Paoua, Central African Republic

Following an assessment conducted in the far northwest of the Central African Republic in August, Doctors Without Borders/Médecins Sans Frontières (MSF) plans to open a medical-nutritional project at Bocaranga. In addition to the armed conflict between the rebel APRD (the French acronym for the Popular Army for the Restoration of the Republic and Democracy) group and government forces, groups of highway bandits contribute to the insecurity in the area, stifling economic activity and restricting people's access to health care. MSF has been working in Paoua since March 2006. Despite the constant threat of attack, the population has recently managed to move around again, on most roads, within 30 kilometers around the town. The hospital in the town is extremely busy, and MSF is also in the process of resuming its activities in the surrounding area, by supporting health posts there. Delphine Chedorge, MSF head of mission, describes the situation on the ground.

You took part in an assessment in the far northwest of the Central African Republic: what is the situation in this area?

The evaluation, which was carried out in August, mainly concerned the sub-prefecture of Bocaranga. This town is situated in the belt where the highway bandits are active. These bandits, also known as zaraguinas, kidnap for ransom community members who are assumed to possess goods (particularly herds of cattle, which are very highly valued), or they attack passers-by and vehicles on the road.

We also went a little further north, to the sub prefecture of Ngaoundai. Following attacks by the rebel APRD group, this area was subjected to two waves of violent reprisals by government forces, in April and June.

Today, the APRD has extended its zone of influence to sections of roads between the two towns, and the highway bandits have been pushed back a little further south. These past few months, the number of exactions perpetrated by the different armed groups against civilians has decreased, but the risk of the situation flaring up again is very real. Roads are still dangerous as the area between Bocaranga and Ngaoundai is still the setting of regular clashes between rebels, bandits, and the military over control of the territory, with villages and roads serving as front lines.

How does this situation affect the life of the local population?

They live in a constant state of insecurity, because of the attacks by the bandits, the APRD, and the reprisals from government troops. It is estimated that since 2004, 30,000 Fulbhe—families of herders especially targeted by the highway bandits—have fled to Cameroon to escape violence. At least the same number has fled to the forest, near their fields, a few kilometers from their village, living in makeshift shelters. In addition, the threat of more attacks means that people are in the habit of fleeing at the slightest alert.

This insecurity also paralyzes trade. Commercial vehicles are taxed by the various armed groups, and are afraid to circulate, even with an armed escort. Supplies are therefore not reaching the region as they did before. The farmers cannot sell their surplus harvests or their cotton production to get money. As a result, the markets have fewer and fewer goods and prices have increased, especially in the town, while the incomes of the population have plummeted. This impoverishment, as well as the displacement of people into the forest, has severely deteriorated the standard of living.

Has this situation an impact on the health of the population?

The villagers who have fled to the forest are particularly vulnerable to malaria, especially during the rainy season from April to November. The shortage of drinking water and living in makeshift shelters mean they are also highly susceptible to diarrhea and respiratory infections. Access to care is extremely limited as the population cannot travel freely due to insecurity, and also because treatment is expensive, and money is in short supply.

There are no emergency humanitarian organizations present in this area. Until now, MSF has been unable to work there. The health authorities fail to acknowledge the critical nature of the situation and are no doubt afraid that our presence will perturb the medical personnel still working in the area.

During our evaluation mission in Bocaranga, we noted that a small proportion of the displaced Fulbhe families are affected by malnutrition. These families lost their herds, which were their only source of food and trading, and then came to settle in the town, because of the bandits. We have found many children among them suffering from malnutrition.

What kind of work will MSF be able to do in this area?

In the Ngaoundai area, the proximity of a large market at Mbaiboum in Cameroon makes economic activity possible. In addition, the cost of treatment at the hospital, and in the 27 health posts in the surrounding area, decreased thanks to the support of religious missions (a catholic mission and a lay missionary who built the town's hospital) through a few emergency arrangements. Of course, these measures work better in theory than in practice. We could supply them with medicines from time to time, but for the moment we feel the priority is to open a project at Ngaoundai. The situation must still be monitored and the evaluation gone into in more depth.

On the other hand, Bocaranga and Koui sub-prefectures suffer from the same lack of access to health care as in Ngaoundai, but do not have the advantage of a missionary presence to help with the cost of treatment. In addition, as there is no structure to treat severe acute malnutrition and we have identified cases among the disinherited Fulbhe families, such treatment of malnutrition is particularly relevant. We therefore want to start a project to treat children affected by malnutrition, coupled with the distribution of food rations to their families.

Our presence in the zone will provide us with better knowledge of the region's problems and, if necessary, allow us to extend our activities or alert other humanitarian aid organizations of the need to mobilize.

What is the situation like in Paoua, where MSF has been working since March 2006?

In the Paoua area, there was a relatively calm period after the death of Elsa, our colleague who was shot dead while on an assessment to Ngaoundai. Security incidents flared up again in August, although to a lesser extent than in 2006. The government and the rebels are currently having discussions towards negotiating a ceasefire. There are fewer violent clashes, as the military stay in their barracks, while the rebels control the road links. But the process is slow and the situation could deteriorate at any time.

For the moment, the population around Paoua is able to reach a medical center, coming from the north, south and west - sometimes from as far as 30 kilometers away. The hospital is therefore extremely busy: more than 1,000 outpatient consultations each week, 200 prenatal consultations, around thirty deliveries, a pediatric ward with 30 to 50 child patients on average, etc.

In the hospitals where cost recovery is practiced, that is to say where treatment has to be paid for, there is only a fraction of the activity! This shows the importance of free treatment in such a context. MSF's presence is therefore very well appreciated by the population who can come for treatment to the hospital.

Are there any problems with us resuming of our activities in the area around Paoua?

These activities were suspended in June, after the death of Elsa. We gradually started to move around the surrounding area again in July. But we are not going to reinstate the system of mobile clinics operated until June. Sending a medical team into the forest or to a village for a day to give consultations is not a satisfactory solution in a tense situation. MSF's vehicles are likely to be associated with gatherings of people, which puts everyone at risk, the people we want to treat and the teams alike. However, our top priority is to improve access for the population displaced into the forest because of the violence.

We have identified three health stations in the surrounding villages, Betoko, Bedaya and Pougol, where we will support the "emergency nurses" doing their best to provide treatment for the local people. They have little training, lack resources and must charge treatment to fund their activity. We will therefore provide them with medicine to treat the most common diseases (malaria, diarrhea, scabies, and conjunctivitis) and provide them with additional training at Paoua hospital. In a second phase, we hope they will be able to provide treatment for malnutrition without complications and slightly more complex pathologies, such as respiratory infections.

The other essential activity in the area is to be able to refer patients to Paoua hospital. Emergency nurses could identify patients in need of more advanced care. MSF will pay their fare, by bicycle-taxi, for example, so that they can go to the hospital. However we must still find a way to provide treatment for the populations isolated in the forest where there is no health station or health officer.