More than 1,000 civilians are dying every day in the Democratic Republic of Congo (DRC), nearly all from disease and malnutrition, due to a festering conflict that has killed 3.8 million people, according to a new mortality report by the International Rescue Committee (IRC).

AlertNet’s Ruth Gidley spoke to the IRC’s country director in Kinshasa, Alyoscia D’Onofrio, about the report’s findings and continuing instability in eastern Congo.

AlertNet: Rwanda has repeatedly threatened to send troops into Congo to hunt down Hutu extremists whom it blames for cross-border raids. Do you know if Rwandan forces have actually crossed into Congolese territory?

Alyoscia D’Onofrio: There are numerous reports of this. I don’t have independently verifiable data on that. I’ve seen statements from MONUC (the U.N. Mission in Congo) saying they believe there are Rwandan troops inside the DRC. I’ve heard that from other sources, but I can’t comment to say I know this or that.

What are the implications of the tensions for people’s health?

It means continuing instability in North Kivu (in eastern Congo) for the time being, which may or may not spread to other parts of the DRC. We saw in May-June that there was a rapid spread of instability from the fall of Bukavu to a number of demonstrations around the country to some tension within the transitional government. So far, things seem to be holding together. We watch and we wait and we listen and hope that things are going to be okay.

This survey shows quite forcefully the powerful link between insecurity and mortality. Where we have violent deaths reported, even though those deaths are a very small proportion of the overall deaths, the overall mortality in that zone is substantially higher than where there isn’t violent deaths reported. We’ve seen it time and again. So we hope this is not going to lead to further instability.

Most of the death toll the IRC has reported on is due to lack of access to health care because of conflict. How exactly does violence stop people getting medical treatment?

If you’re in an insecure zone, you may not be willing to make the journey to your nearest health centre. You may not be able to make the journey and your own calculation of the risks of getting to the health centre may outweigh your estimation of what might be wrong with you.

Then you’ve got the impact of violence on the system and structure of the health process and how this stops access in other ways. You’ve got relatively simple things like the destruction and damage of the physical infrastructure – health centres getting burnt or looted. You’ve then got the degradation of water supplies and sanitation systems which may then exacerbate health issues.

More than that, you’ve got people fleeing and taking skills and knowledge with them, training being disrupted. So you lose that group of people who are skilled in identifying illnesses and dispensing appropriate medicines.

In some remote areas, there are people working in health centres who have had three months of training. If you compare that to the norm of training you would expect a doctor or pharmacist to have, not even just in a Western or Northern context, you can see there’s a problem.

Then you’ve got ruptures in supplies. Instability and the threat of violence can prevent essential medicines arriving.

Traditionally, people pay for consultations and medicines. So if people are too scared to go to health centres or health centres aren’t able to get medical stocks, attendance drops right off. Inflow of resources to the health centre drops right down so they can’t replenish stocks. They can’t pay their staff. Staff may then start to float away.

Similarly, if you can’t get out to tend your fields, and you can’t get your produce to market because of insecurity along the fields or transport routes, then you don’t have the resources to get health care.

All of these things reinforce each other. And you get a bit of a vicious cycle.

Then overlay on top of that the incredibly difficult geography in certain parts of this vast country, where the distance between one health centre and another may be tens or hundreds of kilometres along some pretty awful tracks. It may not be an option just to go to your next available health centre if your local one is damaged or destroyed.

What kind of health problems are we talking about? What exactly do people die of?

Bear in mind this is based on interviews with heads of household about the people who have died in their household over the 16-month period, and we’re asking for their explanation, so they’re not necessarily medically precise.

The biggest category is fever, which in most cases is probably malaria. Then diarrhoeal diseases, acute respiratory illnesses and malnutrition.

What kind of obstacles do aid workers face in Congo?

In the eastern provinces, insecurity is a still an issue in many cases. Disruptions occur on a regular basis – it’s by no means a stable situation. It’s still quite a militarised situation across most, if not all of the country.

Getting medicines to the right place at the right time can involve a whole range of planes, trains and automobiles, right down to the motorbike on a little canoe to cross rivers to get access to some of the more remote areas.

Is there anything you can do about that?

We’ve helped to rehabilitate the train line from Kinsangani to Ubundu, to the south of Kisangani, which will help us to get into Ubundu health zone and start to improve conditions there. This train runs alongside a stretch of the river that is non-navigable by boat, so it also helps to link up a longer transport network that runs right from Kinshasa up to Kisangani.

The report says that deaths dropped dramatically in Kisangani once conflict moved away...

Once MONUC was there, once the situation had stabilised, we and other agencies were able to get in.

In terms of turning this vicious circle into a virtuous circle, there are two main components. One is security and stability. That’s a necessary but insufficient condition to improve health access. Once you’ve got that, then it’s investment in the health infrastructure. Health centres and water and sanitation systems are essential services to improving health as well as health care.

We try to work with the structure there and get it back up on its feet. It’s about revitalising the existing system rather than going in and replacing it with something else. We don’t just roll up and give out free medicines. It’s about trying to help the Congolese to manage their health centres again.

We procure and supply essential medicines, in line with Congo’s Ministry of Health guidelines. We provide training and guidance to the health zone management, and to health centre staff. We work with the help zone management to design and implement an appropriate tariff structure for consultancy and medicine. We have experimented with a number of strategies to help get the poorest and the most needy population to get access to health care as well.

This is not to say that the system is up and running – this is an ongoing process.