Study finds extreme mortality rate in Central African Republic

A new study by public health researchers presents stark evidence that the Central African Republic (CAR) is experiencing a severe health and humanitarian emergency, with what is likely the highest measured nationwide mortality rate in the world, a rate four times higher than a 2010 United Nations estimate. The present crisis is linked to the arrival of COVID and its associated disruptions, as well as human rights abuses by the Wagner Group, a Russian paramilitary organization, which seeks to regain national territory after a decades-long hold by rebel groups.

The findings are based on a nationwide mortality survey and appear in the peer-reviewed journal Conflict and Health. Members of the research team hold positions at Columbia University Mailman School of Public Health; Université Evangélique en Afrique, Bukavu, Democratic Republic of the Congo (DRC); Johns Hopkins Bloomberg School of Public Health; as well as an anonymous contributor from Bocaranga, Central African Republic.

In 2022, the researchers interviewed 699 households that included 5,070 people, in both government-controlled areas and those not in government control across CAR. Interviewed households had a birth rate of 42.6/1,000/year and a crude mortality rate of 1.57/10,000/day. This equates to 5.6% of the population dying each year. The birth rate was lower and the death rate markedly higher in areas outside of government control. By comparison, in the U.S., 1% of the population dies each year; in the DRC, that figure is 2.5%.

Families described diarrhea as well as malaria or fever as the primary reported causes of death, with violence accounting for 6% of all deaths. Most people expressed that they were desperate for assistance, asking for health care (26.9%) and food (25.2%). A disturbing 82.3% of households reported adults ate ≤ 1 meals per day at the time of interview. Similarly, 72.6% of children, who have greater nutritional needs and are at higher risk for malnutrition and its associated morbidities, ate ≤ 1 meals per day at the time of interview.

The survey finds an acute dearth of children under age 3 in a population with low contraceptive use, implying either a recent elevation of infant mortality, a decrease in birth rates due to extreme stress, or both. Corroborating the likelihood of a reduced birth rate, 25.5% of known pregnancies resulted in a loss. This is higher than the fraction recorded in neighboring Eastern DRC in 2002 during a period of extreme conflict. These findings align with a 2022 UNICEF report that food insecurity and malnutrition are widespread in CAR and imperil the lives f tens of thousands of children.

Officially, the Central African Republic has a gross national income of $425 per person, a life expectancy of 54, and is ranked fourth from last on the Human Development Index. For the past two decades, much of the country has been under the control of anti-government rebels. Conditions have reportedly changed since 2020 as mercenaries from the Wagner group have expanded their activities in rebel-held parts of the country. They have been accused of widespread killings, public executions, torture, and rape, as strategies of demoralization and disruption. Dozens of households surveyed described not being able to travel to visit their fields, hunt, fish, or forage for survival because combatants would attack or kill them.

The authors write, "CAR is experiencing a severe health emergency, with the highest measured nationwide mortality in the world to our knowledge. UN-published death rate estimates appear to be less than one-fourth of reality. There is a desperate need for food aid in the form of general distributions in CAR, along with the accompanying work programs, seed, and tool distributions needed to restart local economies. This is of particular importance in rural areas outside of government control. While some humanitarian actors are doing their best to respond, the crisis level mortality rate suggests that the needs in CAR are being largely unmet."

Study authors include Karume Baderha Augustin Gang (first author), Université Evangélique en Afrique, Bukavu, DRC; Jennifer O'Keeffe, doctoral student at Johns Hopkins Bloomberg School of Public Health and Columbia Mailman alumna; anonymous of Bocaranga, CAR; and Les Roberts, professor emeritus of population and family health, Columbia Mailman School (senior author).