Stranded in
the DesertMédecins Sans Frontières (MSF) is an international medical relief organisation.
MSF is an independent and neutral aid agency that serves all people regardless of their race, politics or religion.

April 2013

© Nyani Quarmyne

Layout : w w w.okidokidesign.net - Yesmine Sliman Lawton

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CONTENTS

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CONTENTS

5INTRODUCTION

6

Context

7

Refugee stories

10 MSF’s response to the refugee crisis
11 Sub-standard living conditions in the camps
12 The impact on refugees’ health
15 CONCLUSION

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INTRODUCTION
Since the start of the conflict in Mali in January
2012, hundreds of thousands of people have fled toother locations inside the country or to neighbouring
countries. More than 270,000 people have been
displaced within Mali, according to the United
Nations, while more than 170,000 refugees have fled
to neighbouring Burkina Faso, Mauritania and Niger.
Mauritania hosts the highest number of refugees,with some 68,000 people registered by the Office of
the UN High Commissioner for Refugees (UNHCR)1
in camps in Mauritania.
The camps in Mauritania are located in a remote, arid
region close to the border with Mali. The refugees relycompletely on outside assistance and humanitarian
aid for their survival, including such basic needs as
food, water, shelter and medical care.
So far the humanitarian response has been far
from adequate. Aid agencies including UNHCR
and the World Food Programme (WFP) have beenslow to respond to the continued influx of new
refugees, resulting in high levels of malnutrition
amongst children who have been in the camps
for several weeks. In temperatures of 50 degrees,

refugees receive only 11 litres of water a day,and shelter and sanitation have been vastly
inadequate for their needs. Recently, the provisionof food, water and sanitation has improved,
but the situation is still extremely precarious
and aid organisations need to maintain their
humanitarian response for as long as necessary.
Médecins Sans Frontières (MSF) has been providing
healthcare to the refugees in Mauritania since
February 2012. In recent weeks, MSF has beenscaling up medical and nutritional services in
response to deteriorating health among refugees
as a result of the sub-standard living conditions in
the camps.
Due to the ethnic and political background of thisrefugee crisis, there is little prospect of the refugees
returning to Mali in the near future. The challenge
for aid agencies will be to put in place long-termplans that will bring living conditions in the camps
up to acceptable humanitarian standards.

1 See http://data.unhcr.org/MaliSituation/country.php?id=132

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CONTEXTThe Malian refugee crisis has a complex ethnic and political background. The
Tuareg, a nomadic Berber people whose territory straddles northern Mali, have longheld dreams of independence. An armed Tuareg uprising in 1990 was unsuccessful,
but after the return of large numbers of Tuareg fighters from Libya after the fallof the Gaddafi regime, the conflict flared up again in January 2012. Soon after the
Tuareg independence movement – the National Movement for the Liberation of
Azawad (MNLA) – took control of northern Mali, the first wave of refugees arrived
in Mauritania. These refugees were mainly Tuaregs who remembered the reprisals
that had taken place after the ethnic conflict of the early 1990s.
Between March and June 2012, other armed opposition groups – including Al Qaeda
in the Islamic Maghreb (AQIM), the Movement for Unity and Jihad in West Africa(MUJAO) and Ansar Edine – clashed with the MNLA, taking control of several of thenorthern territories. In the capital, Bamako, in the south of the country, the trouble
in the north led to a coup in March 2012 by members of the Malian armed forces,
with the elected president ousted from power. At this time a second wave of refugees
arrived in Mauritania, which included all the ethnic groups found in Mali.
Between June 2012 and January 2013, the major towns and surrounding land innorthern Mali were effectively administered by the armed opposition groups, who
imposed a strict Islamic rule of law over the territory. Relatively few new refugees
arrived in Mauritania during this period. However, there was significant internal
displacement of people, with hundreds of thousands of people fleeing the north ofMali to seek refuge in the south.
Negotiations between some of the opposition groups and the Malian transitional
government broke down in January 2013, leading to an offensive by opposition forces
to the south, which was seen as threatening the capital, Bamako. In response, theFrench army arrived in Mali to join Malian forces in pushing back the rebel advances.
Within several weeks, the armed opposition groups had abandoned all the major
towns in the northern regions. The French-led military intervention and its aerial
bombardments of northern Mali caused panic among the nomadic population andtriggered a third wave of refugees; at its peak, 1,300 refugees were arriving every day
at Fassala, the border crossing between Mali and Mauritania.
Since the French army’s intervention, the situation in northern Mali has been highly
unstable, with the armed opposition groups reverting to guerrilla tactics, including
roadside mines and bomb attacks in populated areas. Meanwhile, the Malian army
is accused of widespread revenge attacks against the remaining Tuareg and Arab
population. This insecurity, combined with the displacement of a significant partof the population, has led to a complete collapse of the local economy, with foodresources becoming increasingly scarce.
The latest refugees to arrive in Mauritania from March 2013 cite food insecurity andthe collapse of basic services as their main reasons for fleeing Mali.

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Refugee stories

MSF conducted 100 interviews between February and mid-March 2013 with existing refugees in the camps and withnew arrivals at Fassala border crossing between Mali and Mauritania.
The interviews are a snapshot of the situation, and by no means portray the entire ethnic complexity of the conflictand resulting refugee crisis. However, this snapshot does provide an insight into the underlying tensions, and indicatethat people’s fears of the re-emergence of old ethnic and political tensions are at the root of the crisis. It also
indicates that this is likely to be a prolonged situation which will require a sustained response from aid agencies.
Profile of refugees
The majority of the refugees in Mbera camp are
pastoralists who lived nomadic or semi-nomadic
lifestyles in Mali. Dependent for their living on
livestock, about 55% of the nomads interviewed by
MSF in Mbera camp have family members still in Mali
– usually young men – who have stayed to take careof the cattle. Often the young men come to Mbera forshort stays before returning to their herds in Mali.
The ethnic composition of the people interviewed
shows the same diversity as in northern Mali. The

main ethnic groups in Mbera camp are Tuaregs (65%of interviewees) and Arabs (26%), with 9% from otherethnic groups. The majority (97%) of those interviewed
are from the Timbuktu region.
Reasons for fleeing
Almost half (45%) of those interviewed in Mbera camp
had fled pre-emptively, out of fear of reprisals by the
Malian army or local population. Many were able tobring belongings, clothes, money and even cattle withthem to Mauritiania.

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“I left three of my sons in our village in Mali to take care of the
livestock. With the other village chiefs, we took the decision to leaveout of fear of the Malian army. I lost brothers and cousins in 1992.
I saw a lot of atrocities and I lost a lot of loved ones in the conflict.
I almost lost all my animals too. This time we left early. Nobody
knows when we will be back but, at my age, I have no desire to go
into exile every ten years. We want a lasting solution. I do not want
to die in Mbera, I want to die at home, surrounded by all my family
in my native land.”Ibrahimou, 71 years old
About one in four (24%)2 refugees had fled direct fighting where their life or the livesof family members were in danger.

“I had no problems with my neighbours from other communities.
Things changed after the outbreak of the violence in January
2012. Overnight, we could not leave the house. Our neighbours
threatened and insulted us. We had to hide to avoid confrontation.
For them, all ‘white skins’ are rebels. I was very affected by theaggressive words and deeds of my former neighbours and friends.”
Mamoudou (not his real name), from Bamako
The seizure of power by Islamist groups in cities such as Timbuktu, Gao andKidal had pushed 3% of interviewees to flee.

“After the takeover of Timbuktu by Ansar Edine, our lifechanged. Jihadists paid young men to join their movement. We
women struggled. I had to cover my whole body before goingout. Women no longer had the right to speak or greet people
in the street. Life was very hard for us. My family and I stayed
three months under Ansar Edine, but when I was warned andthreatened by the police because of my clothes, I preferred toleave the city permanently.
Maymouna, 21 years old, from Timbuktu
One in five (20%) of the refugees interviewed had arrived after the French-led
military intervention.

“I fled with my family because of the bombing. They did notbomb the place where we were staying, but we could hear thenoise when they started bombing Timbuktu. I was afraid. I
fled with my husband, leaving behind our livestock and somemembers of the family. I had just given birth, so the journey was
not easy. I got sick and so did my children. I vomited and had
diarrhoea. We took food and water with us, but the heat and thetransport difficulties made the journey really hard.”
Awa (not her real name), 32 years old, from Timbuktu
2 Includes direct and indirect threats by the Malian army or pro-army militias, and includes bombings.

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The most recent arrivals interviewed in the final two weeks of the survey(8% of interviewees) said their main reasons for leaving Mali were foodshortages, a lack of basic services such as healthcare, and the breakdownof economic activities.

“Life has become very hard. I had nothing to give to mychildren. There was nothing to eat, shops were closed or
empty. There was no market for cattle. I could not stay
because I have small children to feed.”
Halima, 24 years old, from Léré

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MSF’s responseto the refugee crisis

In late-February 2012, soon after
the first influx of refugees started
arriving in Mauritiania, MSF began
medical and nutritional activities forrefugees and the local population in
the district of Bassikounou.
MSF is providing free-of-charge basic and hospital-level healthcare, as
well as antenatal care for pregnant
women. Our medical teams initially ran two health centres in Mbera
camp and supported two healthposts, one in Mbera and one at theborder post of Fassala.
In January 2013, as a new wave ofrefugees arrived, our teams adapted

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their response to deal with emergency needs by setting up a third
health centre. During this time thenumber of consultations went from1,500 to 2,500 per week.
So far, since the start of 2012, ourmedical teams have carried out
over 85,000 consultations, attended
200 births, and treated some 1,000
severely malnourished children.
With the nearest hospital locatedmore than 200 km away, MSF has
also set up an operating theatre in
the village of Bassikounou to provide rapid medical care and stabilise the most serious cases before

referring them to the hospital in
Nema.
Protecting children against measles
is another top health priority in thecamps for our staff. In the confinesof the camps, amongst children
who are often suffering fromchronic malnutrition, an epidemicof measles could be devastating.
Our teams have vaccinated close
to 10,000 children against measles
since March 2012.
MSF runs medical programmes in
the Malian regions of Mopti, Gao, Sikasso, and Timbuktu, as well as forrefugees in Burkina Faso, and Niger.

“It took us two days to get to Fassala. We
were tired, but still alive, and safe – thatwas the most important thing. Now wehave to adapt to life in Mbera – it is going tobe very hard. My daughter gave birth here
and we had nothing for the baby. He’s still
suffering from malnutrition and he has
been admitted to the MSF programme.
The food here is not the same as what wenormally eat. We are nomads, we needmeat and curdled milk, but here they give
us rice and oil. I was poor in Mali, but here
it’s even worse. I’ve got absolutely nothing.
Also, I feel completely foreign and far awayfrom my home country. I want northern
Mali to return to peace so that I can finallygo back.”
Azarra (not her real name),
40 years old, from Timbuktu
Since March 2012, MSF has been calling attention
to the deplorable conditions greeting new arrivals
to the refugee camps in Mauritania and the impact
these conditions are having on the health of close to70,000 refugees.3
In January 2013, humanitarian aid came underincreasing pressure following the influx of 15,000
refugees. Three months later, a number ofmeasures have been implemented and we are now
seeing some improvements to the supply of aid tothe camps. Nevertheless, with a refugee crisis thatis likely to continue, the challenge will be to continue
to provide assistance that meets humanitarian
standards.

Poor hygiene
When an extension was added to Mbera camp toaccommodate the new refugees arriving in January
2013, our teams witnessed a situation where there
were only four latrines for 12,000 people. Humanitarian
standards4 call for a minimum of one latrine for every
20 people. There had also been no distributions ofhygiene kits, soap or jerry cans for five months. To
improve the dire sanitary conditions in the camp,
additional latrines are now being built and there havebeen distributions of soap.

Water shortages
In the desert region where the camps are located,neither refugees nor locals have sufficient access toclean drinking water. In Mbera camp, refugees receive
just 11 litres of water per person per day, instead of the
20 litres recommended by humanitarian standards.
With daytime temperatures hovering around 50
degrees, staying hydrated is essential, especially foryoung children and the elderly. Water shortages also
increase the likelihood of diseases linked to poor
hygiene. For refugees and locals who have livestock
to care for, getting access to sufficient water for theiranimals in this drought-prone region is a real problem.

Lack of shelter
A number of refugees who arrived in January 2013
had to wait more than four weeks to receive sheltermaterials. Arriving with few possessions, they had no
option but to build makeshift shelters using scrapsof cloth and sticks. While most families have now
received a tent, there are still some 2,000 people living
in large temporary tents while they wait to receive
shelter materials.

3 http://www.doctorswithoutborders.org/news/article.
cfm?id=5797&cat=field-news, http://www.doctorswithoutborders.
org/press/release.cfm?id=5921, http://www.doctorswithoutborders.
org/press/release.cfm?id=6005&cat=press-release, http://www.
doctorswithoutborders.org/news/article.cfm?id=6091&cat=field-news,
http://www.doctorswithoutborders.org/news/article.cfm?id=6534,
http://www.doctorswithoutborders.org/news/article.cfm?id=6634
4 http://www.refbooks.msf.org/MSF_Docs/En/Refugee_Health/RH.pdf

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The impact on refugees’
health“When we arrived in Mbera, my baby got
sick, lost his appetite and would no longer
take my milk. The doctors tell me that heis malnourished. Even I have lost weight
and feel weak. Conditions in the camp
are harsh. The food is not enough and thechildren don’t have enough milk. They do
not give us any milk here. We are nomads– we need milk; it’s a basic part of ourdiet. We sold the tent that they gave us inorder to be able to buy something to eat. A
lot of people are doing that.”
Awa (not her real name),
32 years old, from Timbuktu
Most of the illnesses treated by MSF teams during
medical consultations in Mbera camp are directly
linked to the poor living conditions and lack ofaccess to water and food. Each week, staff at MSF’s
health centres in Mbera see an average of 1,000
people with respiratory infections, 200 people withdiarrhoea, 100 people suffering from skin infections
and 30 people with malaria.
In November 2012, a retrospective mortality survey
carried out by MSF in Mbera camp showed a mortality
rate of 3.22/10,000/day among children under theage of two5, a rate that exceeds emergency levels.
These figures suggest that children under the ageof two living in the camp die at rates two or threetimes higher than in other parts of Mauritania.
Of the deaths recorded during the period coveredby the survey, 13% involved children under the ageof two, 43% involved children aged under the ageof five, and 22% involved people of 60 or over. The
primary causes of mortality within the camp werediarrhoea (27%), fever/malaria (24%) and respiratory
infections (16%).
5 According to the MSF survey conducted in November 2012, the crude
mortality rate is 0.76 /10,000/day and the mortality rate is 1.46 /10,000/
day for children under the age of five.

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Nutritional situation
In November 2012, a nutritional survey conducted in
Mbera revealed that almost one in five children (17%)
living in the camp was malnourished and that one in
20 children (4.6%) was suffering from the most severe
form of malnutrition.
The refugees are entirely dependent on food rations
provided in the WFP’s monthly distributions. The rations
include 12 kg of rice, 3 kg of pulses, 1.5 kg of corn soya
blend [fortified flour], 0.75 kg of oil and 0.6 kg of sugar.
This food aid is not adapted to the nutritional needsof young children. Mothers receive no milk for theirchildren, and while the rice they receive helps alleviate
hunger, it does not provide the nutrients that are
essential to a child’s growth and development.
The food aid is also not adapted to the dietary customsof the predominantly pastoralist refugees, who areused to a diet based on milk and meat. Some families
admit they regularly sell a portion of their rations so as
to buy milk and meat to feed their children.

Malnutrition on the increase in 2013
Between January and February 2013, MSF’s feeding
programme saw an increase in weekly admissions,rising from 42 to 106 severely malnourished children.
In late-February, the majority of admissions to theprogramme (85%) were for children who had recently
arrived in Mauritania. However, the nutritional
screening carried out by MSF at Fassala health postshows that the vast majority of refugee children6 arriveat the Mauritanian border in good health.
MSF recommends providing families with food rations that contain CSB ++, which is made from milk,
6 If a MUAC band shows red, the child is suffering from severe acutemalnutrition. Orange indicates moderate acute malnutrition. Yellow meansthat the child is “at risk” and green indicates that there is no problem.
Between January and February, MUAC screening of almost 4,000 children at
Fassala showed 96% green, almost 3% yellow, and less than 1% red.

oil and sugar, in order to meet the nutritional needs of children under the age of two and to prevent them frombecoming malnourished.
At Fassala health post, MSF’s medical teams conducted a systematic screening for malnutrition based on the midupper arm circumference (MUAC) measurement of children aged from six months to five years. A comparative
analysis of the medical data shows that children who had recently arrived developed malnutrition problems after
being in the camp for six to eight weeks.
Weekly evolution of severe malnutrition cases detected among refugee
children arriving in Fassala and Mbera camp, weeks 1-13 2013

Cases number

180
160
140
120
100
80
60
40
20
0

1

2

3

4

5

6
7
Weeks

Fassala (malnutrition screening)

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9

10

11

12

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Severe Malnutrition Admissions in Mbera Camp

Apart from the food rations being unsuitable, the problem is being exacerbated by delays in providing food aid to
new arrivals. Refugees are registered in Fassala but do not receive any food aid at this point, so a family arriving
at Mbera camp after the monthly rations have been distributed might have to wait for four weeks before receiving
any food assistance. As a result, many new arrivals are forced to rely on existing refugees sharing their own rations
with them. This situation is likely to be contributing to the increase in malnutrition rates amongst children.

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© Nyani Quarmyne

CONCLUSION
Malian refugees in Mauritania, staying in remote
camps close to the border, are completely reliant on
external aid for all their basic needs including food,water, shelter and medical care.
The majority of refugees have not experienced major
health problems on their journeys to reach Mauritania.
But on arrival in the refugee camps, their healthcondition is deteriorating rapidly – the result of poor
living conditions, inadequate food, a lack of shelter andsevere water shortages. Most notably, young children
who have been in the camps for several weeks are atincreasing risk of malnutrition.
So far the humanitarian response has been far from
adequate. While the provision of water, food andsanitation has recently improved, it remains dependent
on outside assistance and humanitarian aid.
The refugee crisis is not going to go away. The majorityof refugees interviewed by MSF spoke of their fears, if
they stayed in Mali, of reprisals by the Malian army
or other ethnic groups – fears rooted in ethnic andpolitical tensions which go back decades. With theseissues far from resolved, combined with ongoinginsecurity and economic difficulties in northern Mali,these refugees are unlikely to return home in the near
future.
The challenge will be to provide continued assistancethat meets humanitarian standards. MSF calls on all
aid agencies to ensure long-term planning to maintainadequate standards for all those who face a future in
the camps.

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