Sudan: genocide has killed more than the tsunami

News reports have consistently reported 70,000 dead in Darfur. This figure is certainly wrong. Infact, at least three and perhaps four times as many people have died. By this time next year the death toll may equal that of Rwanda in 1984

DR. JAN COEBERGH
Parliamentary Brief, London, February 2005

The conflict in Darfur broke out just before the US and UK invaded Iraq. Not surprisingly, it received barely a mention. By early 2004, it was becoming apparent that Khartoum was not waging a counter-insurgency operation but war against its own civil population: there was a huge rise in the numbers of refugees, displaced people and reported deaths. During the summer of 2004, the US Congress, followed by the US State Department and then the EU parliament, declared the Sudan government’s actions genocide. A UN mission is due to report in late January 2005 as to whether genocide has occurred.

There was intensive media attention for a few weeks, then other news – the school siege in Beslan – interrupted. Attention has not properly returned to Darfur since then. The tsunami disaster in South East Asia, and the Naivasha peace agreement make it less likely that it will do so.

Nevertheless, the situation is deteriorating and the scale of the tragedy in Darfur needs to be spelled out. Substantially inaccurate reporting needs correcting also.

One illustration of the horror that has been and continues to be experienced by people in Darfur is the number of dead in the conflict. The figure widely quoted between October 2004 and January 2005 is 70,000. But this figure is almost certainly wrong; the true death toll is nearer 300,000.

The figure of 70,000 dead derives from a misreading of a WHO study on mortality made in mid-September 2004 (50,000 dead) and updated (to 70,000) in a statement given to journalists on 14 October by Dr Nabarro, head of World Health Organisation (WHO) emergency response efforts. He was, as he has subsequently explained, only estimating deaths among the displaced population in camps and did not include those still living in the countryside, living in the three state capitals, in camps inaccessible to humanitarian aid, and amongst the refugees in Chad.

And he was only estimating deaths from disease and malnutrition, specifically excluding deaths from violence, wherever those deaths occurred. He was also making an estimate from 1 March 2004 to October 2004, excluding the loss of life previous to that, and of course since then.

It continues to be widely quoted three months later, and as if no one has died in Darfur since October 2004, despite his estimate that 6,000-10,000 people would die per month for the next few months, giving a figure of around 90,000-100,000 dead from disease and malnutrition in the camps accessible to aid since March 2004.

Does it matter how many have died ? Yes. It gives us a correct picture of the scale of the tragedy in Darfur and helps us measure our response. Counting the dead also values them. And it allows us to properly estimate the cost in lives this war will claim in the months ahead.

After all, these were, and are, preventable deaths. Our only source of information on mortality rates are the surveys carried out amongst internally displaced people in camps in Darfur and among refugees in eastern Chad. Using the surveys it is possible to establish a likely range of total deaths from violence and disease and malnutrition.

World Health Organisation
WHO surveyed 20,775 internally displaced people (IDPs) out of an average of one million IDPs in accessible camps between 15 June and 15 August 2004. At that time, Dr Nabarro estimated that at least 50,000 internally displaced persons have died from disease (in some cases exacerbated by malnutrition) since April 2004. He estimated that 6,000-10,000 IDPs are dying each month of disease.

Between April 2003 and April 2004, an average IDP population of 400,000 would have suffered an excess mortality of 40,558. Added to the 50,000 and 6,000- 10,000 excess deaths in October, November and December 2004, perhaps 108,588-120,558 people have died in IDP camps in Darfur due to disease and malnutrition since mass displacement started, based on WHO data.

Medecines sans Frontieres/Epicentre Carried out interviews with 17,519 people out of a population of 215,000 IDPs between April and June 2004 in four sites in West Darfur. Violence caused 68-93 per cent of deaths during displacement and 49 per cent to 74.5 per cent including time at camp. IDP camps are still very unsafe: violence continues to kill in the camps (it accounts for 6.7- 21.4 per cent of all deaths in camps).

Between 2 and 4.7 per cent (confidence interval (CI): 0.6-6.8 per cent) of the total population was killed during the recall period (the period the interviewees are asked about), predominantly during the attacks on their village and before they reached the IDP camps.

The percentage killed extrapolates from 13,200 (0.6 per cent) to 149,600 (6.8 per cent) and a mean estimate of 73,700 (3.35 per cent). This number does not account for excess mortality before and after the 180 day period around displacement, of which there is clear evidence, as below.

United Nations and the Centre for Disease Control
They conducted a survey among 556 households of Sudanese refugees in frontier settlements and refugee camps in eastern Chad for a recall periodbetween 7 November 2003-10 June 2004.

The main cause of death for children older than 5 years’ was war-related (64.1 per cent) (47.7-80.4 per cent). The recall period includes periods before displacement when mortality was less. Extrapolation to excess deaths of refugees in Chad during the recall period is 2,760 (confidence interval (CI): 2,369- 2,948).

The US Department of State/Coalition for International Justice (CIJ) Interviewed 1,136 Darfurian refugees in July/August 2004 in eastern Chad. 61 per cent of refugees in Chad saw a (at least one) family member being killed. Household sizes vary from 5 to 7. In Western Darfur 90 per cent of the population in IDP camps were displaced by violent attacks on their village.

This extrapolates to a range between 172,542-232,269 violent deaths for the whole conflict in Darfur. It assumes, falsely, that only one family member was killed. However it is a large extrapolation from 1,136 interviews to a total waraffected population of 2.27 million.

Those outside the studies Eric Reeves, a Sudan researcher, has used USAID projections of mortality in Darfur for 2004-2005 and applied them to 500,000 people in inaccessible rural areas (as estimated by the Office for the Coordination of Humanitarian Affairs, OCHA, a UN organisation).

For the four months from June to September 2004, USAID projections indicate an average Crude Mortality Rate of almost 9 per day per 10,000 (for a population without humanitarian aid and experiencing severe food shortages). As wild food gathering and survival skills are counteracted by continuing insecurity it is hard to estimate mortality in these people. However it would have caused 51,000 excess deaths in just these four months. Even if it is half that it would still leave 25,000 deaths.

Underestimates of mortality
Several reasons for underestimating mortality exist in all these studies. All interviews would fail to detect the death of whole families. Under-reporting of neonatal and infant deaths in similar surveys has been documented. People could also be afraid that, despite assurance, reporting deaths will affect their food rations.

In the MSF and WHO study, more people were absent and had disappeared than had died. It is difficult to imagine what happened to these people, but some are likely to be among the dead. These extrapolations assume that the crude mortality rate for those 3.9 million Darfurians not classified as war-affected by the UN remains unchanged. This is unlikely; they also suffer from banditry, insecurity and the 60 per cent rise in the price of food.

Finding a total: three combinations
1. A total death toll due to violence of 172,542 in all of the war-affected population (Coalition for International Justice) and excess deaths from disease and malnutrition of 108,588 in IDP camps in Darfur (WHO) and 25,000 deaths ininaccessible areas reaches a total of 306,130 excess deaths between February 2003 and December 2004.

Violence is the cause in 56.4 per cent of these deaths. The low risk sample of the World Food Program study estimated 35 per cent of deaths due to violence and the MSF study (including time at camp) gave between 49 per cent and 74.5 per cent of deaths from violence. This confirms that an estimate of violence accounting for 56.4 per cent of deaths is not far off the mark.

2. Combining the Lancet (73,700) and WHO studies (extrapolated to 126,490) would give a total of 218,449 deaths.

3. Extrapolating the UN figure of 70,000 deaths back to April 2003 with WHO data gives 110,558 deaths from disease and malnutrition. Assuming violence to be the cause in 56.4 per cent of all the excess deaths gives a total of 253,573 deaths.

Many people have died as a result of conflict in Darfur. Figures of 218,449, 253,573 or 306,130 deaths since April 2003 are very rough estimates, but considerably more accurate than the numbers currently quoted in the media.

And which ever total you go with, it is an ever increasing one. This year looks worse than last.

Better or worse in 2005?
Violence: MSF showed that most violent deaths occurred during displacement, but continue at a lesser scale in the IDP camps.

People are being attacked when they attempt to return to their villages and displacement of people still continues.

In December, 20,000 more IDPs arrived at Kalma camp in South Darfur, scene of much recent fighting. Despite progress in the South, there is little sign of a political solution in sight: all expectations must be that the war will continue to claim lives through violence as it did in 2004.

Malnutrition and disease: Extrapolating deaths of disease and malnutrition is troublesome since humanitarian access has improved for most of 2004, but deteriorated in recent months: Save the Children-UK has had to pull out, and WFP temporarily ceased food deliveries due to increased insecurity. What is disturbing is that in November 2004 only 61 per cent of people in need of assistance received food: 200,000 people in North Darfur received no food assistance. This food gap has never been bridged in Darfur, despite the conflict now being two years’ old.

Prolonged malnutrition, exhaustion of food supplies and increased prices of food are now taking, and will increasingly take, their toll on the population. Some experts have predicted that these factors could push Darfur into an even greater crisis than at present. With the world losing interest, that is more rather than less likely.

In all of this, it is easy to forget the children who are not born because families are separated or a husband or wife killed. Men cannot marry because without livestock and female fertility also decreases with malnutrition and stress. Nor must one forget the children who are born: rape has been widespread. Malnutrition will affect all those that survive, for the rest of their lives.

Jan Coebergh is a doctor with an interest in epidemiology. He worked in Darfur before the present crisis.