Central Africa Republic Series

Alina Potts writes this piece as part of our ongoing series about the Central African Republic:

In our two months of surveying around CAR, we saw very little traffic. The white vehicles and blue flags of the United Nations provided us with a great deal of safety, security, and speed, but the roads were eerily free of passing trucks or pedestrians, even in the conflict-free areas. Outside our windows we observed tiny villages, really collections of mud houses – maybe 15 or 20 – laid out along the road, often with great swathes of forest stretching between them. The typical sights we associate with travel in Africa, those of overcrowded bush taxis, women carrying large market bundles on their heads, and children leading loaded-down pack animals to a bustling market, were eerily absent in CAR. Beyond the 50 kilometers of paved road outside of the capital, Bangui, the near total lack of gas stations or banks pays testament to the scarcely-felt effects of governance.

One of the few things we did notice, particularly as we drove through the conflict-affected North, were white NGO Land Cruisers parked in small villages. Sometimes it was Triangle seemingly there to check on a water pump; sometimes it was the International Committee of the Red Cross (ICRC) engaged in what looked to be a meeting with the community. In our own vehicles, a UNICEF Child Protection Officer sometimes rode along to check the condition of schools and meet with village leaders. Yet in this context of remote, often isolated villages, linked by poor roads and tormented by bandits … how does one deliver health services? NGOs have built large, well-equipped hospitals in town centers, yet many Central Africans outside of those towns cannot reach them. Community-based health workers, mobile clinics, and free ambulance services are some of the tried-and-true tools in the aid work arsenal for increasing availability and accessibility of health services.

Close to the Chadian border, we stopped in a village in rebel-held territory and met a very sick young woman. One of our interviewers, a trained, female social worker from CAR, spoke with this woman and her mother. She had tuberculosis, and from the sound of her labored breathing, she was not doing well. She had sought treatment in the capital, but decided this was too far from her family. Faced with isolation from everything she knew and loved, and certain death, she had chosen the latter.

Unable to transport her ourselves due to the infectious nature of TB, we drove back to our base of Bocaranga and went immediately to the Médecins Sans Frontières (MSF) feeding clinic. With the sick woman’s permission, we explained to the MSF staff her condition, the remote location of the village, and how to find her. We can only hope that their ambulance service reached her in time.

Having services provided by NGOs is not ideal for many reasons, sustainability being primary among them. Capacity building of government is a slow process, near impossible in areas outside of government control. In the interim, NGOs can provide the bridge from no services to more sustainable ones, saving lives and reducing suffering in the process. For this young woman and many others—the woman willing to walk 30 miles to an MSF feeding center with her infant until we gave her a ride; the child suffering from malaria until we found medicine in the market, because the city’s hospital did not have enough drugs for a full course of treatment—health cannot wait, and it cannot depend on the serendipitous intervention of strangers.

Les Roberts, Clinical Associate Professor at Columbia University’s Mailman School of Public Health has worked extensively in countries ranging from Zimbabwe to the Democratic Republic of Congo. For the last month he’s been coordinating a blog series for ONE on the Central African Republic. You can read the full series here.

His most recent post, on the impact of conflict on the Central African Republic, is below.

The impact of conflict on Central Africans is obscured if one only counts up the number of violent deaths or war-related causalities, each a tragedy in its own right. There is no doubt that the six organized rebel groups and the ever present threat of poachers and road bandits contribute to an insecurity that rarely escapes the minds of most of the rural population. But any active fighting is contained in small pockets of the country and the majority of the population lives in areas with little to no rebel or bandit activity.

It is conflict’s ability to prevent a population from accessing life’s basic services that cultivates disaster. CAR’s health system is in ruins, with even the most basic of services out of reach for many. People are dying because pharmacies aren’t stocked and the nation’s few trained doctors tend to remain in the capital, Bangui, due to the rest of the country’s insecurity, poor transportation links, and the inability to access any salary the government manages to pay them from rural areas.

In Mobaye we met a young man in agony three days after he had been in a devastating motorcycle accident. He wasn’t from the town and had no family nearby; he was traveling through there as an apprentice to a team running a trucking business. Their truck had broken down. He walked with a limp, leaning on a large stick, his shoulder and shattered right arm were supported with a sling made from a small strip of cloth and he wore a t-shirt draped over his head to hide the extensive damage to his face.

After his accident, three days earlier, he was taken to the hospital. They had given him the cloth that supported his broken arm, and possibly some pain medication. The only other thing they could give him was something called an ‘evacuation paper.’ This sheet stated that the hospital could not treat him and that he needed to be taken to Bangui. But his truck had broken down and there was no other transport. When we arrived in town with our UNICEF vehicles, we were the only hope he had. We took him to the next largest town – five hours away – and from there he found family to travel with him to the capital. In Bangui we hope he could have his broken limbs set, receive antibiotics for the infections spreading in his open wounds, and maybe something for his pain. We hope. But what if we hadn’t arrived in Mobaye on that day? What could he have done?

In our nation-wide survey, when we asked Central Africans what problems they and their communities were facing, people throughout the country primarily mentioned disease, lack of food, and water, even in the insecure areas. When asked what would help them and their communities cope with these problems, the answer was never UN peacekeepers or a military response to the conflict; It was health care, water, food, medicine, and trained health staff. One might call these “the basics.” CAR’s civil war is complicated, but the needs of the civilian population are not. How can we help to assure that Central Africans have reliable access to these “basics,” at the very least?

-Les Roberts, Clinical Associate Professor at Columbia University’s Mailman School of Public Health

Les Roberts, Clinical Associate Professor at Columbia University’s Mailman School of Public Health has worked extensively in countries ranging from Zimbabwe to the Democratic Republic of Congo. He previously wrote for the ONE Blog about the situation in Central African Republic here:

The rate of mortality among children under five years of age, a key indicator in the Millennium Development Goals, has dropped globally by approximately two-thirds since 1960. This may be one of the greatest achievements in all of human history. While this decline has been less dramatic in Africa than in other regions, the under 5 year-old mortality rate declined 9% between 1990 and 2005 across the continent. Yet this overall achievement hides a startling disparity. Over the past 15 years, Egypt, Morocco, Tunisia and Libya have roughly halved their under 5 mortality rate, while a few countries have actually experienced increases in child mortality…with CAR being perhaps the most striking example.

This past summer, our team led a survey of 60 randomly picked locations across the country, in order to find out the extent of the crisis in CAR. Half of these locations were in areas serviced by the Central Government, while the other half were largely in areas where government presence in terms of services—and the rule of law—is hardly felt.. Using the experiences of these villagers and townspeople to represent those of all Central Africans, we estimate that roughly 7% of the population died in the past year. This is 3 or 4 times the normal rate in this region, and our interviewers recorded roughly twice as many deaths as births.

It is a freakish event for our species to shrink without widespread violence. It happened in parts of the Congo a decade ago, in Somalia in the early 1990s and in parts of Sudan and Ethiopia in the 1980s. Population declines from infectious diseases are an indication that society has ceased to provide even the most basic of protective functions. Of the 512 deaths people told us about, which occurred either in their households or the homes of their next door neighbors, many were from unknown causes. Of those cases where people thought they knew the cause of death, malaria or fever, diarrhea, HIV and TB accounted for most. These illnesses, along with respiratory infections, account for most deaths in this region of Africa. Despite the country’s tumultuous history, the various armed groups and bandits active on its soil, and its volatile neighbors (Sudan, Chad, and the Democratic Republic of Congo all border CAR, while Uganda’s rebel Lord Resistance Army have found a base there), only 10 (2%) of the deaths we recorded were from violence.

Few understand that this is the nature of war in Africa. Yet in the major civil wars in Africa—the Biafran conflict in Nigeria, which spawned humanitarian aid as we know it, and the wars in the DRC, Sudan, and Liberia—violence has never accounted for more than 15% of all known deaths. Instead, war deprives people of the most essential services: access to health care, the ability to stay where they have their own buckets and dishes, the ability to send items down the road to market. In the next installment, we will describe how even the lowest levels of unrest in CAR have resulted in the collapse of life-saving services, and what this meant for the lives of several Central Africans that we encountered along the way.

Les Roberts, Clinical Associate Professor at Columbia University’s Mailman School of Public Health has worked extensively in countries ranging from Zimbabwe to the Democratic Republic of Congo. Today he writes about a lesser-known country– the Central African Republic:

The Central African Republic (CAR) is a little known nation in the middle of Africa with a population of only four million. The country was fleetingly in the public eye as the hunting grounds of choice of former French President Charles De Gaulle, and for the 1987 Coronation of Jean-Bedele Bokassa, an obscenely extravagant event made famous in the Werner Herzog documentary, “Echos from a Somber Empire.”

What is less easy to observe is that CAR is a land that is nearly ideal for human development. The land is fertile and plentiful, rainfall is parsed into two growing seasons, there are diamonds and gold and expanses of tropical jungle. In the North of the country, the climate is arid and a variety of animals roam in large national parks. In the South, the mighty Oubangui River forms the border while assuring plentiful water and forest parks that bring visitors from around the world to see gorillas and forest elephants. This land of agricultural and tourist potential has had one of the most politically unstable periods of post colonial independence of any African nation. Adding to the troubles is the fact that the country has borders with the conflict-laden areas of Eastern Congo, Northern Uganda, Darfur, and Chad. Over the past two decades, agricultural exports have plummeted, roads and infrastructure have decayed, and the country has evolved to be one of the world’s poorest.

Columbia University, in conjunction with UNICEF, recently conducted a survey about problems facing women and children in CAR. In the days to come, our partners at Columbia University will explore with us if CAR is presently the world’s worst humanitarian crisis, and the opportunities of effective compassion and humanitarian response that the crisis presents.