The lives of thousands of people across Central African Republic are at risk because aid workers are being forced to withdraw from cities and villages due to escalating violence.

Médecins Sans Frontières is among the organisations unable to provide vital healthcare, preventing treatment for malaria during the disease’s high season, with the result that “people are dying for sure”, according to Caroline Ducarme, MSF’s head of mission in the country.

Ducarme said the situation was having a particularly alarming impact on pregnant women. She described how, in the town of Bakouma, women had been denied a safe place to give birth because the health centre was “not functional” and had not received any deliveries since early June.

MSF has warned that the growing number of armed groups in CAR, and the complex, shifting nature of their allegiances, is making it impossible for aid workers to operate in some areas. The organisation has suspended work in Bangassou, a city of about 25,000 people in the south-east, and halted a project in Zemio, further along the border with the Democratic Republic of the Congo. In one incident in Zemio, armed groups entered a hospital in which 7,000 internally displaced people had sought refuge, shooting and killing a baby as it was held by its mother.



“We have seen a lot of NGOs leaving places where they have been threatened, looted, and the situation is just unsustainable for them,” said Ducarme.

This week, Mercy Corps also announced that it is halting work in the villages of Nièm and Yéléwa, in the west of the country, where local militias have gained control.

Fighting in Bangassou has prompted 35,000 residents to flee, according to the UN. Photograph: Natacha Buhler/EPA

One of the world’s poorest nations, CAR has experienced sectarian fighting since 2013, when François Bozize was overthrown as president by mainly Muslim Seleka rebels. In response, the anti-balaka militia was formed and violence between the two groups has led to thousands of deaths. The conflict has forced a million people to flee their homes, and more than half the population is now in dire need of assistance.

Last month, the UN’s emergency relief coordinator, Stephen O’Brien, warned that he had seen “the early warnings of genocide” during a recent visit to the country.

In Yéléwa, Mercy Corps said as many as 130 children orphaned from violence were living with host families in July.

While operating in Bangassou MSF staff treated patients who had walked 135km from Bakouma to receive healthcare, said Ducarme. “That’s pretty impressive in terms of what they have to endure to just get healthcare, when it’s high season for malaria. If malaria is not treated on time then people are dying for sure. It’s the same for pregnancies. We know there haven’t been any deliveries since 10 June in Bakouma because the health centre is not functional – they cannot receive any drugs, there’s no security.”



Displaced people from Gambo count bags of grain in Loungougba, in south-east Central African Republic. Photograph: Alexis Huguet/AFP/Getty Images

MSF has been unable to reach Mobaye, Zangba and other areas with high rates of malnutrition for five months. “There are lots of places … we cannot access any more; we cannot see what’s happening, but we know it’s very worrying,” said Ducarme.

MSF has warned that civilians are increasingly being subjected to attacks or counterattacks based on their ethnicity or religion. A willingness among armed groups and their local supporters to prevent the “enemy” from getting assistance has also been noted.

In August, six Red Cross volunteers were killed in an attack on a health centre in Gambo, a town in south-east CAR. It was the third attack on Red Cross workers in the country this year.

The situation in the south-east is especially volatile, said Ducarme. “You have to negotiate and network with all those armed people if you want to get access to those villages. It’s very difficult to get acceptance and renegotiate every 5km. There are new alliances everywhere. There are divisions of groups, creations of new groups.



“We cannot talk about anti-Balaka any more. It’s very difficult to get a sense of the motivation behind those groups,” she said.

Hospital lab technician Leon Bambeteba stands amid rubbish at a hospital that was looted during an attack on Gambo in which dozens of civilians were killed. Photograph: Alexis Huguet/AFP/Getty Images

Aid workers are also facing hostility because some groups question their independence, said Rodolphe Moinaux, CAR country director for Mercy Corps. “The UN integrated mission is blurring the line between political, military and humanitarian action and we have difficulty presenting ourselves to the communities and armed groups as non-governmental and independent. I would advocate … a humanitarian coordinator completely dedicated to humanitarian response, to not mix with the other agents of political agenda or military agenda,” he said.

Sara Sywulka, acting country director for Tearfund, said that while there is greater stability in Lobaye, in the country’s south, there is a dire funding shortfall. “The humanitarian response plan, which is the basis for the UN appeal, is funded at 27%. We see a lot of potential to do great work and there just isn’t the funding available for it,” said Sywulka.

On Tuesday, the UN announced $45m (£35m) would be released from the central emergency response fund to four countries “struggling in crises away from the headlines” – CAR, Afghanistan, Chad and Sudan.

“The situation has deteriorated a lot in the last couple of months,” said Moinaux. “The international community needs to re-engage with CAR diplomatically and financially.”