February 8, 2017; Reuters

In southeastern Chad, Doctors Without Borders, or Médicins Sans Frontières (MSF), is reporting an outbreak of hepatitis E, an occasionally fatal liver disease. Hepatitis E is spread through contact with fecal matter, usually in contaminated water, and is more prevalent in poorer communities with insufficient access to water purification.

Hepatitis E has a low fatality rate, about one percent, except in pregnant women, whose fatality rate with the disease is 10-30 percent. Because it is overwhelmingly spread through unclean water, its prevalence in developed countries is very low—about six percent in the United States.

So far, about a dozen people in Chad have died in care, although MSF says there may be more people who died without coming to seek treatment. As they treat the victims of the disease, MSF is simultaneously trying to treat the root cause by rolling out a clean water campaign and educating people about the importance of soap and chlorinated water.

Rolland Kaya, MSF mission head in Chad, said, “As a medical organization, it is not usually MSF’s job to intervene on a large scale in water chlorination activities, but with no other options to help stop the spread of the virus, we are obliged to fill this gap.”

Chad’s health and water systems are inadequate for its population, which has swelled by 300,000 refugees from Sudan in the recent years. In fact, a study by WaterAid ranked countries’ access to clean water and put Chad in the bottom five.

Part of the problem in Chad is a lack of government resources. A ranking of 185 countries by wealth put Chad at 154, with about five percent as much wealth as the United States. It’s pretty hard to build sanitation infrastructure with so few resources.

Development efforts in Chad have also been hampered by conflict. Chad endured civil war from 1966–1996, and then from 1998–2003; in 2004, fighting from the Darfur region across the border in Sudan spilled into Chad. Sudanese conflict, which NPQ has covered in the past, affects Chad, both through the refugees who flee across the border and through accusations of Sudanese interference in Chadian conflict and affairs.

In 2009, the Red Cross and five other organizations withdrew operations from Chad, citing an inability to keep their personnel safe.

Since 2010, internal conflicts have been mostly controlled, though President Idriss Déby, who has been in power since 1990, continues to face opposition. Now, though, the terrorist group Boko Haram is attacking the country, diverting time and resources and deliberately targeting health centers.

Harvard Medical School researcher Margaret Bourdeaux has pointed out that one of the unmentioned casualties of conflict areas is healthcare systems. It takes time, resources, risk, and infrastructure elements like electricity and communication to run an adequate healthcare network, and rebuilding such a network after conflict can take a long time—longer than the public clamor for aid and attention usually lasts.

There are currently 3.7 physicians per 100,000 people in Chad, according to the World Health Organization (WHO). A significant portion of Chad’s healthcare, therefore, is provided by foreign NGOs. This is good news in the short term, but bad in the long term; Bourdeaux and her colleagues found that there can be conflicts of interest when security interests are prevalent in areas that receive foreign health aid.

MSF has previously been forced to go beyond medical aid provision, such as when they rescued refugees from the Mediterranean Sea. Now, they are asking for other NGOs to step in and help promote water sanitation in Chad before the hepatitis outbreak spreads.

Unfortunately, American aid to the region may be jeopardy at this critical time. USAID’s regional partner since 2008 is Africare, an aid organization with the broadly stated mission to “improve the quality of life of the people in Africa.” As part of their healthcare work, they provide abortifacient contraception, which would make them ineligible for USAID funding under the recently reinstated Mexico City Policy.

Access to clean water is a challenge in many parts of the world, and is only becoming more difficult as global warming produces more droughts and desertification. It is also a concern in the refugee camps springing up around the world in response to the refugee crisis. However, as MSF and Chad are finding out the hard way, it is a pressing need that must be addressed before bigger problems come along.— Erin Rubin