People’s Health in Darfur – Dependent communities

Remco van de Pas, MD

24 August 2006
The author wrote this article after having worked for six months as a humanitarian worker in the war-torn region of Darfur, Sudan. At present the international community is debating a possible UN intervention in Sudan. Humanitarian intervention itself, although valid in complex emergencies, has serious side effects and can even leave the community fully dependent on international aid. The article promotes ‘appropriate’ intervention with a focus on individual communities. Besides assisting the affected individuals, communities must be supported in claiming their right to health as part of a larger human rights approach, holding the duty bearers accountable for the violated and neglected health determinants.

Total excess mortality in Darfur, over the course of more than three years of deadly conflict, significantly exceeds 450.000. At present an estimated 2.0 million people have fled their communities in Darfur. This document does not appeal to these numbers as indicators for stronger humanitarian involvement, international justice or intervention of UN forces or the like. Others have done this already on broader scale, with only limited results so far, though efforts are continuous and meticulous in their analysis.
At present the international community is pressuring the Sudanese government to accept UN forces on Darfurian ground. The mandate such a force should have is the subject of heated debate. The UN Security Council advises sending troops and enforcing the current AMIS forces under a Chapter VII resolution, which would allow UN troops to use armed forces to protect civilians. The Sudanese government nevertheless opposes this resolution, arguing that with the current Darfur Peace Agreement (DPA) the UN mandate must be limited to ‘peace’-keeping forces (A chapter VI resolution): to monitor the implementation of several elements of the DPA, such as disarming the Janjaweed and other militias, and voluntary return by the internally displaced community under the promise of community compensation by the Sudanese government. This proposed ‘peace’-keeping mission would be more or less similar to the one present in South Sudan, where the UN is enforcing the Comprehensive Peace Agreement (CPA) on South Sudan as signed in January 2005.
The partial signing of the peace agreement in Abuja, Nigeria by the parties involved and under strong mediation of the African Union was being viewed as a success by the international community. Despite this agreement, and partly as a result of it, peace has not reached the displaced people of Darfur yet. The SLA faction led by AdulWahid ElNur, representing the Fur community, has not signed the agreement, as equitable representation at a national and regional political level is not included in the agreement. Wahid ElNur points to a crucial issue, the fact that ‘the root cause of the Darfur conflict is a political one. Inequitable share in power has always been a disadvantage to the region of Darfur’.
The conflict in Darfur, complicated with a history of (religious) colonialism and ethnic differences, is an issue of resource and power sharing. Some persons reason that causes for the conflict can be found in the age-old disparities between tribes, sultanates and colonial powers. (An argument that was used for the conflict in Bosnia-Herzegovina in the mid-90s) Despite these disparities a fragile balance existed for decades, as different groups lived alongside each other, sharing and trading goods, cattle and scarce products available in the dry savannah.
Since the big famine in the mid-80s in Darfur, families had to struggle to assure that enough food was available for the families at the end of the season. Land had to be shared by pastoral farmers, who grazed their cattle on the barren soil and nomadic tribes that made the annual passage from North to South in search of water and fertile land for their cows and camels. Traditional landowners’ rights were in place, overseen by the Sheirs of each tribe. Justice and reconciliation were made possible by means of community tribunals. In the current social disruption, the youth no longer listens to community elders. Instead, they solve their issues with Kalashnikovs. Although daily life has always been a struggle in landlocked Darfur, and poverty has been endemic, people have found a way to accept the ‘others’ in their environment. The current conflict is partly a domestic issue, but three mechanisms alter the situation.
First, the colonial presence is still felt in Darfur. Since the independence of 1956 from the combined Egyptian-English Government, Darfur’s frontiers and tribes have been divided among different countries. To the west is unstable Chad, partly supported by the French military, there to support stabilisation of the region. Chad’s frontier with Darfur divides Zaghawa and Massalit tribal grounds. Darfurians never obtained the possibility to share power in central or regional governments. The Khartoum government has functioned and is functioning as a colonial power in the Sudanese provinces. This was the case in South Sudan and is still the case in Darfur and eastern Sudan (Red sea and Kassala provinces). The influence of Libya should also not be underestimated. In the nineties, in its efforts to create an Arab league in North Africa, its president colonel Ghaddafi sent troops through the Libyan Sahel to support ‘Arab’ nomadic tribes in their domination of the other Darfurian tribes. Through the economic axis that Sudan shares with Russia and China, by means of industrial and oil investments and weapons trade, the military economy is funded. The other axis, consisting of European countries and the U.S.A., has some interest in the oil fields in southern Sudan, which are being negotiated in the CPA. The African Union is trained and supported by NATO; although no western troops are on the ground, their weapons and military equipment have their origin in western factories. Darfur’s conflict is also a good arms deal for the western governments.
A second issue is the globalisation process that has changed the world rapidly over the last decade. Means of communication have skyrocketed, mainly through widespread availability of Internet and mobile phone networks. Mass commercial advertisement leads people into the consumption trap, bound by a shared, unconscious, drive to obtain ever more products. Large number of families have to keep up with the middle class and hence to be part of the modern world. An ever-widening gap can be distinguished between the have and have-nots. The middle class in Khartoum has more in common with its counterparts in, for example, Dubai, Cairo and Amsterdam than they share with the marginalized people in the outskirts. This pattern can also be seen in the Internally Displaced People (IDP) camps and Nyala town. The camps will slowly become permanent settlements, while Kalma IDP camp probably will become a town on its own. At one point these outskirts and their inhabitants will be forgotten – not because the population have lost their interest in this chronic tragedy, but because life pushes families forward to continue daily economic activities. These activities are necessary to survive in an urban setting, where an average of 36 per cent of all households lives below the locally defined poverty line The population is not the one to be blamed, they take their part in the system, but it leaves them easily to manipulate. In a sensitive, ethno-religious environment, this comes in very handy – not only here in Darfur, but in many difficult places in the world.
Related to these consumption patterns is a rapid degradation of the environment. As the Sahel expands, nomads in Darfur are forced southwards to find water and grazing lands for their cattle, clashing along the way with the pastoral farmers over the available land. Desertification can be seen all over the transsahelian countries, provoking famine and disputes. The next wars will not be fought over oil but over the access to safe water. The USA and Europe (or the OECD countries) alone consume more than 50 % of the world’s energy resources. Global warming renders less space on earth (desertification, polluted industrial areas, rising sea levels) available for human beings to guarantee a safe livelihood to share resources. This degradation of fertile soils is a recipe for more disaster.
We now confront a complex emergency situation with only the means the humanitarian community is able to provide. The response was and is still necessary as people are in dire need. The actual provision of humanitarian assistance is not in doubt, but the manner and partition is. The humanitarian world has become big business as well. American and European donors set restrictions to the funds and the way programs are carried out. For instance, the food rations distributed by the UN World Food Program have to be procured through selected agencies. The majority of medicines that are used in primary health clinics are obtained through European agencies. International NGOs (INGOs) have flocked to confront emergency situations, as these are the places where substantial funding can be obtained. The tsunami in Indonesia, crisis in Darfur and recent earthquakes are good examples of this mechanism. The result is a humanitarian assistance that leaves some communities dependent on the INGOs. In Darfur, the main assistance is focused on the IDP camps around the three state capital cities of El Geneina, El Fasher and Nyala. The countryside and rural communities lack this humanitarian assistance, as insecurity is a realistic threat for humanitarian workers. What can be observed is an imbalance between available services. The best example may be the difference between the Kalma and Gereida IDP camps, almost equal in size (about 100.000 persons), and both located in South Darfur. Gereida town, overwhelmed by IDPs, is difficult to access for NGOs and UN institutions, leaving a huge number of people in need of shelter, safe water, food and protection. Kalma, on the other hand, highly politicised, is conveniently located to Nyala town where most NGOs are based. Two years after the instalment of Kalma and the start of a then already delayed humanitarian response, the IDP population is stuck. With few micro-economic opportunities and, for the moment, unable to return to their original villages, destroyed or occupied by ‘others’, the IDP community is left with the sole option to claim and maintain some rights and identity. One of these is the right to be an Internally Displaced Person (and not someone who is ‘relocated’ or who has ‘resettled’). This ‘victimized’ position into which people have been forced, leaves a grim situation in the IDP camps. Families wait in queues for food, water, and medicines to arrive, and shelters to be built, quarrelling and fighting with each other in this stressful environment. Organisations focusing on psychosocial rehabilitation, micro-economic activities and reconciliation mechanisms are doing their best to reverse this trend. IDP camps, however, are simply not the environments for community empowerment.
About one third of the patients in the camp clinics demonstrate somatic complaints that are aggravated by psychological and social stress. Since medical NGOs mainly have the mandate to treat emergency medical cases and acute infectious diseases, chronic diseases can only be addressed symptomatically. Although the World Health Organisation and Ministry of Health are pushing for strategies to address diseases like HIV, TB and mental disorders, the lack of financial and political will to address diseases that are rooted in social disruption leave these programs on standby for the moment. In humanitarian emergencies, funds are allocated for a period of one year and rapid progress must be made. Hence vertical programs addressing health issues are in the majority. Malaria, diarrhoea and malnutrition are reduced by providing antimalarials, ORS and enriched food. Health messages are given to the population about the necessity of using impregnated bednets, proper hygiene and breastfeeding the infants. To be fair, all these programs are necessary in the humanitarian work, but all too often they are not embedded in a broader strategy that addresses root causes of disease. The displacement and impossibility to economically maintain a family’s livelihood itself increases by tenfold the relative risk on poor health status and mortality.
Is it surprising that IDPs sell the bednets they were given on the market? What about health messages about hygiene when people are crowded into a camp? From a clinical and public health approach we treat symptomatically. We cannot cure, but alleviate symptoms. Many lives have been saved, but the community and social nucleus itself is destroyed.
What is the alternative? In medicine, diseases can be prevented, and if they occur can be prevented from worsening. In public health, the goal is to prevent outbreaks of communicable diseases such as meningitis and cholera. To prevent a humanitarian emergency may be more difficult, but possible. In Eastern Africa, fragile balances exist (or have already been disrupted) between communities and interests groups about natural and political resources. The Democratic Republic of Congo, with all its mineral resources, has suffered gravely in recent years. The Central African Republic and Chad face crises as governments might topple. Ethiopia and Kenya, with their varied ethnic tribes, are constantly at risk of famine. Somalia is still inflamed and devastated by an ethno-religious conflict. And Sudan, with its 20 years of war in the South, continues to be the country with the largest internal displaced population on Earth. Because major political and economic structures can be analysed, but are almost impossible to alter, international assistance must focus on individual communities. This assistance must be humble in character and rely on the knowledge and character of the community. In general they are the ones who know best how to organise the resources. Communities must be supported in claiming their right to health as part of a larger human rights approach, holding the duty bearers accountable for the violated and neglected health determinants.
In the meantime, the international community must keep analysing, discussing and lobbying on the effects that WTO agreements, oil, mineral and water exploitation, weapons trade have on regions and environments. A widening gap will grow between the globalised haves and the have-nots who are left behind. More and more people risk tumbling over into this last group. Will we let it happen on our watch?
Darfur & The Netherlands, July 2006
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Remco van de Pas, MD