200,000 Darfurians have crossed the border to seek refuge in neighbouring Chad and roughly 1.4 million people fled their homes but remain displaced inside Darfur. Direct and systematic attacks against civilians provoked this mass displacement. For example, in a survey carried out in Kebkabyia village in North Darfur in August 2004, 98% of the people interviewed said they had to flee their village of origin because of violence.

"The attack on my village happened early in the morning. The Janjaweed and the Government soldiers were divided into three groups and each group had a different task. The first group took every man between the age of 18 and 40. They put them on trucks. Another group looted our huts. And the last group took the cattle. The Janjaweed told us [the women] that they would bring our men to Deleig. When we arrived in Deleig two days later, we saw the dead bodies of our men laying on the ground in the streets."

- Female IDP, 30, Deleig (West Darfur)

The displaced and refugees uniformly describe the perpetrators of these acts of violence as soldiers, Janjaweed or Arab men on horses and camels. People paint a horrifying picture of the massive flight from their homes.

Violence

MSF often works in conflict areas, where there is ongoing war and civil populations suffering the impacts of violence and deprivation. In most such circumstances, violence is an indirect killer - leading to massive public health crises with diseases and malnutrition responsible for most of the excess mortality. Darfur does not fit this scenario. Retrospective mortality surveys show that a huge number of people have died due to direct violence. In a study among 893 displaced families in Kalma, South Darfur, carried out in September 2004, nearly half of the 104 deaths (50) reported over a seven-month period for people over 5 years of age was due to violence. All but three of these deaths had occurred in people's home villages. Among displaced families in another camp in South Darfur, Kass, 59% of deaths in the previous 4 months in the age group 18 - 49 years was due to violence.

In Murnei camp in West Darfur, where 80 000 displaced people had fled from 111 different villages between September 2003 and February 2004, one in every 20 people or 5% of the original population of those villages were killed in violent attacks. Men accounted for three out of every four deaths, but women and children were also killed, with more than 75% of the deaths among women and 50% of the deaths among children reported due to violence.

"I was in my house with my wife and children, when we suddenly heard some shooting. So we went outside. There were Janjaweed all around. They shot at me, in the chest, but I survived. But they killed my 3-year-old son, right in front of my eyes."

- Male IDP, 45, Deleig (West Darfur)

The consequences of this violence have not been felt equally by all population groups in Darfur. MSF works indiscriminately, and on an impartial basis, providing help to all people only according to need, yet the reality is that the majority of patients treated in MSF clinics and feeding centres are of Fur, Massaleit and Zaghawa tribal origin.

Pattern of attacks

Repeatedly people have described to MSF how the Janjaweed encircled their villages and fired guns at random to draw people out of their homes. Once people were outside their huts, the shooting was more targeted and people who tried to escape or defend themselves were killed. There was hardly any time to bury the dead with dignity as surviving family members had to flee for their own lives. Attacks are continuing in certain areas in North Darfur provoking similar mass displacement.

"The Arabs attacked on 12 December 2003, at around 8a.m. They came on camels and horses. They left their camels and horses at distance and walked toward the village. They shot first blindly at the crowd and then in my direction. My brother who was standing next to me fell down when the shot hit him. We took his body to bury him in Al Geneina. But it was too unsafe to reach the city so we buried him on the road on our way to Chad."

- Refugee woman, 30, Mileta village (Chad)

"During the attack on my village, my husband got killed in front of me. While everybody ran away, I stayed with his dead body for three days. There was nobody to help me to bury the body. I covered his body with a piece of cloth and left."

- Female IDP, 40, Deleig (West Darfur)

Attacks were also launched from the air. People described how Antonov planes began bombing villages, schools, mosques and health centres. As people tried to flee, the Janjaweed on the ground moved in to destroy the villages. On other occasions, the latter conducted ground attacks with support from land cruisers and powerful weapons.

"My father, brother and uncle were killed in my village by helicopter shots. While we were escaping the attack, on the road, the Janjaweed came with land cruisers and weapons."

- Female IDP, 15, Kalma camp (South Darfur)

Rape and sexual violence

Because of the sensitivity of this issue, the number of women reporting sexual violence in MSF clinics is thought to under-represent the scale of the problem. In many reported cases the rape happened several months ago and women and young girls had not dared to visit a health facility earlier to seek treatment and, undoubtedly, the majority will not have sought treatment at all. Rape and the fear caused by rape is a prominent feature of the crisis in Darfur. MSF's medical activities have uncovered a high incidence of sexual violence. In a survey in Murnei camp, West Darfur, for example, nearly 14% of the 132 victims of violence treated by MSF medical teams from MSF from April to June 2004 were victims of sexual violence. Most of the cases of sexual violence, which have come to MSF's attention, occurred during the original attacks on villages. Over a two-month period (August and September 2004), in South Darfur, MSF-Holland treated 123 victims of rape. At least 100 of these cases happened during the attacks on the victim's home villages. According to patients, in all cases the assailants were armed men who forced their victims at gunpoint. Gang rapes and abductions have also been reported. Among the cases MSF treated, five women told how armed men detained them for a few days, during which time they were raped several times and mistreated. A 23-year-old woman described how a group of Janjaweed raped her during the attack of her village in January 2004. They asked her to take her clothes off but she refused and ran to the mosque. They followed her and raped and beat her in the mosque. She was left unconscious with wounds on her body and head due to the beating. Scars visible on her body supported this account.

"The Janjaweed want to show that they are in control and hope that everybody will move away from the land. The rapes are a sign of provocation against Fur men/rebels: "if you're a man, you cannot let this happen to your wives; so come and fight against us". Then women are afraid to tell their husbands they have been raped since they don't want them to go and fight. They only say they have been beaten. But men are fully aware that their wives are raped..."

- Female IDP, 20, Garsila (West Darfur)

Stripping the population

The attacks on the villages forced people to flee with nothing. The attackers stole or destroyed almost everything during the attacks on villages leaving people to try and survive in Darfur's hostile environment. Groups of distressed people were then continually harassed, beaten, raped and looted as they moved, to keep them in a state of fear and to ensure they left the area. People recounted that the Janjaweed and the Government soldiers cut access to water sources and made holes in people's jerricans to prevent them from bringing water with them as they fled the violence. There are reports that many people, especially the most vulnerable ones (children and the elderly) died of thirst during the escape.

"Some Government soldiers and Janjaweed encircled our village, Artala. They stopped us from going to the wells to take water and stole all our resources (food and belongings). They were all around the wells and they looted our huts. They also blocked the roads. The only road they left open was the road to Kubum."

- Male IDP, 40, Kubum IDP site (West Darfur)

People fled, violence continued. Controlling most of the main roads and present in the fields, the Janjaweed continued to assault and rob the people as they fled their villages. Very often, the few belongings the displaced managed to bring along with them were stolen during raids along the roads. Villages and surrounding fields were literally burnt to the ground. It is obvious when driving through the burnt villages that the destruction included not only the demolition of huts and food stocks, but also the devastation of fruit trees, irrigation and people's fields. There is nothing to sustain the survivors of the attacks should they desire to return to their villages.

The search for refuge

Although the people driven from their villages have gathered in "sites" which they believe to be safer, there is no real refuge for this traumatised population. People continue to be the target of different forms of violence and intimidation: murders, assaults, and rapes.

In the MSF survey of 900 families carried out in Kass in South Darfur in September 2004, violence was the second most important reported cause of death in persons over 5 years of age in the previous four months. 53% of these deaths had occurred since arrival in the place of "refuge".

The situation in Darfur perverts the very idea of refuge. People escape the attackers once, yet they cannot find real safety. Constant insecurity and harassment, as well as lack of basic essentials for survival, mean that many displaced people are continuously on the move, abandoning one place and trying desperately to establish a place of safety in another.

Over the last seven months, the great majority of displaced people have been displaced several times, often within a short period. People walk for hours from one village to another to find a place where they can settle. But neither the roads nor the places of settlement are safe.

Although the level of violence is not the same in the places of refuge as it was in the places of origin, there are still an unacceptable number of incidents occurring in many places where the displaced have sought shelter. This general climate of insecurity generates further displacement and aggravates the vulnerability of the population.

In general, people create their own relative security by gathering in certain locations, mainly major urban centres, where sudden surges in population numbers and density completely outstrips the local capacity leading to a host of medical concerns. In Kalma camp for instance, the estimated population in June 2004 was around 26,000 people. Over a two-week period, the camp doubled in size due to a population influx mainly from West Darfur. In September 2004, the population figure was 66,000 people. Those newly arrived had left their villages of origin several months before and stopped in several locations before they reached the camp. After such prolonged distress migration without access to assistance, the health and nutritional status of the newcomers on arrival is disastrous. The constant increasing of camp population numbers has led to a sustained inability for the insufficient aid programming to control the public health crisis and continuing high levels of malnutrition and disease.

Nutritional status of the population

Many displaced people demonstrate greatest concern and anger over food shortages and the destruction of their food stocks. People claim they will be attacked if they return to their fields. There was almost no planting in May and so even if there were good rains there will be virtually no harvest in many conflict effected areas in November this year.

Food aid does not cover all the needs to fill this gap. The displaced and host populations had to wait nine months after their arrival until the first food aid was distributed. When MSF first arrived in Darfur, the number of people (especially the children) close to starvation was staggering. For instance, on the first day the MSF therapeutic feeding centre in Kalma opened, 112 children were admitted.

Erratic general food distributions started in February 2004 but became more regular only in May-September 2004 - and then only in the main camps along major roads and around large towns. The food distributions to date have not completely addressed the high levels of mortality among starving children, but have for now prevented a looming famine. However, the distributions still only cover half of the assessed needs of the displaced population21.

Many areas are still unassessed and pockets of displaced are still not receiving food, mainly in the rebel-controlled areas. People cannot buy food because their belongings have been stolen, they have no income and food prices have increased. Many populations in Darfur have been reduced to full dependency on aid. The numbers dependent on food aid are only likely to increase next year with the failure of the November harvest.

"We are depending so much on the food rations distributed by the organisations. We have no source of income, as there is no work available in Deleig. The only option is to collect wood and to sell it in the market. But it becomes too dangerous only 1 or 2 kms far from Deleig."

- Female IDP, 24, Deleig (West Darfur)

"I have two children and I don't have anything to eat at home. My husband was killed last February (2004) and I have no other relatives here. I have no wood and no money to build a shelter so I live at somebody's place. I can't go outside to get some wood because one of my children is sick [severely malnourished child admitted in MSF feeding centre]. I'm also very hungry."

- Female IDP, 19, Kalma camp (South Darfur)

Although the nutritional crisis in the major sites in West Darfur has been stabilised after May 2004, it remains very fragile for host and displaced populations. Any interruption of assistance would result in an immediate and drastic deterioration of their nutritional status.

In the camps in South Darfur, the situation is still cause for particular concern.

Based on MSF statistics, malnutrition is reported to be the second cause of death, after diarrhoeal diseases. Different nutritional surveys highlight that malnutrition is the direct result of lack of food shortages and not due to environmental factors.

In early July 2004, when Kalma camp received a major population influx, the number of new admissions of children under 5 in the feeding centres grew exponentially. Among the new admissions, almost 40% of children were from displaced families who had arrived very recently in the camp (less than two weeks before).

But the majority of children newly admitted remained among children already in the camps for some months. This situation is a worrying indicator of the critical nutritional conditions of both the new arrivals and those who have been longer in the camp.

Some women explained that the delivery of food relieves them from going outside the towns and therefore they are less exposed to beatings and rapes. Food distributions and therapeutic nutritional support cover some of the immediate needs of the population. According to the UN, still 49% of the food needs are uncovered. The displaced are either exposed to risk or confined in a state of semi-starvation - dependent on international food aid.

Health status of the population

Mass displacement and food shortages have a serious impact on the health status of the population. The very precarious living conditions of the displaced have favoured the development and spread of preventable diseases.

The main reported causes of deaths are diarrhoeal diseases, respiratory infections and malaria. Almost 45% of MSF consultations are for diarrhoeal diseases and acute respiratory infections, while malaria cases, particularly acute during the rainy season, represent the third main disease seen during consultations.

The high incidences of all three diseases can be traced to people's lack of adequate shelter and appalling water and sanitation conditions in the camps.

The crude mortality rates remain above the emergency thresholds, which are one per 10,000 per day for all ages and two per 10,000 per day for children under 5.

Mortality rates are alarming. In Kalma camp (66,000 people), in South Darfur, the retrospective mortality survey from September 2004 showed that in the past seven months, approximately 2,500 people have died, of which 1,100 were children under 5. In other words, around 20 children have been dying every day in the past seven months. These figures are far above the emergency thresholds.

Estimates over August do not show any appreciable improvement, despite increased access to health resources in Kalma camp (due to lack of food and water and new influxes of severely affected people).

Measles has been a major killer of malnourished children in the past months. UNICEF supported the Ministry of Health to vaccinate - but coverage was so low that the epidemics continued with disastrous effect. MSF has repeatedly asked to carry out measles vaccination campaigns but the Ministry would not allow NGOs to vaccinate as they claimed they had already done the job.