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The international aid group Doctors Without Borders found a pattern of abuse and sexual exploitation by some local and foreign staff working in Chad along the Sudanese border, in some cases targeting underage girls or trading food or jobs for sex with refugees, according to a confidential internal memo obtained by The Associated Press.

The Doctors Without Borders report — completed in July and first reported Saturday by The Associated Press — found 59 allegations of abuse and said 18 staff members were dismissed and barred from future employment. In some cases, the group told AP, the allegations couldn’t be verified or the perpetrators identified. The report also said some of the repeated exploitation suggested potentially organized “sexual trafficking.”

The organization said it launched the monthslong investigation in response to AP reporting that women had accused staff of sexually exploiting them in displacement sites in Chad, where hundreds of thousands fled from Sudan’s devastating civil war, now in its fourth year. The report credited AP as playing “a fundamental role as an external whistleblower.”

The findings by Doctors Without Borders — one of the largest employers and biggest aid organizations in the refugee camps in eastern Chad — indicate the abuse was more widespread than previously reported.

Sexual exploitation has repeatedly surfaced during humanitarian crises despite years of efforts by aid organizations to prevent abuse.

In the cases AP found in Chad in 2024, women said people meant to protect them — humanitarians, local security forces — offered money, easier access to assistance and jobs in exchange for sex. Such sexual exploitation in Chad is a crime.

And in its report, Doctors Without Borders noted that the cases found in Chad stand out because it had allocated extra resources to combat and prevent abuse. The memo also said the findings likely only scratch the surface, as many women were hesitant to speak openly.

In response to questions about the memo, Doctors Without Borders — also known under its French acronym, MSF — called it “a candid internal analysis” that laid out where systems failed.

The 59 allegations of misconduct ranged from sexual harassment to exploitation and abuse and “represent a serious breach of MSF’s values and responsibilities, and we deeply regret the harm caused,” MSF said in its written response.

MSF operates in contexts where people are vulnerable and dependent on humanitarian assistance, which creates power imbalances and risks of abuse that must be addressed, MSF’s statement noted. It said the investigations were meant to proactively confront the abuse.

In some of the cases investigated, tracing the people involved wasn’t possible because of the scale of the emergency and movement of people, it said.

Since issuing the report, MSF has strengthened recruitment efforts, reference checks and complaint systems, it told AP.

Still, the group said in its statement that it recognized that significant work remains to ensure lasting change.

The report detailed several types of abuse and exploitation within Doctors Without Borders

MSF launched its investigation in fall 2024 and found allegations of exploitation and abuse of Chadians, Sudanese refugees, and MSF staff and contractors.

The report says the group was investigating several cases of sexual exploitation of female refugees in exchange for food, water and milk. It also found cases of sex in exchange for jobs, and the prostitution of female refugees, including underage girls. It cites a block in a refugee camp where staff were seen searching for girls, and said community leaders implemented a curfew to prevent young girls from “’visiting’ MSF staff.”

In one incident cited in the report, seven refugee girls, allegedly hired as daily workers, were put into an MSF vehicle and told they were going to water distribution and construction sites. The girls, however, were taken to a different location and “exposed to” sexual abuse and requests for sex, according to the report.

In addition, some female Chadian staff were threatened with losing their jobs if they refused to have sex with supervisors or colleagues, the investigation found.

In focus groups conducted by investigators, women said they often chose to remain silent, worried it would jeopardize access to care. Some said they didn’t know they had the right to speak up or share feedback, according to the report.

MSF staff and community leaders told investigators they were afraid to report abuse for fear of losing jobs or assistance. The report noted that half a dozen community leaders said even though their daughters or sisters had been victims of abuse, they chose not to report to MSF.

The report also said that some who spoke up didn’t get help, with several alerts receiving no follow-up.

The memo said some feedback mechanisms, such as boxes where people could place complaints, were largely ineffective.

MSF employs tens of thousands of people across dozens of countries, with jobs ranging from doctors, nurses, midwives and epidemiologists to human resources, logistics, construction and sanitation specialists. The report did not specify which jobs those accused of abuse held. In its email to AP, MSF said it would not provide details such as employment category because of privacy and safety concerns.

MSF’s email emphasized that it has implemented improved reporting methods and integrated prevention and detection responses in its operation — for example, including confidential reporting channels in its current response to Congo’s Ebola outbreak.

Doctors Without Borders was unaware of most cases of abuse before AP’s reporting

Prior to AP’s reporting, MSF was unaware of most of the cases of abuse, according to the report.

In 2023, the report said, MSF had conducted weeks of training with staff and community leaders about prevention. But efforts didn’t have a lasting impact and were undermined by high staff turnover, it said.

The memo said the urgent need for personnel and the absence of reference checks had resulted in the hiring of people with a history of misconduct or abuse.

As a result of the investigation, the report said, 18 staff — including international, local and contractors — were or were about to be classified as “Do Not Hire.” But the report said there was no system in place to share names of people flagged as such, specifically for local staff, meaning they could get jobs in another MSF location.

The report made several recommendations: clearly communicating expected behavior to staff, employing “serious reference checks,” and creating one effective database for “Do Not Hire” staff.

Still, MSF acknowledged in the report that it had previously experienced similar allegations — the 2021 Ebola outbreak in Congo and reports of widespread exploitation and abuse by aid workers and peacekeepers in several West African countries in 2002 — but little had shifted overall.

“As a reminder, a rather similar diagnosis and recommendations were made in 2021,” said the memo. “Yet this led to no significant change.”