The Impact of a Massive Population
Movement on Environmental Health in
Goma, Zaire 1994
Susie Low
Former Executive Director MSF Australia. Susielow@tpg.com.au.
Every year, hundreds of thousands of people are forced to leave their homes in fear,
and flee to another country. The will to live is what takes them there. Currently there
are 22 million refugees in the world.
The spontaneous movement of large numbers of people will inevitably have a
significant impact on the environment. In return their health will suffer. Arriving in an
alien situation, refugees face hunger, fatigue, humiliation and grief. Their first concern
it to survive, to find food, water and shelter. The environmental changes generated by
mass population displacements have critical implications not only for the well-being
of the refugees themselves, but also for their relationship with the host country, and
for the development potential of the areas where they settle. Significant problems
arise from deforestation, land degradation and depletion and pollution of water
resources, and unavoidable competition for natural resources between refugee and
host populations. This can often influence the decisions of governments to offer
asylum to refugees.
For most countries, the loss of forest cover may be a major issue because of habitat
degradation, the loss of ecosystem functioning and, often, reduced levels of income or
a lower quality of life. For most of the world's displaced people, wood constitutes the
primary source of fuel and shelter material. Quantity and quality of water is also a
common problem with any major influx of people, as is the production of a great deal
of excreta and other waste materials. If they are not properly treated, the soil and
groundwater can quickly become contaminated.
In extreme cases, the depletion of natural resources may pose an immediate threat to
human life. Refugees who do not have access to wood or a substitute fuel, for
example, may not be able to cook, or keep themselves warm, thereby becoming
vulnerable to malnutrition and other illness. Exposure to the smoke that is emitted
when fuel alternatives such as crop residues and dung are used for cooking can cause
respiratory and eye infections. If local water sources are overused and polluted, and if
alternative supplies are not possible, deaths are likely to occur as a result of
dehydration and infectious diseases.
In situations where rare species or unique ecosystems are threatened by mass
population displacements, irreversible losses in global diversity may occur. The
immediate need to sustain human life comes into direct conflict with the longer-term
objective of environmental protection, which, ironically, in turn, will sustain human
life.
Case Study: Goma, Zaire
from July 1994
"This is the beginning of the final days. This is the apocalypse…"
This is how one Goma resident described the sudden influx of almost a million
Rwandan refugees into his quiet hometown.
Background
April 6, 1994, the Hutu presidents of Rwanda and Burundi were killed when the plane
that was carrying them back from peace talks in Tanzania was shot down. The
following morning, radical elements of the Rwandan military captured both Hutu and
Tutsi politicians who had favored reconciliation, and summarily killed them. Fuelled
by vicious messages broadcast by the racist Hutu radio station des Milles Collines, the
violence spread. Groups of Hutus armed with grenades and machetes systematically
hunted down and killed Tutsis, resulting in a death toll from April to June of between
500,000 and one million. The international community did nothing.
The Rwandan Patriotic Front (the Tutsi rebel army) fought back, steadily gaining
ground, and by July 4, was able to capture the two main cities of Kigail and Butare.
As they advanced hundreds of thousands of Hutu refugees fled across the border into
Tanzania, Burundi, and ultimately, Zaire.
Goma was a small border town at the northern end of Lake Kivu, in Zaire, with a
population of about 15,000. On July 14, the first refugees crossed the bridge from
Rwanda. It was impossible for Zairian officials to stop the flow. The following day,
over 500,000 arrived, the next day, another 500,000. At Kibumba, just 10k north, also
on the border, refugees steamed in at the rate of 15,000 every hour. In Bukavu, south
of Goma, a human chain 25 k long was winding over the border.
The bulk of the refugees arrived in Goma and stopped, exhausted, hungry and scared.
They camped on doorsteps, in schoolyards, traffic islands, cemeteries, in fields so
crowded people could only sleep standing. They began cutting down trees to make
shelters, to cook their food. They bathed, washed and collected water from the lake.
Within three days, approximately 1.2 million people had arrived. The United Nations
High Commissioner for Refugees (UNHCR), World Food Program (WFP), and MSF
and Oxfam (the only non-governmental organizations, [NGO] already in place) had
underestimated the magnitude of the disaster. Stocks had been prepositioned by the
UN, and MSF had set up an emergency stock of drugs, and tents for dispensaries for
an influx of only 300,000. Oxfam had placed stocks of water pumps, storage materials
and pipes for 50,000.
One million people living in crowded conditions with inadequate shelter, inevitably
contaminated water sources, and no sanitation because of the volcanic environment,
was a formula for disaster in a region where both cholera and dysentery were known
to be endemic.
The Impact on Health
People began to get sick. On July 18, the first cases of cholera were confirmed in
Goma town. A laboratory identified the causative organism as Vibrio cholerae 01,
biotype El Tor, Serotype Twawa, resistant to affordable antibiotics such as
tetracycline and doxycycline. More than 3,000 cases were reported the first day.
Initially medical workers lacked even the most basic therapeutic tools - oral
rehydration salts, intravenous solutions, intravenous giving sets, beds, bedpans,
buckets, drugs, even clean water. By July 22, case fatality rate (CFR) reached a peak
of 22%. For most cholera epidemics in refugee camps within the last two decades the
CFR has been between 2 - 3%. As NGO capacity improved, clinics and cholera
treatment centers were set up, and by July 26, the CFR had dropped to between 3 5%. In total, 10% of the refugee population died during the cholera epidemic - the
most lethal refugee crisis in recent history.
During this time, the death rate was distressingly simple to estimate. Because the earth
was volcanic rock, it was impossible to dig graves to bury the dead. Bodies were left
by the road and, and when NGO's became more organized, they were collected by
trucks which took them to mass graves for burial. Prior to the body collection, when
people died in the cholera treatment centers and clinics, the bodies were left outside,
and sprayed with chlorine or covered with lime. This was supposed to slow
decomposition to buy some time before a solution could be found for their disposal.
An effective response to the growing health crisis was often hampered by
inexperienced NGO's. By the second week of August there were more than 30 relief
agencies and 400 expatriate workers operating in the camps around Goma, many were
inexperienced, and struggling to find a useful role. One US based NGO airlifted
10,000 cases of Gatorade to treat cholera patients. This is not an efficient treatment.
This came at a time when MSF was desperately trying to bring in more supplies of
oral rehydration solutions, the most basic, effective and cheap treatment for cholera,
and the small Goma airstrip was clogged with Hercules aircraft full of either media or
inappropriate supplies.
Mass vaccination for cholera was not considered. Apart from the dubious benefit of
the cholera vaccine, It would have taken a team of 80 - 100 health care workers 10 -16
days to vaccinate the whole population. By the time the vaccine could have been
obtained, administered, and provided immunity, the epidemic would have already run
its course.
The cholera outbreak was quickly followed by another water-borne epidemic:
dysentery, caused by Shigella dysenteriae type 1, which causes bloody diarrhea, fever
and abdominal cramps. This is also a highly resistant strain, and the only effective
drug available was ciproflaxacin, which cost $20 for a full treatment, a formidable
sum in a situation where thousands of people are infected. Over the next week 40% of
deaths were associated with dysentery.
Another serious impact of the overcrowding was the onset of cerebrospinal
meningitis. Based on experience elsewhere in Africa, a threshold incidence of 15
cases per 100,000 in a single week was used to predict a full-blown epidemic. During
one week, the incidence in Kibumba camp reached 19 per 100,000. A mass
vaccination campaign was launched and the development of the epidemic was
averted.
Malaria is endemic in this region, and given the overcrowding, poor condition of the
refugees, and siting in previously unoccupied areas, a mosquito control program was
established in a high risk area of one camp. Residual insecticide was sprayed in the
huts within 500m of a small lake and no further cases of malaria were reported.
By the second week of August, MSF and Center for Disease Control (CDC Atlanta)
had put in place outreach activities that would allow health workers to promptly
identify sick refugees, along with a standard system of health surveillance; diseases of
public health importance were recorded and routinely reported to UNHCR. This
information system was instrumental in detecting the growing meningitis epidemic,
responding to the high cholera case-fatality rate, and identifying dysentery as a major
health problem. Data collected routinely in clinics was complemented by information
gathered by camp surveys.
During August, 20% of children under 5 were assessed as acutely malnourished.
Normally, fewer than 5% of African children are acutely malnourished. It can be
argued that this was related to environmental factors. There was no registration of the
refugees, and given the extreme overcrowding, food distribution was problematic. The
same individuals who had held authority in communities in Rwanda were in charge of
food distribution. These were the civil authorities who had perpetuated the genocide.
Their militia controlled the camps, and siphoned off supplies to the members of the
armed forces who were retraining within the camp confines, planning an insurgence
into Rwanda. Unaccompanied children, and children of households where there was
no adult male were particularly vulnerable to this extortion. Aid workers who
attempted to implement a registration system that would allow all families equal
access to relief items were threatened with violence.
As late as October, it was estimated that approximately 600,000 refugees in Katale
camp required WFP food rations. Yet, WFP was distributing rations for 1.2m, and
still there was high malnutrition.
Water & Sanitation
The eventual control of the cholera and dysentery outbreaks was directly related to the
provision of sufficient uncontaminated drinking water, and sanitation systems
established in all the camps.
During the first days of the influx, the only water source was Lake Kivu. On July 24,
6 days after cholera had hit, the Dutch, French and US Armies collaboratively
installed two reverse osmosis water purification units and a large capacity hydro subpump which pumped water out of the lake, and stored it in containers by the lake.
This did not prevent refugees from coming to lake to fill up buckets as they had done
when they first arrived. Some bucket chlorination was done, even prior to any other
purification treatment, but not enough. Some now argue that if effort had been
concentrated here, at the source, at the outset, the epidemic could have been averted.
Zairian authorities, concerned about possible violence between Tutsi inhabitants and
Hutu refugees forced the refugees to leave Goma town. The only direction they could
go was north. They settled in Mugumga (3k north), Kibumba (10k north), Kahindo
(25k north) and Katale (50k north). Kibumba had become home for many refugees as
they crossed the border, despite the fact that the nearest water source was Lake Kivu,
10k away. In Katale there was a small, inadequate, contaminated river and in Kahindo
and Mugunga, nothing at all. All these locations were situated on volcanic rock.
Water needed to be brought in. 60 trucks were used daily to carry up to 2 million liters
of water per day to 68 locations in the campsites. Chlorine was added as the trucks left
the Lake, and after traveling for 90 - 120 minutes, was suitable for consumption. It
was then pumped into tanks installed in several sites in the camps, then piped to
distribution points throughout the camps. All sorts of problems plagued the delivery
program: scarce fuel supply, poor condition of the trucks purchased in a hurry, pump
breakdowns, poor road infrastructure in the camps, but most importantly, insecurity.
A significant factor contributing to the rapid dissemination of cholera was the lack of
adequate sanitation arrangements. The influx was so rapid that when the refugees
arrived in Goma town, there were no latrines. Refugees defecated where they stood,
slept and ate. The situation was no better when many had moved out of Goma to the
other sites. All were situated on volcanic rock - no holes could be dug - either to
defecate, or bury their dead.
Initially MSF instigated a system of allocating intensive defecation areas, small
screened areas with gravel on the ground and a layer of sand on top. People were
given a shovel and a cup of quicklime to take in with them, so they could sprinkle
lime on their excretions, scoop it up with the shovel and dump it in a wheelbarrow
near the exit. The wheelbarrow was emptied into a pit at the back of each area.
Dynamite was used to create these pits. After a while it was not practical to blast new
pits in the basalt rock, so the waste was loaded into trucks and dumped off site.
Eventually, latrines were built using small depressions in the ground, building them
up as necessary with masonry. In some camps drilling equipment was used to build
public latrines, but there were too few machines for the needs. As the liquids in the
latrines were not soaking away, latrine emptying became necessary quite early on, and
the waste was trucked away and dumped off site. It was very difficult to get pumps
robust enough to deal with all the waste that ended up in the latrines, so a lot were
emptied by hand.
By 12 August, one month after the influx, there was still only one latrine for each
1,029 inhabitants in Mugunga, one per 500 in Kibumba, and one per 184 in Katale.
Soap, the main tool used to promote personal hygiene was not distributed until well
into August.
The amount of infectious waste generated during the cholera epidemic was enormous.
Cholera treatment centers and clinics used incinerators, and would blast a pit in the
volcanic rock and bury the material. It is unacceptable that during this time a number
of disreputable NGO's were responsible for dumping waste in the fragile Virunga
National Park. This waste was scattered by monkeys, baboons and other animals.
Such disposal practices clearly had significant health implications.
Deforestation
Within three days of the arrival of the refugees, Mount Goma was completely
deforested, over 300 hectares.
The sudden influx of over one million refugees caused irreversible damage to the
vegetation in Zaire's Virunga National Park, a UNESCO World Heritage site. An
estimated 7,000 -10,000 m3 of wood and grass were being collected from the park by
refugees every day from August to December 1994. Deforestation accelerated
problems of environmental degradation and there was a significant increase in soil
erosion and loss of biodiversity. An environmental impact study commissioned by
The United Nations Development Program (UNDP) documented various categories of
extensive damage and identified other problems such as poaching in national parks,
and landslides in refugee camps located on hill slopes caused by uprooting of trees
and bushes.
How these factors, combined with the "rule by fear" in the camps impacted on the
health of the refugees needs to be considered.
In an attempt to solve the problem of supply of cooking fuel, UNHCR distributed a
new fuel-efficient stove to all refugees. They also supplied timber to burn in these
new stoves, but due to the distribution scheme (by the militia), the most vulnerable
did not receive supplies. Refugees soon abandoned the new stoves because their
traditional stone fires could burn large pieces of wood (regularly edged into the fire),
while the "free" and less bulky firewood for their new stoves had to be chopped into
small pieces to fit. Many did not have either the tools or the enthusiasm to follow
through with the new concept. They went back to ransacking the forest.
Another industrious NGO designed and distributed a fuel-efficient coke fire. The
Rwandan militia in charge of the camp launched a lucrative black market in coke.
They would chop down the trees in the forest, make coke and sell it back to the
refugees and the guilty NGO at exorbitant prices.
Impact on the Virunga National Park
For the first time in the history of the United Nations, a study was commissioned by
the UNDP to assess the environmental impacts of refugees.
The national park at Virunga was established in 1925 and declared a World Heritage
Site by UNESCO in 1979. It contains the highest number of mammal species in the
whole of Africa. Of these 200, 23 species are in the IUCN Red List of Endangered
Animals. It is also the only place where two endangered Gorilla sub-species live. 200
of the world's 600 Gorilla, Gorilla berengei, currently live in this park.
It is also Africa's richest protected zone in birds, with 698 species: 25 are endemic,
and 65 are considered to be endangered species. In total more than 100 plants, 26
mammals, 25 birds, 30 reptiles and 11 amphibians are endemic to the Park, and some
are known not to exist in any other part of the world. With the exception of the
elephants, all the other large herbivores have been poached extensively, a situation
further exacerbated by the armed militia in the refugee camps. In Mugunga, for
example, the 50,000 soldiers started full-scale economic activities by selling charcoal,
fuel wood, other forest products, and poached meat. Zairian authorities sent to control
deforestation activities, were threatened.
Zaire's forest ecosystems contain about half of Africa's remaining tropical rainforest,
and is the second largest tropical forest in the world after Brazil. Zaire boasts all of
Africa's biotypes with flora made up of about 10,000 known plant species of which
some 3,000 are endemic, representing a unique source of valuable forest products and
medicinal plants.
The incursion of the refugee population inevitably damaged this unique and sensitive
ecological zone. The spread of human and medical waste perpetrated by disreputable
NGO's within the park, posed a risk of spread of disease to wildlife, and humans.
Conclusion
The impact on the physical health of the refugees has been clearly defined. What
should also be considered is the effect on the emotional and mental well being of the
population.
The environment in which the refugees lived was one of intimidation and fear. The
former Rwandan army controlled the camps. Any refugees who expressed a desire to
return to Rwanda were beaten, tortured or killed. Food and fuel supplies were
withheld from the most vulnerable (usually households with no adult male) and
diverted to the soldiers. Patients in the clinics often disappeared overnight, to be
replaced by a soldier, or a member of the soldier's family because the militia
determined access to healthcare.
This was the same population who had witnessed the torture and death of family and
friends in Rwanda, had been forced to either kill or be killed during the genocide, and
who had suffered the loss of surviving family members through cholera or dysentery.
People lost their minds. One Rwandan woman danced naked on the road, shouting
curses at the corpses lying by the roadside, and hurling abuse at the young children
sitting alongside the bodies of their parents.
It is impossible to ever know or understand the true impact of this disaster on the
Rwandan people. It is only possible to accept the trauma of those days, and how the
situation created a population sick in body, mind and spirit. A population that could
not be expected to distinguish between human and environmental survival.
The horror of the first few weeks of the Goma disaster will remain forever in the
memories of those involved. While the immediate images of Goma were of
dehydrated people dying of a terrible disease, of decaying bodies littering the road-
side, of a sea of people trying to survive, a constant haze of smoke from cooking fires,
of hills covered in tree stumps, the underlying horror stemmed from an awareness of
the inhumane behavior that had led to the exodus in the first place.
References
Biswas A, Tortajada-Quiroz H (1994) Environmental Impacts of the Rwandan Refugees.
UNDP report.
Gibbs N (1994) Rwanda: Cry of the Forsaken Country. Time Magazine.
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UNHCR (1995) Refugees and the Environment. UNHCR, New York
UNHCR (1995) The State of the World's Refugees: In Search of Solutions. Oxford University
Press, Oxford.
Adisa, J, (1996) Zaire: A Worse Case Scenario? In: The Comfort of Strangers: The Impact of
Rwandan Refugees on Neighbouring Countries. Habitat, London.
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