Doctors Without Borders

[Podcast] MSF Frontline Reports

Thu, 02 Jul 2009 22:00:00 GMT

At least 10 percent of the population in Bolivia is carrying the parasite for Chagas disease. Few people, including medical staff, are aware of its prevalence, but MSF is running a groundbreaking program there.

Also: MSF is offering mental health care to displaced people in Mindanao, in the Philippines, and providing health care in Balochistan province in Pakistan, where decades of insecurity has made medical services rare.

Pakistan: MSF Increases Support as Health Facilities Struggle

Thu, 02 Jul 2009 22:00:00 GMT

MSF in Mardan District

Mardan Medical Complex

153 patients treated between June 4 and 20
41 patients in emergency room from June 19 to 21

Takht Bhai Rural Health Center

2,900 patients treated between June 2 and 20, primary and emergency care
205 antenatal consultations
13 deliveries

Pakistan’s Mardan District, in North West Frontier Province, is trying to cope with an influx of more than one million people fleeing war in the region. While Doctors Without Borders/Médecins Sans Frontières (MSF) teams have not detected alarming mortality or epidemic rates among the population, existing medical facilities in the region are trying to cope with meeting the basic health needs of an extra one million people. MSF has increased the number of hospital wards in the Mardan Medical Complex and is supporting the nearby Takht Bhai Rural Health Center to help treat the growing number of patients.

Mardan Medical Complex: Meeting the Needs of Displaced People

In the women’s ward of Mardan Medical Complex, a displaced mother from Swat sits on a bed with her three-month-old baby. The boy weighs only 1.8 kilograms (4 pounds) and is limp in her arms. The district hospital in Mardan referred the baby to the MSF-managed ward in this hospital, which is just outside the city.

“This undernourished baby needs 24-hour surveillance and must be fed therapeutic milk every three hours,” said Dr. Salha Issoufu, the MSF emergency coordinator in Mardan. “It is very hard for the staff in the district hospital to provide that sort of care when the number of patients they receive has practically tripled since the arrival of so many more displaced people.”

The district hospital in the center of Mardan is easily accessible for residents and the newly displaced. It was quickly overburdened by the sheer number of patients after fighting began in the Swat Valley and Buner. While Pakistani health authorities quickly reinforced their teams, sending medical personnel from around the country to Mardan, the hospital is nonetheless beyond capacity. To relieve the patient load, MSF opened a 20-bed ward in Mardan Medical Complex on June 4; it soon doubled in size. On June 19, MSF began working in the emergency room.

“We haven’t seen alarming signs of an overall medical emergency, other than the need to increase the capacity of local health structures,” said Dr. Issufou. “Some of the most common medical problems we have seen so far are related to dehydration due to diarrhea and extreme heat here. The displaced families come from a much cooler climate in the mountains. Children and old people are particularly vulnerable to the heat. In terms of epidemics, cholera is endemic in the region so an epidemiological surveillance has been set up by authorities, and MSF is ready to provide support if necessary.”

Takht Bhai Rural Health Center: 24-Hour Reproductive Health Care

The Takht Bhai Rural Health Center is about a 30-minute drive from the Mardan Medical Complex. In coordination with local health authorities, MSF began working there on the June 2 and is carrying out medical consultations for displaced people, including antenatal consultations. MSF also set up a delivery room in the center.

“When we first came to Takht Bhai Health Center, the situation looked chaotic because the staff was totally overloaded,” said Jean Pierre Amigo, emergency coordinator for MSF in Mardan. “MSF was already carrying out consultations in a neighboring camp for displaced people, but we also needed to support health facilities outside the camp. There was a particular need to provide a 24-hour delivery room, so we renovated the existing delivery room in Takht Bhai and ensured 24-hour medical care to assist deliveries.”

Together with the local health authorities, MSF has started an outreach campaign to make sure that women are aware of the free, round-the-clock service. “There is really no reason for women to deliver in dangerous conditions when they have a freshly rehabilitated center with medical staff on call 24 hours a day to help them,” said Jean Pierre. “Each week the number of deliveries and consultations doubles, including antenatal consultations. We’re now rehabilitating more rooms in the health center to expand the capacity.”

Hopeful Signs Amid Overcrowding

Back in the Mardan Medical Complex, a boy with acute diarrhea arrives from the district hospital and is quickly isolated.

“They have no room to isolate cases in the district hospital, so the boy was sent to us here,” said Dr. Issufou. “The district hospital is so crowded that there are two or three patients to a bed in the pediatric ward. And in some beds you might find a boy like this one with acute diarrhea sharing a bed with a child suffering from a respiratory infection. Overcrowding increases the risk of infections spreading between patients.”

Meanwhile, the small malnourished baby admitted the day before appears more alert and is starting to look around—a good sign.

“I’ve spent the past months taking him to different hospitals,” said his mother. “But I couldn’t keep going to Peshawar because it was too expensive. So I brought him back home to Swat. We fled from the fighting and came to our family who live here. I have seven daughters, and this is my only son. I just want him to get better.”

Dr. Issufou is optimistic. “In the past 24 hours the baby’s situation has improved. He’s eating well and is much more awake than when he arrived. In two more weeks he should be well enough to leave the hospital.”

In Mardan district, MSF also operates an outpatient clinic in a displaced persons camp housing 5,800 people, and provides shelter, relief items, and water and sanitation services for the displaced in the camp. Mobile clinics providing antenatal consultations are carried out in eight different schools that are housing displaced families.

In Pakistan, MSF does not accept funding from any government or donor agency, and relies solely on private donations from the general public to carry out its work. MSF also runs medical programs in Peshawar, Lower Dir, Malakand, Mansehra, Kurram Agency and Baluchistan province.

Bangladesh / India: Shelter Main Priority for Cyclone Survivors

Thu, 02 Jul 2009 22:00:00 GMT

View Cyclone Aila - Bangladesh and India in a larger map

One month after cyclone Aila struck Bangladesh and the eastern Indian state of West Bengal, people continue to suffer from ongoing floods during high tide. Shelter, drinking water, food and sanitation are badly needed. People in remote areas have reportedly still not received any help.

Doctors Without Borders/Médecins Sans Frontières (MSF) is distributing relief items, provides basic health care and is checking and repairing water sources, assisting around 75,000 people in Bangladesh and 15,000 people in India who are affected by the aftermath of the cyclone.

Ongoing flooding

The floodwater destroyed houses, livestock, shrimp farms and agricultural lands. People live in makeshift shelters on the remaining parts of the embankments. Some villages continue to get flooded twice a day during high tide.

“People are up to their necks in the water,” says Rivkah van Barneveld, who is coordinating the emergency response in West Bengal. “Houses are either destroyed or flooded, most people can’t sleep dry. With the monsoon arriving very soon, shelter is one of the main priorities. MSF is providing families with plastic sheeting and blankets.”

Skin infections and diarrhea

Water supply systems and latrines have also been destroyed by the floods, increasing the spread of diarrhea and other communicable diseases. Lacking clean drinking water, people use water containing human waste for bathing, washing, and sometimes drinking.

Pre-existing health facilities in India are functioning relatively well. In the Bangladeshi flood-affected areas, MSF is running mobile clinics.

Emergency coordinator Megan Hunter says: “We’ve visited 10 different sites so far and see about 250 people a day, mainly for diarrhea or skin infections. MSF is distributing soap, buckets and chlorination tablets and shows people how to use them.”

In the next days, an additional emergency team with a water and sanitation specialist as well as medical staff and logisticians will travel to Bangladesh.

Somalia: Hijack of MSF-Rented Vehicle Ends in Tragic Death

Thu, 02 Jul 2009 22:00:00 GMT

In the early evening of Wednesday, June 24, 2009, a private vehicle rented by Doctors Without Borders/Médecins Sans Frontières (MSF) was attacked in North Galcayo, Somalia as it returned from referring a patient from one MSF facility in the south of the city to another facility in the north.

A female caretaker accompanying the patient was shot and killed and the driver of the vehicle was injured. The third passenger, an MSF staff member, was unhurt. The driver has since received treatment and is in good condition. The car was taken by the attackers.

The attack is not considered to have been directed against MSF. However, it demonstrates an unacceptable level of violence that puts at risk MSF’s ability to provide health care for hundreds of thousands of people throughout the country.

MSF began work in Somalia in 1991. Since January 2008, MSF’s projects throughout south and central Somalia have continued to operate thanks to the commitment, hard work, and courage of dedicated Somali staff, supported by a team based in Nairobi that visits whenever security allows.

MSF calls on all combatants to respect medical structures and activities so that people—irrespective of their political, religious, or military affiliations—can access much needed health care.

In 2008 alone, MSF teams performed 727,428 outpatient consultations, including 267,168 for children under five years of age. Over 55,000 women received antenatal care consultations and more than 24,000 people were admitted as inpatients to MSF-supported hospitals and health clinics. MSF teams performed 3,878 surgeries, 1,249 of which were injuries caused by violence. Medical teams treated 1,036 people suffering from the deadly neglected disease kala azar and more than 4,000 people were treated for malaria. More than 1,550 people began tuberculosis treatment. Nearly 35,000 people suffering from malnutrition were provided with food and medical care, and 82,174 vaccinations were carried out.

Bangladesh: Rohingya Forced Out of Makeshift Camp With Nowhere to Go

Thu, 02 Jul 2009 22:00:00 GMT

Bangladesh 2009

A woman and child stand inside a destroyed shelter in Kutupalong makeshift camp.

The Rohingya, a Muslim minority population in Myanmar, have fled severe repression and persecution in their homeland and sought refuge in Bangladesh and other neighboring countries for more than 50 years. Sadly, few find the assistance they desperately need and instead are forced to survive in huge makeshift camps with little or no basic amenities, including food or water. Now, increasing violence and intimidation in a makeshift camp in Kutupalong, Bangladesh, is forcing the Rohingya to flee once again. Doctors Without Borders/Médecins Sans Frontières (MSF) reports on the appalling living conditions and maltreatment refugees are enduring at the hands of local authorities there.

She returned from her work at the usual time. But on this occasion Laila’s eyes couldn’t believe what she saw. Ever since she had moved to Kutupalong seven years ago, life had been difficult, the surroundings filthy and the help little to nonexistent. But now she had lost her shelter and the small things that made up her home lay totally destroyed. “Why?” She asked the authoritative figure standing among the group. In response he brandished a knife and threatened to cut her if she complained any further.

Bangladesh 2009

People gather water in Kutupalong makeshift camp.

Laila is one of 25,000 unregistered Rohingya refugees in the area who have sought a safe place to live on the outskirts of the state-endorsed refugee camp supported by the UN High Commissioner for Refugees (UNHCR). Unlike their approximately 10,000 registered counterparts, the unregistered refugees in Kutupalong struggle to survive day to day, living in squalid conditions, vulnerable to ill health and exploitation. “It’s some of the worst poverty I’ve ever seen,” says Gemma Davies, MSF project coordinator in Kutupalong. “People are living in makeshift shelters built out of bits of plastic and wood or whatever they can find. They don’t even have basic things to cook with. And the sanitation is appalling.”

An MSF team has just recently set up an emergency health intervention in the camp. In the last weeks, the situation has spiraled out of control. “This highly vulnerable population is facing imminent expulsion by the local authorities who are using unacceptable methods to uproot them from their homes,” says Davies. “We hear people were dragged out of their shelters if they refused to move. There was one four-year-old girl who arrived at our clinic with knife injuries and another five-day-old baby that had been thrown onto the ground. It is totally unacceptable.”

“If I go to get wood, I’ll get arrested; if I collect water I’ll get beaten; if we move our houses, we’ve got nowhere to go.”

Even as the inhabitants of the UNHCR-supported refugee camp at Kutupalong celebrated International Refugee Day on June 20, MSF was informed by unregistered refugees that they had once again been told by the local authorities to leave. People were first ousted from land surrounding the UNHCR-supported camp, and then forced off the adjacent Government forestry land.

The MSF clinic at Kutupalong, originally intended to deliver basic healthcare to children under five years old and to treat the high levels of global acute malnutrition in the camp, has become a haven for those exhausted by what is happening. “They come to us for solutions, which we can’t offer them,” says Davies. The team of MSF medics and Bangladeshi staff feel totally helpless in a situation that is swiftly spiralling out of control. “One day, we had more than 50 people turn up to our clinic, saying that they had nowhere to go, they didn’t know what to do, they’d been moved three times in the last week. And we can’t do anything to change their situation. They’re tired. People are threatening suicide now,” Davies says.

“If I’m told to move again, they can kill us, they can run us over. They can poison us, but I’m not going to move again,” said one woman living in Kutupalong camp whose feelings of desperation and resignation are shared among the refugees. “If I go to get wood, I’ll get arrested; if I collect water I’ll get beaten; if we move our houses, we’ve got nowhere to go.”

Amid the unrest, MSF continues to offer medical care to those in need of assistance, both camp residents and host community alike. “Our clinic is still very basic and it’s really just for under-five-year-olds. But given the recent events, people of all ages who have suffered violence have been coming to our clinic. Fortunately, the 27 people who came the other day mostly had minor injuries. So at least we can treat their wounds and offer clinical support,” Davies says. “We don’t have the solution for these people. It’ s frustrating, but what we can do is provide whatever medical support we can, be there with them, and bear witness to what is happening.”

MSF has assisted people in Bangladesh since 1992, most recently setting up a basic healthcare program in the Chittagong Hill Tracts, assisting victims of Cyclone Aila and implementing an emergency intervention to assist unregistered Rohingya in Kutupalong makeshift camp, with services also open to the host community.

[Video] Voices of the Youth from Eastern Congo: Survive

Thu, 02 Jul 2009 22:00:00 GMT

One young man from Eastern Democratic Republic of Congo recounts how he survived a bomb attack near his home and speaks about the life he envisages after the war stops.

This video is part of MSF's Condition: Critical, a multimedia project that gives a voice to the people affected by war in eastern Democratic Republic of Congo. MSF has been working in North and South Kivu provinces since 1992, carrying out emergency surgery, treating injuries such as gunshot wounds and burns, and running mobile clinics to reach those who have fled to remote areas. MSF teams respond to epidemics such as cholera and provide medical and mental health care to victims of sexual violence.

Burundi: After Six Years Treating Rape Victims, MSF Hands Over Bujumbura Project

Thu, 02 Jul 2009 22:00:00 GMT

Burundi 2008 © François Dumont/MSF

Victims of sexual violence receive treatment at the Seruka Center in Bujumbura.

On June 19, 2009, Doctors Without Borders/Médecins Sans Frontières (MSF) will hand over operation of the Seruka Center in the Burundian capital of Bujumbura, to a local association. The center has been specializing in the treatment of victims of sexual violence for the past six years. “Initiative Seruka pour les victimes de Viol” (ISV) was created in 2008 by members of the Burundi national staff working in the Seruka Center.

“We have covered a great deal of ground since the center opened in 2004, and it’s time for MSF to hand its activities over,” said Luis Encinas, MSF’s operational coordinator in Brussels. “The Seruka Center has raised awareness of the reality of rape in Burundi and has brought it out of the dark. MSF is passing on an equipped and functioning center, run by staff trained in the medical and psychological care of victims of sexual violence.”

In six years, the Seruka Center cared for more than 7,800 people who had suffered from sexual violence. The number of people seeking help at the center has now stabilized at around 130 a month. In order to respond to the still significant needs, the continuity of the center’s activities will be assured through support from the French Cooperation, the United Nations Population Fund (UNFPA), the United Nations Development Fund for Women (UNIFEM) and the United Nations Children’s Fund (UNICEF).

“There is a great deal of work ahead of us, and some difficult challenges to face,” said Christa Josiane Karirengera, coordinator of the Seruka Center and a member of ISV. “In Burundi, rape is still a reality, and we battle with it through our movement ‘OYA!’ which means ‘NO!’ in Kirundi. Moreover, the Seruka Center remains the only facility in Burundi offering medical and psychological care for people who have suffered sexual violence.”

Patients at the center currently receive appropriate medical and psychological care, involving treatment of wounds; prevention measures against HIV/AIDS, hepatitis B and sexually transmissible infections; prevention against undesired pregnancy and psychological support. More than 85 percent of rape patients now come to the center within the first 72 hours, following the center's efforts to inform women about this critical window which allows HIV/AIDS prevention measures to work to their full effect.

MSF has been working in Burundi since 1993. In addition to the Seruka Center, MSF runs an emergency gynecological-obstetrics center in Bujumbura Rural province, and continues to respond to medical emergencies in Burundi, including the recent nutritional crisis in Kirundo province and the floods in Buterere commune, in Bujumbura Mairie.

Pakistan: More War-Wounded and Displaced Civilians Coming from Lower Dir District

Thu, 02 Jul 2009 22:00:00 GMT

A steady increase of civilians with injuries caused by the war are reaching the main referral hospital in Pakistan’s Lower Dir district where Doctors Without Borders/Médecins Sans Frontières (MSF) is working to provide emergency medical care. Coming mainly from neighboring Swat, but also from the Maidan area in Lower Dir, more than 150 war-wounded have been treated since the end of April. At the same time, families from Maidan have been arriving in the two camps for displaced people where MSF is working.

As fighting continues in certain areas of Pakistan’s North West Frontier Province and tribal zones, access to medical care for the war-affected population is practically nonexistent. In Swat, an estimated 80 percent of health facilities are not functioning due to lack of medical personnel and supplies, but also because health centers have been destroyed, according to reports coming from the region. Curfews and continued violence make it very difficult for patients to travel to the few functioning hospitals in Swat or to hospitals outside the district.

However, some war-wounded civilians are managing to travel to Timurgara Hospital, the district referral hospital in Lower Dir. An MSF medical team has been treating patients in the emergency room and providing medicines and medical materials there since March.

“Last week when I was in Timurgara, 10 war-wounded patients from Swat, including four children, arrived at the emergency room on the same day,” said Stefan Van Der Mussele, medical supervisor for the MSF program in Lower Dir.

“The injuries were caused either by bullets or explosions. Two brothers, ages five and six, were both wounded; one of them was unconscious with a neck and head injury. They came with three women who were also wounded. In the resuscitation room there was no hope for a man who was dying from a severe head injury and had lost part of his brain. In the same room, an eight-year-old boy received treatment for his wounds while his father stood by his side, covered in the boy’s blood, trying to be strong in order to help his son.”

Since June, the MSF medical team working in the emergency room has been treating an average 700 patients each week for a variety of ailments. MSF has treated 159 war-wounded patients since April 26. Patients needing surgery are stabilized and then transferred to the surgical department where Ministry of Health surgeons are working.

Relaxation of curfews is allowing more patients to arrive in Timurgara. “Initially, the war-wounded from Swat arriving in Timurgara were travelling through the hills in order to avoid the main roads during curfews. One patient arrived with his intestines hanging out. He had been brought like this by his family, and managed to survive,” explained Stefan. “Patients are now arriving by the main roads, and are sometimes transported by ambulance.”

Wounded are also arriving from the Maidan area of Lower Dir, around 30 km (20 miles) north of Timurgara. With few functional health structures in the area, and no hospital with surgical capacity, people must make it to the district hospital for proper treatment. Families fleeing the violence in Maidan have been settling in camps, unused buildings, and with resident families in the southern areas of Lower Dir district. Widespread insecurity throughout the region is affecting MSF’s ability to assist the population.

“Though families displaced by fighting are finding refuge in the area and some of the war-wounded are arriving at the hospital, this zone remains highly unstable, situated only a few kilometers from the war zone,” said Gael Hankenne, MSF head of mission in Pakistan. “This, coupled with general insecurity in the province, greatly limits the number of teams and programs we are able to run to assist the population and strengthen local hospitals. It is vital that actors in the conflict facilitate the evacuation of wounded and sick to functioning medical facilities.”

Since August 2008, MSF has been working in two camps hosting 6,000 displaced people in Lower Dir. Sammar Bagh camp and Sadbar Kallay camp were initially set up to accommodate families who fled fighting in Bajaur Agency. Since May this year, most of the displaced people from Bajaur have left the camps and have been replaced by families escaping violence in Maidan.

MSF has provided shelter and relief items and is managing the water supply and the sanitation system in the camps. Outpatient consultations are carried out by MSF in Sammar Bagh camp and by the local health authorities in Sadbar Kallay. However, for the past three months, MSF presence has been greatly reduced by insecurity.

In Pakistan, MSF does not accept funding from any government or donor agency, and relies solely on private donations from the general public to carry out its work. MSF also runs medical programs in Peshawar, Mardan, Malakand, and Mansehra districts of the NWFP, in Balochistan province, and in Kurram Agency.

[Press Release] Long-Suffering Rohingya in Bangladesh Face Unacceptable Abuse

Thu, 02 Jul 2009 22:00:00 GMT

Kutupalong, Bangladesh, June 18, 2009—Thousands of unregistered Rohingya refugees living in the Kutupalong makeshift camp, Bangladesh, are being forcibly displaced from their homes, in an act of intimidation and abuse by the local authorities. The international medical organization Doctors Without Border/Médecins Sans Frontières (MSF) has treated numerous people for injuries, of which the majority were women and children. Furthermore, MSF has witnessed countless destroyed homes and heard many reports of people being warned to remove their own shelters or face the consequences.

“I was working. When I went back to my shelter I found it totally destroyed,” said a camp resident. “An inspector was there with nine or 10 people. I asked why they destroyed my house. They showed me a fish cutter and said, ‘If you say anything, I’ll cut you.’ ”

The Rohingya, a Muslim ethnic minority originating from Myanmar, are denied citizenship and suffer persecution and discrimination in Myanmar. Hundreds of thousands have fled to Bangladesh and Thailand.

To date, an estimated 25,000 people have flocked to the Kutupalong makeshift camp hoping for recognition and assistance. Instead of finding help, they have been told that they cannot live next to the official camp, supported by the Bangladesh Government and the United Nations High Commissioner for Refugees. Nor can they legally live on adjacent Forestry Department land. They have nowhere to go and no way to meet their basic needs.

“I cannot move,” said another camp resident. “If we go to collect wood we will be arrested. If we collect water we will be beaten. If we move our house, where should we go?”

In March, 2009, MSF was alerted to fast-rising numbers in the makeshift camp and conducted an assessment. There were 20,000 people living in dire humanitarian conditions with global acute malnutrition rates above the emergency threshold, 90 percent food insecurity, poor water and sanitation, and no assistance.

“To forcibly displace this group when they are already so vulnerable is outrageous,” said Gemma Davies, MSF project coordinator for the Kutupalong makeshift camp.

MSF responded immediately by treating the severely malnourished children, offering basic health care and improving water sources and waste facilities.

“Within four weeks of opening, we had almost 1,000 children in our feeding program,” said Davies. “The rainy season has begun and the appalling water and sanitation situation is further deteriorating, increasing the risk of communicable diseases. These people have little to no access to even the most basic of services and they are being forced to flee in fear, with nowhere to turn. The situation is deplorable.”

Denied citizenship in Myanmar, hundreds of thousands of Rohingya have fled their homes to seek refuge abroad. Few have been granted refugee status. The majority struggle to survive, unrecognized and unassisted in countries such as Bangladesh and Thailand.

A fundamental solution for the Rohingya, not only in countries where they seek asylum but at their origin, is crucial to restoring the health and dignity of these long suffering people.

[Press Release] Growing Insecurity Forces MSF to Leave its Largest Health Center in Somalia

Thu, 02 Jul 2009 22:00:00 GMT

Nairobi/Brussels, June 17, 2009 — After nine years of providing health care for the population in Bakool region, Doctors Without Borders/Médecins Sans Frontières (MSF) has reached the regrettable conclusion that it does not have sufficient security to continue its work. This decision was MSF’s alone and the organization was not expelled by the authorities. MSF medical activities elsewhere in Somalia continue.

Somalia is a very difficult place to provide humanitarian assistance as was underlined by the abduction of two MSF medical staff in Bakool in April 2009. MSF is grateful that the incident was resolved positively with the help of the community.

However, following the abduction and other serious incidents over the past year, MSF can no longer safely provide quality medical care to the people living in Bakool.

For the past several months, MSF has run the project from a distance, complemented by short visits of international technical support staff. With the abduction, the possibility of even this approach has eroded.

“Given the immense needs in Bakool and beyond we have continued to work under difficult circumstances, but unfortunately we now have to concede that the risks there have reached unacceptable levels,” said Jerome Oberreit, Director of Operations at MSF.

MSF hopes that despite our departure the population of Bakool will find ways to mitigate the loss of services provided by MSF and that they will recognize the efforts by our Somali staff for the past nine years.

MSF activities in Bakool include the Health Center in Huddur – the largest in-patient facility in South and Central Somalia - and four outlying health posts in Labatan Jerow, El Garas, El Berde and Rabdure.

During the nine years of the program, the Huddur Health Center expanded from a single feeding center for malnourished to a fully functional Health Center with a capacity of 278 beds and 157 staff receiving continuous training.

Since 2002 the Huddur Health Center and the health posts have provided 272,700 outpatient consultations, while 11,075 have been admitted to the Health Center. Of these, 3,314 were treated for Kala Azar and 945 for Tuberculosis. Additionally, 1,913 children have been treated for severe malnutrition.

In the past 14 months, MSF has been forced to close four projects due to increasing insecurity including abductions and fatal attacks on our staff in Somalia. The continued free medical activities that MSF provides in the regions of Banadir, Bay, Galgaduud, Hiraan, Lower Juba, Middle Shabelle, Lower Shabelle and Mudug will depend on the communities and authorities providing conditions that prevent such incidents toward our staff and health facilities.

The international medical organization Doctors Without Borders/Médecins Sans Frontières (MSF) has worked in Somalia since 1991.

Since January 2008, MSF's projects in South and Central Somalia have been run by dedicated Somali staff, supported by international staff based in Nairobi who visit whenever security allows. The commitment, hard work and bravery of these Somali staff meant that MSF was able to continue providing health care to hundreds of thousands of Somalis throughout 2008.

In 2008 MSF teams provided 727,428 outpatient consultations, including 267,168 for children under five. Over 55,000 women received antenatal care consultations and more than 24,000 people were admitted as inpatients to MSF supported hospitals and health clinics. There was a total of 3,878 surgeries performed, 1,249 of which were injuries caused by violence. Medical teams treated 1,036 people suffering from the deadly neglected disease kala azar, more than 4,000 for malaria and started 1,556 people on tuberculosis treatment. Nearly 35,000 people suffering from malnutrition were provided with food and medical care and 82,174 vaccinations were given.

Pakistan: Health Services and Host Families Strained by Massive Displacement

Thu, 02 Jul 2009 22:00:00 GMT

Pakistan 2009 © Jean-Pierre Amigo/MSF

MSF staff work in a camp for displaced persons in Mardan District, providing health care, as well as water and sanitation, and distributing relief goods.

The recent violence in Pakistan’s North West Frontier Province (NWFP) has left more than 2.1 million people displaced, according to official figures. The overwhelming majority have found refuge in small improvised camps or with host families in the region, mostly in Mardan District in central NWFP. The situation remains precarious for both host and displaced families as local resources are stretched to accommodate new arrivals. Doctors Without Borders/Médecins Sans Frontières (MSF) is reinforcing local health structures to help them cope with the new and increasing needs, and is providing relief items to displaced families living outside and inside official displaced persons camps.

Most displaced people living outside of official camps

More than 80 percent of the two million internally displaced people are estimated to be living outside official camps. They have been taken in by host families or have set up improvised camps in schools, mosques, or abandoned buildings made available by communities. Some households are hosting up to 50 people in a single room. Women and children are typically sleeping inside and the men outside, or people sleep in shifts.

“Displaced people living with host families and in improvised settlements are dispersed over the whole region," said Eymeric Laurent-Gascoin, MSF field coordinator in Peshawar. "We’re targeting areas where there are high concentrations of displaced families since we don’t have the capacity to cover the needs of all the people everywhere."

Health service are overwhelmed; MSF providing support

The massive influx of people is straining the capacity of local health services. Hospitals in the region must cope with increasing numbers of patients suffering from medical emergencies and war wounds. Some of the hospitals visited by MSF teams are experiencing 30 to 100 percent increases in patient consultations and admissions. MSF is now reinforcing the capacity of emergency rooms, wards, and referral systems of health structures in Mardan, Lower Dir, and Malakand.

“Though there is an increasing number of organizations providing support to primary health care structures in Mardan, the population also needs functional referral hospitals with around-the-clock emergency services,” said Fabien Schneider, MSF head of mission.

In Mardan since June 4, MSF teams have set up a 40-bed ward and are working in the emergency room of the Mardan Medical Center. During the first 10 days of activity, 94 patients were treated, of which 21 were war-wounded. Also in Mardan district, MSF is supporting the emergency room of a rural health center in Takht Bhai and is operating an ambulance system to send severe cases to hospitals supported by MSF in the region.

In Lower Dir, MSF is supporting emergency services of Timurgara District Hospital, where an average of 700 patients are treated each week in the emergency room. From May 7 to June 7, 128 people with war-related injuries were admitted, including women and children coming mostly from Swat. MSF is also supporting the emergency services of two additional health structures—Sammer Bagh and Munda—in Lower Dir, treating 350 to 400 patients each week.

In neighboring Malakand district, MSF supports the 40-bed ward, emergency room, obstetric services, and surgical department of Dargai Hospital. The MSF surgical team performs 100 operations each month. Around 35 deliveries are carried out each week.

“We are greatly limited by the security situation,” said Eymeric. “Ideally, we would have multiple outreach and mobile medical teams identifying needs and carrying out distributions and medical consultations, but we can’t increase the number of our teams or travel freely around the region in such a volatile security environment. We know that the displaced we reach receive good quality aid, but it feels like a drop in the ocean compared to the massive number of people who have fled the war.”

Massive displacement raises risk of disease

Pakistan 2009 © Malin Lager/MSF

Displaced people take refuge at a camp in Mardan District, where MSF provides support.

Risks of epidemics are higher with increased population density, rising temperatures in the region, and difficulties in accessing primary health care, particularly in rural areas where there are few functional health centers. Among the 2 million displaced, around 60,000 are pregnant women, according to official estimates. In order to facilitate access to primary health care, MSF is carrying out consultations, including antenatal care and mother-and-child health care, in two displaced persons camps and in 14 different sites situated in areas hosting displaced families. MSF staff carry out between 2,950 and 3,200 consultations each week in Mardan, Lower Dir, Peshawar, Charsadda, and Mansehra districts.

“Scabies, respiratory tract infections, and general body pain are the most common health problems that we see so far,” said Anja Braune, an MSF nurse responsible for primary health care activities around Peshawar. “Children under five years of age and pregnant women are particularly vulnerable. I meet patients every day that need medical treatment, but most of all there is a huge need, especially amongst women, to talk about the traumas they experienced while fleeing the violence.”

MSF distributing relief goods

MSF is also distributing relief items, including tents, mattresses, blankets, hygiene kits, and cooking sets, to displaced families in Mardan, Peshawar, and Lower Dir. In May, over 2,000 kits of basic relief items were distributed to displaced families living in improvised camps or staying with host families. MSF is also managing three camps in Lower Dir and Mardan, covering most of the basic needs in terms of shelter, non-food item distribution, and provision of water and sanitation facilities for 11,000 people.

MSF also runs medical programs in Balochistan Province, Kurram Agency, and Mansehra District. In Pakistan, MSF does not accept funding from any government or donor agency, and relies solely on private donations from the general public to carry out its work.

[Ideas & Opinions] New Deal To Boost Production of Life-Saving Vaccines: What The Doctor Ordered?

Thu, 02 Jul 2009 22:00:00 GMT

Geneva June 12, 2009—A number of governments and the GAVI Alliance, a group of public and private stakeholders whose common goal is to spread childhood vaccination programs, have officially committed today to pay a set price for significant quantities of pneumococcal vaccines in a bid to speed up its roll-out in developing countries. The future of the scheme now depends on pharmaceutical companies choosing to participate. International medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) warns that while the objective is laudable, the mechanism leaves significant challenges still unmet.

By contributing to the pneumococcal vaccine advance market commitment (pneumo-AMC) led by GAVI Alliance, donors aim to reduce the time lag between the release of a vaccine in wealthy countries and its roll-out in developing countries. Pneumococcal bacteria cause severe pneumonia and meningitis, killing between 700,000 and one million children each year. More than 90 percent of these deaths occur in developing countries.

“If the AMC works, it could get new vaccines to the poorest countries much faster,” says Dr. Tido von Schoen-Angerer, director of the MSF Campaign for Access to Essential Medicines. “The previous generation of pneumo-vaccine has been on the market since 2000 but is only reaching children in Africa this year, so there really was an urgent need for change.”

If companies do chose to collaborate in the scheme, the AMC would work by guaranteeing a set price of US$7 per dose in return for the manufacturers committing to producing sufficient quantities.

“But it is still impossible to say whether the pneumo-AMC will leave room for developing country suppliers, or whether the US$1.5 billion reward will all be swept up by the big players like GlaxoSmithKline and Wyeth,” says Laurent Gadot, a health economist with the MSF Campaign for Access to Essential Medicines. “And it’s only if developing country manufacturers enter the market that we can expect prices to come down to more affordable levels in the future.”

MSF is also concerned that although the AMC will boost access to the vaccine in the developing world, many developing countries are de facto excluded from the deal.

“The US$7 per dose price is limited to the poorest countries. Children in other developing countries like in Latin America will likely still go without the new vaccine,” says Dr. von Schoen-Angerer.

More research and development into vaccines is necessary to answer the needs of poor countries. But MSF does not think that an AMC, although it could create the conditions for the scaling up of production capacity, could trigger that innovation.

“There has been a lot of talk about AMCs as a tool to stimulate medical innovation. But this pneumo-AMC was not about innovation—only about creating incentives for increasing the production of a vaccine that was coming to the market anyway,” said Dr. von Schoen-Angerer. “AMCs cannot be touted as the answer to the lack of medical R&D into neglected diseases, and countries need to be very clear on this point before embarking on similar AMCs in the future.”

Contributors to the AMC are Italy, at US$635 million; the UK, at US$485 million; Canada, at US$200 million; Russia, at US$80 million; Norway, and the Gates Foundation at US$50 million each.

DRC: MSF Steps Up Medical Assistance to People Affected by Violence in the North

Thu, 02 Jul 2009 22:00:00 GMT

DRC 2009 © Vanessa Vick

At right, a man recovers in the MSF-supported Dungu Referral Hospital after he was attacked by Ugandan rebels from the Lord's Resistance Army.

In the areas of Haut-Uélé and Bas-Uélé, in the northeast of the Democratic Republic of the Congo (DRC), Ugandan rebels from the Lord’s Resistance Army (LRA) have committed violent attacks in response to military operations launched by the armies of Uganda, DRC, and Southern Sudan.

MSF is providing assistance to this abandoned population, which has been left to its fate in a highly isolated region. For this reason, MSF has opened two new projects, providing support to a health center and two referral hospitals in Faradje and Niangara.

MSF has been working in this region since last September, notably at the hospital in Dungu, in Haut-Uélé district. Now teams are stepping up activities in light of increased attacks on the civilian population, which has resulted in an influx of displaced people who have no access to medical assistance.

“In February, our teams carried out evaluation missions in different parts of the region, focusing on areas receiving little or no coverage from other humanitarian organizations, at least from a health aspect,” said Amaury Grégoire, MSF emergency coordinator. “The situation is critical. Health structures are either non-existent or in a deplorable state. There are few or no medicines available and those that are, are simply not affordable. We have also had to cope with a lack of medical staff; the majority have fled the violence along with the rest of the population.”

MSF supporting hospitals and health centers

The MSF teams are renovating the medical structures, training the medical staff who are still present, and providing free healthcare for both the displaced and local populations, many of whom have been sheltering the displaced for several months.

The nutritional situation is also cause for concern. “In addition to a number of crops being destroyed by severe rains, the displaced populations, far from home, are not in a position to grow any food at all,” said Grégoire.

In Niangara, close to 10,000 displaced people have found refuge in the town center and 15,000 refugees have settled in the outskirts of the town. The MSF teams are providing support to the referral hospital and an outlying health center, mainly treating malaria, acute respiratory infections and sexually transmitted infections, and seeing some 250 people a day in the hospital. Special consultations have been set up for victims of sexual violence.

In Faradje, not far from the Sudanese border, several thousand people have taken refuge in three different sites. The MSF team has started supporting the general referral hospital, carrying out some much-needed refurbishments to bring it up to standard. It has also installed water tanks, providing the hospitable with safe drinking water.

“Directly affected by the atrocities”

According to the United Nations High Commissioner for Refugees (UNHCR), the total number of refugees in Haut-Uélé and Bas-Uélé currently stands at around 190,000.

“These people have fled terrible violence and lived through the worst horrors,” Grégoire said. “They have lost a father, a mother, a husband, a wife, or a child. Most of their villages have been burnt to the ground. They have been directly affected by the atrocities. Thousands of people are suffering from the violence they have lived through or seen: some have been kidnapped, raped, beaten up, or simply killed.”

MSF has introduced special consultations for the victims of sexual violence. An MSF psychologist will join the team soon to train the local personnel on providing psychological care to victims.

It is not only the displaced who need urgent humanitarian assistance in Haut-Uélé and Bas-Uélé. Many of the resident families offering them shelter are in an increasingly precarious situation themselves.

“The displaced people have been offered shelter and help by the local families,” said Emmanuel Lampaert, MSF medical coordinator. “Initially, this is a positive thing, as it helps new arrivals to survive. However, in the long term, this system undermines the overall standard of living for both the displaced and the host families. And so it is an even bigger group of people who need help and their needs are huge.”

Bangladesh: The Rohingya Moved From One Deplorable Situation to Another

Thu, 02 Jul 2009 22:00:00 GMT

Bangladesh 2009 © MSF

Children play around polluted water streaming through Kutupalong unofficial camp, where an estimated 20,000 people are living.

Doctors Without Borders/Médecins Sans Frontières (MSF) was recently alerted to a growing health crisis in the Kutupalong area of Bangladesh, where thousands of Rohingya—a Muslim ethnic minority originating from northern Rakhine state in Myanmar—are struggling to survive unassisted in a makeshift camp.

The MSF team in Bangladesh immediately arranged an assessment of the area, which revealed an unacceptable humanitarian situation. An estimated 20,000 people were found to be living in foul conditions, with little access to safe drinking water or sanitation.

“In Kutupalong unofficial camp the water and sanitation situation is appalling and needs to be addressed urgently,” said Michel Becks, MSF water and sanitation expert. “Feces and polluted waste water can be found throughout the camp, presenting a significant health risk. There are insufficient water points and those that are available are very poorly protected.”

A nutritional survey showed equally alarming results. According to an MSF emergency assessment report, the prevalence of global acute malnutrition exceeds the emergency threshold and food insecurity is severe among the majority of households. With the forthcoming rainy season presenting an additional immediate threat to the health of the population, urgent interventions are required to prevent further death and disease, the report concluded.

Bangladesh 2009 © MSF

MSF staff assesses the humanitarian conditions at the camp.

In response to the situation, MSF is in the process of starting an emergency program providing basic health care to children under 5 years of age, running an outpatient and inpatient feeding program, and taking measures to improve the water and sanitation in the camp.

The Kutupalong makeshift camp is situated south of Cox’s Bazaar, in the region surrounding the official Kutupalong refugee camp operated by the UN High Commissioner for Refugees. It has reportedly been in existence for over a year, gradually increasing in population size. The camp is populated by Rohingya, a people who for decades have fled the persecution and discrimination they face in Myanmar to seek refuge elsewhere. Sadly, few people find the assistance they hope for and many go on to suffer countless indignities in the countries to which they have fled.

Approximately 25,000 people are officially recognized as refugees in Bangladesh. Hundreds of thousands more people struggle to survive without recognition or assistance, moving from one deplorable situation to another, vulnerable to exploitation.

MSF has been providing medical assistance to the Rohingya for years and is witness to their ongoing suffering both inside and outside of Myanmar. A fundamental solution, not only in countries where Rohingya seek asylum, but most importantly at their origin in Myanmar, is crucial to restoring the health and dignity of these long-suffering people.

MSF Assists Populations in Violence-Stricken Areas of DRC and Southern Sudan

Thu, 02 Jul 2009 22:00:00 GMT

In the northeast of the Democratic Republic of the Congo (DRC) and in the south of neighboring Sudan, Ugandan rebels from the Lord’s Resistance Army (LRA) have been perpetrating acts of extreme violence on civilians in response to operations conducted against them by national armies of the DRC, Uganda, and southern Sudan. Hundreds of thousands of people have been forced to seek refuge in camps or with host families and are living in extremely difficult conditions. Several Doctors Without Borders/Médecins Sans Frontières (MSF) teams operating in DRC and in Sudan are providing emergency assistance and free medical services to displaced people and to local residents.

Democratic Republic of the Congo

In Dungu, a town located in the northeast of Haut-Uélé district in DRC, an MSF team composed of eight international staff and 60 Congolese staff have been providing assistance to the population since September 2008. MSF is supporting the general hospital where 60 surgical interventions, including 25 caesareans, have been carried out in three weeks. Thirty children have been admitted to the pediatric ward and 52 severely malnourished children have been registered to the nutritional program.

MSF also supports medical activities in two health centers in the vicinity of Dungu, providing primary heath care and medical and mental health support to victims of sexual violence.

The MSF team is currently assessing the situation in settlements where displaced people have sought refuge to the south of the town. Where security allows, they are also conducting measles vaccination campaigns and distributing basic items such as plastic sheeting, basins and soap. In addition, they are working to improve hygiene conditions for displaced people and monitoring the risk of epidemics.

Once medical activities in Dungu are well established the team will evaluate the needs in Ndigima and Duru, north of Dungu. They are currently conducting assessments in the areas of Dingila, Limay, Bangadi, and Doruma.

Since May 11, a team of 14 MSF workers has been supporting the general reference hospital of Niangara, close to the Sudanese border. The team is offering free medical care, including emergency surgery and care for victims of sexual violence. MSF has also put in place the pharmacy in the general hospital and has trained local medical staff in recognizing the most common diseases, such as malaria, acute respiratory infections, and sexually transmitted infections.

In addition, an MSF team is supporting a health center in Wawe that provides medical assistance to the displaced people in that area.

In Niangara, the medical needs are very acute. The MSF team is carrying out about 1,000 consultations a week, mainly for displaced people. There are currently 10,000 displaced people in the center of Niangara and 15,000 in the outskirts.

To the east, six MSF international staff are supporting the general reference hospital in Faradje and providing free medical care. On average, they are providing more than 1,000 consultations per week; about a third of the patients are children under the age of five. Malaria, acute respiratory infections and intestinal infections are commonly seen; all can be deadly if left untreated.

The MSF team has also strived to improve quality of care in the hospital and has prepared an emergency set-up, with which the hospital could receive and treat a sudden influx of injured people.

Between 22,000 to 25,000 people have fled violence in Faradje and Aba, and have sought refuge in Ariwara and Imbokolo areas, in neighboring Ituri district. An MSF team of 55 is providing these people with medical assistance, nutritional support, and vaccination against measles. MSF has also distributed basic items and improved hygiene conditions in camps.

Southern Sudan

Towards the end of 2008, attacks by Ugandan rebels on numerous villages near the Congolese border and also in the Democratic Republic of Congo itself, caused thousands of Sudanese people to flee their homes and Congolese refugees to cross the border and seek refuge in Sudan. There were 1,000 people between December and January, and, in response to this, MSF started supporting two primary health care clinics in Gangura and Sakura, in Sudan’s Western Equatoria State, close to the border with DRC.

Since January 2009, more and more people have fled violence in many of the counties of Western Equatorial State. As internally displaced people and refugees moved to other areas, MSF finished its intervention in Gangura and Sakura and opened in February 2009 new projects in Ezo, Naandi, and Makpandu, assisting a total of around 22,000 people living in camps.

Living conditions in the camps are squalid and precarious at best, and MSF is installing water and sanitation facilities. The team is closely monitoring the situation in order to respond adequately in case it deteriorates further, while also continuing to assess the humanitarian situation in neighboring areas.

The MSF team supports health centres in collaboration with the Ministry of Health and provides drugs, medical, and logistical material. They run weekly mobile medical clinics where they refer sick patients and provide supervision and training to health staff. MSF is also monitoring the risk of epidemics, doing massive vaccination against measles, and providing psychological support to victims of violence and abuse.

In February 2009 MSF teams in neighboring Central Equatorial State also began assisting Congolese refugees in Lasu, approximately 50 km (30 miles) from the Congolese border, with urgent medical and non-medical support. Initially, MSF assisted in two temporary camp locations in Libogo and Nyori where more than 6,000 people had sought refuge. In both locations the majority of refugees arrived from Congo without any of the essential basics needed for everyday life.

MSF teams distributed 1,250 bars of soap, while other organizations distributed kits with essential items such as blankets to women and children.

In Libogo, MSF teams quickly repaired a borehole in the area to provide clean water to the more than 2,000 people gathered there.

In Nyori, people were seeking shelter under trees, so MSF constructed five shelters with 66 subdivisions—each subdivision accommodating one to two families. MSF also connected a water network from the local stream to the school where people were seeking shelter and built 10 shower rooms and 10 latrines.

In March the United Nations High Commissioner for Refugees (UNHCR) created one camp in Nyori to host the Congolese refugees together. Inside this camp MSF set up a health facility with inpatient capacity and a pharmacy. This facility provides an average of 500 consultations a week, antenatal care, deliveries and treatment for malnutrition. MSF teams also constructed all 39 communal latrines for the camp and drilled two new boreholes.

In addition, MSF organized six health promoters who move throughout the camp, raising awareness of tuberculosis, malaria, and water-borne diseases.

In April, MSF carried out a mass vaccination campaign against measles, vaccinating 1,638 children in the camp.

Somalia: MSF Treats War-Wounded Patients at Guri-El Hospital

Thu, 02 Jul 2009 22:00:00 GMT

MSF offers free medical treatment in nine regions of Southern and Central Somalia. The organization has worked at Istarlin Hospital in Guri El, Galgaduud region, since 2006. MSF also runs two health posts in the area: one in Dhusa Mareb, the capital of Galgaduud, and one in Hinder.

In 2008, 63,425 consultations were provided in the outpatient departments of the hospital and health posts, and free medication was provided to all patients in need. Almost 4,000 people were admitted to the hospital.

Doctors Without Borders/Medecins Sans Frontieres (MSF) has treated dozens of war-wounded patients following fighting in the town of Webho in Central Somalia on June 5.

The patients arrived on the night of June 5 at the 80-bed MSF-run Istarlin Hospital in Guri El, approximately 60 km (40 miles) northeast of the clashes in the region of Galgaduud.

After initial triage by the medical staff on duty, seven patients were identified as in need of urgent surgery; six were treated in the outpatient department and discharged immediately thereafter; and the rest were admitted for further treatment of fractures and other non life-threatening injuries.

To cope with the large influx of patients to the hospital, which was already almost full due to a measles epidemic, extra staff were called in and additional bed capacity was created by clearing auxiliary rooms and using the corridors. On June 6, a ward round was carried out to ensure that all patients ready to go home were discharged.

Delay of measles campaign

Since the beginning of May, MSF has treated more than 104 cases of measles in the Istarlin Hospital and the outpatient department staff were in the process of preparing for a measles vaccination campaign in the area.

Preparations included visits to a number of villages, some up to 54 km (35 miles) from Guri El, in search of more cases and to inform the villagers about the upcoming vaccination campaign, which will commence in the coming weeks.

However, due to a limited availability of qualified staff, the nurses and nurse aides responsible for the measles activities have been re-assigned to care for the wounded in the hospital. The outreach activities have consequently been put on hold and nurses and nurse aides are on stand-by.

MSF will resume the measles activities in the coming days.

Sri Lanka: MSF Field Hospital Ready to Provide More Assistance for Wounded in Camps

Thu, 02 Jul 2009 22:00:00 GMT

Displaced people look through the barbed wire that borders a camp at Menik Farm.

While Sri Lanka’s Ministry of Health has set up a system to provide initial treatment to the wounded and sick people in displaced persons camps, the needs remain immense, requiring around-the-clock medical presence in the camps to respond to all emergencies. Doctors Without Borders/Médecins Sans Frontières (MSF) is ready to scale up surgical and medical care inside the camps if authorizations are provided

“We have lots of infected war wounds that have been poorly treated. For some wounds the treatment is coming weeks later, for others it is months later.”

An inflatable MSF field hospital is currently the closest referral hospital for the 220,000 displaced people living in Menik Farm camp in northern Sri Lanka. Along with six hospitalization tents, the hospital is equipped with two operating theatres and an intensive care room. The MSF medical team working in this hospital is currently treating war-wounded patients and those suffering from pneumonia and other severe respiratory infections, as well as dehydration caused primarily by diarrhea. The 100-bed facility received its first patients on May 22 and its first surgical cases on May 26.

Ambulances arrive from the five zones of Menik Farm camp bearing some of the displaced people in need of hospitalization. Around 70 patients lie on their beds under the white tents of the MSF field hospital, just across the road from Menik Farm.

In the operating theater, MSF surgeons are performing six to 10 minor surgical procedures every day on people suffering from injuries caused by shell blasts, gunshots, or accidents. MSF surgeons remove dead and infected tissues from wounds—several times if necessary—to try to avoid amputations “We have lots of infected war wounds that have been poorly treated,” said Dr. Mike D. Newman, an MSF surgeon. “For some wounds the treatment is coming weeks later, for others it is months later.”

In the tent full of patients, a woman with a bandage around her head waits to be examined. Selva* was injured in the Vanni, the former conflict zone, on the May 19. Her husband and elder daughter were also wounded. They wrapped some clothes around their wounds to stanch the bleeding. The next day, they managed to reach the Omanthai crossing point to escape the fighting, and the army told them to go to the onsite clinic. But Selva refused, afraid that if they became seperated her family would be loaded onto a bus and taken to the camps, effectively separating them. Two days later, once she was in a Menik Farm camp, she sought care in the overcrowded camp hospital. It took another two days for a doctor to treat her and refer her to the MSF field hospital, by which time her wounds were infected.

Next to her bed, an 18-year-old boy has multiple injuries: three-month-old bullet wounds in his arm and shoulder and one-week-old shrapnel embedded in his knee. With a homemade bandage around his knee, Dilan* walked for two days out of the battle zone, before being sent to the Menik Farm camps with a dressing over his knee. Still in great pain, he went to the camp hospital, where his dressing was changed and he was given some medicine. But over the following three days he received no follow-up care. Though the medicine eased the pain, an infection was spreading. Eight days after his injury, Dilan arrived at the MSF field hospital.

There are probably hundreds of people like Selva and Dilan who have not received the close medical follow-up that war-wounded patients require. Though Ministry of Health doctors working in the camps are doing their best to cope with the number of patients, there is a need to provide a 24-hour service where war-wounded patients and other medical emergencies can be identified, treated, and referred to the field hospital as quickly as possible. MSF has the capacity to scale up these services in the camps and continues to pursue discussions with the authorities in Colombo.

Journey of a War-Wounded Patient Seeking Care

Dipesh*, 37, is a patient at the MSF field hospital. Since he was wounded over a month ago, Dipesh has been going from one medical structure to another looking for treatment.

He has been unable to walk for a month, and cannot help his wife and two children as much as he would like, but now he is finally undergoing surgery.

Dipesh was injured on April 20 while escaping from the Vanni, the now former battle zone in Sri Lanka’s north. With a large, deep wound on his right foot, he continued to walk and managed to cross the frontline. At the first crossing point, the army bandaged his foot and told him to ask for medical care at the main crossing point in Omanthai. But the crossing point was extremely crowded, and he was sent straight to a camp without seeing a doctor. Once in the camp, Dipesh asked again to go to the hospital but no authorizations to leave for medical care were given before the registration process was completed. It took four days to be registered and only then was he referred to the hospital in the nearby city of Vavuniya.

A surgeon in Vavuniya hospital cleaned his wound for the first time, almost a week after Dipesh had reached the government-controlled area. But no follow up was possible as the hospital was too crowded and Dipesh had to go back to the camp. That same day, May 2, all the displaced people in his camp were moved to a camp at Menik Farm.

In Menik Farm, it took him four days to see a doctor as the clinic in the camp was so crowded. The doctor was obliged to refer Dipesh to another hospital, because the wound was too infected. For three weeks, from the May 9 to 27, Dipesh went every other day to a hospital in Cheddikulam on a bus provided for patient transfer, in order to have his wound dressed. On May 27, he was referred to the MSF field hospital outside Menik Farm, which had just begun surgical activity. Today he is receiving a second wound debridement for his injury.

When he wakes up after the surgery he anxiously asks “How did it go?”

“It’s not that bad now; it’s improving,” the surgeon answers after opening Dipesh’s bandage. The wound is far from healed, but the infection is under control.

* Names have been changed

Southern Sudan: MSF Continues to Provide Care Amid Increasing Violence

Thu, 02 Jul 2009 22:00:00 GMT

Enlarge

Doctors Without Borders/Médecins Sans Frontières (MSF) provides care to hundreds of thousands of people in six states in Southern Sudan. In recent months, increasing violence and insecurity caused mostly by fighting between different tribes, as well as heightened tensions around disarmament initiatives, criminality in the regional capital, Juba, and road banditry has made it more difficult for MSF field teams to reach people in need of aid.

The needs in Southern Sudan continue to be immense, with MSF teams stretched to ensure the provision of basic and secondary health care and to respond to emergencies. Currently, MSF has 1,143 national staff and 129 international staff in Southern Sudan.

Working amid ongoing insecurity: treating victims of violence

"Their homes have been burned, along with their food stock. The people who managed to flee have nothing with them—they ran for their lives so they couldn’t bring any clothes or cooking pots."

In early 2009, there was a sharp increase in inter-tribal violence in Jonglei, Upper Nile, Lakes, and Warrap states resulting in hundreds of deaths and the displacement of thousands of people.

In May, an attack on the village of Torkej in Upper Nile State, bordering Jonglei State, resulted in many wounded arriving in nearby Nasir, where MSF runs a hospital providing basic and secondary health care, including inpatient facilities and treatment for malnutrition, maternal health, tuberculosis care, and kala azar, as well as surgical care. A total of 57 victims made it to the hospital. Many patients suffered multiple gunshot wounds and needed follow-up surgery and care. The majority were women and children. Several thousand civilians have been displaced by the ongoing clashes, with around 2,000 people fleeing to the outskirts of Nasir and Jigmir.

Two other brutal clashes occurred in March and April 2009 in Pibor and Akobo counties in Jonglei State. Upwards of 15,000 people fleeing the violence arrived in Akobo, south of Nasir, near to the Ethiopian border. In response, MSF sent a team to assist staff at Akobo hospital. Some 36 wounded patients were treated, mainly for gunshot injuries. Eight patients were flown to Leer Hospital in Unity State, run by MSF, for further surgery. MSF also provided the hospital in Akobo with medical supplies, mosquito nets, and food and blankets for the wounded and their caretakers.

“Nearly all the patients tell us they lost family members in the violence. We heard horrific stories—women and children were attacked and killed in their homes, and children were also kidnapped,” says Dr. Jonathan Novoa, MSF medical coordinator in Akobo County.

“Many patients had multiple gunshot wounds—a 10-year-old boy had three bullet wounds to both his legs. One mother we treated had lost five children and her husband. She managed to escape with only her smallest baby who had been shot in the arm; both survived and made it to the hospital. The wounded and their families are suffering from the trauma of the attacks. Their homes have been burned, along with their food stock. The people who managed to flee have nothing with them—they ran for their lives so they couldn’t bring any clothes or cooking pots. They sleep outside.”

On the other side of Jonglei State, following attacks in Lekwongole, Pibor County, in early March, another MSF team evacuated injured people to Pibor hospital. More than 40 patients were treated for violent trauma wounds resulting from gunshots. The 22 most seriously injured were flown to hospitals in Juba and Boma for urgent surgery.

Dr. Catherine Van Overloop, Medical Coordinator for MSF in Pibor Country explains, "Even up to ten days after the attacks on Lekwongole, wounded people were still arriving in our clinic. They had been hiding in the bush, too afraid to move. Fearing more attacks they didn’t dare seek the medical treatment they urgently needed, so they reached us when their wounds were even more infected. The people are so fearful here. For days after the attacks, the women in Pibor were too afraid to ever leave their children alone, in case there was another sudden clash and the children were killed or taken. They brought them absolutely everywhere with them, even to work, carrying them on their backs, afraid they might have to suddenly flee."

Villages on the border with Congo attacked

Towards the end of 2008, attacks by the Ugandan rebel group, the Lord’s Resistance Army (LRA), near the Congolese border and also in Democratic Republic of the Congo (DRC) itself, caused thousands of Sudanese people to flee their homes and Congolese refugees to cross the border and seek refuge in Sudan. In response, MSF started supporting two primary healthcare clinics in Gangura and Sakura, in Western Equatoria State, close to the border with DRC. By the end of 2008, 7,200 medical consultations had been provided to both the resident and refugee populations in these two areas.

In January 2009, more displaced people arrived in the area, and MSF decided to start an emergency intervention in Western Equatoria State. Mobile teams started working in Ezo, Naandi and Makpandu, supporting primary health care centers; providing mental health counseling; doing nutritional screenings and referrals of patients; training Ministry of Health staff; and providing medical and logistical materials.

In February, MSF teams in neighboring Central Equatorial State also began assisting Congolese refugees in Lasu, approximately 50 km (30 miles) from the Congolese border. Initially, MSF assisted in two temporary camps in Libogo and Nyori where more than 6,000 people had sought refuge. In both locations, the majority of refugees arrived from DRC without any of the essential basics needed for everyday life. MSF teams worked to provide shelter, repair boreholes and build showers and latrines in the camps.

The following month, when the UN High Commissioner for Refugees (UNHCR) created a camp in Nyori, MSF set up a health facility with inpatient capacity and a pharmacy. This facility provides general medical consultations, antenatal care, deliveries and treatment for malnutrition. In the first week, 500 consultations were provided. MSF teams also constructed 39 communal latrines for the camp and drilled two new boreholes. Health promoters were employed to raise awareness of diseases like tuberculosis, malaria, and water-borne diseases. MSF also vaccinated 1,638 children in the camp against measles.

Responding to Outbreaks and Epidemics

Large-scale outbreaks of meningitis, measles, cholera, and malaria are common in Sudan. In the early months of 2009, MSF teams responded to several outbreaks of cholera: in Peth, in Aweil East, northern Bahr-el-Ghazal State; Pibor, in Jonglei State; and Gogrial town, Warrap State. Where possible, MSF worked alongside the Ministry of Health, providing treatment, medical supplies, tents, and staff as necessary.

In Juba County, Central Equatoria State, where there are cholera outbreaks every year MSF has started preventive activities including health promotion and the provision of clean water in communities at risk, such as Kator and Munuki. In order to improve hygiene and reduce the number of deaths from water-borne diseases, MSF is providing clean water by repairing existing boreholes in the community and drilling new boreholes, including in four health centers.

In February, MSF responded to a meningitis outbreak in Kapoeta, Eastern Equatoria State, vaccinating 65,322 people and supporting health structures in treating people infected with the disease. MSF also coordinated with other agencies to respond to meningitis cases in northern Unity State.

Medical care at all levels

MSF’s activities continue in other parts of Sudan. An absence of healthcare staff, structures, roads, transport, other aid agencies, and investment in health care means that in some areas MSF is often the only medical organization present. In Aweil, Bahr-el-Ghazal State, MSF supports a hospital, focusing on providing healthcare to mothers and children and nutritional care. In the disputed areas of Abyei and nearby Agok, in Warrap State, MSF runs outpatient clinics and provides nutritional care in both fixed and mobile clinics. In 2008, 8,950 outpatient consultations were provided and over 1,200 severely malnourished children were treated. In 2009, MSF began a reproductive health program providing antenatal care and safe deliveries in the Abyei region.

In Pieri, Lankien, and Pibor, all in Jonglei State; Nasir, in Upper Nile State; and Leer, in Unity State, medical staff provide all levels of health care, ranging from consultations for respiratory tract infections to lifesaving surgery. In 2008, medical teams provided over 360,000 outpatient consultations, almost 20,000 antenatal consultations, 1,098 surgeries, many of them emergency surgical interventions for gunshot wounds, and admitted about 8,300 people as inpatients. Some 492 people were started on treatment for tuberculosis in 2008. Malaria is a growing concern. In 2007, 4,400 people were treated for malaria in Leer hospital. In 2008, this number rose to 25,500, and in the first four months of 2009 the MSF team had already treated 14,000 patients.

Northern Yemen: MSF Treats War Wounded in Razeh

Thu, 02 Jul 2009 22:00:00 GMT

Since May 5, fighting has occurred nearly every day in Razeh, northern Yemen. For now, Doctors Without Borders/Médecins Sans Frontières (MSF) has been able to continue working at the city hospital and has treated 41 war-wounded since that date. Most are civilians—22 men, nine women and six children—and six of them were referred to regional hospitals after being stabilized by MSF teams. At the same time, the hospital’s typical activities—emergency room, hospitalization, mother-and-child health, and nutrition—have slowed daily because nearby fighting has limited patient access to the facility.

Security conditions have worsened considerably. Since early May, several incidents—in particular, stray bullets that have reached the hospital and shells that have fallen close to the facility and the house where MSF staff live—have also posed risks for the medical staff. However, a smaller team, including our expatriate project coordinator, remain at the hospital.

There is no fighting in the Al Tahl region, where Yemeni and international MSF employees working in the hospital remain on site, supported by a surgical team.

MSF has worked in the Saada governate in northern Yemen since September 2007, providing medical care to the population affected by the conflict between government forces and Al Houthi rebels that began in 2004. MSF operates two projects in the Razeh and Al Tahl hospitals and provides medical support, including primary care and hospital referrals, in several outlying towns.

[Voice from the Field] Central African Republic: "Fear is a constant issue"

Thu, 02 Jul 2009 22:00:00 GMT

A woman cooks over a fire in a displaced persons camp in Kabo.

Despite the implementation of the peace process that is to end years of conflict, various armed groups, including the Central African Republic (CAR) military and rebel groups, are still fighting in various regions in the north. In addition, confrontations between several local groups and armed bandits compound insecurity and violence in the area. Gabriel Sánchez Ibarra has just returned from the country after working one year as MSF’s general coordinator for CAR and he shares his views and experience.

Could you tell us briefly why violence has intensified in CAR in the past months despite the peace accord?
Violence has never stopped, it has always been present. Sometimes it is the result of the political conflict between the government and armed groups and sometimes it is different: banditry or intra-community conflicts. For some months, some of the groups or rebel factions that signed ceasefire agreements in 2007 and 2008 have become active again after several disagreements linked to the peace process. This has triggered a renewed escalation of political violence.

What are the humanitarian and medical consequences these attacks have had for the population?
The most relevant consequence of the most recent attacks has been population displacements, a constant feature in CAR for some years now. This time it has affected some specific regions, where people have fled due to fear of fighting and potential reprisals. Some attacks have even taken place far from the fighting, in areas where people had once taken shelter. The displacements have also occurred during periods of vulnerability for the population—the onset of the rainy season, during the annual peak in malaria and the sowing season. These factors have not only made living conditions tougher where displaced people have taken shelter, but also prevented farming from taking place in certain areas, thereby threatening the already poor food security in the region.

What are we doing to address these needs? What are the difficulties we are facing?
Working in conflict areas is always complicated. Making sure that aid reaches those in need without jeopardizing the life of the patients or the teams is an ongoing challenge. These issues are exacerbated in CAR because the people MSF needs to assist during emergencies are located far away, in places where access is difficult and the population lives in fear, in terrible fear.

The needs to be addressed are always the most basic ones because being displaced and in the forest without any infrastructure whatsoever makes you very vulnerable. The displaced themselves and the traditional authorities required that the very few organizations present in the region provide primary healthcare, shelter, kitchen utensils and food. MSF has been able to assist negotiating with the armed groups operating in the area and coordinating actions with other organizations. Independence, access to the displaced, and security conditions need to be negotiated on a day-by-day basis.

What projects is MSF running in CAR?
The MSF project in Kabo has been designed based on two components. A stable one, with a 100-bed hospital and a broad range of services available to the people: an outpatient and inpatient department emergency surgery, programs on various diseases such as HIV and tuberculosis and mother and child health care.

The second component consists of rapidly responding during the emergencies or crises that periodically hit the region by being reactive and trying to provide shelter or health to the people directly affected by violence, epidemics or displacements. During the peaks in violence in the past few months, both our long-term and emergency components were fully operational. Despite violence, the MSF hospitals never closed, services continued and access to heath facilities was guarantees. But some of the population was unable to approach the hospital structure freely due to fear, fighting or displacement. This is why MSF has reached out to them by travelling to the roads and the camp sites and providing them with medical consultations, or distributing survival items.

How has this been done?
The displaced have settled very far from the roads, further inland than usual as they have been attacked even in the forest. This has made assistance and even contacting them difficult. This is why MSF has had to put in practice new types of mobile clinics travelling by bicycle and on foot to venture as much as 12km into the forest.

Are we seeing mental health problems among the population? Any intervention plans?
Obviously after three years of violence, people experience traumas, fear, and behavior problems. Some IDPs have told us that they’ve had to flee as many as three times in a year and a half and are very tired of this ongoing instability. Fear is always present when you talk to them: fear of physical violence and fear of seeing their houses burned down or looted. We have confirmed an increase in stress patterns and other unspecified conditions that could be linked to them: anxiety or insomnia, for instance.

MSF in CAR has a lot of experience in providing care for patients directly affected by violence, such as those injured or traumatized, and in handling health problems faced by displaced people. However, we have to improve the psychosocial component of the support we provide for victims. The service package that MSF offers in violence contexts is comprehensive, and during this month’s violence we also tried to develop the psychosocial component.

MSF is also treating sleeping sickness in CAR. What are the difficulties in treating this disease in a conflict setting? If people are affected by violence and are forced to flee, is it difficult to continue treating in the midst of a volatile context?
There has been a lot of progress in terms of adhering to treatment and nearly all our patients complete it. We have also improved detection of patients through active search in all the neighbourhoods of Batangafo and surrounding areas. The problem, however, is that we increasingly need to venture into traditionally unsafe areas where there are likely very high prevalence rates. We need to take into consideration that northern CAR has one of the highest rates of sleeping sickness in the entire world.

Regarding population displacements, the greatest impact is not on providing treatment but on follow-up and monitoring to help us detect relapses and follow up cure processes. However, in Batangafo this has not been possible yet due to the context.

Have we got problems to gain access to peripheral areas? What are the challenges posed by active case search?
The teams have been able to diagnose over 30,000 people and treat over 1,000 since 2006. Participation is enormous, exceeding 80 percent of the total number of inhabitants. The problem now is to transfer this strategy, which works and which MSF has been able to implement in other places, to other traditionally unsafe areas or where, due to the absence of State infrastructures, the population barely has access to health. The objective now is to grow in terms of diagnosis and treatment capacity without jeopardizing the program and venturing into villages that have been neglected during these past years due to violence.