In the past seven years, Youmusa and his family have been uprooted four times because of fighting in the Central African Republic (CAR). In 2016, they arrived near the town of Bambari, in the country’s south, where they settled in a camp for displaced people called Elevage.

Youmusa thought that his family had finally found safety. But after a period of relative quiet, a new wave of violence hit the country at the end of 2020, linked to national elections. As clashes broke out in Bambari, all the camp’s 8,500 residents were forcibly expelled on 5 June. All buildings, including mosques, shops and a malaria point set up by Médecins Sans Frontieres (MSF), were burned to the ground.

Around 250 kilometres to the northeast, in Nzacko, Jean-Marie* and Rose* also know what it’s like to flee due to the cycle of violence that has gripped CAR. Nzacko, which lies 190 kilometres to the north of Bangassou, where an MSF team is based, has been regularly confronted with attacks, lootings, extortion and destruction over the past decade. In January, clashes in the town resumed in the wake of the elections. 

Jean-Marie and Rose, along with most of Nzacko’s 15,000 residents, fled the town. 

“We were in the forest for four months,” says Jean-Marie. “We struggled to find food. We were all very weak, especially the children.”

Jean-Marie, Rose and the thousands of people who fled, were living in very precarious conditions, unable to access humanitarian assistance because of the insecurity.

It is a critical situation, which has been going on for years.  

“With the exception of MSF, few organisations have had access to the town since 2017, even though the situation there is worrying for things such as malnutrition and water-borne diseases,” confirms Pelé Kotho-Gawe, MSF nurse supervisor. “Even if our trips were short, we managed to get there. But with the resumption of fighting earlier this year, access has been made impossible."

As clashes eventually ended, Rose, Jean-Marie and the rest of Nzacko’s residents gradually started to return. In July, MSF was the first humanitarian organisation able to return to the town in order to assess needs and support the only existing health centre.

“When we arrived, we found a health centre in shambles,” says Pelé, who led the first MSF trip a few days earlier. “The pharmacy was empty.”  

“Equipment was non-existent or inadequate, and the staff were not sufficiently trained to provide adequate care to people, while the needs were enormous,” says Pelé. “In the forest, malaria and malnutrition had taken their toll.”    

On this first visit back in Nzacko, it takes our teams four days to restock the pharmacy shelves, conduct training for health staff and community health workers, manage medical consultations, and install solar panels to provide the electricity needed to cool the vaccines.

It is all part of a race against time, given the number of patients squeezed into two poorly equipped wards, with cracked walls and narrow beds. 

Back in Bambari, like most of the people who were forced to leave Elevage camp, Youmousa and his family now live in the compound of the town’s central mosque, while others are being hosted by local families. Living conditions around the mosque are dire. People share small, crowded rooms, others sleep in makeshift shelters. The rainy season makes the situation worse.  

“When a storm hits, the water comes in from all sides. The tarp is old and has holes, and the ground is just dirt, so the inside of the shelter becomes a mess,” says Yougouda. “But the hardest thing for me is to feel useless, because we are entirely dependent on humanitarian aid.” 

People living in the makeshift camp do not feel safe. Hawa and her husband have not left the mosque since they arrived. She says she is afraid of being arrested because they don’t have identity cards. They sometimes send their children to find firewood and food. But she worries about her eight young daughters.  

“When they leave the mosque, I worry that something could happen to them, that maybe they won’t come back,” says Hawa. Her husband, Rebeau, says he can barely sleep because of the worries. He feels bad about not being able to feed and protect his family. 

Many Central Africans are deprived of the most basic essential services. According to the UN, more than half of the people are considered to be in need of humanitarian assistance, and nearly 1.4 million are displaced or refugees. CAR continues to be one of the countries with the most critical situations in terms of life expectancy, maternal mortality, malnutrition and lack of access to healthcare.  

Giving birth in CAR can be dangerous. In Nzacko, Octavia, 33, is about to give birth to her seventh child. The contractions started more than three hours ago, and she feels weak.  

“She hasn’t eaten all day because she has nothing left and has to feed her children,” explains Sylvie Grengbo, the midwife at the centre. “This is going to be difficult.”

Such situations of exhaustion and malnutrition can be life-threatening for both the mother and the child. In recent months, there has been a marked increase in maternal mortality in the area.  

Fortunately for Octavia, the arrival of our team with glucose and misoprostol – a drug that helps induce labour – will provide support. Regaining some strength, Octavia can finally take her son in her arms after five hours of effort. It’s 5:30 p.m., the baby is out of danger. So is she.

But the cycle of violence continues.  

In mid-August, Sallet returned from herding his cows outside Bambari when an armed man on a motorbike suddenly stopped and fired shots at him, leaving him bleeding on the ground.  

A friend later managed to get the young man to the MSF-supported hospital in Bambari, where doctors were able to remove a bullet from his abdomen and stabilise him. But the damage to Sallet’s spine was so severe that our teams had to transfer him by plane to the capital, Bangui, to get specialist treatment.  

In so many villages and towns across CAR, years of war and violence have fuelled a catastrophic situation for people.  

“My dream is to find a place where we can settle forever, where no one can kick us out,” says Rebeau in Bambari. “I would like to speak to the armed groups and ask them: what do they gain by generating so much pain?”