View inside the town of Ndu, northern DRC, where thousands of people from the Central African Republic sought refuge due to a non-state armed group attack on Bangassou on January 3rd. According to some estimates, over 12,000 refugees arrived in Ndu in just a few days. © Dale Koninckx/MSF

CAR: A visual journey through a year of renewed violence in an old conflict

In late 2020, violence once again struck Central African Republic (CAR), a country that has undergone decades of intermittent conflict. We look back at the work of teams from Doctors Without Borders/Médecins Sans Frontières (MSF) over the past year as they supported vulnerable people in need by providing essential healthcare often under very difficult situations. 

Map reflecting some of the MSF interventions in the Central African Republic.
Map reflecting some of the MSF interventions in the Central African Republic.MSF


People displaced from their homes by fighting, within and beyond CAR’s borders
People displaced from their homes by fighting, within and beyond CAR’s bordersDale Koninckx/MSF


People arrive in the village of Ndu, in Democratic Republic of Congo (DRC), after crossing the Mbomou river from Central African Republic. Amid contested elections in December 2020, a newly formed coalition of non-state armed groups called Coalition des Patriotes pour le Changement (CPC) launched an offensive against the government of CAR.

Bangassou was one of the places hit by the violence. On January 3, 2021, hundreds of people sought refuge within the MSF-supported hospital and more than 10,000 people fled towards Ndu, in DRC. MSF supported people in both Bangassou and Ndu by providing shelter, cater and medical care.

The town of Bouar was hit by the violence. The CPC attacked positions of the Central African Armed Forces (FACA) and the UN Peacekeeping Mission (MINUSCA) in the town. More than 8,000 people were forced to leave their homes. Nearly half of them stayed in the city’s former cathedral. “It is total destitution,” reported an MSF team member. “Living conditions in the sites hosting displaced people are deplorable, particularly due to the lack of clean drinking water.”

The journey of a wounded patient
The journey of a wounded patient.Adrienne Surprenant/Collectif Item for MSF

During the early weeks of the renewed conflict, fighting was particularly intense. In just one month, MSF teams treated 258 people wounded in the violence countrywide. France Beldo, 31, was hit by a stray bullet on the terrace of her home on 13 January in Bangui as the CPC reached the outskirts of the capital. She was taken to SICA hospital, a surgical trauma facility run by MSF. The bullet penetrated her hand, chest and shoulder but did not damage any vital organs.

On January 22, 2021, France was discharged from hospital, one day after the government had announced a 15-day countrywide state of emergency. “I was wondering if I would survive or not,” said France. “It was only when I arrived here that the doctors told me: ‘It is going to be fine’. I can see now their work made me heal. People are filled with worry. I wish that the fighting would stop so that the country could be quiet.”

Not all wounded people had the same luck as France. In the end of December 2020, we lost a colleague, a medical staff who was off-duty and had taken a public transport truck on his way from Bambari to Bangui when gunfire suddenly erupted. He was transferred to Grimari for treatment but succumbed to his injuries shortly afterwards.

Sexual violence, a public health issue exacerbated by the conflict
Sexual violence, a public health issue exacerbated by the conflict.Adrienne Surprenant / Collectif ITEM/

“After the assault, I thought I would take my own life,” says Charlotte (not her real name), an 18-year-old survivor of sexual violence from Bangui. After her mother died and her father rejected her, Charlotte went to live with her aunt and uncle. One day, when the house was empty, her uncle raped her. Her aunt refused to believe her and Charlotte felt completely alone and desperate. Charlotte reported the rape to the police but no action was taken. Charlotte sought support at MSF’s Tongolo centre, where 9,000 survivors of sexual violence have received medical, psychological and psychosocial care since 2017.

Sexual violence has become a public health issue in CAR, exacerbated during periods of conflict. MSF staff in Tongolo report that perpetrators are often known to their victims – be they friends, neighbours or relatives. With the resumption of conflict in early 2021, survivors in areas affected by violence identified armed men as the most common perpetrators of sexual violence.

Emergency needs across the country
Emergency needs across the countrySeigneur Yves Wilikoesse

“I have been sick since we fled to the bush,” said in April Thérèse, a woman displaced from her home and sheltering in Grimari. “I feel cold all the time and I have pain all through my body. I vomit constantly and have diarrhea.” For weeks, she was unable to see a doctor, instead treating herself with traditional medicines and plants.

With the conflict heavily impacting people’s acess to healthcare, MSF deployed emergency teams across the country to assist people affected by the violence. The teams ran mobile clinics in existing health facilities, schools and camps for displaced people. In Grimari, Bossembelé and Ippy, they provided more than 5,000 medical consultations between December and April, with a focus on emergency treatment, children under five and pregnant women. Most patients were treated for malaria, one of CAR’s top killers.

Volatility in rural areas
Volatility in rural areasIgor Barbero/MSF

After the initial push by the armed opposition, government and allied forces gradually regained control of CAR’s major cities and towns, forcing non-state armed groups into the bush. The situation became very volatile in many rural areas across the country, with frequent fighting and attacks on local populations.

In late May, Tanguina Chela fled her village of Gmganga, close to Kabo town, along with her husband and three children. Most of Gmganga’s 200 inhabitants left following fears of potential retaliation against local communities accused of collaborating with government forces.

“I left everything I had there,” said Tanguina in Kabo in June. This was the third time that she had been displaced from her home. “Throughout my life I have suffered a lot,” she said. “Since I was seven years old, the same story has always repeated itself. I have been on the move a long time due to the war. I have lost my belongings, my farmland, everything… I have children, but I don’t even know how I will feed them.”

Tanguina is one of 1.4 million Central Africans currently displaced from their homes, which is nearly one-third of the country’s population.

Repeated attacked on medical care
Repeated attacked on medical careIgor Barbero/MSF

The conflict severely impacted the provision of medical care. In the first half of 2021, MSF teams came across dozens of health facilities that had been ransacked, damaged and occupied by armed men. Armed incursions into hospitals saw patients subjected to violence, physical abuse, interrogation and arrest. Community health workers in rural areas were threatened and assaulted and motorbike riders delivering lifesaving drugs and transporting sick patients to hospitals were attacked and robbed at gunpoint. Some of them were injured and even killed.

As a result of these incidents, on several occasions MSF had to temporarily suspend some medical activities, including providing lifesaving care, supervising health centre staff, supplying drugs and transporting patients. “Being forced to suspend some of our activities only exacerbates people’s vulnerability and results in the avoidable deaths of young children and women with complications in pregnancy and childbirth, among others,” said MSF’s Deputy Program Manager Gisa Kohler in July.  

Camps for displaced people not spared from violence
Camps for displaced people not spared from violenceLys Arango

One place repeatedly affected by the violence was Bambari. Following clashes in early June, some 8,500 people were expelled from the Elevage makeshift camp for displaced people, on the outskirts of the town. The camp was burnt to the ground and an MSF-run malaria point in the camp was also destroyed. Most residents sought initial refuge in the compound of a mosque in Bambari town where they lived for months in difficult conditions.

Youmousa’s family have suffered years of conflict and been displaced from their home several times. The destruction of Elevage camp proved to be too much for Youmousa’s elderly mother. “She wasn’t able to cope with one more change,” said Youmousa in August. “After we got kicked out from Elevage, she refused to eat, she didn’t sleep and she hardly spoke. She died and we buried her in Bambari cemetery, a long way from her hometown.”

Returning to a health centre in shambles
Returning to a health centre in shamblesMSF

When the MSF team entered the village of Nzacko in July, they found a succession of ruined buildings overgrown with vegetation, burnt-out cars and abandoned markets and shops. Since January, most inhabitants had fled the village, living in very precarious conditions, unable to access humanitarian assistance because of the insecurity. When the fighting eventually ended, the population gradually returned.

“When we arrived, we found the health centre in a shambles,” said MSF nurse Pelé Kotho-Gawe. “Meanwhile malaria and malnutrition had taken their toll on the villagers who had been sheltering in the forest.”

Octavia Braza, 33, was about to give birth to her seventh child. She hadn’t eaten all day because she had no food left after feeding her children. Recent months had seen a marked increase in maternal mortality in the area. Fortunately for Octavia, the arrival of the MSF team with supplies helped her avoid complications and give birth safely. After five hours of labour, the baby was born.