Southern Chad—The Forgotten Crisis

Special Field Report

By Mary-Louise Scully, MD

Dr. Scully is Director, Travel and Tropical Medicine Center, Sansum Clinic, Santa Barbara, CA.

Dr. Scully reports no financial relationships relevant to this field of study.

One of the truly enjoyable aspects of practicing travel medicine and preparing patients for travel is learning about the diversity of volunteer programs and nongovernmental organizations throughout the world. Even more intriguing is hearing the details about the personal motivations that lead a person to go off and dig a well in an African village, teach women in Afghanistan to be hairdressers, or deliver solar backpacks to children in rural Rwanda. The range of volunteers extends now from high school students right up to retirees, and no corner of the world is off-limits, even areas with political unrest and personal safety concerns.

So, when Bill Felstiner, former Associate Dean of the Yale Law School, arrived in my office for his pre-travel visit to southern Chad, I was curious about his motivations. Needless to say, Chad is not a popular travel destination. Bill and co-founder Catherine Swysen had formed a non-profit organization, Chad Relief Foundation, whose mission was to provide assistance to the people of southern Chad. Significant media attention is given to the 250,000 western Sudanese refugees in eastern Chad, but it is less well known that there are also about 40,000 refugees in southern Chad who have been displaced from their homes in northern Central African Republic (CAR) because of fighting between governmental troops and armed rebel groups. These refugees in southern Chad are sometimes referred to as the "forgotten refugees." Chad Relief Foundation (CRF) asked me to travel to southern Chad in October to help assess the medical needs in this area. The trip also was intended to follow up on the progress of previous CRF-sponsored projects and to hand-carry $26,000 of donated medications from Direct Relief International.

Chad is one of the 10 poorest countries in the world. It is estimated that 80% of its 10.1 million people live with less than $1 per day, mostly as subsistence herders and farmers. At 496,000 square miles, Chad is slightly smaller in size than Peru with mostly desert and mountains in the north but savanna and grasslands in the south. Transparency International, a global coalition against corruption, lists Chad among the 10 worst countries of the world on its corruption index. Oil production in Chad began in 2003 but, unfortunately, very little, if any, oil revenues trickle down to actually improve the living conditions of the local population. President Idriss Deby has remained in power despite numerous rebel coup d'état, most recently in February 2008. Some volunteer groups (Engineers without Borders) have set Chad "off limits" for volunteer efforts due to security threats from rebel activity and rogue bandits.

Map of ChadOur specific destination was Gore, Chad, which is about a 10-hour car drive south from the capital of N'Djamena. (See Map.) In Gore, the United Nations High Commission of Refugees (UNHCR) has facilities that direct operations in the three nearby refugee camps. Amboko camp was first opened in June 2003 (12,045 refugees), the Gondje camp was opened in 2005 (12,600 refugees), and the most recent camp, Dosseye, opened in 2006, has about 8,318 refugees. The UNHCR contracts with the Cooperazione Internazionale (COOPI) and UNICEF to provide health care to the residents of the camps. Other NGOs in the area providing relief include Africare, CARE, ACRA, and the World Food Program.

Malaria is the largest health threat. During the peak rainy season, May through October, about 80% of consultations to the camp health clinics are for malaria. The WHO estimates one out of five children younger than age 5 die in Chad, and about 22% of these deaths are attributed to malaria. There are only two doctors to oversee the camp health clinics (> 32,000 refugees), so trained nurses and assistants maintain the daily triage of patients. Patients with a fever over 103°F are tested with rapid diagnostic test malaria tests (RDTs) provided by the Mentor initiative. If positive, presumptive antimalarial treatment is given. Artemisinin-based combination therapy (ACT) medications such as artemether-lume-fantrine or artesunate-amodiaquine are in high demand, but many patients still receive chloroquine or Fansidar when supplies for ACTs run short, as they often do.

HIV in Chad is an unfolding story. A 2005 national survey found an adult HIV prevalence of 3.3%, but this is likely a gross underestimate as voluntary testing is not routinely available. A new facility at the Amboko camp and the local hospital in Gore (presently staffed by Médecins Sans Frontières) have begun programs to provide voluntary testing for HIV. Patients diagnosed with HIV, especially pregnant women, are to be educated on their disease with focus on the available strategies for prevention of maternal-fetal transmission. These programs are newly initiated and in great need of financial support.

Vaccine clinics in the refugee camps teach a valuable lesson. In the United States, high vaccination rates led to a low prevalence of measles, hepatitis, and tetanus, making these diseases seem just "words" to American mothers. But Chadian mothers know these as real diseases, having watched non-immunized children suffer or even die. These mothers will wait in line for hours in the 100-degree heat and sun at a vaccine clinic just to insure that their children are among those immunized. Standard immunizations include BCG and polio at birth; tetanus, hepatitis B, Hib, and polio at 6 weeks, 10 weeks, and 14 weeks. Yellow fever and measles are given at 9 months. Vitamin A, nutrition supplements, and nutrition clinics focus effort on improving the extensive malnutrition problems, especially in pregnant women and infants.

Health care and vaccination programs for the refugees are better, at the moment, than for most of the local Chadian population who need to rely on local health clinics run by the government whose support and funding are sorely lacking. Eventually the UNHCR and other NGOs in southern Chad will need to transition southern Chad to self-sustaining health and education programs. But most local health and education administrators feel that with the present state of the government, the internal and external conflicts of the area, and the relative lawlessness of rebel groups and bandits, the prospect for the future is grim.

The story of onchocerciasis (river blindness) illustrates these problems. Chad was one of the 16 African countries receiving regular ivermectin treatment support through the African Programme for Onchocerciasis Control (APOC) and ongoing donation of drugs from Merck & Co. Launched in 1998, the Chad program received $1.639 million and, despite there being only one APOC site in Chad (Cameroon has 15 sites), the positive effects of the community-directed treatment programs in decreasing river blindness was apparent. However, as the 2012 APOC deadline to end financial support in Chad approaches, the government is failing to fill the void. We visited a small rural village in the far southwestern corner of Chad near the border of Cameroon and CAR where the incidence of river blindness is increasing again. Community treatment programs formerly in place have declined, and the village chief explained simply, "no one comes anymore."

For the moment, the people of southern Chad are fortunate to have the UNHCR and several NGO groups in the area working to improve health, education, and the living conditions of both locals and refugees amidst immense obstacles. These people are often assigned to this remote area for one- or two-year contracts, and because of safety concerns no family members are allowed to join them permanently. I came away from Chad and the experience now understanding that the real unsung heroes are those who commit years and sometimes even their entire lives to the complex world of humanitarian relief.

For more information on humanitarian relief in Chad, please visit www.chadrelief.org.

For updated travel and health information on Chad, please see the Travel Medicine Advisor web site's Country Maps (www.travelmedicineadvisor.com).