The Central African Republic (CAR) is one of the poorest countries in the world. Its GDP per capita in 2022 was estimated at US$491 per year.
The nation of roughly 5 million people has been in political turmoil since a violent takeover of power in 2013. A "total breakdown of law and order" has persisted for nearly 20 years. Roughly half of the countryside has been outside the government's control.
In an attempt to gain back control, the government unleashed a campaign led by the Russian mercenaries, the Wagner Group, in 2020. A report documenting widespread human rights abuses in the CAR by the Wagner Group describes "well-planned campaigns of mass killing, torture, and rape". This is consistent with the broader content of press releases and speeches coming from the UN Office of the High Commissioner for Human Rights.
The result is that CAR is now experiencing an acute humanitarian crisis.
One of the symptoms of the collapse is the country's high mortality rate. Two surveys published over the last two years have suggested that large areas of the country were experiencing mortality above the emergency threshold. One was a survey done by Médecins sans Frontières in 2020 in Ouaka Prefecture. The other covered most of Ouham-Pende Prefecture and was done with the International Rescue Committee in 2018. The studies found that 4.9% and 5.0% of the studied populations were dying per year.
These estimates are four times higher than the 2020 UN mortality estimate of 1.1% per year for the CAR. Most agencies, such as the Centers for Disease Control and Prevention, consider the doubling of the baseline mortality as a crisis, and four times the baseline is one of the three criteria used to define a famine.
Because of the discordance of recent mortality measures and the official mortality rate, as scholars of public health with research experience in conflict settings, we conducted a survey to measure the nation's crude mortality rate - the fraction of the population dying per unit of time without considering whether it is a young or old population.
Our study found that 5.6% of the population died in 2022. This is an astonishing mortality rate, in terms of how people are suffering and how wrong the official statistics are. Most of these deaths were from malaria and diarrhoea. We also found that mortality was markedly higher in the areas outside government control.
The dire conditions under which people are living in the CAR have elicited very little interest or humanitarian response from the rest of the world. Yet, as the mortality figures show, there is a desperate need for food aid, along with work programmes and seed and tool distribution.
This is of particular importance in rural areas outside government control. While some humanitarian actors are doing their best to respond, the crisis-level mortality rate suggests that the needs in the CAR are largely unmet.
Mortality
We carried out a survey in two areas. One was in the part of the country within the government's control (roughly half of the country), and one in the areas mostly outside its control. We randomly selected 40 clusters of 10 households in each.
We found that the birth rate was lower and the death rate markedly higher in areas outside government control. Families described malaria or fever and diarrhoea as the primary reported causes of death. Violence accounted for 6% of all deaths.
People cited access to food and access to medical care as their biggest challenges. Households reported eating roughly half as many meals in 2022 as they had in 2020. Only 15% had received food aid distributions in 2022 despite high levels of malnutrition recorded in the country.
These two challenges interact with each other. Children and other vulnerable people like the elderly who would normally survive an episode of malaria or diarrhoea need competent medical attention to survive when malnourished. Yet, because of economic strife and violence, attendance in rural clinics is generally down compared to previous years.
The cost of healthcare is another factor. Some NGOs provide free healthcare, but most visited by our research team charge a modest user fee. While not standardised, they typically charge an amount equivalent to between half and one US dollar, and sometimes charge separately for drugs. The non-clinic costs such as transport can be even greater.
Another cost is that people are forced to make informal and illegitimate payments when trying to get to healthcare facilities. Many mentioned that police or rebel soldiers demanded money to pass at checkpoints. In Ouaka Prefecture, where the charity Médecins Sans Frontières, also known as Doctors Without Borders, provides medical services with no user fees, an interviewee told us that his daughter had recently given birth at home rather than going to the hospital, because the police at the checkpoints knew a pregnant woman would be desperate to get by and they would charge more than the usual 500 franc (about US$0.8) fee for her to pass.
What next
Higher nationwide death rates have occurred in Africa in the past. Estimates suggest that at least 500,000 of 7 million Rwandans died violently in 1994. During Nigeria's secessionist war in Biafra from 1967 to 1970 between 1 million and 3 million are estimated to have died. These events triggered dramatic escalations in humanitarian response, aid money and political attention.
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Our study couldn't distinguish the relative importance of decades of ongoing conflict, extreme poverty, the economic disruptions since 2020, or the widespread disruption efforts of the Wagner Group in causing the extreme mortality observed in the CAR.
Nevertheless, it's clear that they are all contributing to the mortality rate. We can find no examples since 1994 of an entire nation dying at such a high rate as we measured in the CAR in 2022.
Humanitarian actors have been raising the alarm for over a decade. The UN has been warning of extreme food insecurity for two years. To the credit of certain agencies, households report food distributions in some of the most critical areas.
Our findings show that despite these efforts, aid is woefully insufficient. Given that the US government alone gave over US$330 million in assistance to the CAR in 2021 and 2022, one has to ponder whether the humanitarian community can do better. In particular, are we in the humanitarian community ignoring one of the world's worst humanitarian crises?
Leslie Roberts, Professor Emeritus of Population and Family Health at CUMC, Columbia University
Jennifer O'Keeffe, Doctoral Candidate, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University
Karume Baderha Augustin Gang, Doctoral Candidate, Université Evangélique en Afrique
