MSF takes an innovative approach to eliminating sleeping sickness, taking mobile clinics by Land Rover and boat to far-flung parts of sub-Saharan Africa.

Apart from MSF, there are few organisations in the field dealing with sleeping sickness, a disease of the nervous system that is spread by the tsetse fly, causing severe neurological disorders or even death.

Dr Andreas Lindner is a member of MSF’s team, working to combat this neglected disease in Chad, Central African Republic, South Sudan, Republic of the Congo and Democratic Republic of Congo.

He shares his insight and experience on combating sleeping sickness:

Finger prick screening for sleeping sicknes, DRC. If this test is positive further more complex tests are needed to confirm sleeping sickness.
© Robin Meldrum

Opportunity to eliminate sleeping sickness 

“We’ve been presented with a unique opportunity to help eliminate sleeping sickness. 

Over the past few years, the disease has slowly been coming under control and, with a concerted effort, it’s feasible that the next few decades will see the elimination of this disease.

It’s in sight, but everything depends on what we do now, and our willingness to really focus and invest resources and manpower into tackling the disease.

I’ve spent the past few months working in areas affected by this disease in Chad, Central African Republic and Republic of the Congo, and what I’ve seen has convinced me that, although this disease is still a problem, the opportunity is there to deal with it.

Elimination is our aim but, in order to achieve that, we need a sustained effort to overcome some serious obstacles.

Ready-to-use tests

Firstly, we need new diagnostic tools in order to identify the disease, as the current tools aren’t up to the task.

Right now, if we want to diagnose patients with sleeping sickness, we have to use a lot of complicated equipment, including centrifuges and microscopes, which are cumbersome and difficult to use in remote areas.

If you’re out in the middle of Central African Republic, travelling by boat up a river, it’s not efficient or practical to be using such complex equipment.

What we need are ready-to-use tests that can be used by local health staff in rural health posts. Like the malaria test, it should be a simple finger-prick test, where small drops of blood are put on a test and you quickly get the result.

Time for action

These tests are in the development pipeline, but we can’t afford to wait several years for them to come online.

There are people suffering and dying now, and there has to be a concerted effort to move things along. Now is the time for action. 

Along with research and development, more effort needs to be put into control of the disease in the here and now. It means we have to go to remote areas which are often politically unstable and have weak health systems. We have to go and find patients in their villages, with systematic screening.

There are large areas in endemic countries without surveillance, where we just don´t know what is going on. Apart from MSF, there are few organisations in the field dealing with sleeping sickness.

MSF innovation

MSF team conducts a lumbar puncture test for sleeping sickness, required to determine the appropriate course of treatment. DRC, February 2011
© Robin Meldrum

We also need more innovative approaches to control, which is why, at MSF, we came up with the idea of creating an international mobile sleeping sickness team.

In some of these remote areas where the disease is prevalent, we can’t justify setting up a full and permanent project.

But what we can do is establish a small mobile unit made up of a lab technician, a medical doctor and a few others, who can travel across regions in a number of countries screening people and treating the disease.

I was in the first team that set out in August last year, and we started working in areas where the national control programmes struggle, and where political instability or remoteness make disease surveillance and management difficult.

Reaching the sick

There were a lot of lessons learned. In southern Chad, we screened a little village of about 2,000 people over two-and-a-half days. There was a good response and we didn’t find a single patient.

But after the screening was finished and we had moved 50km on into Central African Republic, people from the same village caught up with us, with a young woman who was suffering from the disease.

The woman was unable to walk, or even to feed herself. We asked her why she hadn’t come to the screening, and she told us she had felt too sick to come.

That was a real wake-up call for us, because it showed us how difficult it can be in remote environments to really get to the people who need help. We need to visit the most far-flung villages and look into people’s huts to find those who are too sick or too ashamed to come for help.

We learned a similar lesson with fishermen, who are exposed during their working day to the tsetse fly. In order to reach these people, we quickly realised we had to be up at dawn, before they headed out on their boats, otherwise we would miss our chance.

National programmes needed

However, all the smart approaches in the world will not make a difference to this disease unless we put our full support behind national control programmes and national health systems in countries where the disease is endemic.

With health services already fighting other epidemics such as HIV, it’s easy for sleeping sickness to become even more of a neglected disease.

In many of these countries, the national programmes are poorly equipped and don’t have the capacity to deal properly with the disease.

We have to realise that, ultimately, it is the national control programmes – and not MSF, or any other organisation – that will get this disease under control, and they need all the support and cooperation they can get.

We’ve talked about a ‘final push’ to eliminate sleeping sickness, but in reality that makes it sound too quick, easy and short.

What we really need is a firm commitment over the coming decade – or more – to tackle this disease. I’m optimistic that it can be done.”

• Find out more about MSF's work on sleeping sickness
   

MSF is delighted that attention is finally being paid to some of the diseases that have been neglected for too long. The US and UK’s increased support to control of worm diseases, mainly by preventive chemotherapy through mass drug administration, is encouraging.

However, in the midst of all the positivity MSF wishes to highlight what is still missing if deadly neglected diseases are truly to be eliminated.

Neglected tropical diseases

MSF staff test a mother and child for Chagas disease. Bolivia. © Juan Carlos Tomasi

Though the World Health Organisation, donors and development agencies are drawing attention to Neglected Tropical Diseases, they are underplaying the challenge of tri-tryps or kinetoplastids diseases such as Chagas disease, sleeping sickness, and visceral leishmaniasis.

These illnesses are slated for elimination or control in the World Health Organisation’s Roadmap 2020.

Eliminating tropical diseases

However, so far the strategy is missing some key elements, and the goals to eliminate or control these diseases will only be credible when some critical remaining gaps are filled.

• Briefing paper pdf: What ‘Uniting To Combat Tropical Diseases’ Really Requires

• Annex pdf: Issues to consider on commitments announced by pharmaceutical companies at the Meeting on Neglected Tropical Diseases

Drug companies and donations

By putting so much emphasis on drug donations, MSF is concerned that the WHO’s priorities are at risk of being influenced by what products companies are offering.

 Ultimately, the commitments outlined above by Gilead, Novartis and other companies reflect the policies of the companies, but do not necessarily reflect public health priorities.

Invisible wounds

MSF are providing mental health care to people affected by the recent earthquakes in eastern Turkey.
© Knut Maehlumshagen

Parts of life are returning to normal, with children back at school and shops and markets open again, in Van, Eastern Turkey.

However, some people are still struggling to come to terms with what has happened to them, as well as the stigma of mental health problems, as some of our patients have testified:

A member of the rescue team: “There was one building collapsing. When I arrived there was one man asking me to go in and save his wife and baby child. We did everything we could, but the building collapsed and they died.

"The only thing I could do was cry with this man. So we cried together. I still dream about it.”

Twenty-one-year-old boy: “I cannot talk with you outside, because people gossip, but I know you are here every week and I only had courage to came to see you today, because I think I´m going crazy.

"I cannot sleep in the container, because I remember my previous room, where I had my computer and could talk with my friends.

"I cannot see my girlfriend, because she went to another city after losing everything in the quake; I cannot read or meet my friends, because I cannot enjoy the things I used to enjoy before the quake. Am I going crazy? Can you help me?”

Mental health support

“People have the normal stress reaction: nightmares, loss of appetite, sleep problems or even insomnia," says Maria Palha, an MSF psychologist working in Van.

"They feel helpless, they are afraid to die, some cannot even recognise their village.

“First they were reluctant to come to our mental health group sessions, but little by little we won their confidence and now they speak openly about their frustrations, and come back each week,” she adds.

So far, 3,000 women and 1,800 men have benefited from group sessions and 40 people with more severe symptoms have received individual mental health support.

“In one of the villages we had a five-year-old boy who came with his mother and told us ‘I am scared and my mum is always angry. You need to help us.’

"This shows how people understand now that psychological support can help them, and this is already an achievement,” says Palha.

MSF is also approaching the villages’ schoolteachers to offer support, and is offering psychological support to 91 families of refugees and asylum seekers who have been affected by the quake and live in makeshift settlements in the city of Van.

Background information

In December last year MSF and Helsinki Citizens’ Assembly (hCa), in collaboration with the Turkish Ministry of Family and Social Policy and the Centre for Crisis Coordination in Van, started a two-month psychological support programme in 31 villages outside Van city centre.

In addition to providing mental health support, MSF, in collaboration with Turkish organisations Hayata Destek and hCa and local authorities, has distributed 2,000 winterised tents and 2,000 cooking kits for 12,000 people in 37 villages in Van province.

MSF physiotherapy session in a Libyan detention centre. September 2011.
© Benoit Finck

MSF teams began working in Misrata’s detention centres in August 2011 to treat war-wounded detainees.

Since then, MSF doctors have been increasingly confronted with patients who have suffered injuries caused by torture during interrogation sessions.

The interrogations were held outside the detention centres.

In total, MSF has treated 115 people with torture-related wounds and reported all the cases to the relevant authorities in Misrata.

Patients returned to torture

Since January, several of the patients who were returned to interrogation centres have been tortured again.

“Some officials have sought to exploit and obstruct MSF’s medical work,” says MSF General Director Christopher Stokes.

“Patients were brought to us for medical care between interrogation sessions, so that they would be fit for further interrogation.

"This is unacceptable. Our role is to provide medical care to war casualties and sick detainees, not to repeatedly treat the same patients between torture sessions.”

MSF medical teams were also asked to treat patients inside the interrogation centres, which was categorically refused by the organisation.

Alarming cases

The most alarming case occurred on 3 January 2012 when MSF doctors treated a group of 14 detainees returning from an interrogation centre located outside the detention facilities.

Despite previous MSF demands for an immediate end to torture, nine of the 14 detainees suffered numerous injuries and displayed obvious signs of having been tortured.

The MSF team informed the National Army Security Service – the agency responsible for interrogations – that a number of patients needed to be transferred to hospitals for urgent and specialised care.

All but one of the detainees were again deprived of essential medical care and were subjected to renewed interrogations and torture outside the detention centres.

MSF demands immediate end to torture

After meeting with various authorities, MSF sent an official letter on 9 January 2012 to the Misrata Military Council, the Misrata Security Committee, the National Army Security Service and the Misrata Local Civil Council, again demanding an immediate stop to any form of ill treatment of detainees.

“No concrete action has been taken,” says Stokes. “Instead, our team received four new torture cases. We have therefore come to the decision to suspend our medical activities in the detention centres.”

MSF has been working in Misrata since April 2011, in the midst of the Libyan conflict. Since August 2011, MSF has worked in Misrata’s detention centres, treating war-wounded, performing surgeries, and providing orthopaedic follow-up care to people who had suffered bone fractures.

MSF medical teams have carried out 2,600 consultations, including 311 for violent trauma.

MSF will continue its mental health support activities in schools and health facilities in Misrata, in addition to its assistance to 3,000 African migrants, refugees and internally displaced people in and around Tripoli.

MSF is an international humanitarian medical organisation which has worked in Libya since 25 February 2011.

To ensure the independence of its medical work, MSF relies solely on private donations to finance its activities in Libya and does not accept any funding from governments, donor agencies, or military or political groups.

This is all occurring as the Global Fund to Fight AIDS, Malaria and Tuberculosis prepares to celebrate its tenth anniversary on 28th January.

Horrific conditions

The conditions surrounding access to care for people living with HIV/AIDS in DRC are horrific.

At the Centre Hospitalier de Kabinda (CHK) in Kinshasa, MSF has observed an excessively high number of patients arriving with serious complications resulting from lack of treatment.

Their advanced illness creates unacceptable suffering.

André, 42 year old man, in MSF's HIV centre, Kabinda Hospital, Kinshasa, January 2011
© Mario Travaini/ MSF

"I have worked with HIV-positive patients in many countries in central and southern Africa, but what I'm seeing in DRC has not existed elsewhere for years," says Anja De Weggheleire, MSF's medical coordinator in DRC.

"The situation here reminds me of the time before any antiretroviral (ARV) treatment was available.

"Our doctors face serious complications every day that could be prevented if patients received early ARV treatment."

Eighty-five percent of patients lack treatment

The number of HIV-positive people in DRC is currently estimated at more than one million, 350,000 of whom could benefit from ARV treatment. However, only 44,000 are receiving treatment at this time.

This represents a 15 percent ARV coverage rate, one of the lowest in the world (of all African countries, only Somalia and Sudan have similar rates).

DRC is also one of the two lowest-ranked countries in western and central Africa in terms of the prevention of mother-to-child transmission of HIV (PMTCT).

Only one percent of pregnant women estimated to be HIV-positive have access to PMTCT treatment here. Without treatment, approximately one-third of the babies who are exposed to the virus will be born with HIV.

Reducing funding threatens lives

Despite these disastrous indicators, donors have not given DRC the priority it deserves. What is worse, some donors – such as the Global Fund – are withdrawing or sharply reducing their funding.

While the Global Fund is the leading supplier of ARV drugs in the DRC, the countries that finance the Fund have not kept their promises. As a result, the Global Fund is having to lower its sights.

This pull-back by donors is directly threatening the lives of thousands of people in DRC.

De Weggheleire sounds the alarm. "If nothing is done, it is highly likely that the 15,000 people currently on the waiting list and in urgent need of ARV drugs will be dead within three years.

"As horrifying as that number is, it represents only the tip of the iceberg when you realise that most people living with HIV/AIDS in DRC do not know their HIV status. Many will die in silence and neglect."

Commitment critical

It is crucial that Congolese authorities meet their commitment to provide free prevention services and free treatment for people living with HIV/AIDS.

It is also critical that donors immediately mobilise the necessary resources to ensure that patients waiting for ARV treatment are not condemned to die.

MSF has been working in DRC for more than 30 years, operating HIV/AIDS programmes since 1996. In October 2003, MSF was the first organisation to provide free ARV treatment to patients in DRC.

Through its healthcare support programmes and its AIDS project in Kinshasa, MSF treats more than 5,000 patients in six provinces, more than 10 percent of the number receiving ARV treatment throughout the country.

In Kinshasa, MSF is treating 20 percent of the total number of patients on ARV treatment in the Congolese capital.

Today, MSF is launching a communications and advocacy campaign that will continue throughout 2012 to raise public awareness of the very serious situation facing people with HIV/AIDS in DRC and to encourage all actors to expand ARV coverage.

People living in dozens of tribal villages are caught up in the conflict, unable to reach the Health Ministry’s clinics in Chhattisgarh state.

Dr Rebecca Cuthbert describes how MSF takes the clinics to them:

Dr Rebecca Cuthbert travels with weekly mobile teams into the forests of central India to bring healthcare to the villagers in Bijapur in Chhattisgargh state.
© MSF

It takes five minutes to walk down the sandy back lane to our office, where I open the padlocks on the doors with my jailer-size ring of keys and check the whiteboard I prepared last night about the work for the day ahead.

Mobile clinics

We run five mobile clinics every week; today there will be 14 of us, which means carrying a lot of water.

In the summer, when temperatures are highest, we take up to three litres of water for each person.

We will also carry all our supplies, including lab equipment and drugs, health cards and registration books, plastic sheeting and privacy screens, and two cold chain boxes.

As the team starts to arrive, everyone starts in on their assigned tasks, though the cooks have been working since 5 am to prepare our lunch. Ice packs are placed in coolers. Backpacks are stacked and ready for loading.

Security updates

At the morning meeting, we get our security updates. We’ve heard that the Naxalites may impose a bandh, a travel ban, which means roads could be blocked by treetrunks or newly dug trenches. 

Next, we rush through a host of last-minute questions:  Where is the driver? Where are the snacks? Where is my phone? Then everyone piles into two cars and we’re off.

Buffalo amble languidly along Bijapur’s main road, competing for space with bicycles and cars and children walking to school.

We drive through a checkpoint and out into the country, taking care to avoid chickens, piglets, dogs and cows, and waving to excited children who run through the fields towards us.

An hour later, we park, shoulder our backpacks, and then set off single file behind a team member carrying the MSF flag.

Walking with a clinic

Towels, hats and scarves protect our heads from the already burning sun. The narrow path winds though forest, around paddy fields, and across rivers that are waist-high and fast-flowing in the rainy season but little more than puddles now.

Along with the occasional villager, we pass women carrying bundles of rice or loads of firewood on their heads and a child on their hip, and hunters with their bows and arrows.

After walking for an hour, we arrive at the village and set up the clinic. Like clockwork, the team affixes swathes of green material between poles to make separate screened-off areas for antenatal and postnatal visits, for patients waiting to be seen, for a laboratory, and for vaccinations.

The drug dispensers arrange boxes of medications on an old cot. Scales for weighing children are hung and the nurses prepare to vaccinate for polio, diphtheria, tetanus, petussis, measles, and hepatitis B. 

The doctor gets prepared, while the health educator begins speaking with people waiting to be seen about treatment and prevention for diarrhoea, scabies, and malaria — all common in these parts.

Translating healthcare

The first patients are registered. Communication takes time and patience, since information must often be translated into Hindi, which the nurses speak, English, for the international staff (if necessary), and the local dialect.

MSF has a translator on hand who picks up registration cards and calls patients in to see the doctor. They and their caretakers are interviewed at length about their medical histories and their most recent visits to healthcare facilities.

After seeing the doctor, some are sent for additional tests or for medications, while others go for vaccinations or wound care (all children younger than five go to the nurses for vaccinations).

Pregnant women and people seeking treatment for malnutrition are sent directly to the nurses.

Anyone with a fever is immediately tested for malaria. (We see less malaria in the summer than in later months, but rapid diagnostic tests can detect both falciparum and mixed malarial infections.)

Anyone with tuberculosis sees the health educator for support and counselling.

Childhood malnutrition

As time passes, we try to move the lab out of the heat and cool the thermometers in the cold chain. It’s very hot and very dusty, but the team remains in good spirits, focused on their work.

The drug dispensers patiently explain how patients should take their medicine, using small bags with pictures of the number of tablets required at each time of day to convey the information to a population who did not have the opportunity to learn to read and write.

Some children get their first dose of malaria treatment grounded up and administered with water and sugar.

Most of these children are quite skinny. Illnesses decrease their body weight, especially between the age of one and two; many qualify for supplementary feeding or admission into the intensive feeding programme.

MSF provides mothers with nutrient-rich therapeutic food as well, using community health and outreach workers to explain how important adherence to a regular feeding schedule is and later to trace the progress the children make.

Life-threatening emergencies

I remember a young man came to the clinic with a big cloth covering a massive, bone-deep axe wound in his forehead that he said happened five days earlier.

We cleaned the wound on site, then first took him to the Bijapur district hospital and later arranged his referral to the neurosurgical department in Raipur, some 10 hours drive away.

This patient’s wound eventually healed and he was able to return home, but referrals are complicated undertakings.

The team leader and the doctor evaluate all emergencies that require immediate treatment.

We have to take into account the fact that many people will not feel comfortable going into town given the political climate in the area and the possibility that any patient can be stopped and questioned at checkpoints along the way.

All patients need a caretaker with them as well, and a male relative has to give consent if their female family member needs an operation or a blood transfusion.

Maternal care

If patients need to go to our mother and child healthcare facility in Bijapur, MSF makes sure they are able to get there.

Because the local diet involves mainly rice, vegetables, and dal, many expectant mothers arrive frighteningly anaemic.

This creates complications in childbirth and means we need to monitor haemoglobin levels, provide iron supplements, and occasionally carry out transfusions.

MSF has been working with the Bijapur district hospital to set up a blood storage unit that can provide blood when necessary, such as in the event that obstructed labour necessitates emergency obstetric surgery.

MSF also now performs C-sections when required; the alternative is referral to a hospital four hours away.

Wrapping up at sunset

The team leader and counterpart keep a close eye on the time, knowing that we need to be back in the office before 5 pm to avoid being out after dark.

Since we won’t be back for a week, they make sure there is enough time to see all the remaining patients and do all the necessary tests, then dismantle the clinic, walk back to the cars and drive back to Bijapur.

When we set off, our backpacks are lighter but everyone is still shouldering a considerable load.

None of us has eaten since we arrived, so we stop along the way for a snack — small packets of spicy Indian noodles — and some water.

It’s still very hot and the team is largely quiet as we walk, the song of cicadas is the only sound on an otherwise silent journey.

Good clinic?

Upon reaching the two white MSF vehicles, we eat some more and drink cool water, then drive back down the makeshift mud roads and onto the cement roads that lead to the office.

“Good clinic?” the project coordinator asks when we return. “How many patients did you see?”

It was a good clinic. This is what we are here for: the good days and the hard days, days which start early and finish late, and the feeling of doing decent work with the support of an enthusiastic and dedicated team.

• Find out more about MSF's work in India

Many were injured in the bush, where thousands have remained, afraid to come out of hiding. Our medical teams are now treating serious wound infections, some several weeks old.

Some of our patients have shared their testimonies with us.

Warning: these testimonials contain descriptions of extreme violence. You might find them upsetting.

• Read about the current situation and MSF's response here

1. Patient testimony of a 24 year-old woman who was shot in the leg and in the cheek in the attack on Lekwongole on December 27th, 2011. Her only daughter, age three, was abducted.

A 24 year-old woman who was shot in the leg and in the cheek in the attack on Lekwongole on December 27th, 2011. Her only daughter, 3, was abducted.
© Heather Whelan/ MSF

"Our village was one of the first to be attacked. Three women, including me, ran with our children – my own three year old daughter and two of their boys 10 and 11 years old.

We could only carry water with us for the children, no food, no clothes, nothing.

We ran and tried to hide in the high grass when we heard them approaching.

But they heard my child crying so they found us three women and the three children.

Extreme violence

"They abducted my child and slit the throats of the two boys in front of us. They told us three women to run – we ran 10 metres and they started shooting.

The other two women were killed right away. I was shot in the leg so I fell down. They came over to me and shot me in the head to make sure I was dead and left me there for dead.

But the bullet just went through my cheek so I survived.

I crawled to the river to take water and stayed there alone for seven days in much pain. I didn’t know where my family was or what had happened to my daughter, my only child.

Hiding for eight days

"On the eighth day I couldn’t stay there alone anymore so I used a stick to get up and walked for two hours until I came across neighbours who cared for me for seven days.

They told me that my mother was missing. Then they left me to inform my family where I was. I was alone again for two days.

I crawled again to the river to take water. Then my husband’s brother found me and carried me for three days to Lekwongole. 

I couldn’t walk, I was so tired and it was very painful.

Families killed

"Then MSF returned to Lekwongole and drove me to Pibor. I found out the next day that my mother was not just missing, she was dead.

I felt so lonely. My mother is dead yes but at least if my child was still with me I would be okay.

But I’m not okay, I don’t even know what happened to my child.

From my family 10 people have been killed, four women and six men.  From my husband’s family eight people have been killed. 

They also abducted my sister’s son, who is six years old. It is very painful because my whole family has been killed.

My only child has been taken – I feel so alone and it’s very painful. 

For the future if I get something to work with then I will but only God knows. People are just stuck here with nothing now."

2. Patient testimony of a man, 39, who was shot in the arm in the attack on Pibor on December 31st, 2011.

A man, 39, who was shot in the arm in the attack on Pibor on December 31st, 2011.
© Heather Whelan/ MSF

"When the attack happened on my village, we fled into the bush with no food, just water for the small children.

I was shot in the arm and hid in the bush with my wound for eight days. So much blood was coming out, sometimes I would just sleep without knowing it.

At night it was so painful I couldn’t sleep. It took me another three days to walk to the hospital.

Hiding underwater

"I was lucky. They didn’t find my family when I was shot because they ran ahead and entered the river, keeping just their mouths open out of the water to breathe, hiding the rest under the water.

You might be found if you hide in the bush but if you’re under the water they won’t find you.

In my community, some have been killed, many are still missing. We don’t know if they are dead or not – we saw some who were killed.

There are children who have been taken.

We are very happy MSF is here – we thought MSF would not operate again because everything was looted.

We were afraid you would not come back. If MSF wasn’t here, I would not feel better, maybe I would have died.

Homes destroyed

"My home has been burnt to the ground, all of it, everything. I don’t know if I can go back home – because so many are missing, many are dead.

We want to go back to cultivate, maize and sorghum for the children, but now there is nothing there.

Those who are still alive, what do they think about all this death, the missing? Many are still crying, still looking for their missing children and wives - how can we think about our future?" 

3. Testimony of a mother whose one-and-a-half year old daughter was severely injured in an attack on the village of Wek, in northern Jonglei State on January 11th, 2012.

"At 5pm, our village called Wek was attacked. We all began to run away.

My sister was carrying my daughter who is ona-and-a-half years old, along with another child. As I was running away, I found my daughter on the ground, crying and all alone.

She was shot in the face and her mouth was cut by a knife. I picked her up and continued running through the bush.

MSF treating wounded

"Eventually we stopped running and had to spend the night in the bush until morning.

One day later a member of our community found us and brought us to the MSF clinic in Yuai, two hours away from my village Wek.

We received treatment here until MSF brought us by plane to their hospital in Nasir.

At this moment, I have no information about my husband. I think he was killed."

4. Testimony of a neighbor of a one-and-a-half year-old child who suffered severe head trauma on the January 11th attack on the village of Wek, northern Jonglei State.

"This is the child of my neighbours. Both his mother and father were shot and killed. 

His head was beaten against the trees. He was left for dead in the bush.

He was abandoned, without any help.

We, the community, came looking for people who needed help in the bush and we found him, still alive and alone.

We brought him to the MSF clinic in Yuai where MSF treated him."

5. Patient testimony of an 18 year-old girl who suffered gunshot wound to the leg in the attack on the village of Wek on January 11th.

"It was evening when we were attacked. People all around us were being shot and cut with knives.

When I heard the shooting, I tried to run away with my husband and my children, but I was shot in the leg and I fell down.

One of my children and my husband were killed immediately.

I was collected by my community and they brought me to the MSF clinic in Yuai.

MSF then brought me by plane to their hospital in Nasir. I expect I will be cured as I’m with MSF."

Since re-launching emergency medical activities in Pibor on 7th January MSF has treated 47 patients with gunshot wounds – 16 women and eight children.

A further 43 patients have so far been treated for stab wounds, beatings or wounds sustained while fleeing in the bush. 
 

Wounded patients are still arriving at the Médecins Sans Frontières MSF (Doctors Without Borders) hospital in Pibor, three weeks after the violent attack on the main town and outlying villages in Pibor County.

Even running away is not enough. Many people were injured in the bush, where thousands have remained, too frightened to come out of hiding.

MSF medical teams are now treating seriously infected wounds, some several weeks old.

Since re-launching emergency medical activities in Pibor on 7 January, MSF has treated 47 patients with gunshot wounds – 16 women and eight children.

A further 43 patients have so far been treated for stab wounds, beatings or wounds sustained whilst fleeing to the bush.

MSF colleague killed

People displaced by cattle raiding in Pibor county, Jonglei State, South Sudan, April 2011.
Liang Zi

In the wake of the Pibor attack, MSF learned on 16 January the tragic news that Allan Rumchar, an MSF watchman, and his wife had been killed.

Three weeks after the attack, 25 of our 156 locally recruited staff are still unaccounted for, and we remain extremely concerned for them.

The violence in Pibor is not isolated. After the village of Wek in northern Jonglei State was attacked on 11 January, MSF evacuated 13 patients by air to our hospital in Nasir.

The majority of patients were women and children needing urgent surgery.

This follows an attack in August 2011 on the town of Pieri and surrounding villages, during which scores of villagers were killed. In the past six months, 185 seriously wounded patients have sought care from MSF teams in Lankien, Pieri and Yuai.

“We are seeing a cycle of attacks and reprisals throughout this area of northern Jonglei,” says MSF head of mission Jose Hulsenbek.

“For the civilians in this part of South Sudan, the fear of having to flee their homes or being killed is very real.”

Extreme Violence

One recurring characteristic of the attacks in Jonglei is their extreme violence.

One woman treated for a gunshot wound by MSF in Pibor said she had fled into the bush with her husband, children and 15 other family members.

After running for 11 hours, they were found by a group of men who shot at them.

“We scattered. My baby was hit as I carried him on my back and I was shot in the thigh.

"I tried to hide in the high grass but they found me because my baby was crying.

"They started beating my daughter until she kept quiet. They left us behind thinking we were dead.”

Her son was also treated by MSF for a bullet wound to the chest that remarkably left him alive.

Humanitarian concerns

MSF is extremely concerned for the health and wellbeing of civilians forced to flee, either from fighting or from fear of an attack.

These people hide out in the bush, with very little shelter, if any. They have limited access to food and are prone to illness.

They return, often to find only ashes where their home used to be.

Village and clinic destroyed

Lekwongole, a village north of Pibor town where MSF runs a clinic, scarcely exists now, and all that remains of the MSF clinic is the concrete floor and walls.
© Heather Whelan/ MSF

Lekwongole, a village north of Pibor town where MSF runs a clinic, scarcely exists now, and all that remains of the MSF clinic is the concrete floor and walls.

Karel Janssens, MSF project coordinator, says, “The people told me that during the day they dare to come out of hiding in search of food or to seek medical care, which MSF restarted on 18 January.

"But at night they return to their hiding places in the bush where they are at risk of contracting malaria or respiratory infections.”

In Pibor, approximately half the consultations since 7 January have been for malaria, as people are exposed when sleeping in the bush.

Civilians targeted

A deeply worrying pattern is emerging, where people and their scarce resources are deliberately targeted by all the armed groups in this inter-communal violence.

Hospitals, health clinics, water sources – these have become targets for armed groups on all sides, suggesting a tactic of depriving people of their basic life essentials just when they will need them most, after fleeing into the bush.

The targeting of civilians is the greatest concern for Colette Gadenne, MSF operations coordinator for South Sudan:

“After these attacks many women and children are coming to us shot, stabbed, beaten.

"They try to keep safe by hiding in the bush, but it seems that even running away is not enough”.

In a December 2009 report ,‘Facing up to Reality: Health crisis deepens as violence escalates in Southern Sudan’, MSF documented the escalation of inter-communal violence in Jonglei and Upper Nile States, and its increasing impact on civilian populations.

MSF treated 392 patients wounded by violence that year, and estimated that 86,000 people were displaced.

The situation has not improved. In the past six months, MSF has treated more than 250 patients wounded in violence in Jonglei State, the majority of them women and children.

• Read accounts from survivors

• Find out more about our work in South Sudan

MSF has been working in South Sudan since 1983, currently in more than a dozen projects covering eight states.

The medical humanitarian organisation runs its own medical facilities or supports Ministry of Health facilities in six locations in Jonglei State, providing basic healthcare, therapeutic nutrition and treatment for kala azar and tuberculosis, serving a total of some 285,000 people.

In 2011, the MSF medical facilities in Lekwongole, Pibor and Pieri were targeted and either destroyed or ransacked during inter-communal violence.

MSF condemns the targeting of unarmed civilians and of medical assets by any group carrying weapons.

TB is one of the most serious public health challenges facing Cambodia, with a prevalence rate among the 22 highest in the world.

Community education, hands-on direct treatment and follow-up of TB patients in Kampong Cham province is at the core of MSF’s strategy for treating TB.

Advocacy at the national level for the expertise and experience that MSF brings to the project site will be replicated throughout Cambodia’s national TB response.

TB spreads

MSF staff conduct a home-based visit for a DR-TB patient in Kampong Cham province, Cambodia.
© Eddy McCall/ MSF

TB is spread through the air by an infected person coughing and is an opportunistic infection that takes advantage of weakened immune systems.

Among underprivileged communities in Cambodia, weakened immune systems are all too common due to malnutrition and HIV infection.

Poor hygiene and living conditions are also key contributing factors to the spread of the disease in the country.

Expanding care

MSF first arrived in Kampong Cham Hospital in 1994 and launched a basic TB programme, which later developed into HIV care.

In 2008, MSF built a new TB ward and upgraded the hospital’s laboratory facilities.

Since then, MSF has significantly expanded the project to include:

• TB/HIV co-infected patients

• drug resistant (DR) TB

• paediatric TB support

as well as introduced new innovative practices to try to turn back the tide of TB infections in the province.

Active detection

MSF staff work with Ministry of Health doctors to identify potential TB cases in other parts of the hospital, particularly the paediatric ward due to the challenges of detecting TB in children.
© Eddy McCall/ MSF

In addition to co-managing Kampong Cham Hospital’s TB department and introducing a new rapid TB diagnosis machine to speed up the testing process, MSF staff work with Ministry of Health doctors to identify potential TB cases in other parts of the hospital, particularly the paediatric ward due to the challenges of detecting TB in children.

Previously the TB response in Kampong Cham province has been based on passive detection, meaning that a patient feels unwell and presents themselves at the hospital for treatment where they are then tested and treated for the disease.

MSF has introduced a more active approach, where counsellors educate newly diagnosed TB patients about the disease, find out who they have been in contact with, and then approach and convince at-risk contacts to be tested for the disease free of charge.

In many cases this will comprise family members, particularly children, but also work colleagues, friends and extended family.

Contact tracing

The introduction and expansion of contact tracing in the follow-up system has also been key to improving TB detection in the target population.

“The aim of contact tracing is to go out into the community and try to actively look for TB,” said MSF TB referral doctor Adam Phillip Liu.

“In doing so, we aim to hopefully minimize the number of patients who present later with disease and reduce the number of patients who can potentially spread the disease to others in the community.

"In that sense it’s a more efficient and economical approach.”

Patient support

MSF provides support for those identified through contact tracing to travel to the hospital for testing, as well as treatment and follow-up counselling if they are found to be infected.

“Contact tracing is very important because people that have been in close proximity with a TB-infected person are at the highest risk of contracting the disease, much more than the general population,” said head of mission Jean Luc Lambert,

“Every year, around 500 new cases of TB are found per 100,000 people nationally in Cambodia, according to the World Health Organisation.

"Trying to screen so many people is just not realistic or sustainable, which is why targeted proactive detection through methods such as contact tracing is so essential.”

On average, around 70 percent of the people identified through contact tracing come to the clinic for consultation.

Counselling and nutrition

MSF staff conduct a home-based visit for a DR-TB patient in Kampong Cham province.
© Eddy McCall/MSF

Forty-five-year old Srey (not her real name) was diagnosed with DR-TB and joined MSF’s treatment programme shortly after her husband died from the disease in 2010.

Living around 40kms from the hospital in a remote village with four children to look after, coping with the side effects from the medication has been extremely challenging.

Srey participated in MSF’s peer support and group patient sessions, which are designed to help those on treatment understand and cope with the severe effects of the medication.

“In the beginning I used to have bad side effects like fevers, dizziness, headaches and abdominal pain - it was very hard,” said Srey.

“I wanted to stop the treatment but after I saw the other patients trying, I wanted to continue even though it was so difficult.”

In addition to closely monitoring Srey’s progress and the health of her children, MSF teams regularly visit Srey to provide counselling support and make sure her family has enough to eat.

Due to the high toxicity of the DR-TB drugs, it is essential that patients must maintain an adequate level of nutrition.

“If I don’t have food to eat, I am really unwell and the side effects are really bad,” Srey explained.  

A local village health nurse trained by MSF visits Srey daily to provide medication and helps her continue to adhere to the treatment programme.

“Before I was a normal villager but now I don’t talk to anyone, I just stay at home,” Srey said,

 “My relatives only come sometimes to visit me for a short time, but they never stay very long. They know I have TB.”

Preventing drug-resistance

Proper treatment of regular TB generally takes between 4-6 months while DR-TB can take up to two years to cure and involve expensive medication with extremely severe and unpleasant side-effects.

DR-TB can develop when a patient prematurely stops their regular TB treatment, so it is crucial that every TB patient continues their treatment until the end.

This requires extensive patient education and comprehensive follow-up of all TB patients once they begin the home-based phase of their treatment.

“If the follow up is not good, there’s a high chance that the patient will abandon treatment because TB patients often tend to feel better after a few weeks or months and they don’t think they need the medication anymore,” said MSF TB doctor manager Manesha Ahluwalia.

“The more contact you establish with the patient, the more they understand that they need to continue the treatment.

"It’s basically aimed at reinforcing the idea that completion of treatment is crucial, not only for the patient’s health but also for public health in general,” she added.

Since January, MSF staff have conducted over 6,000 consultations at Kampong Cham Hospital’s TB department and more than 600 new TB patients have been enrolled.

In addition to numerous follow-up consultations and home visits with existing DR-TB patients, a telephone hotline provides home-based patients with direct contact in case of emergencies.

TB outreach

MSF doctor and counsellor participate in a TB education radio programme twice a month
© Eddy McCall/ MSF

As part of the community outreach and education activities, an MSF doctor and counsellor participate in a TB education radio programme twice a month and organise regular awareness-raising education seminars at pagodas, universities, high schools, mosques and other minority populations.

All of these activities are aimed at increasing understanding of the disease and its treatment in the community, as well as reducing stigma against TB.

“We don’t win the war against this disease only inside the hospital – it’s outside in the community where the real impact can be made through targeted proactive detection, providing quality care, comprehensive follow-up practices and effective awareness-raising activities,” said Jean Luc.  

• Find out more about MSF's work on TB

• Read about our other projects in Cambodia

This includes the closure of two separate 120-bed medical facilities for the treatment of malnutrition, measles and cholera.

The closure of activities in this district halves the assistance MSF is providing in Mogadishu.

For now, MSF projects will continue to provide medical care in the other districts of the capital, as well as in 10 locations in the rest of Somalia.  

Safety essential for aid work

Women and children at an intensive therapeutic feeding centre in Hodan District, Mogadishu, October 2011.
© Yann Libessart / MSF

However, the continuation of MSF work to assist Somalis in need of medical care is dependent upon the respect for personnel, patients and medical facilities.

Where these conditions prevail, MSF remains committed to continue its activities in Somalia.

“It is hard to close health services in a location where the presence of our medical teams is genuinely life-saving every day,” states Christopher Stokes, MSF General Director,

“but the brutal assassination of our colleagues in Hodan makes it impossible for us to continue working in this district of Mogadishu.”

Assisting Somali people

In Hodan, MSF has been assisting 200,000 Somalis who had fled to the capital in recent months.

Since August 2011, treatment has been provided to 11,787 malnourished children, 1,232 patients for acute watery diarrhea and 861 measles patients.

MSF teams have also vaccinated 67,228 children against measles.

Our kidnapped colleagues, Montserrat and Blanca         © MSF

Safe release

MSF strongly reiterates its call to all parties, the leadership and the people of Somalia, to facilitate the safe release of Montserrat Serra and Blanca Thiebaut, MSF aid workers who were abducted in Dadaab refugee camp in Kenya on 13 October 2011 while carrying out emergency assistance for the Somali population.

MSF has been working in Somalia continuously since 1991 and currently operates 13 projects in the country, including medical activities related to the ongoing emergency, vaccination campaigns, as well as nutritional interventions.

MSF also assists Somali refugees in camps in Dadaab, Kenya, and Dolo Ado, Ethiopia.

This month MSF faces a humanitarian dilemma in Somalia following tragic attacks on our staff.

We visit Doro refugee camp in South Sudan where MSF is working to provide water, sanitation and medical care for 20,000 refugees.

Our teams in Cambodia have created a faster way of detecting TB, and in Chad we train village malaria workers to diagnose and treat malaria in their community.

In Democratic Republic Congo our paediatric teams are working flat out due to a high rate of malaria in children.

Finally we review what MSF has achieved in Haiti in the two years since the devastating earthquake.

For Dr Krieger, this mission provided an opportunity to address the lack of specialised medical care in the Gaza Strip.

He shares his experience with us:

Inflatable hospital

"The MSF team is operating in the MSF mobile field hospital set up last August to address the lack of space available at Nasser hospital due to its on-going rehabilitation.

Due to heavy rain in the preceding week, the MSF inflatable hospital had to be reconstructed and the ground of the tent elevated by using a wood construction.

A further hygienic and noisy challenge was the fact that just outside of our tent the hospital road was rebuilt, with a lot of dust and construction machines passing by every five minutes.

But all the material I needed was available. Hygiene and sterilisation were also highly satisfying. 

Two hundred and twenty patients had been identified in advance by the teams. Consultations started on the 23rd of November and were undertaken together with Dr Hassan Hamdan, the head of the burn unit of Nasser Hospital.

Out of these 220 patients, and according the inclusion criteria, we chose 56 for surgery. Eighty percent of the cases were post burn constructions, followed by congenital deformities in hands and one tumor case.

Eighty nine percent of the patients who had been operated on were children under 18 years old; 36 percent were females.

Experienced team

MSF Surgical team at Nasser hospital, Khan Yunis, Gaza, September 2010 © MSF

We had in total nine days to operate. We could undertake four to five operations per day, ending up with 35 operations in total.

The MSF anaesthetist was very experienced. Even anaesthesia on very young children was possible.

Organisation of the daily logistics and communication with the patients were very well managed by local staff, all the operation theatre (OT) logistics were done by the MSF OT nurse in a highly qualified way.

Satisfying results

The functional results we have followed up so far were fully satisfying.

Furthermore we had no infection, hygiene protocols are strictly followed and the preparation and cleaning of the patients by the team is of high standard.

Hand surgical cases we mostly followed up in the MSF Gaza rehabilitation clinic: dressing and physiotherapy including splinting are provided under the supervision of doctors and physiotherapists.

I think there is future surgical work for MSF, especially in hand surgery and flap coverage of burn sequelae.

The team spirit was very motivating.

In between the operations we could frequently do dressings or consultations of new cases.  Cooperation with Dr Hamdan of Nasser Hospital is very good as he is interested in gaining new techniques.

We had very good surgical discussions and I left him my textbooks electronically for further reading.

Security was fine during my whole mission, we could move and work every day, still there were incidents reported during the night. This did never affect our own security.

I had a very good and challenging mission in this field.”

Future collaboration

Dr Krieger was very satisfied with his mission and is willing to come back or to recommend it to other surgeons.

Three more surgeons are expected to arrive before the end of the year to finish the rest of the planned surgeries.

Such operations provide an opportunity for MSF and Palestinian experts to exchange medical techniques and surgical procedures related to elective reconstructive hand surgery and anesthetic procedures, including those of young children.

Specialised surgery in Gaza

In July 2010, MSF signed an agreement with local health authorities and opened a specialised surgery program in the Nasser hospital, in Khan Yunis, in southern Gaza Strip. 

Several times a year, MSF teams – composed of surgeons, operating room nurses and anaesthetists – carry out missions, working closely with Nasser teams. 

As with MSF's other activities in Gaza, the goal of our surgical program is to rehabilitate trauma patients, to help them to regain optimal use of their limbs.

• Find out more about our work in Palestinian Territories 

• Read about MSF field staff experiences

 

The patients were taken to MSF’s hospital in Nasir, Upper Nile State, where they are receiving urgent surgical treatment. Five adult women and two adult men had gunshot wounds and the remaining six patients were children under five, with beatings or gunshot wounds.

Violence

“We are very concerned that the majority of the wounded in this latest wave of violence are women and children,” said MSF Head of Mission for South Sudan, Jose Hulsenbek.

“These 13 patients have survived the night, but some of the children are still in critical condition with severe trauma to the head,” she said. 

MSF supports a small outreach clinic in Yuai, northern Jonglei State, about two hours outside of Wek, Uror County, where the latest violence took place.

Wounded

MSF is continuing to monitor the situation and if further severely wounded people continue to arrive at Yuai clinic, they will be referred to the MSF-run hospital with surgical facilities in Nasir, Upper Nile State.

This latest round of inter-communal violence follows an attack in Pibor County in late December 2011/early January 2012, where the MSF-run hospital in Pibor town was looted and ransacked.  MSF emergency teams resumed medical activities in Pibor town on Sunday 8th January.

Impartiality and neutrality

MSF has demonstrated its complete impartiality and neutrality over the years, working in many different communities in South Sudan.  In 2011, three MSF medical facilities were targeted in Jonglei State.

We condemn the targeting of medical facilities by any armed group. MSF commits to continuing to bring humanitarian aid and medical assistance to the population of Jonglei State.

MSF has increased its hospital capacity in areas affected by the quake, providing 600 hospital beds and serving a population of over two million people.

• Read about our recent work in Haiti

While emergency outbreaks can be treated, prevention is key. There must be improved access to clean water and good sanitation facilities for people in Chad. 

Cholera outbreak

More than 450 people died and 17,200 cases of the disease were reported in 2011, numbers that have not been seen since 1996.

At the height of the epidemic in August, up to 1,250 new cases per week were recorded, a third of those in the capital city of N'Djamena.

Medecins Sans Frontieres MSF (Doctors Without Borders) mobilized more than 325 national and international staff at 23 health care centers in Massakory, Am Timan, Abou Deia, Mandelia, Pala, Fianga, Lere, Lai, Bongor and N'Djamena.

Continuing epidemic

A mother watches over her nine year old son who fell sick with cholera during the 2010 outbreak. Cholera Treatment Centre, Goy Godoum, Chad.
© Yasmin Rabiyan

"The outbreak was a continuation of the 2010 epidemic.

"It never really ended, therefore we witnessed two events: cases before the rainy season, and a wide geographical spread.  37 out of 61 districts were affected," says Michel-Olivier Lacharité, head of MSF programs in Chad.

Last spring, MSF teams worked closely with the Chadian Ministry of Health to establish treatment centers, oral rehydration points (ORP) and awareness activities to limit the spread of the disease.

MSF also carried out case management training at public health facilities.

MSF treated three-quaters of patients

By late November, MSF had treated more than 12,700 people, about three quarters of cases in the country, with cure rates approaching 99%.

Activities were still being carried out in late November even though the number of cases had dropped sharply. 

Because there are concerns about a possible resurgence of cholera, MSF teams continue to monitor the situation and are ready to intervene, if necessary.

In 2010, MSF treated more than 6,800 cases of cholera in the country.

Prevention is key

"We must consider strategies to help people," says Dr. Michel Quere, MSF medical advisor.

"Cholera epidemics are the result of several factors: lack of access to drinking water, latrines and sanitation facilities, but also a delay in care, due to a misunderstanding of the disease and difficult access to care.

"If public authorities and development actors are not involved in these structural causes, the population of Chad will face these epidemics, year after year. "

Vaccines

MSF is working along-side authorities, to ensure better coordination between health care providers in Chad, in order to facilitate a rapid treatment of cases, along with the introduction of an oral vaccine recently approved by the World Health Organization.

"The vaccine raises hopes that the spread of disease around the outbreaks, such as Lake Chad, for example, could be limited.

"To do this, close collaboration between ministries of health in the region, international public health actors and non-state actors such as MSF will be necessary, "says Dr. Quere.

• Learn more about cholera

In 2011, MSF responded to outbreaks of cholera in Cameroon, Chad, Niger, Nigeria, Papua New Guinea, Zambia and Haiti, among others.

In Chad, MSF also operates in Massakory, Moïssala and Am Timan and has expanded access to care for vulnerable people (children, pregnant women) and treats deadly diseases such as malnutrition and malaria.

In Abeche, MSF offers treatment for vesico-vaginal fistulas in women of childbearing age.

A 12 -person medical and logistics team returned to Pibor on Saturday, but the climate of uncertainty and the state of our facilities, looted during the disturbances, have made it difficult to provide healthcare for the people affected by the violence.

Concern for missing staff

MSF's looted clinic, Pibor, South Sudan, January 2011
© Parthesarathy Rajendran/ MSF

As of Tuesday 10th January, 60 of the 155 locally-hired MSF staff in Pibor county remain unaccounted for.

We are very concerned for their welfare, as we are for the fate of all the inhabitants who fled into the bush to save their lives.

“There is a strong sense of uncertainty in the area around Pibor,” says Colette Gadenne, programme manager for South Sudan.

“Lots of people, including many of our local staff, are looking for lost family members in the bush, fearing the worst.

"This, and the irreparable damage to most of our drugs and medical material, makes it extremely challenging for us to mount an effective emergency response for those in urgent need of medical care.”

Ransacked hospital

MSF primary health care hospital in Pibor County, before the recent violence. © Liang Zi

The MSF-run hospital in Pibor town was totally ransacked.

Although the main concrete building and roof are largely intact, little if any of the medical equipment or drugs are currently useable.

MSF is rehabilitating the facilities to allow the team to resume medical activities, and has airlifted more than one ton of supplies, including drugs and medical and logistical material, to Pibor town, with more to follow this week.

MSF provide emergency care

In these constraining circumstances, MSF has started to provide emergency medical care for the people who have returned to Pibor town.

Until more people have returned from the bush, where they are scattered over a large area, it is impossible for MSF to have a clear view of what the precise medical needs will be.

Over the coming days MSF will assess the non-medical needs and will undertake an appropriate humanitarian response depending on its independent findings.

Commitment to healthcare

• Since 2005, the MSF team has provided healthcare for the 160,000 people in Pibor County, as well as providing healthcare in other parts of Jonglei State.

• MSF is committed to providing the high quality of healthcare we offered before the violence as soon as possible.

• MSF has demonstrated its complete impartiality and neutrality over the years, working in a great many different communities in South Sudan.

In 2011, three MSF medical facilities were targeted in Jonglei State.

We condemn the targeting of medical facilities by any armed group.

MSF commits to continue to bring humanitarian aid and medical assistance to the people of Jonglei State.

Since the quake Médecins Sans Frontières MSF (Doctors Without Borders) has built four hospitals – all operating free of charge for patients. One third of all cholera cases in Haiti were treated by MSF.

We have 2,000 staff in Haiti working round the clock to provide the medical care people need.

People still lack healthcare

MSF hospital in Leogane
© Yann Libessart

Soon after the earthquake, major pledges to rebuild Haiti were made.

However, two years later the reconstruction needs of the healthcare system in Haiti remain immense.

Most Haitians continue to face great difficulties in accessing healthcare.

Reconstructing healthcare systems takes time and money, and qualified medical personal and medical infrastructure are in short supply.

MSF response

MSF has responded to the lack of healthcare in the two years that followed the earthquake by:

• building four emergency hospitals in the area affected by the quake, serving over two million people.

• treating around a third of cholera patients during the 2010 outbreak.

• being prepared and ready in the event of future cholera outbreaks.

• supporting a Ministry of Health hospital in the Cité-Soleil slum.

• managing 600 hospital beds, shared over five facilities.

• employing 2,000 personnel, 90 percent of whom are Haitian.

All MSF centres are open 24 hours a day. All treatments are free.

The four new MSF hospitals are in parts of Haiti where people's needs are great. They also address specific health issues.

Childbirth

Mother and baby in MSF's emergency obstetric center, in the Delmas 33 area of Port au Prince
© Yann Libessart /MSF

Haiti has the highest rate of maternal mortality in the Americas.

Last April, MSF opened a 130-bed referral center for obstetric emergencies, in Port-au-Prince’s Delmas 33 neighbourhood, to assist women who have complications during their preganancy, which threaten their life, or that of their baby.

Since the centre opened, medical personnel have performed 1,432 operations and assisted in the birth of over 4,600 babies.

One of the newborns was Esther, whose mother, Belgarde, says: "I lost my first three children right away after giving birth,

"The last one was premature, too, but thanks to the care she's received here, I am hopeful that I'll be able to take her home soon."

From tents to concrete

After the earthquake a temporary, inflatable tent hospital was set up on the sports field of the Saint-Louis de Gonzague School in northern Port au Prince.

On 9th May 2011 the new 208-bed Drouillard hospital was opened to replace the temporary hospital.

Its teams:

• deal with medical and surgical emergencies.

• treat major burn cases.

• provide physical therapy.

• provide mental health follow-up care.

On average, 55 new patients are treated and 20 surgeries are performed every day.

Psychological vulnerability

"The earthquake is no longer responsible for the cases we see today, which have to do primarily with road or household accidents and with violence," says medical director Félix Konan-Kouassi.

"On the other hand, we do observe increased psychological vulnerability since the disaster.

"Patients find it more difficult to bear up under additional trauma, such as an attack or an accident."

The only hospital in Léogâne

MSF's hospital in Léogâne © Yann Libessart/MSF

Nearly 80 percent of Léogâne, a city to the west of the capital, was destroyed by the earthquake.

Chatuley Hospital, in Léogâne, was initially a temporary installation, set up in response to the 2010 quake. The hospital now operates out of containers that house 160 beds.

It remains the immediate region's only hospital, treating emergencies and providing obstetric and gynaecological care and pediatric care.

In 2011 the medical staff:

• treated 73,741 patients.

• performed 3,755 operations.

• assisted at 4,501 births.

Hope

Lastly, in the industrial area of Tabarre, east of Port-au-Prince, construction teams are putting the final touches on the Nap Kenbe – “hope" in Creole – center, which is scheduled to open in February 2012, as an additional resource for Haitians who need free medical care.

Containing 108 beds, it will provide emergency trauma and abdominal surgery, with a focus on treating children.

MSF is also continuing to provide care at a referral and emergency center in Martissant, which opened in late 2006 and treats an average of 4,370 patients each month.

People still at risk

While MSF is striving to address a deficit in health care we also has to remain alert to potential new emergencies such as cholera, which remains a risk.

The cholera outbreak in October 2010 affected more than half a million patients, MSF treated around a third of them, deploying 4,000 staff at the height of the crisis.

"Hundreds of thousands of people still live under terrible conditions in makeshift camps," says MSF's medical coordinator, Wendy Lai.

"Access to drinking water and sanitation is very limited throughout the entire country, particularly in rural and remote areas.

"This situation promotes the spread of infectious disease.

"While the number of new cases of cholera has fallen considerably, we still see several hundred each week and the risk of seasonal resurgence remains very high.

"We must remain extremely vigilant."

 
Rebuilding healthcare

Working on the water and sanitation installation outside MSF's Tabarre surgical centre.
© Halimatou Amadou/MSF

"Much of the capital's healthcare infrastructure disappeared on 12th January, 2010 – and it was limited and not even fully operational prior to that date," says Gérard Bedock, MSF's head of mission in Haiti.

"The earthquake revealed and exacerbated the shortcomings of Haiti's healthcare system.

"It will take a long time to rebuild.

"In the meantime, we are working to fill the healthcare gaps to the extent possible, while responding to potential new emergencies, such as cholera."

Funding

MSF has spent twice as much money in Haiti than was raised in our emergency campaign.

In the two years following the quake MSF has recieved 115 million US dollars in fundraising and spent 237 million US dollars.

The 2010 cholera outbreak was an unexpected expense and the lack of healthcare provision in Haiti is enormous. 

Much work remains to be done. MSF are committed to helping the people of Haiti which we are able to do thanks to the generosity of our supporters unrestricted donations.

If you would like to help us help Haiti please consider making a donation to MSF.

• Video: See us in action in Haiti

• Find out more about our work in Haiti

MSF launched its first projects in Haiti in 1991, carrying out emergency programmes during natural disasters and crisis situations.

Earthquake aftermath

Tuesday 12th January 2010 will forever remain engraved in Haiti's collective memory.

Nearly everyone in the country lost a relative, friend or neighbour in the earthquake that hit that day, and many survivors continue to suffer physical or psychological after-effects.

The piles of rubble and gaping holes in the streets of Port-au-Prince show that the city's infrastructure still bears the physical scars.

MSF affected

Médecins Sans Frontières MSF (Doctors Without Borders) had been working in Haiti before the disaster and sadly lost 12 staff members that day.

Two MSF hospitals – the La Trinité trauma center and the Solidarité obstetric and gynaelogical clinic – were destroyed.

MSF immediately deployed its emergency response to the earthquake as supplies and staff were already present in Haiti. MSF also rapidly responded to a cholera out-break in October 2010

Earthquake response

Immediately following the earthquake, MSF undertook the largest emergency intervention in its history:

Between January 12th and October 2010 MSF

• treated 358,000 people

• performed 16,570 operations

• assisted at 15,100 births

Cholera epidemic

In late October 2010 a major cholera epidemic struck Haiti.

More than 500,000/half a million cases of cholera were recorded in the country.

MSF set up operations on an unprecedented scale.

At the height of the crisis, some 4,000 health care providers were working at more than 75 facilities in Haiti.

Nearly 170,000 patients with cholera symptoms were treated between October 2010 and November 2011.

MSF has a large-scale emergency preparation and rapid treatment plan in place in case of another widespread outbreak.

Aid workers attacked

Philippe Havet (right) and Andrias Karel Keiluhu, better known as ‘Kace’ (left). © MSF

Two Médecins Sans Frontières (MSF) Doctors Without Borders colleagues, Philippe Havet and Andrias Karel Keiluhuo, were killed last week by a gunman while implementing emergency assistance projects in Mogadishu.

Three months ago, two MSF aid workers, Montserrat Serra and Blanca Thiebaut, were abducted in Dadaab refugee camp in Northern Kenya while carrying out emergency assistance for the Somali population.

MSF condems attacks

These attacks on aid workers must be condemned in the strongest of terms.

They put in jeopardy life-saving medical projects that are already far from adequate in addressing the scope of the medical needs of the Somali people.

Somali people are extremely vulnerable after 20 years of civil war, international interventions and institutional collapse. They get less assistance than they need.

MSF is confronting the difficult dilemma of working in a place like Somalia where the needs are not only extremely great, but the risks are also exceptionally high for the safety and security of all our staff.

Safe release

As we consider this dilemma, MSF is requesting that all people, especially the authorities in control of areas in Somalia where our kidnapped colleagues are being detained, do everything possible to facilitate the safe release of Blanca Thiebaut and Montserrat Serra.

Assisting Somali people

MSF mobile team performing measles vaccinations, screening for malnutrition and providing care to the sick children in internal displacement camps of Hodan District, Southern Mogadishu, Somalia. August 2011
© MSF/ Feisal Omar

MSF has been present in Somalia continuously since 1991 assisting Somalis in need on all sides of ongoing fighting and conflicts. 

Over the last six months, MSF has treated 225,000 patients in Somalia, vaccinated 110,000 children and cared for 30,000 malnourished children in 14 projects. 

Additionally, MSF provides assistance to Somali refugees in nine projects in Kenya and Ethiopia, where finding the balance between the massive medical needs of the population and the risks that MSF teams are forced to endure is increasingly challenging. 

Safety essential

“To effectively continue our medical humanitarian work in Somalia to support the population affected by the conflict, MSF needs all parties to the conflict, the leadership as well as the people of Somalia to support us in this work and help ensure the safety and security of humanitarian workers,” says Dr.Unni Karunakara, International President of MSF.

“For our colleagues Philippe and Kace, this failed tragically. For Blanca and Mone, the leadership and people of Somalia have the responsibility to facilitate the safe and prompt resolution of their abduction.”

These attacks on aid workers must be condemned in the strongest of terms. They put in jeopardy life-saving medical projects that are already far from adequate in addressing the scope of the medical needs of the Somali population.

Needs great and risks high

MSF is confronting the difficult dilemma of working in a context like Somalia where the needs are not only extremely great but the risks are also exceptionally high for the safety and security of all our staff.

As we consider this dilemma, MSF is requesting that all people, especially the authorities in control of areas in Somalia where our kidnapped colleagues are being detained, do everything possible to facilitate the safe release of Blanca Thiebaut and Montserrat Serra.

MSF in Somalia

MSF has been present in Somalia continuously since 1991 assisting Somalis in need on all sides of ongoing fighting and conflicts. Over the last six months, MSF has treated 225,000 patients in Somalia, vaccinated 110,000 children and cared for 30,000 malnourished children in 14 projects. 

MSF also provides assistance to Somali refugees in nine projects in Kenya and Ethiopia, where finding the balance between the massive medical needs of the population and the risks that MSF teams are forced to endure is increasingly challenging. The net result is that the Somali population - extremely vulnerable after 20 years of civil war, international interventions and institutional collapse - receives less assistance than it needs.

“To effectively continue our medical humanitarian work in Somalia to support the population affected by the conflict, MSF needs all parties to the conflict, the leadership as well as the people of Somalia to support us in this work and help ensure the safety and security of humanitarian workers,” says Dr.Unni Karunakara, International President of MSF.  “For our colleagues Philippe and Kace, this failed tragically. For Blanca and Mone, the leadership and people of Somalia have the responsibility to facilitate the safe and prompt resolution of their abduction.”

Natural disasters are frequent in the Philippines, however the timing of MSF's response to the recent floods was almost unexpected. Pier-Luigi Testa, MSF's deputy emergency program manager, explains what happened.

Devastation left by the recent typhoon that hit Mindanao, Philippines.
© Pauline Busson/MSF

Unexpected intervention

In December, an MSF team was headed to Mindanao Island to assess emergency health needs in the Cotabato, Maguidanao and Davao areas, where armed conflict has been underway for several years.

On 16th December, during the assessment, a typhoon struck Mindanao, causing many deaths and widespread damage on another part of the island.

The team halted its evaluation mission and went to the flooded sites.

Typhoons

A month earlier, another MSF team had arrived in Bulacan province, north of Manila, after a typhoon hit there.

Team members had carried out medical consultations, provided water and distributed non food items to the affected people.

Some 30 typhoons of varying severity hit the Philippines every year, often causing significant damage.

Homes destroyed

The rivers overflowed their banks and flooded entire villages and neighborhoods. The towns of Cagayan de Oro and Iligan were the most affected.

The water and mud carried off and destroyed houses.

MSF staff evaluate the devastation left by recent the recent typhoon that hit Mindanao.
© Pauline Busson/MSF

Finding shelter

Many people fled and took shelter in evacuation centers that the authorities set up in schools or 'barangay halls', public buildings that house important meetings for people of the neighborhood.

The needs in these centers are comparable to what we generally see in refugee camps.

Several international NGOs arrived right away to provide aid, deliver basic supplies and food and build latrines.

However, MSF is unique as it is the only NGO able to provide health care in cooperation with the Ministry of Health.

Training local staff

The MSF team will take over from the Ministry of Health staff members who had been sent out just after the typhoon hit and must return to their regular workplace.

The team is training local staff to carry out medical consultations at the sites housing the victims from Cagayan de Oro (21,000 people divided among 22 centers) and Iligan (14,000 among 20 centers).

Homes destroyed by floods, Mindanao, Philippines.
© Pauline Busson/MSF

Disease risk

We have already identified the main medical issues, which are watery diarrhea and respiratory infections.

We have also detected suspected cases of leptospirosis and tetanus which will be closely monitored.

The team will also be monitoring the victims' living conditions and their situation.

Tent camps have been set up to relieve the evacuation centers and, in particular, the schools, which must be available for the students, who will return soon.

• Find out more about MSF's work in the Philippines
  

Update: Friday 6th January 2012

Parthesarathy Rajendran, MSF head of mission in South Sudan, visited Pibor on Thursday 5th January. He spoke to the Guardian newspaper:

"I was there this morning, which is an hour away by plane from Juba [the capital]. Parts of the town have been burnt, our facilities were completely looted, but people are coming back and are not afraid any more. It is stable now.

"There are enormous needs, some people need every single item. Our first priority will be medical care, but we are planning to provide non-food items as well so people can start rebuilding."

People are slowly returning to Pibor and MSF will be providing assistance to the people there as soon as possible.

Tuesday 3rd January 2012

“Thousands of people have fled for their lives in Lekongole and Pibor in the last week and are now hiding in the bush, frightened for their lives,” said Parthesarathy Rajendran, MSF head of mission in South Sudan.

MSF's primary health care hospital in Pibor County prior to the violence. © Liang Zi

“They fled in haste and have no food or water, some of them doubtless carrying wounds or injuries, and now they are on their own, hiding, beyond the reach of humanitarian assistance.”

Ghost town

The village of Lekongole has been razed to the ground and an MSF team that assessed the situation in Pibor on 28th December described it as a ghost town, virtually everyone having fled into the surrounding country.

While the people are hidden in the bush, we cannot reach them to clean and dress wounds, treat diseases and provide general primary healthcare. The longer they are in the bush, the more serious it will become for people who are injured or sick.

MSF facilities looted

During the violence, two MSF medical facilities were looted and damaged; the clinic in the village of Lekongole on 27th December, and the small hospital in the town of Pibor on 31st December.

A third MSF clinic in the nearby village of Gumruk has not to our knowledge been affected. These three medical facilities are the only healthcare available for the 160,000 people in Pibor County and the nearest alternative medical facility is more than 100km away.

MSF condemns attacks

MSF condemns in the most serious terms the targeting of neutral and impartial medical facilities. 

We have provided neutral medical aid in South Sudan for the last three decades, working in many different communities in the country, treating anyone who needs medical care irrespective of their ethnicity, religion or political affiliation.

Yet besides the two recent incidents, in August last year our medical facilities in Pieri, further north in Jonglei State, were also looted and burned. MSF subsequently treated 157 wounded, mostly women and children.

Safety fears

Ten MSF international staff were relocated to Juba on 23rd December, just before the latest violence erupted, and our 156 locally hired staff were strongly advised to leave their town or village and seek refuge in the area.

Although we have established contact with a few of them, many cannot be contacted as they have taken flight along with their families and neighbours. Their precise whereabouts are unknown and we are deeply concerned about their safety.

Emergency care

MSF is ready to return and recommence providing emergency care as soon as possible.

“There are several crisis situations evolving in different parts of South Sudan right now,” adds Rajendran.

“Our medical teams are also currently responding to the crisis of refugees fleeing conflict in neighbouring Sudan.

"These are staunch reminders that despite independence, acute emergencies are still all too present in South Sudan and the capacity for emergency humanitarian response remains an absolute priority."

MSF in Sudan

MSF started working in Sudan in 1978 and begin activities in the area that is now South Sudan in 1983.

MSF works in eight of 10 states in South Sudan today, providing healthcare in 15 projects via roughly 2500 national staff and 200 international staff.

MSF and MSF-supported clinics serve a variety of communities, are free of charge and are open to all.

In 2010 MSF teams across the country carried out 588,000 outpatient consultations, treated 37,000 people with malaria, delivered 20,000 babies, cared for 18,000 hospitalised patients, and cured almost 26,000 malnourished children under five years.

• Read more about MSF in South Sudan
  

We will sorely miss Philippe and Kace; their energy, humour and commitment (both are 10 year MSF veterans). Our heartfelt sympathy goes out to their loved ones. MSF still doesn't have all the facts, but we can share further details of what happened, following staff debriefings.

Philippe Havet (right) and Andrias Karel Keiluhu, better known as ‘Kace’ (left). © MSF

Despite stringent security rules (for example, metal detector use) an MSF Somali logistics assistant got into the MSF compound with a gun.

The staff member opened fire inside the MSF office. Philippe died immediately, Kace later in the evening following surgery.

We believe the shooting was a result of the non-renewal of the individual's contract, a decision taken with clear support from the community, as he was suspected of theft.

This was an act of violence by an individual, not related to any politics. Somalia is a lawless environment and every man has a gun.

MSF is faced with a terrible dilemma now. Our medical teams wish to maintain life-saving activities in Mogadishu and Somalia but must now review levels of exposure and risk. The people of Somalia are the victims of this violence as much as MSF is. Abandoning them is the last option for us.

Also, while we grieve for Kace and Philippe, we continue to ask for the release of our MSF colleagues kidnapped on the 13th October, 2011 in Dadaab, Kenya, currently thought to be in held in Somalia.

MSF teams have worked in Somalia since 1991 and currently operate 13 projects there. MSF also assists Somali refugees in Kenya and Ethiopia

09:50 Friday 30th December

It is with great sadness that Médecins Sans Frontières / Doctors Without Borders (MSF) confirms that two MSF staff members were killed on Thursday as a result of a shooting in the organisation’s compound in Mogadishu.

While one of the aid workers died during the shooting, the other was transferred to a hospital and died after surgery.

The victims are Belgian and Indonesian nationals. Philippe Havet, a 53-year-old from Belgium, was an experienced emergency coordinator who had been working with MSF since 2000 in many countries, including Angola, the Democratic Republic of Congo, Indonesia, Lebanon, Sierra Leone, South Africa and Somalia.

Andrias Karel Keiluhu, better known as ‘Kace’, was a 44-year-old medical doctor who had worked with MSF since 1998 in his native Indonesia as well as in Ethiopia, Thailand and Somalia.

The exact circumstances of the shooting are not yet clear. Our priority is to take care of those most affected by this tragedy, in particular the families and the colleagues of the victims.

MSF will be relocating some staff for security reasons, but remains committed to continuing our humanitarian work in Mogadishu and elsewhere in Somalia.

Philippe and Kace were in Mogadishu working with the MSF teams to provide emergency medical assistance to displaced persons and residents of the city.

We are deeply shocked by this tragic event and we will greatly miss Philippe and Kace. We extend our heartfelt sympathy and condolences to their families and friends.

MSF has been working in Somalia continuously since 1991 and currently operates 13 projects in the country, including medical activities related to the ongoing emergency, vaccination campaigns, as well as nutritional interventions. MSF also assists Somali refugees in camps in Dadaab, Kenya and Dolo Ado, Ethiopia.

This book examines the reality of the compromises MSF made – some successfully and some less so – to try and help the people suffering most in the world today.

• Humanitarian Negotiations Revealed is now available to read free online

Humanitarian Negotiations Revealed. Click the picture to read the book online. © MSF

Humanitarian myths

It is written by MSF insiders, but is far from a PR exercise. Decisions made in the ‘heat of battle’ by MSF are unpicked and critiqued.

Released just a few weeks before MSF celebrated its fortieth anniversary, the book sets out to deliberately puncture a number of the myths that place humanitarianism above politics.

Writers describe how, in fact, it is the difficult negotiations with varying parties, each of whom have their own vested interests, that can permit an aid agency to work in a given area – or not.

At a time where humanitarian actors are questioning their ability to overcome the obstacles they are encountering, this book seeks to help fuel the debate on their ambitions and the best ways of fulfilling them.

The reality of MSF efforts

Case studies from recent conflicts such as Yemen, Sri Lanka and Afghanistan lay bare the reality of MSF’s efforts to reach the most affected people, and explore just what the limits of compromise should be.

There are also a series of thematic essays that explore broader issues, such as the real usefulness of aid responses to natural disasters.

Médecins Sans Frontières MSF (Doctors Without Borders) has scaled up into full emergency mode in Upper Nile State to respond to the sudden influx of thousands of refugees fleeing conflict in neighbouring Sudan. 

Clinical officer Michael Kipsang and nurse Sita Cacioppe try to rehydrate 18-month old Deng.
© MSF Avril Benoit/MSF

And around the town of Agok, in Northern Bahr al Ghazal State, our teams are facing the spectre of a food shortage and has launched a preventive supplementary feeding programme for children who risk becoming malnourished in the months ahead.

Conflict and emergency

The 22-year war that ended in 2005 left South Sudan’s healthcare provision in a parlous state that could be described as an emergency in its own right.

Now, in the contested area of Abyei between the two Sudans, fresh conflict has pushed the local population to escape further south, resulting in an estimated 100,000 displaced people.

Other conflicts across the border in Sudan – particularly in Blue Nile and South Kordofan states – have forced tens of thousands of refugees to flee across the border over the past month, and they are still coming.

The burden of these multiple crisis situations is heavy, and aid organisations need to move onto an emergency-response footing.

Refugees in urgent need of assistance

MSF launched an emergency response in the refugee camp in Doro, in Maban County, on 28th November. The camp’s population has now reached 25,000 with families continuing to make the long journey by foot from Sudan’s Blue Nile state. 

Our teams immediately started providing primary health care and started digging latrines.

The water and sanitation workers also fixed water points and installed a 15,000 litre water bladder to reduce the waiting times of up to 12 hours that were making life a misery for the women and girls responsible for filling their families’ plastic jerry cans.

Diseases and diarrhoea

Women who have just crossed the border into South Sudan at the village of Khortumbak. Most of the refugees have walked for more than a week with as many possessions as they can carry to get to the border. © Jean-Marc Jacobs

Medical consultations have revealed a consistent pattern of malaria, respiratory tract infections and diarrhoea among the new arrivals that have, in some cases, been walking for weeks to reach safety.

“When they arrive in Doro, in terms of their nutritional status, their immunity is down so they will not react for malaria and other diseases in the same way as a healthy person,” says Dr Asaad Kadhum, emergency coordinator.

Medical action

To date our team has performed more than 1,500 out-patient consultations, and is currently setting up an in-patient facility in the camp to treat more seriously ill patients.

In the coming days there will be a measles vaccination campaign to make sure all children under 15 years old are vaccinated.

Refugees

Near the village of Alfuj, to the north of Doro and close to the border, many thousands of Sudanese from another part of Blue Nile state have gathered with their belongings under the sparse trees.

Their exact numbers are still unknown. After a rapid assessment MSF immediately started the emergency distribution of BP-5 nutrition bars to children under five years old and on the day of the first visit treated 150 of the most urgent cases of  diarrhoea, respiratory diseases and malaria.

These families told MSF their people had been on the move since September – initially hiding in forests near their crops but eventually fleeing across the border after three straight days of fighting convinced them it was no longer safe to stay.

They expressed two urgent needs: for food and for health care. A local nurse among the refugees was doing his level best to keep a clinic running under a tree but he had no medications to offer.

The MSF team will return regularly to this group to provide emergency food and a mobile clinic for the most seriously ill.

Food emergency

Widow Naynkor Manyiel walking home from the supplementary feeding distribution in Abathok, South Sudan. © Avril Benoit/MSF

The unfolding food emergency has additional causal factors quite apart from added burden of returnees, refugees and internally displaced South Sudanese.

There has been widespread crop failure, flooding, trade disputes, and inflation in the local markets. Families eat sometimes, sometimes not.

“If nothing is done, the situation could become dramatic,” said Ines Hake at the conclusion of her an 11-month assignment as medical team leader at the MSF hospital in Agok.

Hake took part in the assessment that prompted the medical organisation to start blanket supplementary feeding for 20,000 young children.

The survey found that 65 percent of households in the region were accommodating family members displaced by the conflict in Abyei.

Feeding children 

“In this already impoverished region, there are now many more mouths to feed,” Hake worries.

“For the moment, the lives of the children that we are targeting are not in immediate danger,” Hake explains.

The aim of preventive supplementary feeding is to reduce chance that children become so malnourished that they will require therapeutic feeding or, worse, hospitalisation.

Crisis

Nurse Sita Cacioppe has witnessed the tragedy of full-blown food crises. Her previous field assignments with MSF have included working in an emergency malnutrition program in Chad, and more recently in the overflowing camps in northern Kenya where malnourished Somalis sought refuge from violence and food shortages.

The difference in this emergency intervention is that it’s all about avoiding what could otherwise be inevitable.

“If we can prevent malnutrition now before it kicks in, we’re preventing kids dying,” she said, adding that her own motivation is “to try and prevent us from coming out onto the field and finding hundreds of actually starving children.”

MSF has been working in South Sudan since 1978. More than 2,000 South Sudanese staff work alongside almost 200 international staff in more than a dozen projects covering eight states. 

“For the diseases our medical teams encounter every day in places where we work, 2011 was a year of both critical progress and dangerous backsliding,” said Dr. Tido von Schoen-Angerer, executive director of MSF’s Access Campaign. 

MSF's 'Ten Stories that Mattered in Access to Medicines in 2011' report. © MSF

“At a time of so much promise, it is crucial to continue pushing forward, and refuse to accept a double standard in care between rich and poor countries.”

The list covers key developments regarding diseases MSF confronts in developing countries:

• landmark findings about HIV treatment as HIV prevention

• the strikingly low number of people receiving treatment for more lethal, drug-resistant forms of tuberculosis

• a new subsidy intended to lower the price of malaria treatments that is headed in the wrong direction

• a dangerous global shortage of the drug needed to treat the parasitic slow killer Chagas disease

• slow progress on better adapting food aid to meet children’s needs

• vaccine prices finally becoming more transparent

• the first-ever guidelines to treat an HIV/AIDS ‘opportunistic infection,’ cryptococcal meningitis  

It also looks at key policy developments of the year, including:

• unprecedented funding shortfalls at the Global Fund to Fight AIDS, Tuberculosis and Malaria

• drug companies cutting across-the-board discounts in middle-income countries

• the continued struggle to ensure affordable generic medicines can be produced in India, the ‘pharmacy of the developing world’

Download Ten Stories that Mattered in Access to Medicines in 2011 as a pdf or visit the MSF Access Campaign website to find out more.
 

When the Global Fund to fight AIDS, Tuberculosis and Malaria announced it had to cancel its new round of funding because it was running out of funds, it felt like a punch in the face for me and for thousands of other health workers at Médecins Sans Frontières MSF (Doctors Without Borders).

Unni Karunakara, President of MSF International. © Joshua Lutz/Redux

The news could not have come at a worse time. Just when years of hard work, coupled with new scientific advances, bring hope that we can push back the three diseases that kill millions every year, donors drop their commitment to the Global Fund.

So instead of continuing on a path toward reversing the epidemic killers, health ministries in the hardest-hit countries may have to witness a reversal of hard-won progress itself.

Lifeline for millions

MSF’s treatment programmes are mainly funded by the contributions of private individual donors, but ministries of health rely heavily on the Global Fund.

Set up in January 2002, the Fund has become a lifeline to millions of people in the countries where MSF works, estimating that its funding stream has directly contributed to preventing an average of one million deaths per year.

We have seen ministries of health successfully run ambitious programmes that they never could have imagined without outside support.

HIV care threatened

But donors have left the Global Fund in the lurch, with some withholding or delaying their promised contributions, and others not giving anything at all.

With no resources to pay for any new proposals until 2014, the Fund has told hard-hit countries they can’t scale up effective HIV treatment for three years, unless they have already approved grants. TB and malaria will also suffer.

This effectively means health ministries will be forced to ration care, and make the difficult decision to provide less than optimal treatment because the better treatment simply costs too much.

And this at a time when scientific advances could successfully be pushing back all three diseases.

HIV treatment as prevention

Take AIDS. Ten years ago, in countries like Thailand and South Africa, MSF piloted programmes that challenged the very notion that treatment couldn’t be rolled out in poor communities.

This year, 30 years into the epidemic, research has delivered the evidence that HIV treatment itself can be a decisive tool for pushing back the pandemic.

A person put on treatment earlier is 96 percent less likely to pass the virus on to others. Yet today, the majority of people tested positive continue to go untreated.

With HIV treatment now a key tool for HIV prevention, we have a historic opportunity to reverse AIDS. At this crucial time, donors should be funding the Global Fund, so countries are empowered to seize this opportunity and implement bold programmes that can turn the tide on the epidemic. But instead, countries have been told to hit the brakes.

TB and urgent treatment

MSF nurse assisting an MDR TB patient at MSF's clinic in Mumbai. © Cristina De Middel

Take tuberculosis. For the first time, the number of TB cases worldwide is on the decline, although it remains shockingly high for a curable disease, with more lethal, drug-resistant forms on the rise.

Here, too, treatment is prevention: if people are on treatment, they are less infectious.

A new advance in diagnostic technology has improved our ability to determine who has drug-resistant TB and therefore to put them on the right treatment. Scaling up is now a matter of urgency.

Malaria and death

Take malaria. The combination of providing bednets to prevent malaria and effective combination therapy to treat the disease have significantly reduced incidence.

A landmark clinical trial in 2010 showed that better treatment for severe forms of malaria in children can dramatically reduce death rates. But kids continue to be treated with quinine, which is cheaper, but far less effective.

And malaria continues to kill hundreds of thousands of people every year, most of them young children. While prevention remains the mainstay of the fight against malaria, MSF has estimated that switching treatment for severe forms would cost around $30 million more, but can save 200,000 lives per year.

Global Fund ‘closed for new business’

There has never been a better time to push forward, build upon progress and use new scientific evidence to rein in these epidemics.

Affected countries should take their responsibility. Many of them want to be ambitious, and also want to take on a bigger role in footing the bill. Uganda, for instance, wants to double the rate at which people are put on to HIV treatment, and Uzbekistan wants to significantly increase the number of people receiving treatment for drug-resistant TB.

But countries can’t do this alone. So where will the funding come from, with a ‘closed for new business’ sign hanging on the front door of the Global Fund?

Refuse to settle for rationed care

It’s time for the Global Fund Board to end its passivity and raise the alarm about the urgency of the situation – it must refuse to settle for rationed care and stalled ambitions caused by donors turning their backs.

The Board needs to hold an emergency donor conference within the next half-year to raise the resources needed to finance a new funding opportunity for countries in 2012.

Donors that have promised funding need to pay up. Old and new donors, including emerging economic powers like China, India and Brazil, who have yet to give this year need to step up to the plate.

It is unacceptable and unconscionable that as the Global Fund turns 10 in January its bitter gift to the world is a three-year hiatus in the fight against the three killer diseases. Donors must deliver on their promises.

Survival

In my work with MSF I have seen people die from AIDS, from TB and from malaria. But in recent years, I have most of all seen people survive these diseases.

The Global Fund is a crucial part of the most ambitious health project in history, and millions of people alive today are testimony to its success. We simply can’t afford to squander the opportunity we have now to deal these diseases a final blow.

In 2010, MSF provided HIV treatment to more than 180,000 people in nearly 20 countries, TB treatment to 30,000 patients, and malaria treatment to 1.6 million. 

Within a few months of its implementation, the teams had treated nearly 700 patients.

A population at risk

Smoking, poor diet, lack of exercise, hypertension, diabetes, and especially the stress of years of war have meant the Chechen people are more susceptible to cardiovascular disease, which affects one person in six.

In the absence of equipment and specialised medical staff, these diseases are responsible for more than 62 percent of deaths in the Republic. The national average is lower, at 56 percent.

In 2009, the Republican Emergency Hospital (REH) in Grozny registered 1,555 patients who had suffered a heart attack, with 33 percent of the cases fatal.

At that time, the cardiology and intensive care unit had no functional defibrillator, ECG machine or Holter monitor and there was no way of carrying out specialised biological examinations or fibrinolytic treatment.

The only way to treat a patient with cardiovascular disease was if they travelled to Moscow, a distance too great for the most urgent cases.

Emergency heart care

At the end of 2010, MSF opened a cardiology and intensive care programme in the surgical and cardiovascular intensive care unit of the emergency hospital in Grozny.

Given the weaknesses in the health system and the gaps in the knowledge of the field of cardiology, the aim of MSF was to improve the ability of Chechen cardiologists to diagnose and treat emergency cases.

The first few months were devoted to developing equipment, supplies and medicines, and to training staff on treatment methods specific to cardiology.

Consultations with the patients then followed.

Since February 2011, the emergency unit in the cardiology department recorded almost 700 admissions, with more than 100 patients resuscitated using defibrillators.

Fibrinolysis is a process to dissolve a blood clot before it reaches the heart, which without treatment is fatal. The first fibrinolysis took place in early July, and teams have carried out 15 since.

"Before the arrival of MSF, this procedure had never been done here. We did not have the necessary equipment or drugs," says Dr Madina Saidarkhanova, the head of the cardiac intensive care unit.

A first in MSF history

Aside from medical issues, there have been some challenges.

"This is the first time that MSF is implementing a project for cardiac emergencies. This is a highly specialised medical activity. However, based on preliminary results, it is a success," says Vladimir Najman, MSF head of mission in Russia.

By the end of 2011, the mortality rate had fallen to 7.82 percent.

Our teams work with the Ministry of Health in all departments – pediatrics, surgery, maternity, emergency, outpatient care, treatment of tuberculosis and HIV – in this 155 bed hospital.

Our reporter takes you into the wards on a typical day...

Inside the hospital

An MSF medic examines a patient at a health centre in the Central African Republic (CAR).
© Talia Bouchouareb/MSF

It is 7.30am at the MSF hospital in Paoua. This is the time when the night shift updates the day team on the night's developments.

The doctor on duty explains the cases of the patients hospitalised during the night in the different units.

He asks his colleagues' advice and opinion regarding any problems.

Later, around 8am, Dr Frédérique Eygonnet heads to the pediatrics department, which she oversees.

"Paoua is the only hospital in the region," she explains.

"Patients come from the city, but also from health centers located on the outskirts, about two hours away. On average, we receive four to five patients every day who have been transferred by motorbike from our health centers."

• Read MSF's report on the Central African Republic (CAR)

Motorcycle 'ambulances'

The hospital has approximately 155 beds. It includes several buildings that house the medicine, surgery, maternity, malnutrition and pediatrics departments.

One wing has been designated as the 'TB village' and is reserved for patients with tuberculosis. Another building is dedicated to patients living with HIV.

A dozen motorcycles are parked in the central courtyard under a tree. They transport the patients arriving from the clinics that MSF manages in the bush.

Surgery

Together with Neema Kaseje, the surgeon, Frédérique visits the patients who have had or are awaiting surgery.

Neema tells her colleague that she was called twice the previous night: "Around 11pm, I was called in to see a patient who suffered a skull fracture in a fall. I came back later that night to perform a caesarean.

"But that's pretty standard. I don't have anything special to report today."

Children in danger

Next, accompanied by the nurse and the nurse's aid, Frédérique visits the pediatric intensive care unit and the neonatology unit. She asks about each patient, speaking to the mother and the night nurse.

She is particularly concerned about a newborn in the neonatology unit. The little girl was born three days earlier and suffers from respiratory insufficiency. Frédérique asks the nurse to do an X-ray exam.

"The visits take a long time," she says. "The department is very crowded and there are often two children to a bed. My visits are regularly interrupted by emergencies. Most of the time they involve children with severe malaria anemia, who must be transfused very quickly."

Malaria

A bit further off, two newborns lie in bed under the worried, watchful eye of their mother. They are ill with malaria and have become anemic. They need a blood transfusion.

Malaria is one of the leading causes of hospitalisation. When it’s not treated, it causes many deaths among children under five years.

Gaspard, a two-year-old boy, is lying in another bed on the ward. He was admitted for  severe malaria anemia. The child also presented with marasmus, a severe form of malnutrition. He needs a transfusion right away and also requires treatment for malaria.

Courting catastrophe

"In certain cases of severe malaria – the neurological form, for example – children have convulsions or sometimes fall into a coma," Frédérique says.

"When I started my mission, everything was very intimidating and stressful. It felt like we couldn't manage anything, that we were courting catastrophe.

"And then, very soon, we realised that we were developing automatic responses and we would perform cardiac massage on infants, calmly, without even breaking a sweat."

It's almost 3pm and time to return to the MSF base, located not far from the hospital. Frédérique is on duty tonight. She is making preparations to return to the hospital in case of emergencies – but she'll drive there because you don't go out at night on foot.

Stats

Paoua hospital:

• 155 beds (total)

• 18 maternity beds

• 55 pediatric beds

• 10-15 new HIV/TB patients admitted monthly

Emergency mortality rates

Baby is examined in MSF clinic in Besse, Central African Republic. © Anna Surinyach/MSF

The report draws on four mortality studies conducted by MSF in the past 18 months, which reveal mortality rates in some regions at three times the emergency threshold.

The areas with the highest mortality rates are not affected by violent conflict and do not host large numbers of displaced people.

Mortality rates at this level constitute a humanitarian crisis,* and indicate that the situation is out of control.

Medical aid is insufficient

In the report, MSF concludes that existing levels of medical assistance are nowhere near enough to meet the scale of the needs.

The report outlines the necessity for increased efforts to conduct larger medical operations that reach more of the population.

"The country’s health system has been torn apart by years of political and military instability, major organisational problems, and a lack of security in the northern and eastern regions, all of which have had a catastrophic effect on the health of the population,” says Olivier Aubry, MSF’s head of mission in the Central African Republic.

Forgotten humanitarian crisis

The country has the second lowest life expectancy in the world, at 48 years, and the fifth highest death rate from infectious and parasitic diseases.

So far the catastrophe has gone unnoticed by the outside world, despite its severity.

Aubry says: “Last July, in Carnot, the mortality rate for children under five was three times as high as that seen amongst under-fives in Dadaab refugee camp, in Kenya. But, in Carnot, the crisis was unknown.”

Donors scaling down

Despite the health emergency, the report argues that commitments shown by the government and by the international community are moving in the wrong direction.

The government has been scaling down its investments in health, as have international donors, while humanitarian assistance has failed to reduce the widespread medical crisis.

Both the government and international donors appear to be actually disengaging from health provision in the country.

MSF calls on all parties, including the government and the international community, to expand assistance provided for people’s health in the Central African Republic, and reminds them that if old models of assistance are not working, new ones must be created.

MSF’s programmes in Central African Republic

MSF has been working in the Central African Republic since 1997 and, at the end of 2010, had 1,243 staff working in the country.

MSF projects support nine hospitals and 36 health centres and health posts. In almost all cases, MSF works in Ministry of Health facilities, seeking as close cooperation as is possible.

In 2010, MSF staff in the Central African Republic treated 582,253 people as outpatients and 24,185 people as inpatients.

* The 'crude mortality rate' is used to define a humanitarian crisis. The emergency threshold is above one death per 10,000 people per day. (World Health Organization)

• Read about a typical day working in an MSF hospital in CAR

The explosion occurred close to a market in central Kunduz around noon.

MSF teams treated patients with blast-related injuries, including severe internal wounds, bleeding and burns.

The MSF surgical hospital in Kunduz is the only trauma centre of its kind in northern Afghanistan, October 2011
© Olof Blomqvist/MSF

“Patients started arriving at our hospital within five minutes of the blast. Two people were severely injured and needed immediate surgery, the rest of the patients were stabilised,” said Erwin Guillergan, MSF coordinator at the Kunduz surgical hospital.

Urgent surgical care

Since August 2011, MSF has been running a surgical hospital in Kunduz that provides urgent surgical care and follow-up treatment for people wounded in the conflict, and those suffering from life-threatening injuries.

Hundreds of patients have been treated in the hospital since it opened.

In all locations where MSF is working in Afghanistan, a strict no-weapons policy is implemented to ensure patient safety and security.

MSF teams also work in Ahmed Shah Baba Hospital in Kabul, and Boost Hospital in Helmand province’s capital Lashkar Gah.

In both locations, MSF provides free medical care, working in all wards of the hospitals.

MSF plans to open a maternity hospital in Khost province in early 2012.

For its work in Afghanistan, MSF relies solely on private donations, and does not accept any government funding.

• Read more about MSF in Afghanistan

• Read more about the refugee situation in South Sudan

• A refugee in South Sudan speaks to MSF

MSF set up a temporary clinic in Doro, South Sudan, on 28th November. To date MSF has conducted 700 consultations in the temporary clinic, including 100 patients treated for malaria and more than 100 ante natal consultations.

Women who have just crossed the border into South Sudan at the village of Khortumbak.
© Jean-Marc Jacobs/MSF

Because this is not a good sanitary environment for giving birth, a midwife will shortly join the MSF team, which also includes:

• a doctor
• a nurse
• two clinical officers
• a health promotion office
• other humanitarian emergency specialists

Medical care

Most of the refugees seeking medical attention present with respiratory and diarrhoeal diseases.

This is largely due to people sleeping without shelters in the cold nights and the lack of clean drinking water and accessible sanitation. Malaria is also common.

The clinic is providing vaccines, notably against measles, tuberculosis and tetanus for specifically vulnerable individuals and young children.

Children suffering from malnutrition are receiving ready-to-use therapeutic foods fortified with the proteins and minerals they need to regain their strength.

Water and sanitation

MSF’s water and sanitation specialists have started digging latrines and are setting up temporary measures to speed up the supply of chlorinated water.

These are emergency measures until other nongovernmental organisations can scale up their operations to provide comprehensive water and sanitation services.

In all, MSF has 15 international staff and upwards of 70 locally hired staff working to provide the urgent healthcare and basic water and sanitation requirements in Doro.

MSF logisticians have started setting up a dedicated clinic in the heart of what will be Doro refugee camp. The team expects to start mobile clinics or other medical services in other areas of Maban County affected by the sudden influx of refugees.

• Read more about the refugee situation in South Sudan

• A refugee in South Sudan speaks to MSF

• Read about MSF emergency medical response in South Sudan

• A refugee in South Sudan speaks to MSF

The walk from their homelands in Blue Nile State, Sudan (north), took anywhere from one week to one month.

The walk from their homelands in Blue Nile State, Sudan (north), took anywhere from one week to one month.
© MSF

Although the work to set up a properly organised refugee camp is under way, no family groups arriving at the gathering point at Doro have yet been allocated a plot.

So the reality for most is still to find a small tree or bush under which to spread the belongings they were able to carry.

"We came, all of us..."

The refugees say they have fled war in Blue Nile State in neighbouring Sudan.

A community elder who recently arrived told MSF staff that he believes his entire community of 5,000 has fled to Doro.

“We came, all of us,” he said. “No one remains behind.”

He said his community is largely subsistence farmers, cultivating land for food. Their newfound circumstances, which he is worried may last for years, are unsettling.

Many of them have been in this situation before, as past refugees in camps in Ethiopia for a decade during the civil war in Sudan.

“I feel very bad being here because we see that life will be difficult for us with no food and water,” he said. “My people keep asking me how we are going to survive in this place.”

MSF medical response

The limited services in the area are overwhelmed. Near the perimeter of what is being marked out as the refugee camp, a borehole with a hand pump is now overcrowded with women and girls who sometimes wait in line with their plastic water containers for up to 12 hours. Tensions are rising.

“Many of the patients that we see in our clinic have respiratory diseases,” says MSF clinical officer Robert Mungai Maina.

“And there are many patients with diarrhoeal diseases because for the past weeks there were no latrines and there is not enough water. Today we had four cases of bloody diarrhoea and many more cases of watery diarrhoea.

“We are also seeing malnourished children, some with moderate and some with severe malnutrition.

“We’re here to provide healthcare, but with our water and sanitation team we are also digging latrines, preparing to supply water, trying to meet the immediate needs.”

One 33-year-old man told MSF that he had come to seek safety, but that he was presented now with a new set of problems.

“[During our journey] my children would ask me, ‘Where are we going?’ They wanted to go home. I told them we were running away from the war. We needed to get to a safe place.

“But here there are a lot of problems facing us. We came to a place where we can be secure, but food security is now replacing the other security problem that we ran from.”

After spending 10 years in a refugee camp in Ethiopia during Sudan’s civil war, he returned home in 2005, working as a Community Health Worker with an NGO in Blue Nile State, Sudan.

He is now registered as a refugee again. MSF interviewed him in Doro camp, South Sudan on 7th December 2011.

• Read about MSF’s emergency response to this refugee crisis here

• Read more background on the refugee situation in South Sudan

Fleeing conflict in Sudan

“The journey here was very hard for us. It was so far. For me and my family it took about one week and a half to come here to Doro.

Our small children could not walk far. My wife and our 11-year-old each carried the twins, who are one year old, on their backs.

I was carrying our food and belongings. The others – who are aged nine, seven and four – had to walk by themselves. The four-year-old can walk, but after a while he started crying.

When we were on the way, the children were very hungry. Some of them were sick with diarrhoea. The sun was hot.

We drank water that was not clean. But we managed to reach this camp.

Difficult journey

Every day we started our journey early in the morning. We would walk for four hours at a time, then rest under a tree.

If the children could not walk any more, we stayed there overnight. They would have a bit to eat and start playing.

You could see their faces change suddenly when we told them it was time to start walking again. They knew they would be tired and they started crying.

If they were okay to keep walking, we would go for another four hours. We were always looking for places where we could find water.

My children would ask me, “Where are we going?” They wanted to go home. I told them we were running away from the war. We needed to get to a safe place.

South Sudan: refugee reality

Here there are a lot of problems facing us. We are just staying here because of security; we think we will be safe here.

This place is very cold at night. We light a fire because we have no sheets or blankets.

The only water is the hand pump for the local people from the area. There are many of us coming and we have to share the water together with the local people here.

Sometimes my wife goes to the water pump first thing in the morning and only comes back in the evening with water.

It can take up to 12 hours to wait, from early in the morning to late at night. If she were to leave, she would lose her place in the line.

People here know MSF is giving health care to them by opening this clinic. If MSF hadn’t come, they could have suffered more. You hear people talking about how it is good that this clinic is helping them.

I just want to tell the world we need help, a lot of help, from them. We came to a place where we can be secure, but food security is now replacing the other security problem that we ran from.

I will stay here until our home place has peace. But I worry that we may be here for a long time.”

• Read about MSF’s emergency response to this refugee crisis here

• Read more background on the refugee situation in South Sudan

Visceral leishmaniasis, also known as ‘kala azar’, is a neglected parasitic disease spread through the bite of a sandfly.

The Leishmaniasis parasite is transmitted to humans by biting sand flies. Photo by MSF

Visceral leishmaniasis is endemic in 76 countries worldwide. In East Africa, regions in Ethiopia, Kenya, Sudan and South Sudan are particularly affected.

The disease is fatal without treatment.

Hiv and kala azar

“People living with HIV are particularly vulnerable, so it’s critical that HIV programmes kick start a response to this neglected disease,” said Dr. Rachel ter Horst, medical advocacy advisor with MSF, (who presented MSF field experience and research on the management of HIV/VL co-infection at ICASA).

“In countries like Ethiopia where HIV and visceral leishmaniasis interact and co-infection is a problem, HIV programmes are essentially faced with the same paradigm as with tuberculosis.

HIV programmes have learnt to think TB – they also need to learn to think visceral leishmaniasis.”

North-western Ethiopia has the highest burden of HIV/VL co-infection, as around one in three patients with visceral leishmaniasis is also HIV-positive.

HIV

Visceral leishmaniasis interacts with HIV in many ways:

• People living with HIV are at much higher risk of developing this disease.

• Visceral leishmaniasis accelerates progression to AIDS.

• Relapses are almost inevitable in people living with HIV. 

• HIV-positive patients respond less well to anti-leishmanial treatment with each subsequent relapse.

But successful treatment of the first episode of visceral leishmaniasis and early initiation of antiretroviral therapy may delay and reduce relapses.

“As a first step, HIV programmes in areas that are endemic for visceral leishmaniasis should actively screen people living with HIV for this life-threatening disease,” said Dr Ter Horst.

“Co-infected patients should then be given antiretrovirals as soon as possible after starting anti-leishmanial therapy.”

Combination therapy

New data presented at ICASA by MSF suggests that the use of high-dose combination treatment regimens for co-infected patients can improve survival in the longer-term.

Early results suggest that treatment with liposomal amphotericin B at higher doses, combined with miltefosine, may have higher safety and efficacy than other options.

“Until now, treating people living with HIV who also suffer from visceral leishmaniasis has led to pretty bleak outcomes,” said Dr. Koert Ritmeijer, MSF health advisor.

“Existing treatments were failing – some like SSG are too toxic and lead to high mortality in co-infected patients, others like liposomal amphotericin B are safe but aren’t effective enough. 

"We’re now seeing high-dose combination therapies have led to better initial cure rates, including in patients who had been cured of VL but have since suffered a relapse.”

Further research

Two clinical trials co-sponsored by MSF, the Drugs for Neglected Diseases initiative (DNDi), and the Institute of Tropical Medicine in Antwerp (ITM), and in collaboration with Gondar University in Ethiopia, will be implemented in 2012, both to confirm these promising results and to investigate the benefits of preventive therapy to reduce the occurrence of relapses. 

“With the prospect of better treatment options, if the studies confirm these results, we hope that improved treatment guidelines will be implemented throughout the region in the near future,” said Dr Ritmeijer.

MSF's December 2011 briefing document, The Double Burden:HIV/visceral leishmaniasis co-infection in East Africa is available from msfaccess.org.

In East Africa, MSF diagnoses and treats HIV and visceral leishmaniasis in several areas where the latter is endemic: Jonglei, Unity and Upper Nile States in South Sudan, Gedaref in Sudan, Abdurafi in Ethiopia, Pokot in Kenya.

MSF has treated more than 100,000 patients for visceral leishmaniasis worldwide since 1988.

However, access to some of the WHO-recommended medicines ranges from difficult to non-existent in developing countries.

High risk of death

According to data presented by MSF at the ICASA AIDS conference in Addis Ababa, cryptococcal disease is a major cause of illness and death in many parts of Africa.

The study looked at the cause of death among 36,664 people started on antiretroviral therapy (ART) in 25 MSF treatment programs in Africa, Asia and Eastern Europe between 2002 and 2010.

In the study, patients infected with extrapulmonary cryptococcosis had a 3.5 times increased risk of dying in the first six months after antiretroviral therapy was started, the greatest risk of all opportunistic infections associated with HIV.

HIV

“Our findings show that people living with HIV/AIDS are frequently contracting and dying of cryptococcal disease,” said Dr. Daniel O’Brien, HIV/AIDS Advisor with MSF and one of the authors of the study. 

“It’s very good news there are finally clear guidelines on how to diagnose this disease early and treat it, but access to the drugs needed to treat remains a big challenge.”

Barriers to access

The main drugs recommended by WHO include amphotericin B and flucytosine as the first line, with amphotericin B and fluconazole as alternatives when the first regimens  are unavailable or unaffordable.

Access to flucytosine is restricted by the fact that it is not registered in most countries in sub-Saharan Africa, where the HIV burden is highest. Registration barriers also exist for amphotericin B, and there have been global shortages of the drug, with South Africa and other countries likely to face stock-outs this year. 

In South Africa’s KwaZulu Natal province, researchers found that only 35 percent of patients received any amphotericin B at all, with only eight percent receiving the recommended two week treatment course. 

“To address HIV/AIDS properly depends on being able to prevent, diagnose, treat and cure the opportunistic infections that are ultimately causing AIDS deaths,” said Dr O’Brien.

Yet it is an anniversary that the world’s 15.1 million refugees have little reason to celebrate. Today, states are increasingly shutting their borders and restricting the assistance they give to refugees and people seeking asylum.

By Christopher Stokes, MSF Belgium General Director

Governments ignore responsibilities

Child refugees in the Dadaab refugee camp, Kenya.
© Nenna Arnold /MSF

We can expect ministers and heads of state to speak of their steadfast commitment to the convention, but this is disingenuous.

Too often, national governments circumvent or simply ignore their responsibilities to refugees, with serious medical and humanitarian consequences for those they have committed to protect.

At the core of the Refugee Convention lies the idea of asylum. The increasingly restrictive policies of governments – while not necessarily in contravention of international, regional or national legislation – violate the spirit of the convention and the meaning of asylum. In turning their back on refugees, states end up playing a repressive rather than a protective role.

Denying asylum endangers lives – South Africa

In South Africa, Médecins Sans Frontières has witnessed Zimbabweans without passports being barred entry at the main border post, denying them the possibility of applying for asylum.

As a result, many seek an unofficial route into South Africa, exposing them to myriad dangers, from drowning in the Limpopo river, to attack by crocodiles, to falling victim to violent criminal gangs who roam the borderlands.

In the first six months of 2011 alone, our staff treated 42 people who had been raped by gang members while trying to cross the border.

We fear there are many more victims who did not seek our assistance.

Europe fails asylum seekers

Europe, which was the focus of the Refugee Convention at its inception in 1951, performs no better in its treatment of asylum seekers.

This year, the popular uprisings in North Africa pushed some 57,000 refugees, asylum seekers and migrants to flee across the Mediterranean to Italy and Malta. Perhaps as many as 2,000 people perished at sea.

Those who survived the journey found themselves detained in reception centres in appalling conditions. In March this year, 3,000 new arrivals were forced to sleep on the docks on the island of Lampedusa for several days, sharing 16 toilets and surviving on just 1.5 litres of water per day.

Countries shirk responsibility

Refugees from the recent conflict in Libya are assessed by MSF staff in Lampedusa, Italy.
© Mattia Insolera

Aiming to curb the landings on its coasts, the Italian government quickly moved to sign bilateral agreements with the new Tunisian interim government and the Libyan Transitional Council, despite the ongoing war in Libya.

These agreements amounted to pushing back potential asylum seekers from Europe’s shores to North Africa.

Italy, along with several other European countries, was party to the Libyan conflict, and thus bore an even greater responsibility to ensure that people fleeing the war were given decent reception conditions and access to an efficient and fair asylum procedure.

Developing countries host the most refugees

Even for those who are successful in their applications for asylum, refugee status is often not enough to survive.

Shunned and deprived of assistance, many refugees are condemned to migrate further, in search of a way to provide for themselves and their families.

Today this is more true than ever as – unlike 60 years ago – developing countries now host the vast majority of the world’s refugee population.

Almost half a million Somalis now live – if that is the right word – in Dadaab, the world’s largest refugee settlement. The first refugee shelters were put up in Dadaab, in northern Kenya, over two decades ago.

Now the Dadaab camps make up Kenya’s fourth largest city.

Children’s health worsens in Dadaab camp

This year we conducted medical surveys in an area of the overcrowded camp where new arrivals were settling, only to find that malnutrition rates amongst the under-fives actually increased.

Children who had fled hunger and violence in Somalia, and survived the gruelling journey to Kenya, were now in worse health than when they first arrived.

Somali refugees, it seems, have no safe place to go.

Aid agencies

Medical and humanitarian activities have a tangible, but ultimately limited, impact on the welfare of refugees, asylum seekers and all those fleeing violence or economic collapse in their home country.

Wider questions of assistance, protection and long term solutions urgently need to be addressed. People are increasingly mobile, and their motivations to cross borders are diverse.

Governments need to come up with solutions that do not see migration management working at cross-purposes with refugee protection.

The Refugee Convention  

In the meantime, the Refugee Convention remains the most important tool for refugee protection and assistance.

When all states actively demonstrate their commitment to refugees through policies that are in line with the spirit of the convention, then world leaders and refugees alike will really have something to celebrate.

People living in this area of eastern DRC have to contend with ongoing insecurity and outbreaks of violence that push them out of their homes. They suffer from preventable diseases like cholera, measles and malaria. They are often unable to access medical care, which is why MSF has been working there for 30 years.

• Read more about DRC

This month we visit the busy MSF hospital in Paoua, Central African Republic; the only hospital for the region’s 120,000 inhabitants. In Democratic Republic of Congo, MSF are training local staff in different techniques in obstetrics and gynaecology.

We take a look at the heart of Grozny, where MSF set up a project for cardiac care in 2010, and Malawi where MSF have been committed to providing anti-retroviral drugs for HIV/AIDS treatment since 2001. 

After 20  years away from Somaliland – first in Sweden and then in the UK – Sohur has returned to help people still caught up in the violence and insecurity that forced her family out.

•  Read more about Somalia

“This commitment today is the shot in the arm that the global HIV/AIDS response needs right now. We hope this marks the end of donors walking away from supporting global HIV/AIDS, despite evidence that the epidemic can be reversed.

"People living with HIV around the world will be watching closely to make sure this commitment is turned into reality.

"Now it is time for all governments – both donors and affected countries alike – to step up, fund the Global Fund, and increase the pace of HIV treatment scale-up, so that the effort to end AIDS is not derailed.

"Our doctors and nurses started treating people with HIV in developing countries a decade ago, in the face of widespread skepticism, and yet today half of the people who need treatment now have it. 

"This is the best time to charge full speed ahead and get treatment to everyone who needs it so we can save lives and get ahead of the wave of new infections.”

Dr. Tido von Schoen-Angerer – Executive Director, Access Campaign, Médecins Sans Frontières 
 
CONTACT: MSF UK Broadcast Relations Manager Sophie Scott,  44 (0)7889 178 473.

Many of the refugees have told Médecins Sans Frontières MSF (Doctors Without Borders) staff that they fled bombing in and around their villages in Blue Nile State.

Women who have just crossed the border into South Sudan at the village of Khortumbak. Most of the refugees have walked for more than a week with as many possessions as they can carry to get to the border. © Jean-Marc Jacobs

“I decided to leave my place as war was coming,” said a 50-year-old man in Doro. “We saw the aeroplanes. They bombed our village. We have been on the road for eight days. There were long lines of people walking with us.

"We arrived three days ago, but we only had the little food that we brought with us and we have spent a few days without food.”

MSF emergency response

On Monday 28th November, MSF started an emergency medical intervention in the village of Doro, some 40km from the border with Sudan.

An estimated 13,000 men, women and children have already arrived and the MSF team has seen thousands more walking with what possessions they can carry from the border area towards the gathering-point at Doro.

Thousands of refugees arrive

“The place they are gathering is not a refugee camp yet, as the organisation and the allocation of plots to families is just starting,” says Jean-Marc Jacobs, Deputy Head of Mission in South Sudan, who was in the area last week to assess the need for an emergency medical response.

“But the scrubland is filling up with refugees and the queue of new arrivals registering keeps getting longer. The sheer numbers are overwhelming the capacity of the local health clinic.”

Emergency medical response

Over the weekend MSF managed to get the first supplies of drugs and medical equipment to Doro, and on Monday a team of three medics started providing medical treatment for the refugees.

“For now we are concentrating on the most critically ill,” says Dr Asaad Kadhum, coordinator of MSF’s emergency team on the ground in Doro. “So far today [mid-afternoon Tuesday] we have treated 118 patients in our clinic.

"Severe cases of malaria, diarrhoea and respiratory diseases are our priority, and up till now we have treated 22 of these urgent cases. Now that we are getting up and running, we expect to see around 120 patients a day in our fixed clinic.

"But the camp is covering a large area and is growing, so we will need to start up a mobile clinic team as soon as possible to reach all those that need medical care.”

Severe malnutrition and child health

The MSF team will start a therapeutic feeding programme over the coming days to treat the children under five affected by severe malnutrition.

Vaccinations to prevent the spread of communicable diseases will be essential and the team can already see that there will be a critical need for ante-natal and maternal health consultations as there are many pregnant women who will be giving birth in extremely difficult conditions.

Drinking water and sanitation

The needs are expected to increase in the coming days and weeks as more refugees arrive, and healthcare is not the only urgent requirement in Doro.

There are only two boreholes in the area and people are queuing up to five hours, with the 13,000 refugees and the local inhabitants all trying to get the water they need. There is not a single latrine yet, and it is unclear how these people are going to get enough food.

“In a situation like this drinking water, sanitation and healthcare cannot be dissociated,” says Dr Kadhum. “Our water and sanitation expert is evaluating what we more urgently need to put in place. And we are expanding the medical team to give us the flexibility to work where the needs are greatest, either in the camp or closer to the border crossing points.”

Refugee stories

Closer to the border, hundreds of families are scattered in the scrubland, getting some rest before starting the second part of their journey to Doro.

“We think there are around 8,000 refugees on the move, walking slowly from the border crossings towards Doro,” says Dr Kadhum.

“They are exhausted, and they are terrified. You can see the fear in their eyes. And we do not know how many more people will cross the border in the days and weeks to come.”

The evolution of this crisis is hard to predict. Yet with many more refugees on the move medical and basic material assistance will continue to be urgently needed and all possible measures must be taken to ensure that the refugees can find shelter in a safe and healthy environment.

The Global Fund, financed largely by governments, was set up 10 years ago as a ‘war chest’ to fight the spiralling AIDS pandemic and tackle malaria and TB, the two other infectious diseases that claim millions of lives each year.

Unni Karunakara, President of MSF International. © Joshua Lutz/Redux

MSF works alongside health authorities to deliver lifesaving treatment in many countries which rely on Global Fund support, and where last week’s announcement has caused widespread concern and even panic.

Dr Unni Karunakara talks about MSF’s response to the funding crisis and what needs to happen now.

As a medical organisation treating patients with HIV, TB and malaria across the developing world, what is MSF’s reaction to the news of the cuts at the Global Fund?

There’s a huge sense of shock and dismay within MSF that the Global Fund – which has delivered such a massive leap forward in HIV, malaria and TB treatment worldwide through the projects it funds – should be hit right now by a funding crash that puts so many people’s lives at risk.

MSF works in many of the countries affected and we can see how fragile the hard-won gains are.

The Global Fund is now saying it will provide the thinnest of lifelines to help countries whose treatment programmes would otherwise face disruption between now and the beginning of 2014. 

We find it shocking that donor governments and the Global Fund board members are effectively sending the message that countries need to stop accepting patients on treatment programmes.  

Who is responsible?

There has been a general decline in funding for AIDS over the past couple of years, but the dramatic drop now is down to the behaviour of the donors to the Global Fund.

Some of them have cut back on the amount they committed to pay – like Denmark and the Netherlands. Others have stopped contributing due to domestic economic crises – for instance Ireland, Spain, and Italy.

MSF is concerned that the largest contribution, from the United States, is in jeopardy.

Ultimately, however, all of the funders are responsible for voting to cancel this round of grant applications and, over the longer term, starving the Global Fund of urgently needed resources. 

How damaging will the cuts be for people on HIV treatment?

In some countries where we work, authorities were already struggling against the odds to provide HIV treatment even before the cuts were announced. In Zimbabwe, for instance, the country is already relying on buffer stocks to cover drugs shortages.

It will be possible to continue expanding treatment on a very small scale, through efficiency measures and innovative ways of delivering care. But no ambitious expansion of treatment will be achieved without substantial new funding

The pity of it is that many affected countries are trying ambitious new strategies that could actually stop the HIV epidemic in its tracks. New study results show that people under treatment not only benefit as individuals, but they are also less likely to transmit the virus to others, in effect protecting the community.

This is not the time to pull the plug on funding.

What is your message to government funders?

We know it’s a tough economic climate and many people in wealthy countries are facing hard times. But we need to keep international funding for medical aid in perspective. The amounts needed to save lives in poor countries are miniscule compared to overall national budgets in wealthy nations.

Making believe we can somehow reduce the numbers of people needing treatment by rationing medical care is not the answer. Government funders and countries where these diseases take their toll need to step up to the challenge. Now.

We need to put in place ongoing funding mechanisms, such as the much talked about Financial Transaction Tax. But it will take time for these new mechanisms to deliver and, in the meantime, there is an urgent need for countries to demonstrate leadership by providing the funds necessary to put millions on lifesaving treatment.

Let’s not shoot the wheels off the ambulance just as we are beginning to get where we need to go.

• Update January 2012: MSF have been providing psychological support to the people of Van since December 2011

Collaborating with the Turkish Ministry of Health and the Van Crisis Coordination Centre, MSF teams will address urgent needs for mental health support in Van.

Psychological impact

“Many people are still in shock after the terrible experience of the quakes," explains Patrick Wieland, MSF head of mission.

“Many of them have lost family members and friends, and some have no one left. Their houses have collapsed, they have lost all their belongings and they have to deal with a harsh new reality and extremely cold weather conditions, which will take months to improve.

“Every day we see that there is a clear need to address the psychological consequences of this earthquake, which has taken a significant toll on the local population.” 

Mental health workers

A team of mental health workers will be working in the villages around Van, carrying out group and individual counselling sessions for both adults and children. MSF will also offer psychological care to refugees and asylum seekers that have been affected by the earthquake and are living in camps and settlements in the area.

An MSF emergency team arrived at the earthquake-affected areas of Van and Ercis on 25th October.

Since then, in collaboration with two Turkish organisations, Hayata Destek, Helsinki Citizens’ Assembly (hCa) and other local partners and authorities, MSF has provided thousands of people in villages in the Van region with tents suitable for winter conditions and cooking kits.

Despite the situation, MSF medical teams never stopped providing medical care in the biggest refugee camp in the world, and MSF has now resumed all medical activities in Dagahaley.

MSF in Dadaab

A malnourished child at the MSF hospital in Dadaab refugee camp in Northern Kenya. © Brendan Bannon

MSF teams are working to ensure quality medical care for the refugees. The 300-bed hospital in Dagahaley is running at full capacity, and four health posts out of five have been reopened.

More than 2,100 children are being treated in nutritional programmes, and 200 were admitted to hospital with medical complications.

Teams are holding more than 5,500 consultations per week in the health posts, and there have been more than 400 weekly hospital admissions.

War and displacement

Yet another year of war and reduced humanitarian assistance in Somalia has meant the forced internal displacement of hundreds of thousands of people, and many have left to look for a safe place in neighbouring countries.

The health needs of the population were already huge before the nutritional emergency currently affecting the horn of Africa. It is in this situation that MSF is struggling to provide care.

Refugees

MSF medical teams are particularly worried about the refugees.

“Now, almost all aid agencies have reduced their activities. We fear we may go back to how it was last summer, when the health status of the refugees was actually worsening in the camps," says Dr. Jean-Clément Cabrol, MSF’s Director of Operations.  

"The people’s situation had finally been improving when the security incident happened. The current reduction of activities could make for a dramatic impact on the refugees.

"For example, today, those who can make it to cross the border and seek refuge in Dadaab have no access to shelter, food and non-food items”

Measles, cholera and epidemics

The situation remains very fragile indeed. In recent months, MSF teams had to deal with a measles outbreak that affected the entire refugee camp complex. More than 380 cases have been treated in MSF medical structures since August, and nearly 113,800 people have been vaccinated.

Watery diarrhoea is currently posing a serious health risk and cases of cholera have been confirmed in all three camps. MSF is running a 50-bed cholera treatment centre in Dagahaley, and 45 patients have been admitted in the last 10 days.

Eastern DRC is still volatile, marked by shifting alliances between armed groups, ongoing military operations, instability, insecurity, banditry, and violence.

Attacks against civilians and aid organisations are rising, making both the population and humanitarian aid workers increasingly vulnerable.

Violence

Rape, murder, kidnapping, and random acts of violence are daily occurrences for millions of people.

The instability continues to push people from their homes, and at times limits MSF’s ability to provide free and lifesaving healthcare.

Lack of investment in the healthcare system results in a lack of infrastructure and properly trained medical staff throughout the country.

While medical needs are enormous, people are left struggling to access the most basic level of healthcare services. 

Low life expectancy 

“For patients to get access to healthcare, they often have to walk for many hours,” explains MSF Head of Mission Christine Buesser.

“Imagine you are a pregnant  woman, and you may even have to carry another child on your back. These distances are very difficult to overcome. This is a daily challenge – just to get to a heath facility.”

Decades of neglect of the health system in DRC have resulted in a rise in infant and maternal mortality rates across the country. Life expectancy here is among the lowest in the world.

Epidemics: a permanent emergency

Logistical constraints due to the country’s enormous size, a lack of investment in healthcare facilities, and poorly trained health workers lead to weak national disease prevention measures.

The dysfunctional Expanded Program on Immunisation (providing routine immunisation), together with the lack of sustained vaccination strategies create a permanent health emergency in the country and preventable epidemics – including cholera, measles, and malaria – take a heavy toll on the Congolese population.

Malaria, measles and cholera

Outreach nurse Emmanuelle Wahl is taking care of baby in the Cholera treatment unit in Bweru.
© Ben Milpas

Malaria is the leading cause of illness and death in DRC, and MSF medical teams continue to treat large numbers of patients in 2011. Malaria treatment represents one third of consultations at MSF clinics.

Since late 2010, there has been a measles epidemic in DRC. More than 14 million children have been vaccinated, including more than three million by MSF.

However, these urgent efforts have not halted the epidemic and four out of 11 provinces have not yet been covered by the immunisation follow-up campaign.

Vaccinations and outbreaks

MSF has been responding to cholera outbreaks along the Congo River and in the capital, Kinshasa, since April 2011, treating patients and building treatment facilities.

The threat of a cholera outbreak combined with the start of the rainy season in August is especially worrying in densely populated urban centers without proper sanitation systems.

Fighting AIDS

In DRC, only 12 percent of HIV-positive patients are receiving antiretroviral (ARV) drugs, and 95 percent of women living with AIDS don’t have access to treatment that can help prevent the transmission of the disease to their unborn children.

Despite this situation, DRC is now facing a serious challenge in funding the figth against AIDS.

In 2011, World Bank stopped funding its HIV/AIDS programs in DRC and several other donors still work with very limited funds with regards to DRC’s substantial needs. In addition, the Global Fund, which is the largest financing mechanism in the fight against HIV/AIDS, faces a major funding shortfall from donor countries.

Lobbying for HIV treatment

MSF midwife Sam Perkins reassures 18-year-ols Zawadi. © Yasuyoshi Chiba

The current donor retreat could leave thousands of patients in DRC without treatment and prevent more people from accessing treatment, threatening to undermine all the progress made since the introduction of ARVs in the country.

MSF continues its ongoing lobbying efforts to maintain donors’ support in order to respond to the crisis.

Sleeping sickness 

Half of all cases of the neglected and fatal disease Human African trypanosomiasis – also called sleeping sickness – occur in DRC, particularly in the Haut-Uélé and Bas-Uélé districts of Orientale Province in the northeast.

Prevalence can reach five percent in some areas, well beyond the threshold of 0.3 percent needed to consider it a public health problem.
 
The disease is transmitted to humans through the bite of infected tsetse flies and is fatal if left untreated. Displacement and instability have contributed to its spread, and the lack of roads makes accessing patients difficult.

MSF in DRC

Since 2007, MSF has treated an average of 1,000 patients per year. For the next three years, teams are planning further exploratory missions to reach more patients and diminish the prevalence of sleeping sickness in the region.

In 2011, more than 2,500 MSF staff have worked in 10 of DRC’s 11  provinces to provide free and lifesaving health care. MSF has been working in the country since 1981.

In Cairo, violent clashes have concentrated around Tahrir Square, where the situation remains tense. Egyptian volunteers are working in field hospitals to provide medical care to the wounded.

The Ministry of Health is running mobile clinics, providing ambulances, and has mobilised nearby hospitals to treat casualties.

MSF in Tahrir Square

A team from Médecins Sans Frontières (Doctors Without Borders) MSF has been visiting Tahrir Square on an almost daily basis, and is in contact with Egyptian healthcare professionals who are working in the field hospitals, as well as with the public hospitals which are receiving the bulk of the casualties.

MSF has made some donations of drugs, medical and surgical items to four hospitals in Cairo.

The MSF team has also been in regular contact with health facilities in Alexandria and Suez, where violence has also been reported, visiting both cities and donating material to Suez general hospital.

Tear gas and protecting patients

“We have been made aware of one field hospital that has had to shift locations more than once, owing to tear gas inside the premises, and of one patient requiring protection from other parties while being treated,” says Mario Stephan, MSF’s country representative in Egypt.

“We would like to reiterate that hospitals and health facilities must be respected by all parties so that medical care can be provided to all patients who need it.”

Medical care 

Over the past months, MSF has been working with Egyptian volunteer doctors and providing training on treating the wounded.

MSF is continuing to evaluate the medical needs in Cairo, Alexandria and Suez, and remains ready to provide more medical support if needed.

MSF is an international medical humanitarian organisation present in Egypt since 2009. MSF is currently setting up projects with the aim of assisting Egyptian and migrant populations in Cairo.

The Global Fund will provide for a ‘transitional funding mechanism,’ whereby countries known to be facing a disruption of programs for HIV, TB and malaria before 2013 will be offered a chance to apply for funding to cover their most essential needs.

An MSF nurse examines the lungs of a TB/HIV co-infected patient in Chiradzulu District Hospital, Malawi.
© Julie Remy

For HIV, this funding can cover medicines for people already on treatment, but does not provide for scale-up of HIV treatment.

Funding will also be restricted for treatment of drug-resistant forms of TB.

Global Fund donors

MSF calls on the Global Fund and donors to immediately raise the resources necessary for the minimum lifeline the Fund has extended to countries otherwise facing disruptions this year, as well as providing a new regular funding opportunity.

The dramatic resource shortfall comes at a time when the latest HIV science shows that HIV treatment itself not only saves lives, but is also a critical form of preventing the spread of the virus, and governments are making overtures that there could be an end to the AIDS epidemic.

HIV treatment on the ground

Yet on the ground in hard-hit countries where MSF works, the devastating effects of the overall funding crunch are becoming apparent.

For example, Cameroon and Zimbabwe are facing shortfalls in the near future to support people already on treatment, and the Democratic Republic of Congo severely caps the number of people able to start on life-saving HIV treatment.

In other countries, such as Mozambique, funding problems have prevented the country from providing earlier treatment and better drugs, per WHO-recommended guidelines.

Plans on hold

Further countries may have to put important plans on hold, such as Malawi, which in addition to wanting to scale up HIV treatment, wants to provide earlier and life-long treatment for all HIV-positive pregnant women to not only protect their babies, but keep themselves healthy. 

Some countries, including Kenya, Lesotho, and South Africa, had already been told by the Global Fund that they weren't eligible to apply for funding from Round 11 because of lacking funding.

In those countries, HIV treatment coverage lies at 52 percent, 66 percent and 49 percent, respectively.

Governments must act

“There’s a shocking incongruence between both the new HIV science and political promises on one hand, and the funding reality that is now hitting the ground on the other,” said Dr. Tido von Schoen-Angerer, executive director of MSF’s Access Campaign. 

“Donors are really pulling the rug out from under people living with HIV/AIDS at precisely the time when we need to move full steam ahead and get life-saving treatment to more people. 

"All governments must chip in to the effort to curb HIV, but especially those with the capacity to really make a difference must urgently step up and support a new funding opportunity for countries by the Global Fund.” 

The medical aid organisation has suspended a portion of its operations in the Masisi area and is concerned about the fate of its patients.

Shooting

The MSF ambulance travelling from Mbitsi health clinic to Masisi hospital. © Yasuyoshi Chiba

During the night of 20th to 21st November, a number of armed men forced their way into the MSF residence compound and opened fire.

One member of the team was wounded by a bullet to the shoulder. He was treated by his colleagues and is now in stable condition.

To maintain the safety of its teams, MSF has been forced to suspend the project’s mobile treatment activities until further notice.

However, MSF will continue to provide a minimum level of emergency support service at the Masisi General Referral Hospital.

MSF deplores violence

MSF deplores this violence that has once again hampered its ability to provide help and assistance to the population.

“In addition to the shock experienced by our team, this incident prevents us from properly carrying out our field medical activities and so negatively affects the local population,” stated Gaël Hankenne, MSF head of mission in Kinshasa.

Regular attacks

This incident comes at a time when MSF’s teams are regularly being targeted for attacks. In April 2011, in South Kivu, two members of MSF were wounded by gunfire and the organisation was also forced to temporarily suspend a portion of their activities in the region.

MSF has been present in DRC since 1981 and delivers primary and specialised hospital care in health centres or mobile dispensaries throughout the country.

MSF has had a presence in the Masisi health area since 2007 and provides the full range of secondary health care in the Masisi General Referral Hospital and primary health care out of the Masisi and Nyabiondo health centres.

MSF has also established a system of mobile clinics to provide assistance to the sick in the Bukombo displaced persons camp and in areas impacted by a lack of security.

Last year, MSF provided over 108,952 consultations and carried out 1,783 surgeries in the Masisi area alone.

• More about MSF in DRC
  

The Israeli embargo of the Gaza Strip, which began in 2007, together with years of financial crisis within the Palestinian Authority in Ramallah and the chronic lack of cooperation between the Palestinian Authority and Gaza authorities, have caused harm and threaten Gaza's health system and its patients. 

Drug companies stop supply

Health facilities in the Gaza Strip face a serious shortage of drugs and medical supplies. While MSF makes regular donations, no aid actor can meet the full range of needs. © Juan Carlos Tomasi

Last spring, drug companies stopped supplying the Palestinian Authority.

The situation, which had been worsening steadily for several years, deteriorated further in 2011 and has reached an alarming level.

As Israeli bombs struck the Gaza Strip in mid-August, local health authorities called on international aid actors working in the area for help.

Since that time, they have asked for donations on a regular, long-term basis.

However, no humanitarian actor – including MSF – has the financial and/or logistical resources to provide the drugs and medical supplies needed by the Territory's health facilities.

Essential medicines

Thirty six percent of essential medicines are lacking. Stock-outs represent a real threat to patient health.

In late September 2011, 164 essential drugs – 36 percent of necessary supplies, compared to 25 percent in 2010 – were completely unavailable. Only 260 of the 900 required medical supply items (specifically, single-use items) were supplied. 

For now, UNRWA clinics, run by the UN relief agency for Palestinian refugees, provide patients with chronic illnesses access to treatment.

The medical areas most affected are:

• Surgery

• Intensive care (certain anesthetics are lacking altogether)

• Hemodialysis

• Treatments to prevent organ transplant rejection

• Oncology

• Hematology (no coagulants)

• Psychiatric medications (only 33 of the 46 essential psychiatric drugs are available)

• Ophthalmology (all eye surgeries have been halted)

• Maternity

• Pediatrics

• Catheterisation laboratory procedures for the diagnosis and treatment of heart disease

Patients' lives in danger

The five medical centers that treat kidney disease in Gaza will face drug shortages within a few weeks and their patients' lives will then be in grave danger.

Throughout 2011 MSF made periodic donations when specific, urgent needs arose.

Since 2008, the organisation has regularly criticised the politicisation of the Palestinian health sector and the impacts of the conflicts – both internal and external – on patients deprived of critical medications and medical care. 

While MSF, an emergency medical aid organisation, can establish an action and donation plan, it cannot provide the full range of drugs and medical supplies. We remain particularly concerned about the future of Gaza's patients and ill residents.

Listen to the podcast to hear the real story from staff and patients in Somalia.

• Read more about MSF in Somalia

Thousands of people have been forced to flee Somalia and are seeking humanitarian aid in refugee camps in Kenya and Ethiopia. A measles epidemic is spreading. The lack of infrastructure and services is worsening the population’s vulnerability.

In recent weeks, civilians have endured new military offensives launched in southern Somalia and the capital Mogadishu.

MSF and Somalia

A severely malnourished child gets IV (intravenous) line inserted. Somalia. © Sven Torfinn

It is in this context that Médecins Sans Frontières MSF (Doctors Without Borders) has, in less than six months, provided intensive medical care to more than 10,000 severely malnourished children who were brought to the facilities.

MSF has projects in:

• northern Kenya (mainly Dadaab)
• eastern Ethiopia (in refugee camps in Malkadida, Kobe, Bokolmayo, Hilleweyn, Dolo Ado)
• across much of south-central Somalia (in Marere, Beletwayne, Dinsor, Daynile, Mogadishu, Jowhar, Guriel and Galcayo)

MSF has also enrolled a total of 54,000 children in outpatient feeding programmes for the severely malnourished in more than 30 locations in these three countries.

Measles and malnutrition

At the same time, MSF teams have been battling the deadly combination of measles and acute malnutrition, which affects children in particular.

A large proportion of the population has not been vaccinated – against measles or any other disease – because years of instability, lack of effective government and a functional state have caused the health care system to collapse. Measles, if untreated, can be highly fatal for children.

Vaccinations

MSF teams have vaccinated more than 150,000 people in and around Somalia for measles, and have treated more than 5,000 patients for the disease this year.

Much more needs to be done, however. The vaccination effort needs to be scaled up in Mogadishu, where waves of people continue to arrive, seeking assistance.

In certain parts of the country, access has been greatly limited by the presence of armed groups. Medical teams have not been able to reach the population there, not even to assess their situation and mass measles vaccination campaigns have been blocked.

Camps and cholera

Dadaab is full of children. The number of babies born in the MSF hospital has doubled since last year.
© Nenna Arnold /MSF

The arrival of the rainy season may further worsen conditions for children and adults living in makeshift camps in Mogadishu and elsewhere.

In the capital, the proportion of children suffering from waterborne diseases – including diarrhoea, which also contributes to malnutrition – is now on the rise.

MSF is preparing to deal with possible cholera outbreaks whose effects on hundreds of thousands of already malnourished people living in crowded conditions could be devastating.

Insecurity and fighting

All of this is occurring against a backdrop of insecurity and fighting, for which the Somali people continue to pay the price.

On 30th October, MSF treated 52 wounded people – including 31 children – in the southern town of Jilib, after an attack caused civilian casualties among the displaced.

Ten days earlier, MSF teams in Daynille, on the outskirts of Mogadishu, treated 83 patients for gunshot and blast wounds, and was forced to suspend the measles vaccination campaign it had there. However, thousands of people displaced by conflict and drought continue to arrive in Mogadishu.

Dadaab refugee camp

For years, Somalis have crossed the border to seek refuge in neighbouring Kenya, with an historical peak in June 2011 when more than 40,000 people arrived.

Present in the camp since 2009, MSF offers comprehensive health care to the population of Dagahaley camp. In Ifo camp, activities had to come to a halt after the kidnapping of two of MSF staff on 13th October. In Dagahaley, the insecurity forced MSF to scale back activities temporarily, which are increasing again now.

The fighting in southern Somalia and along the Kenyan border, and heavy rainstorms and floods, have slowed to a trickle the number of people presenting themselves to authorities at the Dadaab camp. Meanwhile, the numbers of people fleeing into Ethiopia is increasing.

Inside Somalia

During these last six months, the organisation’s emergency efforts have proved difficult to translate into concrete actions for the Somali people, because of the lack of security both in the country and at the borders, and also due to ongoing restrictions imposed on MSF operations in certain parts of Somalia.

Despite this, MSF was still able to scale up its activities and open new projects, in addition to the nine medical facilities that had already been running in south-central Somalia, making it the main provider of free healthcare in the region.

The distribution has benefited 12,000 people living in Van and Ercis, the cities most affected by the quake.

In collaboration with local organisations MSF teams have distributed 2,000 winterised tents and 2,000 cooking kits to 12,000 people.
©MSF

Earthquake response

“The population is still suffering aftershocks and they are very scared of going back to their homes.

"Also, it has started to snow and these people are very worried about the lack of shelter with winter coming,” explains Guillem Pérez, emergency coordinator. 

“Temperatures are very low at night, the current situation persists, and it will take months before their lives go back to normal,” he adds.

MSF assistance

MSF will provide the affected population in Van and Ercis with psychosocial support through local psychologists in the next days.

MSF will also set up a reference system so that those living in rural areas who need specialised assistance can receive it in the hospitals. MSF also plans to train national staff.

The pre-existing health system was strong and is therefore responding well to medical needs. However, an MSF team will remain for at least the next two months, to be able to respond to any new needs that may arise, once the first phase of the emergency is over.

Georgina has just returned from Somaliland and has previously worked for MSF in Pakistan, Haiti and Sierra Leone.

She has a huge amount of experience and makes a great impression on her patients and colleagues.

Expert advice

Her manager said: "Georgina is one of the best midwives I have ever had the privilege to work with.

"She pulls off procedures that would have most of her colleagues stumped and does so with flair."

Questions for Georgina

Georgina will be answering questions on her experiences with MSF, what it is like to work as a midwife, what inspired her to join us in the first place and what she feels are the qualities necessary to do the job she does.

If you fancy working for MSF this is a great opportunity to chat to someone who does! We look forward to hearing from you...

To highlight the critical humanitarian and medical needs in urban settings, Médecins Sans Frontières MSF (Doctors Without Borders) is now launching Urban Survivors – a multimedia project in collaboration with the NOOR photo agency and Darjeeling Productions.

• Visit the Urban Survivors site

Slum emergency

“Slum residents live in a constant state of vulnerability,” says Loris De Filippi, operational director for MSF.

“Not only do they live in places that are unfit for human habitation, they also face discrimination and neglect from other parts of the society.

"Through the Urban Survivors project we want to put a human face to the humanitarian emergency that exists in many slums around the world.”

Urban Survivors

The Urban Survivors web-documentary – at www.urbansurvivors.org – takes the visitor on a virtual journey through five slums where MSF is actively running projects:

• Dhaka, Bangladesh

• Karachi,  Pakistan

• Johannesburg, South Africa

• Port au Prince, Haiti

• Nairobi, Kenya

Featuring the work of award-winning NOOR photographers, Urban Survivors lets the visitor discover more about the daily lives of people in these slums, the humanitarian issues they face, and what MSF is doing to address these problems

“At the moment, the capacity to receive more people and provide the necessary food, nutritional care, medical care, drinking water, sanitation and more is grossly insufficient,” said Wojciech Asztabski, MSF Project Coordinator for the Dollo Ado intervention.

Somalia crisis

The impact of the drought has been exacerbated by high local cereal prices, excess livestock mortality, conflict and restricted humanitarian access in some areas. © MSF

The camps currently house around 130,000 refugees from Somalia, the majority fleeing the food crisis and conflict.

In recent weeks the number of refugees crossing the border into Ethiopia has increased to approximately 300 per day, numbers not seen since July.

The increase in the number of refugees indicates that people in Somalia remain highly vulnerable.

Nearly all refugees state that they left Somalia because of a severe lack of food combined with increased insecurity.

Families fleeing Somalia

"I didn’t want to leave Somalia, but the hunger and the fighting made life too difficult,” said a new arrival, a 39-year-old mother.

“My husband and my mother are still in Somalia, we did not have enough money to travel, so I travelled alone with the four children. We travelled by donkey cart for seven days and nights. Now my son is very sick, he can’t eat and every day he looks more exhausted."

Refugee camps

MSF, in collaboration with authorities and other organisations, has assisted in the refugee camps since 2009.

Since last May, MSF has dramatically scaled up its programs to improve the situation and bring mortality rates under emergency thresholds, but the organisaton warns that the emergency is far from over.

“We should be expecting thousands more to come across the border over the next weeks,” added Mr Asztabski. “The reception centre and the transit camp, where people stay until they are settled in one of the refugee camps, are rapidly filling up.”

The transit camp currently hosts over 6,000 people, a number that is expected to rise by thousands per week over the next weeks.

“There are not enough latrines, nor enough shelter or drinking water. More capacity is needed here on the ground, and very quickly too,” added Mr Asztabski.

Overcrowding and illness

The existing refugee camps where people are referred to after the transit centre are currently full, and the reception centre and transit camp are not equipped to receive people for prolonged stays.

 MSF warns that insufficient levels of shelter, water and sanitation will further weaken an already vulnerable population.

"This place is making us ill,” stated another refugee in the transit camp. “We have been here for 14 days, and here it is safe, but we have no place to sleep. The tents are overcrowded. Children and women are weaker than men, so they become ill here.”

Call for action

MSF is ready to provide life-saving assistance for a prolonged period, and is calling for the Ethiopian authorities to continue facilitating the necessary imports of medicines and materials, while allowing experienced international staff to provide the necessary support.

Increased capacity by other agencies is also urgently needed. A new camp is scheduled to be completed and opened in a few weeks’ time.Under the circumstances, MSF calls for greater effort to make this camp ready earlier to lessen the burden on the transit camp as soon as possible.

Background

The drought affecting the Horn of Africa has had a dramatic impact on the people of Somalia, who are already suffering from 20 years of conflict, a desperate lack of development and the most basic services.

MSF has been working uninterrupted in Somalia since 1991 and teams assist people inside Somalia as well as Somali refugees in Ethiopia and Kenya.

MSF is currently treating more than 22,000 vulnerable children in its nutrition programmes. Despite significant challenges, MSF teams have to date vaccinated more than 126,000 people against measles. 

• Update 31/10/2011 11.30am: MSF can confirm five casualties and is currently treating 45 wounded, 31 of whom are children. The lesser number is due to people dismissed from hospital since last night.

At the time of writing at least three people are reported dead and 52 injured, mostly women and children.

MSF is transporting the wounded to the hospital in Marere, in Lower Juba, southern Somalia,  for stabilisation and treatment, and may have to refer some patients to other facilities due to limits to the surgical capacity at the hospital.

Somalia has been hit by a severe humanitarian crisis since May this year and hundreds of thousands have been displaced due to violence and drought.

Jilib houses a population of around 1,500 displaced households and MSF had been providing them with medical care, including therapeutic feeding for acutely malnourished children. The organisation also distributes basic relief items such as soap, cooking oil, blankets and sheltering materials.

MSF urges all parties to the conflict in Somalia to respect the rights of civilians in conflict.

MSF has been working in Somalia continuously since 1991 and currently operates 13 projects in the country, including medical activities related to the current emergency, vaccination and nutritional interventions. 

In Dadaab, Kenya, MSF resumed operations in 2009, while assisting Somali refugees in the camps of Dolo Ado, Ethiopia.

After a first phase of assessment in order to identify the major needs and gaps, MSF will now focus on providing relief goods in rural areas where assistance has been more difficult, in collaboration with Turkish NGOs.

Population outside the main cities in need of assistance

“The main hospitals have not been affected by the earthquake. The health system was strong and is responding adequately to the medical needs. In Van and Ercis, the two main cities, the response by the Turkish authorities has been globally good,” explains Jerome Souquet, MSF emergency programme manager.

“However, the MSF team has identified a number of villages outside the main cities where people are living in very harsh conditions with temperatures below zero at night.

"Some have lost their homes and others are afraid of aftershocks and do not want to go back to their houses. Some people are sleeping in cars, in very precarious conditions, and need assistance.”

Aid distribution

In collaboration with Turkish NGOs, MSF will distribute winterised tents, blankets and cooking sets to some 10,000 people.

Two cargo planes with 140 tonnes of relief material are being sent from Dubai, where MSF has a logistical base. At the same time, the team on the ground is being reinforced in order to prepare the distribution.

Water supply and psychological assistance

As the water system in these villages has been damaged by the earthquake MSF is also exploring temporary solutions in order to resume water supply. 

The team is also in conversation with local teams of psychologists in order to start providing mental health assistance to the affected population, an important need in the aftermath of an earthquake.

This area, located in the southern department of Escuintla, is the most affected, where some 5,000 people have not yet been assisted.

MSF works to improve living conditions

"The most urgent food and medical needs have been covered locally," said Stefano Zannini, MSF’s emergency coordinator.

"However, we will distribute blankets, mattresses and hygiene kits to improve the living conditions of some 1,000 families living in remote areas. Some of them are still displaced, while others were able to return to their homes, but in some cases people have lost everything."

“It is important to prevent an increase in respiratory infections and other diseases related to poor sanitation."

Mobile clinic and free consultations

In Honduras, where torrential rains have affected thousands of people, MSF has deployed a mobile clinic and offered more than 140 medical consultations to the Marcovia communities in the southern department of Choluteca.

An assessment of the health and medical needs has shown that the health system has quickly responded and that patients have free access to primary health care. MSF is thus focusing on the epidemiological surveillance of infectious diseases, such as dengue, malaria and leptospirosis, and on the disinfection of 20 contaminated wells identified in the area.

The organisation will also conduct a mass distribution of doxycycline to support health centers in the prevention of leptospirosis, which is endemic in the region.

MSF has been working in Guatemala since 1984 in various projects. The organisation currently provides medical, psychological and social assistance to victims of sexual violence in Guatemala City.

MSF has worked in Honduras since 1974. In the capital city, Tegucigalpa, teams are currently providing medical services to the most vulnerable population, victims of violence.

Given the frequency of natural disasters in Central America, MSF is ready to provide emergency assistance to disaster victims in the region and maintains an emergency team based in Panama.

This month our teams treated war wounded in Libya as fierce fighting continued in Sirte. In Somalia, millions of people need healthcare and MSF has been working with displaced people in Mogadishu.

Over in Haiti, MSF is working to control a cholera epidemic. And teams in the Central African Republic are tackling many health problems.

The campaign had been scheduled to last three weeks and to reach 35,000 children. Measles is currently wreaking havoc in Somalia. Sixty thousand have been already vaccinated against measles over the last two months.

"Combined with malnutrition, measles is now the main killer of children in Somalia,” says Duncan McLean, head of MSF programmes in Somalia. “Only vaccination can stop the spread of the epidemic.”

Unstable security situation

During the first five days of the campaign, 4,831 children aged six months to 15 years were vaccinated in different parts of Dayniile. But clashes between the forces of the Transitional Federal Government, supported by AMISOM (the African Union Mission in Somalia), and Al Shabaab, put a stop to the vaccinations.

"As long as the security situation is not stabilised, it will not be possible to resume the vaccination campaign,” observes McLean.

“And when this happens, we will have to completely rethink our strategy because many people have fled the combat zones. Tens of thousands of displaced people were living in camps in Dayniile, many for a long time and some who had arrived recently from drought-affected regions.”

In addition, many people were wounded during the clashes. On 20th ctober and the day after, MSF teams at Dayniile Hospital received 83 patients who had been injured by gunshots or explosions. Forty one were hospitalised and eleven surgical procedures were performed.

Malnutrition

MSF has supported management of emergencies for the hospital in Dayniile since August 2007.

Starting this past April, MSF has also supported the treatment of severe malnutrition. Twenty four malnourished children were receiving intensive treatment before the fighting erupted. In most cases, frightened mothers chose to leave with their children; only six currently remain under care.

MSF continues to work in the Dayniile hospital and in Mogadishu, where our teams provide medical and nutritional assistance to displaced populations.

MSF has been working in Somalia continuously since 1991 and currently operates 13 projects in the country, including medical activities related to the current emergency, vaccination and nutritional interventions.

MSF resumed operations in Dadaab, Kenya, in 2009, and it also assists Somali refugees in the camps of Dolo Ado, Ethiopia

However, the intricacies of clan rivalries, the absence of an effective government, and general insecurity make it very difficult to reach the level of assistance that is needed.

Donate to MSF's Somalia appeal:

• Read more about MSF's work in Somalia

All wounded patients must have access to care and must be able to receive treatment without discrimination and fear of reprisal.

Hospital damage

Ibn Sina Hospital in Sirte has borne much of the brunt of the fighting that has raged. Last week, MSF teams based in Misrata were able to travel to Sirte and observe the damage at the hospital.

"Ibn Sina Hospital came under fire and was attacked," said Barbara Frederick, MSF emergency coordinator.

"An explosion destroyed an operating room and most of the windows were damaged. As a result of the fighting over the last few weeks, patients had to be moved into the hallways."

Patient security

Security was not ensured at the hospital.

"Last week, there were many fighters coming in and out of the hospital with their weapons, checking the patients," said Frederick. "We don't know who they were looking for."

After assessing the needs at Ibn Sina, MSF provided surgical supplies, organised the resumption of surgery in the hospital's two refurbished operating rooms and delivered 150,000 litres of water. 

The hospital, which had been without water and electricity, is now fully functional once again. Libyan medical officers have arrived to assist, making it possible to resume surgical services.

Access to care

Security, however, remains critical to ensuring that all wounded patients have access to care, regardless of which 'side' they belong to, as stipulated by international humanitarian law, said MSF.

Most of population of Sirte has fled the city, which now resembles a ghost town. Some civilians are still unable to leave, however, because of fighting in northern areas.

MSF is calling on the warring parties to ensure that civilians have access to care, and to respect the security and integrity of the wounded people inside medical facilities.

“Haitian authorities and international aid actors need to do much more to treat and prevent cholera,” said Romain Gitenet, MSF head of mission in Haiti.

MSF teams loading mules with medical material destined for the Cholera Treatment Center of Cheno village.        © Frederik Matte

“There is an urgent need to improve healthcare, provide access to clean water, and ensure proper sanitation.

"Clean water and sanitation are essential to halting the spread of cholera.

“Even though the international community has pledged huge sums of money to assist Haiti, thousands of Haitians are still getting sick from cholera every week, and some are still dying.”

Cholera deaths

Since the first cases of cholera were identified in October 2010, more than 465,000 Haitians have fallen ill and more than 6,500 people have died, according to Haiti’s Ministry of Health. The ongoing rainy season is facilitating the spread of the disease.

At the same time, MSF is seeing international organisations involved in healthcare, water and sanitation withdrawing from the fight against cholera in Haiti. Yet the needs remain significant and urgent.

There continue to be dangerous and unpredictable fluctuations in the number of cholera cases. For example, in the fourth week of August MSF treated 281 patients for cholera in Port-au-Prince; by the end of September, cases jumped to 840 per week.

Cholera response

It is likely that cholera will continue to be present in Haiti for years to come. Haitian authorities will ultimately have to take responsibility for responding to the disease. But they have not yet been able to mount an effective response countrywide.

While ensuring that Haitians’ urgent needs for cholera care are adequately met, international aid actors should do more to assist the Haitian government in rapidly integrating proper cholera treatment into healthcare facilities, and in implementing prevention plans.

MSF has been working to transfer management of the healthcare facilities it has been supporting back to the Ministry of Health.

Saving lives

Port-au-Prince, two patients affected by cholera are receiving a treatment in one of the MSF cholera treatment center. © Frederik Matte

Meanwhile, the focus must be on saving Haitians’ lives.

According to Gitenet:  "Cholera patients continue to die from dehydration in remote areas of the country simply because there are no oral rehydration points or treatment facilities nearby, or because of a lack of trained healthcare personnel or community outreach workers. This is unacceptable."

About cholera and MSF’s response to the epidemic

Cholera is a bacterial infection that spreads primarily through contaminated water and food, and through interpersonal contact. It can kill quickly, but is easy to treat if appropriate healthcare services are available.

It is also easy to prevent through access to clean water, regular hand washing and hygienic food handling. But a majority of Haitians living in rural areas and urban slums can’t access potable water or proper hygiene and sanitation facilities.

Since the beginning of the cholera epidemic in October 2010, MSF has treated more than 160,000 patients for cholera, about 35 percent of total cases reported nationwide.

MSF teams are currently responding to cholera in the Martissant, Carrefour, Delmas, Choscal, and Drouillard neighborhoods of Port-au-Prince; and in the Ouest, Nord, and Artibonite departments. 

Contact

Hannah Ward, Press Officer
Direct line: 44 (0) 20 7067 4265
Out of office hours press line: 44 (0)7889 178 472
e-mail: hannah.ward@london.msf.org

MSF firmly and clearly disassociates itself from any armed activities and related declarations launched following the abduction.

Military actions

Blanca Thiebaut, age 30, from Madrid, was abducted from the Dadaab camp. © MSF

MSF is actively and fully engaging with all relevant actors in order to seek a safe resolution of the abduction.

Abductions are extremely complex and need to be handled with care, therefore MSF is very concerned that security and the resolution of the incident could be compromised by any use of force being related to the case.

“MSF is currently engaging with all relevant actors to seek the safe and swift release of our colleagues and any use of force could endanger this,” says Jose Antonio Bastos, president of MSF in Spain.

“We want to strongly distance ourselves from any military or other armed activities, declarations or presumptions of responsibility related to this case.”

MSF's work continues

MSF continues to provide assistance to people affected by the current crisis in Somalia, Kenya, Ethiopia and Djibouti, despite the already highly complex security environment.

As a result of the attack, MSF has temporarily suspended activities in Ifo two camp, Dadaab, where the abduction took place.

These activities include two health posts and mobile clinics that were providing primary healthcare, reproductive health and antenatal care, routine vaccination programmes and referral services for secondary healthcare.

MSF hospital

Montserrat Serra, age 40, from Girona (Palafrugell) was abducted on 13th October. © MSF

In Dagahaley camp, MSF has ensured the continuation of life-saving medical activities in the 243-bed hospital, with nearly 200 patients being treated in the in-patient therapeutic feeding centre.

However, five health posts had to be momentarily suspended and medical teams are currently on stand-by, ready to resume all activities as soon as security conditions allow it. Part of the nutritional program, which was treating 15,000 people, was also put on hold.

Dadaab and Somalia

MSF has been working in Somalia continuously since 1991 and currently operates 13 projects in the country, including medical activities related to the current emergency, vaccination and nutritional interventions.

In running such programs, MSF maintains an ongoing dialogue with key actors on the ground.

In Dadaab, Kenya, MSF resumed operations in 2009, while it also assists Somali refugees in the camps of Dolo Ado, Ethiopia.

“We are deeply concerned about the fate of our two colleagues. MSF is committed to continue providing healthcare to the Somali population in and outside Somalia,” says Bastos, “but the level of assistance to populations is being deeply impacted by such attacks. It is extremely alarming”. 

12 year old Ahmed (name changed) is being treated for a gunshot wound in the MSF surgical hospital in Kunduz. © Olof Blomqvist/MSF

The hospital, which opened on 29th August, provides urgent surgical care and follow-up treatment for people suffering life-threatening injuries.

Northern Afghanistan's only trauma centre

Fighting over the last year in Kunduz has led to large numbers of people who have sustained bomb blast, shrapnel and gunshot wounds, and who are in need of specialised surgical care.

The new hospital is the only trauma centre of its kind in northern Afghanistan and is equipped with an emergency room, two operating theatres, intensive care, as well as X-ray and laboratory facilities. There are separate male and female inpatient wards.

Right to receive treatment

MSF services are completely free of charge and available to anyone meeting the admission criteria – which includes anyone that is either violently or accidently injured.

"The only label we use is ‘patient,’” said Dr Dorian Job, MSF medical coordinator in Afghanistan. “Every injured person has the right to receive medical treatment, and we make no distinction between civilian or combatant.”

The MSF surgical hospital in Kunduz is the only trauma centre of its kind in northern Afghanistan.
© Olof Blomqvist/MSF

MSF works impartially

In all locations where MSF is working in Afghanistan, a strict no-weapons policy is implemented to ensure patient safety and security.

It is imperative that no armed people are present in medical structures. Such a presence could make the facilities targets of attack.

MSF relies solely on private donations for its operations in Afghanistan, and does not accept any government funding.

It is the duty of all parties to a conflict to respect the rules of international humanitarian law, including those concerning the protection and respect of medical structures, medical personnel and patients.

MSF teams also work in Ahmed Shah Baba Hospital in eastern Kabul, and Boost Hospital in Lashkargah, Helmand Province. In both locations, MSF provides free-of-charge lifesaving medical care, working in all wards of the hospitals.

MSF relies solely on private donations for its work in Afghanistan and does not accept any government funding.

But brave and determined staff are helping hundreds of people as the violence rages around them.

Dr Gabriele Rossi, MSF emergency coordinator, describes a very serious situation in Sirte. This interview was conducted on 13th October 2011.

Fighting and shooting

MSF is working across Libya. These MSF surgeons are at work in the Abbad Hospital, Misrata. © MSF

“We are in Ibn Sina hospital right now, which is the main hospital in Sirte. We have been here for three days.

"Today we have been hearing more firing and shooting than yesterday – there is lots of noise, and the constant sound of heavy artillery.

"The fighting is going on in the north of the city, and from here we can see a lot of fighters heading towards the frontline, with ammunition, with armoured pick-ups and even tanks.

"In the areas of Sirte we have travelled through, there are no civilians at all: all the houses are destroyed and empty.

"Before the conflict there were 100,000 people in Sirte, but in the past three or four weeks 75 to 80 percent of the people have fled, most of them towards Misrata.

No water, no electricity

"The estimated 10,000 people who are still here are in the north part of town and are completely trapped by the fighting. There is no water or electricity.

"In the hospital we have electricity, thanks to a generator, but until today there was no water. The atmosphere in the hospital is extremely heavy. There are about 50 patients, all with trauma wounds, fractures or burns, and all in need of surgery.

"Most of the patients are young adults, but we also have some women and children who have been injured in the fighting.

Shortage of doctors

"In the past few days, the patients haven’t been able to receive proper medical care, due to a shortage of doctors and due to the lack of water. Without water it’s impossible to do any kind of surgical intervention.

"The wounds of some patients are really bad and very infected. They need urgent surgical debridement. The situation is very serious.

"MSF has brought in 50,000 litres of water and more water was brought in by other actors. So we now have water running in the hospital.

"Ibn Sina hospital is in a very damaged state, with signs of the heavy fighting. All the patients are on the ground floor, while the first floor and the basement are taken up with about 50 people who are sheltering from the violence and waiting for the chance to leave.

Armed checks on patients

"Security-wise, the hospital is not safe. Yesterday and today, there have been a lot of fighters entering the hospital with guns, checking every patient and looking for we-don’t-know-who.

"It is very important that hospitals, medical staff and ambulances are allowed to provide aid unhindered and in safety. For our team it’s not safe to stay here at night for the moment, so each evening we make the two-hour journey back to our base in Misrata.

Heroic staff

"The hospital’s medical staff have been amazing – I would say they have been truly heroic. In the past weeks there were about five Libyan doctors working here, and 25 to 30 nurses, many from India and Bangladesh.

"The staff have worked through the intense crisis of the past few weeks and been directly exposed to violence. They have worked under shelling, under bombing, and under the threats of Gaddafi loyalists ordering them to come and treat their soldiers. Now they are exhausted and need all the support they can get.

"Fortunately the staff situation is better now, as the hospital has just received eight medical doctors from Tripoli – including surgeons and anaesthetists – and four more nurses. So now the situation is returning to normality. MSF’s team is made up of three medical doctors, two nurses and a psychologist, and we have just been joined by two more nurses and two psychologists.

Following months of fierce conflict, parents and medical staff are concerned for the mental well-being of children in Libya. Misrata. © Eddy McCall/MSF

Stress, nightmares and depression

"The mental health needs are enormous. At least 15 of the 50 patients, all of whom have trauma-related injuries, are also in huge psychological need, suffering from post-traumatic stress disorder.

"They suffer from nightmares, flashbacks, and depression. Some can’t even speak, but just cry, and one patient is suicidal. 

"All of the patients, particularly the mothers and the children, are in enormous need of support – they’re trying to bear the weight of what’s happened to them.

"When we first arrived there was a lack of medicines. The first delivery we did was of painkillers, antibiotics for all the wound infections, plus drugs for chronic diseases. The pharmacy is chaotic, but at least now it is well furnished.

Trapped by fighting

"Everyone here has a huge commitment to improve the conditions in the hospital to make it functional. In Sirte, there are probably around 10,000 people still trapped by the fighting, some of them injured but unable to leave their houses.

"If the situation calms down over the coming days, people will be able to access the hospital, which will receive many more patients. That’s why it’s so important to ensure that everything – the staff, the medicines, the electricity and the water – is in place.”

MSF has been present in Libya since February 25 and is currently working in Bani Walid, Misrata, Sirte, Tripoli, Yefran, Zintan. To ensure the independence of its medical work, MSF relies solely on private financial donations to fund its activities in Libya and does not accept funding from any government, donor agency, or from any military or politically affiliated group.

• Read the latest news from Somalia by following the links on the right

• Find out more background about MSF in Somalia

The emergency team of medical doctors, nurses and logisticians, conducted medical assessments starting in early October after typhoons Nesat and Nalgae hit the northern part of the Philippines.

MSF teams conduct mobile clinics in Calumpit in Bulacan province, Luzon, the Philippines.
© Cecile Aslanian/MSF

Although to date most of the government operated evacuation centres in the affected areas are closing, MSF finds that there are still six areas in the Bulacan province (Bulusan, San Jose, Panducot, Sapang Bayan, St Lucia, Meyto) inundated, with limited accessibility and healthcare provision.

MSF mobile teams

In Bulacan, two MSF mobile teams (including two medical doctors, two nurses and two midwives from the Ministry of Health) run primary healthcare consultations for the affected populations.

For patients who require life-saving treatments and hospitalisation, they are referred to the provincial hospital by a 20 minute ride by the ambulances operated by the Ministry of Health.

Rice crops destroyed

“We have been taking mobile medical clinics by boat and car to the most vulnerable population still in areas completely inundated, sometimes up to two floors,” said Pierluigi Testa, MSF emergency coordinator.

“The team is now paying attention to the nutritional status of children under the age of five years because almost all of the rice crops in the region have been destroyed, including the next harvest.

"They will also be monitoring for any outbreaks of acute watery diarrhoea and leptospirosis [a bacterial infection].”

Relief supplies

MSF also conducts epidemiological follow up in relocation centres, and facilitates the proper functioning of the remaining health centres, and fills the gaps of drugs and equipments if necessary.

MSF will continue to assess medical needs in other areas including Hagonoy and Tarlac, and has already visited the district hospitals of Malolo, Hagonoy and Calumpit, where healthcare provision is limited.

Other than providing healthcare assistance, MSF is also assessing the need for provision of relief supplies to the affected populations. Eight hundred jerrycans have already been distributed.

With the expectation that another potential tropical depression may strike the Philippines, an MSF team is on the ground to be on standby for further assessments.

• Read more about MSF's work in the Philippines
  

Two international staff, both Spanish, were taken. As yet, MSF has not been able to establish contact with the two staff taken. A crisis team has been set up to deal with this incident.

Blanca Thiebaut, age 30, from Madrid. © MSF

Staff named

The two Spanish colleagues abducted are Montserrat Serra, age 40, from Girona (Palafrugell) and Blanca Thiebaut, age 30, from Madrid, both working as logisticians for MSF in the Dadaab refugee camp.

Their families have been informed. MSF is calling on all media to respect the privacy of the families in this difficult time.

Aid jeopardised

"We are in regular contact with the families of our colleagues involved and relevant authorities since the first moments.

"We are doing all we can to ensure their safe and swift return. Our thoughts are with them and their families," says Dr José Antonio Bastos, president of MSF in Spain.

Following the attack, MSF has evacuated part of its team working in Dagahaley and Ifo, two of the three refugee camps in Dadaab. As a consequence some crucial medical activities have had to be stopped. However, MSF is still maintaining life-saving activities.

This attack jeopardises assistance to thousands of people in urgent need of humanitarian aid and a quick and satisfactory solution is necessary.

Montserrat Serra, age 40, from Girona (Palafrugell).
© MSF

No further comment

These incidents call for prudence and discretion. In order to facilitate the best and swiftest resolution of the incident, MSF will not provide further information for the moment nor will it comment on statements, rumours or public information related to it.

MSF is also calling on all actors involved to refrain from commenting publicly about this incident.

“The current publicity around the incident is particularly unhelpful, for it can only hurt the families and jeopardise efforts to get our colleagues back,” says Dr Bastos.

• MSF started providing medical assistance in Dadaab in 2009.

• MSF will provide an update on its ongoing activities in Dadaab in due course
  

Since July, more than 150,000 Somalis have left the provinces of the country's central region –Bay, Bakool, Hiran, Lower and Middle Shabelle – seeking refuge in Mogadishu.

"MSF told me that my son was suffering from malnutrition..."

Mogadishu cathedral: between the pillars of this unroofed building, refugees who flee starvation find shelter. © Martina Bacigalupo/Agence VU

Deka, a 26 year-old woman, left Lower Shabelle after her cows died:

"I travelled with my son on the top of a truck for two days to reach Mogadishu and find my cousins in the Barwako camp

"People from MSF told me that my son was suffering from malnutrition, so I went with them to their hospital. My son is starting to get better, and I am, too, because I am fed here."  

Thousands of people like Deka are fleeing to Mogadishu, driven by failing harvests, livestock dying because of drought, increasing prices and perpetual insecurity.

Health threats

This kind of exodus poses a host of health problems. But measles currently is the greatest threat and Médecins Sans Frontières MSF (Doctors Without Borders) is mobilised to halt the spread of a disease that is particularly fatal for children.

Since early August, MSF has vaccinated more than 40,000 children under the age of 15.

"That sounds like a lot, but if we are to have any hope of stopping the epidemic, we'd have to vaccinate at least 10 times that number," explains MSF medical manager, Dr. Andrias Karel Keiluhu. "Logistical and security constraints limit our goals."

Access and violence

Humanitarian aid organisations are struggling to access the most affected areas because of the ongoing conflict between the Transitional Federal Government (TFG), which is assisted by troops from the African Union Mission in Somalia (AMISOM), and the armed Al-Shabaab group.

That is why Somalis are migrating in such great numbers, hoping to find aid in Kenya, Ethiopia and the Somali capital.

Living in the ruins of Mogadishu

MSF doctors and nurses helping Somali displace people southern Mogadishu howl wadaag district.
© Feisal Omar

Like Deka, most of the new arrivals move into existing camps, swelling their already sizable populations. Others have settled in the few unoccupied spots remaining in the city.

Their makeshift housing, assembled from bits of wood and plastic, is scattered among the ruins of the capital. More than 200 sites of varying size have been identified.

Deploying aid in this patchwork of shantytowns is particularly complicated. The camps empty out during the day as residents leave in search of food.

"Food distributions are still irregular and inadequate," says MSF program coordinator Eymeric Laurent-Gascon. "Some of the displaced persons have not received any food since they arrived and are relying on help from those around them.

"Several NGOs have set up feeding centers with food purchased on local markets, but this has led to significant inflation. If prices continue to rise, the entire population of the city will soon be unable to feed itself without external assistance."

Malnourished children

The percentage of children suffering from malnutrition may vary from five percent to 50 percent across displaced persons camps, depending on how long ago they arrived and their access to distributions of food and water.

The most recent arrivals are generally in the worst shape. In Mogadishu, MSF is managing four therapeutic feeding centers where the most serious cases are hospitalised. In September, nearly 500 children were treated there.

In addition, mothers who come to any of the dozen MSF outpatient treatment centres receive a weekly supply of ready-to-use therapeutic foods – peanut butter enriched with essential nutrients – for their young children.

To date, more than 5,000 children have benefited from these products.

Infectious diseases

Mogadishu's population is currently estimated at more than one million – and half are displaced people.

Medical needs far exceed available health services and more people continue arriving daily.

The displaced populations are living in precarious health conditions, their immune systems already weakened by poor nutrition.

Many have never been vaccinated. Infectious diseases – including cholera, pneumonia, dengue fever and malaria – are common in the city and the rainy season, which will be begin in October, could increase their spread.

Truck bomb and security

Though a massive truck bomb killed dozens of people in the capital on 4th October, the situation there, relative to times past, has been fairly stable of late.

"That could change, so it's ever more urgent to provide as much as assistance as possible in the near term," says MSF head of mission Thierry Goffeau. 

"New humanitarian actors have arrived. It is now critical that everyone work together to identify and meet the population's needs, while remaining very watchful. The deadly attack reminded us that periods of calm are often temporary in Mogadishu."  

• Find out more about MSF's work in Kenya
  

Over 446,000 people had been infected by the disease, and approximately 6,300 people had died from it, according to figures from the Ministry of Public Health and Population at the end of August.

MSF teams in Haiti

An MSF doctor examines a patient inside the cholera treatment centre in Barrate, Port au Prince.
© Jean Marc Giboux

Since the first cases of cholera were confirmed in October 2010, Médecins Sans Frontières MSF (Doctors Without Borders) has treated almost 160,000 patients.

Its teams have been deployed in nine out of the 10 departments in Haiti.

At present, the MSF teams are fighting cholera in Port-au-Prince, as well as in the departments of Artibonite, Nord and West.

Worsening situation

The MSF teams have observed a significant increase in the number of patients admitted in the four cholera treatment centres run by MSF in Port-au-Prince.

“In the space of a month, we have gone from fewer than 300 admissions a week to more than 850, which unfortunately suggests that the situation will worsen in the weeks to come,” says Gaétan Drossart, Head of Mission in Haiti.

Poor hygiene and cholera

One of the cholera treatment centres (CTC) in which MSF is working is in Martissant, one of the most deprived areas in the capital.

Driving along the main road that leads to the CTC, it is impossible not to notice how vulnerable the population is. Between the piles of detritus, water from the leaking sewers is seeping into and flooding several roads. This creates an environment in which infectious diseases can spread very easily.

“The hygiene conditions in the area are atrocious. It is extremely densely populated with very little in the way of functional sanitary infrastructure, which facilitates the spread of cholera, especially when people drink contaminated water and food,” explains Nicolas Charret, the on-site project coordinator.

The CTC is attached to the emergency centre permanently managed by MSF. This is where MSF treat people infected by vibrio cholerae, the bacterium that has been spreading throughout Haiti for the last year.

The centre has 90 beds and at present is treating more than 250 patients a week, which would be its maximum capacity.

Diagnosis and treatment

Mathias Kennes, a nurse at the CTC, explains that with cholera cases it is essential to quickly determine the degree of dehydration suffered by the people admitted because this is the cause of most deaths. The treatment is then adapted according to the observed severity of the case.

“If the person is severely dehydrated, they need to be treated straight away, either intravenously or through a nasogastric tube. With the correct treatment and intensive monitoring, patients, even those severely ill, usually recover in three or four days,” he says.

MSF providing rapid care

In the tent housing the convalescent patients Amonly Jaquette, a 19-year-old man from the local area, talks to the MSF staff. He says that initially he felt bloating in his stomach, which was quickly followed by diarrhoea.

“I knew right away that I was ill because it was really intense. I’d heard on the radio that if this happened, you had to do something. I knew that MSF were in Martissant. So I turned up and they took care of me immediately,” he says.

After three days of treatment, Amonly is hoping to go home soon. However, before he leaves, he explains that he is going to try and take more appropriate hygiene measures, including getting hold of chlorinated water.

But he also says that it will not be easy to maintain these standards, given the lack of sanitary facilities in the area, which are shared by most of the residents.

In Haiti, almost a year after the cholera outbreak, resources for adequately preventing the disease remain rudimentary and at the mercy of the uncertainties of life in the country.

Médecins Sans Frontières MSF (Doctors Without Borders) has been providing basic healthcare to displaced families living in camps or in tents on the roadside.

Flood waters

Registration area of MSF mobile clinic in the Dadah camp for people displaced due to the floods.
© P.K. Lee/MSF

Although the rains have finally stopped and the water is starting to recede, thousands of people are still unable to return home.

MSF continues to work in the area, providing basic healthcare and monitoring the health of affected communities.

Badin district, in southern Sindh, was one of the worst affected areas. In Tando Bago, an eastern sub-district of Badin, land on both sides of the elevated main roads was still under water two months after the floods first struck.

Escaping to safety

Sanna* is a mother of two. Like many families in Badin, her house was totally destroyed by the floods.

“The most valuable things we have now are the cooking utensils,” she says.

She and her family walked until they found a piece of land just high enough to escape the water. It soon became a camp for people displaced from their homes by the floods, with around 200 families from different villages living there.

The displaced people have used whatever materials they can find to build makeshift shelters, including branches, plastic sheeting and leaves. People in the camp have limited access to clean drinking water and food.

Children at risk

“Since we arrived here we have only received two food distributions of 2kg of flour. I eat just two meals a day – chapatis and nothing else,” Sanna says.

Asked where she gets drinking water, Sanna points to a pond of stagnant flood water not far from her tent and says: “This is where we fetch the water from.”

Sanna was pregnant when the floods hit her village. Her baby was born 10 days ago in her shelter in the camp, and the unhygienic living conditions mean her newborn son is particularly vulnerable to disease.

“He has had diarrhoea since the first day he was born,” says Sanna. “Maybe I will lose my son.” 

MSF action

An MSF doctor gives consultations at a mobile clinic in a camp in Dadah for people displaced by the floods.
© P.K. Lee/MSF

Following an independent assessment of health needs, MSF is running mobile clinics in camps for displaced people in Tando Bago sub-district, providing basic healthcare, free of charge, to people like Sanna and her baby.

The most common medical conditions are diarrhoea, respiratory tract infections, skin diseases, fever and malaria.

MSF’s team is also supporting staff in providing outpatient consultations at the Tando Bago Tehsil hospital.

MSF has provided jerrycans, soap and bed nets to more than 750 displaced families, and has distributed 48,000 litres per day of clean drinking water in villages and camps for displaced people.

Mobile clinics and health care

The situation has improved since the last week of September.

“In Tando Bago, water has started receding and displaced families are going back home, though some remain in camps or living under tents on the roadside,” says Dr Erwin Lloyd Guillergan, MSF’s emergency team field coordinator.

“We will continue our mobile clinics based on the needs in the camps. We will also keep monitoring the health situation and explore the possibilities of providing safe water in the villages where the displaced people come from over the next few weeks.

"If there are any immediate, unmet health needs or the risk of diseases breaking out, as an emergency organisation, we will be ready to respond.”

Currently MSF has seven international staff and 23 Pakistani staff working in Badin on the emergency response in the wake of the floods.

* Names have been changed to protect patient anonymity.

Since 1986, MSF has been working in Pakistan with Pakistani communities and Afghan refugees who are victims of armed conflict and natural disasters or who lack access to medical care.

MSF teams are currently providing free emergency medical care in Kurram Agency, Khyber Pakhtunkhwa, Baluchistan and Sindh provinces.

MSF relies solely on private financial contributions from individuals around the world and does not accept funding from any government, donor agency or military or politically-affiliated group for its activities in Pakistan.

• Read more about MSF in Pakistan
  

For the last 10 days, MSF has attempted to deliver aid to Sirte where, according to doctors in the town, the healthcare situation has continued to deteriorate.

After receiving emergency surgery, this man was referred to the Ben Ashour clinic, where MSF is carrying out orthopedic surgery alongside Libyan medical staff. © Niklas Bergstrand/MSF

“They say that their hospital is overrun with wounded and they aren’t always able to respond to other gynaecological or paediatric emergencies, or treat people suffering from chronic conditions,” said Dr MégoTerzian, emergency response co-ordinator for MSF.

“Moreover, they have to deal with cuts in power and water and a lack of urgent medical supplies. 

"They need anaesthetics, antibiotics, analgesics and blood for transfusions,” added Dr Mégo Terzian.

MSF in Sirte

Initially, due to the fighting, the MSF team based in Misrata could only deliver medicines to a small town 10km away from Sirte. Since 3rd October, MSF has managed to send medicines and medical supplies to Sirte itself, notably an oxygen concentrator and wound dressing materials.

Emergency treatment was taking place at medical health posts close to the front lines of Sirte and Beni Walid. So a medical health centre was set up in an old holiday home, 50km from Sirte. 

MSF has provided the centre with logistical support, medicines and medical supplies and organised first aid training.  Once they are stabilised, the injured are taken by ambulance or helicopter to Misrata or Tripoli where the closest hospitals with surgical capacity are located.

Surgical team

In the Kasr Ahmed hospital in Misrata, an MSF surgical team looks after the urgent and wounded cases.  It also looks after prisoners of war who are being detained in local prisons and moved to this hospital for surgical operation.

Another consequence of the fighting which is taking place on both sides of Misrata is that civilians are fleeing the strongholds of the old regime, like Sirte and Beni Walid. Some are heading to Tripoli and others are seeking refuge around Misrata or joining camps for internally displaced people in Kaddayia, Al Hicha, Wachka.

MSF is monitoring the situation in these camps to ensure medical access for these displaced people. Notably, the town of Al Hicha has opened a camp for 2,000 people where MSF is supporting the Libyan doctors by providing medicines.

MSF activity in Libya

MSF has teams in hospitals in Yefren and Zintan in the west of Libya, where they are providing medical supplies and drugs. MSF is also providing mental health support to people affected by the fighting.

In Misrata, MSF is providing medical care, including post-operative care, in many prisons in the town and offering mental health support to detainees, mostly soldiers who have been taken prisoner. 

In Misrata, MSF psychologists play a supervisory role and give training to Libyan pyschologists. They are also holding consultations within the community.

Finally, medical consultations, mental health care and the distribution of essential goods make up the various kinds of aid being offered to migrants sheltering in sites in Tripoli and around.

Tweet Treats is a book of the shortest, sweetest, simplest recipes imaginable. Inspired by Twitter, each recipe is complete in 140 characters or less.

With 500 contributors – and 140 of those being household names – this book came about from the world’s love of good food without the fads.

Tweat Treats inspiration

Newbridge-based writer and MSF supporter Jane Travers hit upon the idea for Tweet Treats in her kitchen one evening when, stuck for healthy dinner ideas, she tweeted for help.

Almost immediately hundreds of responses came back with recipes, from all over the world, and the Tweet Treats project was born.

Tweet Treats recipes

Every recipe is a little gem, as simple to make as it is to read.

There are recipes here for every occasion, from breakfast to dinner, snacks to party food; meals for kids, vegetarians, those who are strapped for cash and those who are short on time.

Marco Pierre White

In his foreward Marco Pierre White writes: “In Tweet Treats it will take you less time to read the recipes than it would take to pour yourself a glass of wine!

"This book really is the love of food pared down to its bones; simple recipes, delicately expressed ... just as you would convey a recipe in a conversation with a friend.”

Jane is very generously donating all her royalties from sales of Tweet Treats to Médecins Sans Frontières. 

Priced £6.99 the book is available on shelves in bookshops and online at O’Brien Press, Amazon and The Book Depository. 

Spread – or tweet – the word!

Médecins Sans Frontières MSF (Doctors Without Borders) has opened four feeding centres in Mogadishu to treat malnourished children and distribute ready-to-use therapeutic food to the refugees. Measles vaccination is also undertaken to respond to the current epidemic.

Donate to MSF's Somalia appeal:

Food distribution in Rajo camp in Mogadishu
© Yann Libessart / MSF

A child in an intense therapy feeding centre in Mogadishu's Hodan district
© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

A malnourished child being weighted in Mogadishu's Rajo camp
© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

© Yann Libessart / MSF

Donate to MSF's Somalia appeal:

MSF staff member delivering Chagas treatment in Aiquile, Bolivia. © Vania Alves/MSF

Thousands of people with Chagas disease will go untreated in coming months due to a shortage of benznidazole, the first-line drug used in most endemic countries.

As a number of countries are actively seeking to reverse the long neglect of Chagas disease, the supply of this treatment threatens to run out.

Therefore, the medical-humanitarian organisation MSF is urging the Brazilian Ministry of Health, which is responsible for the only laboratory in the world manufacturing benznidazole, to respect its commitment to Chagas patients and take immediate measures to make the drug available. 

Chagas treatment

Chagas treatment currently depends wholly on a single pharmaceutical company to produce benznidazole tablets, the Brazilian State laboratory LAFEPE (Laboratorio Farmaceutico do Estado de Pernambuco). Responsibility for producing the active pharmaceutical ingredient (API) used by this laboratory was recently transferred to one sole private company, Nortec Química.

There is not enough API at present to produce the tablets needed, and Nortec has yet to validate production. In addition, LAFEPE has breached its promise to publish and fulfil a manufacturing schedule that would ensure availability of the drug.

As a result, various national Chagas programmes in Latin America are already struggling to meet the demand for new treatment and are expected to run out of stock in the next few months.

Future availibility unknown

No information has been provided by the Brazilian Ministry of Health on what is happening, and the World Health Organization (WHO) and the Pan American Health Organization (PAHO) have not put a contingency plan in place to maintain stocks of this drug for acute cases of Chagas.

Future availability of the drug is not currently known, although according to various estimations it is unlikely to be before mid-2012.

“This situation is unacceptable. In Boquerón, an area with one of the highest rates of Chagas in Paraguay, we are forced to stop diagnosing patients because we simply don’t have the drugs to treat them,” explains Dr Henry Rodríguez, MSF’s head of mission in Bolivia and Paraguay.

“For decades Chagas was a completely neglected disease and just when diagnosis and treatment were finally being made a priority, we’ve run out of medication. We must not allow this to continue; an urgent solution must be found for our patients.”

MSF forced to delay treatment

In recent years, demand for treatment has increased significantly because adults are now being treated as well as children. Besides, the WHO and the PAHO have strongly endorsed diagnosis and treatment at the primary healthcare level. However, all progress made to date is now jeopardised by the shortage of benznidazole.

“Although we know that current treatment is more effective and more likely to prevent complications the sooner a patient is treated, we will be forced to delay it,” says Dr Unni Karunakara, MSF's international president.

Call for swift action

In view of this critical problem, MSF has called upon the Brazilian Ministry of Health to commit to speeding up the current benznidazole manufacturing process by streamlining its validation with the API produced by Nortec.

Given that the production, distribution and sales process will last for several months, Brazil must spearhead a regional contingency plan – with the support of the PAHO – for the rational use of the benznidazole stocks among the most vulnerable groups in endemic countries.

MSF is also urging the Ministries of Health of endemic countries to demand this contingency plan to be put in place as soon as possible, while finding a definitive solution for the long term.

“The Brazilian government has been pioneering in the production of generic drugs, showing its commitment to people who need access to treatment. It must now act swiftly to keep its commitment to Chagas patients worldwide,” concludes Dr Karunakara.

Chagas disease, also known as Human American Trypanosomiasis, is an infectious disease caused by the parasite Trypanosoma cruzi. Endemic in several Latin American countries, it causes 12,500 deaths per year and it is estimated that eight to 10 million people have the disease.

Case numbers are rising in the US, Europe, Australia and Japan as a result of greater international travel.

In most Latin American countries the disease is primarily transmitted by the assassin bug although it can also be transmitted from mother to child, in blood transfusions, organ transplants, contaminated food and laboratory accidents. 

As the disease progresses, around 30 percent will develop heart lesions and 10 percent gastrointestinal damage that may be fatal.

As the situation in the Horn of Africa deteriorates, mainstream coverage of the nutritional crisis in Somalia has been simplistic and has misrepresented the realities.

Generally two dimensions are being explored: the severe human impact of consecutive failing rainy seasons, leading to the worst drought in decades; and the conflict pitting Al Shabaab against the Transitional Federal Government (TFG), backed by the international community and its proxy vehicle, the African Union Mission in Somalia (AMISOM).

Food security crisis

MSF doctors and nurses helping Somali displace people southern Mogadishu howl wadaag district on August 13, 2011. © Feisal Omar

MSF's own analysis of the situation is that a larger array of factors has negatively affected southern Somalia and led to the current crisis.

Somalia is going through a major nutritional and food security crisis, as is confirmed by experts, MSF's interlocutors and field data: the extent of the problem is compounded by constraints – both structural and anecdotal – that have raised the spectre of a full-blown human disaster in the weeks and months to come, with the current situation already far above international emergency thresholds.

Displacement and its causes

Drought-prone areas of southern Somalia, which have been dependent on food aid for decades, have suffered from the sustained degradation of humanitarian access over recent years, constraining the response to the crisis inside the country itself.

The situation has mainly been caused by Al-Shabaab's suspicions of aid provided by western organisations, resulting in restrictions on the movement of both international staff and supplies.

The response has further been restricted by the international community's security agenda, driven by global 'war on terror' dynamics, which have led to the excessive politicisation of aid in Somalia. Aid has been criminalised by UN Security Council Resolutions 1844 (in 2008) and 1910 (in 2010), which specifically targeted the 'material support to anti-TFG/AMISOM groups'.

Preventative displacement

MSF staff check a child for signs of malnutrition using an upper arm measurement. © Feisal Omar

As the drought worsened in spring 2011, it appears that agro-pastoralists – mainly sub-clans of the Rahanweyn in Bay, Gedo, Bakool and parts of Lower Shabelle, and sub-clans of the Darod (Marehan) – engaged in 'preventative displacement' for the most vulnerable to camps across Somalia's borders or to Mogadishu.

It was believed that aid would be available in these places, as it was understood by Somalis themselves that this 'dry season' would be catastrophic.

This pattern explains the make-up of the refugee population, with Somali men remaining behind to care for the remaining livestock while trying to salvage some of the upcoming agricultural harvest.

Intervening in Dadaab, Kenya

The consequences of this large-scale displacement have been witnessed firsthand by MSF in the Dadaab camps, in north-eastern Kenya, where Somalis have been moving to receive the assistance they are entitled to under international legal standards.

The population of Dadaab has grown steadily over the years due to the conflict in Somalia. This year, however, the ongoing drought has caused massive displacement, leading to the influx of refugees crossing the border from Somalia to Kenya.

Over recent years, the humanitarian response to Somali refugees in north-eastern Kenya has been poor. The capacity and the management of existing structures, as well as service delivery to refugees, have not reached basic standards. Even before the current wave of arrivals, the camp population already exceeded planned projections.

Kenyan government

Dadaab is full of children. The number of babies born in the MSF hospital has doubled since last year.
© Nenna Arnold/MSF

The Kenyan government's security concerns have influenced Kenyan policies towards the conflict inside Somalia, while leading to an aid environment increasingly dominated by political considerations.

Lengthy, stalled processes over new camp locations and pervasive bureaucratic hindrances are the norm in Kenya.

Blockages of intended aid operations aim at ensuring full control over refugees and reinforce perceptions that Dadaab is both a burden on and a threat to the Kenyan state.

The current emergency has slowly been escalating in the region, despite the early warning systems that have been put in place over the years.

Dadaab remains the largest complex of refugees in the world, with new arrivals seeking assistance on a daily basis. Around 400,000 refugees live in the camps and are confronted with an ever-shrinking access to essential services.

Despite the scale-up of aid, the expectation is that living conditions will deteriorate further, with the total population expected to reach 500,000 by the end of 2011.

Urgent needs

Newly displaced refugees are in urgent need of assistance and face unacceptable delays in getting registered. Registration is vital as it allows them access to ration cards and food distributions.

Since July refugees are receiving food and non-food items (NFIs) before their registration, but delays are far too long and the process not carefully monitored. This avoidable bottleneck is further compounded by the clear lack of capacity by Kenyan authorities and UNCHR to address the issue.

As a direct result, MSF's medical teams are not only seeing children who are malnourished upon arrival, but also some whose nutritional status continues to deteriorate once they are living in the overstretched camp.

Shelter capacity needs to be increased, while boreholes need to be drilled to support a water system nearing breakdown. Medical services are required throughout the camp to ensure basic levels of healthcare.

Providing assistance to vulnerable people caught in the politically biased paradigm of the global 'war on terror' has become unnecessarily complicated.

Humanitarian action – its limits and its relevance

 Head of Mission Karin Fischer is helping the nurse in the TFC (Therapeutic Feeding Centre) ward at the hospital MSF runs in Galcayo South. © Sven Torfinn

Through the realities MSF is witnessing in the field, the debate about whether or not to donate money for emergency assistance in Somalia becomes increasingly bogged down between two extremes: aid provided amidst 'terrorism related' violence fails to reach those in need; at the same time, it is understood that a massive injection of aid would actually be needed.

According to MSF, an acute emergency currently exists only within parts of Somalia and amongst Somali refugees.

The food security crisis is caused by a combination of conflict, displacement, bureaucratic obstacles to aid provision, misguided policies and drought. It is, in essence, a man-made disaster, aggravated by a natural phenomenon.

Policy failures by Somali, regional and Western authorities have all contributed to the crisis, resulting in restrictions in both the quality and quantity of aid, while fearing that the aid would fall into the hands of so-called terrorists.

Delivering aid in Somalia

The significance of this analysis is that humanitarian assistance itself bears little responsibility for the current crisis in Somalia, while aid is only a limited part of the solution.

Humanitarian assistance is a rough remedy, deployed when politics and economic development have failed. It prevents a situation from deteriorating even further, but is emphatically apolitical and can therefore offer no resolution to the root causes of crises.

Delivering aid in Somalia is difficult and dangerous, but not impossible. Provided it is executed in an impartial, neutral and preferably independent way, it will reach those in need, as MSF's 12 major projects throughout Somalia – which are currently treating approximately 35,000 malnourished children – prove on a daily basis.

Arjan Hehenkamp
General Director
Médecins Sans Frontières (MSF) Amsterdam

Caroline Abu-Sada
Research Unit Coordinator
Médecins Sans Frontières (MSF) Geneva

Tarak Bach Baouab
Humanitarian Affairs Advisor
Médecins Sans Frontières (MSF) Amsterdam

To read the original version of this article please visit the Public Service Review website.

MSF Home Visitor in the field in Zahedan.
© Siavash Maghsoudi

Zahedan, capital of the province of Sistan-Baluchistan, is an Iranian city located approximately 70 kilometers (20 kilometers as the crow flies) from the border with Pakistan and Afghanistan.

Since 2001, MSF has been providing free medical care to Afghan refugees and Iranians lacking the resources to pay at clinics located in the city's poorest neighborhoods: Shirabad, Karimabad and Besat.

Iranian authorities

For the last several years, Iranian authorities have been returning Afghan refugees in the region to their country. In addition, in 2007, Sistan-Baluchistan was placed off-limits to foreigners for reasons of "internal security".

MSF has continued its activities there since 2008, thanks to the presence of its local staff and has been the only international organisation still "tolerated".

"We received ultimatums a number of times from Iranian authorities instructing us to leave the area," says Karine Gillain, head of mission in Tehran. "We would negotiate each time and always managed to delay closure for several months, but last week we had no choice and had to end our activities." 

Patients risk losing access to care

MSF's doctors, nurses and midwives held an average of more than 5,000 free medical consultations per month in the two clinics that remained open until now, including one dedicated to maternal and child care. Most of the patients were women and children from poor families.

"We hope that the Ministry of Health facilities will care for the patients who came to our clinics, just as we have been sending them the most urgent cases up to now," says Gillain.  "However, we fear that the poorest patients will not be able to pay for treatment or will be afraid to seek care."

• Read more about MSF's work in Iran

MSF nurses reported irregularities on the appearance of the product such as friability and discoloration of the tablets.

Supply lapse

Last week, these ARVs were confirmed to be falsified versions of World Health Organization (WHO) quality-assured (‘prequalified’) drugs that were purchased via a distributor certified by the Kenya Pharmacy and Poisons Board.

These antiretrovirals contain lamivudine (150mg), zidovudine (300mg), and nevirapine (200mg).

“MSF takes this supply lapse seriously and is focused on ensuring that patients are informed and receive appropriate medical follow-up,” says Dr. Alexandra Vandenbulcke, MSF medical coordinator in Kenya.

Ministry of Health

As soon as the quality alerts were reported by the MSF nurses, MSF informed the Kenyan Ministry of Health, WHO and other international partners involved in procurement of medicines. MSF put the drugs under quarantine and the falsified batches were sent back to the supplier.

MSF has started to trace and notify patients who have received the falsified products, and has secured adequate replacement drugs for affected patients.

MSF will offer adapted medical follow-up to these patients and optimise treatment options when necessary.

MSF places great importance on the quality of the drugs used in its projects, using WHO-prequalified ARVs. MSF is demanding a full investigation into the circumstances of this supply lapse to ensure the best quality of medicines for patients.

In Somalia, tens of thousands of vulnerable children are at risk when the disease sweeps through overcrowded displacement camps where malnutrition levels are high and immunity low.

MSF inside Somalia

Dr Unni Karunakara examines a child at a mobile clinic in Mogadishu, Somalia, close to the former frontline.
© MSF

Médecins Sans Frontières MSF (Doctors Without Borders) runs 13 medical-nutritional programmes in Somalia .

Around 5,500 malnourished children are receiving therapeutic feeding,

And nearly 500 children with medical complications on top of severe malnutrition are being nursed back to health in eight intensive therapeutic feeding centres (ITFC).

Measles and malnutrition

“Measles is an airborne infection and conditions in overcrowded camps create the ‘perfect storm’ for outbreaks," says MSF nutritionist Dr Susan Shepherd.

"Malnourished children under five are the most susceptible. They get caught in a vicious circle where measles and malnutrition wear down their weakened body's defences, which can push them over the edge with complications like pneumonia and diarrhoea.

"The first priority in such emergencies is to vaccinate against measles and to rapidly treat all the cases you can identify."

Nutrition crisis and infections

MSF projects around Somalia detected a steady number of measles cases – 3,049 cases since January – and then there was marked increase before the onset of the nutrition crisis.

Between May and September a total of 2,132 cases were reported – 70 percent of the year’s caseload in just four months.

In Hodan district, where MSF operates one of three ITFCs in Mogadishu, over 50 percent of the severely malnourished children have measles too. These children are isolated to prevent the spread of disease.

Treatment and immunisation

Teams in Marere, southern Somalia, have also witnessed measles outbreaks. And all MSF projects in Mogadishu have reported cases – whether in therapeutic feeding programmes or outpatient services.

It is vital that measles patients get treatment quickly after being identified by MSF outreach teams. The treatment aims to prevent complications such as respiratory infections.

Somalia’s legacy of war, conflict, lack of development and a collapsed health system means that level of routine immunisation coverage is extremely low – the World Health Organisation puts it about 30 percent.

This is a particular concern as MSF facilities are treating measles in older children and adults, when outreach teams find them.

Stopping measles

Head of Mission Karin Fischer is helping the nurse in the TFC (Therapeutic Feeding Centre) ward at the hospital MSF runs in Galcayo South. © Sven Torfinn

MSF has already vaccinated over 50,000 children against measles since July this year – despite constraints and concerns for the safety of medical staff – mostly through outreach activities and small-scale immunisations.

Implementing mass vaccinations, the first choice to fight outbreaks, is not easy in an insecure environment like Somalia.

Several vaccination teams are needed. A typical team can consist of up to 10 people, who need to be recruited, trained, equipped and deployed.

Creating space for action

Setting this up in Somalia today is complicated. It involves time-consuming negotiations with local leaders, authorities and even armed groups who control certain parts of central and southern Somalia, to allow vaccination campaigns which could save thousands of lives.

But it doesn’t end there. Negotiations also often have to extend to simpler things like hiring people and vehicles in a one of the most difficult places in the world.

MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions.

Over 1,400 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, surgery, treatment for malnutrition, as well as support to displaced people through health care, water supply and relief items distributions in nine locations in South- and Central-Somalia.

MSF is also providing medical care to Somali refugees in Kenya and Ethiopia.

The facility was constructed by Médecins Sans Frontières MSF (Doctors Without Borders) through private donations. The Ministry of Health and MSF teams will be jointly running this new centre.

MSF health centre

The King Mswati III surrounded by officials and MSF team. ©MSF

The new DR-TB wing can accommodate a maximum of 30 patients. International standards for infection control were integrated with the use of natural ventilation.

The ward also includes a laboratory with state-of-the-art technology.

Among the features MSF is proud to introduce is the molecular analyser, which detects specific drugs resistance in less than two hours, allowing clinicians to quickly put patients on the right treatment.

The opening ceremony attended by the King

The ward was officially opened on the 20th September 2011. The inauguration was attended by the King of Swaziland Mswati III, members of his government and his cabinet, as well as representatives of World Health Organization and NGO partners.

The event took place before a large crowd of Swazis gathered behind the newly erected building.

TB epidemic

While commending Swaziland efforts in its fight against TB, and particularly the recent decision of the government to declare the epidemic as an emergency, the president of MSF, Dr Abiy Tamrat, warned King Mswati III against the consequences of the financial crisis affecting Swaziland.

“We wish to appeal to you to ensure that all measures are taken by your government for the timely procurement, supply and distribution of drugs and lab supplies to health facilities and patients.

"Defaulting on this commitment would directly impact on the lives of many and on our chances to successfully curb the dual HIV-TB epidemic affecting the Kingdom," said Abyi Tamrat.

Drug resistant tuberculosis a worsening problem

The management of DR-TB is a growing challenge in Swaziland. Almost eight percent of new TB cases are infected with a drug resistant form of TB and 20 percent of TB cases in Swaziland are DR-TB.

There are currently more than 800 cases of DR-TB in the country, and 172 alone in the region of Shiselweni, where MSF has worked since 2007.

DR-TB treatment is very taxing for the patients. They need a daily injection for at least six months and take up to 18 pills per day. Adverse effects are many and require even more medicines.

Community-based approach

Because it is humanely and practically impossible to keep patients in hospital for months, the new DR-TB ward comes as a complement to a community-based approach.

“For the majority of our very sick patients, this is the only opportunity to access good quality of care, close to home, in case they need hospitalisation," explains Dr. Natalia Tamayo Antabak, the medical head of the newly DR-TB ward.

Since 2007, MSF teams have been focusing their efforts on facilitating the free access to integrated HIV and TB services at the lowest point of care, the Primary Health Care clinic.

Today, there are 22 rural clinics in the Shiselweni region that offer decentralised TB care and treatment to more than 2,000 patients every year. In the Manzini region, five clinics offer decentralised care for drug sensitive and drug resistant TB.

• Read more about MSF's work in Swaziland

On 15th September the Executive Council in charge of humanitarian affairs in Saada announced new conditions under which all humanitarian and non governmental organisations have to work in this region.

A view od Al Talh Hospital, Saada, Yemen. MSF has suspended work in the region.                                        © Arnaud Drouart/MSF

Among other measures, these new conditions include:

• an end to all independent assessments of medical needs within the governorate.

• a ban on international staff supervising activities.

• the obligation to replace all Ministry of Health staff working with MSF with staff proposed by the Executive Council.

MSF in Yemen

“These new conditions would greatly affect our possibility to guarantee the quality and effectiveness of our work,” says Dr Vipul Chowdhary, MSF representative in Yemen. “We had no choice but to suspend our activities”.

In Al Talh and Razeh, MSF was supporting two Ministry of Health hospitals covering a catchment area of almost 400,000 people.

In Al Talh, secondary healthcare, including surgical services, were provided. In Razeh, MSF provided primary and emergency healthcare, nutritional recovery and maternity.

Discussions with authorities

The organisation is currently willing to engage in discussions with local authorities to define acceptable conditions in which to run independent humanitarian activities.

“We hope to find a common ground with local authorities in order to restore previous conditions which have allowed us to provide valuable medical services for the past four years. MSF is willing to continue its medical emergency activities for the sake of the population,” says Dr. Chowdhary.

MSF has been running medical activities in war-torn Saada governorate since 2007. After the ceasefire of February 2010 put a stop to hostilities between the Yemeni government and the forces of Al Houthi, MSF was able to restart and develop its activities in several areas of the governorate.

In the first six months of 2011, almost 20,000 outpatient consultations were provided in Al Talh hospital, with an average of 30 emergency consultations each day. Between February and August 2011, MSF teams performed 428 surgical interventions.

MSF has also been running primary healthcare activities, including antenatal care for pregnant women and screening for malnutrition in children, in Al Talh and Razeh hospitals and in four health units in Saada governorate.

MSF activities in Al Talh and Razeh were suspended respectively on 21st and 26th September .

Médecins Sans Frontières MSF (Doctors Without Borders) is a private international association, providing humanitarian medical relief in more than 65 countries around the world.

MSF does not accept funding from any government for its work in Yemen and relies solely on private donations.

• Read more about MSF's work in Yemen
   

The Drugs for Neglected Diseases initiative (DNDi) recently announced a new project to help develop appropriate HIV drugs for children.

• Find out more about The Drugs for Neglected Diseases initiative 

In the coming days, an MSF team of 13 will  launch mobile clinics in camps for people displaced from their homes in southern Badin district, in the sub-districts of Tando Bago, Dadah and Chabralo.

The MSF team has conducted assessments throughout Badin district in the past week.

Disease risk

An MSF doctor examines a patient at a mobile clinic in a camp for people displaced by floods. © P.K. Lee/MSF

“We saw roads that were partially flooded, the roadsides lined with makeshift tents made of plastic sheeting where displaced people were taking refuge. There were no latrines to be seen,” says Dr Erwin Lloyd Guillergan, MSF’s emergency team field coordinator.

“In such poor hygiene conditions, people are especially vulnerable to respiratory tract infections and water-borne diseases.”

In the camps for displaced people, there is a need for medical care. Acute watery diarrhoea, suspected malaria, skin infections and respiratory tract infections are all common, while some children are suffering from suspected malnutrition.

Displaced people camps

In those camps which the MSF team visited, supplies of clean water and toilets were either non-existent or limited, with people often being obliged to defecate in the open. 

The team will continue to identify the unmet needs in Tando Bago, Shahid Fazul Rahu and other sub-districts in the coming days. MSF’s team in Sindh province currently has four international staff and nine Pakistani staff, but they will be reinforced in coming days by additional staff.

Beyond Sindh province, existing MSF teams are working throughout the country, preparing to respond to the humanitarian needs caused by the flooding.

Since 1986, MSF has been working in Pakistan with Pakistani communities and Afghan refugees who are the victims of armed conflict, of a lack of access to medical care and of natural disasters.

Our teams are providing free emergency medical care in Kurram Agency, Hangu and Peshawar, in the Lower Dir, Malakand and Swat districts of Khyber Pakhtunkhwa Province, and in Baluchistan and Sindh provinces.

MSF's programmes in Pakistan are funded exclusively with private contributions and no government funding.

• Find out more about MSF's work in Pakistan 

The short film also looks at MSF’s psychological and support work for patients in Armenia. And we catch up with the fight for access to essential medicines in the developing world.

Seven people died before arriving to the hospital. Medical teams carried out emergency surgery and stabilized many patients. Eight people with head injuries and open fractures have been referred to Peshawar for further treatment.

Casualty department

“Most of the patients are severely injured, with open fractures and limb, chest, and abdominal injuries,” said Dr. Zaheer, assistant medical officer for MSF in Timergara. “As of late this afternoon, seven patients underwent emergency surgery.”

Since 2009, MSF has been supporting the casualty departments at Timergara District Hospital,including the resuscitation room, observation area, and emergency operating theatre. MSF has also worked with hospital staff on mass casualty preparedness.

MSF surgical teams

More than 1,300 patients are treated each week at the hospital’s emergency room, both by Ministry of Health and MSF medical teams. Approximately 100 surgeries are conducted each month in the MSF emergency operating theatre.

MSF also supports the delivery room in the mother-and-child healthcare ward, as well as the hospital’s blood bank, laboratory service, and sterilization and waste management systems.

Marere and the surrounding villages of Jilib, Keytoy and Osman Moto are host to around 5,000 displaced Somalis, who have fled conflict and drought elsewhere in the Horn of Africa country.

In this feeding centre in Marere, hundreds of children are treated every month; a measles outbreak here could be disasterous.  © Magnus Hallgren

Fleeing the humanitarian crisis

However, just like in all other places where it is active in Somalia, the organisation finds itself limited in its intervention methods and freedom to operate, and fighting the outbreaks is proving an uphill battle.

Hundreds of thousands of Somalis have been on the move within the country and crossing the borders fleeing the humanitarian crisis that started earlier this year.

Civil war, violence, lack of development, lack of relief assistance, and the current drought have made these people extremely weakened, and malnourishment and opportunistic infections are rife.

Cholera and measles outbreaks

Cholera and measles are typical opportunistic diseases that occur in places where people gather who are weakened and malnourished, whose immune systems are low, where clean drinking water is scarce and sanitary conditions insufficient.

“Since the outbreak of the measles epidemic among the displaced people, we managed to treat over 150 cases,” said Silva Colona, MSF Project Coordinator for Marere.

“Ideally we would do mass vaccination of all children in these villages. That is the only way we know to stop an epidemic among vulnerable people.

"Until now, this has not happened; if the authorities grant us the possibility to do mass vaccinations amongst the children in the affected locations, we can prevent an epidemic and many unnecessary deaths.”

This MSF hospital in Marere treats 3,000- 4,000 patients a month. It is the only structure in Southern Somalia where doctors are working and free medical care is offered. © Magnus Hallgren

Treatment centres

MSF also set up a cholera treatment centre in the hospital that the organisation has been running for eight years in Marere.

MSF is opening a cholera treatment unit and a measles treatment centre close to the displaced people’s camp at Jilib to respond to the increase in the number of cases.

Over the past few weeks, more than 80 cases of cholera have been treated, more than enough to set the alarm bells ringing.

Cholera being highly infectious, patients have to be kept in isolation. MSF is also preventing further infections by hygiene promotion and chlorination of water wells.

Relief items

This week, MSF also distributed relief items to the displaced people in Jilib. Blankets, buckets and cooking pots were handed out to over 1600 households that are lacking the most essential items.

MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions.

Over 1,400 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, surgery, treatment for malnutrition, as well as support to displaced people through health care, water supply and relief items distributions in nine locations in South- and Central-Somalia.

MSF is also providing medical care to Somali refugees in Kenya and Ethiopia.

Médecins Sans Frontières MSF (Doctors Without Borders) has started working in medical facilities in the capital, and continues to work in other regions, donating lifesaving medications and supplies, and transferring patients in need of urgent medical assistance.

Tripoli

During the peak of the fighting, 16-year-old Ibrahim was hit by a bullet when he was driving in a car to the mosque together with his parents. © Niklas Bergstrand/MSF

• The medical situation in Tripoli is slowly improving, despite continuing shortages of electricity, water and fuel, which are crucial for households and medical facilities.

• Although hospitals are still stretched, they are now more capable of dealing with the backlog of patients.

• Shortages of medical personnel are being overcome as more and more medical staff return to their stations. Medical and non medical Libyan volunteers are also working to fill gaps where needed.

• Supplies of medicine and medical materials are getting replenished, but MSF teams that have visited and evaluated hospitals have seen that there are still shortages in specific medical supplies like external fixators, as well as medicine for the treatment of chronic diseases.

Migrants living in and around boats on an abandoned military base on the outskirts of Tripoli. 800-1000 migrants and refugees have gathered there in fear of harassment and violence. © Ron Haviv/VII

• On Thursday 1st September, an MSF surgical team started to work alongside local health personnel at the Ben Ashour clinic in central Tripoli, to operate on orthopedic cases (second line surgery).

• Migrants and refugees from sub-Saharan Africa continue to face deplorable living conditions and need access to basic essentials such as water and food. Hundreds are squatting in various informal settlements around the city, fearing harassment and arrest and unable to access proper medical care or security.

• MSF is currently carrying out medical consultations and distributing clean water in two different locations where approximately 1200 migrants are gathered. Since the 27th of August, around 350 consultations have taken place with a focus on women’s health and mental health support.
   

Misrata

• MSF is providing a surgical support in two Misrata hospitals. In Qasr Ahmed hospital, MSF is doing emergency surgery and trauma-related second line surgery. This hospital has two operating theatres (one was rehabilitated by MSF) and 151 surgical acts were performed in August. In Abbad hospital, MSF is providing surgical support on a case-by-case basis.

• 

  With much of Misrata's health system absorbed by the conflict, hospitals and clinics are struggling to meet the normal health needs of the general population.
  © Eddy McCall/MSF

  In Qasr Ahmed hospital, MSF has treated wounded patients who had been transferred from Tripoli and Bani Walid. MSF is also providing post-operative care, including physiotherapy, for wounded patients who have undergone surgery.

• In Misrata , MSF has set-up a surgical mobile unit ready to be dispatched to locations where there is no capacity to provide urgent medical care or treat an influx of wounded. This unit is designed to stabilise wounded patients and perform life-saving surgery.

• MSF is running a mental health program in the city, which includes activities in the community, in the hospitals, and the city’s military prison.

• The MSF team carries out around 15 community group visits a month with around 200 people that participate in psychosocial group sessions. Activities also include training and consultations in 10 hospitals and health centres.

• An average of 100 new consultations per month are being carried out in these health structures, along with follow up visits with previous patients. Around 10 new patients are also being seen in the city’s military prison each week.

• MSF is also providing staff support, material support, and training in the Al Noor and Zliten Hospitals.

After receiving emergency surgery, this man was referred to the Ben Ashour clinic, where MSF is carrying out orthopedic surgery alongside Libyan medical staff. © Niklas Bergstrand/MSF

• In addition, MSF is providing medical and post-operative care for 50 prisoners in the military and civilian prisons who need to be followed up with on a daily basis. 

Benghazi

• MSF is referring patients who need reconstructive surgery to an MSF run hospital in Amman (Jordan). So far eight people wounded during the conflict have been transferred to Amman for orthopaedic or maxillo-facial surgery.

Zintan and Yerfan

• MSF is supporting the hospitals in Yefren and Zintan in Western Libya.

• MSF is providing staff, medical supplies and equipment to support the emergency room, the operating theatres and the post-operative care unit.

• Between July and August, MSF saw the numbers of wounded doubling, but the situation in and around Yefren is now calmer.

• In Zintan, MSF is providing psychological support in health centres to people affected by the violence.

Karliene Kleijer, MSF emergency field coordinator in Liben, spoke to us upon her return from the field.

How was it to set up operations in southern Ethiopia (following the need for increased medical care after Somalis started fleeing massively to Ethiopia)?

Karliene Kleijer, until recently MSF emergency project coordinator in Liben, Ethiopia © MSF

Humbling. It is very impressive to be confronted with the challenges the Somali population are facing.

Talking to the mothers who are coming with their children to our hospitals for malnourished children just makes me realise how rich and easy my life is and has been.

They have faced hunger, oppression and conflict for many years, managed to survive, decided in the end to leave Somalia as the situation became life threatening and then have to engage in a dangerous road trip to arrive in a chaotic situation in Ethiopia.

At the same time it is good to be able to setup activities so quickly and see patients improving over time. The nice thing about treating malnourished children is that the ones who survive change very quickly from a very sick and weak child into a laughing and playing child which makes all the hard work worthwhile.

What were the conditions like that you and your team worked under?

The climate of the Liben region is harsh: hot temperatures, strong winds, lot of sand and dust and the desert is full of rocky surfaces making it very difficult to set up tents, doing construction or to run health services.

At the same time the team could return at the end of the day to our compound in the village where our sleeping tents had some coverage of the wind, while the refugees have to live in their tents in the open desert.

What do you currently see as the greatest challenges facing the refugees?

The challenges are enormous. We are still trying to provide the bare minimum for this refugee population, to make them survive.

Their health and nutritional status is extremely fragile. The services and living conditions for the refugees are still not optimal: food, water and shelter are not there in adequate amounts, and the hygienic situation is a concern.

The UN, the government of Ethiopia and several NGO's are working hard to improve this, but there is still a long way to go. At this moment we don’t focus on the refugees’ future or their social wellbeing, but about ensuring they can survive the next weeks.

"Talking to the mothers who are coming with their children to our hospitals just makes me realise how rich and easy my life is and has been." © Sisay Zerihun / MSF

I met a mother of four children - ranging one to seven year of age - in our temporary clinic in the Hiloweyn refugee camp on the first day that we had started our activities.

The oldest of the children was moderately malnourished, the other three kids severely malnourished, and all four had eye infections.

The mother told me she had left 70 days ago from Kismayo in Somalia as her last four goats had died and she had no means anymore to feed her children.

After 28 days of travelling they arrived in Ethiopia, and it took a number of days to be registered as refugees. Then they had to live and wait in the transit camp near to the border for another six weeks.

She told me that her children had become more malnourished after she arrived in Ethiopia as they did not have enough food in the transit camp.

She was happy that they had now finally reached the refugee camp, as hygiene had been very bad in the transit camp.

I felt so bad because I felt that as the international community we had failed her: not being able to give her better assistance when they arrived in Ethiopia.

At the same time, she was hopeful and smiled and felt her situation had now improved. I just hope we prove her right.

What do you currently see as the greatest challenges facing MSF in Liben?

The biggest challenge for MSF is to ensure that our medical supplies and experienced staff continue to arrive in time.

"Their health and nutritional status is extremely fragile... food, water and shelter are not there in adequate amounts." © Sisay Zerihun / MSF

One challenge in this is of course our own pipeline of personnel and medicines.

Also there are many rules and regulations set by the government of Ethiopia. That is understandable but it is not always easy to comply and it sometimes takes much time.

Other activities?

Our clinics and health centres in Liben are accessible to everybody, refugees and local residents.

We try to recruit staff as much as possible from among the local population, but this is not always possible and we get a lot of criticism for bringing in skilled staff from other parts of Ethiopia, or bringing in expats.

Our services and resources are going to the refugees, while the local population are facing drought too. Many live in poverty, so of course they want to share some of the benefits.

Temporary diarrhoea treatment centres

Starting in July, MSF has opened temporary diarrhoea treatment centres in existing hospitals in Mingora in Swat district, in Timergara in Lower Dir district and in Hangu in KPK, as well as in Sadda in Kurram.

MSF is also providing treatment to patients suffering from acute watery diarrhoea in the isolation ward of Tehsil Headquarter (THQ) hospital in Dargai and in the outpatient department of THQ hospital in Alizai in Kurrum.

As of 4 September, a total of more than 5,400 patients have been treated.

Of the four temporary diarrhoea treatment centres, the one in Mingora has seen the highest number of patients, with an average of 200 per day.

Sharp increase around Eid holiday

In late August, the number of cases increased sharply over the course of a week, rising from 73 patients per day to 270 patients per day. About 25 percent of these were children under five years old.

“Acute watery diarrhoea is an easily treatable disease, but it can spread quickly, so prevention is as important as treatment,” says MSF Medical Coordinator Dr Jacob Maikere.

“The number of cases that we saw, especially in Swat, increased significantly during and after the Eid holiday (week of 29th August).

"The situation is now stabilising, but we still need to continue the treatment with patients and our efforts to control the spread of disease.”

MSF is reinforcing its medical teams in Swat and Timergara with three extra international staff and around 30 extra Pakistani staff, who are working alongside Ministry of Health staff on the ground. It has also brought in extra specialised medical supplies.

Water and sanitation support

To prevent the spread of the disease, MSF is providing water and sanitation support in affected areas in collaboration with local communities and medical authorities.

This has included cleaning, disinfecting and chlorinating of wells and springs in villages in Swat and Timergara.

Training for medical staff

MSF teams are also providing training in hospitals to existing medical staff, to strengthen their capacity to deal with the patient cases. 

MSF is also closely monitoring the situation in neighbouring areas. Following an assessment in Nowshera and Mardan, MSF has donated treatment materials, including IV fluids and oral rehydration solution, and has carried out staff training in local health facilities.

MSF is a medical humanitarian association providing free emergency medical assistance to people in need, independent of any political or military groups, in more than 65 countries around the world.

Since 1986, MSF has been working in Pakistan with Pakistani communities and Afghan refugees who have been affected by armed conflict, natural disasters or a lack of access to medical.

MSF teams are currently providing free emergency medical care in Kurram Agency in FATA, Hangu, Peshawar, Lower Dir, Malakand and Swat districts in Khyber Pakhtunkhwa province, and in Baluchistan province.

MSF relies solely on private financial contributions from individuals around the world and does not accept funding from any government, donor agency, or from any military or politically-affiliated group for its activities in Pakistan.

The medical humanitarian organisation Médecins Sans Frontières/Doctors Without Borders (MSF) is deeply concerned about the implications of the current economic crisis in Swaziland on people living with HIV/AIDS.

To pre-empt stock ruptures, which are already affecting patients, MSF has supplied a contingency stock of antiretroviral (ARV) drugs that will serve some 18,000 AIDS patients in its project areas for at least one month.

This stock will only cover the needs of a fraction of the 70,000 patients currently on ARV treatment in Swaziland, and will not be sufficient to address the needs of those still waiting to be enrolled.

MSF calls on the government of Swaziland and the Ministry of Health to act decisively in ensuring proper management and supply of ARV drugs to the Swazi health facilities and ensure that funds are secured and reserved for supplies of ARV drugs, for laboratories, and for drugs for treating opportunistic infections.

“For all people currently on antiretroviral treatment, and for those eligible to get started on antiretroviral drugs, an uninterrupted supply of medication is crucial to the success of their treatment and thus to their survival,” says Aymeric Péguillan, head of mission for MSF in Swaziland.

Depending on a patient’s health status and the length of the treatment interruption, ARV ruptures can lead to the development of drug resistance, to a rapid decline in a patient’s health and even to death. In addition to the HIV patients who are receiving treatment, MSF is worried that those not yet on ARV drugs may also be affected by the funding gap in the general health system.

“The threat to the capacity for HIV testing and counselling is real, and laboratory services are now becoming affected, as the reagents needed for tests are in extremely short supply at the moment,” says Péguillan.

MSF, together with the Ministry of Health of Swaziland, has been providing HIV and TB care to patients in Shiselweni region since late 2007, and to patients in Manzini region since mid-2010.

By the end of June 2011, out of almost 18,000 HIV-positive people in need of treatment in Shiselweni region, 13,083 patients were on antiretroviral treatment, including more than 5,000 managed at clinic level. There are currently 4,279 patients on antiretroviral treatment in the Mankayane area, and 305 at the Matsapha industrial site clinic, both situated in Manzini region.

The current emergency unfolding in and around Somalia is being portrayed by many aid organisations and the media in one-dimensional terms, such as “famine in the Horn of Africa” or “worst drought in 60 years”.

But only blaming natural causes ignores the complex geopolitical realities exacerbating the situation and suggests that the solution lies in merely finding funds and shipping enough food to the Horn of Africa.

Dr Unni Karunakara, international president of MSF, visits an MSF hospital in Galcayo North © Sven Torfinn

Unfortunately, glossing over the man-made causes of hunger and starvation in the region and the difficulties in addressing them will not help resolve the crisis.

"Profoundly distressing situation"

I just returned from Kenya and Somalia and what I and my colleagues from Médecins Sans Frontières MSF (Doctors Without Borders) are seeing on the ground indicates a profoundly distressing situation.

In Mogadishu, I met a young woman from the southern region of Lower Shabelle who is now living in one of the many makeshift camps appearing all over the city.

She left home with her husband and seven children because of a bad harvest and because they could not afford food and water.

Somewhere along her trek, she had to leave her husband and three children behind, as they were too weak to complete the five-day walk.

Sadly, her story echoes those of thousands of other families in southern and central Somalia who have been ravaged by conflict for years and tipped over the edge by drought.

Malnutrition is chronic in many parts of the Horn of Africa and there needs to be a long-term international effort to ensure that nutritious foods are reaching the people who need them.

Today, however, the most urgent needs are concentrated in southern and central Somalia. Even if we do not have a full picture, we know the situation is dire from the large numbers of Somalis arriving in a weak condition in the capital city, Mogadishu, and at camps across the border in Kenya and Ethiopia.

"Failed harvests exacerbated what was already a catastrophe"

The failed harvests exacerbated what was already a catastrophe. Somalia is the theatre for a brutal war between the Transitional Federal Government, strongly backed by Western nations and supported by African Union troops, and armed opposition groups, most notably Al Shabaab.

In a failed political landscape, it is this war, combined with the internecine rivalries of the various Somali clans, that has kept independent international assistance away from many communities.

"Virtually no access to healthcare"

The Somali people are trapped between various forces who are depriving them of assistance, either for their own political reasons, or in an effort to weaken their opponents.There is virtually no access to healthcare in vast tracts of land across the country.

Dr Unni Karunakara: "We already have more than 8,000 acutely malnourished children in our feeding programmes, and many children are not just suffering from malnutrition" © Sven Torfinn

Against the backdrop of conflict, where many agendas are at play, it is difficult for a medical humanitarian organisation like MSF to expand health services and have an impact.

MSF has been working in Somalia for two decades and has projects in nine locations on both sides of the front lines – in areas under the control of the Transitional Federal Government and Al Shabaab.

"Many children are not just suffering from malnutrition"

We are doing everything we can to scale up our activities to meet the growing needs. We already have more than 8,000 acutely malnourished children in our feeding programmes, and many children are not just suffering from malnutrition.

All four of the children I met who made it from Lower Shabelle have measles in addition to malnutrition.

They live with their mother and thousands of other displaced people in crowded, unsanitary conditions.

Others from these camps complain of skin and eye infections, watery diarrhoea and respiratory tract infections. Some are too weak even to seek food or healthcare.

"Scaling up operations inside Somalia is slow and difficult"

In refugee camps in Kenya and Ethiopia we have been able to provide medical and nutritional care for tens of thousands people.

But scaling up operations inside Somalia is slow and difficult. MSF is constantly being forced to make tough choices in deploying or expanding our activities.

Without the ability to carry out independent assessments and provide assistance in what we believe to be the hardest hit areas, we will not be able to prevent the worst consequences of this emergency.

Humanitarian aid has come to be seen by all sides in the conflict as either an opportunity or a threat.

In areas considered to be the epicentre of this crisis, Al Shabaab, already suspicious of western agendas, has placed bans on foreign staff, on the supply of medicines and materials by air, and on vaccination activities.

Even the temporary lifting of US restrictions on the provision of aid in areas controlled by Al Shabaab is unlikely to improve access.

Elsewhere, seemingly endless negotiations turn simple procedures like hiring a nurse or renting a car into projects that take up precious time at the expense of the rapid response that is needed.

"We may not be able to reach the communities most in need of help"

The reality of providing aid in Somalia today is about as grim as it gets. Our staff run a constant risk of being shot or abducted while they provide lifesaving medical assistance.

In spite of our constant negotiations with all parties to the conflict to gain access, we may have to live with the reality that we may never be able to reach the communities most in need of help or that we will have to compromise some of our independence when we do reach them.

It is amid this hostile climate that slogans like “Famine in the Horn of Africa” are being used to raise impressive amounts of money for food and other supplies being sent to the region.

But I am concerned with the last mile: getting assistance and supplies from the ports of Mogadishu to the people who need it urgently.

Unless all parties remove the barriers that stand between organisations with the capacity to save lives and the people who rely on them for their survival, thousands more may continue dying preventable deaths.

Dr Unni Karunakara
International president, Médecins Sans Frontières 

• Read about MSF's efforts to reach the most vulnerable in Somalia

• View locations of MSF activities in Somalia on a map
  
  

Clashes claim civilian lives

Women queueing in front of the therapeutic feeding centre at the MSF-run hospital in Galcayo South.
© Sven Torfinn

The hospital in Galcayo North, partly supported by MSF, has treated 60 wounded, most of them civilians, while 20 wounded have been treated so far at an MSF-run hospital in the southern part of the city.

Until now, the fighting is reported to have claimed 18 lives.

"MSF extremely concerned"

“MSF is extremely concerned about the high number of civilian casualties that this round of fighting has caused,” said Rolland Kaya, MSF’s project coordinator.

“We will continue to monitor the situation up close and provide more medical assistance if necessary.”

MSF activities in Galcayo

MSF has provided the hospital in Galcayo North with additional surgical materials and other medical stocks needed to cater for the influx of wounded people.

MSF is working in the hospital’s outpatient department, focused on providing medical care to children under 12.

In July, MSF opened a new inpatient paediatric department, while the organisation also provides therapeutic feeding for malnourished children.

In Galcayo South, MSF provides an extensive package of healthcare, including surgery services.

Galcayo is experiencing serious medical needs, not only among the local population but also among the thousands of displaced people who have fled violence and drought in other parts of the country during the ongoing nutritional emergency.

MSF is the main provider of free healthcare services for hundreds of kilometres around Galcayo.

MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions.

Over 1,400 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, surgery, treatment for malnutrition, as well as support to displaced people through providing healthcare, supplying water and distributing relief items in nine locations in south and central Somalia.

MSF is also providing medical care to Somali refugees in Kenya (Dagahaley and Ifo camps, Dadaab) and Ethiopia (camps in the Liben region).

The international medical organisation has increased its capacity to treat malnourished children in its nine projects across the country in response to the recent rise in malnutrition levels.

• View locations of MSF activities in Somalia on a map

However, one month after MSF’s initial emergency response began, progress in providing medical care outside Mogadishu is still slow.

Twenty years in Somalia

A severely malnourished child gets an intravenous line inserted. Head of Mission Karin Fischer helps the nurse in the TFC (Therapeutic Feeding Centre) at the hospital MSF runs in Galcayo South. © Sven Torfinn

The restrictions placed upon MSF’s activities in southern and central Somalia, coupled with concerns about security in the capital, Mogadishu, have so far limited the expansion of its emergency medical activities.

People in southern and central Somalia have been plagued by armed conflict, drought, and a lack of social services and healthcare for the past 20 years.

Alfonso Verdu, MSF’s programme manager in Somalia, says: “The current nutrition situation comes on top of the already immense unmet medical needs”. 

MSF has been working to address the unmet medical needs over the past 20 years. The organisation has set up numerous health projects providing a variety of services, including primary healthcare, care for mothers and children, tuberculosis treatment, secondary healthcare, war surgery and eye surgery.

Emergency response in the face of drought

Today most of these projects have moved into emergency mode to provide assistance to communities weakened by a severe drought. 

While MSF teams are prioritising treatment for malnutrition in Galcayo, Jowhar, Guri El, Dinsor and Marere, it is still proving extremely difficult to go beyond the gates of MSF’s established health facilities to reach the most vulnerable people.

Verdu says: “Despite repeated efforts and negotiations, we have still not been able to open new projects and develop new activities in southern Somalia.”

Limitations on MSF's medical activities

In southern and central Somalia, MSF’s limited access to people in need is due to restriction on their movements by armed groups.

In Mogadishu however, the problems are related to the organisation’s concerns over the security of its staff.

In the capital, the situation is extremely volatile and access to certain neighbourhoods is hindered by sporadic outbreaks of violence.

In Mogadishu, MSF’s medical teams are battling a deadly combination of measles and acute malnutrition, which particularly takes its toll on children.

Therapeutic feeding centres

A girl holds her young malnourished sister in therapeutic feeding centre ward at the MSF-run hospital in Galcayo South, Somalia. © Sven Torfinn

In the past two weeks MSF has set up two inpatient therapeutic feeding centres with the capacity to treat 145 children.

More than 100 severely malnourished children with medical complications have already been admitted to these centres, which provide intensive around-the-clock care.

In one of these centres, 38 percent of the malnourished children admitted last week have been diagnosed with measles.

Several mobile teams have set up outpatient therapeutic feeding centres to treat severely malnourished children who are not suffering from medical complications.

More medical needs

Since 8th August, additional teams have vaccinated more than 16.000 children against measles.

MSF mobile teams have come across countless people suffering from respiratory tract infections, skin infections and cholera.

On 25th August, MSF opened a cholera treatment centre, which has admitted 22 people.

In Mogadishu, as in the rest of Somalia, much more needs to be done to provide assistance to people living in some of the most difficult conditions on earth.

• Read about MSF's efforts to reach the most vulnerable in Somalia

• View locations of MSF activities in Somalia on a map

Where we can work, our doctors face immense pressure due to the large numbers of people who need emergency assistance.

Dr Faiza Adan Abdirahman is the medical doctor in charge of the paediatric department at Istarlin hospital, where MSF has been working since January 2006. She spoke by phone on 30th August.

Where we can work, our doctors face immense pressure due to the large numbers of people who need emergency assistance.

"Our main focus is malnourished children"

A mother with her malnourished child in the therapeutic feeding centre ward at an MSF-run hospital in Somalia. © Sven Torfinn

I’m in charge of the paediatric department where I deal with newborns and children up to the age of 14. Our main focus at the moment is the large number of malnourished children coming to us.

The children we’re treating are severely sick. It’s only three pm and we’ve already admitted 70 children. These are children who are so ill that they can’t even take medicine on their own. In our outpatient department, we are receiving a lot of patients.

"With malnourishment, come all manner of other diseases"

Before the droughts, less than 20 percent of our patients were malnourished, but now the number is closer to 50 percent.

With malnourishment, come all manner of other diseases. Many of these children are suffering from watery diarrhoea and pneumonia.

We’re also seeing other problems and complications such as measles and renal and heart problems.

For children whose condition is critical and a second medical opinion is necessary, we use telemedicine technology to connect with a paediatric specialist based in Nairobi.

We have been holding real-time medical consultations between Guri El and Nairobi since last December, so far the results have been positive.

A lot of the children we’re treating are very young, of breast-feeding age. Breast milk contains vital antibodies that babies need to fight off infection, and without it, they’re left defenceless.

"Mothers have nothing to eat and are not producing milk"

"Mothers themselves have nothing to eat and, as a result, are not producing milk" © Sven Torfinn

But we’re in a situation where mothers themselves have nothing to eat and, as a result, are not producing milk.

This means children aren’t being breastfed and are left vulnerable. We’re seeing the results of this on a daily basis.

Bishaaro's story

Let me tell you about one patient we’re currently treating. Seven-year-old Bishaaro was brought to us in a very bad state.

She was weak and had ulcers all across her body, which were all infected. She also had liver problems, was severely anaemic and, after we ran some tests, we found she also had kala azar, which is a tropical disease transmitted by sandflies that is deadly if left untreated.

We started treating her immediately, giving her medicine and a blood transfusion. But then she started bleeding from her nose and her mouth.

She lost so much blood that we had to give her a second blood transfusion. Bishaaro is getting better now and her bleeding stopped. We all have high hopes that she’ll recover fully and go home soon.

"We're facing a lot of challenges"

We’re facing a lot of challenges here at the moment, so many, in fact, that we’d probably be here all day if I listed them all.

We have parents who are opting for traditional medicine when their children fall ill, with traditional doctors burning and cutting the children’s skin in an attempt to heal them.

Children eating Plumpy Nut, or Eezee Paste, a nutritious paste for malnourished children in MSF-run hospital.     © Sven Torfinn

These wounds get infected and, as these children’s defences haven’t fully developed, they either die or come to us in terrible shape with all sorts of infections.

We have parents taking away their children before they complete their treatment, and then returning them to us when their condition has deteriorated even further.

Most of all, space is the biggest issue. We’re currently treating the largest number of patients at the hospital since I’ve been working here, and space is at a premium.

We are over capacity and are constantly working out ways of keeping malnourished patients apart from those suffering from TB or measles. Putting them together is simply not an option.

Despite all these major challenges, lives are being saved and we are able to assist these children, many of whom would have died.

To respond to the increasing needs in Guri El town, MSF teams started running mobile feeding clinics, distributing water and relief items in several locations where internally displaced people are gathered.

Since January 2006, MSF has been working in Guri El’s 80-bed Istarlin hospital which provides outpatient services for adults and children and inpatient services including a paediatric ward, a female ward, an operating theatre and surgical ward.

Also in Galgaduud, MSF runs one health post in Dhusa Mareb, the other in Hindere.

MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions.

Over 1,400 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, surgery, treatment for malnutrition, as well as support to displaced people through health care, water supply and relief items distributions in nine locations in south and central Somalia.

MSF is also providing medical care to Somali refugees in Kenya (Dagahaley and Ifo camps) and Ethiopia (Liben).

2010 measles epidemic

In 2010, MSF ran a massive immunisation campaign in Fizi health zone aiming to vaccinate 120,000 children against measles in six weeks. © Haavar Karlsen

The DRC has been affected by a measles epidemic since late 2010. More than 106,000 cases have been recorded to date and more than 1,100 persons have died, the majority of them children.

The epidemic has already reached Katanga, East and West Kasai, Maniema and South Kivu provinces, largely because the 2010 supplementary vaccination campaigns planned initially were not carried out.

Epidemic returns

When the authorities declared a measles epidemic last April, certain necessary measures were then taken quickly: children under five years received emergency vaccinations and supplementary campaigns were organised last July.

More than 11 million children have already been vaccinated, including three million under the age of 15, with MSF's assistance.

More vaccination campaigns needed

However, these urgent efforts have not managed to limit the spread of the epidemic. A few weeks ago, it reached Equateur and Orientale provinces, where vaccination coverage is very poor.

"Vaccination campaigns had been planned for September 2011 in Orientale and Equateur provinces, but the decision to carry them out has not yet been confirmed," warns Dr. Northan Hurtado, MSF's vaccination coordinator.

"Measles is a contagious disease and the complications can be life-threatening. There is still time to save lives by vaccinating all children under five who have not yet been vaccinated."

WHO and Unicef mobilised

The two leading partners of DRC's Ministry of Health – the World Health Organisation and Unicef – have mobilised.

Mass immunisation campaigns are important because they raise the level of vaccination coverage and prevent unnecessary deaths. © Haavar Karlsen

The vaccines have arrived in Kinshasa. The decision to launch the campaigns now rests solely with the government, with its financial participation the key issue.

"With the start of the school year, we face an increased risk"

Dr. Laurence Sailly, MSF's medical coordinator in the DRC says, "If the campaign is not conducted in September, it could then be postponed because when the rainy season starts, it will be very difficult to organise the campaign.

"And with the start of the school year, we face an increased risk of infection among children."

MSF believes that the epidemic could spread into Oriental and Equateur provinces and asks the government to ensure that vaccinations will begin in September in order to halt the spread of the disease.

The international medical humanitarian organisation, which has started providing basic health care to two communities of displaced foreign nationals, says they need urgent protection and assistance.

About 1,000 migrants are living in and around boats at this abandoned military base on the outskirts of Tripoli in fear of harassment and violence. © Ron Haviv/VII

One community of about 1,000 refugees and migrants lives in and around boats on an abandoned military base in Tripoli, while another group of 200 have sought shelter on a farm since fighting broke out in southern areas of Tripoli.

"Many of these people already fled from fighting in their home countries, such as Somalia, Sudan or other African countries", says Simon Burroughs, MSF’s emergency coordinator in Tripoli.

"Some people came to these makeshift camps looking for a way to cross by boat to Europe – while others came to seek refuge from the fighting in Tripoli. All of them remain trapped with nowhere to go."

MSF has provided medical consultations in both locations and is planning to distribute clean drinking water and hygiene items.

"Many suffer from respiratory infections, skin diseases and gastro-intestinal complaints,’" describes MSF medical coordinator Dr. Paulo Reis.

"These medical problems are linked to their very poor living conditions. Most of the medical conditions we have treated are also stress-related – including difficulty sleeping at night due to extreme and constant fear."

Patients have told MSF how they are unable to leave the makeshift camps due to the fear of being harassed, beaten or arrested within the city.

They told the MSF team that they have been threatened at night by unidentified armed men. Those migrants staying on the farm have been ordered to leave immediately.

National authorities, the United Nations High Commissioner for Refugees (UNHCR) and the International Organisation for Migration (IOM) need to ensure the protection and basic needs of these refugees and migrants trapped in and around Tripoli.

MSF staff and port residents help build a water bladder at the makeshift camp where around 1000 migrants are taking refuge. © Ron Haviv/VII

MSF, which provides assistance to refugees and migrants in Tunisia and in southern Italy, stresses that international borders must remain open; both neighbouring states and European governments must ensure access to asylum procedures and humane reception conditions.

In Tripoli, MSF continues to support strained medical facilities with medical supplies and staff when needed.

MSF medical and surgical teams are supporting Libyan medical staff in Tripoli’s Central Hospital and in the Ben Ashour clinic.

A boat with more than 10 tons of medical and logistical supplies will arrive in Tripoli today, 30th August.

For more information or interviews, please contact Hannah Ward on 44 (0) 207 067 4265 or Hannah.Ward@london.msf.org

MSF has been present in Libya since February 25 and currently provides impartial medical and humanitarian assistance in Benghazi, Misrata, Tripoli, Yefren, Zawiyah, Zintan and Zlitan.

To ensure the independence of its medical work, MSF relies solely on private financial donations to fund its activities in Libya and does not accept funding from any government, donor agency, or from any military or politically affiliated group.

The hospital is called CRUO – Centre de Référence en Urgences Obstétricales (Referral Centre for Obstetric Emergencies) and began treating patients in March of this year.

Round-the-clock emergency care

MSF's emergency obstetric center in the Delmas 33 area of Port au Prince. Newborns in the center.
© Yann Libessart/MSF

MSF built CRUO following the destruction of its previous emergency obstetric care hospital, Maternité Solidarité, in the January 2010 earthquake.

The new 122-bed facility provides 24-hour free care for women who are experiencing a range of serious, often life-threatening complications in their pregnancies.

These include conditions like pre-eclampsia and eclampsia, obstetric hemorrhage, and uterine rupture.

Since March, more than 1,700 women have delivered at CRUO, including 380 in the first two weeks of August alone. All of these were emergency deliveries.

Other health care services

CRUO offers a full range of reproductive health care services, including antenatal and postnatal care, family planning, treatment of sexually transmitted diseases, and counselling and testing for HIV.

In addition, the hospital provides neonatal care and offers mental health counselling to patients.

The hospital is staffed by a team of primarily Haitian health professionals and support staff. It is equipped with its own laboratory, blood bank and pathology department.

In providing these emergency obstetric care services, MSF continues to work in close collaboration with the Haitian Ministry of Health, in particular the nearby La Paix hospital.

MSF began providing emergency obstetric care to Haitian women at Jude Anne hospital in Port-au-Prince in 2006, seeking to help reduce Haiti’s extremely high levels of maternal mortality.