describe the state of dereliction of the health care centers in this province: the general hospital here is . lthy and lacks the most basic equipment. I've seen operating theaters with leaking roofs, centers where there's not even a chair for the consulting nurse, let alone for the patients. In the pharmacies, the shelves are empty and in the wards beds and mattresses are missing or broken." Many clinics around the country are in a similar state, in terrible condition and lacking basic supplies. Access to communities in need in DRC is not only hindered by con. ict. In many parts of the country, geographical constraints compounded by population movements related to the war have also made access to health care impossible. In November 2002, MSF reorganized a health zone project in Equateur, Katanga and Orientale provinces in order to more effectively reach the people. MSF teams travel extensively throughout the health zones, visiting villages and health centers and conducting clinics and vaccination campaigns. "The major challenge the team faces is transport," explains Courtin. "There are no roads beyond 20km from the city." In many projects, supplies are carried by team members on motorbikes or canoes, or even on their backs. "One of our teams last week walked 58km through swamps to reach a remote health center," continued Courtin. The health zone initiative also enables MSF to reach Congolese who are hiding in isolated areas to escape the violent civil war.

A cruel and unjust end for a child of twelve

With minimal or no health care in many places, preventable diseases claim thousands. The story of Francine, told by MSF volunteers present at the Kabati therapeutic feeding center in Nord-Kivu, where she arrived on May 13, 2003, is illustrative. "Skeleton thin, she lies in the examining room, coughing and in acute pain as the doctor checks her abdomen. She is diagnosed with advanced disseminated tuberculosis, from which she will almost certainly die. A cruel and unjust end for a child of 12 years." (This description was also published in The British Journal of General Practice, July 2003.) Less than half the country's children have received basic vaccinations, and outbreaks of disease are a common occurrence. MSF is committed to helping bring the countrywide measles vaccination rate for children up to 85% (it is now less than 40%), so massive vaccination campaigns are routinely implemented in all parts of the country where teams are present. During the past year hundreds of thousands of children were vaccinated in both western and eastern DRC.

Malnutrition and cholera also claim countless lives. Many MSF projects include therapeutic and supplementary feeding centers, which can be either long-term or opened for short periods of time during emergencies. One example of a typical project: in October 2002, MSF opened a therapeutic feeding center for 100 children and launched mobile clinics in Musao, Katanga province. Soon after, a similar nutrition project began in Mukubu, just on the other side of the Congo river, where people are constantly fleeing combat between different Mai-Mai factions. The Musai project was able to close at the end of the year, but the Mukubu center is ongoing, despite continuing security problems. These two centers were extensions of the many projects of hospital and clinic support already underway in different parts of Katanga province.

MSF teams have become accustomed to receiving people in very poor condition, due to the violent civil war, poverty and the terrible health conditions. "So many people seem completely beaten down by the situation here. They arrive at the feeding centers without spirit, as if the wind had been knocked out of them," described one MSF worker.

To help respond to the year-round outbreaks of cholera, MSF runs a rapid response program. Based in Kinshasa, Kisangani, Goma and Kalemie, the Congo Emergency Pool (CEP) is a base for epidemic surveillance of the entire eastern portion of the DRC. Weekly radio reports from across the region keep the team informed of outbreaks and help shape interventions.

AIDS, unforgotten

MSF has also begun to provide care for people living with HIV/AIDS in DRC, a problem that elsewhere in Africa makes the headlines but that here is overshadowed by so much else. In the city of Bukavu in Sud-Kivu, one project targets a population of more than 600,000. Activities include treating sexually transmitted diseases (STDs) and opportunistic infections, voluntary counseling and testing, and home-based care for some patients (with antiretroviral treatment beginning as this report goes to press). In the capital Kinshasa, many people are infected with STDs which are often not treated properly at existing health centers.

MSF teams in Kinshasa provide quality treatment while raising awareness among high-risk groups; 45,000 people with STDs are cared for through 34 health centers each year; 1,500 people with HIV also receive treatment for opportunistic infections, with ARV treatment planned for the near future. HIV/AIDS projects are also underway in Katanga and Equateur provinces. Other specialized projects in the DRC include program to combat sleeping sickness in Equateur province, with plans to expand this work to Kasai and Orientale provinces.

Significant insignificance

With over 150 international and 1,600 national staff, at any one time MSF teams are trudging through the rainforest with essential medicines and supplies on their backs, listening to nearby explosions and gun. re while operating on wounded in a makeshift clinic, or providing some small assistance to thousands of displaced people who tell their stories of atrocities and survival.

MSF is committed to providing need-based emergency medical care in the DRC, but in the face of such a devastating crisis, the scope of the needs can be overwhelming. This is true from the isolated villages deep in the forest, to the capital city, to the crowded camps for the displaced in Bunia and Beni. What becomes clear in the comments of the doctors and nurses and logisticians who continue to work in DRC is that it is the people they help that make it worthwhile. "In Shabunda, people tell us of the hope we have provided by working in the hospital and staying with the them throughout the years of attacks they have faced," says operational director Kenny Gluck. "The insignificance of our actions in terms of the fate of the Congo is only counterbalanced by the effect we have on individuals and communities in the few places where we work."

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