Heavy fighting in the Central African Republic since the overthrow of the government of President Francois Bozize in March 2013 has forced thousands of people to flee into the bush, leaving them at the mercy of disease, without adequate healthcare and with scant access to food and clean water. The International Committee of the Red Cross (ICRC) had been focusing on livelihood support in the north of the country, but it shifted into emergency response mode, often in partnership with the Central African Red Cross Society. Teams evacuated casualties, collected and buried dead bodies, provided emergency medical treatment, traced people separated from their families and distributed food, water and emergency supplies to some of the thousands who fled their homes. This work is only possible with the acceptance of local forces and communities, though this is tenuous and can be short-lived, and ICRC and Médicins Sans Frontières staff have been killed. Donor money has been in short supply and the international response has been slow, despite the enormous scale of needs.
New ambitions in health
In the initial emergency response, the ICRCs focus was on supporting war trauma surgery. Now the goal is to try to work along the chain of care, from first aid training to supporting tertiary hospital services. In the region around Kagabandoro in north-central CAR, clinics and health buildings were looted and destroyed in fighting at the start of the year. The ICRC the only health provider in the area set up five mobile primary health care teams who for several months undertook daily trips to offer basic medical care. However, these clinics cannot provide follow-up care, and are used only as a last resort to provide health services to people entirely without access to health care. With a degree of security returning to the area the ICRC is rebuilding five health centres, where its teams can work in situ to deliver care and increase the skills of local staff. In Kagabandoro hospital itself, an ICRC team practices internal medicine and performs minor surgery. War-wounded are referred to Bangui hospital and flown there by an ICRC plane, though many patients are fearful of crossing MuslimChristian lines and refuse to make the trip. Patched up, they often prefer to travel onwards, accompanied in relative safety by their own ethnic group. Around 70 adults and children a month are admitted suffering from acute malaria. Prior to the conflict there was a massive distribution of anti-malarial nets, but many people have fled to the bush without any protection from mosquito bites. However, the main activity in Kagabandoro hospital is delivering babies (around 60 a month).
Responding to sexual violence
The hospital in Kagabandoro also offers clinical services to rape survivors. The ICRC had been planning to step up its response to sexual violence in CAR, but the wave of conflict that swept through the country and divided communities along confessional lines has made the service an unfortunately more vital necessity. The hospital treated 28 sexual violence victims in the first four months of 2014, 16 of whom were under 18 years of age, while the mobile clinics treated 20 cases. The caseload is the tip of an iceberg. Both in the hospital and at the mobile health clinics the ICRC has been offering psychological care for victims, using a threeperson team that includes a trained psychologist, the only one in the entire region. The rebuilt health centres will allow a more permanent service, and although there is still huge stigma associated with sexual violence, these services will hopefully be more widely used as women and girls come in from the bush to seek assistance.
Keeping health safe
In the capital Bangui, the ICRCs goal is to widen the scope of hospital care beyond the treatment of war trauma. Upgrades are planned at Banguis main hospital, including the building of an X-ray facility. A major challenge is delivering health care safely. A CAR Red Cross volunteer and an ICRC staff member were killed in separate attacks this year, and four MSF staff died in an armed robbery at a health clinic in northern CAR in April. Hospitals, assumed to be places of safety, are often where extreme emotions and deadly weaponry co-exist. In Bangui hospital, wounded from the mostly Muslim Seleka forces who overthrew Bozize literally lie side by side in wards with rival Christian militiamen. While such impartiality of care is impressive and necessary, it does not imply harmony or a lack of tension. Careful patient management is needed to reduce flashpoints. Some patients have to be transferred out of the hospital back to their communities at the end of each day as weaker security overnight leaves them vulnerable to attack. The hospital is in a poorly secured compound, with the fence along one side easy to climb. Unarmed civilian guards paid by the ICRC control entry, and a small detachment from the African Union peacekeeping force offers a calming presence. While there have been no ethnically motivated attacks, weapons have been confiscated from visitors and threats against patients reported, particularly at night when the curfew means ICRC staff are not present.
Bangui is a test-case for the ICRCs HealthCare in Danger project. Health Care in Danger is an ICRC-led project of the Red Cross and Red Crescent Movement running from 2012 to 2015. It aims to improve the delivery of effective and impartial health care in armed conflict and other emergencies by mobilising experts to develop practical measures to be implemented in the field by decision-makers, humanitarian organisations and health professionals. One of the projects recommendations is to use workshops involving all staff and stakeholders to agree practical steps for protecting hospitals. Discussions include whether to increase the height of the fence, and how to do so without turning the hospital into a fortress, as well as whether a safe room is needed, and if so who should have access to it. The goal is to develop best practice and share it with similar ICRC operations, including those in South Sudan and the Democratic Republic of Congo. If the workshop approach is successful in Bangui it will be replicated in Kagabandoro, where discussions on impartial care and the protection of health workers have taken place with the local Seleka commander, whose base is uncomfortably close to the hospital. When another zone commander needed treatment the local officer intervened to ensure that he entered the medical facility without his armed escort.
A far greater challenge to safe treatment exists outside the hospital walls. The CARs ethnic geography has changed dramatically in a short period of time, with violent communal clashes creating sectarian enclaves that it is life-threatening to leave. The sick and wounded faced the choice of dying from their condition or being attacked while travelling to hospital. The problem is particularly acute in Bangui, where Muslims became trapped in two districts, PK5 and PK12. At the end of April international forces escorted around 1,300 Muslims out of PK12 to relative safety in the north of the country.
The ICRC emergency response is still needed, and must be nimble and flexible as the nature of the conflict evolves. But longer-term planning must be in place to ensure basic minimum standards of healthcare are in place country-wide. The ICRCs traditional approach of building acceptance for its work through dialogue, explanation and demonstrable impartiality will continue hand in hand with newer tools, such as the HealthCare in Danger workshops being tested in CAR, and will be adapted for use in other conflicts where the right to safe treatment for the wounded and sick is challenged.
Sean Maguire is Head of Communications and Spokesperson, International Committee of the Red Cross, UK and Ireland