The Fastest to Die

A study reveals how deeply the wounds of conflict have cut the Central African Republic -- and not where you would expect.

On July 30, the president of the Central African Republic, an eccentric army chief named François Bozizé, issued a decree postponing the country's presidential and parliamentary elections. The new vote is scheduled for January 2011, having been pushed back for the fourth time due to supposed security concerns. The people of this small, conflict-torn country will have to keep waiting for a vote. But the truth is, they really can't wait. The country's population is dying four times faster than the rest of Africa.

Over the last year, we led a research team that conducted perhaps the most extensive survey on the impact of violence on the Central African Republic's population. The results, which will be published in the Aug. 4 issue of the Journal of the American Medical Association, reveal a country besieged by violence and extreme poverty. We asked 1,879 adults in five administrative areas of the country about their lives, their security, and their experience with conflict. More than three-quarters said they had either witnessed or personally experienced traumatic events during the wave of violence that began in 2001, and more than half met criteria for depression or anxiety. The monthly death rate was five per 1,000 individuals (in the United States it is 0.7; the average for sub-Saharan Africa is 1.3). Put another way, 6 percent of the country's population is dying every year.

What's behind all these deaths?

One obvious cause is conflict. Outbreaks of fighting have been common in the country for the last several years, despite a recently negotiated peace agreement between the main rebel contingents. And lately, the Lord's Resistance Army, a violent northern Ugandan rebel group known for killing, abducting, and mutilating civilians, has taken sanctuary along the border with the Democratic Republic of the Congo.

Yet it turns out that relatively few casualties -- less than one-fifth -- are directly linked to violence. Our study found that epidemics of disease and the country's lack of basic health care, education, and social services contribute more to mortality than any fighting. Even in zones relatively free of fighting, in the southern part of the country, mortality rates are well above the threshold for acute emergency.

That doesn't mean war has nothing to do with the deaths. When civilians flee the outbreak of conflict, they often end up in squalid displacement camps with limited access to land, leaving them incapable of growing food and generating income. Their quality of life further deteriorates as health centers, roads, and schools are destroyed or abandoned. Poor living conditions favor the outbreak of diseases, such as cholera; violence adds physical and psychological trauma. And even as the need for care skyrockets, the collapse of health services means that little or none is available -- even the most basic treatments for malaria or natal care.

Meanwhile, armed groups and bandits roam freely, preying on anyone who can supply the goods that they need. That kind of insecurity can be paralyzing. Our survey found that more than one in four respondents felt unsafe while walking or sleeping at night, going to the nearest village, or meeting strangers.

This pattern is not specific to the Central African Republic; conflict has created equally dire humanitarian disasters in places like eastern Congo and Darfur, Sudan. But in the CAR, these effects of war devastated a system of social services that barely existed in the first place. The country ranks among the last in the U.N.'s Human Development Index, just ahead of Sierra Leone, Afghanistan, and Niger. It has one of the most politically unstable post-colonial histories; since its independence in 1960, every president who has ruled the country has either come to power through force or been overthrown by a military coup. The result, a failed state that offers no or little services outside the capital, Bangui, is as damaging to its people as the violence itself.

Responding to the humanitarian disaster in the Central African Republic will take more than just an end to conflict. To be sure, security is imperative, but regardless of the level of violence, the population must have access to health care and other basic services if it is ever to recover from the effects of war. This will require a legitimate government, accountable to its citizens. And as the people of the Central African Republic told us, this is no small task.

When asked what had turned their country into such a death trap, two-thirds of the respondents identified the fight for power as the main cause for the violence. Half the respondents proposed political dialogue as a way out, and 94 percent plan to vote if and when elections are finally held. Most felt confident that they would be able to vote freely. Unfortunately, the only two contenders for the presidency are Bozizé and his predecessor, Ange-Félix Patassé (Bozizé ousted Patassé in a military coup in 2003). Both men have horrendous human rights records, including killing and sexual violence perpetrated by troops under their command. This is the only political reality many in this country have known; together, the two men have occupied power for nearly two decades.

Many civilians have lost all hope that their situation could improve. Asked whether they believe a lasting peace can be achieved, a quarter of the respondents simply said, "No."


Survey Charts Darfur Opinion for First Time

Those most affected by the crisis say they want Sudan's President Omar Hassan al Bashir prosecuted, are skeptical of chances for peace, and insist on reparations for crimes.

KHARTOUM—More than seven years into the crisis in Sudan's western region of Darfur, the first survey to systematically document the views of Darfuri refugees is being released Thursday.

The report, entitled "Darfurian Voices," offers a rare, direct insight into the mindset of those most affected by an ongoing conflict that the United Nations estimates has already left 300,000 dead and another 2.7 million displaced. 24 Hours for Darfur, a U.S.-based organization, interviewed more than 2,000 Darfuri refugees on the Chadian side of the Sudan-Chad border to compile the results.

The findings of the survey indicate that Darfuris remain skeptical of the prospects for peace, hugely supportive of indictments against the Sudanese leadership by the International Criminal Court, and adamant about the need for reparations (though not necessarily as a condition for peace). The report provides nuanced feedback on issues of peace, justice, and reconciliation to policymakers, journalists, and activists eager to bring the crisis to an end. It also raises questions about whether current international efforts are headed in the right direction.

The report couldn't come at a more opportune time. On the heels of local and national elections, Sudan is now headed full speed for a referendum in January 2011 that will offer the autonomous south of the country the opportunity to secede. The South is likely to vote for independence, and as such, international attention has shifted away from Darfur, preoccupied instead with sporadic violence along an oil-rich North-South border. Many international Sudan-watchers fear that if the vote does not proceed smoothly, the January referendum could spark a return to outright civil war.

But the survey is a potent and needed reminder that the situation in Darfur has not been resolved. No matter the outcome of the referendum, the Darfur crisis demands ongoing global attention. Two of the report's detailed findings -- that Darfuris want to see the Sudanese president prosecuted and are skeptical of peace talks -- seem particularly pertinent this week, emphasizing the importance of thoughtful international engagement with the situation.

On Monday, the International Criminal Court (ICC) issued a second arrest warrant for the Sudanese President, Omar Hassan Al Bashir, adding three counts of genocide to the list of seven crimes for which he is already indicted. The "Darfurian Voices" report indicates that Darfuris overwhelmingly support the Hague-based court, with 98 percent of those surveyed saying they want to see Bashir put on trial at the ICC. That comes in stark contrast to the view expressed by the African Union, which has repeatedly called Bashir's indictment "detrimental" to the pursuit of peace. When asked what development would most likely help peace to be achieved in Darfur, the refugees' most common response was the arrest and prosecution of Bashir.

Refugee opinion is also clear with respect to peace talks. Darfuris are despondent about the prospects of success from ongoing negotiations over power and wealth-sharing between the Sudanese government and several Darfuri rebel groups, now being held in Doha. Only 18 percent of Darfuri men and 38 percent of women surveyed believe the negotiations will lead to peace. This pessimism may be shaped by their perceptions of previous peace processes; in one of the report's more sobering statistics, an overwhelming 96 percent of respondents feel that the peace negotiations to date have failed to take into account their interests. (In other words, one might interpret this as a feeling among refugees that the peace talks have not fully addressed the reality of their situations on the ground.)

Officials here in Khartoum say privately they are confident they will soon reach a peace deal with those rebel groups now participating in the Doha talks. But refugees fear that even if an agreement is reached, Bashir will fail to uphold it. Moreover, survey respondents said that any meaningful agreement would require the involvement of all the different factions, including the two main rebel groups that remain outside the process.

Some aspects of the report present troubling views of Darfur's future. Only 23 percent of women surveyed from the refugee population could imagine themselves ever able to live peacefully with the ethnic groups most involved in the mass killing, rape, and displacement of civilians in Darfur as members of the Janjaweed militias.

Political reconciliation does not look easy. When asked to explain the root causes of the conflict, almost nine out of 10 respondents named either Bashir or his government. (Less than 1 percent suggested drought, desertification, or resource scarcity, which were the causes highlighted by U.N. Secretary General Ban Ki-Moon in a 2007 Washington Post op-ed.)

The sobering results of the "Darfurian Voices" survey more than justify the pains taken to assemble it. After developing the questionnaire in consultation with academic experts and members of the Darfuri diaspora, Ethan Siller, research manager at 24 Hours for Darfur, says the team sought out interviewers who were fluent in local languages, had "extensive experience" working with displaced persons, and would administer the survey "in an objective manner." The three largest funders of the project were the U.S. State Department, Humanity United, and the Open Society Institute.

Of course, it's worth remembering that the report represents only the views of Darfuri refugees in Chad, which may differ from the views of displaced Darfuris still living in Darfur. The researchers say they would have liked to have conducted the survey inside Darfur, but believed it would not be feasible. The Sudanese government has consistently blocked access to the region, security concerns in Darfur persist, and researchers feared that respondents would not be comfortable answering sensitive questions freely.

For Darfur -- a situation that has captured international attention in a way that African crises rarely do -- it seems surprising that Darfurian Voices is the first truly systematic effort to sample the views of a large group of those most directly impacted. In part, this can be attributed to the sheer technical and logistical difficulty of conducting such a project. But seven years into the crisis, the failure by the policy and advocacy communities to obtain this kind of information is troubling. There is a dangerous tendency for those outside a situation as complex as Darfur to believe they can generate solutions absent the input of those directly affected. Of course, late is better than never. It's about time we heard the views of Darfuris themselves. 

Christopher Farber