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“Chronic Medical Emergency” in Central African Republic

Medecins Sans Frontieres: commitments by the government and international community go “in the wrong direction”.
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Stemming the tide: an MSF doctor at work in the Central African Republic. Picture by Sarah Elliott for MSF.

In “a plea for the Central African Republic”, leading international health organisation Medecins Sans Frontieres (MSF) warns today – Tuesday – that the country is in “a state of chronic medical emergency”.

In its report “Central Africa Republic: A State of Silent Crisis”, MSF says the country of 4.5 million people, wracked by internal conflict, partial economic collapse and a “phantom health system”, is under high risk of becoming “trapped” - “not considered urgent enough for significant emergency aid; not considered trustworthy enough for meaningful development assistance”.

“CAR will become trapped”

Speaking to Think Africa Press, MSF humanitarian officer and report author Sean Healey explained that five surveys carried out by MSF in Central African Republic (CAR) found that the mortality rate of 0.8 per 10,000 people per day in Dagahaley, in the Dadaab refugee camp in Kenya, matches the lowest of the surveyed areas in CAR – in the Carnot urban commune in CAR, the mortality rate was 3.8 per 10,000 per day.

The mortality “emergency threshold” of one death per 10,000 per day was established so humanitarian actors could have a “clarion call” for action. Yet the report warns that CAR is “not considered urgent enough for significant emergency aid”. Key to the development of this ominous situation, says MSF, is the way in which humanitarian aid is conceptualised.

“There is a conception of humanitarian aid which overly focuses on moments of extreme crisis,” Healey said. “What the report says is that if you look at the medical data the whole country is in crisis, and the whole country therefore deserves greater amounts of medical assistance.

“If you only approach from moments of extreme crisis what does it mean for a country like CAR, which has been in crisis since 2003, and perhaps even longer? In terms of assistance levels, we see this long-analysed concept of the gap between humanitarian and development assistance very much existing in this country.

“We deliberately chose the term ‘chronic medical emergency’ as almost a contradiction in terms: emergencies are supposed to be short-term events after which things return to normal. But here, normal is unacceptable, normal is the situation we see in CAR.”

“Significant contributing factors”

At the heart of CAR’s medical emergency is a huge prevalence of preventable and treatable diseases, particularly malaria, HIV/AIDS and tuberculosis. MSF believes that these diseases combine with crisis, conflict and displacement, and a “phantom healthcare system which has failed to make even minimum-quality care available and accessible to the population” to make up the three “significant contributing factors” at the heart of the chronic medical emergency.

MSF ranks malaria as “the major threat to public health in CAR”: it is the principal cause of morbidity and mortality among children, the greatest cause of death in hospitals, with “every individual in the population infected at least once per year” and only 6.4% of expected cases detected and treated.

CAR has the highest HIV prevalence in Central Africa with only one third of those in need of antiretrovirals (ARV) having started treatment. It is thought that 110,000 adults and 17,000 children are HIV-positive, with 11,000 people dying from HIV-related complications every year. Tuberculosis is listed as another major killer, while, notably, “The estimated prevalence, incidence and mortality rates of TB all doubled between 1990 and 2009”. MSF finds that national programmes for HIV and TB are “weak” and that connections between them are “embryonic”.

Also of note are sleeping sickness – four of sub-Saharan Africa’s remaining pockets of the disease are in CAR – a lack of vaccination coverage for childhood illnesses, and Global Acute Malnutrition rates of 11.9% in surveyed areas.

How can we respond?

MSF believes much more must be done at both the domestic and international level; by the government of CAR, and by international donor governments and the humanitarian and development community.

The political-economic situation faced by CAR is dire: it is among the worst performers in the human development index, ranking in the world’s bottom ten, and since independence in 1960 the state has seen a mixture of military and civilian rule marked by a number of coups, and has been unable to stamp out internecine conflict or bring meaningful economic growth and take advantage of its gold, uranium and diamond deposits.

However, former military ruler François Bozizé, who first came to power after a coup in 2003, has won two consecutive elections, most recently in January this year, and rebel groups are signing peace agreements. Although severely constrained by significant resource and capacity limitations, Healey says there are “plenty of areas” in which improvements can be made by government, especially the “unacceptable” decline in investment in health in the past decade, “mismanagement in government functions [and] problems of accountability”. But, he adds, pointing to a malaria technical symposium hosted by the ministry of health, there is a good attitude in government, a willingness to engage and receive assistance.

“CAR has had a lot worse moments in its political history,” says Healey. “In some ways, this should be a hopeful moment for the country in a political sense. Most actors have signed a ceasefire with the government.

“Humanitarian actors are saying ‘what does this mean for our presence?’. But you can’t look at the political situation as the determinant, you have to look at the situation of the population and their health outcomes. And their health outcomes say that regardless of whether you call your assistance humanitarian, emergency, development, long-term, or whatever it is, that country needs assistance now and in many different forms.

“There are people who can be cured of treatable diseases now through humanitarian assistance. And they are not, in our view, because the humanitarian community is not doing enough to help them.”

The international element

Perhaps symbolic of the plight of CAR is its relationship with the Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest funder of health programmes in the country.

The Global Fund came in for criticism in January this year after a news report highlighted missing money from the Fund in four African countries. The reports were soon followed by leading donors Sweden and Germany withdrawing funds until an internal investigation had been completed. The investigation found that anti-malarial medication was stolen and sold on the black market in 13 countries, mostly in sub-Saharan Africa.

While CAR is not one of the 13, MSF says that “the suspension of Global Fund disbursements because of corruption allegations caused months-long nationwide ruptures in 2010 and 2011 for malaria, HIV and tuberculosis medicines with serious effects on patients”. As a result, people bought drugs unlicensed private pharmacies and “itinerant drug sellers”. Non-profit research group Africa Fighting Malaria claims the Fund is “fully aware” of “major problems” at CAR’s “Central Medical Store”.

MSF says that suspended agreements with CAR led to a nationwide stockout in 2010 of both the artemisinin-based combination therapy recommended for treating malaria and antiretroviral drugs for HIV. The Global Fund told Think Africa Press that CAR is not currently facing a stockout and has large stock at central level which the “Principal Recipient” is finding difficulties in distributing nationwide. “The Global Fund is currently working with in-country partners such as UNICEF, WHO and MSF, to address this issue and to find an immediate and sustainable solution,” spokesman Marcela Roja said.

Healey says MSF understands and supports the Global Fund’s choices in CAR. “The issue is how we can find an appropriate balance between the risk levels and the burden levels,” he says. “In this particular instance we are not convinced that the balance has been correctly struck. The reason for the massive prevalence of the diseases we are talking about is not entirely unconnected to the reasons why the risks are great for accountability of funds - there’s not a direct ‘equals sign’ but they are part of a set of problems that affect the country. We are saying that more thought has to go into the balance between risk and accountability and severe and extreme burdens of disease.”

Healey points out that there are many international humanitarian and development agencies and international donor governments not present in CAR, and many which are engaged are “starting to make hopeful glances towards the door”. Yet it is these organisations and governments that MSF believes can make the difference in CAR.

“We have the tools and interventions available to us to make a very big difference for the population in CAR and we would like to say to all actors who have the capacity to use the tools to go out and use them,” Healey said.

“If there was more effort by the international community more lives could be saved.”

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