Academic analyses of the prolonged crisis in the Central African Republic (CAR) and the international response to it are rare. This masks the depth of the crisis. The most recent outbreak of conflict alone, following a coup d'état staged by the Séléka rebels in March 2013, left countless civilians dead,1 more than half a million people displaced, and over half of the 4.6 million population in immediate need of aid.2 Several regional and international organizations, including the African Union (AU), the Economic Community of Central African States (ECCAS), the European Union (EU), and the United Nations (UN), became involved in the process of crisis solution, with all of the organizations deploying troops to the CAR. Their efforts have thus far born limited results; fighting and human suffering continue.

After a brief overview of the conflict, this Briefing documents and explores the international response to the current crisis, mainly covering the period between the Séléka's rise to power in March 2013 and April 2014, when the UN Security Council passed resolution 2149 to establish the UN operation MINUSCA (Mission multidimensionnelle intégrée des Nations Unies pour la stabilisation de la République centrafricaine). The Briefing specifically seeks to scrutinize relations between the various stakeholders involved in crisis solution, including international and regional organizations and individual states. It shows that there is competition between them for visibility, relevance, and control over the process, leading to strained relations between the key organizations, particularly between the ECCAS and the AU and between the AU and the UN. These strained relations in turn have led to delayed responses to the crisis and are only understandable through a consideration of the interests of the organizations' member states. Particularly interesting in this context are Chad and France, the two states with most influence over the CAR.3

Conflict history

The CAR has witnessed several crises since independence from France in 1960; it has yet to experience a peaceful decade. Despite the first peaceful and democratic elections in the country's history in 1993, the elected President, Ange-Félix Patassé, soon lost public confidence because of widespread discontent over prevailing social and economic problems, non-payment of salaries, and claims of ethnic favouritism in the army.4 A number of unsuccessful mutinies and coups were staged against Patassé over the following decade. The Central African Economic and Monetary Community and the Community of Sahel-Saharan States, as well as the UN and France, responded with a number of peace operations, none of which led to a sustainable peace.5

Domestic and international pressure on Patassé increased and culminated in a successful coup in March 2003, led by the former army chief of staff, General François Bozizé. In the course of Bozizé's rise to power, the CAR's bush war started. The Libreville Comprehensive Peace Agreement would only be signed on 20 June 2008. This agreement established the Mission de consolidation de la paix en Centrafrique (MICOPAX). It was led by the ECCAS, a regional organization comprising Angola, Burundi, Cameroon, CAR, Chad, both Congos, Equatorial Guinea, Gabon, and São Tomé and Príncipe.

Despite an increase of MICOPAX troops in 2012, and further peace agreements signed with other rebel groups, the fighting continued. At that time, the rebel movement Séléka (meaning ‘alliance’ in the Sango language), led by Michel Djotodia, emerged as a coalition of predominantly Muslim anti-government militias. In December 2012, it began an offensive targeting the Christian population and supporters of Bozizé.

The Séléka soon gained ground and advanced towards Bangui, the capital city. A peace agreement was signed in January 2013 between the Séléka and Bozize's government, but frustration about the agreement and Bozizé's reluctance to adhere to it led to renewed fighting. Having lost Chad as a close ally, and unsuccessfully appealed to France to intervene, Bozizé was overthrown by the rebels and on 25 March 2013 Michel Djotodia declared himself President of the CAR, plunging the country into a yet deeper crisis.

Although officially the Séléka had been dismantled in September 2013, the group persisted. Several hundred people were killed in fighting between the Séléka and the emerging anti-Balaka, a group comprised mostly of young men whose families had been killed in the Séléka's brutal campaign, and who were now seeking revenge. The UN's director of operations for the UN Office for the Coordination of Humanitarian Affairs, John Ging, bluntly assessed the situation in the CAR as ‘a tinderbox that can ignite into something very, very big and very, very bad.’6 The UN warned that the CAR ‘is at risk of spiralling into genocide’,7 and so did France.

Amidst the ongoing conflict, ECCAS leaders met in January 2014 and pressured Djotodia and his Prime Minister to step down. Regional leaders and the French government seem to have underestimated the Séléka and failed to grasp that it was a very loose coalition over which Djotodia did not have effective control. As a result, they overestimated the extent to which his resignation would help restore order and weaken the Séléka. Following Djotodia's forced departure, the National Transitional Council of the CAR, set up as a temporary Parliament after the coup in March 2013, elected Bangui's mayor Catherine Samba-Panza as the new President.

Despite Samba-Panza's plea for disarmament of the Séléka and the anti-Balaka, fighting continued. The anti-Balaka split into a majority group, willing to negotiate, and a minority group under the tutelage of the ousted Bozizé, which continued its fight. Observers argue that while the Séléka are a functioning apparatus of fighters, the anti-Balaka should be seen as an ‘organism’ or ‘xenophobic movement’ with ‘multiple centres’.8 The anti-Balaka lost momentum in February 2014 having achieved their main goal, which was to throw out the Muslims.9 To provide one example: in Yaloké, a town in the west where up to 30,000 Muslims lived prior to the conflict, Human Rights Watch counted fewer than 500 Muslims in February 2014.10

The international response to the crisis

In 2013, a robust international reaction to the crisis seemed inevitable, given the looming genocide and the war between the Séléka and the anti-Balaka, with its religious dimension. With its MICOPAX mission, ECCAS had operated in the CAR since 2008, but in 2012 the troop-contributing countries had decided on a partial withdrawal of troops due to limited progress and decreasing financial support from the EU. With the rise of the Séléka rebels and the transformation of the crisis into a fight between Christians and Muslims, however, MICOPAX made an unprecedented comeback when, at a summit on 21 December 2012, ECCAS leaders agreed to reinforce it by dispatching additional troops. At its formal end in October 2013, the operation comprised almost 2,700 troops and police officers from Cameroon, Chad, Congo (Brazzaville), Equatorial Guinea, and Gabon.

At that time, the AU was following the events in the CAR and the ECCAS's response. Initially, the AU did not take the political lead within the region, but this changed in the last week of December 2012, following a visit of the AU chairman, Benin's President Thomas Yayi Boni, to the CAR.11 Prior to that, the chairwoman of the AU commission, Nkosazana Dlamini-Zuma, had simply endorsed the ECCAS's efforts and called on the international community to support them. After the Séléka rebels advanced to Bangui in early 2013, the AU Peace and Security Council took its first concrete measures. It imposed a travel ban on persons undermining the Libreville Agreement of January 2013 and froze their assets;12 and two days later, after the successful coup d'état, it suspended the CAR from the AU.13 At an ECCAS summit on 18 April, that organization asked the AU to provide assistance for MICOPAX, but insisted on taking the lead. Effectively, this request opened the door for further, hitherto unforeseen, engagement on the part of the AU.

Following a military mission tasked to assess MICOPAX's needs – led by the AU, it also comprised representatives of the ECCAS, the EU, the UN, and La Francophonie14 – the AU Peace and Security Council took the lead, issuing a statement of support, ‘in principle’, for the establishment of an operation within the CAR.15 On 19 July 2013, the African-led International Support Mission to the CAR, better known under its French acronym MISCA (Mission internationale de soutien à la Centrafrique sous conduite africaine) was established. MICOPAX's transformation into MISCA began on 1 August 2013.

At that time, preparations for a French operation were also under way. The UN Security Council, acting under Chapter VII, not only authorized MISCA in its Resolution 2127 of 5 December, but also a French operation in support of that mission.16 With some troops already on the ground, France immediately started its Opération Sangaris, comprising some 1,600 troops. The French, fighting together with the AU troops, focused their operation on Bangui and the capital's strategic airport; they then secured a logistically important corridor in the CAR's west, stretching from the Cameroonian border to Bangui at the border to Congo (Kinshasa). In February 2014, the CAR was divided into five sectors, controlled respectively by Cameroon, Chad, Congo (Brazzaville), Congo (Kinshasa), and Gabon. With the exception of Gabon, which has no border with the CAR, each sector extended from the border with the responsible country into the CAR's interior.17

In addition to the French and the AU-led operations, the EU Council in February 2014 initiated the operation of EUFOR RCA (European Forces Republic of Central Africa), intended to contribute to a secure environment in the CAR. Authorized by UN Security Council resolution 2134, the operation got under way in April 2014 and is expected to run until the end of 2014.18 From the start of its operations, the AU had sought support from the UN while at the same time wishing to prove itself a capable security provider in Africa, and hence to function independently for as long as possible.19 However, UN Security Council resolution 2149 of 10 April 2014 established the UN Multidimensional Integrated Stabilization Mission in the CAR, MINUSCA, which was scheduled to take over from MISCA in September 2014, with the inclusion of ‘as many MISCA military and police personnel as possible’.20 Given the AU's aim to prove itself a capable security provider, news of the UN's takeover met with considerable displeasure.

Strained relations between various organizations

When we move beyond an overview of the international reaction to the crisis and begin to explore both the interplay between the different organizations and the interests of the member states behind them, it becomes clear that relations among the organizations are somewhat troubled. In the period being considered, the AU, the ECCAS, the UN, and, to a lesser extent, the EU competed for control over crisis solution, but also for relevance and visibility. Chad and France in particular were driving the organizations' agendas.

In general terms, the relations between the AU and Africa's regional economic communities are problematic. Most member states of the regional economic communities see their organizations as better positioned for regional crisis solution than the AU; they also wish to keep tight control over their regional affairs. The case of Mali, where the Economic Community of West African States competed with the AU for leading role, is just one example.21 But with regard to the CAR, the AU viewed the ECCAS as incapable of handling the crisis. The Europeans and the US shared this view, with one European official arguing that the ECCAS had ‘earned the money’ to conduct a security sector reform programme ‘but did nothing’.22 While the AU's takeover was positively perceived beyond the ECCAS region, it caused frictions between the ECCAS and the AU. The ECCAS Secretary-General visited AU headquarters in mid-2013 to clear up the ‘misunderstandings’ between the organizations and pave the way for MISCA.23 One of these ‘misunderstandings’ was the AU's displeasure at ECCAS's recognition of a coup leader as president, given the Union's strict position against unconstitutional changes of government.24 By the same token, the ECCAS considered itself better positioned to solve the crisis and hence wanted to remain in control, whereas the AU saw the crisis as falling under its mandate.

The establishment of MISCA did not mean that the ECCAS entirely withdrew from the CAR. It pledged 100 million dollars to support the country,25 appointed a special representative, and maintained a small office there. ECCAS states also remained the main troop contributors to MISCA. MICOPAX's transformation into MISCA started in August 2013, but due to the strained relations it took the AU four months to complete this task. The delayed response posed great dangers for civilians: during this period the security situation deteriorated notably, with the Séléka and anti-Balaka engaging in particularly intensive fighting that led to the death of countless non-combatants.

The AU needs regional economic communities like the ECCAS but it faces a dilemma in its dealings with them: member states of these communities are more willing than other states to deploy troops for peace operations – in fact, they are supposed to do so with their regional stand-by brigades, which are one pillar of the African Peace and Security Architecture. The willingness to send troops is frequently linked to regional states' political and economic interests, as well as the fact that conflicts can potentially spill over boundaries. However, as with Ethiopia in the context of the AMISOM operation in Somalia, and as with Chad in the MICOPAX/MISCA context, these countries are as much part of the problem as contributors to the solution.

With Chad's unexpected decision to withdraw its 833 troops from the CAR, following accusations that the country had perpetrated an unprovoked attack on a crowded market in Bangui on 29 March 2014 that left about 30 people dead, the AU operation faced this problem directly: it had lost a committed troop contributor whose personnel were needed for the short-term goal of stability and thus had to be replaced quickly. At the same time, Chad, which was deeply embroiled in the conflict and had meddled in the CAR's affairs for years, was now out of the country – at least its troops were gone – making it more difficult for the Chadian government to exert pressure on it. In general, there is a need to strike a balance between the short-term interest centred around stability, for which regional states and their organizations are needed (they can deploy troops quickly) and the long-term interest centred around getting these states disengaged from the crisis. Neither the AU nor any other actor has come up with a solution that is a panacea for managing this tightrope walk.

Chad had been widely considered the ‘predominant power broker’ but also the ‘most complicated aspect in the CAR’.26 In the period under discussion, Chad's President, Idriss Déby, skilfully used the ECCAS and France as conduits through which to push his agenda and secure the tightest possible hold on the CAR, with security interests dominating his thinking. Given the porous borders in the region, any conflict in the CAR can spill over to its neighbours.27 Reportedly, all opposition groups that have challenged Déby have been formed in the CAR, which served as a rear base for them.28 Economic interests have also been a dominant factor: Chad pumps its oil in the border region with the CAR, with oil reservoirs stretching into that country's territory.

President Déby made two astute decisions to secure control over the crisis-solution process. In the first place, he mobilized the ECCAS, positioned the organization as a key vehicle for tackling the crisis, and then kept tight control over its actions, challenging any leadership aspirations of the AU by insisting on the organization's central role – even after the establishment of MISCA. Second, he secured the loyalty of France by assisting that country militarily not only in the CAR but more importantly in Mali, where Chadian troops bore most casualties while France concentrated on providing intelligence – and yet received international credit for having stabilized Mali.29

Like AU–ECCAS relations, those between the AU and the UN are not optimal.30 AU, EU, and UN officials agree that it was a mistake to ‘rehat’ the Mali operation after only six months under the AU's aegis. They disapprove of the AU not having been given a chance to prove itself as a capable security provider. For this reason, in early 2014 there was a widespread sense among senior officials of all the organizations involved that it was important to avoid making the same mistake in the CAR. Once the AU was in charge of the operation, an EU official noted that the organization now ‘needed a success story’: this with the Mali setback fresh in mind, and given that almost the entire AU peace-operation budget comes from donors who wish to see a functioning African security architecture.31 The AU thus had an interest in running MISCA for at least 12 months to both prove itself as a security provider and have a significant impact on the security situation.

The AU has not yet developed the skills to engage holistically in post-conflict reconstruction and therefore aims at establishing bridging missions that the UN will then take over. There was a debate, mainly between France and the United States, concerning the proper time to hand over MISCA to the UN. There were three main reasons why the US government wanted the AU mission to run longer: the AU is a less risk-adverse organization than the UN, with less defensive rules of engagement; it operates in a less expensive fashion; but it can still (perhaps more effectively than the UN) contribute to the US goal of a more stable CAR, which might otherwise turn into a safe haven for Islamic terrorists. France, however, had a different view. Despite its geopolitical and economic interests in the CAR, it wanted to multilateralize its operations as quickly as possible. With the Mali operation running at the same time, France had overstretched itself financially, and thus appealed to both the UN and the EU for help. More importantly, a UN operation was France's only exit strategy. With its proxy Chad having left the CAR – to the great dismay of France, which tried to persuade the Chadian government to keep their troops in place – the country needed another partner to share the burden, and the UN was one option.

France's other pillar in its multilateralization strategy, the EU, eventually established EUFOR RCA, which had 1,000 troops at its disposal for a nine-month period starting in April 2014. Although France contributes about half of the troops and thus covers a large part of the operation, in line with the EU's ‘costs lie where they fall’ principle, meaning that each state pays for the costs of its own operations, it has gained some relief: other European states have sent troops, including Estonia, Italy, Portugal, and Spain, and yet others, such as Germany and Sweden, have provided airlifting and other logistical assistance.

In contrast to the relations between the AU and the ECCAS and between the AU and the UN, the AU–EU relationship is largely unproblematic when it comes to the CAR. The EU efforts are considered complementary and EUFOR RCA is intended as a bridging mission, not challenging the AU's role but supporting it. This point notwithstanding, the EU was pleased to see EUFOR RCA play a proactive role in the CAR crisis, given the EU's efforts to be visible internationally and show a capacity to deliver ‘out of area’ as well.32

Conclusion

Despite the EU's largely unproblematic involvement in the CAR crisis, the fact remains that a cluster of actors with particular interests has emerged to confront it. These organizations have competed for control over crisis solution, relevance, and visibility, and have often been driven by key member states, particularly by Chad and France. The delayed transformation from MICOPAX into MISCA not only reflected the strained relations among the various actors, but also impeded an effective international response to the crisis, with fatal results for the CAR's citizens. The number of casualties increased particularly sharply during the MICOPAX–MISCA transformation. No thoughtfully planned peace operation, active long enough to have an enduring impact on the security situation in the CAR, has been established thus far. Much depends now on the ability and willingness of the UN, which has taken the lead and pushed the AU and the ECCAS into the background, to streamline international efforts and engage in sustainable post-conflict reconstruction, including the construction of a viable state with functioning security organs and a reconciliation between Muslim and Christian communities. The UN must now walk the tightrope of quickly deploying a well-planned and well-executed mission to satisfy the needs of the CAR, while simultaneously accommodating the demands and interests of the AU and the ECCAS, and allaying the concerns of Chad, France, and other stakeholders.

1.

The EU and the UN speak of nearly 2,000 dead. European Community Humanitarian Office (ECHO), ‘Central African Republic ECHO factsheet’, 27 May 2014, <http://ec.europa.eu/echo/files/aid/countries/factsheets/car_en.pdf> (28 May 2014); Amnesty International notes that ‘Seleka forces killed countless civilians’. Amnesty International, ‘Q&A: The Central African Republic's human rights crisis’, 9 April 2014, <http://www.amnesty.org/en/news/qa-central-african-republic-s-human-rights-crisis-2014-04-09> (28 May 2014).

2.

ECHO, ‘Central African Republic ECHO factsheet’.

3.

The Briefing is based on numerous interviews with senior officials from the AU, the EU, ECCAS, and the UN conducted in Addis Ababa in February 2014. Further information is drawn from interviews with other experts from major embassies in Addis Ababa. All interviewees are involved in the process of crisis solution for the CAR. The request of several interviewees to remain anonymous has been respected.

4.

Angela Meyer, ‘Regional conflict management in Central Africa: from FOMUC to MICOPAX’, African Security2, 2–3 (2009), pp. 158–74; 159–60.

5.

For more information on the background to the conflict and the international response, see International Crisis Group, ‘Central African Republic: Anatomy of a phantom state’ (Africa Report No. 136, 13 December 2007); Angela Meyer, ‘Regional security cooperation in Central Africa’ in James J. Hentz (ed.), Routledge Handbook of African Security (Routledge, Abingdon, 2014), pp. 229–41; Ilmari Käihkö and Mats Utas, ‘The crisis in CAR: navigating myths and interests’, Africa Spectrum49, 1 (2014), pp. 69–77; Martin Welz and Angela Meyer, ‘Empty acronyms: why the Central African Republic has many peacekepers, but no peace’, Foreign Affairs Online, 24 July 2014, <http://www.foreignaffairs.com/node/138767> (25 July 2014).

6.

BBC News, ‘Central African Republic's UN protection force approved’, 30 October 2013, <http://www.bbc.com/news/world-africa-24744757> (22 May 2014).

7.

BBC News, ‘UN warning over Central African Republic genocide risk’, 4 November 2013, <http://www.bbc.co.uk/news/world-africa-24800682> (14 February 2014).

8.

Interviews, officials from the AU, the EU, and the UN, Addis Ababa, February 2014.

9.

Interview, UN official involved in the CAR operation, Addis Ababa, February 2014.

10.

Human Rights Watch, ‘Central African Republic: Muslims forced to flee’, 12 February 2014, <http://www.hrw.org/news/2014/02/12/central-african-republic-muslims-forced-flee> (8 March 2014).

11.

AU, ‘The African Union warns against any attempt to seize power by force in the Central African Republic’ (Press release, Addis Ababa, 31 December 2012).

12.

AU Peace and Security Council, ‘Communiqué’ (PSC/PR/Comm. (CCCLXXII), Addis Ababa, 23 March 2013), para. 6.

13.

AU Peace and Security Council, ‘Communiqué’, (PSC/PR/Comm. (CCCLXXIII), Addis Ababa, 25 March 2013), para. 8.

14.

AU Peace and Security Council, ‘Communiqué’ (PSC/PR/Comm. (CCCLXXV), Addis Ababa, 10 May 2013), para. 5.

15.

AU Peace and Security Council, ‘Communiqué’ (PSC/PR/Comm. (CCCLXXX), par. 6, Addis Ababa, 17 June 2013), para. 6.

16.

UN Security Council, ‘Resolution 2127’ (S/RES/2127 (2013), New York, 5 December 2013).

17.

For the sake of simplicity I offer no in-depth analysis of the status of the eastern part of the CAR, where Joseph Kony's Lord Resistance Army is likely to have sought refuge, leading to a significant presence of soldiers from South Sudan, Uganda, and the United States.

18.

European Union External Action Service (EEAS), ‘Factsheet Central African Republic’, 10 February 2014, <http://eeas.europa.eu/statements/docs/2014/140117_03_en.pdf> (12 March 2014).

19.

AU Peace and Security Council, (PSC/PR/Comm. (CCCLXXIII), para. 10.

20.

UN Security Council, ‘Resolution 2149’ (S/RES/2149, New York, 10 April 2014).

21.

Thomas G. Weiss and Martin Welz, ‘The UN and AU in Mali and beyond, a shotgun wedding?’, International Affairs90, 4 (2014), pp. 889–905.

22.

Interview, European official, Addis Ababa, 24 February 2014.

23.

Interview, official from the ECCAS region, Addis Ababa, 18 February 2014.

24.

Interviews, senior AU, EU, and UN officials, Addis Ababa, February 2014.

25.

ECCAS Secrétariat Général, Communiqué de presse, Addis Ababa, 31 January 2014.

26.

Interviews, Western diplomats, Addis Ababa, February 2014.

27.

Roland Marchal and Victoria Bawtree, ‘Chad/Darfur: how two crises merge’, Review of African Political Economy33, 109 (2006), pp. 467–82; Marielle Debos, ‘Fluid loyalties in a regional crisis: Chadian “ex-liberators” in the Central African Republic’, African Affairs107, 427 (2008), pp. 225–41.

28.

Interview, UN official, Addis Ababa, 20 February 2014.

29.

Interviews, senior AU and UN officials involved in the Mali operation, Addis Ababa, February 2014.

30.

Paul D. Williams and Arthur Boutellis, ‘Partnership peacekeeping: challenges and opportunities in the United Nations–African Union Relationship’, African Affairs113, 451 (2014), pp. 254–78; Weiss and Welz, ‘The UN and AU in Mali and beyond’.

31.

Interview, EU official, Addis Ababa, 24 February 2014.

32.

Ibid.

Comments

1 Comment
Challenges in Responding to Massive Displacements in Resource-poor Settings: The Case of Central African Republic Refugees in Eastern Cameroon
9 November 2015
Caroline Abu Sa'Da (with Christine Jamet, Program Manager)
Head of the Research Unit (UREPH), Medecins Sans Frontieres Operational Center Geneva (MSF-OCG), rue de Lausanne 78, CH-1211 Geneva 21,

Summary: The violence in the Central African Republic (CAR) since December 2013 has resulted in massive population displacement into neighbouring countries. Cameroon is the most affected country since it received the largest number of refugees from the CAR. In September 2014, approximately 100,000 refugees were present in the eastern part of Cameroon. MSF was already present in Cameroon for several years when the first refugees arrived in January 2014. An emergency operation was set up to address the most urgent medical and nutritional needs of the people. Several ethical challenges can be outlined. They are not new to humanitarian aid workers but remain unsolved and continue to represent a source of psychological distress for the actors involved. (i) Resource scarcity compared to the magnitude of needs and the capacity of local health services (ii) Being prevented from providing better relief and helplessly witnessing the deterioration of refugees' health (iii) Having to discharge children prematurely, due to the high mobility of their families (iv) Having to comply with (obsolete?) Ministry of Health protocols, where better strategies could be applied

Key words: Medical Humanitarian Project, Massive Displacements, Resource-Poor Settings

Acknowledgements: The authors wish to thank Dr Philippe Calain for his invaluable comments on the first version of this article.

On December 5, 2013, in the Central African Republic (CAR) the anti- Balaka, a militia formed to oppose the Seleka opposition force that took control of the country in March 2013, attacked the capital Bangui. This incident provoked fierce fighting with ex-Seleka forces, leading to many deaths and injuries within the civilian population. With Christians considered supporters of the anti-Balaka and Muslims, ex-Seleka supporters, both populations are stigmatized, as such. They have been and continue to be targets for reprisals, driving them to gather in enclosed sites, such a churches, mosques and hospitals. The same day, deployment of French forces, which gave priority to disarming and confining ex-Seleka forces, helped to strengthen anti-Balaka attacks against all those they considered supporters of the former rebel coalition. Chadian merchants, Fula and Central African Muslims thus all became targets of systematic reprisals in Bangui and in the western part of the country. While some took refuge in enclaves, others sought to flee the country (MSF 2014).

This violence in the Central African Republic (CAR) since December 2013 has resulted in massive population displacement into neighbouring countries, including Chad, the Democratic Republic of Congo, the Republic of Congo and Cameroon. Cameroon is the most affected country for two reasons: First, it received the largest number of refugees from the CAR, and second, it was already host to some 90,000 CAR refugees from previous waves. In September 2014, approximately 100,000 refugees were present in the eastern part of Cameroon, while thousands of Nigerian refugees were pouring into the western part of the country due to ongoing violence in Nigeria.

People crossing from the CAR into Cameroon have suffered from extreme violence. As mentioned by a MSF report published in July 2014: "The testimonies gathered by MSF teams in Chad and Cameroon highlight the breadth of the violence that the populations experienced both in the CAR and as they fled the country. The Central African refugees who reach Cameroon today are exhausted, sick and traumatized. Unlike the people who arrived initially, entering the country quickly in January 2014 by convoy or private transportation, those who cross the border today have walked for weeks, if not months, making their way through the western part of the country to escape the violence. Their health and nutritional status is very alarming, with nearly one of every two children suffering from malnutrition." (MSF 2014).

In the East and Adamaoua regions (Eastern part of Cameroon, at the border with CAR), refugees from the CAR are spread over more than 300 sites (villages, camps, informal gathering, etc.) across 50,000 square kilometres (UNHCR, 2014), which challenges humanitarian aid workers extremely. This logistical challenge is further aggravated by poor road conditions, which makes access to refugees difficult. At the time of writing, 100 to 200 people a week were still crossing the border into Cameroon, where the security situation was degrading.

MSF was already present in Cameroon for several years when the first refugees arrived in January 2014. An emergency operation was set up to address the most urgent medical and nutritional needs of the people, who were suffering mainly from malnutrition after weeks of walking in the bush with no available food. Two projects were launched : one in the town of Garoua-Boulai, on the main road from Bangui to Yaounde, and another one further south where people settled in an informal camp in the village of Gbiti. This intervention is ongoing.

Several challenges can be outlined. They are not new to humanitarian aid workers but remain unsolved and continue to represent a source of psychological distress for the actors involved. The situation faced by CAR refugees and its humanitarian and political response has clearly put humanitarian workers in an uncomfortable moral situation. However, this can be said of most of the emergency situations where mass population displacements occur. The following examples encountered in Cameroon are similar to what was described by Schwartz et al :"(...) ethical challenges (...) emerge from four main sources: (1) resource scarcity; (2) historical, political, social and commercial structures; (3) aid agency policies and agendas; (4) norms associated with health professionals' roles and interactions" (Schwartz et alii, 2012).

i) Resource scarcity compared to the magnitude of needs and the capacity of local health services

Resource scarcity at different levels (country level and humanitarian system level) has had a significant impact on this crisis. Developing countries host over 86% of the world's refugees (UNHCR, 2013). This means that refugees are being hosted by countries with deficient health systems and poor infrastructure. In eastern Cameroon, resources are very limited. It is a forest area where access to medical care is limited. A massive arrival of refugees put structures, which were already inadequate for the local population, under severe strain.

The foreseen protractedness of the situation is also an ethical issue, because teams on the ground already know that there is little chance of seeing an improvement in the situation in the next few months, leaving people in a very dire situation without the necessary resources (human and financial) to adequately respond to the needs.

Due to the scarcity of resources and the urgent needs of the population, teams are working under very high pressure to save a maximum of lives, but sometimes have to accept that their work is not enough considering the needs. A comprehensive approach towards the refugees' situation is clearly lacking, and MSF has been the only actor responding to medical needs for a very long period of time.

ii) Being prevented from providing better relief and helplessly witnessing the deterioration of refugees' health

The first MSF teams who arrived in Cameroon to set up the emergency medical and humanitarian projects were confronted with the slow organization of the humanitarian system in the face of an emergency. The delay in the humanitarian response was aggravated by three factors: the underreporting of the situation in Cameroon, the lack of humanitarian actors able or willing to address emergency needs, and finally the lack of funding for this specific crisis due to many other ongoing crises.

UNHCR, the lead UN agency for this emergency, delegated some of its activities to other organizations, some of which were sometimes outside of their field of competences. For example, in Batouri, a town in the East of Cameroon, an African-based NGO was running a nutritional center where the weekly mortality in this center was at 24% (while international standards set up the threshold at 10%). Despite this mortality rate, it took UNHCR five weeks to transfer the management of the center to MSF teams. MSF, which was equipped with better resources and experience, was at first actually prevented for administrative and political reasons by UNHCR from taking over the nutritional care of refugees in Batouri town during this period, and this led to the preventable deaths of refugee children.

(iii) Having to discharge children prematurely, due to the high mobility of their families

The political and social situation of both the host community and the refugees had an impact on the humanitarian response. The eastern part of Cameroon, as mentioned earlier, had already received a massive influx of CAR refugees several years before. In addition, during the journey from the CAR to Cameroon, many families were split up. As a consequence, either people were willing to find family members who had already settled in the region since 2007, or some families moved from camp to camp as soon as they heard of family members lost during the journey. These patterns had two consequences: First, it was very difficult to locate refugees and have an accurate idea of their numbers, and second, some children were suddenly discharged from nutritional programs even though they were still in poor health conditions. This is why refugees did not necessarily set up in official camps. Moreover, the number of official camps was limited, and the absorption capacity of the existing ones was insufficient, giving the newcomers no choice but to adopt alternative solutions. Gado camp, near Garoua-Boulai, increased as such because it was the first point where people knew that sufficient and quality services were delivered. It was indeed the first organized camp set up by UNHCR and the authorities, where MSF was in charge of water, sanitation and health. It therefore attracted high numbers of refugees but because there was a lack of anticipation from UNHCR and the authorities, the camp was almost full as soon as it was opened.

(iv) Having to comply with (obsolete?) Ministry of Health protocols, where better strategies could be applied

Cameroon's Ministry of Health (MoH) was in charge of organizing health care during the crisis, and MSF had to adapt to its protocols, in particular the nutritional ones. The MoH protocols were appropriate for a low level case load of malnutrition mainly due to associated diseases. But in this situation, malnutrition was due to a dire lack of food for people who had to walk weeks and months to reach Cameroon. This malnutrition mainly affects children under 5 (because they are always the most affected group),but was also affecting elder children, a proof of the severity of the situation. We could say that the MoH protocol was not adapted to the management of large numbers of severely and acutely malnourished children. As MSF was not allowed to implement its own nutritional guidelines, better adapted to the current situation, it created considerable moral distress for MSF teams. Moreover, even if national malnutrition guidelines existed, the knowledge at Cameroon's health staff level was extremely limited and national appropriation was totally inexistent. This is very concerning with regards to the added-value of developing such guidelines at the national level, since they are pushed for by UNICEF for fund raising or milestone reaching obligations but are not followed up with trainings or equipment and therefore leading to uselessness.

References:

UNHCR, 2013, http://www.unhcr.org.uk/about-us/key-facts-and- figures.html

UNHCR, 2014 Cameroon Country Profile, http://www.unhcr.org/pages/4a03e1926.html

Medecins Sans Frontieres, Central African Refugees in Chad and Cameroon: "Suitcase or Coffin", July 2014.

Schwartz (Lisa), Hunt (Matthew), Sinding (Chris), Elit (Laurie) , Redwood-Campbell (Lynda), Adelson (Naomi), De Laat (Sonya), Ranford (Jennifer), Western Clinical Health Ethics: How well do they Travel to Humanitarian contexts?, in Abu Sa'Da (Caroline, ed, Dilemmas, Challenges and Ethics of Humanitarian Action, Reflections on MSF' perception project, MSF/McGill - Queen's University Press, 2012.

Conflict of Interest:

None declared

Submitted on 09/11/2015 7:00 PM GMT
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