Barbara Smith, IRC, Kibumba Report

General Situation in Kibumba
Barbara Smith, IRC

Kibumba is a camp 28 kilometers north of the town of Goma. It is the most populous of all the Rwandan refugee camps in the area and it is the farthest from a clean water source. These two factors, in addition to the volcanic rock preventing latrine construction and burial of the dead which all refugee areas share, contributed to the rapid deterioration of the situation in Kibumba. Within two weeks of the relocation of 300,000 refugees from Goma to Kibumba, cholera and dysentery became epidemic, death rates from dehydration and exposure soared, meningitis and serious malnutrition problems started.

Almost no one in Kibumba who is not attached to the military remains healthy. Those with enough strength to care for themselves must devote all their energy to finding food, water and building a shelter. There is almost no attempt to organize the camp for the common good, and resources are obtained purely by competition among the refugees. Consequently, only those people who can endure walking long distances (up to 28 km without food water or even shoes) and waiting for hours (including standing in line overnight) for food, water and shelter materials survive. Frequently there are fistfights and riots with machetes at the distribution points. People who cannot fight or who cannot endure the arduous physical tasks required for survival have no recourse but to find a spot to lie down and usually, to die

In most such refugee emergencies in Africa, the death rates are highest among children under five. In this situation, the death rate is high among this group, but due to the physical endurance and strength required by adults to survive this situation, the death rate among adults is equally high. This has caused a serious problem with orphans. Mothers literally work themselves to death trying to care for their family. They lay down and die leaving their children sitting next to their dead bodies. Usually, the children are so confused they do not understand for many hours that their mother is dead nor what to do about the situation when they realize they are alone. Often the children sit next to the body for days before they either wander off or the lie down and die. (Relief workers have similar difficulty identifying which people laying down are dead and which are still alive.)

The camp is so densely populated that from a few meters away, one could not see ground in between the people at all, only the mass of people, it smelled of dead bodies and was dusty from all the people walking and smoky and sticky from all the wood fires and had a low rumble of people talking sharply to each other. Almost never did anyone laugh or cry. When the refugees did greet each other, they said "Be strong".

The appalling circumstances in the camp coupled with the absolute inability of the refugees to organize themselves have made a chaotic situation in which no outside relief agency was able to manage for the first three weeks of the existence of Kibumba. Dead bodies lined the road between the camp and Goma, traffic jams of relief vehicles, water tankers as well as Rwandan army vehicles, Zairian commercial vehicles and refugees on foot all selling wood and relief supplies clogged the few roads into the camp. Passage through the few kilometers of the camp proper could take hours and often times became completely impossible.

Infectious feces were everywhere, guards with sticks fought off sick people struggling to enter the few clinics, and unending procession of people carrying heavy loads of water or bundles of wood for shelter or cooking were being pushed and shoved both by each other and by the vehicles which made no attempts to slow down or to accommodate the people walking along the road. The traffic patterns were so dangerous that it was not until a water tanker lethally hit a truck of 14 ·Year old Boy Scouts did people begin to try to organize safer driving practices.

The first three weeks of Kibumba camp

Immediately upon the creation of Kibumba in July, the relief community understood what a costly mistake it was to place so many people so far away from any water. Cholera began almost instantly, which in spite of MSF's huge project to treat those stricken, grew enormously until a private U.S. pumping firm, helped by the U.S. army and air force, began to pump 350,000 liters of clean water for tankers to deliver to Kibumba residents and clinics did cholera start to abate. MSF was in charge of the tanker delivery, Oxfam built storage containers, Goal drove buses up and down the road collecting people dying of dehydration.

IRC staff arrived during the second week of Kibumba's existence. Initially there was no equipment for IRC to use independently, so the first several days were devoted to conferring with UNHCR a ministrative, medical and sanitation staff, establishing a base in Goma, and assisting with Goal's rehydration program (IRC became the IV rehydration staff) and meeting with local "chiefs" within the camp to identify the best place to begin IRC projects once equipment and staff did arrive. After the first visit to the camp, no IRC logistical or administrative people elected to return to Kibumba for over a week. The base operations in Goma were established relatively quickly. Logistics within the camp, transport of water and drugs to the camp and a base of operations within the camp in addition to the program implementation, recruiting and paying of staff was done by medical personnel who were able to tolerate the conditions of Kibumba.

The conditions in Kibumba were unnerving to relief workers not only because of the crowding, the smells, the filth and the bodies, but because of the fact that no one was able to fill even a small percentage of the need. No agency had the staff or equipment to immediately stem the death or misery in Kibumba or any refugee affected area. If relief workers opted to define a small goal and devote all their energy to that, such a choice necessitated ignoring and literally driving by or walking over thousands of people dying every day and offering no assistance. If relief workers chose to stop and help people in need, they were unable to even help all the people along the road leading to the camps without spending all day and never even making it to Kibumba.

Every relief agency was forced to make a choice of who and how to help. Almost all agencies chose to identify a discrete project within the camps and devote all their resources to their identified project. Relief workers drove to Kibumba passing by the hundreds of dying people on the road. Once in Kibumba, relief agencies put great effort into minimizing the effect of the chaos of the camp on their work. For example, clinics were built to care for the sick, but 10 foot high walls around them had to be built and strict entrance requirements put in place and enforced by guards armed with sticks in order to keep the clinic operational. All staff for these clinics had to step over many dying people lying around the perimeter of the clinic hoping but failing to gain entrance inside. Often staff could not arrive at the clinic until 11 AM because traffic prevented the relief vehicles from passing into Kibumba and to the clinic site. Every morning, the largest number of new dead bodies could be found around the clinics.

Water distribution was conducted with the same philosophy. Tankers arrived at certain points to fill bladders. The strongest people immediately pushed to the front of the lines and filled their gerry-cans until the water was depleted. No arrangements were made for weaker people who were left without water and no help was offered to the thousands of people dying along the road due to dehydration.

Food distribution was meager, but was the only sector that was able to employ a distribution system not entirely based on competition. Most of the refugees fled in their complete villages and many of these villages stayed together during the movement into Zaire. "Chiefs" could be identified in these districts. They were then given sufficient food for the number of people in that district. If the chief was fair, everyone, strong and weak alike were eligible to get a share of the food.

The Rwandan military was very much in evidence in the camp. When I was walking around, soldiers would be having political "talks" with the population in various areas of the camp. Military trucks were used to get wood and sugar cane and other food and then sold to the refugees at high prices. Rwandan military trucks were notorious for stopping in the middle of the road to sell food and making the road impassable for hours.

The military remained organized, the soldiers remained well fed, but never were their resources used for the good of the civilians. Indeed when food or water riots would erupt, the eventual winners who took all the food or water were young healthy members of the military.

By the end of the third week of the re1ief effort, the clinics were functioning well within their walls, but some of them were over half empty while people died outside. Clinics devoted to treating cholera victims (and later dysentery patients) were always filled to overflowing, but only with people who were either able to walk to the clinics (sometimes more than 5 Ian away from where they "lived" or who had family who had the strength to carry them to the clinic or who was lucky enough to meet an expatriate willing to transport them to the clinic). In any event, the death rate in Kibumba was never believed to have been more than one-third cholera related. CDC's statistics), leaving more than two thirds of the people dying from other causes and with little chance of reaching a clinic. By the second week of Kibumba, there was one MSF cholera clinic, one MSF general clinic and one Goal rehydration station with an attached orphanage. The Federation of Red Cross was building a large hospital but was unable to open because of a lack of a water source. They did have an enormous amount of supplies and were very gracious in lending IRC medical staff ORS and IV fluids until IRC's supplies were delivered.

IRC's program in Kibumba
For the first four days I was the only IRC staff member in Kibumba and there was no vehicle. I went to Kibumba with Goal and worked in their project for some hours daily and spent the rest of the time walking through the camp meeting chiefs, field staff from UNHCR, Red Cross, MSF Holland, Belgium and France. It was immediately clear that IRC not have the resources to immediately open a clinic that required many meters of plastic for walls, vehicles, a tanker for water delivery and large amounts of fluids, ORS, drugs and buckets (for fecal waste).

However, it was also immediately clear that there was a need for a project to try to bring some of the resources to the weakest people who were dying by the thousands despite the daily increases of available water and other commodities. Goal's buses picked up dying people along the· road and brought them to their rehydration station and was enormously successful in saving lives. The only disadvantage to this project was that families were separated (because only one person was allowed to accompany a sick person on the bus.) Transporting part of a family up to 25 km from the other part of the family meant that some families were permanently separated this way.

In addition, these busses were only able to fill a small part of the need. Thousands of people were lying in ditches along side the road in the camp, in heavily used defecation fields, and out in the open all throughout the camp. IRC was clearly able to employ a version of the standard CHW program it implements everywhere in Africa. The main change needed was that trained expatriate medical workers would, in the beginning, function as the CHW's and offer direct medical care in the camp because no refugee person had the strength to try to help someone else and hope to survive himself. (In Rwanda during peacetime, licensed nurses had no more than a 6th grade education).

After walking through the camp a few times, the area most in need seemed to be in the northern section of the camp. All the functioning clinics were in the southern section (called Kibumba II). The initial problems centered on how to organize a program without walls in the camp that would not break down into fights and competition. While finding chiefs proved no problem, it was more difficult to find chiefs who were prepared to effectively deal with the chaos in their area and to allow doctors to work undisturbed.

However, one such chief was eventually found and an offer of assistance was made to him in the following manner: Doctors would arrive in his section and see the sickest people bringing medicine and ORS. However, the chief was responsible for making a list of these sick people who would be seen in turn. No one was allowed to run up to the doctors or to carry their sick relative to the doctor. People must wait their turn in their house. IRC would store the ORS and drugs for use that day in an area near the road. The chief was responsible for the security of that area. If there was fighting, theft or if people refused to wait their turn, the doctors would leave.

The first day that medical staff arrived (one volunteer doctor recruited in Nairobi) we implemented this plan. Upon our arrival, over 100 people who were walking along the road rushed up to get the ORS and the medicine. However, we roped off an area with adhesive tape to store the medicines, four guards with sticks watched this area and we refused to work until people vacated the roped off area and we could move into the camp. Eventually this happened, and we started going house to house to see people who were lying dying. In one small area, there were 500 names on the list who needed to be seen and almost all of them proved to be very sick. There were a few incidences where ex-army people were on the list and had to invent symptoms, but the biggest problem remained that in families where everyone was sick, only the men were on the list and, the women and children who were often even sicker had no attention paid to them until the doctor arrived. This system worked sufficiently and the next day the sanitarians started working in the same section. Within a week, with the arrival of many more staff members, IRC had six medical teams in three different districts, plus what was called "the ditch" on the side of the road. The sanitarians were constructing over 40 latrine platforms a day and installing them over crevices and holes made of rocks that the refugees had made themselves. The initial fear of the latrines was that people would burn these wooden platforms for cooking fires, but the community seemed to protect these platforms, the only clean place to defecate. The platforms were numbered and the holes and crevices were sprayed. There was no damage to the platforms.

What began without any logistical resources markedly improved after the first week of IRC's program. A pick-up truck was rented and arrangements were made with the American military and Sausalito fire department to give us clean water early in the morning in Kibumba for IRC to make ORS and transport to the camp. They gave us many 20 liter gerry-cans to use in addition to the small number of water containers IRC already had. The WHO kits arrived and we were able to use more medicines. The Red Cross gave us IVs and we were able to start IVs in the camp without moving people. Arrangements for referrals to the clinics for seriously dehydrated people were begun and the IRC pick-up would transport these people to the clinic.

Of the problems faced by the medical people in the camp, the most serious ones were the resistance of the dysentery to the drugs in the WHO kits. The only drug that the bacteria was sensitive to (shigellosis) was Cipro (which is very expensive and not widely available.) JDC doctors were able to help IRC get a substantial quantity of this drug. In addition, HIV positive people often have a reaction to sulfa drugs which are very common in WHO kits and used to treat dysentery before the arrival of Cipro. No one was sure how many of the refugees were HIV positive, but blood samples of hospitalized patients in Goma showed that approximately 20% of the refugees tested positive.

The next two weeks of Kibumba
By the fourth week, many of the most disturbing horrors in had been improved. More water tankers arrived along with an experienced water specialist and 1.2 liters of clean water was being delivered to Kibumba camp. The cholera started to abate. Effective scheduling of the tankers reduced the grid-locked traffic in camp, because much of the water was delivered at night and stored in MSF and Oxfam tanks.

Two Goal volunteers who were from the army in Ireland organized the Zairian Boy Scouts to pick up the thousands of bodies along the road. Several ten-ton trucks were brought tin for this effort and the French and American army brought in equipment for the digging of a mass grave. People had chosen to die in various ways, some dropping at the place where they could no longer walk, some preferring to walk a short ways from the road to die alone, some families making a small encampment and dying together. Several women had died in childbirth with the child only partially delivered. Many old people were found alone. Many bodies were so decomposed that they could not be moved and there were areas where the smell of death persisted, but the thousands of bodies visible along the road were cleared very quickly once that project was started. Two UNHCR field officers were in charge of the burial site and of trying to count the dead. In the end, they estimated how many had died by labeling the many piles of bodies off-loaded from the trucks as "densely packed", "moderately packed" or" loosely packed."

Water stations were placed by MSF at several locations along the route from Goma to Kibumba allowing dehydrated people to be treated before they were critically ill. These stations coupled with the increased water availability in the camp reduced the number of people walking all the way from Kibumba to Goma to less than a third of what it had been.

Although water was more available, the lack of adequate food was starting to take its effect on the refugees. Cases of obvious starvation were not uncommon and malnutrition levels were rising. There was no supplemental feeding and the only treatment available for the malnourished was rehydration.

UNHCR began distributing sheets of plastic for shelters In addition, many of the stronger women made two day trips to the bush to collect wood and grasses to make houses. The shelter situation started to improve. It became easier to identify areas of greater need by the lack of the bright green plastic sheets people had been strong enough to go collect from UNHCR.

Kibumba started to look like a refugee camp by the third week. Two restaurants had even opened near the road. The number of people selling wood and potatoes and other items along the road increased. During this time most of IRC's medical and sanitation staff began to arrive and the program expanded rapidly. IRC's living compound in Goma was quickly filled to capacity and arrangements were being made for another compound. The installation of the Codan to Nairobi allowed IRC to order quickly needed items (such as Cipro and some milk powder for infants who were orphaned).

Despite these improvements, the numbers of orphans continued to climb. Only Goal had a program to feed and house the orphans in Kibumba and they could only manage 50. The death rate was still quite high and newly dead bodies appeared every day along the road. In addition, the Zairian army began to make their presence known. Kibumba is located within a Zairian national park. The refugees were not supposed to put shelters on the west side of the road only the east. People were threatened with sticks to move their shelters, they were intimidated into giving their money to the soldiers and they were beaten and abused by the soldiers in front of everyone. I saw several instances of such intimidation. UNHCR protection officers were not able to control the military threat to the refugees.

Mental Health and the Rwandan refugee crisis
It seems obvious that the crisis in Zaire is a problem of slowing the death rate and that the problems have very little to do with mental health. I thought so myself until I arrived in the camp and saw how the collapse of people's emotional and community life was significantly contributing to the death rate. No one was able to help anyone else. Extended families refused to care for the orphans. Lack of organization reduced people's behavior to little more than violent competitors. People were forced to step over the unburied bodies of their relatives’ daily in their search for water and food and people became increasingly numb, confused and hopeless.

It is widely acknowledged that one of the principal reasons so many people came to Zaire was an effective propaganda campaign to frighten the people instead of letting them live with the new government. Relentless radio messages about unconfirmed massacres increasingly confused people until they stampeded across the border killing hundreds of their own people under their feet.

UNHCR eventually realized that the state of people's minds had everything to do with the future of people in Zaire. In the basement of UNHCR., they started their own radio station. This station disseminated information about how to survive in the camp and encouraged organization, appeal to reason and some propaganda of their own about the value of returning to Rwanda.

In addition to the detrimental effects that mental health problems had on the situation, it must also be stated that the Rwandan refugees exhibited a great deal of emotional strength in that they did not completely give up the struggle to survive. (Expatriate workers often acknowledged this in jokes about how short it would have taken every one of us to give up if we had had to endure the same circumstances.)

The mental health effects of working in such a situation also affected the quality of the relief effort. It was very easy to become quickly overwhelmed with the situation. People stopped listening to each other, worked frantically, but were unable to evaluate the usefulness of what they were doing, became irritable, unable to sleep well, etc. A significant number of people opted not to return to the camp after their first contact with the situation. Organizing and coordinating effective programs (even having a fruitful meeting) was often hard because of these conditions.

The political life of the relief agencies in Kibumba
Even as people worked furiously to improve the situation in Kibumba, a decision was made by the Federation of Red Cross to move 60% of the people out of Kibumba to another site farther from the border and with more access to water. Nonetheless, it was tacitly acknowledged by all relief staff that it would prove impossible to move 60% of the people from Kibumba in a short time. (The UNHCR plan was for people to walk with their belongings and to leave the shelters they had just built with so much effort). In theory, the Federation of Red Cross was responsible for camp management, but it had proved impossible with the traffic to have coordination meetings inside Kibumba.

Every available person working in Kibumba was so busy doing their job that coordination meetings did not occur until early August, a few weeks after Kibumba opened. UNHCR held Goma-area wide meetings in Goma every afternoon, but almost no field people could stop their work early enough to make the trip back to Goma in time to attend the meetings. The net result of this situation was that it appeared that no one was in charge of Kibumba and services were provided or not provided depending on who took their own initiative to start a program. The clearest example of the lack of direction in Kibumba and elsewhere was the arrival of Swedish sanitarians who brought hundreds of tons of equipment and had over 60 sanitarians on stand-by to come to Goma. They waited for instructions of what to do to help the relief effort. For days they received conflicting instructions and ended up sitting in the compound of UNHCR for almost a week doing nothing while dysentery and other sanitation problems became rampant in Kibumba.

UNHCR as well as everyone else was overwhelmed with the amount of work to be done and the rapidly changing and chaotic situation in the camps. No one, in the beginning, was critical of other people's attempts to help in the situation just as no one was critical of the Swedes waiting to find an organized way to start their program. In the beginning of Kibumba camp, UNHCR and all NGOs shared resources quite willingly and showed respect for each other's efforts.

As the situation stabilized (relatively), more meetings were held among the exhausted aid workers. It was clear to everyone that tempers were becoming more volatile, it was hard to concentrate and the effects of working in Kibumba had not improved anyone's judgment. The effect of this on IRC's program is becoming more pronounced even weeks later. Although all agencies were apprised of IRC's program, MSF-Belgium took increasing exception to the use of outreach teams in Kibumba. They believed that only clinics could provide the care needed by the refugees and believed that refugees "playing little doctors" would damage the health of the refugees.

IRC's position from the first (which seems to be unanimous among all IRC staff in Goma) was that clinics were essential in the camp particularly during the cholera epidemic, but there were still too many people who could not benefit from the improving services in the camp because they could not stand up. When I left, all the agencies were to finally have a meeting in Kibumba to "divide" the camp among the different programs. The philosophical differences have continued to grow between IRC and MSF. MSF's word, because they were so well prepared for the emergency and brought so many resources in order to help the refugees, carries the most weight of any in Kibumba (including the Red Cross or UNHCR). It would be a great change of leadership roles in Kibumba, if MSF's desire to change IRC's program does not prevail.
--------------------

Barbara Smith’s assessment mission has been very successful. You are now responsible for completing assignments 2 and 3 from the initial request letter. Use bullet points for your recommendations.