Congo’s Death Rate Unchanged Since War Ended

DAKAR, Senegal — Five years after Congo’s catastrophic war officially ended, the rate at which people are dying in the country remains virtually unchanged, according to a new survey, despite the efforts of the world’s largest peacekeeping force, billions of dollars in international aid and a historic election that revived democracy after decades of violence and despotism.

The survey, released Tuesday, estimated that 45,000 people continue to die every month, about the same pace as in 2004, when the international push to rebuild the country had scarcely begun. Almost all the deaths come from hunger and disease, signs that the country is still grappling with the aftermath of a war that gutted its infrastructure, forced millions to flee and flattened its economy.

In all, more than 5.4 million people have died in Congo since the war began in 1998, according to the most recent survey’s estimate, the latest in a series completed by the International Rescue Committee, an American aid organization. Nearly half of the dead were children younger than 5 years old.

Perhaps most alarming, while the death rate has slightly decreased in eastern Congo, the last festering node of conflict, it has actually increased in some parts of central Congo, though the area has not seen combat in several years. The study’s authors and other aid organizations said the focus of aid dollars on the east and neglect of the region by government were the most likely explanations for the changes. These surprising findings demonstrate the depth and complexity of Congo’s continuing crisis, said Richard Brennan, health director for the International Rescue Committee and one of the survey’s authors.

“The Congo is still enduring a crisis of huge proportions,” Dr. Brennan said. “Protracted elevations of mortality more than four years after the end of the war demonstrates that recovery from this kind of crisis is itself a protracted process. The international engagement has to be sustained and committed for years to come.”

The survey was based on a sample of 14,000 households surveyed in 700 villages and towns across Congo from January 2006 to April 2007.

Its authors emphasized that the figures in the report are estimates, based on widely accepted statistical methods for estimating death tolls in disasters, but the cumulative figure for how many have died since the war began has a wide margin of error given the difficulty of the terrain in Congo and the lack of precision in basic demographic information, like the prewar mortality rate or even Congo’s current population.

Still, improvements in security since 2004, when the last survey was completed, meant that researchers were able to visit many areas that were off limits last time, and as a result, its authors said, the current survey provides the most complete picture yet of the toll of Congo’s slide into despair.

That picture is not encouraging. The mortality rate in Congo is 57 percent higher than the rest of sub-Saharan Africa, the survey found. Particularly hard hit were young children, who are especially susceptible to diseases like malaria, measles, dysentery and typhoid, which can kill when medicine is not available. In one village in North Kivu Province, a hot spot of continued fighting, three women of the 20 households surveyed had lost two children each in the 16 months covered by the survey period, Dr. Brennan said.

Less than half a percentage point of the deaths were caused by violence, illustrating how the aftermath of war can be more deadly than combat itself. Much of the emergency aid is focused on the eastern part of the country, where militia battles with Congolese troops have chased nearly half a million people from their homes in the last year. A peace agreement to end that conflict was reached Monday.

But the increased mortality in areas outside of the volatile east is particularly worrying because it points to longer-term problems that endure long after the bullets have stopped flying.

“Given the nature of this country, the vast differences in terrain, the broken infrastructure, I am not surprised,” said Alan Doss, the newly appointed chief of the United Nations’ vast peace operation in Congo. “This will take a long time to turn around.”

The Congolese government spends just $15 per person each year on health care, according to the World Health Organization, less than half of what is recommended to provide the most basic but lifesaving care, like immunizations, malaria-fighting mosquito nets and hydration salts.

“The past two years, we can say the health situation has not improved at all,” said Brice de le Vingne, operations coordinator for the region that includes Congo for the aid group Doctors Without Borders. “The only thing that improved a bit is mobile phone coverage. We now are in contact with more people to know that the situation is not good.”

Mortality surveys are crucial tools for aid agencies, United Nations peacekeepers and even historians, but the methods used to compile them have come under attack.

For example, a 2006 survey by the Johns Hopkins Bloomberg School of Public Health that concluded that 600,000 Iraqi civilians had died since the American invasion — far above the estimates given by the Iraqi government and other sources — was attacked as “not credible” by President Bush and the Pentagon, and criticized by other scientists as well.

For the current survey, teams of workers fanned out across Congo, a nation as big as the United States east of the Mississippi, but with rivers instead of roads, canoes and bicycles instead of airplanes and cars.

Debarati Guha-Sapir, director of the Center for Research on the Epidemiology of Disasters, a research institution in Belgium, said that the Congo survey was methodologically sound. Still, extrapolating from clusters of data over an area as vast and with as many unknowns as Congo presents particular problems, she said.

“The fact is that you have a high mortality rate in Congo altogether by any standard,” Dr. Guha-Sapir said. “Of which some is the result of conflict, some is governance, some is that no heath services are available in many areas, some is just pure poverty and the horrible legacy of what colonialism and Western greed did to Congo.”

A number of variables make the survey results inevitably imprecise, particularly when trying to turn an abstract death rate into a number of actual deaths. The population of Congo, for example, is essentially unknown: the United Nations estimated it to be 56.8 million; the Congolese Ministry of Health says it is 69.9 million. If the United Nations figure is right, for example, the actual number of deaths in the most recent survey period would be 522,000, but if the government figures are right, the figure would be 1.05 million, the study found.

The number of deaths attributed to the conflict and its aftermath is based on how many people would be expected to die under normal circumstances. Because Congo’s prewar mortality rate is disputed by different sources, it is also a source of imprecision.

According to various United Nations estimates, the prewar rate was below that of sub-Saharan Africa as a whole, but the survey’s authors said they chose to use the higher rate of the continent to be conservative.

Still, even the death rate for sub-Saharan Africa could be a problematic baseline, said Dr. Guha-Sapir, because in many countries the most basic kinds of censuses are carried out rarely, and not always with precision.

Ultimately, using the most conservative and least conservative assumptions, the data show with 95 percent certainty that 3.5 to 7.8 million people have died since 1998, according to the survey’s authors.

An earlier survey by the International Rescue Committee, completed in 2004, was published in 2006 in The Lancet, a British medical journal, but the most recent survey was declined for publication by The Lancet. Other experts said such a rejection did not necessarily undercut the scientific validity of the findings.

Dr. Brennan said that despite inevitable imprecision, the data point to a vast crisis.

“Is it possible that as few as five million people died?” he said. “It’s much more likely that 5.4 million died. But the exact number isn’t as critical. These data can help us understand the scale of the problem and target our solutions to save lives.”