Providing inadequate health care to populations under the siege of conflict

Nothing New in Ituri…

Von Marilyn McHarg / Médecins Sans Frontières Schweiz

In August 2005, Médecins Sans Frontières (MSF) released a report* highlighting the situation in Ituri, Democratic Republic of Congo. Despite numerous attempts on the part of MSF and other organizations to assist populations in Ituri, many civilians continue to be caught in extremely violent conditions, to experience deplorable rates of morbidity and mortality, and face unacceptably low levels of health care with negligible access to health services. The international community including donor governments, UN agencies, and NGOs, along side the national and local authorities, not to mention the militia who continue to destabilize the region with impunity, have utterly failed this group of people.

Although we have been present in Bunia town since 2003, it was not until autumn 2004 that our teams managed to access remote populations outside of Bunia. Through providing health services, war surgery, cholera interventions, and sexually based violence medical care, we were in a position to quantify and qualify the extent of suffering related to the direct and indirect effects of war.

Based on our observations, violence has been a regular feature in the lives of those trying to survive in Ituri. Most unfortunately, this is not new. For several years, civilians have faced murders, torture, rape, kidnapping, and humiliation with atrocious cruelty.

Since 2003 our surgeons have managed war-wounded cases on a regular basis, with up to one-third of the surgeries related to war injuries.

“In 2003, war wounds were the primary cause of hospitalization for adults. Adult fatalities were often related to complications due to trauma. Unable to easily access treatment, particularly because of unsafe roads, the most seriously wounded did not make it to health care facilities. Patients with abdominal and thoracic wounds rarely arrived at the hospital in time. Between March and May 2005, the number of hospitalized patients doubled. This directly reflected the escalation of conflict in the area.” (MSF Report)

Sexual violence also has been a common element in the conflict. Through our medical activities, our teams established that more than 3,500 had been victims of sexual violence since 2003. In July 2005 alone, an average of 8.2 raped women actively presented to our clinic every day. This unacceptable level of rape is representative of the recent months and exemplifies the unabated nature of violence in Ituri. According to a survey in April 2005, the ages of those violated ranged between 8 months and 80 years. Seventy-five percent of all incidents involved multiple assailants. Seventy-eight percent were carried out by armed fighters, with 80 percent involving the use of weapons.

“When they attacked the village, people took refuge in another village. They followed them and took them to another village. After looting and burning the huts in that village, the armed men gathered up all the girls and took them to be their wives faraway into the forest. One of them forced himself on me and penetrated my vagina the entire time I was there - a month and a week. I escaped one night when all the fighters were sleeping. I spent two days walking through the bush.” (Girl, 14 years old)

Unacceptably high death rates among those isolated in the remote areas have been partially linked to violence, as well. For instance, in April 2005, a retrospective mortality survey was conducted and revealed mortality rates among children under five. These rates were three times higher than the emergency threshold and in part directly connected violence while in the bush. In fact, children under five accounted for 29% of the violent deaths reported. As well, those under five arriving to hospital accounted for one third of the admissions. These young patients often came in critical condition, required emergency intervention, and presented with increasingly high risks of death.

From violence to disease

The indirect consequences of violence have had a devastating effect on the populations. Once forcibly displaced from insecure areas, many have sought refuge in camps protected by the UN Mission in the Democratic Republic of Congo MONUC. In these locations problems of overpopulation, inadequate hygienic living conditions, insufficient food, water, and health care have contributed to outbreaks of diseases such as measles, cholera and other forms of diarrhea. “People who died in the camps during this time primarily lost their lives to fevers and diarrhea (86% of reported deaths for children under five). Seen as often in outpatient consultations as in hospitalizations, malaria and acute respiratory infections are the two main pathologies affecting the displaced and are intimately linked to the unstable conditions surrounding this population.” (MSF Report) The very existence of these safe havens has had a magnetic effect that has actually contributed to the deteriorating health conditions on a morbidity level due to the conditions faced in these areas.

It is important to note that the correlation between death and violence was strong while populations were in the bush, and transitioned to a correlation between death and disease while seeking refuge in pockets protected by MONUC. Theoretically with the increased safety, these pockets should be accessible to aid agencies and populations, affording possibilities for medicalised interventions that could make a significant difference. However, these pockets are isolated along unsafe roads to the extent of being islands within dangerous areas.

Safely accessing these camps can be done if organizations are willing to accept armed convoys for protection. However, this poses an even greater risk for NGOs trying to maintain higher levels of independence. It is already extremely difficult to differentiate ourselves from the United Nations Mission in the Democratic Republic of Congo, due to our proximity in Bunia town, our need to periodically interact, and due to the very simple point that we are all foreigners there to intervene in one way or another. The UN is present in Ituri with the main objective of enforcing peace. By virtue of their role they are easily seen as party to the conflict, particularly by those militia at the other end of their guns.

NGOs: Collaborators and Spies?

Any significant associations made between the UN peace keeping, UN humanitarian agencies and NGOs risks linking humanitarian organizations into the category of party to the conflict. This can negatively impact on others perception of our neutrality and reduce humanitarian space by reducing our capacities to safely access all of the populations who are most in need. We must maintain a solid level of independence to be able to meet needs whenever and wherever they may exist, as opposed to wherever MONUC is travelling. This involves being correctly seen as neutral. Despite many efforts in reinforcing our independence, we have not managed to sufficiently influence the perception of others about our different role from that of the UN. The task of asserting independence is further hampered by the confusion that comes from the UN actively linking aid with military, as well as from NGOs who regularly rely on armed escorts.

Overall, the medical observations of our teams and the medical data supporting our experiences have been shocking and only have furthered our resolve to respond to health needs of those suffering most from the direct and indirect effects of violence in Ituri. However, by June 2005 two of our staff were subjected to the violence of Ituri and kidnapped. Although we see that our team was in the wrong place at the wrong time, it did not help that we were seen as collaborators and spies for the UN.

Under the circumstances faced by our staff, we had no choice but to cease our activities in the interior. In these areas peripheral to Bunia, all MSF medical and humanitarian assistance stopped. This development was nothing short of failure. Our only solace has been the continuation of our 300 bed hospital in Bunia town that usually has a full occupancy of emergency cases which is only partially accessible to those most in need.

Admitting failure…

“Today, we have to recognize that outside Bunia, even the most minimal amount of aid does not reach populations while the violence carried out by parties to the conflict is unacceptable. The admission of failure exists on two levels: lack of protection for civilians and generally insufficient access to humanitarian aid. This involves first and foremost the protagonists of the conflict. Yet, it also concerns the entire international community despite the undeniable efforts it has made and the resources it has put into place.” (MSF Report)

For the most part, civilians are left to struggle for themselves facing high levels of violence, disease and death. The efforts that continue in the region, do so with minimal impact on the overall health situation, leaving most attempting to survive under very precarious conditions.

*Marilyn McHarg, Operational Director, Médecins Sans Frontières / Ärzte Ohne Grenzen (MSF) Switzerland. Based on the MSF Report “Nothing New in Ituri : the Violence Continues: MSF Switzerland, August, 2005. Contact:

Do No Harm

Seven Lessons

  1. Assistance becomes a part of the CONFLICT CONTEXT. It is not neutral, but becomes a part of the context.
  2. There are two realities in any conflict situation: DIVIDERS AND CONNECTORS. Dividers are those factors that people are fighting about or cause tension. Connectors bring people together and/or tend to reduce tension.
  3. Assistance has an IMPACT on both dividers and connectors. It can increase or reduce dividers or increase or reduce connectors.
  4. RESOURCE TRANSFERS are one mechanism through which assistance produces impacts: what aid agencies bring in and how they distribute it.
  5. IMPLICIT ETHICAL MESSAGES are the other mechanism of impact: what is communicated by how agencies work.
  6. The DETAILS of assistance programs matter: what, why, who, by whom, when, where, and how.
  7. There are always OPTIONS for changing assistance programs to eliminate negative impacts (increased conflict) or to improve positive contributions to peace.

”The Do No Harm Project seeks to identify the ways in which international humanitarian and/or development assistance given in conflict settings may be provided so that, rather than exacerbating and worsening the conflict, it helps local people disengage from fighting and develop systems for settling the problems which prompt conflict within their societies.” (



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