On July 2, the international medical relief agency, Médecins Sans Frontières issued a scathing condemnation of the neglect of basic health-care needs of the population of Angola. The plainly worded document accuses both warring parties in the country's long-running civil dispute of "turning blind eyes to the obvious, serious, and often acute humanitarian needs of the Angolan people".

For the past 26 years, the country has been devastated by a bitter civil war between the government and the rebel forces of the National Union for the Total Independence of Angola (UNITA). The continuing warfare is fuelled largely by the control and sale of diamonds by UNITA and oil by the government.

According to MSF, which has been working in Angola since 1983, the medical and nutritional emergencies are not just the expected consequences of an ongoing war. Both warring parties, the report says, employ forced-displacement strategies to "drive large populations from their land and then pin them down in restricted areas, where the authorities then fail to provide food or health care".

In addition, lack of access to these areas is a "major concern for international humanitarian organisations". As a consequence, it is impossible to assess levels of emergency in certain areas, says the report, but based on preliminary data, "levels of malnutrition and mortality must be among the highest seen in Angola over the past years". MSF adds that a government medical officer confirmed that there are emergency conditions in many government-controlled towns to which humanitarian aid has no access.

"The evidence presented by MSF is compelling and tragic", Anthony Zwi (London School of Hygiene and Tropical Medicine, London, UK) told The Lancet. "It raises two challenges. How can we ensure that ongoing chronic conflicts, which have horrendous implications for affected populations, are not forgotten? Second, the report implicitly highlights the need to enhance global mechanisms, perhaps through the International Criminal Court, for calling to account leaders such as UNITA's Savimbi who use food as a weapon; target markets, populations, and services; and perpetrate abuses against civilian populations."

As the MSF report points out, UNITA rocket attacks on aeroplanes belonging to the United Nations World Food Programme (WFP) forced suspension of humanitarian assistance flights for several days last month. WFP condemned the action: "The attacks on WFP aircraft, painted white and clearly marked with the WFP's insignia, endanger not only aid workers but also the provision of vital humanitarian assistance, thereby threatening the health and welfare of hundreds of thousands of internally displaced people."

Some 200,000 people in Kuito, in Angola's central highlands, including 40,000 severely malnourished children are entirely dependent on food aid. The city has been practically isolated for months because military activity prevents access by road. Cristina Müaut;ller, WFP's public affairs officer in Luanda, Angola, told The Lancet that in the past week alone "nutritional centres in Kuito saw a 50% increase in children and mothers". A distinct problem, she added, is the contribution of the ongoing conflict to the breakdown of family structure.

"The absence of fathers leaves mothers with no means to support their children", she said. A cause of great concern for the WFP in Angola is that mothers "will often forgo their rations in favour of their children. As a result, their energy status is low, creating health complications for the future".

Enrico Pavignani, an independent consultant with a long-term interest in the Angolan health sector, questioned the MSF report's criticism of both warring parties: "We need to differentiate a corrupt and poorly functioning, but legitimate, government of Angola from UNITA, the malicious force which has contributed greatly to sustaining the war for years. Talking about them in the same breath and not differentiating their motives and roles is unfair, unhelpful, and indirectly legitimises UNITA. Bolstering the ability of the government to deliver services must remain a priority for donor agencies and non-governmental organisations."

In response to this criticism, MSF spokesperson, Nathan Ford, reiterated the central message of the report that "both side are responsible for this war, which has kept the civilian population in the middle of conflict for years".

Furthemore, he pointed out that the oil industry is expected to invest US$3·5 billion a year in Angola during the next decade. Yet "faced with manifest medical and nutritional needs, the Angolan authorities display a striking lack of interest in the health of their population. In 1999, only 2Ã?·8% of the total state budget was allocated to health".