The Fastest to Die

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."