For humanity as a whole, the health improvements achieved since 1960 have been unprecedented. In the past 50 years, mortality among children under five years old has dropped by two-thirds; a reduction perhaps equal to that seen in the 500 years prior to 1960. The Millennium Goals are, in essence, an attempt to get the countries that have not yet acquired such improvements over the past half-century the chance to catch-up. The Central African Republic (CAR) is a classic example of a country that needs to catch-up.

At the Gapminder website, both UN statistics and earlier data on income and life expectancy are available graphically for virtually all countries in the world. A review of the last two hundred years of data is an inspirational reminder of how healthy and wealthy the planet is today compared to decades past. And in looking at this data, only two obstacles are shown to halt the otherwise unabated march toward social progress taking place in almost every country of the world over the past two centuries: HIV and war.

Looking at Figure 1, we see the life expectancy over time for the five countries with the highest rates of HIV infection among their citizens (Botswana, Lesotho, South Africa, Swaziland, Zimbabwe).

Starting in the 1990s, these five countries experienced at least a 50% rise in mortality over less than a decade. Interestingly, this leap in mortality does not correspond with a drop in national income. Figure 2 shows what I would guess are the world’s six deadliest recent conflicts lasting more than five years (the typical gap between UN mortality measures) but less than 20. Note that, in every war except those in Vietnam and the Democratic Republic of Congo, the death rate generally rises over the period of war. Not by chance, each of these wars corresponds with a sharp decline in national income.

Of the two big barriers to improving health and wealth, our ability to prevent HIV and mitigate its consequences has been better, perhaps even spectacular. This is especially true when comparing it with other major killers of the past, such as plague and tuberculosis. In fact, Figure 1 suggests that the availability of anti-retroviral drugs in Botswana has perhaps already started to decrease the country’s overall mortality. Likewise, global technical capacity to mitigate the health consequences of war has also improved dramatically in recent decades. However, the difference between the two is this: HIV prevention and response is focused on the most afflicted countries. Yet for security and political reasons, the countries most in needing the of the life-saving support of water, sanitation, shelter, and medical support offered by the humanitarian community receive a disproportionally small amount of humanitarian aid.

In previous blogs, we have presented the facts as they stand: the Central African Republic (CAR) is in the midst of a severe humanitarian crisis, with the population shrinking due to lack of medical care and economic collapse. It is also has an adult HIV+ prevalence of over 6%. While we have little data from Somalia with which to assess mortality, it is likely that one of these two counties is presently the world’s worse humanitarian crisis. Despite this, little humanitarian service—in terms of money, personnel, or supplies—has flowed to these countries in recent years.

As we look ahead to the next 50 years, and think about bringing the most downtrodden and impoverished people closer to the ever-improving global average, we can look to the past 50 years for some important lessons. Many problems with technical solutions have been effectively addressed. Vaccinations have eradicated small-pox and greatly reduced measles and a host of viral illnesses. Insecticide-treated bednets and drugs have made great headway against malaria. Breakthroughs in nutrition, especially therapeutic feeding in the home, have yielded spectacular gains in the past decade. But social problems—such as corruption, literacy, lack of effective judicial institutions—and protection of civilians in times of war, have proven harder to address.

In CAR, roughly 300-400 excess deaths occur each day due to the lack of a functioning health system. The country’s security problems should not limit relief. Even its lack of roads doesn’t have to cut off relief. Relief is only limited by a lack of global interest. If we as a species are going to address the big challenges that remain in our future, perhaps CAR, where the barriers to doing good are small and the potential to do good is large, would be a great place to start.

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

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.

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.