Basic health care is scarce within Karbi Anglong and much of Assam state and the area's recent outbreaks of violence have only made the situation worse for thousands of people. Below, Hilary Bower describes the current situation in Assam and MSF's activities aimed at providing basic health care and other assistance to those caught in a cycle of violence and neglect.

The situation in Assam, India is one that is not well known to most people. What is happening there? "In late September 2005, three people from one tribe in the Karbi Anglong region of Assam were apparently killed by members of another local tribe. This provoked a spiral of violence, including retribution and general violence. A month later, 30 men, women and children traveling on a bus in the area were attacked with machetes and killed. Houses and whole villages have been burned. People from both tribes have been brutally murdered and burned out of their houses.

"Why this is happening now is difficult to say. These two tribes have lived side by side from time immemorial, as they say here. It may be territorial. It may be that different tribes are struggling for recognition and autonomy and their efforts at self determination are turning to arms. It may be political manipulation. For the people affected, the end result is the same."

What has been the result of this recent violence?

"People on both sides became terrified and started to flee to places of safety. In total, about 45,000 people were suddenly on the move. They did not settle in large camps. Instead, they scattered in schools, community halls, anywhere they could find shelter near a town or police post. Try to imagine 1,000 people living in a school meant for 100 students. There were problems with the latrines and water very quickly and the general health situation became very difficult."

What kind of assistance is MSF providing?

"MSF came to the area because of the urgent needs found among those who had been displaced. There are no other international aid organisations operating in Karbi Anglong. MSF has been working in other parts of Assam state, more to the south, for approximately 10 years. In fact, MSF staff were traveling in Karbi Anglong to carry out a health assessment just a few days before the bus massacre took place in October. We knew tensions were rising and it seemed like an area where we might start working. This part of India is an extremely neglected and isolated area where civilians have very little access to health care.

"MSF brought a doctor, nurse, water and sanitation specialist and health education team from the project in lower Assam to Karbi Anglong immediately after the bus massacre as people started to move very quickly. It was clear that the authorities were overwhelmed by the situation. We started running mobile medical clinics, providing water and sanitation assistance, and working with the displaced, for example, in the area of hygiene, to help them try to find ways to manage their difficult situation."

Are people now living in displacement camps?

"The violence has forced people to move to more urban areas. They have gone into towns looking for safety. So our mobile clinic travels from camp to camp. Initially there were 53 camps. We know where the camps are and go to them. Some are located close to our base, others are as much as a three-hour journey away."

What kind of health problems is the team encountering in the camps?

"It is now low season for malaria. It was "lucky" that the crisis occurred at this time of the year. As a consequence, the level of malarial illness has been relatively low. Now it is cold at night, going down to five or six degrees celsius. Children are coming to our clinics with pneumonia.

"We are also seeing people with skin diseases and diarrhoea and some children are malnourished. Malnutrition in the camps has more to do with other problems. A child gets measles or diarrhoea and this can provoke malnutrition. The team is not seeing large numbers of sick people. This is astonishing considering the sanitary conditions in which the people are living despite our best efforts and those of the authorities.

"In the first week, we carried out a mass measles vaccination campaign for children living in the camps. Measles vaccine coverage is very low in this part of the country. This is less of a problem when children live in scattered villages, but when thousands of people are packed together in crude camps, you can have serious outbreaks.

"Tuberculosis (TB) is common in the area. When people are moving like this, it means that those on TB treatment are also forced to flee and often they discontinue their treatment. When MSF visits the camps, we actively look for people with TB and refer them to the government clinic to get them back on treatment.

"In addition, we are also trying to check all of the pregnant women in the camps and are distributing safe delivery kits in the camps to help them give birth safely. The local health authorities are also keeping track of pregnant women and trying to get them to hospitals when it's time to deliver. But that doesn't always work, so that's why we distribute the kits."

Are people traumatised by their experiences?

"We are seeing what you often see in this kind of situation. People are very uncertain and anxious about their situation. There are lulls in the violence and it looks like things are getting better, then there is another attack. We see quite a lot of adults with aches and pains. One might think: why should we bother with this, it isn't life threatening. But in fact, these symptoms are a physical manifestation of the uncertainty that underlies their present lives. Part of our reason for being here is also to keep attention on the people that have been forced to live like this and to reassure people that they are not forgotten."

What other crucial work is being done by MSF?

"Water and sanitation activities are a big part of the program. We are trucking in water and doing small things that make a big difference. For example, people were dipping buckets into water tanks to obtain fresh water. But if everyone does this, the water will soon become contaminated. So we place the tanks on a ramp. We put pipes into them and install taps, so that people can use the taps and not dip their buckets.

"We are also pressing the authorities to ensure that enough water is delivered to the camps. People need water for drinking but also to keep clean. Without it, people's dignity is quickly reduced. Our water and sanitation work here is just as important as the medical work. Plus, we are providing health education to help people manage in their environment."

Are people still living in any shelter they can find?

"There has been a change in the situation. Originally many people were living in schools. However, the authorities have now constructed makeshift camps in the center of villages that were burned out. This enables people to go back to their own area and harvest their crops. The people have been very worried about missing the harvest season. They have been urged by the government to go back to their own villages.

"Currently, about 17,000 people are still living in camps. But it is important to remember that when people do go home, they are going back to partly burned houses or villages. These villages had little access to health care before the violence broke out. Many of these villages still lack care now. Even though the number of displaced has dropped, the needs have not.

"The authorities say that the people will be out of the camps in the next three months, but they said the same thing about the displaced in lower Assam years ago, and people there are still living in camps."

Is MSF planning to help improve access to care in the long-term?

"There is constant pressure on people here from the various militant groups active in the region. Even the health authorities say that due to the poor roads or the perception or reality of insecurity, they cannot get health staff to visit some villages. Health professionals: doctors, nurses, pharmacists, just won't go. As a result, there are large swathes of the countryside that simply have no access to health care. However, right now we are concentrating on the people living in the camps and those going back to their villages. The situation is still so unclear. Another outbreak of violence could make people run again."