Our results, obtained in insecure field conditions, show the ongoing impact of the conflict on civilian populations, in particular the violence inflicted upon them. Although mortality rates were under emergency thresholds in our surveys, the proportion of violent death was high, reaching over 30% in the global population in two sites and 58% and 71% in the population 5 years and over in the same sites. While the CMRs in our surveys were lower than that of other surveys undertaken in camps during acute crises (4.1/10 000/day in Ituri, DRC 2005), they are similar to results reported from eastern DRC as part of a nationwide survey carried out in 2006 - 2007 [4, 10], The proportion of deaths reported as violent in two of our survey sites is similar to the 67% reported in the Ituri survey, but much higher than the 0.6% violent deaths, reported in the cumulative results of the eastern region in the 2006 - 2007 survey[4, 10].
Our results may under-represent the true extent of deaths due to violence (and violence against individuals), since some villages in Kabizo and Masisi were excluded from the survey for security reasons. These sites, and that from which the team was evacuated, were likely to have been more strongly affected by violence than those in which the survey could be conducted. In addition, the MSF programmes cover a wider more inaccessible area than could be covered in the surveys. The programmes include areas only reachable by mobile teams supporting government health centres that cannot be accessed on a regular basis because of insecurity. These are populations that continue to be affected by conflict, are constantly moving, and likely have high levels of trauma and mortality, as yet unrecorded.
The geographic situation of Kabizo may be linked to the few reported deaths from violence. During the recall period of the survey the relatively large town of Kabizo was overrun and residents fled when the first skirmishes occurred, most escaping the violence; no further attacks occurred in the survey area. In Masisi and Kitchanga, numerous offensives were conducted on multiple villages, which might have led to less warning (as demonstrated by the unanticipated attack on the village in which one survey team was working), resulting in more fatalities.
We did not carry out verbal autopsies in the field. For that reason we present the reported causes of death as either violent or non violent, since we consider that respondents could reliably report this information.
Our results, unlike others obtained in eastern DRC, show mortality linked to disease well below emergency thresholds[2–4, 10]. However, our survey sites were not representative of all of North Kivu and reflect the situation of only selected populations for whom humanitarian aid had been in place for at least a year. The medical care provided to these populations was comprehensive and free of charge, and our results suggest that access to care was good. Although not quantified in our survey, water and hygiene activities were also in place in all sites. Together, these activities could have contributed to the disease-related mortality being lower than that reported in other surveys, and demonstrate that high disease-related mortality rates are not inevitable.
The exposure of the population to violence is also revealed in the number of violent events perpetrated against individuals. Few are exempted, with nearly half the households included in our survey affected during the 8-month recall period.
The episodes of violence against individuals, particularly rape, are likely to have been under-represented in our survey results. Rape is still a taboo subject in many communities of DRC, and reporting can have severe negative consequences for the victim. In our survey nearly all perpetrators were identified as combatants, and there may be under-reporting of violence perpetrated within the community. Another limitation in the data on violence is that we only recorded one type of violence per violent episode. Although this limitation does not affect the number of episodes, it might under-represent what are considered less severe forms of violence--eg, an episode of violence might be recorded as rape when the person was subjected to both rape and beating.
Our results also reveal the prevalence of forced labour in two of the survey sites. Civilians, usually men, are used to carry material for combatants, frequently for long distances and usually under threat of violence if they do not comply. The frequency of forced labour in our survey areas is higher than reported previously.
The high proportion of households who had basic non-food items, livestock, or food-stocks stolen, and who had limited or no access to their fields exposes more of the precarious existence of these populations. While in these sites NGOs have generally replaced essential items, the same might not be true for other populations of North Kivu. The poor access to fields and loss of livestock also suggests that households may struggle to meet even basic needs in the short and medium terms. Although we did not collect specific information about why fields could not be accessed, it might be linked to the distance the population have been displaced. In insecure conditions, individuals are unlikely to stay overnight at their fields, which would be necessary if they are more than a few hours walk from their current residence.
Our results show the continual instability of the population, many of whom had fled at least once during the 8-month recall period, many more than once, and most as a result of direct attacks on their homes at the time of the displacement. This is in contrast to rumours within the international community that villagers had been fleeing pre-emptively, before combatants arrived. In general, the displaced did not flee far from their homes, most walking for less than 2 days before settling. An area of direct conflict may be located very close to an area where the population settles. The challenge faced by humanitarian organisations is to provide aid for the dispersed populations and to ensure the security of their teams.
The prevalence of violence as seen in our survey results is high and reflects what is reported by field teams. The MSF programmes see many survivors of sexual violence (in one site, an average of 68 per month from a population estimated at around 140 000; L Berryman, personal communication), although it is thought that the team manages to reach only a small proportion of survivors due to lack of access to information and issues of stigma and confidentiality. MSF mental-health programmes in the region treat people who have commonly experienced a combination of different traumatic events: having to flee and hide from enemies, houses being destroyed, family members, neighbours, and friends being killed or disappearing, witnessing someone being killed or raped, being raped, and properties, livestock, and fields being confiscated. Their main complaints are anxiety related, with sleeping disorders and intense psychological distress the most frequent symptoms (L Berryman, personal communication).