Two months after “Cross‑sectional survey in Central African Republic finds mortality 4‑times higher than UN statistics” was published, wondering why the world does not care.

Gang Karume, Jenn O'Keeffe, and Les Roberts thought that if they told the world that Central Africans had a mortality rate higher than recorded for any country in decades, food and more assistance would come. This blog explores the reasons for their naivete.
Two months after “Cross‑sectional survey in Central African Republic finds mortality 4‑times higher than UN statistics” was published, wondering why the world does not care.
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Cross-sectional survey in Central African Republic finds mortality 4-times higher than UN statistics: how can we not know the Central African Republic is in such an acute humanitarian crisis? - Conflict and Health

Background CAR is one of the poorest countries in the world. While UN statistics suggest that there is no health emergency in the country, two recently published mortality surveys contradict this. Moreover, recent accusations of massive scale human rights abuses by mercenaries suggested the need for a nationwide mortality survey. Methods Two stage cluster surveys were conducted in two different strata: one in the roughly half of the country within the Government’s control, and one in the areas mostly outside of the Government’s control. We randomly selected 40 clusters of 10 households in each stratum. The survey included questions on vital events with open-ended questions about health and household challenges at the beginning and end of each interview. Results 70 of 80 selected clusters were successfully visited. We interviewed 699 households, containing 5070 people. 11 households (1.6%) refused to be interviewed and approximately 18.3% of households were absent at the time of visitation, mainly in the safer Government controlled areas. Interviewed households had a birth rate of 42.6 /1000 / year (95%CI 35.4–59.7) and a crude mortality rate (CMR) of 1.57 /10,000/day (95%CI: 1.36–1.78). The birth rate was lower and the death rate markedly higher in the strata outside of Government control. Families described malaria or fever, and diarrhea as the primary reported causes of death with violence accounting for 6% of all deaths. Conclusions CAR is experiencing a severe health emergency, with the highest measured nationwide mortality in the world to our knowledge. UN published death rate estimates appear to be less than one fourth of reality. There is a desperate need for food aid in the form of general distributions in CAR, along with the accompanying work programs, seed and tool distributions needed to restart local economies. This is of particular importance in rural areas outside of the Government control. While some humanitarian actors are doing their best to respond, the crisis level mortality rate suggests that the needs in CAR are being largely unmet.

Measuring mortality in a crisis or conflict setting is particularly likely to draw criticism or have unexpected negative results compared, for example, to vaccination or nutritional surveys. In preparing for our recently published Cross-sectional survey in Central African Republic finds mortality 4‑times higher than UN statistics, we anguished for months over what real or perceived errors might arise and how to prevent them. We prepared for every security, operational, and epidemiological scenario we could think of. Between the three of us, we have over 50 years of humanitarian experience conducting dozens of such surveys.  Many of these did not produce the hoped for increase in humanitarian support. Others resulted in severe unintended consequences.  Through the errors and the failures, we have tried to learn. 

Twenty years ago, GK was involved in IRC’s mortality measurement in Eastern DRC. His involvement resulted in the detention and torture of his brother, who looks similar and has the same family name, by Rwandan forces. For this survey, we went to great efforts to keep our local staff safe. Our experienced local lead made all key security decisions. He designed bright orange team shirts that would mark our presence as NGO workers and make it easy to locate one another. We kept the schedule and routes flexible to adjust to shifts in local security. JO spent months working on a mortality project in an acute conflict for a highly respected NGO, only to have HQ officials, high above the field staff, decide without local consultation that the data should not be released.  HQ thought the backlash might disrupt programming efforts.  Our NGO, RHA, chose to do this survey in part because we are not currently operational in the Central African Republic (CAR). LR worked on a war-time survey that was criticized for inadequate precision after war affected areas were not sampled separately from the rest of the country. To reduce this risk, we had Central Africans on the team with extensive contextual knowledge separate strata for the government and non-government-controlled areas.  Because our findings were so far from the official UN statistics, we included a table showing 10 other mortality surveys in recent years. Two UN initiated nationwide surveys showed mortality estimates more than twice the official statistics.  Three had estimates higher than ours.

But we did make mistakes. While violent deaths were caused by both national and international armed groups, many stories of rape and displacement focused on Russian Mercenaries present in the country. We did not explicitly ask about these experiences.  They arose naturally in our open-ended questions. Thus, our mistakes seemed to be less technical and more about missing key aspects of the larger context. Since the article was published, all of the feedback from the field has been positive.  REACH shared a press release highlighting our study. It matches the results of their key informant remote monitoring. UN OCHA and MDM have recently highlighted the severity of the crisis. Unfortunately, in all our anticipation of criticism, amidst our fear for the safety of our team, in all of our planning, strategizing, and organizing, we had forgotten a key factor in our efforts to bring attention to the crisis- the world does not seem to care about the Central African Republic!

A decade ago, over a period of years, MSF’s website touted CAR as the world’s silent crisis    or most neglected crisis.  In 2017, NRC used the same phrase.  There was a similar outcry from IRC in 2010.   Equally fascinating, is how there have been dozens, perhaps hundreds of media segments with themes like “the worst crisis most people have never heard of” and “a Crisis the World Neglects.”  All of this universal declaration of disinterest and neglect beckons the question, why?

Why does the world not care about the Central African Republic?

Rhetorical questions like this never have an easy answer, and a single explanation is usually insufficient. Over-simplified replies like “there is a Christian - Muslim divide” gloss over deeper subtexts, like the university-educated subcultures having more influence with the wealthier Northern Hemisphere. Explanations like colonial boundaries that did not consider existing land divisions based on ethnic groups, language, or cultures are valid, but are difficult to use when developing death-averting responses. In the aftermath of publication, we are contemplating three contributing factors in this crisis: CAR is complicated, the global humanitarian community has lost its ability to prioritize crises and responses, and the interplay between free-market capitalism and nationality leave little space for aiding the poorest of the poor.

Complicated. The word complicated applies to CAR’s crisis in dozens of ways.  It is one of the poorest nations in the world. The median income is unknown but the World Bank says the GDP per capita is about $460/year.  Perhaps 2/3rds of the country has been outside of the Government control for most of the last two decades.  This has created an entire economy independent of the Bangui based Government. The main instigators of violence in 2022 according to our interviewees, was Wagner mercenaries, who may or may not take orders from the Bangui Government that denies employing them. In the last election, only about 15% of the population voted. There are high levels of violence and insecurity in six bordering countries. The levels of corruption are astonishing. Thus, unlike Ukraine where one country has invaded another or Sudan where two warring parties with distinct leaders are engaged in an open power struggle, it is not clear how or with whom diplomatic and humanitarian players could engage to end CAR’s high mortality.

Inability to prioritize crises and responses. In 1963, the Red Cross defined “humanitarian imperative” as, “No human caught in a life threatening situation should be denied assistance.”   (see Princeton Encyclopedia of the World Economy Vol. 1). In 1990, Toole and Waldman proposed a doubling of the baseline mortality as qualification for a humanitarian crisis.  Within a few years, CDC, MSF, and WHO had all agreed. The widespread use of this metric to define a crisis pushed the humanitarian community to focus on addressing the main causes of death, prioritizing saving lives first. Over the years the definition has evolved to "... avoid making people suffer or they help people who are suffering” (See Collins Dictionary 2023) or for the Red Cross, “The right to receive humanitarian assistance, and to offer it, is a fundamental humanitarian principle which should be enjoyed by all citizens of all countries.”  Thus, in the three decades since mortality rates began defining humanitarian crises, rights-based programming and appreciation of issues like mental health and education, has grown.   While this programming is important, it often means the NGO community has moved away from saving lives. In many ways this is a great thing. It broadens our capacities and expectations for compassionate and holistic responses.  However, it also means, that for those fixed on women’s rights issues, Iran and Afghanistan are very important crises despite little mortality elevation.  For those concerned about the global threat of climate change, the threat of nuclear war, or the rise of nationalist extremism triggered by the migrant flows to Europe and North America, the 5 million people trapped in CAR dying at many times the rate that WHO reports, are not a priority. Interestingly, we can find no credible, nationwide mortality estimate as high as the 1.57/10,000 per day we measured in CAR, since the Rwandan genocide in 1994. Table 4 in our article includes ten estimates of mortality since 2009.  If the official UN estimates are wrong, as these ten estimates suggest, since 2009, over a million more Central Africans have died than the UN acknowledges. Unfortunately, deaths from malaria and diarrhea are of less media and political interest than deaths from violence.  This is true even if violent and non-violent mortality are correlated, as they are in CAR and as they were in neighboring DRC 20 years ago. If mortality rates drove humanitarian and diplomatic responses, there would be no country in the world getting more aid and press attention than CAR.  But alas, the humanitarian endeavor is not so simple.

The interplay between free-market capitalism and nationality. Ukraine, which had eight times the population of CAR, has experienced crudely similar numbers of deaths (twice as many from violence, fewer from indirect causes) in 2022.  The press focus on this crisis has been ubiquitous and appropriate since the war began, as it represents a global power struggle and the threat of nuclear war.  Despite only an eight-fold difference in population, the global attention for Ukraine has been exponentially greater than that for CAR. This has been seen many times before. 20 years ago, a crisis in DRC triggered 1/20th the per capita aid sent to Kosovars.  We live in a world where the median household income is around 10,000 Euros.  It is not by chance that countries like CAR & Niger, with less than 1/10th the median global income, are neglected. Flaherty showed how internet-based sources and the UN were better at reporting violent deaths in Venezuela and Syria (countries with median incomes above the global average) than in CAR and Mali. This was attributed in part to the social and internet-based networks between the affected populations and residents in Europe and North America. The inequity of attention paid to crises is further complicated by the fact that those crises closest to Europe have lighter skinned people with higher incomes than crises with higher mortality rates further south.   There may be many conscious and unconscious mechanisms that cause the world to be more accepting of deaths that occur in darker-skinned people than in lighter-skinned ones. While a host of measures have been suggested to reduce the levels of inequity between countries (The Alma Ata Declaration, global minimum wage for goods that cross borders, a global CO2 tax to support climate protections in the poorest nations, free elementary schools), none have been seriously employed - likely because it would involve taxing and disempowering the wealthy. Many national and religious doctrines proclaim that all humans are created equal and should enjoy equal rights. To Central Africans who earn 1% as much as Americans and have 1/2000th spent on their education, these proclamations may seem absurd.  The lack of response to their deaths suggests that the “we take care of our own” value arising from nationality in the wealthiest nations is paramount at the moment.  WHO’s 1978 declaration that health is “a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal” seems to be trumped by the right of nations not to engage beyond their own borders.

Conclusion, patience is not a virtue. Science often produces evidence that is ignored. Exciting new vaccines roll-out at the speed of a glacier.  Cigarettes are linked to cancer, and it takes decades for societies to respond.  The fact that Central Africans dying at a rate of 8 or 9 times that of their neighbors in Uganda and Tanzania seems surreal. The notion that this has been known for a decade and the UN seems to be masking it, only makes it more bizarre.

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