Since December 2020, there has been a resurgence in the conflict between government forces and armed groups in the Central African Republic (CAR). In recent months the situation has become extremely volatile in many rural areas across the country.

Insecurity caused by the fighting and fear of attacks have forced many to flee towards larger towns. The violence has also severely impacted the ability of organisations to provide healthcare.

Naodia was at home, about to sleep, when the first bullet struck her in the abdomen. The shooting soon shattered the window next to the bed where she was lying with her two-year-old daughter. They hurriedly looked for safety next to Naodia’s husband and other two children, who were already sleeping on the floor. Soon after that, the attackers set their house on fire.

Naodia, 25, is from Beltounou, a village on the outskirts of Kabo town, in northern CAR, close to the border with Chad. As in many other parts of CAR, this area has seen a significant rise in violence that has, once again, spread throughout the country. CAR already had some of the poorest health indicators of any country in the world.

According to her neighbours, on the evening of 23 June, eight men armed with automatic weapons attacked Beltounou for about an hour. Four people were killed, four others were injured and 15 houses were burnt to the ground. Most of the 2,000 inhabitants fled in the aftermath of the attack.

“The attackers must have thought we were already dead when they left the area,” says Naodia. “We left the house in flames and hid in a nearby forest. I could barely walk; I had pain throughout my body, not only because of the gunshot wound, but also because I was four months pregnant. My husband got hold of some bicycles and we started the journey to Kabo in the middle of the night.”

It took them three hours to cover the 13 kilometres from Beltounou to Kabo, along a dirt road littered with water-logged potholes left by the ongoing rainy season’s frequent storms. “My husband carried the children and one of my brothers carried me. It was very difficult and we suffered a lot,” says Naodia as she recovers from surgery at the MSF hospital in Kabo. “At least I am alive, but we lost everything we had. I don’t even have my own clothes now.”

Like most of her neighbours who also fled Beltounou, Naodia and her family are staying in Kabo, a town of over 60,000 people, a fifth of whom have been displaced from other areas. Most settled here following earlier periods of violence, but newly uprooted communities have been pouring in steadily since April.

From attacks on towns to insecurity in rural areas

In late December, a newly formed coalition of non-state armed groups launched an offensive against the government of CAR amid fraught elections that ratified Faustin-Archange Touadéra as president.

The coalition combined armed factions that in previous years had fought against each other. They managed to take temporary control of some major towns and, in January, even reached the outskirts of the capital, Bangui. However, later in the year government and allied forces regained control of the semi-urban areas and pushed the armed opposition into the countryside.

The current situation in rural areas around towns in CAR has become extremely volatile, due to frequent clashes between government forces and armed groups, attacks on villages and exactions against people.

On a late-June morning, the noise and cries of dozens of babies waiting with their young mothers to be vaccinated at a health centre in Farazala, a small town a couple of hours from Kabo, offers a false impression. Faya*, a local health worker here, claims that far fewer people are now showing up for medical appointments.

“Before, there were more people coming from the nearby villages, but this has decreased because of the insecurity,” he says. “Women who live just four or five kilometres away are now giving birth at home instead of coming here. Some people are too afraid to even work in their fields or to fish and hunt. In some cases, the fields have actually been destroyed.

“We used to transfer a lot of patients between Farazala and Kabo through a system of motorbike riders put in place by MSF, but this is not easy now.” Faya<p><span lang="EN-GB" style="font-size: 11.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-theme-font: minor-bidi; mso-ansi-language: EN-GB; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">The name was changed to preserve anonymity&nbsp;</span></p> recalls that, as clashes started, members of the armed groups took many of the motorbikes from the people. Later, when government and allied forces regained control of this territory, the use of these vehicles on some of the main roads was restricted, under the belief that people using the motorbikes could be fighters.

In the areas where motorbikes are able to move around, riders delivering lifesaving drugs and transporting sick and wounded patients to hospital have sometimes been attacked, injured and robbed at gunpoint. These acts of violence are usually attributed by the warring parties to uncontrolled elements.

Community health workers, trained to treat common diseases, including malaria and diarrhoea, screen children for malnutrition and refer critical cases to the hospital, have also been threatened and assaulted in rural areas.

Access to healthcare constrained

The ongoing insecurity has forced our teams to periodically suspend some medical activities in the areas around Kabo and other towns, including Batangafo, Bambari and Bria. This has included at times supervision visits, patient referrals and the work of some community health workers, which is particularly concerning during the rainy season, when cases of life-threatening diseases, like malaria, peak.

At the same time, MSF hospitals in the towns have seen an increase in the number of patients in need of treatment as more displaced people arrive. “We also see more patients with injuries caused by violence, particularly sexual violence,” says Benjamin Collins, MSF medical team leader in Kabo.

A life of repeated displacement

Over the last eight months, hundreds of thousands of people have been displaced. According to the UN, over 1.4 million people in CAR have now been forced from their homes, nearly a third of the total population, with half now refugees in neighbouring countries.

One of these newly displaced is Tanguina Chela. At the end of May, she fled from her village of Gmganga, along with her husband and three children. Most of Gmganga’s 200 inhabitants left following a rise in violence and fears that, with the progress of government and allied forces, armed opposition groups would retaliate against local communities accused of collaboration.

“I left everything I had there. Now I have no food and I have to beg to get any,” says Tanguina.

Sadly, none of this is new to her. This is the third time she has been forcefully displaced. The previous times were in 2007 and 2012. 

“Throughout my life I have suffered a lot. Since I was seven years old. The same story always repeats itself. I have been on the move a long time due to the war,” says Tanguina. “I have lost my belongings, my farmland, everything… I have children, but I don’t even know how I will feed them.”

Tanguina is now in one of the settlements for displaced people in Kabo, called site B. The coordinator of the site, Gotologue Auguste, estimates there are over 4,200 people living there.

At a water point, children and women with babies on their backs take turns to pump water into their jerry cans. Not far away, some people listen to a song in Sango composed by a Bangui music band encouraging people to wash their hands with soap amid the coronavirus pandemic, but few people wear face masks in the area.

Nearby, children play with tyres and a football made of a jumble of plastic; teenagers carefully prepare small teabags for sale and cook some pieces of meat over a coal fire. Some women prepare food in metallic cooking pots over open fires.

Site B is now largely indistinguishable from the rest of Kabo. Most of the hundreds of small, round houses, made of sun-dried bricks with grass roofs, have been there for years. As people vacate the houses, they are quickly taken by newly arrived displaced people like Tanguina, who was given a one-room hut.

Little hope for a change

Something similar happens with site C, another settlement for displaced people situated nearby. Hawa Ahmat has been here since 2013, when violent clashes between the Séléka and Anti-balaka armed groups and retaliations from both against communities engulfed PK13, her neighbourhood in Bangui. 

“At that time, I lost a lot of my family; my dad, brother, several nephews,” says Hawa. Around 1,000 people like her were evacuated on trucks by the International Organization for Migration. Some went to Moyenne Sido and others arrived in Kabo.

“Before, we earned a good living as merchants. We even used to go to Ndjamena, in Chad, to buy clothes, carpets, perfume and other things, and sell them in Bangui. But now I barely have anything,” says Hawa. “I try to do small jobs, like cleaning people’s houses or selling firewood, to survive.”

Despite her memories of the events that made her leave, Hawa misses Bangui and one day she would like to return, but this seems unlikely in the near future. “Even if I am an optimist, I don’t know where the solution to our problems lies. I feel pain seeing my children grow up uneducated, without having the chance to go to school. This is no future at all,” she says.