In the southern part of Mauritania, particularly in the Hodh el Chargui region, Malian refugees have endured years of violence and hardship. The renewed conflict in northern Mali in 2023, involving Malian armed forces and their Russian allies against armed groups such as the Group for Support of Islam and Muslims (GSIM or JNIM), caused entire villages to be abandoned, with thousands seeking refuge in this remote part of Mauritania. Many of these refugees have experienced violence and live in extremely difficult conditions. MSF teams have reported the extreme precarity of their situation and the lack of adequate humanitarian aid. Since the 1990s, every conflict in Mali has led to population movements toward the Hodh el Chargui region in Mauritania. In 2012, northern Mali was taken over by a coalition of separatist movements and jihadist groups, who then controlled the area. Malian refugees were then gathered in the Mbera camp, near Bassikounou, which became the de facto third-largest city in Mauritania, with a population of 120,000 people. Since 2023 and the resurgence of violence in northern and central Mali, new refugees are encouraged to be hosted within the host community, not to go to the camp, which has reached saturation, explains Sabrina Hazi, MSF coordinator in Bassikounou. The new refugees live mainly in informal sites scattered across the vast semi-arid region. Most fled their villages in Mali quickly, leaving behind all their belongings and lives. While they have found safety in Mauritania, they face extreme poverty. The dry season, from November to July, is particularly difficult, marked by water shortages and food insecurity. MSF relaunched operations in the Hodh el Chargui region at the end of 2024, starting with mobile clinics and later supporting the structures of the Mauritanian Ministry of Health. The medical services were already insufficient for the local population, and the new wave of refugees created a real health crisis. MSF came to address important primary health needs for both Mauritans and Malians. Dr. Isabelle Manguet-Youla notes many cases of anemias and chronic diseases in adults, such as diabetes and hypertension. These diseases require regular medication, which is at risk due to the distances and the challenges of preserving medicines in camps without electricity. A Malian patient suffering from malnutrition presented herself at an MSF mobile clinic. She said she consumed whatever she found and had barely the strength to eat. She also had a severe calcium deficiency. When asked if she drank milk, she broke into tears, explaining that in Mali she had plenty of livestock and milk, but in Mauritania she never drinks a drop. Her tears were also a sign of great psychological suffering, linked to her flight from Mali. Access to water is difficult throughout the region, which is hit hard by climate change, including for Mauritans, but it is a daily struggle for the recently arrived refugees. Humanitarian action is largely focused on the Mbera camp, leaving the informal sites around it aside. Often installed far from the wells, they have to travel several kilometers by cart or on foot to fill water cans, hoping not to find an empty reservoir upon arrival. The wells are too few in this area and often non-functional. During the dry season, and especially between April and June when temperatures exceed 48 degrees, it is very difficult to find water. Several times a month, injured civilians cross the border into Mauritania, seeking care, which is inaccessible in the center and north of Mali. Mid-September 2026, three women and a man, injured by a drone strike, were brought to the Aghor health center supported by MSF. Their camp, located about twenty kilometers from the border, was attacked, as rumors spread about the presence of Russian soldiers and paramilitaries in the area. Mariam*, 45 years old, has a deep wound on the buttock caused by a projectile fragment. She testifies on her hospital bed that when she heard the sound of drones, she understood that Wagner was attacking the village. Her shelter was hit by a strike. Everyone started to flee. These men also attacked a family at a wedding party. They beat a man to death and threw his body into a well. Traumatized, Mariam refuses to return to her village in Mali. The Epicentre study conducted in 2025 confirms the extent of the violence experienced by the refugees. Most of the people questioned for this study came from the regions of Tombouctou, Ségou, and Koulikoro. They were massively exposed to extreme violence, seen or experienced, before and during the exile from Mali to Mauritania: torture, arbitrary executions, kidnappings, sexual violence, targeted destructions, committed by armed groups and mercenaries. Most are survivors, says Dr. Manguet-Youla. Mohammed and his wife Kheira* accompany their daughter Aicha*, 16 years old, to a psychological follow-up consultation at the health center in Fassala, where MSF works. Their lives turned upside down eight months ago, when mercenaries arrived in their village, located about ten kilometers from the commune of Léré. The Wagner* arrived in their village. They arrested Kheira's brother and another man to question them. They beat them, then took them a few kilometers away and killed them. They were not able to recover their bodies but saw their photos that circulated on social media; they were decapitated. Mohammed says he does not know why they were after them. Sometimes jihadists come to their village, but they have nothing to do with the jihadists; they are not in this war. Their daughter Aicha was in her uncle's house when the mercenaries arrived. She was shaken by the Wagner. Mohammed immediately left the village with his wife, Aicha, and his five other children to take refuge in a neighboring village. But the next day, JNIM jihadists came and chased them away. It was then that the family fled to Mauritania, where Aicha arrived in a state of shock. She was taken care of at the MSF health center in Douenkera, located just a kilometer from the Malian border. In a state of traumatic stupor and suffering from multiple infections, she was hospitalized in the city of Bassikounou for a week. According to the United Nations High Commissioner for Refugees (UNHCR), 83 percent of the new arrivals are women and children fleeing insecurity in northern and central Mali. Some of the women we see in consultation say they have experienced terrible things, but social and cultural norms prevent them from talking about rape, it is a taboo subject, explains Sylvie Mbairo, head of mental health activities for MSF in Mauritania. The weight of customs is very heavy, a woman who has been raped is a disgrace for the family but also for the entire community, and especially the village chief. She risks rejection. The family prefers not to talk about it so that she is not stigmatized and can marry and hope for a normal life. Many of the Malian refugees MSF receives in consultation suffer from psychological disorders. Upon arrival, and although safe, the refugees report the persistence of physical and psychological impacts attributed to the violence, which are exacerbated by their difficult living conditions - economic precariousness, food insecurity, limited access to water, care, and means of subsistence. Members of the host community also suffer from impoverishment and competition for resources, threatening peaceful coexistence, notes the Epicentre study. On average, six new patients appear each week in the centers where MSF intervenes for psychological and social follow-up, but this represents only the tip of the iceberg of the needs. Identifying people who need help while the population is scattered in the desert is a real challenge. Moreover, the specialists are not numerous enough in Mauritania: the Hodh el Chargui region has only one psychiatrist. To address these shortcomings, MSF is implementing a program allowing medical personnel not specialized in mental health to treat depressive or psychotic disorders, a first step to help thousands of people rebuild their lives. Mental health agents trained by MSF offer psycho-social support sessions in four health centers near the Malian border. Husseina, 60 years old, came to seek support from MSF, traumatized by a drone attack in March 2025. A refugee in Mauritania, she used to go every week to the Jdeir market, a Malian village located about ten kilometers from the Mauritanian border, to sell dried okra, her only means of subsistence since she left Mali two years ago. On March 16, 2025, while Husseina was there with her son-in-law, drones flew over the market, following cars nearby. The explosions caused dozens of deaths and injuries among the crowd. Husseina's son-in-law died in front of her. After this attack, she no longer managed to sleep. Since her medical care and thanks to the psychological follow-up of an MSF counselor she sees every month, she has regained sleep, but she no longer goes to the market to sell vegetables. Today my life is harder than before. It is even more difficult to find food and especially water, she explains. If more than 35 percent of patients seen in health centers supported by MSF identify experienced violence as a stress factor, it is mainly their living conditions in Hodh el Chargui that often lead to depressive and anxiety disorders.