Despite suggestions by the Angolan authorities that a "normalization process" is underway, for civilian victims of the ongoing war, the situation is anything but normal. Both sides of the civil war continue to manipulate the population in their struggle for power. Threats and outright violence by the two parties to the conflict, UNITA and the Angolan armed forces, have forced the displacement of thousands to the towns of Kuito, Malange, and Kaala. In the past two years, in the nine provinces (of a total of 18) where MSF has access to work, medical teams have noted an increase in indiscriminate violence (murder, mutilation, rape) and a serious deterioration in the medical and nutritional situation, with government authorities having essentially withdrawn from the health system. In the central hospital in Kuito, the capital of Bié province, 74 percent of surgical operations are for war-related injuries, including mine accidents. Massive displacement has led to food crises. In the town of Kaala, in the Huambo province, MSF noted in March 2000 a 20.5-percent global-malnutrition rate among the displaced population. Angola exports 800,000 barrels of oil per day, yet there is no oil to fuel hospital generators, the only source of power in the large hospitals, and in many provinces there is only one available doctor.
>> Read the MSF report "Angola: Behind the Facade of Normalization"
International attention to the ongoing plight of the people of Chechnya has faded ever since the massive bombardment by the Russian Army ended early in 2000. But while the world turned away, the bombing has been replaced by a more insidious form of violence. An MSF report, Chechnya: The Politics of Terror, issued in November, cites eyewitness accounts of random executions, arbitrary arrests, "disappearances," and torture. An estimated 400,000 people are still displaced by the fighting or too fearful to return to their homes because of the risk of arrest or arbitrary violence. Despite public claims that the war has ended, each day Chechnya's hospitals report new dead or wounded from mines, gunfire, shelling, and aerial bombing. Over a year after war started, war wounds are still the number one cause of death in Chechnya's hospitals. Fear of arrest and torture at Russian military checkpoints denies people their right of access to health care. The destruction of hospitals and the lack of medicines and salaries for medical staff have exacerbated the horrendous health care situation in Chechnya.
Many millions of people with treatable diseases continue to die needlessly because of a lack of access to essential medicines in the developing world. For the past six months, hope for a measure of help for people with AIDS has hinged on five pharmaceutical companies' promise to drastically reduce AIDS drug prices for people in poor countries. The companies have thus far failed to deliver and country-by-country negotiations drain already strained health resources in the developing world. In addition, resistance to drugs that treat malaria and tuberculosis-two of the world's most deadly diseases-is spreading to all parts of the globe, while new drug research remains at a standstill. Several newer drugs are available but have more severe side effects and are 10 to 100 times more expensive than older treatments. Most of the estimated 4 million victims who die annually of these diseases are poor people who do not represent a lucrative market for pharmaceutical companies, so there is little incentive for the companies to develop drugs for them. Through its Campaign for Access to Essential Medicines, MSF is advocating for greater use of generic pharmaceuticals, in combination with lower-priced patented drugs, to treat the many infectious diseases ravaging the developing world.
>> Visit the MSF Access to Essential Medicines Campaign Website
Since the Asian economic crisis and fall of President Suharto in 1998, Indonesia has been in crisis, and in 2000, clashes erupted throughout the world's fourth most-populous country. The political struggle among the old guard and new forces of democracy is accompanied by reawakening tensions among some of the 300 ethnic groups spread out over 13,000 islands. "Ethnic cleansing" is taking place in North Maluku, while a bloody civil war unfolds on the streets of Ambon. The provinces of Aceh and Irian Jaya have become stages for violent confrontations over issues of independence, and hundreds of thousands of East Timorese remain trapped in West Timor after fleeing organized militia attacks in the wake of East Timor's vote for independence. More than one million people have been displaced, and the health services are as unprepared for these people as they are for the leagues of war-wounded. Although no national statistics are kept on humanitarian need, wherever MSF teams go, they find thousands of people living on the edge of survival.
Beginning in the summer of 2000, renewed fighting, coupled with the worst drought in 30 years, has inflicted new wounds on the population of Afghanistan. The situation is rapidly worsening in the western province of Herat and neighboring regions. Delayed food assistance and the ongoing fighting are forcing thousands of Afghans to flee en masse. Since June of this year, about 55,000 people have moved to the city of Herat, and have settled in six existing refugee camps. Food is scarce in many regions of the country, and people lack clean water and warm clothes and blankets. The situation is compounded by the closing of neighboring international borders, denying potential refugees protection and assistance. MSF volunteers have also responded to several cholera outbreaks and there have been reports of typhoid, hepatitis, meningitis, and other epidemic diseases. The health system continues to heave from unevenly enforced restrictions on women's employment.
The conflict that has been called the "African World War" entered its fourth year in October, with civilians continuing to face catastrophic conditions. The country has merely 2,000 Congolese doctors for its population of 50 million, and life expectancy has dropped to 45. Epidemics of diseases like meningitis, cholera, shigellosis (bloody diarrhea), and measles are coupled with periodic outbreaks of polio and plague (nearly eradicated in the West), as well as AIDS and sleeping sickness. Without an effective government, roads are no longer passable, and medicines are in short supply. The population of Kisangani, eastern Congo's largest city, has been trapped since 1996, as nearly 20 armed groups, both Congolese and foreign, vie for power. In May, MSF and the International Committee of the Red Cross (ICRC) working in the health centers and hospitals in Kisangani, counted 27 civilian deaths and 155 wounded in three days of fighting.
The Rohingya refugees in Bangladesh are caught between a rock and a hard place: They are neither citizens of their home country, Myanmar (Burma), nor can they become citizens of Bangladesh. Members of a Burmese Muslim ethnic minority group, they fled Burma's civil war in 1992. Of the original 250,000 refugees, only 21,000 are still in Bangladesh, but repatriations of the remaining people have trickled to fewer than 10 families per month. The Myanmar government has refused entrance to many of the families who wish to return home; while others have a well-founded fear of returning. Muslims, who live in Myanmar's Rakine State, are deeply marginalized there, and the political situation in Myanmar continues to deteriorate. In the camps, refugees have experienced both physical and mental abuse by camp authorities, and there is chronic malnutrition. Unlike many of the world's other refugee populations, the Rohingyas have been denied freedom of movement. Therefore, they are unable to sustain their own income-generating projects, which would otherwise contribute positively to their health and well being.
Although news of mutilations and other hideous abuses of civilians received improved coverage in 2000, untold suffering pervaded large swaths of the country that are almost entirely without humanitarian aid or international observation. By mid-July, an estimated 200,000 people were driven from their homes by fear, violence, and hunger, as the war between government and rebel groups was reignited. Many displaced people have left rural villages for overcrowded camps in towns ill-equipped to handle the influx. In the northern province, fighting has halted aid programs, while people fleeing the region put pressure on areas such as the western peninsula where the capital, Freetown, is situated. In June, MSF teams in Mile 91, a town in northern Sierra Leone, reported that food shortages had led to severe malnutrition among displaced children under five, as well as high rates of malaria, respiratory infections, and exhaustion. Most of the displaced people interviewed by MSF cited attacks by government helicopter gun-ships as their reason for leaving their homes; however there were also reports that the rebel Revolutionary United Front (RUF) continued to perpetrate abuses such as killings, rapes, amputations, forced labor, flogging, and looting.
In Colombia, the civilian population is trapped by a conflict that claims thousands of lives each year. The humanitarian needs are growing as more and more people become isolated by fighting, or are forced to flee over and over again. It is estimated that close to two million people have been displaced since 1985--more than half in the last four years--overwhelming social services and local coping mechanisms. As frightened rural residents flood the cities, slums overflow with people whose basic needs are unmet and who are threatened by rampant urban violence and kidnappings. Those who are not displaced have also become prisoners in the cities, as travel has become more dangerous. Meanwhile, the conditions of those remaining in rural areas are even more precarious and their rights as non-combatants increasingly jeopardized. Because of both insecurity and budget shortfalls, health posts and even hospitals go without medicines or medical material, and medical staff is sometimes unpaid.
Nigeria, the most populous country in Africa, is a land of massive inequality. It is the twelfth largest oil-producing country, but one of the poorest per capita. After 30 years of military rule and eleven coups, the new civilian government has its work cut out for it: the health system is in total disarray. The United Nations estimates that almost half of the population has no access to health services. Only 43 percent have access to safe drinking water. The life expectancy is a mere 53 years, and malaria is the number one killer of infants. Seventy percent of deaths of children under five are caused by diarrhea, malaria, and acute respiratory infections. The immunization system has deteriorated for lack of investment, leading to epidemics of infectious diseases. In addition pollution from the oil industry, provider of the country's wealth, has led to serious environmental problems in the Niger Delta area.