COMMENTATOR (COMM):
Charlene has suspected meningitis. She could die. Meningitis can be treated, but Charlene is unlikely to be cured. That’s because she’s a citizen of the Central African Republic.

LEA KOYASSOUM DOUMTA, Minister of Health:
In the heart of Africa, there are 4 million people who are there and who need help. The doctors see their patients dying because they don’t have something just to save their lives.

Dr LUIS GOMES SAMBO, Regional Director, World Health Organization:
They cannot provide the necessary care to people who are really suffering with diseases and dying.

DAVID NABARRO, World Health Organization:
The real challenge is to find ways of getting finance for countries like the Central African Republic before the situation deteriorates into a total humanitarian crisis”.

COMM:
Could the Central African Republic (CAR) become Africa’s next crisis? Life has been given rare access to CAR, especially the health service, to find out just how bad the situation is. The United Nations is calling it the world’s ‘most silent crisis’.

The Central African Republic has largely been forgotten. A landlocked country of just under four million people, bordered by Congo, Chad and Sudan. Politically it’s been unstable for decades, since it was granted independence from France in 1960. From 1966 it was ruled by the decadent and notorious self-declared emperor, Jean Bedel Bokassa. He was eventually overthrown in 1979 in a coup backed by French commandos. Almost 20 years of further political instability culminated in mutinies by the army in 1997. Strikes and riots by civil servants followed three years later. There have been four coups in the past decade. The last was in 2003, when the current President – Francois Bozizé – seized power while his predecessor was out of the country. There was a brief civil war until Bozizé’s forces took control. Today the Central African Republic is struggling to avoid economic and social chaos. The President claims health is close to the top of his agenda.

FRANÇOIS BOZIZÉ, President CAR:
Health is a priority for the Central African Republic’s development and its future. The country’s health situation has been made more difficult by the events that took place in the Central African Republic, the uprisings and fighting. And in order to do this we have made enormous efforts to ensure that the Ministry of Health’s budget accounts for between 15 and 20 per cent of the national budget.

COMM:
At the moment the figure is nearer 5 per cent, according to the Minister of Health. That amounts to about $8 million. But will that money change things for Charlene? She is fighting for her life. Her chances are slim. Infant mortality rates in the Central African Republic are among the highest in the world. Even if Charlene survives, she’ll struggle to reach five. If she makes it that far, she’ll probably live only until her 39th birthday: life expectancy is that low. This clinic, in the capital Bangui, is funded by a Baptist church mission, and sees around 100 patients every day. There is just one qualified doctor and two nurses. There are very few drugs, vaccines or medical equipment, and this clinic is better equipped than other hospitals in the Central African Republic. It’s the first port of call for local people and their children because it’s free. If the children don’t put on any weight after being fed high protein meals it’s assumed they have some other illness and they’re referred to Bangui’s Paediatric hospital which isn’t free.

Dr ROBERT VOMILIADE, Clinic Director:
The major problem at the moment is malnutrition. The people don’t have any more money; they don’t have enough to eat which means that the children become more and more malnourished. We’ve also noticed an increase in the number of orphans. Because of AIDs there are a lot of orphans. Mum or Dad has died, so the grandmother lives with the children. Every day we see at least 5 to 8 orphans who have lost their father or mother or both.

COMM:
HIV and AIDS is cutting a swathe through the Central African Republic. Fifteen per cent of the population is infected and the figure is rising, according to the latest UN figures. At the Community Hospital in the centre of Bangui, the capital, the newly appointed Minister of Health, Lea Koyassoum Doumta is touring the wards to get an idea of the grim task she has taken on. On the maternity ward she was told how many women died giving birth.

Dr SERGOU MAGENE, Head of Maternity Unit:
Indeed the latest figures are in the region of 146 per thousand births. It’s quite high and is also linked to recent events. Recent events have meant that sanitary structures were not adequate for the appropriate treatment. We think this explains what has been happening.

COMM:
On average, 600 babies are born at this hospital every month – but 90 mothers will also die in the same period. In the developed world, the lifetime risk of women dying in pregnancy or childbirth is one in two thousand eight hundred. In Sub-Saharan Africa, it’s one in 16.

MINISTER OF HEALTH:
Bon courage!

We should reduce the mortality rates, among women, among children. In Africa, generally when people are sick they just stay home and they get to hospital mostly late and so this is a problem and we have to be with them and to get them to come to hospital and treat them, so that we can reduce some of the mortality rate.

COMM:
Persuading them to come maybe difficult because for a hospital, this place is a real health risk. The main waste incinerator hasn’t worked for years and the water treatment plant has completely fouled up. Apart from becoming a breeding ground for mosquitoes, which carry malaria and yellow-fever, the contaminated water in the system is leaking.

JOSEPH KETE, Director of Hospital:
The treatment plant broke down a while ago and hasn’t been working since. And the major problem with this is that waste water is not being treated and is going straight into the canals next to the residential areas. And our biggest concern is the huge risk that poses to public health, because as this water is running alongside residential areas, there is always the possibility that children or other people will come into contact with it and that’s our real worry.

COMM:
Repairs will cost around $12,000 but the limited funds available have to pay for emergencies.

Dr SERGOU MAGENE, Head of Maternity Unit:
And often at the maternity unit everything is an emergency. A woman who arrives to give birth, it’s an emergency. A woman with an ectopic pregnancy. A woman who’s bleeding it’s an emergency. You see everything is an emergency.

COMM:
Most patients have no money for medicines. Doctors are rarely paid and when they do it’s money they’ve been owed for years.

Dr SERGOU MAGENE, Head of Maternity Unit:
Since the events of the previous government there has been an accumulation of salary arrears. So we have a total of roughly 48 months of salary arrears.

COMM:
The Minister of Health continues her journey. She’s travelled a hundred kilometres outside Bangui, accompanied by members of the World Health Organization – one of the few agencies operating in the Central African Republic. They’re visiting a hospital at Damara an area close to the border with Congo. Anywhere else the presentation of an examination bed, some scales and a few medical supplies might not seem like something to make such a song and dance about, but in Damara it’s a major event. In 2002 and 2003, the region was the scene of heavy fighting between Bozizé’s rebel army and the MLC - Congolese supporters of former President Patassé, known locally as the Banyamulenge. The violence was not confined to soldiers. This woman, Marie Therese, is one of the few victims willing to speak out about what happened.

MARIE THERESE:
When the Banyamulenge came, my husband had gone to Bangui and they came – there were 12 of them who broke into the house and they all raped me and I fainted and lost consciousness.

COMM:
Her children were forced to watch, including her son who was just 4 years old at the time. When Marie Therese’s husband came back he called her a whore and threw her and their seven children out of their home. Many other women suffered similar fates.

MARIE THERESE:
We women have been abandoned by our husbands need help. I’m selling this liquor but how much can I get out of this? We are stigmatised and despised by the population – they call us the Banyamulenge whores.

COMM:
The women are still suffering from the attacks both physically and mentally. Unable to get medical treatment after the hospital was ransacked, some have since died. There was little access to HIV testing. Dr Bagaza Barthelemy is the only doctor here. But he’s responsible for 29,000 people. Assisted by a handful of nurses and midwives, he delivers 25 babies a month and deals with dozens of cases of ectopic pregnancies and other serious gynaecological problems.

Dr BAGAZA BARTHELEMY:
One doctor for 29,000 inhabitants! It’s not easy, we get no rest. I’m here all the time. I literally have to sleep standing up. I spend every night here at the hospital and you can see what it’s like! I’ve been here for a year and 8 months. It was just after the events of the military political takeover. Everything was taken – the solar panels, the people took everything. Everything!”

COMM:
In part two – has the Central African Republic been forgotten by the international community? What, if anything, is being done to help?

PART TWO

COMM:
The Central African Republic could be the next big crisis in Africa. So what help is the country receiving? In 2003, according to UNDP, it got just $12.9 dollars per person. Other countries at the bottom of the UN’s poverty index got much more. Chad got $28.8 dollars, Niger got $38.5 dollars. A UN appeal for emergency aid following the civil war two years ago still hasn’t been answered.

DR. LUIS GOMES SAMBO, Regional Director, World Health Organization:
The response was very, very weak – below the expectations – I don’t know why. I think that we need to bring more evidence to an international level, we need to sensitise the partners and donors so that we address the needs of the people because our concern is the health of the people because people are suffering with diseases and they are dying at very early ages and this is a disaster.

COMM:
The weak response may be the result of a number of factors: Firstly, the Central African Republic is not a country with a great reputation for political stability. There have been four coup d’etats in the past decade. That’s precisely how the current president, President Francois Bozizé, came to power. His coup was in 2003, though it wasn’t his first. He led one unsuccessful coup in 1983 and is suspected of leading another in 2001. But defying the sceptics, Bozizé has kept his promise and democratic elections were held in May 2005. He was duly elected president with 64% of the vote in the second round. Bozizé has pledged to restore the country’s national unity and security, but despite all this, foreign governments have been slow to respond to his repeated requests for assistance and support.

PRESIDENT BOZIZÉ:
In effect help from the international community is not as forthcoming as we expected. We believed that after the return of a legal constitution, the support would be general, ongoing and substantial. But alas it is slow in coming.

DAVID NABARRO, WHO:
The best means to ensure more responsive government is to have a healthy educated populace - public that will themselves start to exercise their rights ideally through democratic or other means in order to try to pull the resources from the State into the poor communities. But if poor people are sick and not educated then it is very difficult for them to participate in the political process.

COMM:
Another deterrent to donors may well be the country’s poor financial record. The Central African Republic’s external debt, including arrears: currently totals $1.1 billion dollars according to the International Monetary Fund. Of that about $450 million dollars is owed to the World Bank, another $160 million dollars to the African development bank, $350 million dollars to bilateral governments and about $36 million dollars to the International Monetary Fund itself.

MARK LEWIS, International Monetary Fund (IMF):
The Central African Republic has not been servicing its external debt for some time, so for that reason, by nature it does present a repayment risk for the Fund.

COMM:
Figures for domestic debts are estimated at around $400 million dollars. Part of this debt is in unpaid salaries to civil servants and part of it is what is known “ghostworker fraud” where wages are claimed for people who don’t exist.

MARK LEWIS, International Monetary Fund (IMF):
The fiscal position in the CAR is, to sum up, very difficult. They have weak revenues, in part because of the low level of economic activity but also weak administration and corruption problems. And then on the spending side, they have difficulty in controlling spending notably on the wage bill with the result that they accumulate domestic arrears and they have been unable to finance essential social services, like they might have wished to in the past.

COMM:
In 2004 the International Monetary Fund did approve an $8 million dollar credit. It was given on the strict condition that the payroll problems and ghostworker fraud were dealt with. But even if the financial problems are slowly being addressed, the Republic’s history of conflict and coups has done little to reassure the international community. Along with the US Embassy, the International Monetary Fund closed its office in 2003 because of the security situation during the coup.

MARK LEWIS, International Monetary Fund (IMF):
The closure of the IMF’s office in Bangui had nothing to do with repayment issues, that was strictly a reflection of the deteriorating security environment at the time.

DAVID NABARRO, WHO:
We can’t easily put UN staff on the ground in difficult countries particularly where the security situation means that their lives are at risk, or that they might get kidnapped or raped or some such. We couldn’t put anyone on the ground in that situation. It’s got worse for us since the UN HQ was bombed in Baghdad in 2003.I myself was in that bomb and very lucky to be sitting here talking to you.

COMM:
But despite their offices being looted and wrecked during the last coup, the World Health Organization took the decision to stay.

DAVID NABARRO, WHO:
What we’re trying to do is concentrate on ways to invest in countries where the State is weak. Until we can get better investment in humanitarian outcomes in countries like C.A.R, the chances of actually seeing better governance start to appear because people have so much to hassle about over whether they are going to get food or water to deal with their daily needs or whether they are going to survive the next outbreak of disease, that their capacity to participate in the building of society is very limited. This is an example of the kind of country where interventions in health in terms of basic survival is key to the rebuilding of democratic institutions and a strong State”.

COMM:
Recently the US Department of State sent a Chargé d’Affaires to Bangui and the IMF says it would reconsider its position should the security situation change.

MARK LEWIS, International Monetary Fund (IMF):
We have regular visits to the Central African Republic which allows us to have a constructive dialogue with the authorities and looking forward should the opportunity present itself we would certainly reconsider opening the office in Bangui.

COMM:
Meanwhile, recent heavy rains brought serious flooding to parts of the country. Around 20,000 people lost their homes.

Dr LUIS SAMBO, WHO:
The situation is miserable and we are making an appeal to the International Community to come and deepen the knowledge about what is going on here in terms of the social and economic reality and even the political reality so that external aid can reach this country and these people. Because they really need it.

MARK LEWIS, International Monetary Fund (IMF):
Well I can’t speak for the international community, but I could say two things. First there are huge needs throughout the world competing for scarce aid resources and the C.A.R. of course is just one of many countries that have needs both for urgent humanitarian assistance as well as long term development support. And I would add that I think that there’s a perception, fairly or unfairly that in the past, aid resources have not been effectively used.

COMM:
And competition for aid means countries often get neither adequate or timely assistance when they need it.

DAVID NABARRO, WHO:
We were talking about the problems in Niger for well after a year after the locust invasion which swept through the SAHEL and decimated crops, but the money only came for operations in Niger when TV pictures of terrible suffering were being broadcast. And it’s such a frustration that we have often have to wait for the catastrophe to get the money we really need.

COMM:
Could the C.A.R become another Niger? Back in the Intensive Care unit at the Paediatric Hospital, these babies’ hopes of survival are diminishing by the hour. In the operating theatre next door, the main sterilisation unit is broken and these instruments – about to be used in an operation - are simply being boiled. Charlene was referred here yesterday. Tests show she doesn’t have meningitis. But she does have malaria. It will stay with her all her life – however long or short that may be.

END

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