MSF Activity Report 2007

2007 t MSF Activity Activity MSF Repor

n 2007 over 26,000 doctors, I oday MSF is an international medical oday MSF is an international medical experts, water and sanitation engineers and administrators provided medical aid in over 60 countries. nurses, and other medical professionals, logistical medical professionals, and other nurses, T with national sections humanitarian movement in 19 countries. MSF International Office 21, Switzerland 116, CH-1211 Geneva Case Postale Lausanne, 78 Rue de Tel (+41-22) 8498 400, Fax (+41-22) 8498 404, Email [email protected], www.msf.org Médecins Sans Frontières (MSF) was founded in 1971 by a small group of doctors and journalists access all people should have that who believed non one of the first MSF was relief. to emergency governmental organisations to provide urgently needed medical assistance and to publicly bear witness to the plight of the people it helps. The Médecins Sans Frontières Charter About this Book

Country text and sidebar material written by Médecins Sans Frontières is a private international Wei Baozhu, Siân Bowen, Jean-Marc Jacobs, Anthony Jacopucci, Alois Hug, association. The association is made up mainly of doctors Isabelle Jeanson, Duncan Mclean, Sally McMillan, Anna-Karin Moden, and health sector workers and is also open to all other Alessandra Oglino, Hélène Ponpon, Susan Sandars, Natalia Sheletova, Sheila professions which might help in achieving its aims. All Shettle, Véronique Terrasse, Elena Torta, Caroline Veldhuis, Joanne Wong of its members agree to honour the following principles: Special thanks to Médecins Sans Frontières provides assistance to populations Montserrat Batlló, Daniel Berman, Laure Bonnevie, Karen Day, Tory Godsal, in distress, to victims of natural or man-made disasters and Myriam Henkens, Pierre Humblet, Anara Karabekova, Fernando Pascual, Jordi to victims of armed conflict. They do so irrespective of race, Passola, Barry Sandland, Miriam Schlick, Susan Shepherd, Emmanuel Tronc, religion, creed or political convictions. Caroline Veldhuis, Tido von Schoen-Angerer and all the field, operations and communications staff who reviewed material for this report. Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and Managing Editor Siân Bowen the right to humanitarian assistance and claims full Research & Editorial Support Hélène Ponpon and unhindered freedom in the exercise of its functions. Photo Editor Bruno De Cock, Sofie Stevens Proof Reader Emily Wood Members undertake to respect their professional code of ethics and to maintain complete independence from all French Edition political, economic or religious powers. Coordinator Hélène Ponpon Translation Translate 4 U sàrl As volunteers, members understand the risks and dangers (Aliette Chaput, Emmanuel Pons) of the missions they carry out and make no claim for Editor Hélène Ponpon themselves or their assigns for any form of compensation other than that which the association might be able to Italian Edition afford them. Coordinator Barbara Galmuzzi Translator Selig S.a.S. Editor Barbara Galmuzzi

Spanish Edition Coordinator Javier Sancho Translator Pilar Petit Editor Eulalia Sanabra

Graphic Design Studio Roozen, Amsterdam, The Netherlands Printing Kunstdrukkerij Mercurius, Westzaan, The Netherlands

The country texts in this report provide descriptive overviews of MSF work throughout the world between January and December 2007. Staffing figures represent the total of full-time equivalent positions per country in 2007. Reasons for Intervention classify the initial event(s) triggering an MSF medical-humanitarian response as documented in the 2007 International Typology study. Country summaries are representational and, owing to space considerations, may not be entirely comprehensive.

cover Photo Nurse working with MSF treating baby with severe dehydration in Pieri, in Jonglei State (South Sudan) © Sven Torfinn 1 Contents Médecins Sans Frontières 4 |

2 | MSF missions around the world

| 4 The year in Review Activity Report Dr. Christophe Fournier, President, MSF International Council

7 | Accountability: An MSF perpective Christopher Stokes, Secretary General, MSF International 2007 10 | Overview of MSF operations 7 | 11 | Reasons for intervention Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

13 | Deciding when to leave Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

1 4 | MSF Country Programme closures

1 5 | Photo story | Most under-reported crises of 2007 13

2 5 | Glossary of Diseases MSF Projects around the World

2 7 | Africa

5 7 | Asia and the Caucasus 71 | The Americas 15 | 77 | Europe and the Middle East Sidebars

43 | Prevention of mother-to-child transmission of HIV

47 | Leaving Rwanda 66 | Child malnutrition 27 | 85 | Gaza strip

86 | Audited Facts and Figures

88 | Contact MSF 2 3 MSF Missions around the world Médecins Sans Frontières

PAKISTAN NEPAL 81 | Iran 81 | Switzerland 82 | Iraq 69 | Thailand

BANGLADESH 79 | Italy 70 | Turkmenistan

Malawi Zambia BOLIVIA Zimbabwe

Mozambique

swaziland

Lesotho South Africa 4 5

Médecins Sans Frontières

If we were asked whom we treat the most often, we would Addressing maternal mortality The Year in Review reply: first young children, then young women. Amongst the Maternal mortality represents a quarter of female mortality in displaced, refugees and populations caught up in fighting or the majority of the countries we work in. Half of the deaths are by Dr. Christophe Fournier, President, MSF International Council whose health structures have collapsed, beside the directly linked to the moment of delivery or the subsequent 24 hours. wounded or those affected by specific epidemics, women and Another quarter happen during pregnancy.

children occupy the majority of our consultations. This is the Activity Report

THE YE AR IN R EVIEW reason why we have to put a particular energy into improving This explains why we should put so much of our attention into the way we address some of the main pathologies responsible antenatal care and deliveries. The more direct complications of for the mortality and the morbidity of these two categories delivery for the women (haemorrhage, eclampsia) are difficult to of population. anticipate but if handled in time should not prove fatal. The

medical technology required for treating these complications was 2007 Overcoming childhood dangers standardised half a century ago in developed countries. It is well Once beyond the first days of life, children who die before their known and not difficult to use. Obviously it requires qualified fifth birthday usually succumb to infectious pathologies such as personnel, appropriate drugs and adequate transfusion products, pneumonia, diarrhoea, malaria, measles and AIDS, particularly as but it saves the lives of both mother and child. In 2007, we half of them suffer from malnutrition. The good news is that our carried out over 500,000 antenatal care consultations and almost weapons against the main diseases decimating young children are 100,000 deliveries. Yet, a dramatic impact on maternal mortality increasingly effective and may even, potentially, allow us to is difficult to achieve as the vast majority of pregnant women are prevent a good number of them including: not coming to any health structure for follow up and even less for delivery except when a complication occurs. Among the dif- • Pneumococcus is a class of bacteria responsible for a large ferent post delivery chronic complications, vesico-vaginal fistulas number of lower respiratory infections. A particular vaccine are the most disabling and stigmatising and we are exploring the that covers the prevalent strains in Africa exists and we are possibilities of further developing our surgical care to women starting to use it. affected.

• Rotavirus is responsible for more than a third of diarrhoea Access to family planning is obviously a precondition for all cases in children. We are looking forward to seeing the use of women in being able to determine how many pregnancies they the existing vaccine against this virus being recommended for choose to have. This is one activity that we have to reinforce and Africa and other contexts where we have to intervene. extend systematically to post delivery care, nutrition programmes, HIV activities, so that all women can access these kinds • The measles vaccine has been around for a long time and its of services. systematic use has increased. Unfortunately, the vaccination coverage is often too low, particularly in some regions of The pre-requisites to progress sub-Saharan Africa to prevent repeated epidemics. We have the sense that we should be at a turning point in the medical care we can offer to our patients. Yet, considerable steps • With the new conjugate vaccine for meningitis, we will be and obstacles have to be overcome. This is in particular why we able to durably immunize populations exposed to recurrent continue to fight to ensure that the Doha agreements, allowing epidemics particularly in the Sahel region of Africa. But this the production of generic medicines, are not constantly called vaccine will only be available for use in 2009. into question. In 2007, we were once again the instigators of a petition, this time against the laboratory Novartis for its law suit • We are still waiting for a malaria vaccine, but at least the attacking the Indian Patent Act. We were reassured when the Artemisinin based Combination Therapies give us a highly laboratory lost as this meant we could continue considering India effective therapeutic weapon. as a source of good quality and affordable medicines for our patients. The current system for encouraging research is based on • There is no vaccine for HIV yet either, but an antiretroviral the market and the patent protection. Discussions are underway treatment protocol can considerably reduce the risk of at World Health Organisation level for setting up a system en- mother-to-child transmission when administered correctly, couraging research into essential health needs that have a dis- and we can effectively treat infected children with improved proportionate impact on poor countries. These discussions aim to Once beyond the first days of life, paediatric forms of antiretroviral drugs. set up new mechanisms that will not rely on the sale of medi- children who die before their cines or vaccines for financing research but rather will put funds • Finally, we now have ready-to-use therapeutic foods that upfront for the research stages of well-defined products - like for fifth birthday usually succumb to allow us to treat far more children suffering from acute mal- example through the creation of prize fund to boost the develop- infectious pathologies such as nutrition more effectively and as out-patients in most cases. ment of tuberculosis diagnostics. We also use them at increasingly early stages of malnutrition pneumonia, diarrhoea, malaria, and are measuring their impact on morbidity and mortality of measles and AIDS. children in their first years of life.

Nyakabanda camp in Kisoro, Uganda © Vanessa Vick 6 7 Médecins Sans Frontières

Our daily struggle to gain access held hostage by the fighting. Somalia was one of the major crises If we were asked what represents our major daily challenge, we of 2007 and the situation is only getting worse. would reply access to civilian populations in areas of war or conflict. Despite the Geneva conventions signed by States nearly • We are not present in Iraq, except in the autonomous region 60 years ago, and some superficial posturing we are hardly ever of Kurdistan where we are based in two hospitals capable of

welcomed by warring governments or factions into the field of handling large numbers of wounded from neighbouring towns. Activity Report

THE YE AR IN R EVIEW their own action. This reality can carry a heavy price. Both inter- Yet, transferring these patients remains problematic. We are national and national MSF staff have been kidnapped or killed also trying to open a hospital in Iran to handle serious surgi- during the last year. In Somalia, an MSF nurse and doctor were cal cases that cannot be properly treated in Iraq. Our ortho- kidnapped and held captive for several days in December 2007 paedic and reconstruction surgical programme in Amman

and three of our colleagues were deliberately murdered in continues for those seriously wounded patients we manage to 2007 February 2008. And in Central Africa a logistician was killed in transfer to Jordan and we provide essential supplies to a large June 2007. number of hospitals where we cannot sustain a real presence.

The reality is that we face continuing difficulties intervening in • The ongoing deterioration of the conflict situation in numerous conflict areas in 2007: Afghanistan drastically reduces the access to medical and humanitarian facilities for the civilian population in several • In Darfur, where we have a high presence, we struggle to provinces. Today, most humanitarian actors, apart from the reach some areas, our convoys are attacked and we are looted ICRC, are mainly absent from the unstable areas where the right down to our stocks of medicines. coalition forces and the opposition groups are fighting. MSF left the country in 2004, following the murder of five col- • In Ethiopia, we tried in vain to intervene in Ogaden, where leagues in Badghis province on June 2, and to date there have anti-governmental counter-insurrection operations were dis- been no concrete results from the judicial investigation. placing local populations. This access was consistently re- However, we remain very concerned about the potential medi- fused. cal needs of the most vulnerable. MSF has to consider an operational return to an environment where it will be a great • We increased the presence of our teams in Somalia, particu- challenge to be perceived as a neutral actor to the conflict. larly in and around Mogadishu, where a third of the population has fled the latest wave of violence. Yet, despite our ap- We will persevere because this is the mandate we have given peals, our work is at best not respected and at worst deliberately ourselves but the reality of our working environment means we targeted. The recent murders of our colleagues forced us to will never assume that our action, the perception of it and its withdraw our international teams, which has obviously reduced legitimacy are clearly and universally accepted. our capacity to meet the increasing needs of civilians fleeing or

Accountability: An MSF perspective by Christopher Stokes, Secretary General, MSF International It is access to victims A woman holds her child in a IDP camp in Kabo in the northern Central African Republic. in areas of war or © Spencer Platt/Getty Images conflict that remains The general drive for accountability of humanitarian organi- Since the early 1990s, the ‘humanitarian sector’ has embraced the major challenge. sations is necessary and timely. Aid organisations have to increasingly ambitious efforts to measure humanitarian assist- both ‘give account’ and ‘be answerable’ for the choices they ance. There has been a significant increase in the number of make. However, there are different ways of approaching initiatives trying to ensure degrees of accountability. These ini- accountability and each organisation has to find its own way tiatives started by trying to define common principles of action based on its field of activity, mission and principles. (ie: The Red Cross Red Crescent Code of Conduct). They continued

Displaced flee fighting in Karuba and Mushake as fighting rages in Karuba, Kivu Province, DRC. © Marcus Bleasdale / VII 8 9 Médecins Sans Frontières

to focus on promoting evaluation (ALNAP) and standardising methods for project planning (logical framework) and creating MSF’s approach to accountability common standards (Sphere) and consistent methods for information gathering. is based on several principles.

An important driver was the desire of governmental donor agen- MSF’s approach to accountability is based on several principles. Activity Report cies to better account for their funds, and to bring order to a We consider that we are accountable for what we set out to sector seen as largely unregulated (it effectively remains so). achieve and the means that we use to do this. In that respect, The drive for greater accountability was also shaped by a desire our action is primarily to be assessed in terms of its relevance, bility: An MSF pe rs pective a bility: to exert greater governmental control over aid delivery to ensure meaning the extent to which our interventions reach and corre-

that aid contributed to the greater goal of coherence in terms of spond to the actual needs of the most affected populations in a 2007 humanitarian assistance to countries in need. This integrated crisis, as well as to our scope and competence as a medical hu- Account approach requires that all sectors act in synergy to promote for manitarian organisation. |

y example the peace-building priorities of the donor community in a given country. They consider humanitarianism more as a tech- Our action should also be assessed in terms of its effectiveness,

e ssa nical action rather than as a principles-based political challenge. meaning the extent to which our programmes achieve expected results based on their objectives. Being an aid organisation firmly attached to principles such as impartiality and independence MSF has been cautious in ap- Thirdly, our action should be assessed on its efficiency, meaning proaching the accountability issue as framed in the humanitarian the way in which inputs (human, material and financial resourc- sector. There is a need for appropriate, innovative and adaptable es) are used to achieve intended outputs. Treating a child with cholera in a MSF cholera treatment center in Luanda, Angola. © Paolo Pellegrin/Magnum Photos tools to monitor and evaluate the effectiveness of aid deployed, to avoid the development of bureaucratic mechanisms that will Beyond these three key criteria, the intervention’s broader not improve our standards or relevance. impact, meaning its effects, both direct and indirect, intended and unintended, should also be considered. Saving lives and learning lessons

In 2006, Angola’s worst-ever recorded outbreak of cholera affected 15 of the 18 provinces. The crisis emerged just Being an aid organisation firmly Our approach to accountability aims to be realistic, taking into as MSF was withdrawing from the country after 23 years, a fact that may have restricted the initial reaction and consideration the fact that the often highly volatile and insecure delayed intervention. Despite treating almost 40,000 people, MSF directors requested a full evaluation of the attached to principles such as contexts in which we work offer ‘only bad choices’. impartiality and independence MSF programme to determine MSF’s effectiveness and efficiency and, equally important, document any lessons learned. has been cautious in approaching We seek to recognise the diversity of constituencies, at local, national and international levels, that have a stake in our medi- Although cholera had previously been endemic in Angola, At the same time, the dramatic growth of Luanda’s population the accountability issue as framed cal humanitarian work and aim to address their particular needs there had been no significant outbreaks in 10 years. However, rendered the classic urban strategy, which relies on the in the humanitarian sector. and interests. the many years of civil war had seen massive population move- speedy movement of ambulances to ferry patients to a single ments into towns without any significant expansion or im- treatment centre, unsuitable and ineffective. And MSF’s late Finally, we view our assessments as an ongoing learning process. provements to sanitation systems. reaction meant the usual balance of early prevention and Mistakes will continue to be made and failures will occur, due to curative activities became, by necessity, focused on curative The way we look at accountability in MSF, assessing the results the fact that humanitarian aid is a real-time response to acute Population density, poor sanitation and regular population activities only. of our action in order to improve our operations and the quality needs in exceptional circumstances that require risk-taking, movement combined with catastrophic effect in mid-February. of medical assistance to patients, is our main objective. innovative approaches and difficult judgment calls. Within six days of the first cases being detected in the capital All these lessons to be learned were highlighted in the Luana, an epidemic was declared. The disease quickly spread evaluation report. Yet, despite these oversights and obstacles, For example, as an early protagonist of artesunate combination In conclusion, accountability for MSF could be defined as a proac- along the main transport routes to neighbouring provinces. MSF teams still cared for nearly 80 per cent of all cases treated therapy to alleviate malaria and anti-retroviral therapy for people tive process of deeper “engagement” with those who we define as in the country during the crisis accounting for more than living with AIDS in resource-poor settings, MSF has developed our stakeholders, reporting the reasons for our choices, the re- As MSF was preparing its withdrawal from Angola, there was 40,000 people of which most survived (with a case fatality careful programme monitoring tools to be able to publish the sults of our actions and the limits, challenges and dilemmas an assumption that the outbreak would be handled by the rate of only 2.3%). In addition MSF organised appropriate results of these interventions in order to effect wider change. inherent in our work, based on our responsibilities as a medical Ministry of Health, without investigating its capacity to do so. logistics, coordinated sufficient supplies to be brought into Subsequent advocacy efforts led to some national health priori- and humanitarian organisation in order to change and improve Relying on official data on the epidemic that eventually Angola, and acted when no one else did. MSF also raised ties and protocols being modified after the release of this data, our response. proved anything but reliable meant MSF teams also underesti- awareness of this forgotten epidemic and called on other to the benefit of previously neglected patients. mated the potential scale of the crisis and took longer than agencies to also intervene. Accountability to beneficiaries is still in its infancy and it is the usual to become functional. Even then, continual surveillance MSF has increasingly sought to give a strong scientific base to its hardest to achieve. The example of Angola given here concerns systems were weak and data recording patchy. No intervention can ever be described as ‘perfect’. There will field work; through initiatives such as its epidemiology centre, the effectiveness and impact of MSF’s intervention during the always be a system that might have been more effective, a known as “Epicentre”, which carries out research and training in massive 2006 cholera epidemic. The Angola report is part of a These factors were exacerbated by the failure to appreciate the process that might have been more efficient, a treatment that latest epidemiology practices. This initiative aims to increase the mutual accountability drive whereby critical reviews of interven- changed context of this emergency. Whereas previous cholera might have been more available. No organisation can ever capacity to monitor and evaluate the effectiveness of interventions are conducted and debated within MSF. outbreaks had been restricted to the capital and coastal areas, become truly accountable unless it accepts this reality – tions through mortality and morbidity surveys. the greater freedom of movement and accessible transport because it means there is always room for improvement and systems meant there was a significantly increased risk that it is always worth striving for more. transmission of the disease would spread inland. Médecins Sans Frontières Activity Report 2007 11

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atural disasters atural - health disruption of and destruction such of In an environment care systems, medical, surgical and psychological a collapse of including instability, conflict and of care effects Indirect is needed. suffer- to lead also economy, a ruined and infrastructures general care medical essential from excluded are people a result, As ing. and services, and can be devastated by epidemics sickness. as sleeping diseases such known suchTB, malaria, or lesser as AIDS, in health working teams based on medical are operations MSF range the cover services to medical offering structures/hospitals or as malnutrition a conflict, such to inherent crises medical of wells constructs also MSF needed, When problems. health mental materials. shelter offers and water drinking clean dispenses and N Populations affected by natural disasters require medicalan immediate humanitarian response. They find themselves material homes, their lost suddenly having conditions, desperate in - highly trauma are They relatives. and members family goods, tised, in need of rapid and diverse medical care andAccess support. to the disaster area and the victims is usuallyand demands complex fast identification of multiple needs. precarious particularly affected, having are people poorest The habitats answers: medical support such as surgery, psychological and and psychological as surgery, support such medical answers: addressing actions preventative and programmes, nutritional hospitals in existing provided are These risks. epidemic potential

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n each country where MSF is working, Policy and Advocacy Coordinator, MSF International Coordinator, and Advocacy Policy ronc, I also

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is one or more of four events has taken place. its uses so MSF clear or this simple life is not in reality However, expertise its whether decide to judgment and experience previous Armed conflict Populations affected by armed conflict require comprehensivemedical and humanitarian support. These people areof violence,victims civilian populations that have been affectedharassed anddirectly or indirectly through attacks, displaced may be forcibly and subordinated, weakened, are They rapes and killings. home their within or outside refuge for looking homes, their from countries. Reasons for intervention By Emmanuel T December 2008 Republic. African Central Bandoro, Kaga town of held rebel walks in the A woman Platt/Getty Images © Spencer At its core, the purpose of humanitarian action is to save the potential acute suffering and help restore relieve lives, threatening in life of individuals who find themselves circumstances. a medical humanitarian response, and if required, the obligation to speak out to ensure those in need are armed conflict, endemic/ are assisted. The four events exclusion social violence/healthcare epidemic disease, and natural disasters. in all intervene not does MSF therefore, aid and, in delivering conflicts or respond to all natural or man we value added made potential the of an analysis reflect catastrophes.Our actions can bring, and we question the pertinence of our absencepresence inor any given situation on a regular basis.

640 AL 1,212 9,254 10,829 11,463 29,107 34,768 43,202 22,181 12,791 53,626 33,441 64,980

126,454 429,996 166,481 111,125 340,689 122,231 111,292

TOT 2,498,241 8,447,106 1,201,358

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ighlights Total number of people treated for meningitis meningitis for people treated of number Total (PMTCT) treatment treatment (PMTCT) to an outbreak response measles for people treated of number Total to an outbreak in response anti-retroviral treatment at end 2007. 2007. at end treatment anti-retroviral failure. treatment First-line who women HIV-positive pregnant of Number transmission mother-to-child of prevention received Number eligibleof babies born in 2007 who treatment post-exposure received to tuberculosis admissions new of number Total in 2007 treatment first-line to tuberculosis admissions new of number Total drugs in 2007, second-line treatment consultations individual of number Total group or support counselling of number Total sessions treatment to cholera people admitted of number Total solution rehydration with oral or treated centres in measles for people vaccinated of number Total meningitis for people vaccinated of number Total including obstetric surgery, under general or general under obstetricincluding surgery, anaesthesia spinal 2007 at end care anti-retroviral on first-line patients of number Total 2007 at end treatment on second-line patients of number Total patients admitted of number Total Number severeof malnourished children admitted to inpatient or ambulatory therapeutic centres feeding treated medically number majorof Total surgical interventions number medical of and surgical Total interventions violence to direct in response under registered HIV patients of number Total consultations outpatient of number Total cases treated confirmed of number Total Number moderately malnourishedof children centres feeding to supplementary admitted violence sexual cases of of number Total Total number of women who delivered babies, babies, delivered who women of number Total sections Caesarean including and

ctivity deFINITION S TION Meningitis - Meningitis Treated Vaccinations Treated Measles Vaccinations treatment treatment - mother PMTCT - PMTCT baby TB - TB second-line treatment - Health Mental Individual - Health Mental Group Cholera - Measles - Meningitis ARV first-line treatment ARV second-line Inpatient TFC Surgical - Interventions Violence Trauma HIV Activity (Non-exhaustive A Outpatient Malaria SFC Violence Sexual Deliveries care. Activity may involve diagnostics, treatment and follow up.) follow and treatment diagnostics, may involve Activity care. ased B nterventions RA OPE of MSF view I riggering Intervention

Democratic Republic of Congo Republic of Democratic Chad Somalia Sudan South Niger Sudan North Haiti Kenya Liberia Myanmar

10 vent T Event ontext of Interventions Context roject Locations Project roject Expenditure on Project

O 10 12 13 Médecins Sans Frontières

or through the erection of temporary buildings if needed.

vention Provision of relief items such as blankets, tents and cooking oil may also be distributed. These operations are developed through extensive collaboration with national actors, taking into account the importance of local efforts and strategies, and the limita-

tions of an international intervention with regards to time, Activity Report quality and pertinence.

Populations affected by epidemic or endemic disease r e as on s f o inte | 2007 Such populations arise in variable contexts of stability and y conflict. Emergency capacity and innovative medical actions are imperative to ensure a viable response. e ssa

People who live in precarious regions, remote and/or under-

developed areas, slums of capitals and cities, camps or shanty- Labuta, Delta area, Myanmar, May 2008 © Eyal Warshawski towns, often do not receive strong support from the local and international authorities. They are often minority groups, IDP camp of Kilimani, near Masisi, North Kivu. © Cedric Gerbehaye/Agence VU refugees or nomads. They are at increased risk in situations of economic and social dependency. Women and children are the most worrying categories. Exposed to infectious and communi cable diseases, vulnerable during pregnancy, and traditionally less able to express their pains and concerns, women’s Deciding when to leave realities go unnoticed in many countries. The dependency of infants and children further increases their vulnerability. By Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

MSF works in existing medical structures and also establishes new The decision to close or hand over a medical programme or emergency, such as a meningitis or measles epidemic or natural structures if needed. It responds quickly to outbreaks of disease leave a country for whatever reason is always based on an disaster, ceases to exist. In these cases, relief operations are including cholera, measles and malaria. It targets the most vulner- analysis of whether our presence and operations are still eventually replaced by longer-term development activities by other able to infection. In addition, it raises awareness about the risks required and relevant. actors (which was seen eventually after the Asia tsunami). Teams of an epidemic through training and prevention initiatives. will also move on when marginalised populations, such as prisoners Collaboration with local governments and authorities is a condition Stable or unsafe situations and street children, are no longer excluded from healthcare. for implementing activities and rapidly improving the situation. MSF will leave or close a programme when a previously violent Engaging in advocacy to support medical action, as in the case of situation is sufficiently stable and displaced populations have Of course, the decision to stop, close, handover a programme or HIV/AIDS, is also crucial in identifying responsibilities, under- safely been able to resettle in their native areas. On the other leave comes with no guarantee that MSF will not need to return standing political intentions and mounting effective responses. hand, teams may leave if it becomes necessary to denounce the in future (such as with Sri Lanka when MSF left in 2003 but had Bongor, Chad, October 2007. An MSF volunteer giving advice to villagers how to prevent households from malaria infection by using mosquito nets. © Tim Dirven / Panos diversion of aid away from the most vulnerable civilians (refugee to return in 2006 when the conflict escalated again). There is Social violence and healthcare exclusion camps in Zaire 1995 and DPRK 1998). Equally, a conflict situation no guarantee that a conflict will not resume, that medical and Populations affected by social violence and healthcare exclusion can deteriorate to the point when MSF and other humanitarian humanitarian needs will be correctly addressed or will not again often suffer because of who they are. They could be minority staff are threatened or murdered (Somalia 1997, Iraq and reach a medical crisis-point or that the resources and strategies groups, ethnic groups, migrants, displaced people or refugees. Afghanistan 2004). While infrequent, this does happen and often put in place will not be diverted and misused. They may be street kids or night commuters. They may be sex results in the temporary or permanent withdrawal of our teams workers or simply a patient with HIV/AIDS or TB. for their own safety. However, if an authority or armed/political The decision to bring an end to assistance is, therefore, based on group deliberately obstructs MSF’s access to operations in a our experience, our perception of the situation and our concern Living in environments where their conditions and rights are specific area, MSF may use humanitarian positioning or public that our short-term solution should not wrongly substitute more limited or non existent, they frequently do not receive adequate lobbying to try and reverse the situation. permanent solutions. It is an acknowledgement that our actions support from local authorities and also suffer the limits of and presence are limited and replaceable. MSF does not represent international aid. Capacity and responsibility a long-term response to the public health responsibilities of Leaving will be considered when local or national authorities and a State but contributes to strategic healthcare improvements by MSF becomes directly involved to alleviate such daily suffering local actors have the capacity and motivation to restore and training national teams before leaving. with medical, psychological and social activities. Healthcare develop a medical system able to meet the needs of the popula- exclusion requires projects that bring attention to healthcare tion. If there are other actors, humanitarian or otherwise, provid- While it can appear a significant decision to make, ending access and the absence of medical services. MSF’s identity ing medical support, MSF teams will also assess whether their activities reflects the will and identity of MSF to carry out its includes the act of speaking out, and united with patient care is presence brings a risk of effort being duplicated. specific mandate as an emergency medical-humanitarian actor a commitment to bringing attention to the causes of suffering that exists to help the most vulnerable people at times of and the obstacles to providing effective healthcare, and raising A decrease in acute needs extreme crisis. Every year thousands of migrants are employed as seasonal farmer workers in the fields of Southern Italy. the concerns and the realities of our patients to national and These workers remain “invisibles” despite their support to an entire economical sector. © Lorenzo Maccotta MSF will leave when our presence interferes with local activities international actors. and capacities. MSF will end an intervention when a medical 14 15 Médecins Sans Frontières MSF COUNTRY PROGRAMME CLOSURES Most under-reported Angola Until then, Guayaquil had only one reference close collaboration with local partners, carry- MSF started working in Angola in 1983 in hospital and one health unit. MSF opened an ing out 8,159 medical consultations. response to conflict-related medical additional health and treatment unit in the emergencies. It expanded its activities both hospital, and also started three maternity The clinics offered primary healthcare, mental

crises of 2007 Activity Report geographically and medically as unmet needs units and eight health centres, providing health consultations and referrals. MSF also were identified. Broad support was provided free access to counselling and testing, anti organised community health education, for basic healthcare including medical retroviral treatment (ART), lab follow-up, and psychosocial and mental health training for attention for people with tuberculosis (TB), health education. By December 2007, MSF NGOs, community groups and volunteers from HIV/AIDS and Human African Trypanosomiasis finalised the handover of this project to the refugee and asylum seeker communities. 2007 (sleeping sickness). MSF regularly responded Ministry of Health. Over the course of the to outbreaks of diseases such as meningitis, project, MSF attended to approximately 1,770 After building up the capacity of local partners measles, cholera, haemorrhagic fever, and patients and initiated 530 of them on ART. through training and direct support of clinical other health problems including nutritional services, in April 2007 MSF handed the project crises. In 2007, as the state was continuing to MSF worked in Ecuador from 1996 over to local partners, to continue the medical rehabilitate the healthcare system, MSF com- to 2007. and mental health work. pleted a two-year long handover process of its projects to government, local and Japan The health services provided by NGOs, although international development NGOs. Despite the existence of a welfare system that vitally important, are seen as temporary targets the socially disadvantaged in Japan, measures to alleviate some of the health Displaced fleeing war in MSF worked in Angola from 1983 the system imposes a multitude of restrictions problems faced by refugees and asylum seekers. to 2007. and complex procedures, leaving the majority A more permanent solution needs to be found Somalia face humanitarian crisis of homeless people without access to proper that addresses the underlying causes for the Benin medical care. To tackle this socio-medical lack of access to healthcare. As some of the worst violence in over 16 years escalated in problem, MSF launched a programme in Osaka Somalia, international aid and interest appeared to fade. Ethiopian In Mono-Couffo department, a rural area of in 2004, site of Japan’s largest homeless popu- MSF worked in Malaysia from 2004 troops and Transitional Federal Government forces clashed with Benin with the highest prevalence of HIV, MSF lation, with the objective of providing medical to 2007. armed groups, including remnants of the Islamic Courts Union. established an HIV/AIDS programme including care through a fixed clinic. However, this was Civilians were killed or injured and thousands displaced from the education, counselling, testing and treatment not immediately possible so over the next 14 capital, Mogadishu. in 2002, and started providing anti-retroviral Rwanda months, MSF used mobile clinics to conduct medicines two years later. In total, MSF treated MSF has ended its activities in Rwanda after 16 1,351 medical consultations, offering treat- MSF increased its presence in Mogadishu and opened an emergency 903 HIV-positive patients during the course of years in the country. Over the years, MSF’s work ment to 296 patients for conditions including response programme in Afgooye, 30km outside the capital. Here, an the project. At the end of June 2007, the has included assistance to displaced persons, hypertension, diabetes and joint pain. Despite estimated 200,000 displaced people live in harsh conditions with project was transferred to local health war surgery, programmes for unaccompanied several attempts to establish the fixed clinic, little access to food, water and shelter. Many of those remaining in authorities and partners, who are now children and street children, support to victims this never came to fruition due to opposition Mogadishu are staying in makeshift camps and suffer exposure to providing free anti-retrovirals. traumatised by the conflict, programmes to from the local community and authorities. heavy violence frequently. improve access to healthcare, responding to Since June 2005, MSF had also been providing epidemics such as malaria, cholera and Therefore, after much deliberation, MSF Somalia’s 16-year conflict has resulted in some of the world’s worst medical care to people in a refugee camp of tuberculosis, and projects linked to maternal decided to close the programme in early 2007 health indicators, with an estimated life expectancy of just 47 Togolese at Agamé, in the south of Benin. and reproductive health. and referred patients to other health facilities. years. In 2007 MSF ran projects in 10 of the 11 regions of south At the end of 2006, MSF handed over respon and central Somalia. But security concerns prevented MSF staff sibility for medical activities in this camp of Rwanda has now begun a clear shift towards MSF worked in Japan from 2004 from reaching more patients, particularly in Mogadishu. 8,000 people, to the Benin Red Cross. long-term development plans. The number of to 2007. organisations in the country now covers the In August, MSF called on all parties to respect the safety of MSF worked in Benin from 2002 needs of the population. The AIDS epidemic medical workers and allow them access in and around Mogadishu. to 2007. Malaysia appears contained due to the high level of Throughout MSF hospitals, from Jamaame to Galcayo, the medical MSF started working in Malaysia in 2004 to investment by local authorities and the support services provided range from primary and maternal to surgical care. improve access to medical and mental health of many international actors. As a result, MSF Nurses and doctors treat malnutrition, tuberculosis, kala azar, Thousands of Somalis live in Ecuador services for refugee and asylum seeker commu- felt able to end its presence in the country at cholera and war-related trauma on a daily basis. MSF was the first NGO to treat HIV in Ecuador. nities in and around Kuala Lumpur. These the end of 2007. camps like this one north of In 2004 MSF began an HIV/AIDS project in people often have no official status and face However, in December the security situation worsened with the Mogadishu, suffering from a three health areas of Guayaquil town, which difficulties in accessing healthcare. In 2006, MSF worked in Rwanda from 1991 kidnapping and release of two MSF staff, followed by the killing of had the highest prevalence of HIV in Ecuador. MSF opened three mobile clinics, working in to 2007. lack of water, food, shelter and three MSF staff in January. In response to this MSF temporarily evacuated its international staff from Somalia and relied on na- access to medical treatment. tional staff to run activities.

An MSF physician examines a tuberculosis patient in the Maela refugee camp near Maesot. Activity Report ted c r i s e o f 2007 2007 m o s t unde r - epo | y s hoto e ssa P hoto

Women queue to collect water outside the capital city of Harare. Zimbabweans, particularly in high-density areas, face massive water shortages.

Zimbabweans continue to suffer rampant unemployment, rocketing Through programmes in Bulawayo, Tshlotsho, Gweru, Epworth and Every year, an estimated nine million people develop tuberculosis Even under the best conditions in MSF programmes in Armenia, inflation, food shortages and political instability. According to the Manicaland province, MSF provides free medical care to 35,000 (TB) and two million die. Yet there have been no advances in treat- Abkhazia, Georgia, Cambodia, Kenya, Thailand, Uganda and UN up to a quarter of the country’s 12 million people are believed people living with HIV/AIDS. Of these, 16,000 are receiving ARV ment since the 1960s and the most commonly used diagnostic test, Uzbekistan, only 55 per cent of MDR-TB patients completed the to have fled to neighbouring countries in recent years. treatment, nearly a tenth of all people on treatment. However, sputum smear microscopy, developed in 1882, detects TB in only treatment. The rest of them either died, did not improve or could MSF’s ability to care for more people is restricted by the lack of half of cases. Only $206 million of the estimated $900 million not cope with the side effects. The healthcare system now threatens to collapse, with particularly trained health workers, restrictions on who can prescribe ARV needed annually for TB research and development is invested serious consequences for the estimated 1.8 million people living drugs and increasingly strict administrative requirements for worldwide. A further problem for medical staff on the TB pandemic’s front line with HIV/AIDS. Less than a quarter of those in urgent need of international staff to work in the country. is the fact that not all new drugs are tested on those in greatest life-extending anti-retroviral (ARV) treatment receive it and some Treatments and diagnostics are even less adapted for people living need: patients with MDR-TB. A recent article by international 3,000 die each week. Medical professionals are leaving the country, Zimbabweans also face the health consequences of deteriorating or with HIV/AIDS, the easiest prey for the TB bacilli. For the more experts published in the medical journal PLoS Medicine called the government HIV/AIDS treatment programme is oversubscribed non-existent water and sanitation systems. Outbreaks of diarrhoea than 450,000 people a year who become infected with multi-drug- for new drugs to be tested on patients whose TB is resistant to and the lack of ARV supplies has stifled further expansion. The have affected the populations of Harare and Bulawayo. Nor is it resistant TB (MDR-TB) or develop it following incomplete treat- standard treatment. This could make it easier to detect anti-TB high cost of fuel and transport often make travelling to hospitals easy to flee the country, as the numerous reports of refugees ment, the prospects of survival are even bleaker. The few who activity of new drugs and ultimately accelerate drug development. or clinics difficult. attacked along the South African border testify. Some of those who access treatment have to endure up to 24 months taking a daily do make it live with little or no access to healthcare. cocktail of highly toxic and expensive drugs that often trigger violent side effects. 18 19 Expanded use of ready-to-use food Médecins Sans Frontières to reduce child malnutrition Activity Report ted c r i s e o f 2007 2007 m o s t unde r - epo | y s hoto e ssa P hoto

Child eating highly nutritious ready-to- A wounded woman and child use-food product in receive treatment at MSF’s Niger which is used to surgical programme in treat malnutrition in Vavuniya, a town close to the children under five. front lines of the ongoing conflict between government Acute malnutrition in early childhood is common in large areas of the Horn of Africa, the Sahel and South Asia, known as the and rebel forces. world’s ‘malnutrition hotspots’. Every year, five million children © Henk Braam / HH under the age of five die.

Nutrient-dense ready-to-use foods (RUFs) have recently emerged as an effective response, capable of saving the lives of acutely Civilians increasingly under fire in malnourished children. RUFs are milk and peanut based pastes enriched with all the vitamins and nutrients needed for rapid Sri Lankan conflict recovery. They do not require refrigeration or preparation, so most malnourished children can be treated at home. Yet, only a tiny Caught in the middle of fighting between government forces and This dire situation is compounded by a general climate of hostility fraction of severely malnourished children are getting RUFs. the Liberation Tigers of Tamil Eeelam, civilians in Sri Lanka’s towards, and suspicion of, humanitarian aid organisations. Supplementing their daily diets with ready-to-use supplement eastern and northern regions live in terror. Sri Lanka has been in Humanitarian aid is increasingly restricted and civilians suffer foods can also prevent children from becoming acutely malnour- the grips of this fighting on and off for nearly 25 years but the from lack of access to lifesaving emergency assistance. This comes ished in the first place. Treatment and prevention should form conflict, particularly the toll it has taken on civilians, has at a time when areas near the front line of fighting have lost part of all international food aid programmes targeting young attracted minimal attention. nearly all medical specialists and hospitals no longer have the children in areas of high prevalence. human resources to treat the wounded. Targeted bombings, killings, mine attacks, suicide bombings, In Niger in 2007, MSF launched a pilot programme using a abductions, forced recruitment, extortion, restrictions on move- After having to evacuate temporarily in late 2006, MSF is now modified RUF as a supplement to prevent some 62,000 children ment and arbitrary arrests make day-to-day life in Sri Lanka providing medical, obstetrical and surgical care in Point Pedro, from becoming malnourished during seasonal food shortages. increasingly precarious. Hundreds of thousands of Sri Lankans in Vavuniya, Kilinochchi and Mannar. MSF is therefore urging international donors to support the need of humanitarian assistance have been displaced since the systematic purchase and use of RUFs as a treatment and resumption of major fighting in August 2006. preventative measure worldwide.

An IDP camp in Bulengo, near Goma in North Kivu. Activity Report ted c r i s e o f 2007 2007 m o s t unde r - epo | y s hoto e ssa P hoto

Graciela and her family are a few of the millions of Colombians who have had to flee their homes to escape fighting between government, rebel and paramilitary forces.

More than a year after the first democratic elections in decades, MSF has reinforced its activities but the insecure environment As many as 3.8 million people have been driven from their homes Families flee their homes for urban slums with little more fighting between armed groups has continued in the Democratic makes it difficult to deliver comprehensive humanitarian by violence, according to UNHCR, ranking Colombia third in the than the clothes they wear, only to find equally threatening Republic of Congo (DRC) eastern province of North Kivu. Supported assistance. Large areas are inaccessible and incidences of sexual world for the largest number of internally displaced people. As conditions on arrival. They live in overcrowded shacks where by MONUC, the UN force, the government is in open combat with violence are increasing alarmingly. In North Kivu, MSF cared for the conflict in Colombia enters its sixth decade and armed groups living conditions can lead to respiratory infections and diarrhoeal the forces of rebel leader, Laurent Nkunda. Different groups such more than 3,000 victims of sexual violence in 2007. continue to target civilians, many Colombians do not remember a disease but there is little access to healthcare. Very few have the as the Mai Mai and the Rwandan Hutu rebels of the Democratic time when daily life was not ruled by guns and terror. option of returning safely to their homes. Forces for the Liberation of Rwanda are also involved. In Ituri district, where different armed groups to those in North Kivu are in conflict, 150,000 displaced people are utterly destitute, Armed groups have a stranglehold on roughly half of Colombia’s MSF works in 13 of Colombia’s 32 departments. Teams work in Hundreds of thousands of people have fled their homes, often vulnerable to exploitation and assaults. Through the Bon Marché rural areas. Impassable roads deprive civilians of access to isolated rural areas through mobile and stationary clinics and in forced to hide in the forest, with little access to food or basic hospital in Ituri’s capital, MSF has treated 7,400 rape victims healthcare, children are forcibly conscripted into militias and urban areas where displaced families have gathered. Teams healthcare and under constant threat of attack. They are over the last four years, with more than a third admitted in the suspected armed forces collaborators are murdered. At the same provide medical care ranging from vaccinations to reproductive increasingly vulnerable to easily treatable diseases and conditions last 18 months. time, anyone suspected of working with rebel groups face harsh care and emergency services, as well as offering psychological such as malnutrition, malaria and respiratory infections. reprisals by the armed forces. care to victims of violence. Outbreaks of cholera have also struck. MSF also responded to several disease outbreaks in other provinces, including an epidemic of Ebola hemorrhagic fever in southern West Kasai province. 22 23 Médecins Sans Frontières Activity Report ted c r i s e o f 2007 2007

A father and son wait

m o s t unde r - epo at an MSF clinic. | y s A mother sits with her child in Massabiou, a village that was attacked hoto e ssa P hoto by armed militia in April, causing thousands to flee. Those who have returned are now destitute, struggling to survive without food, water or shelter.

Isolated from the outside world since the military junta came to Health services are particularly poor in the western Rakhine state, Fighting between government forces and rebel groups in Harassment and general insecurity frequently forced MSF to stop power in 1962, the people of Myanmar (formerly Burma) suffer where MSF treated 210,000 people for malaria in 2006 and where northern Central African Republic (CAR) since late 2005 has caused its vital mobile clinics at short notice, sometimes for up to eight repression and neglect. September’s crackdown on monks marching Muslims, known as Rohingyas, are denied citizenship rights by the significant displacement of the population. Villages have been weeks. In June, MSF operations in north-western CAR were subject for democracy attracted international attention but the reality of state and suffer numerous forms of abuse. MSF provides Rohingyas pillaged and burned, forcing people to flee into the forest, severely to a lengthy reduction after MSF aid worker, Elsa Serfass, was killed daily life for ordinary people remained hidden. with basic medical care and HIV/AIDS treatment. restricting their access to healthcare and leaving them prey to by rebel gunfire. roadside bandits. Few humanitarian aid groups work in Myanmar where the humani- The slow response to the HIV/AIDS epidemic has fuelled the spread The violence has also forced nearly 30,000 people into neigh tarian space is limited. Donors are reluctant to fund programmes of the disease. MSF offers comprehensive HIV/AIDS programmes in In 2007, MSF supported health structures and provided primary bouring Cameroon, where they lack shelter, food and medical that could support the regime. Time-consuming administrative Yangon, Rakhine, Kachin and Shan states but these meet only a and secondary healthcare in and around Kabo, Batangafo, Paoua, assistance. In 2007, MSF intervened when alarming rates of procedures can make responding to emergencies impossible and fraction of the need. Only 10,000 of the UN-estimated 360,000 Kaga Bandoro, Markounda and Boguila in the north-west, and Birao childhood malnutrition were discovered among this refugee needs assessments challenging. In some regions, such as those people living with HIV are believed to be receiving life-prolonging and Gordil in the north-east. In the first eight months, more population. Affected children were treated and supplementary food gripped by armed conflict involving Karen and Mon rebels along the anti-retroviral treatment and 8,000 of them receive it from MSF. than 100,000 consultations were carried out. Tens of thousands rations distributed. More than 45,000 CAR refugees also gathered Thai border, government restrictions have thwarted aid efforts. Only Few have access to care for opportunistic infections such as of people, including many children under five, were treated for in southern Chad, where MSF works in a district hospital and 1.4 per cent of the regime’s budget supports healthcare services. tuberculosis. The UN estimates that HIV/AIDS kills 20,000 people malaria and other infectious diseases often associated with poor provides assistance to refugees in camps and local residents. in Myanmar every year. living conditions. 24 25 Glossary of Diseases Médecins Sans Frontières Activity Report 2007

A paediatrician examines Chagas Disease Although most people infected with cholera transmission; and provision of anti-retroviral a child in Hospital No.5 First described by the Brazilian doctor Carlos will have only a mild infection, the illness can treatment for patients in advanced clinical Chagas, this parasitic disease is found almost also be very severe, causing profuse watery stages of the disease. in Grozny. exclusively in Latin America, though increased diarrhoea and vomiting, leading to severe

ted c r i s e o f 2007 global travel has led to cases being reported in dehydration and death without rapid treat- MSF provided care for over 166,000 the US and Europe. This potentially fatal ment. Required treatment is the immediate people living with HIV/AIDS and condition damages the heart, nervous and replacement of fluid and salts with a anti-retroviral therapy for more than digestive systems. rehydration solution administered orally or 112,000 people in 2007. intravenously. The disease is transmitted by blood sucking insects that live in cracks in the walls and MSF has developed cholera treatment kits to Human African roofs of mud and straw housing, common in provide rapid assistance and sets up cholera Trypanosomiasis rural areas and poor urban slums in Latin treatment centres (CTCs) in areas where there

m o s t unde r - epo (Sleeping Sickness) | America. People can be infected but show no are outbreaks. Control and prevention Frequently known as sleeping sickness, this

y s chronic symptoms for years. Debilitating and measures include ensuring an adequate supply parasitic infection is seen in sub-Saharan possibly life threatening chronic symptoms of safe drinking water and implementing strict Africa and is transmitted through the bite of develop in approximately 30% of people hygiene practices. certain types of the tropical tsetse fly. More infected. Chagas can cause irreversible damage than 90 per cent of reported cases of sleeping to the heart, oesophagus and colon, shorten- MSF treated over 43,000 people for sickness are caused by the parasite

hoto e ssa P hoto ing life expectancy by an average of ten years. cholera in 2007. Trypanosoma brucei gambiense (T.b.g). The Heart failure is a common cause of death for parasite attacks the central nervous system, adults with Chagas. causing severe neurological disorders and HIV/AIDS leading to death if untreated. Treatment must occur in early acute stages of The human immunodeficiency virus (HIV) is the infection, and to date, drugs have only transmitted through blood and body fluids During the first stage of the illness, people been effective in the acute and asymptomatic and gradually weakens the immune system - have non-specific symptoms such as fever and stage of the disease in children. Diagnosis is usually over a three to ten year period – weakness. At this stage the disease is difficult complicated, with doctors needing to perform leading to acquired immunodeficiency syn- to diagnose but relatively easy to treat. The two or three blood tests to determine whether drome or AIDS. A number of opportunistic second stage occurs once the parasite invades a patient is infected with the parasite. There infections (OIs) such as candidiasis, pneumo- the central nervous system. The infected are few drugs developed to treat the disease nia, and various kinds of tumours are able to person begins to show neurological or psychi- and the current line of treatment can be flourish as the immune system weakens. Some atric symptoms, such as poor coordination, toxic, taking one to two months to complete. OIs can be treated, whilst others are life-threat- confusion, or convulsions. People may also

© Misha Galustov / agency.photographer.ru Apart from managing symptoms, there has ening. The most common opportunistic infec- have difficulty sleeping during the night but been no effective treatment for chronic Chagas tion leading to death is tuberculosis (TB). are overcome with sleep during the day. in adults. Many people live for years without symptoms and may not know they have been infected Accurate diagnosis of the second stage of the As the Chechen conflict recedes, medical MSF Chagas programmes in Bolivia and with HIV. A simple blood test can confirm illness requires taking a sample of spinal fluid Guatemala focus primarily on education, HIV status. and treatment is painful, requiring daily needs remain preventive measures and screening and treat- injections. The most common drug used to ment for children. MSF is now also attempting Combinations of drugs known as anti-retrovi- treat trypanosomiasis, melarsoprol, was It has been nearly four years since the most intense fighting Basic health services, particularly obstetrical and gynaecological to treat adults through a project in Bolivia. rals help combat the virus and enable people developed in 1949 and has many side effects. A subsided between Russian government and rebel forces in the care, are woefully lacking. Through clinics in and around Grozny, to live longer, healthier lives without rapid derivative of arsenic, it is highly toxic and fails republic of Chechnya. Tens of thousands of those who had fled to MSF and local Chechen doctors see a population with high levels of MSF treated 685 people for Chagas in degradation of their immune systems. It is to cure up to 30 per cent of patients in some the neighbouring republics of Ingushetia and Dagestan have now chronic illness, including lung, kidney and cardiovascular diseases. 2007. simplest and easiest to take these drugs prop- areas of Africa. It also kills up to five per cent returned home. The capital, Grozny, is being rebuilt and the The teams also witness a widespread need for psychosocial care erly when they are combined into single pills of people who receive it. Eflornithine, though republic’s airport has reopened. caused by years of violence and displacement. An MSF survey of (fixed-dose combination or FDC). MSF compre- somewhat difficult to administer because it people living in temporary centres in Ingushetia and Chechnya Cholera hensive HIV/AIDS programmes generally requires an IV and a complicated treatment Yet the situation in the region remains highly volatile. Fighting found that nearly all were suffering from anxiety, insomnia or The Greek word for diarrhoea, cholera is a include education and awareness activities so schedule, is a safer, more recent alternative outside Chechnya has increased and there is still a large military depression. water-borne, acute gastrointestinal infection people understand how to prevent the spread being used by MSF in its projects. presence. Abductions, disappearances, assassinations and bombings caused by the Vibrio cholerae bacterium and of the virus; condom distribution; HIV testing continue. Inside Chechnya, the security situation for civilians is Chechnya’s wars also took their toll on the republic’s tuberculosis spread by contaminated water or food. The along with pre and post-test counselling; MSF admitted over 1,700 patients precarious. Dangers range from being caught in sporadic gunfire to (TB) control system. MSF, therefore, supports TB hospitals, serving infection can spread rapidly and cause sudden treatment and prevention of opportunistic for treatment for Human African getting into a car accident involving heavy military vehicles, an a population of 350,000. Since 2006, MSF staff have also run a large outbreaks. infections; prevention of mother-to-child Trypanosomiasis in 2007. increasingly common cause of trauma. reconstructive surgery programme in Grozny to meet the needs of survivors with crippling injuries. 26 AfricA | Asia and the Caucasus | The Americas | Europe and the Middle East treatment becomeslesseffective. a personlessresistant and to other the Infection andweakenattack immunesystem. the diseases emerging asagrowing asboth threat, Co-infection ofleishmaniasisandHIVis toxic reaction insomepatients. sodium The painful, in Kala 100 percentofcases. this the India, cent kala form, visceral leishmaniasis,isalsoknown as certain Leishmania andtransmitted by bites from caused leishmaniasis isatropical, parasitic disease facilities Caused Malari Leishmaniasis in2007. MSF treated over 4,200 peoplefor Largely (Kala Azar) Leishmaniasi existing diagnostic tests, spleen. fever, weight loss,anaemiaandanenlarged Plasmodium, sive headaches, Symptoms includefever, joints, paininthe communities, slumdwellers andrefugees. seasons, infected mosquitoes, particularly duringrainy and clinical Malaria iscommonly diagnosed on abasisof to death. falciparum, present headaches. Africa

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27 Frontières Sans Médecins 2007 Report Activity 28 29 Burkina Faso Burundi Médecins Sans Frontières such centre in Burundi open seven days a A fr icA

| Reason for Intervention • Endemic/ Reason for Intervention • Endemic/Epidemic disease • Social Violence/ week. After five years of activities, the centre

Epidemic disease • Social Violence/ Healthcare exclusion is well established and well known by women Healthcare exclusion Field Staff 442 in the area. Field Staff 248

As development agencies increase their activities in Burundi, MSF has been In the rural district of Bujumbura, MSF Activity Report 2007 In Burkina Faso high levels of infant able to hand over some of its projects to the Ministry of Health and other supports 12 maternity clinics with the man- malnutrition remains problematic in humanitarian actors. However, the health situation in many parts of the agement of obstetrical emergencies. terms of detection and treatment. A country remains precarious, particularly in the area of women’s health. Ambulances collect emergency cases and more decentralised programme has transfer them to private clinics in Bujumbura now been developed to address this. Handing over Musema, Kayanza Province where MSF has where they receive specialised care. However, R LD S AR OUND THE WO MSF also tackled meningitis through a In 2007, two years after Burundi held its first been working since 2004, four clinics and a the worsening security situation around the large scale inoculation programme, post-war democratic elections and four years hospital were handed over to the Baptist capital since August means that transfers are and continued to treat HIV/AIDS pa- after the end of the long-running civil war, church in May. In Karuzi district, where MSF now only posible during the day as the roads tients. Treatment was also provided to MSF handed over programmes in Kinyinya, had worked since 1995, the European are too dangerous at night. street girls and teenagers, vulnerable Kayanza and Karuzi. Community will start supporting a hospital MSF P R OJECT to disease and abuse. and 12 health centres at the beginning of 2008. MSF is currently building a specialised clinic MSF had been working in Kinyinya hospital, in the Kabezi area. When finished, this will The vast majority of Burkina Faso’s population Ruyigi district, since 2003. As well as providing Addressing the health needs of women provide free quality emergency obstetric care depends heavily on successful harvests for secondary care in the hospital, MSF staff also Women’s health issues are often overlooked. so that women with complicated deliveries survival. In the semi-arid Sahel region, border- provided medical and material support to Sexual violence is extensive and there is a will not have to travel to the capital for ing Mali, one of the most densely populated seven health centres around the district. clear need for quality free care. Medical teams medical care. areas, a poor harvest can quickly lead to ex- However as development agencies increase at MSF’s Seruka centre in Bujumbura cared for treme food shortages. As a result malnutrition their activities in Burundi, MSF has been able 1,430 victims of violence, 63 per cent of whom MSF has worked in Burundi since 1992. is endemic, especially among children under to hand over some of its projects to the were under 19 years and 14 per cent were five years old. Ministry of Health and other actors. In under five. The Seruka centre remains the only

In September 2007, MSF launched a project to decentralised the treatment of malnutrition in the Yako and Titao districts by treating chil- The health situation in dren close to their homes using mobile and local health clinics. Only acutely malnourished © Yasuhiro Kunimori many parts of the country children suffering from complications are hospi- remain precarious, talised, while all other children are screened Malnutrition is endemic, especially among and cared for through outpatient consultations particularly in the area in the local health clinics. By the end of children under five years old. of women’s health. December, 7,000 children under five years had been enrolled in the nutrition programme.

Rapid response to meningitis Decentralising HIV/AIDS care and accompanying the girls to public health In mid-February, a meningitis epidemic broke MSF continued to run an HIV/AIDS project in facilities but since the beginning of the year it out affecting over 25,000 people of which over Pissy, now concentrating on improving has been more directly involved in providing 1,700 died. MSF rapidly intervened to support patients’ adherence to treatment through the medical services. Activities include providing health authorities and treat meningitis pa- decentralisation of care. This is done by treatment for sexually transmitted infections tients. By the end of the emergency, MSF had bringing care closer to the patient through and HIV/AIDS, reproductive and obstetrical treated 1,500 people in the capital, local health centres and increased community care, antenatal care and support for victims of Ouagadougou. support which improves the autonomy of sexual violence and improving their legal patients living with HIV/AIDS. More than protection. Some 1,200 consultations and 29 In March, MSF ran a meningitis vaccination 23,000 medical consultations were conducted. deliveries were carried out. MSF also continues campaign in the Pissy health district, the most Since 2004, MSF has provided anti-retroviral to reduce stigma by raising awareness with the densely populated district of the capital. treatment (ART) to people with HIV/AIDS, with authorities and civil society about the violence Approximately 470,000 people were targeted over 4,000 patients receiving treatment so far. inflicted on these girls. In 2008, MSF will hand for inoculations. The following month, MSF over this project to a local partner called vaccinated the population of four rural dis- Street girls in Ouagadougou Keogoo. tricts: Manga, Po, Zabre in the south and In Ouagadougou, MSF manages a project for Gorom-Gorom in the north. In total, MSF street girls and teenagers aged nine to 20 MSF has worked in Burkina Faso since 1995. vaccinated about 955,000 people. years. Initially, the team was only referring

| Reason for Intervention • Armed provinces of Cameroon, with the populations in wound care that includes using a new range district hospital in Yaoundé, MSF also provides

conflict • Endemic/Epidemic disease of Ayos, Akonolinga and Mbalmayo particu- of dressings which should simplify the care for 800 patients with HIV, 525 of whom Field Staff 123 larly affected. Local rumour attributes the treatment and speed up the recovery process are following ART. ‘mystical’ disease to a curse, leading people to which, in turn, should reduce the chance of

Patients received innovative treatment seek treatment from faith healers, often with infection and complications. Feeding refugees from Central African Activity Report for Buruli, a debilitating disease, the catastrophic results. Advanced Buruli requires Republic cause of which is unknown. Medical surgery and physiotherapy. Treating people with HIV/AIDS By the end of 2007, a three-year-long civil war and psychological care continued with In the Nylon district hospital at Douala, and in neighbouring Central African Republic led HIV/AIDS patients, and assistance was MSF’s Buruli project in Akonolinga provides through community facilities, MSF provides to the exodus of over 200,000 people. More

provided to refugees fleeing civil war medical and surgical care for those living in medical and psychosocial care to some 7,500 than 60,000 took refuge at 59 sites along 2007 R LD S AR OUND THE WO in Central Africa. the district. Since 2002, some 600 patients patients with HIV/AIDS, 3,100 of whom are Cameroon’s eastern border, many without have been cared for, 40 to 50 per cent of them following anti-retroviral treatment (ART). The adequate food. MSF assisted refugees in the Overcoming Buruli aged under 15 years. MSF has also tried to raise Cameroon government now provides free East and Adamaoua provinces, distributing Buruli is an emerging and neglected disease in awareness amongst the population about the treatment as part of a developing national 18 tonnes of supplementary food rations to several western and central African countries. disease and availability of treatment, with the programme, although patients must still pay 4,180 people. MSF also screened children for MSF P R OJECT How people contract Buruli is unknown but it result that patients now seek medical help for HIV testing, follow-up consultations and malnutrition and offered medical and appears to develop in populations living close sooner and receive antibiotic treatment before laboratory tests. MSF has worked to simplify nutritional care in collaboration with to rivers. It causes ulceration of the skin, the disease progresses. MSF also conducts protocols to enable the progressive transfer of Cameroon’s Ministry of Public Health for the © Claude Mahoudeau primarily the arms and legs, and destruction active screening and is focusing on a pro the Nylon project to Cameroon authorities. most urgent cases. of underlying tissue and bone. Untreated, it gressive decentralisation of medical care to Effort is also being put into the education of can lead to permanent disability and limb nurses in district health centres. families and communities to follow the full MSF has worked in Cameroon since 2000. Local rumour attributes the ‘mystical’ disease to amputation. a curse, leading people to seek treatment from faith healers, often with catastrophic results. Central African Republic On June 11 all activities came to an Since late 2005, fighting between the govern- Kabo, Batangafo, Kaga Bandoro, Markounda, abrupt halt after the fatal shooting of ment and various rebel groups in the north- Paoua, Boguila, and in the north-eastern areas Reason for Intervention • Armed conflict 27-year-old MSF volunteer, Elsa east and north-west of the country has caused of Birao and Gordil. More than 270,000 outpa- Field Staff 557 Serfass. Elsa was struck by a bullet massive displacement of the population. Many tient consultations were conducted and more while travelling in a well marked MSF villages have been looted or burned, forcing than 16,000 patients hospitalised. Treating vehicle in the Ngaoundai region. The their inhabitants to flee. Most have sought patients for diseases such as tuberculosis, rebel group known as The Popular refuge in the bush, often a few kilometres HIV/AIDS and sleeping sickness. Mental Army for the Restoration of Democracy away from their destroyed homes. Displaced health services were also provided to was responsible for the shooting. MSF people are mostly scattered in small groups communities living with the ongoing threat condemned the murder. Following rather than gathering in camps, apart from of displacement and violence. discussions with all parties involved recently in Kabo. Some villagers have had to in the ongoing conflict and after a flee several times after continued attacks by The chronic insecurity severely affected the careful evaluation of the humanitarian different armed groups. population’s access to healthcare, preventing space, a portion of activities resumed aid organisations from reaching people and one month later. Despite an increase in international aid in stopping many people from venturing out and 2007, many people who have fled continue to visiting the health facilities. As the second The population of northern Central African live in makeshift shelters exposed to the half of 2007 progressed, the growing presence Republic (CAR) continues to live in an elements and in constant fear of a new attack. of bandits and the lack of clear control in environment of chronic violence where many They have no blankets or mosquito nets, no many areas made it extremely difficult for needs are not being met through humanitar- access to healthcare and clean water, and international organisations to work in such ian assistance. Fighting between government struggle to find food. They are particularly an environment. forces and rebel groups abated slightly in the vulnerable to malaria, respiratory infections second half of 2007, becoming a low-intensity and diarrhoeal diseases. MSF has worked in the Central African Republic conflict with isolated but unpredictable since 1997. Many villages have been clashes. At the same time, there was an MSF focused on providing medical assistance increase in attacks by roadside bandits taking to populations affected by the conflict looted or burned, forcing advantage of the general lawlessness that through a network of mobile clinics, hospitals their inhabitants to flee. prevails in the region. and health centres across the north-west in

© Spencer Platt/Getty Images 32 33 Chad Médecins Sans Frontières Goz Beïda, Adé, Kerfi, Koukou, Arkoum, Am Over 180,000 internally rounding Chadian population. The teams also Decentralised care for malaria A fr icA

| Reason for Intervention • Armed conflict • Endemic/Epidemic disease Timam, Am Dam and Dogdoré. In December, treated the consequences of sexual violence Since 2003, MSF has been developing a displaced Chadians are • Social Violence/Healthcare exclusion MSF had to suspend programme activities in and malnutrition, provided health education programme to treat malaria in the southern Field Staff 1,437 Koukou after several serious security incidents. living in camps. and treated communicable diseases. In Adré district of Bongor, one of the most affected by and Iriba hospitals, MSF surgical teams the disease. To overcome the lack of health

In recent years, eastern Chad has experienced a humanitarian crisis affecting MSF continued to provide complete healthcare provided emergency surgery to refugees, workers, the high resistance to the treatment Activity Report the entire population, including residents, refugees and internally displaced to the resident population in Adré, Guereda, hospital of Abéché and prepared stocks of residents and displaced Chadians. and the difficult access to the area over long people. Over 240,000 refugees from Darfur depend entirely on international Birak, Djiré and Wilikouré, ranging from emergency supplies. periods, MSF introduced a therapeutic strategy aid, and the number of internally displaced people sharply increased in 2007, surgery to prenatal care and vaccination Since June 2005, increased violence in using Artemisinin-based combination therapy affecting in turn the host population of the sites where they gathered. campaigns. Assisting refugees neighbouring Central African Republic has and introduced decentralised care by empow- 2007 E u r ope a nd the Middle Eas t Since 2003, more than 240,000 refugees from prompted tens of thousands of villagers to flee, ering the local population to care for those

R LD S AR OUND THE WO | Violence increasingly affecting the sanitary and health crises, with high malnutri- After a period of calm and a ceasefire agree- Darfur have been living in camps in eastern with some 50,000 seeking refuge in southern affected. In 2007, 110,000 people were treated Chadian population tion rates and outbreaks of bloody diarrhoea ment between the government and four rebel Chad, entirely dependent on international aid. Chad. MSF provided assistance including through this programme. In eastern Chad, increasing violence has led to in the first half of the year. Despite difficult groups in October, fighting broke out again MSF continued to provide medical care, water, sanitation and healthcare in the camps massive population displacement, with over security conditions, MSF managed to scale up in late November, with an intensification including paediatric and maternal care as around Goré until April 2007. MSF continues MSF has worked in Chad since 1981. 180,000 internally displaced Chadians living in its assistance to internally displaced people, of the clashes in the last weeks of the year. well as psychosocial support, to some 90,000 to work in Goré district hospital, supporting MSF P R OJECT camps by the end of the year. These people live providing primary and secondary healthcare, Anticipating an influx of wounded, MSF people living in Iridimi, Touloum, Farchana all wards to provide secondary medical care in critical conditions resulting in emergency drinking water, food and relief items around improved the surgical infrastructure in the and Bredjing refugee camps and to the sur- and surgery to refugees and local residents. s | T he A m e r ic as

uc as u Democratic Republic of Congo

Reason for Intervention • Armed conflict • Endemic/Epidemic disease sexual violence every month. In 2007 MSF In Ituri, MSF responded to a Shigella • Social Violence/Healthcare exclusion • Natural disaster carried out more than 25,000 consultations in emergency in Pimbo in May and to a cholera Field Staff 2,386 the hospital. epidemic in Laudjo in June. A new project for sleeping sickness was opened in May in the Malnutrition, epidemics and surgical emergencies continue in DRC. Since 2003, Angolan authorities have on health zone of Doruma, where this neglected Insecurity persists in many regions, particularly in North and South Kivu, various occasions expelled Congolese migrants disease is endemic. Within three months, MSF where the population is subject to violent attacks and causing continual working in the Angolan province of Lunda had screened about 10,000 people and treated displacement. Many areas are totally isolated and deprived of any functioning Norte. According to UN estimates at least more than 450 patients. A fr icA | s i a nd the Ca health infrastructures, illustrated by catastrophic health indicators. 44,000 people were deported to DRC in 2007. In October MSF teams set up a health centre in In August, the influx of an additional 45,000 Assisting victims of violence reinforced the pharmacy with additional Kamako, Western Kasai province, close to the displaced people to crowded camps with Intense fighting between different armed supplies. In October, 330 surgical operations Angolan border. Between November 2007 and limited sanitation just outside Goma led to a groups in the Kivu region has caused thou- were performed, compared to a monthly January 2008, the centre provided medical and cholera epidemic. In September, MSF opened a sands of people to flee their homes since average of 220 since January. psychological care to Congolese migrants, cholera treatment centre (CTC) in a central August. Some sought safety in camps for many of whom were women who had been location between four of the largest camps. displaced people in the regional capital, Repeated displacement, lack of transport and subjected to sexual abuse by Angolan forces. Teams also supported a smaller CTC in Goma

Goma. MSF strengthened existing projects and ongoing insecurity mean that mobile clinics MSF treated about 200 victims of sexual vio- hospital, and CTCs in four health clinics: two © Vanessa Vick opened new projects to try and meet the huge are an essential part of MSF’s work. When lence and offered primary health care to more in Goma itself and two in the neighbouring needs but in many places the fighting and security permits, mobile teams visit numerous than 900 women and children in the Kamako towns of Saké and Kiroche. By the end of Repeated displacement, lack of transport and insecurity forced the evacuation of staff and sites in Masisi and Rutshuru districts. In centre and through mobile clinics. The teams November, over 1,500 people had been treated, the temporary suspension of work. December, MSF carried out 3,299 consultations also collected one 100 testimonies exposing with only six deaths reported. In the last two ongoing insecurity mean that mobile clinics are In North Kivu, MSF opened a new project in in Kitchanga, Kilolirwe, and Mweso health collective rape and physical abuse perpetrated months of 2007, MSF responded to another an essential part of MSF’s work. Masisi, about 80 kilometres west of Goma, at zones. by the Angolan military. outbreak of cholera in Rutshuru district, the end of August. In response to ongoing treating 1,600 people. violence and displacement, a team started Responding to the needs of victims of sexual Responding to disease outbreaks with the Ebola patients as well as searching provinces and treatment for sexually trans working in the hospital and a health centre in violence has long been a key component of The retreat of humanitarian agencies has left On 10 September, an outbreak of the deadly for active cases. mitted infections in Kisangani. In some areas Masisi town, focusing on emergency surgery MSF’s work. Between January and September, large areas of the country abandoned. Many haemorrhagic fever Ebola was declared in of Katanga, South Kivu and Dungu in Oriental and nutritional care. The hospital’s capacity MSF staff treated around 3,000 victims of areas are isolated and the capacity of the new Kampungu, Western Kasai province. Within Ongoing projects province, the situation has stabilised to such was increased from 72 to 170 beds. In October, sexual violence in North and South Kivu. Yet it government is often extremely limited. What days, an emergency team had arrived and was As well as reinforcing and expanding medical an extent that MSF has been able to hand over admissions to Rutshuru hospital, where MSF is not only in active conflict zones where this few health structures exist either do not isolating and supporting infected people. Over activities in the Kivu region, long-running activities to the Ministry of Health and other has worked since 2005, increased by 50 per medical care is so urgently needed. In Bunia, function fully or are not accessible to the two months, MSF teams admitted 46 people projects continue to provide HIV/AIDS care partner organisations. cent. The MSF team added tents to increase where MSF supports the Bon Marché hospital, majority of the population living below the suspected of having the disease. Medical staff in Kinshasa and South Kivu, primary and inpatient capacity, employed more staff and teams continue to see around 150 victims of poverty line. tried to trace anyone who had been in contact secondary healthcare in Katanga and Maniema MSF has worked in DRC since 1987. 34 35 ETHIOPIA GUINEA Médecins Sans Frontières HIV prevalence of between 15 and 20 per A fr icA

| Reason for Intervention • Armed conflict • Endemic/Epidemic disease cent, MSF started providing anti-retroviral Reason for Intervention • Armed

• Social Violence/Healthcare exclusion • Natural disaster treatment in Abdurafi health centre in April. conflict • Endemic/Epidemic disease Field Staff 729 During the course of the year, around 120 Field Staff 272 patients were started on treatment. MSF staff

Conflict escalated in the Somali region of Ethiopia in 2007. As the violence also travel by tractor to 12 sites in the region Rising commodity prices, falling living Activity Report intensified, MSF exploratory missions in the five conflict-affected zones of to run mobile clinics. standards and pervasive corruption in Somali region revealed an alarming humanitarian crisis in which civilians were Guinea triggered strikes and social subject to violence and displacement, their livelihoods threatened and access to MSF implemented a primary healthcare unrest at the beginning of 2007, healthcare severely limited. However, MSF was repeatedly blocked from access- project in Libo Kemkem, Amhara region, leaving an estimated 180 people dead

ing these areas following a team evacuation resulting from a security incident providing quality treatment to some 364 kala and more than 1,000 injured. MSF 2007 R LD S AR OUND THE WO in July. In September, MSF spoke out about the humanitarian situation and the azar patients, treating patients with malaria provided care to the wounded during government’s refusal to allow staff to return to the region. By the end of the and TB in health facilities and supporting a the violent turmoil and continued to year, MSF had still not gained adequate and independent access. therapeutic feeding centre for people suffering treat HIV/AIDS patients in its projects from malnutrition. while also responding to cholera outbreaks during the rainy season. MSF P R OJECT Emergency response Throughout 2007, MSF teams have responded Caring for the wounded to emergencies in Ethiopia. In June, an emer- Violence unfolded in the capital, Conakry, and gency programme was set up at resettlement in cities like Guéckédou at the Liberian border sites in Awi zone and in Quara district, in February as a consequence of the country’s Amhara region, to deal with an outbreak of worsening economic and political crisis. MSF MSF has supported measles and prepare for the malaria season. provided emergency medical assistance to Almost 6,000 children were vaccinated against Conakry’s Matam health centre and to care for people affected measles in Awi zone and 5,000 in Quara Guéckédou hospital, transferring the most with malaria in Dabola district. MSF also provided nutritional screen- serious cases to Donka hospital in Conakry. ing and support in affected areas through MSF treated more than 150 injured people province. mobile clinics. After the summer, MSF re- during this two-month emergency operation. sponded to a major cholera outbreak in Tigray With material and technical support from and Amhara region, treating over 1,700 people. MSF, Donka hospital also cared for a further In October, teams in Gambella region distri 800 wounded people.

© Jean-Pierre Amigo buted non-food items, such as jerry cans or © Claude Mahoudeau cooking sets, to around 41,000 people affected Treating TB, malaria and HIV/AIDS Almost 500 people infected with kala azar were by floods. In mid-November, MSF reacted to Economic stagnation combined with the a nutritional crisis in Afar region by shortcomings of the cost-recovery healthcare Since 2005, MSF has supported care for people Conakry, which accounted for half of all cases. cured in Humera hospital. establishing a therapeutic feeding centre and system has impeded the population’s access to affected with malaria in Dabola province and More than 8,000 cases and about 300 deaths organising mobile teams to visit the worst healthcare. MSF continued to address HIV/ lobbied for the use of Artemisinin-based com- were registered. By November, MSF had opened affected areas. During the intervention, 116 AIDS, malaria and tuberculosis (TB). Around bination therapy (ACT), a more efficient two additional cholera centres in the areas of Delivering essential healthcare respiratory and urinary tract infections and severely malnourished children received care. 32,000 outpatient consultations were treatment to fight the disease. MSF has pro- Ratoma and Matoto, in Conakry. MSF treated Despite the disruptions, MSF’s Ethiopian staff diarrhoea. Support to a Ministry of Health MSF staff continue to treat people infected conducted for patients with HIV and TB, with vided ACT and diagnostics tests to outpatient about 4,000 patients during this operation. in Cherrati continued working with the centre in Wardher resumed at the end of the with kala azar in Humera hospital and support about 700 diagnosed with TB and treated in services and nine health centres in the region. Ministry of Health to provide primary health- year. MSF also conducted an assessment in 10 outreach sites around the region where Conakry and Guéckédou, including many who Although the government agreed in 2005 to Project handovers care and tuberculosis (TB) care in Cherrati’s Degahbur and will start activities in 2008. rapid testing is undertaken. Almost 500 people were co-infected with HIV/AIDS. modify the national malaria treatment proto- In August, MSF ended its project in the region health centre. Construction of a special ‘TB infected with kala azar were cured. col to include the use of ACT, this life-saving of N’Zérékoré (in Guinée forestière), after the village’ was completed during the year, provid- Assistance to vulnerable populations in Existing actors and their capacities have been treatment was still not available to a majority official closure of the Lainé refugee camp ing a number of huts where patients can stay Gambella region was not affected by the Closing and handing over insufficient to meet the needs of HIV-infected of Guineans by the end of 2007, mainly due to following the departure of most refugees. MSF during their eight-month treatment. As well as conflict in Somali region. Working in a health In other parts of the country, MSF was able to patients. MSF has, therefore, run two HIV/AIDS the cost. This may, however, be resolved in the had provided assistance in the camp for five medical care, patients receive food from MSF, centre in Itang and mobile clinics in five areas, hand over its projects to the Ministry of Health. programmes in Guéckédou and Conakry since near future as The Global Fund finally decided years to people fleeing Liberia and Ivory Coast, which appears to increase the likelihood of MSF staff provided integrated HIV and TB care, In January, a primary healthcare project in 2003 and offered anti-retroviral treatment in October to grant funds to Guinea for ACT. offering basic, inpatient, outpatient and them completing treatment. A total of 430 inpatient care and primary healthcare. Fogera was handed over to the national health (ART) since 2004. In 2007, MSF scaled up its MSF is planning to leave Dabola in 2008; in the maternal care as well as treatment for women patients were treated in the TB village. Support to a health centre in Abdurafi, authorities. As the national TB programme was activities and initiated the decentralisation of meantime, MSF will document the use of with HIV/AIDS and victims of violence. On Amhara region, continued throughout the being implemented in Galaha, Afar region, MSF care for HIV/AIDS patients from Matam centre ®Arthemeter to treat severe cases of malaria. departure, MSF gave the hospitals of Lola and When MSF was able to return to Somali region year, focusing on treating and caring for closed its TB project in this area in February. In to several other health centres in order to N’Zérékoré a one-year supply of anti-retroviral in December, teams started supporting a people suffering from kala azar, otherwise May, MSF transferred the HIV/AIDS component bring free healthcare closer to the patients. Responding to cholera outbreaks drugs for HIV positive patients who had Ministry of Health centre and mobile clinics in known as visceral Leishmaniasis. Almost 400 of its programme in Humera, Tigray region, to MSF followed the treatment of 3,900 people Cholera is endemic in Guinea, where poor started their treatment with MSF. Fiiq zone. By the end of the year, MSF teams people were cured. Given the high number of the Ministry of Health. with HIV/AIDS and provided ART to some 2,400 hygiene and sanitation provide a breading were seeing up to 50 patients a day, mainly for migrant workers in the area and an estimated patients, more than 50 per cent of all patients ground for epidemics. The cholera epidemic MSF has worked in Guinea since 1984. MSF has worked in Ethiopia since 1984. under ART in Guinea. was particularly extreme, especially in 36 37 IVORY COAST Médecins Sans Frontières Confiance, where MSF treated several people Until October, MSF supported a local hospital health capacities, MSF handed over its project A fr icA

| Reason for Intervention • Armed with gunshot wounds. This led MSF to in Bin Houyé as well as the district hospital in to the Ministry of Health in April 2007. In the

conflict denounce publicly the repeated attacks, Zouan Hounien, in the south of the Zone de first four months of 2007, 1,243 patients were Field Staff 1,098 robberies, assassinations and rapes Confiance. These projects have now been hospitalised and 6,360 consultations conducted. perpetrated against civilians living in the area handed over to district health authorities. In June, MSF closed its project in the referral

2007 was a turning point for Ivory and to release a collection of testimonies. In MSF also managed mobile clinics and a mobile hospital of Man in the west, where it had Activity Report Coast. After four years of civil war and June, MSF upgraded the Bangolo health centre nutrition programme in Danané and Zouan provided free primary and secondary health- political deadlock, a peace agreement to the level of district hospital. Here, MSF Hounien districts. By the end of 2007, three care since 2003, including anti-retroviral was signed in March, leading to a proc- offers free quality secondary healthcare, mobile clinics and 13 ambulatory nutrition treatment for HIV/AIDS patients and surgery ess of reunification between the gov- including inpatient and emergency services, sites remained. MSF will continue to monitor for the wounded and women with obstetric © Thierry Dricot ernment-controlled south and the in the absence of adequate national health malnutrition in the district until the planned fistulas. Between January and June, MSF car- 2007 R LD S AR OUND THE WO north of the country, previously held support. MSF also runs a primary health withdrawal from Danané in 2008. ried out more than 1,200 surgical interventions by rebel forces. After a national union MSF also runs a primary health centre and mobile centre and mobile clinics, providing basic and 28,000 outpatient consultations. government was formed, the ‘Zone de clinics, providing basic healthcare and treatment healthcare and treatment for malnutrition Project handovers Confiance’, a buffer zone separating in the district. About 85,000 outpatient As public health structures started to function In September, MSF ended its activities in the warring parties, was dismantled in for malnutrition in the district. consultations were conducted during the year. again, the Minister of Health expressed a Guiglo in the west where it offered medical MSF P R OJECT April. Previously monitored by United willingness to take over healthcare. Where care in a primary health centre and treated Nations peacekeepers and French MSF continued to manage services at Danané possible, MSF began to transfer projects to the severely acute malnourished children under military forces, the zone is now se- Improving access to healthcare in system. While continuing to support people hospital in the west of the country at the authorities. This process will continue in 2008. the age of five. Until September, about 26,800 cured by ‘Brigades Mixtes’, a police former rebel areas living in former rebel-held areas, MSF has Liberian border. These included providing outpatients consultations were carried out force integrating both sides. Despite political change, access to health called for a reorientation of the government’s secondary healthcare in inpatient services, During an emergency in 2002, MSF had and 611 children under five were included in Administrative and health civil serv- services continues to be limited for most health policy and free healthcare. integrated care for tuberculosis and HIV/AIDS, launched a project offering free healthcare in the nutritional programme. ants have now redeployed to the north people in Ivory Coast who cannot afford Insecurity remained high until April in the treatment for malnutrition and paediatric and the hospital of Bouaké, a major city in the and west, enabling MSF to hand over healthcare under the current cost-recovery district of Bangolo, in the former Zone de obstetric care. country. Following improvements in regional MSF has worked in Ivory Coast since 1990. some projects to the authorities.

KENYA delivering humanitarian medical assistance Kenyans. MSF’s first HIV/AIDS project opened in Growing resistance to first-line TB treatment is Reason for Intervention • Armed to this population in the Mount Elgon district. 1996. By the end of 2007, MSF was caring for another challenge and MSF has been treating conflict • Endemic/Epidemic disease MSF is mainly dealing with the health over 17,000 people living with HIV/AIDS and people with multi-drug resistant MDR-TB since • Social Violence/Healthcare exclusion consequences of violence against civilians and providing anti-retroviral treatment (ART) to May 2006. In addition social issues, including • Natural disaster repeated short-term displacement. Through a 10,500. housing and food availability, are assessed Field Staff 463 system of mobile clinics and support to primary because these are often the main reasons why healthcare structures in the area, MSF teams Tackling tuberculosis people fail to complete treatment. MSF re- Escalating violence has left many provide access to free quality medical care. Treating HIV/AIDS without also addressing mains the only provider of free treatment for people unable to access healthcare in tuberculosis (TB) is ineffective. TB is the MDR-TB in Kenya. the Mount Elgon region. MSF has In Molo district, fighting, violence and intimi- leading killer of people living with HIV/AIDS. responded by using mobile clinics to dation displaced around 17,000 people by Globally, around 11 million people are thought Treating neglected diseases reach those in need. Throughout the December. Many were living in small camps to be ‘co-infected’ and half of all deaths of MSF works in West Pokot district, Rift Valley © Brendan Bannon country HIV/AIDS and TB infection scattered around the district, so MSF started HIV-positive people are due to TB. Throughout Region, treating people infected with kala rates continued to rise. MSF is treating mobile clinics to assess needs and provide 2007, MSF expanded its efforts to treat people azar, otherwise known as visceral many co-infected patients using new medical consultations and water sanitation infected with TB in Kenya. By the end of the Leishmaniasis. This disease, spread by the MSF is dealing with the health consequences of technologies and facilities. Meanwhile services at different sites every week. year, 1,445 people had been started on treat- sandfly, is fatal if left untreated and affects violence against civilians and repeated short-term MSF continues to campaign for access ment in various projects around the country. around two million people globally every year. to drugs to treat the neglected disease, Ongoing HIV/AIDS care In 2007, MSF teams screened over 1,678 people displacement. kala azar. Despite some positive progress in recent years, Diagnosing TB in patients who are HIV positive for the disease and successfully treated 850. HIV/AIDS continues to have a devastating can be challenging as the sputum samples Responding to ongoing displacement impact on every sector of Kenyan society. produced often do not show the presence of TB Until mid-2006, the only drug available in continues to advocate for the inclusion of SSG test that is ideal for resource-poor settings and Since August 2006, ongoing violence and While around 5.9 per cent of adults are when analysed in standard laboratory tests. Kenya to treat kala azar was a patented drug into the Kenyan Ministry of Health guidelines is encouraging the use of these tests in health disputes over land in the Mount Elgon area of thought to be infected, this can be as high as After months of building and preparation called Pentostan. MSF has lobbied the Kenyan for treating kala azar. Whereas Pentostan costs centres around the district. western Kenya have caused thousands of 35 per cent in some rural areas where MSF work, MSF opened a TB culture laboratory in Government for the use of a cheaper generic 150 USD per treatment course, SSG costs 30 people to flee their homes and seek refuge in works, such as Homa Bay. Working in two of Homa Bay hospital in November. One of only drug called Sodium Stibogluconate (SSG). In USD, so it will be much more easily absorbed MSF has worked in Kenya since 1987. larger towns, higher parts of Mount Elgon, the Nairobi’s slums, Kibera and Mathare, and two five in the country, this laboratory will enable 2007, SSG was registered in Kenya, although into the Kenyan health system. As kala azar forest or nearby villages. These people are locations in the west of the country, Busia and much more effective and accurate diagnosis of manufacturing problems indicate that it will can be difficult to diagnose, MSF is also often trapped between fighting groups and Homa Bay, MSF provides comprehensive HIV/ TB, particularly in patients who are co-infected not be available for supply any time soon. MSF advocating for the use of a rapid diagnostic receive little assistance. In April, MSF began AIDS treatment and care to thousands of with HIV. 38 39 LESOTHO LIBERIA Médecins Sans Frontières importance of seeking treatment within 72 health facilities in Nimba county and with- A fr icA

| Reason for Intervention Reason for Intervention • Armed hours of an attack is increasing, particularly drew from Lofa county. Most were handed over

• Endemic/Epidemic disease conflict • Endemic/Epidemic disease among police and community organisations, to the Liberian health authorities or to other Field Staff 24 • Social Violence/Healthcare exclusion and more patients now seek care earlier. non-governmental organisations. MSF has also Field Staff 1,023 However, despite positive changes to tackle the closed the medical facility at Mamba Point.

issue, MSF is still one of the very few organisa- Activity Report Improving the health of mothers tions providing medical care to survivors of Prior to an international donor conference in and children is the main focus of sexual violence in Monrovia. Washington D.C. in February , MSF released a MSF’s work in Liberia. Although the report stressing the need to find alternatives to situation has improved in recent years, Reducing activities humanitarian assistance and to build capacity 2007 E u r ope a nd the Middle Eas t As Liberia moves towards stability and recon- in the Liberian health services to address the

many Liberians still live in crushing R LD S AR OUND THE WO | poverty. Women and children remain struction, humanitarian organisations in country’s healthcare needs. The paper was used particularly vulnerable and in need of cluding MSF, which work mainly in emergency to brief major donors and States. MSF services a specialised health services. situations, are beginning to leave the country. MSF gradually stopped working in some of the MSF has worked in Liberia since 1990. population of 220,000 Protecting mothers and their children MSF P R OJECT including an estimated Each month, more than 1,300 children are treated at Island and Benson hospitals in the

s | T he A m e r ic as 35,000 people living capital, Monrovia. Benson hospital also with HIV/AIDS. provides maternity care and obstetric surgery, as well as running a women’s health centre.

uc as u Two MSF-supported primary health clinics also handle 13,000 consultations a month. The majority of the patients are pregnant women, new mothers and children. To prevent expect- © Alessandra Vilas Boas ant mothers with HIV transmitting the virus to their child, pregnant women attending MSF Lesotho, also known as the Mountain Kingdom, is a small landlocked country Lesotho and hopes for long-term continuity of clinics are offered free HIV testing and those surrounded by South Africa. Of its 1.8 million inhabitants, an estimated 23,000, services all the more daunting. There are fewer testing positive are enrolled in treatment. more than 1% of the entire population, die each year of HIV-related causes. By than 100 doctors in the entire country, most far the leading cause of death among HIV-positive people is tuberculosis (TB). from other African countries, who are working In April, MSF began offering HIV testing at More than 90 per cent of TB patients in areas where MSF works are also infected in Lesotho while awaiting their certification to Island hospital for children showing symptoms

A fr icA | s i a nd the Ca with HIV. work in South Africa, where they can get associated with the virus. Fifty-four children higher-paying jobs, so their stay in Lesotho is who have tested positive are receiving anti- Over two years, more than 2,200 people have for the baby was available. TB and HIV services usually only temporary. Additionally, in June, retroviral treatment (ART). A new outpatient started anti-retroviral treatment (ART) in were integrated so that HIV-positive patients at a time when the HIV-related workload was section has been added to the hospital for HIV MSF-supported structures. The programme is are systematically screened for TB and TB increasing sharply, over half the professional and tuberculosis patients who get treatment based at Scott hospital in Morija, 40 kilome- patients are routinely offered an HIV test. nursing posts in the 14 clinics supported by and medication but are able to live at home. tres south of the capital, Maseru, and supports Co-infected patients can therefore benefit from MSF and 30 per cent of professional nursing 14 primary care clinics in remote rural areas. a ‘one-stop service’. Efforts were also made to posts at the district hospital were vacant. In Saclapea in Nimba County, MSF has built a The health facilities supported by MSF serve a improve diagnosis of TB, including smear- comprehensive 42-bed health centre, replacing population of 220,000, including an estimated negative and drug-resistant TB. In May, the team in Lesotho, together with the original tent structure with permanent 35,000 people living with HIV/AIDS. other projects in the Southern African region buildings. The hospital provides outpatient and The programme achieved these results within made the decision to launch a report on the inpatient services and has a clinic dedicated to In addition to providing ART, MSF works with a short timeframe by training more nurses; healthcare worker crisis. This was reinforced women’s health. The centre was completed in hospital management and staff to give compre- ensuring weekly visits to each clinic by MSF by advocacy at national and international late 2007. MSF also offers ART for HIV patients hensive care, including HIV counselling and mobile medical teams; recruiting and training levels for measures to improve retention and at the health centre. testing, prevention of mother-to-child trans- ‘HIV/TB lay counsellors’ (mostly members of recruitment of professional health staff and mission, early diagnosis of HIV in infants and the community living with HIV/AIDS enrolled ensure ‘task-shifting’ of certain clinical tasks Providing recovery from, and raising management of opportunistic infections and on the programme) to take on multiple tasks, from doctors to nurses and non-clinical tasks awareness of, sexual violence co-infections, particularly TB. including adherence support; strengthening from nurses to lay health workers. Without Since 2003, MSF has provided medical care for © Sofie Stevens laboratory and pharmacy capacity at the fundamental change, the prospects for ex- survivors of sexual violence in Monrovia and By the end of 2007, over 21,000 people had district hospital; and promoting treatment panding access to ART and improving quality carried out activities to raise awareness of this been tested for HIV (34 per cent HIV-positive), literacy, openness about HIV and community of care in the long-term are bleak. Pregnant women attending MSF clinics are serious problem. Each month, MSF teams in vertical transmission from mother to child involvement in service delivery. Monrovia treat approximately 140 survivors of offered free HIV testing and those testing was reduced to six per cent when both the MSF has worked in Lesotho since 2006. sexual violence, more than a third of whom mother and the baby received an intervention An acute shortage of healthcare workers positive are enrolled in treatment. are under 12 years old. Awareness of the and for whom an early test (DNA-PCR) result threatens further scale-up of activities in 40 41 MALAWI MALI MOROCCO Médecins Sans Frontières Activity Report 2007 for nurses, who are now able to prescribe ART, A fr icA

| Reason for Intervention • Endemic/ a responsibility previously performed only by Reason for Intervention • Social

Epidemic disease clinical officers, medical assistants and doc- Reason for Intervention Violence/Healthcare exclusion Field Staff 652 tors. The decentralisation of HIV services • Endemic/Epidemic disease Field Staff 13 together with the task shifting and intense Field Staff 54 HIV/AIDS is one of the most acute training for care providers has allowed better Recent and increased barriers health concerns in Malawi. In this follow up through smaller, more local health preventing the transit of migrants to country of 13 million people, about structures and home visits. Now patients do Spain means Morocco has become a one million are infected and 86,000 not have to travel long distances to hospitals destination country. Longer-than- die each year. Despite intensive efforts for routine consultations and medication. intended stays in the country have E u r ope a nd the Middle Eas t

by the authorities and international resulted in the recent urbanisation of R LD S AR OUND THE WO | bodies, more than 170,000 people This decentralised approach has allowed MSF migrant populations, notably in Rabat living with HIV in Malawi are still teams in Chiradzulu, Thyolo and Dowa to start and Casablanca. Although living in urgent need of anti-retroviral more than 27,000 people on treatment. conditions are less precarious than in treatment (ART). rural areas, the population faces a MSF also strongly focuses on detecting and higher cost of living with reduced MSF P R OJECT MSF is supporting the implementation of a treating tuberculosis (TB) and malnutrition in means of subsistence and limited access national HIV/AIDS plan. MSF is also closely HIV patients. Both conditions jeopardise the to healthcare. Migrants are exposed to

s | T he A m e r ic as involved in increasing the number and efficiency of HIV treatment. Over 1,700 people, increased exploitation and violence. capacity of health centres to provide life-long many of whom were HIV positive, were Prostitution is common and infectious care for HIV patients in the southern rural admitted for TB treatment. diseases such as tuberculosis (TB) and

uc as u These mobile ‘malaria districts of Thyolo and Chiradzulu and in the HIV/AIDS are emerging. teams’ mean children in isolated villages can Migratory routes have also shifted, with many By December, approximately 19,000 people people now originating from southern countries now receive free treat- such as Mauritania, Senegal and, to a lesser were still on treatment in MSF-supported ment during the rainy extent, regions of the Sahara. Many arrive only structures across Malawi and more than 700 to realise that there is little hope of crossing to season. Spain so unexpectedly stay in Morocco. people were starting treatment in an MSF structure every month. MSF continued to work on preventive and © Bruno De Cock curative healthcare for migrants. Healthcare A fr icA | s i a nd the Ca projects have followed the migrants from rural to urban areas, responding to their increasing central district of Dowa. In order to cope with After more than seven years of working in Malaria is endemic in Mali, where it malaria by offering quality diagnostics and Distance between villages and health centres needs. A new project opened in October to ad- an acute lack of doctors and other health Dowa district hospital in central Malawi, MSF is the main cause of mortality for care using Artemisinin-based combination has been identified as a main obstacle to dress the medical and humanitarian needs of professionals, the strategy has been to shift has handed over its HIV/AIDS project to the children under five. Access to health- therapy (ACT), reducing the cost of treatment access to care, particularly during the rainy migrants in Rabat and Casablanca. In Rabat, the some functions to more junior staff such as Ministry of Health. This project started in care is limited in this country, where and addressing the geographical barrier to season when roads are impassable. MSF has majority of consultations centred on digestive health surveillance assistants. MSF has been 2000 with a strong focus on the prevention 72 per cent of the population still live care. trained community groups and equipped them and respiratory infections exacerbated by precari- focusing on increasing the skills of existing and treatment of sexually transmitted infec- below the poverty line. The cost- with rapid screening tests and ACT, enabling ous living conditions. MSF also treated migrants staff and lay people, including ‘expert pa- tions. In December 2004, the first patients recovery system of care is a serious MSF offers free treatment to all children under them to treat simple cases of malaria in for more serious and chronic diseases, including tients’, to provide essential services. started on ART. By the end of the project in impediment and attendance at health five, and free consultations and treatment for children under the age of 10. These mobile TB and HIV/AIDS. In total, MSF conducted 2,584 October 2007, more than 1,100 HIV patients centres is extremely low. MSF is work- febrile diseases to pregnant women in seven ‘malaria teams’ mean children in isolated medical consultations in 2007. MSF also worked to Specially trained ‘expert patients’ and were undergoing treatment in Eastern Dowa ing to offer quality care for malaria, health centres in Kangaba. A flat rate policy of villages can now receive free treatment during raise awareness of reproductive health issues. members of the community are now able to and more than 270 in Mponela. It is estimated especially to the most vulnerable and only 200 FCFA (50 cents) is also implemented the rainy season. undertake testing and counselling as well as that over 3,300 patients have enrolled in the those excluded from the healthcare instead of the cost-recovery system to enable A new phenomenon has been the increase in providing support to help people continue programme over the last three years. system during the rainy season. the rest of the population to access treatment The number of children with access to quality mental health problems due to the longer stay with their treatment. These tasks were tradi- for malaria and other febrile diseases. healthcare at sites more than five kilometres of migrants in the country and the resulting tionally undertaken by nurses but many became By December, approximately 19,000 people Back in 2005, a medical investigation from a health centre was five times higher in loss of hope. overwhelmed by the increasing number of HIV were still on treatment in MSF-supported conducted by MSF in southern Mali produced Since the implementation of this combined 2007 than in 2006 during high transmission patients combined with a scarce workforce, so a structures across Malawi and more than 700 alarming results. Significant mortality rates system, the number of consultations has periods. Malaria rates fell from eight per cent 2007 saw some improvement in the access to complementary approach was needed. people were starting treatment in an MSF were found, together with poor access to care increased four-fold. In 2007, each health centre in 2006 to 1.7 per cent in 2007 following the public healthcare for migrants in Tanger-Tétouan. structure every month. and high levels of resistance to the chloro- was seeing about 34 patients a day, compared implementation of this new model of care. As a result, the MSF project in Tanger was scaled Nurses can now focus purely on medical quine-based treatments. In collaboration with to an average of eight in 2005. Pregnant down and closed by the end of the year. However issues. MSF is providing HIV-related training MSF has worked in Malawi since 1986. national health authorities, MSF launched a women and children under five are the main MSF has worked in Mali since 1992. MSF will continue to assist migrants in Rabat and project in Kangaba to help people with beneficiaries. Casablanca, and in parallel will advocate for more inclusive national healthcare provision.

MSF has worked in Morocco since 1997. 42 43 MOZAMBIQUE Médecins Sans Frontières include health education, counselling, testing Seasonal floods and cyclone Favio A fr icA

| Reason for Intervention • Endemic/ and prevention of mother-to-child HIV The year started with torrential rains flooding Prevention of Mother-to-Child

Epidemic disease • Natural disaster transmission. the Zambezi valley and forcing some 250,000 Field Staff 565 people to leave their homes. Although heavy transmission of HIV MSF continued to transfer care from hospitals rainfall is a seasonal phenomenon, these

With more than 16 per cent of the to health centres closer to communities. This floods were the worst since 2001 and were Prevention of mother-to-child transmission (PMTCT) of Activity Report population infected, HIV is one of the increases access to HIV care, including ART, exacerbated by the arrival of cyclone Favio. HIV in developing countries is far from optimal. In 2007, main health concerns in Mozambique. and helps prevent hospital congestion and staff an estimated 420,000 children were newly infected with MSF runs various programmes to being overwhelmed by the number of patients. In February, MSF launched a two-month HIV, with almost 90 per cent of them living in Sub- combat the spread of the epidemic as emergency intervention to help people af- Saharan Africa. In contrast, in developing countries the 2007 E u r ope a nd the Middle Eas t The current human resources crisis in the fected in Zambezia and Tete provinces. More

well as providing timely assistance to number of new paediatric infections has dramatically R LD S AR OUND THE WO | areas repeatedly affected by heavy health sector due to emigration and the than 50,000 people benefited. The main activi- declined: in the United States, for example, only 250 rains and floods. effects of HIV on the workforce has been a ties were distribution of clean and drinkable infants are infected each year. major challenge. MSF is providing intensive water, construction of latrines and distribu- Decentralised HIV/AIDS care training to local medical staff and continues tion of plastic sheeting for temporary shelters. The vast majority of HIV-positive children are infected from their MSF has established long-term projects to to simplify treatments for patients with HIV HIV-positive mother either during pregnancy, in delivery, or MSF P R OJECT support the authorities’ response to the HIV/ and tuberculosis. MSF also lobbies the authori- MSF also supported the Mozambican health through breastfeeding. In the absence of any medical intervention, AIDS epidemic. The programmes are based in ties to allow qualified paramedical staff, after authorities by providing medical care in the risk of such transmission is between 15 and 30 per cent if a

s | T he A m e r ic as the capital city of Maputo and the provinces of professional training, to prescribe anti- resettlement centres and helped implement a mother is not breastfeeding, and between 30 and 45 per cent if the © Jean-Marc Giboux Tete in the north-west and Niassa in the north. retroviral drugs and to use ‘lay counsellors’ to surveillance system to detect malnutrition and mother is breastfeeding on a long-term basis. PMTCT is, therefore, a In December, about 14,300 patients were reduce the workload of nurses. There is a potential disease outbreaks such as measles, unique opportunity to stop the transmission of this virus and avoid

uc as u receiving anti-retroviral treatment (ART) strong belief that shifting tasks is the only way diarrhoea and cholera. a new generation being lost to HIV/AIDS. In 2007, an estimated 420,000 through MSF-supported facilities. Programmes to provide HIV/AIDS treatment on the scale children were newly infected with required. MSF has worked in Mozambique since 1984. Ironically, mother-to-child transmission is almost entirely preventable. Developed countries have been successful in reducing HIV, with almost 90 per cent of the risk of transmission to less than two per cent, by implementing them living in Sub-Saharan Africa. medical interventions that include: antiretroviral (ARV) treatment to all HIV-positive women during pregnancy (irrespective of their need for ARV for their own health), and to the infant in the first rely on cultural changes about breastfeeding. This is particularly weeks of life; obstetrical interventions including elective caesarean true in settings where little support can be given to the mother delivery; and complete avoidance of breastfeeding. Such interven- because prenatal and delivery services are not well established or of tions cannot be simply replicated in developing countries, mainly poor quality. While theoretically, implementation of these guide- A fr icA | s i a nd the Ca because it is often risky for the baby not to be breastfed, nor lines could reduce the risk of transmission to between eight to ten acceptable for mothers not to breastfeed. per cent, access to the full package of PMTCT interventions and treatment is limited in many developing countries. In South Africa, There lies the greatest difference between developed and develop- for instance, less than 11 per cent of women have access to services ing countries regarding the risk of transmission. In developed offering PMTCT interventions. countries, formula feeding has totally replaced breastfeeding by HIV-positive mothers. In developing countries however, formula Today some clinical trials provide convincing evidence to support a feeding is often not an option for cultural and financial reasons, but regime of treating all HIV-positive mothers - even those who do also because the lack of access to safe water (needed to create the need ARV for their own health as yet - with triple anti-retroviral formula) increases the risk of infant death due to diarrhoeal and therapy during pregnancy and delivery, as it is done in resource- other infectious diseases. The only intervention recommended by rich settings, but also throughout the whole breastfeeding period. WHO and UNICEF so far to reduce HIV transmission through breast- This could help reduce transmission of HIV in contexts where feeding is that the mother exclusively breastfeeds her baby during formula feeding is not possible. six months (i.e. giving breast milk only, at the exclusion of any other liquid or food) and then weans the baby in a few days. Some questions, however, remain to be answered, and such a strat- Indeed, trials have shown that HIV transmission is reduced in egy still needs to be tested in routine programme conditions. MSF is exclusively breastfed infants, compared to those who received planning to start such field tests with the objective of showing that, With more than 16 per mixed feeding during their first months of life. even in programme conditions, it is feasible, simpler, safer, and cent of the population more effective than the currently recommended strategy. Results of MSF follows the above WHO guidelines, established in 2006. These such pilot projects could hopefully lead to the improvement of infected, HIV is one of however are difficult to implement on a large scale, because they international recommendations. the main health concerns depend on the health status of the mother, but also because they in Mozambique.

| Reason for Intervention • Armed This national progress allowed MSF to begin outbreak in Jigawa state, the most affected

Reason for Intervention • Endemic/Epidemic disease conflict • Endemic/Epidemic disease the handover of its HIV/AIDS project, which areas being Gwaram and Dutse. MSF provided • Social Violence/Healthcare exclusion Field Staff 319 provided ART to over 1,900 patients, to local support to health facilities, trained staff and Field Staff 1,278 partners and authorities. donated drugs and diagnostic tests. A total of

Improved treatment was provided to 583 people were treated. Activity Report patients with trauma related injuries Meningitis outbreak in Jigawa in the Niger Delta. The handover of MSF provided case management between MSF has worked in Nigeria since 1996. HIV/AIDS treatment in Lagos was possible, and MSF responded to a

meningitis outbreak in Jigawa. 2007 R LD S AR OUND THE WO

In 2007, Nigeria was characterised by tensions surrounding the April presidential election and continuing strife in the Niger Delta, a volatile, densely populated area where various MSF P R OJECT armed and political groups continue to struggle for power and control over natural resources. MSF’s trauma centre was established in Teme hospital in Port Harcourt in 2005 to provide free emergency medical services and psychological care. The centre saw peaks of admissions in 2007, owing to several sporadic outbreaks of violence. In August, 70 casualties were received in a two-week period, many having sustained high velocity gunshot wounds. During the year, 6,300 patients were admitted to the emergency room and 2,000 surgeries and 800 psychological consultations

© Anthony Jacopucci were carried out. MSF also provides medical and psychological care to victims of sexual Acute child malnutrition is a serious medical issue that has not been adequately In Zinder, almost a million packets of RUFs violence at the centre and is working to raise addressed in Niger despite increased national and international attention since were consumed and MSF treated 21,542 awareness of this service. the massive nutritional crisis of 2005. An annual ‘hunger gap’ exists between children. MSF is working in two intensive April and September, when family food stocks run out and hundreds of nutrition centres in Magaria and Zinder and The Teme centre underwent technical improve- thousands of children have little access to food or the nutrients they need for in 13 mobile centres. ments in 2007 to advance the quality of care, healthy development. Malnutrition reduces immunity, stunts growth, affects including the introduction of internal fixation brain development and can be fatal. Using RUFs to prevent acute (an operation that mechanically unites the malnutrition ends of a fractured bone). This had a dramatic Child malnutrition is most severe in the In June, with high numbers of children from At the end of 2006, MSF research showed that effect on the quality of the management of regions of Diffa, Zinder and Maradi, where Aguie and Tessahoua arriving at existing more than half of children under the age of orthopaedic injuries and the average length of low weight and stunted growth affect 41 per health centres, a five-month emergency inter- three developed an episode of acute malnutri- stay, which dropped from 23 to nine days and cent of children living in poor households and vention was launched in Aguie. MSF provided tion in two districts in Maradi. MSF therefore nearly tripled inpatient capacity. just over 32 per cent of those in wealthier support to the district hospital and ran the implemented a new approach aimed at prevent- Physiotherapy for orthopaedic cases was also households. nutritional rehabilitation centre during the ing acute severe malnutrition and reducing the improved to reduce any loss of mobility. hunger gap, eventually handing over activities death toll linked to malnutrition. The new Following a nutritional survey in Dakoro to Save the Children UK. In total, 1,102 approach involved distribution of supplemental Improved HIV/AIDS care in Lagos district, Maradi, MSF began a medical-nutri- children were admitted to the hospital, Ready-to-use foods (RUFs) to all children under When MSF started providing free anti-retrovi- tional programme in April, supporting seven 925 for severe malnutrition. three at risk in the area. Such RUFs does not ral treatment (ART) and comprehensive care integrated health centres to provide free care replace regular meals but compensates for major for HIV/AIDS patients in 2003, there were no for children aged five and younger. MSF also In Tahoua district, MSF worked in two deficiencies in diet by providing a child’s daily other agencies providing free ART in Nigeria. supports the maternal health service, paediat- hospitals and six health centres, providing nutrient needs. MSF distributed supplemental In 2006, a President’s decree announced a © Vanessa Vick ric service, emergency obstetric surgery and nutritional support and over 5,000 free month- RUFs monthly to all 62,000 children aged from national programme to offer free ART to all maternity activities of the Dakoro district ly consultations for illnesses such as malaria, six months to three years in one district in HIV/AIDS patients in the country. As a result hospital. A total of 133,000 consultations were diarrhoea, respiratory and skin infections. Maradi during the seasonal hunger gap. 20 centres started offering counselling and Improved treatment was provided to patients undertaken during the year. Approximately 1,200 malnourished children with trauma related injuries in the Niger Delta. were treated every month. MSF has worked intermittently in Niger since 1985. 46 47 Republic of Congo Rwanda Médecins Sans Frontières centres, with 2,700 benefiting from anti-retro- A fr icA

| Reason for Intervention • Endemic/ viral treatment (ART). More than 10 per cent of (Congo-Brazzaville) Leaving Rwanda Epidemic disease these patients were children. Field Staff 71 After 16 years in Rwanda, MSF closed down its activities at the end of 2007, handing over Reason for Intervention • Armed conflict • Endemic/Epidemic disease Caring for children with this life-long disease to the health authorities its last remaining programme (see opposite). The handover

Field Staff 190 At the end of 2007, MSF ended its brings particular challenges. MSF medical marks the culmination of an intervention that has spanned war, genocide, epidemics and Activity Report activities in Rwanda after 16 years in teams, therefore, developed an innovative reconstruction. the country. Over the years, MSF’s work approach focusing on the specific needs of has included assistance to displaced children living with HIV/AIDS in Rwanda. This MSF first began work in Byumba and Ruhengeri districts in 1991, supporting those persons, war surgery, programmes for included discussion of HIV testing of children displaced by the civil war. It was to prove to be the start of one of the most deadly and 2007 E u r ope a nd the Middle Eas t in adult discussion groups, training specialised horrifying periods in the region’s and the country’s history. Within a couple of years, MSF unaccompanied children and street R LD S AR OUND THE WO | children, support to victims trauma- staff in psychosocial care and disclosure of the teams were providing health and nutritional care not only to many suffering from the tised by the conflict, programmes to child’s status to the child and their caregiver internal unrest but also to refugees fleeing massacres in Burundi. improve access to healthcare, using adapted tools. A key part of MSF’s responding to epidemics such as approach was the creation of children-only By 1994, MSF teams were witness to the brutal genocide unfolding in front of their eyes. malaria, cholera and tuberculosis, support groups, which not only give children a Efforts to help survivors were dangerous. Patients and members of the MSF medical team MSF P R OJECT and projects linked to maternal and voice but also allow them to play an active role were killed, and eventually, MSF had no choice but to evacuate. reproductive health. in their treatment.

s | T he A m e r ic as However MSF medical teams managed to return after a few days, crossing the border In 2000, Rwanda faced a growing HIV/AIDS Rwanda has now begun a clear shift towards with Uganda and Burundi. The scale of the suffering they found was such that the © Jiro Ose epidemic and a lack of available resources. MSF long-term development plans. The number of number of staff increased quickly, offering urgent medical care at hospitals in Kigali and

uc as u joined the fight against HIV/AIDS, focusing organisations in the country now covers the Nyamata, and in Byumba and Gitare on the Ugandan border. A health centre was also MSF handed over the screening and treatment of initially on prevention and awareness before needs of the population. The AIDS epidemic opened in Kigali. quickly including medical treatment. appears contained due to the high level of sleeping sickness patients to the Ministry of Health. investment by local authorities and the sup- The capacity of local systems and the involvement In the health centres of Kinyinya and port of many international actors. As a result, Kimironko in Kigali, thousands of patients MSF felt able to end its presence in the country of other external actors have allowed MSF’s After more than a decade of war and unrest, the Republic of Congo has now have been cared for by MSF. At the time of final at the end of 2007. gradual handover and withdrawal. completed its fourth year of post-conflict negotiations. The formal cessation of handover to the health authorities in armed hostilities has allowed the resumption of economic activities concentrated December, more than 6,200 patients were MSF has worked in Rwanda since 1991. principally in the oil town of Pointe Noire and the capital, Brazzaville. The receiving medical care in these two health But providing direct care to the victims was not enough. Shocked by the international Ministry of Health has now taken responsibility for healthcare in the Pool region. community’s refusal not only to recognise the slaughter as genocide but also to intervene A fr icA | s i a nd the Ca The situation is no longer considered an emergency and MSF has therefore started to save lives, MSF went public. A high-profile witnessing campaign ran across Europe, handing over some activities. culminating in the handing over of a report on the genocide to the United Nations. This collective lack of action remains one of the most shameful episodes of recent years. However, medical needs are still numerous in Responding to cholera outbreak Mindouli and Kindamba, in the Pool region, In late January, an outbreak of cholera was In the months following the massacres, MSF gradually expanded its activities across the where malaria, respiratory infections, identified in the city of Pointe Noire and a few country, focusing particularly on displaced and unaccompanied children and supporting diarrhoea, HIV/AIDS and tuberculosis (TB) are weeks later in Brazzaville. MSF supported the health structures that were close to collapse. Massive medical assistance was also prevalent. The country remains prone to Ministry of Health by reinforcing an isolation provided to some two million refugees who had fled the killings and were now living in outbreaks of infectious disease. area for patients and providing medicines, precarious camps in Congo (formerly Zaire) but also Burundi and Tanzania. medical training and water and sanitation MSF provided integrated healthcare in the materials and expertise. The need for MSF to bear witness impartially was unabated. Staff denounced intimidation hospitals of Mindouli and Kindamba. Services and atrocities both in a camp and in Gitarama prison, leading to the expulsion of some ranged from outpatient care, maternal care Project handover MSF teams and the withdrawal of others. Essential work continued elsewhere in Rwanda and treatment of infectious diseases such as TB In June, MSF announced that it would hand and, particularly that along the borders, was to prove essential in 1996 when fighting in and HIV to voluntary-care treatment for HIV/ over its activities and leave the country by Congo sparked a massive return of hundreds of thousands of Rwandan refugees to the AIDS, psychosocial counselling and emergency mid-2008. To ensure continuity of its medical country. surgical care. Overall, MSF conducted over services, MSF will strive to identify other 78,000 consultations. partners, including local non-governmental As the 1990s drew to a close, the situation in Rwanda gradually moved from emergency organisations and the United Nations, to intervention to reconstruction and development. MSF teams continued their work, address- MSF handed over the screening and treatment support the Ministry of Health in the Pool ing the new challenges of rebuilding the healthcare infrastructure, providing mental health of sleeping sickness patients to the Ministry of region. MSF will also support the Ministry of support to traumatised survivors, helping the country cope with the surge of HIV/AIDS Health, though we will remain available to Health to address small pockets of high cases, working to improve maternal and reproductive health and responding to epidemics provide assistance if required. MSF also incidence of sleeping sickness identified and other emergencies. Over the years, the capacity of local systems and the involvement of provided healthcare through its mobile clinics during the final project evaluation of 2008. other external actors have allowed MSF’s gradual handover and withdrawal.

to communities surrounding the towns of © Julie Rémy Mindouli and Kindamba. MSF has worked in the Republic of Congo since 1997. 48 49 Sierra Leone Médecins Sans Frontières Malaria is the main killer of children To make malaria treatment more accessible to In March, an ambulatory therapeutic feeding A fr icA

| Reason for Intervention • Endemic/Epidemic disease under the age of five in Sierra Leone. people in remote areas far from the nearest programme started making it possible to treat

Field Staff 492 In Bo and Pujehun districts in clinic, MSF began to support 30 smaller health a greater number of children. The children southern Sierra Leone, where MSF is posts in rural areas. In November, a pilot come to the health centre once a week for a working, malaria is the most common programme started to train community medical check up and to receive their weekly

disease. During 2007, staff in the malaria workers to test for malaria using rapid supply of therapeutic food, an enriched Activity Report MSF-supported health centres treated diagnostic testing and to offer free treatment peanut paste. more than 100,000 cases of malaria. for uncomplicated malaria with ACT in their villages. Information and education on how The risks of pregnancy MSF is fighting malaria through diagnosis and to prevent and recognise malaria and to Women in Sierra Leone face one of the highest 2007 E u r ope a nd the Middle Eas t treatment using effective tools and drugs. encourage people to seek care quickly are also risks of dying from pregnancy and childbirth

R LD S AR OUND THE WO | Pinprick blood tests, so-called rapid diagnostic important components in combating malaria. in the world. The five MSF-supported clinics tests, are easy to interpret and suitable to use To prevent people from contracting the include a special consultation area for women, in areas where microscopy is not available. As disease, more than 64,000 bed nets were where all medical staff are female. These in all MSF projects, malaria patients are distributed in 2006 and 2007. provide ante- and post-natal care, family treated with Artemisinin-based combination planning, treatment of sexually transmitted MSF P R OJECT MSF-supported health therapy (ACT), drugs that are more effective Gondama referral centre disease and medical and psychological care for centres treated more than earlier medicines, to which the malaria MSF runs the Gondama referral centre, a victims of sexual violence. Normal deliveries

s | T he A m e r ic as parasite has developed a high resistance. MSF’s hospital outside Bo town that offers paediatric also take place in the clinics while compli- than 100,000 cases of experience has also shown that to improve and maternity care and therapeutic feeding. cated cases are sent to the referral centre. access to effective treatment of malaria, both Each month, the centre admits around 500

uc as u malaria. healthcare and medicines have to be free. paediatric patients, 100 malnourished children MSF has worked in Sierra Leone since 1986. Sierra Leone is one of the poorest countries in and 50 pregnant women. In 2007, a new operat- the world and even low patient fees deter ing theatre opened where caesareans and © Ake Ericson people from seeking treatment. other obstetric-related surgery are performed.

Somalia non-food items, such as plastic sheeting and clinics for children under 12 were opened in MSF has increased its emergency intervention was launched in Reason for Intervention • Armed jerry cans. With cholera cases reported in Balcad, Karaan and Lido. In December, the Lido operational presence in late August in camps where thousands of conflict • Endemic/Epidemic disease several locations, MSF staff also focused on clinic was reinforced with an inpatient ward. internally displaced people and refugees, both A fr icA | s i a nd the Ca • Social Violence/Healthcare exclusion providing clean drinking water through water Somalia. Somalis and Ethiopians, gather before trying Field Staff 1,061 trucking distributions. A paediatric clinic opened in the Hawladag to cross the Gulf of Aden to reach Yemen. area of the capital in May had to be closed and Between August and December over 1,000 2007 saw an escalation of violence in Throughout the year, people continued to relocated in November due to insecurity. The MSF expanded its activities, opening new patients were treated for malnutrition. Somalia as fighting intensified between arrive from Mogadishu and needs increased MSF team now carries out mobile clinics in projects in Hiraan region, Lower Juba region the Transitional Federal Government, every day. In Afgooye and Hawa Abdi, a large displaced person’s camps around the city and and Puntland. In Belet Weyne, Hiraan region, Healthcare in a hazardous environment groups linked to the Union of Islamic majority of the 1,700 weekly medical consulta- continues to run an inpatient and outpatient MSF opened a hospital programme in February With 14 projects in 11 regions, MSF was one of Courts and various other armed tions carried out by MSF teams were linked to clinic for children and an ante-natal care clinic focusing on surgical care. Once the surgical the biggest healthcare providers in Somalia in factions, particularly in the capital, precarious living conditions: severe malnutri- in the K4 area of the city, reaching some 250 capacity of the hospital was functioning well, 2007. MSF’s medical teams performed more Mogadishu. As a result thousands of tion, diarrhoea and acute respiratory tract people a day. In late September, MSF started MSF also started a paediatric ward providing than 2,500 surgical operations, 520,000 out people fled Mogadishu, increasing the infections. MSF teams doubled the capacity providing emergency surgical care in a hospi- maternity care. In Jamaame, Lower Juba patient consultations and admitted around medical needs in the country with a in Afgooye and set up a paediatric ward in tal in the Dayniile area, receiving 705 patients region, MSF set up a 30-bed hospital with a 23,000 patients to hospital. Yet the challenges weakened health system. Hawa Abdi. The nutritional care centre in in the emergency room and performing 140 large nutritional programme and outreach of working in such an insecure environment Hawa Abdi also increased its capacity by the surgical interventions in the first three activities in March. Since then, 950 patients were evident. MSF was occasionally forced to Alleviating the suffering end of the year. months. have received nutritional treatment and MSF remove its international staff because of Thousands of those who fled Mogadishu found teams have carried out 1,400 consultations a violence, or threats of violence, against staff themselves living without shelter, food, water Despite the insecurity, MSF also opened new Expanding activities month. Every day, four mobile medical teams and patients, although MSF activities contin- or medical care. In April, MSF launched an projects in Mogadishu itself. A cholera treat- Victims of violence and displaced people were screened between 300 and 1,000 children and ued to be run by dedicated Somali staff. emergency response in Afgooye, a town some ment centre was opened in MSF’s primary not the only ones needing medical assistance. pregnant women for malnutrition. The major At the end of the year, two international staff 30 kilometres west of Mogadishu where many healthcare clinic in Yaqshid in March. By May, The absence of public health services, coupled health problems presented were malnutrition, members were kidnapped in Bossaso and held had sought refuge. MSF teams focused on the centre had admitted over 1,000 patients, with chronic malnutrition, droughts, floods pneumonia, and diarrhoea. captive for a week before being released with- meeting immediate needs, supplying medi- more than double the number treated in and regular outbreaks of cholera and other out being harmed. cines to the few existing health structures, previous cholera outbreaks in the capital. Over epidemics, have left the general population In Kismayo, also in Lower Juba region, MSF such as the Hawa Abdi clinic, and distributing the course of the year, three new outpatient extremely vulnerable. began an emergency surgical project in MSF has worked in Somalia since 1991.

September. In Bossaso, Puntland, a nutritional © MSF 50 51 South Africa Sudan Médecins Sans Frontières The struggle to meet substantial needs A fr icA

| Reason for Intervention Reason for Intervention • Armed conflict • Endemic/Epidemic disease An absence of healthcare staff and health

• Endemic/Epidemic disease • Social Violence/Healthcare exclusion • Natural disaster structures, roads and transport, other actors • Social Violence/Healthcare exclusion Field Staff 3,174 and investment means that MSF is the only Field Staff 56 medical organisation present in many areas of

More than three years after the signing of the Comprehensive Peace Agreement, south Sudan and struggling to meet the Activity Report medical needs in south Sudan remain critical. In many areas, MSF is struggling substantial needs. MSF teams worked in five to maintain primary healthcare services, while reinforcing secondary care and states, providing medical care ranging from emergency outbreak response services. primary healthcare to surgery and treatment of malnutrition and sleeping sickness. Staff in 2007 E u r ope a nd the Middle Eas t 2,000 people were treated, including 255 MSF’s health centres and hospitals in Jonglei,

Emergency response R LD S AR OUND THE WO | In a country devastated by over 20 years of war, severe cases, and more than 630,000 people Upper Nile and Unity State performed over with little or no health infrastructure, where were vaccinated. 350,000 outpatient consultations and more MSF introduced an deadly diseases are common and outbreaks of than 2,000 surgeries. In Unity State, around integrated TB/HIV clinic meningitis and cholera frequent, the ability of MSF teams responded to several cholera out- 150 patients operated on had to be airlifted in MSF teams to respond quickly and efficiently breaks throughout the year by setting up from remote sites. As well as working in fixed MSF P R OJECT in the country in 2003. to emergencies remains crucial. isolation and treatment centres and reinforc- structures, mobile clinics and outreach teams ing teams with additional staff. Some 2,400 are an essential part of MSF’s work, ensuring

s | T he A m e r ic as When meningitis swept through southern people were treated for cholera. In July, MSF that people living in extremely remote areas Sudan in early 2007, MSF emergency teams supported the health authorities in Wau, in without roads or transport facilities can responded immediately. Between January and Bahr-el-Ghazal state, after an increase in receive medical care.

uc as u April, the Ministry of Health reported 11,447 diarrhoea cases. MSF teams also ran measles

© Benedicte Kurzen / Eve suspected cases of meningitis, including 632 vaccination campaigns throughout 2007, The security situation remains precarious. deaths, in nine out of 10 states. MSF teams set vaccinating 47,500 children. After flooding in Outbreaks of fighting are frequent and the In South Africa it is estimated by the UN that over 5.5 million people are HIV- province. Efforts were made to improve up a surveillance system to monitor cases, September, MSF staff distributed essential number of patients in MSF wards suffering positive and about a million are in urgent need of anti-retroviral treatment diagnosis of drug resistant TB in Khayelitsha, supplied health structures with medicines, survival items, such as cooking sets, to 3,000 from violent trauma is high, representing four (ART), half of whom are still waiting. Tuberculosis (TB), including drug-resist- strengthen TB infection control and develop a treated people and launched mass vaccination families in Ayod, Jonglei State. out of 10 patients undergoing surgery in Bor ant TB, is the leading cause of illness and death among those living with HIV. At decentralised community-based model of care. campaigns in all nine affected states. Around Civil hospital (Jonglei State). In November, MSF the same time, South Africa has become the leading destination in the region was forced to withdraw staff temporarily from for migrants fleeing economic and political chaos in neighbouring countries in MSF continues to coordinate the township’s Bor when clashes between different tribes led search of jobs and safety. An estimated 2,000 - 6,000 people cross the border Simelela Centre for Survivors of Sexual to the death of four people within the MSF every day. Despite a constitution that guarantees healthcare for all, access to Violence, which provides medical care, psycho- compound. A fr icA | s i a nd the Ca services for this group is far from assured. social support, forensic examination and police assistance to rape victims in one setting In some areas, MSF has been able to hand over Providing HIV/TB treatment in a More than 200 new patients were started on open 24 hours a day, seven days a week. In or end its activities. In March MSF withdrew township ART monthly but this rate was threatened by 2007, nearly 1,000 survivors of sexual violence from a hospital in Akuem, Bahr El Ghazal Since May 2001, MSF has been providing complete saturation of existing sites and attended Simelela. State, which was established in 2000 during primary care level HIV/AIDS treatment in the severe shortages of health workers. To cope the civil war, when people were unable to township of Khayelitsha, on the outskirts of with the ever increasing number of patients Improving access to care for migrants reach any other health facilities. Services Cape Town, in partnership with the Western and with the goal of reaching 15,000 people by In late 2007 and in response to an increasingly included in- and out-patient care, antenatal Cape Province Department of Health. MSF has 2010, MSF focused on delivering HIV services dire situation, MSF carried out an assessment care, deliveries, treatment for TB and progressively handed elements of the pro- in new decentralised health centres using a and started providing essential healthcare to emergency interventions for meningitis, gramme over to provincial and local health nurse-based model of care, improving clinic migrants, primarily from Zimbabwe. In the cholera, malaria and malnutrition. In the authorities but continues to support TB and organisation and triage of patients, re-defining border town of Musina, Limpopo Province, seven years MSF worked in the hospital, teams HIV services. staff roles and training. MSF also launched MSF provides primary healthcare through provided over 320,000 outpatient consultations new strategies to address the challenges of mobile medical teams on farms and in town- and treated 1,187 people with TB. The Khayelitsha programme has the oldest long-term adherence to ART, including creat- ships. In Johannesburg, MSF opened a small group of patients on AIDS treatment in the ing ‘adherence clubs’ for stable patients on clinic next to the Central Methodist Church In October, MSF handed over responsibility for public sector on the continent. A special ART for at least 18 months with no where 1,500 migrants seek refuge every night. Marial Lou rural hospital, in Warap State, to a priority has, therefore, been set together with complications. MSF provides basic care and enables access to partner organisation and as a new hospital partners, particularly the University of Cape public health services and more specialised © Susan Sandars was opened in Bentiu, Unity State, MSF also Town, to monitor and evaluate treatment Given the extremely high incidence of TB in care through a referral network. decided to end its assistance in this area as results. As of December 2007, nearly 9,000 the township and because 70% of TB patients A country devastated by over 20 years of war, well. Activities there had focused on kala azar, people had been started on ART in clinics are also HIV-positive, MSF introduced an MSF has worked in South Africa since 1999. tuberculosis and HIV co-infections. supported by MSF, including almost 3,000 integrated TB/HIV clinic in the country in with little or no health infrastructure who have been on treatment for more than 2003. Since then Ubuntu has become one MSF has worked in Sudan since 1979. two years. of the busiest primary care clinics in the 52 53 Médecins Sans Frontières

In the mountainous rebel-controlled Jebel south Darfur in search of security. A fr icA

| Mara, MSF provides healthcare in Niertiti, Approximately 25,000 people were in need

where 23,000 of the 33,000 population are of relief. MSF provided clean water and internally displaced. On average, 5,500 con distributed essential survival items such as sultations and 278 hospitalisations take place soap and blankets.

each month. MSF also travels to nearby Thur Activity Report twice a week, consulting 200 patients a day. North Darfur In April, MSF was able to resume medical © Yuri Kozyrev / Noor In Kutrum, MSF staff perform around 1,900 activities in the dispensary in Kaguro, which consultations a month and refer emergency had been on stand-by since a deterioration in

cases to Zalingei hospital. A polio and measles security in mid-2006. Care is provided to 2007

R LD S AR OUND THE WO Many people were killed vaccination campaign reached nearly 10,000 almost 85,000 people completely cut off from and most survivors fled children. assistance since 2003, when the whole area was attacked and most villages burned. Many to the surrounding South Darfur people were killed and most survivors fled to mountains. With a population of 100,000, Kalma is one the surrounding mountains. Activities were MSF P R OJECT of the Darfur’s largest camps for displaced extended to five additional health posts at the people. Here, MSF runs an outpatient health end of 2007 and a network of community centre providing 3,000 consultations a month. health workers was established. Transport and MSF runs three health centres in Kebkabiya, The project includes a special component for access remain a challenge and many of these assisting some 75,000 people, many of whom women’s health and a comprehensive mental health posts are reachable only by donkey. sought refuge in the city at the beginning of health service providing counselling, work- the conflict in 2003. Some 12,000 consulta- shops, support groups and community out- An international team returned to the medical tions take place each month. MSF also reach. In July, the MSF clinic was set on fire by facility in Serif Umra in July. This has been run supports the Kebkabiya public hospital, mainly 2.5 million people arsonists. Tensions in the camp in October entirely by Sudanese staff since an evacuation in the obstetric ward. are currently displaced forced up to 15,000 residents to flee and find of international staff in 2006. There are 7,000 refuge around the capital with little access to outpatient consultations each month. Patients Project closures in Darfur. aid. MSF responded by providing medical care needing secondary healthcare are transferred MSF closed its clinics in Killin and Gorni in the to these displaced people using mobile clinics. to hospitals in Zalingei or El Geneina. Jebel Mara. This area had been stable for many © Yuri Kozyrev / Noor months and had a number of other health MSF provides medical care to approximately In August, MSF started working in Tawila, facilities. MSF also withdrew from the Mornay Darfur 70,000 people in the southern town of where approximately 35,000 internally camp in west Darfur, handing over activities to Muhajariya. Services include inpatient and displaced people had gathered in three camps. the government and other organisations. MSF has provided medical humanitarian aid in the Sudanese region of Darfur increased involvement of the Ministry of outpatient care, surgery and treatment for They had been without health services since In Um Dukhun, bordering Chad and CAR, MSF since 2003, when government forces and allied militia began fighting rebel Health in the area are sufficient to meet the victims of sexual violence. Mobile and inpa- April, when the last relief organisation in the offered primary, secondary and surgical groups seeking greater autonomy for the arid and impoverished region. In 2007, needs of the population. MSF also continued to tient feeding are integrated into the basic area had to leave due to security problems. healthcare for refugees and displaced the political environment became increasingly complex, with continued frag- provide medical and technical support in healthcare programme to respond to the high MSF started mobile clinics and established a communities until the middle of 2007. mentation of armed groups leading to outbreaks of violence and heightened projects at the Aradamata and Dorti displace- number of malnourished children. In October, small inpatient ward in Tawila town. The team insecurity. Aid organisations including MSF were the target of numerous attacks ment camps from a base in El Geneina. an intensive attack on the town casued the suffered several security incidents and had to Until April 2007, MSF teams worked in Shariya, and robberies. Harassment from members of armed forces, increased banditry death of two Sudanese MSF staff. Following be provisionally evacuated in mid-September. south Darfur, a government enclave where and clashes between nomadic tribes led to new population displacements. Seleia, in the north of the province, has wit- this tragic incident MSF evacuated part of its Activities resumed in November. All services 27,000 people had regrouped before being By the end of 2007, the number of displaced people in Darfur had reached close nessed significant fighting. MSF supports a team from Muhajariya. are in place and an average of 3,000 consulta- systematically dispersed by attacks. MSF was to 2.5 million. hospital in the town, providing reproductive tions take place each month. compelled to scale down the programme after healthcare and medical services for victims of MSF opened a new project to assist the resi- repeated robberies from its mobile teams. MSF West Darfur assistance, vaccinations and referrals for the sexual violence and surgical care. At the end of dents and displaced in and around Feina, In Shangil Tobaya, MSF cares for 28,000 also ended outpatient services and a feeding Access to medical care and emergency support seriously ill. Mosquito nets were also distrib- the year, MSF evacuated its international staff providing basic healthcare, ante-natal care and displaced people in the Shangil and Shadat programme for displaced people who had fled is a constant problem for populations faced uted. Following a serious security incident, after an increase in fighting between the JEM a home-based feeding programme. About 130 camps and residents of Shangil Tobaya village. Muhajariya in 2006 and had been living in with ongoing violence in west Darfur, compli- MSF had to shut down its activities in Fora rebel group and the Sudanese armed forces. patients were seen daily and the feeding Services include inpatient and outpatient Seleah and Yassin. cated by refugee arrivals from neighbouring Boranga in November. programme averaged 60 new admissions a departments, a therapeutic feeding pro- Chad. In June, MSF started working in Foro In Zalingei, home to 100,000 displaced people, month. MSF also started running mobile gramme, reproductive health services and MSF has worked in Darfur since 2003. Boranga on the Chadian border, caring for In Habilah, another border camp with over MSF opened two outpatient feeding centres clinics to access a population that remains treatment for victims of sexual violence. 20,000 people living in difficult conditions 22,000 displaced, MSF’s health centre began and handed over some of its activities in the scattered across a broad area. Malnutrition rose in 2007 because continued whose basic needs included food and clean providing mental health services in May. The hospital, where there is an increased presence insecurity meant people still could not drinking water. Mobile clinics were started to health centre is being handed over to Save the of Ministry of Health doctors. In early 2007, newly displaced families began cultivate or grow crops. provide general consultations, nutritional Children, as their presence together with the arriving in the Bulbul area from west and 54 55 Swaziland Zambia Médecins Sans Frontières In November, MSF launched a project to In November, MSF opened a project in the community involvement to enable prevention, A fr icA

| Reason for Intervention • Endemic/ support the national authorities in providing region of Shiselweni, populated by some testing and adherence to treatment.

Epidemic disease decentralised care to people affected by HIV 202,000 inhabitants. MSF works in the hospital This is achieved through the contribution of Field Staff 9 and TB. of Hlatikulu, in two healthcare centres in health workers and people living with HIV/ Nhlangano and Matsanjeni and in 19 rural AIDS, known as ‘expert patients’, who provide

Despite a relatively stable political Both diseases have already had a devastating health clinics throughout the region. This peer support and guidance. Special emphasis Activity Report 2007 situation and what appears to be a effect on the population and the economy. Life project aims to reduce mortality from HIV/AIDS is put on the improvement of prevention and reasonable resource base, about 69 per expectancy at birth is only 32.5 years, the and TB and to improve access to anti-retroviral diagnostics, notably through carrying out cent of the population of Swaziland lowest in the world. The country has the treatment (ART) and TB treatment for those complete tests for HIV/AIDS and TB. MSF also still lives below the poverty line. The world’s highest HIV prevalence rate and one of who urgently need it. provides comprehensive care for complex cases

E u r ope a nd the Middle Eas t the highest levels of HIV-TB co-infection. of HIV/AIDS and TB, including patients with

health situation, which had improved R LD S AR OUND THE WO | in the 1980s and 1990s, has entered a Twenty-six per cent of young adults are In collaboration with the health authorities, multi-drug resistant TB. downward trend as a consequence of infected with HIV and may die in the coming MSF is focusing on decentralising integrated the HIV/AIDS and tuberculosis (TB) years if not given adequate treatment. With care for HIV/AIDS and TB to the level of the In 2008, MSF aims to start 3,000 new patients epidemics. the escalation of the HIV and TB epidemics, health clinics, the closest health facilities to on ART in the Shiselweni region. health infrastructures risk being overwhelmed. the population. The strategy relies on wide MSF P R OJECT MSF has worked in Swaziland since 2007.

Reason for Intervention • Endemic/Epidemic disease

uc as u Uganda Field Staff 157 in Kitgum district. Working in a Ministry of Reason for Intervention • Armed Health clinic, MSF staff provided HIV/AIDS and In July 2005, the Zambian government started providing HIV/AIDS care free conflict • Endemic/Epidemic disease TB care and secondary and reproductive of charge and in 2006 abolished the national cost-sharing system of health- • Social Violence/Healthcare exclusion healthcare to around 70,000 people, most still care. Although the number of medical consultations rapidly increased, no Field Staff 858 living in camps. In Arua district, MSF’s long- viable substitute system of healthcare was implemented. The drug supply was running HIV/AIDS and TB project continues to not adjusted, resulting in occasional stock ruptures and patients sometimes An improved security situation and grow. By the end of December, 11,618 people being asked to pay for drugs, placing an extra burden on those with chronic ongoing peace negotiations between had been enrolled in the programme, with and debilitating illnesses such as HIV/AIDS. the Lord’s Resistance Army rebel group 4,090 receiving anti-retroviral treatment. and the government of Uganda have

A fr icA | s i a nd the Ca resulted in the cautious return home Responding to emergencies MSF has focused on helping people with HIV of thousands of internally displaced On 29 November, an outbreak of Ebola was through a project in the remote ‘transit area’ MSF worked at people who have been living in camps declared in Bundibugyo district, western of Kapiri M’Poshi, a fast-growing town and the integrating care into in northern Uganda for several years. Uganda. This highly contagious hemorrhagic site of main railway transfers. The national As the Ministry of Health takes on more fever has no known cure and is often fatal, so figures estimate that 20 per cent of people in regular health services responsibility in many areas, MSF has MSF teams had to move quickly to contain the Kapiri M’Poshi have HIV. Access to healthcare and provided ART to been able to hand over some projects outbreak and isolate and support those in general and HIV care in particular is limited and focus on providing secondary care, infected. The MSF intervention started in for the 250,000 people living in the rural 700 patients. HIV/AIDS and tuberculosis (TB) care. December and lasted approximately six weeks, Kapiri district, where there are few roads or However, the health situation remains during which 149 patients were treated. means of transportation. fragile. During 2007, regular disease Throughout the year, MSF also responded to transit area in northern Zambia. MSF outbreaks and emergencies demon outbreaks of cholera, meningitis, marburg and © Michael Goldfarb The hospital in Kapiri was recently upgraded worked at integrating care into regular strated the need for MSF’s continued Hepatitis E. to a district hospital but still lacks essential health services and provided ART to 700 presence in the country. staff set up a health centre in Nyakabande district, with eight locations for food distribu- health facilities such as x-ray and surgery. MSF patients. A total of 4,195 HIV patients are In February, an MSF emergency team of more transit camp. MSF also built shelter for the tion and treatment and a stabilisation centre runs a clinic in the hospital and works in 12 followed up in the project. Patients are also Refocusing activities than 75 staff supervised the meningitis vacci- refugees and provided clean water and sanita- at the district hospital. Between July and rural health centres, implementing a decen- screened for tuberculosis (TB) and MSF As some of the camps in the north empty, with nation of 291,000 people in Arua and Koboko tion facilities. December, 159 severely malnourished and tralised model of HIV care so people can access worked with health authorities to ensure people either returning home or moving to districts and assisted the Ministry of Health in 2,698 moderately malnourished children were medical services closer to home. By the end of that treatment for people co-infected with satellite camps, MSF has handed over a the vaccination of another 333,000 people by In February, an assessment by the World Food treated, with 284 hospitalised at the stabilisa- 2007, MSF had enrolled 7,000 patients in the HIV and TB was integrated into primary care. number of projects in Pader, Kitgum, Lira and supplying vaccines and medical materials. Programme in the Karamoja district of tion centre. An MSF assessment in Karamoja project, with 3,500 receiving anti-retroviral MSF also involved the community in preven- Gulu districts to other organisations or the north-eastern Uganda revealed that 20 per district in November indicated that the situa- treatment (ART). Teams conducted over 3,000 tion, treatment and support of people with Ministry of Health. Yet many health needs, MSF teams also provided assistance to refugees cent of those surveyed were suffering acute tion was improving, with a global acute mal- consultations a month. HIV/AIDS. This project was transferred to the such as hospital care and treatment for people who had fled violence in neighbouring coun- malnutrition. MSF teams opened a mobile nutrition rate of 15.3 per cent. Ministry of Health at the end of 2007. living with HIV/AIDS, remain unmet. In May, tries. When approximately 12,000 Congolese therapeutic and supplementary feeding In 2001, MSF established an HIV/AIDS project MSF opened a new project in Madi Opei camp refugees crossed the border in October, MSF programme for children under five in the MSF has worked in Uganda since 1980. in the rural district of Nchelenge, another MSF has worked in Zambia since 1999. 56 57 Zimbabwe Asia and the Caucasus Médecins Sans Frontières A fr icA

Reason for Intervention • Endemic/Epidemic disease • Social Violence/Healthcare exclusion Field Staff 389 Activity Report 2007 E u r ope a nd the Middle Eas t

R LD S AR OUND THE WO | MSF P R OJECT s | T he A m e r ic as uc as u

A fr icA | s i a nd the Ca According to the UN three million economic refugees are estimated to have district hospital and, at the end of 2007, set up fled Zimbabwe, a country characterised by 80 per cent unemployment, rampant a day feeding centre in Epworth to respond to inflation, foreign currency shortages, food insecurity and a crumbling health- the increasing numbers of malnourished 58 | ARMENIA care infrastructure. In addition to the HIV/AIDS crisis, MSF has seen the rise of children seen during the year. 58 | BANGLADESH epidemic diseases such as cholera and tuberculosis. 59 | CAMBODIA MSF also provided emergency clinical support 60 | CHINA Since 2002, MSF has implemented projects in The comprehensive approach to the prevention for diarrhoeal outbreaks in the rural district 61 | Georgia Zimbabwe to prevent and treat HIV/AIDS. and treatment of HIV/AIDS includes voluntary of Gokwe, the town of Kadoma, the Harare 62 | INDIA Despite the efforts of the Ministry of Health counselling and testing, treatment for HIV suburb of Mabvuku-Tafara and in the city of 63 | INDONESIA and other donors, the prevalence of HIV/AIDS and opportunistic infections, prevention of Bulawayo. 64 | KYRGYZSTAN among pregnant women in some areas of mother-to-child transmission, nutritional 64 | LAOS Zimbabwe is above 30 per cent and the general supplements, medical care to victims of MSF has worked in Zimbabwe since 2000. 65 | MYANMAR prevalence is 15.6 per cent, still one of the violence and general psychological support. 66 | NEPAL highest in the world. MSF also carries out HIV/AIDS educational 66 | PAKISTAN programmes and trains health workers to 68 | Papua New Guinea MSF has supported the Ministry of Health in manage the different components of the HIV/ 68 | SRI LANKA decentralising healthcare delivery to rural and AIDS programmes and ART. 69 | THAILAND city clinics in Bulawayo, Tsholotsho, Gweru, MSF has seen the rise 70 | TURKMENISTAN Epworth and Buhera. Increased proximity has The effects of price policies, hyperinflation, 70 | UZBEKISTAN resulted in more patients accessing the treat- food shortages, recurrent droughts and poor of epidemic diseases ment and care they need. By the end of 2007, harvests in recent years, combined with a high such as cholera and MSF was providing care to 35,000 patients with prevalence of HIV and TB, have resulted in HIV/AIDS, approximately 16,000 of whom were worrying trends in malnutrition. MSF supports tuberculosis. receiving anti-retroviral treatment (ART). a therapeutic feeding centre in Tsholotsho

In Sri Lanka, Vavuniya, MSF opened three surgical programs in Point Pedro, Vavuniya and Mannar, all in conflict-affected areas. © Henk Braam / HH 58 59 Médecins Sans Frontières S ARMENIA CAMBODIA a few patients had completed the MSF providing HIV/AIDS care to 42 inmates from UC AS U Reason for Intervention • Endemic/ treatment programme in Abovian, near the three of the city’s main prisons since 2006 Epidemic disease • Social Violence/ capital, Yerevan. and hospital-based and ambulatory medical Healthcare exclusion follow-up for HIV patients co-infected with Field Staff 65 When the programme started in 2005, it drug-resistant tuberculosis (TB).

covered a population of about 300,000 in two Activity Report Poor adherence to treatment pro- Yerevan city districts and occupied a small Kompong Cham, west of Phnom Penh, is one of grammes and late diagnosis of tuber- ward at the Republican TB Hospital. In early the most populated provinces in Cambodia. A s i a ND THE C 2007, MSF started to treat patients in the MSF has been working here since 2003, | culosis (TB) are critical problems in

Armenia. The treatment success rate is renovated 36-bed facility in Abovian dedicated offering comprehensive HIV/AIDS care. During

low and the lack of control over the © Clement Saccomani to drug resistant TB treatment. Inpatient 2008, MSF will transfer HIV care to the 2007 spread of TB is one of multiple treatment is offered, including to those with national programme and focus on treating problems facing the crippled health- Since the programme severe cases of extreme drug resistant TB. Once patients co-infected with HIV and TB, care system. the period of hospitalisation is over, patients including building a new TB ward. Seventy per started in Abovian, are followed up through mobile clinics or cent of current HIV patients in the hospital Armenia remains largely impoverished. The more than 100 patients home-based care until the treatment cycle is ward in Kompong Cham also suffer from TB. complexity and high cost of TB treatment has completed. led to MSF being the only medical agency have been admitted. In Takeo, Siem Reap and Phnom Penh, MSF R LD S AR OUND THE WO dealing with drug resistant tuberculosis Since the start of the programme, more than increasingly focused on developing treatment

(DR-TB) in Armenia. When uncontrolled, this 100 patients have been enrolled. In collabora- © Dieter Telemans for patients affected by TB, including multi- disease has serious consequences. Particularly Treatment for drug resistant TB takes up to tion with the National TB Programme, the drug resistant TB, independent of their HIV alarming is the emergence of extensive drug 24 months and involves a daily intake of objective is to expand the treatment to other MSF increasingly focused on developing treatment status. resistant (XDR) TB, when a patient is resistant dozens of medicines that can cause unpleasant districts of Yerevan. MSF P R OJECT to the main second-line drugs. side effects. Despite this, by the end of 2007, for patients affected by TB. In Takeo and Siem Reap, MSF uses an innova- MSF has worked in Armenia since 1988. tive approach, treating HIV/AIDS as a chronic disease alongside diabetes and hypertension, which also have high prevalence rates. By Reason for Intervention • Endemic/ December 2007 over 6,200 patients had been BANGLADESH Epidemic disease treated for diabetes and hypertension since intervention supporting the existing facilities taking some 1,200 consultations a week, and a Field Staff 245 the beginning of the project in 2002. Reason for Intervention • Endemic/ in Dhaka. In September and October, MSF feeding centre (over 2,100 admissions in 2007) Epidemic disease • Social Violence/ treated over 1,800 diarrhoea cases, about 30 per near Tal camp. Respiratory and skin infections Improved health facilities and a gov- In Siem Reap, MSF works closely with local Healthcare exclusion • Natural disaster cent of which were cholera. were the most common conditions. Due to a ernment commitment to fight HIV/ non-governmental organisations to increase Field Staff 165 lack of access to health care of refugees in the AIDS has ensured critical progress in access to treatment and testing for HIV and Rohingya find little support official camps of Kutupalong and Nayapara, the scale-up of anti-retroviral treat- other sexually transmitted infections. MSF In November a severe cyclone killed Stateless Rohingya people have been crossing MSF opened two 20-bed inpatient units in the ment (ART) programmes in Cambodia. provides medicines, supports the transport of and injured many. MSF responded to the border between Myanmar (Burma) and camps. By the end of the year, these facilities Because of this improved situation sex workers to health centres and referrals to this emergency providing essential Bangladesh for decades. They are a Muslim had admitted 3,800 patients. MSF has begun handing over some of appropriate services for specific care such as medical care. Parallel to this, work minority in Myanmar, a country that does not its HIV/AIDS projects. MSF is currently abortion, post-abortion care and cervical continued to help the stateless people recognise them as citizens. They are subject At the beginning of May, MSF closed its project offering HIV/AIDS care in four cancer. of Rohingya who have little access to to forced labour, land confiscation and restric- in the Chittagong Hill Tracts after eight years. locations and has 8,000 patients on healthcare. tions on movement and marriage but receive It was partially handed over to the Bangladeshi ART, 30 percent of all those on MSF’s paediatric HIV/AIDS programmes little support when they get to Bangladesh. regional health authorities. When MSF first treatment nationwide. throughout the country have seen dramatic Cyclone Sidr destruction intervened, the area was emerging from a improvements in children’s immune system, Cyclone Sidr killed more than 3,000 people and MSF has worked with the Rohingya in 20-year armed conflict between the central In its HIV/AIDS programmes in Siem Reap, growth, development and quality of life. Some made hundreds of thousands homeless. MSF Bangladesh for many years. After opening a government and the indigenous people. Today, Phnom Penh, Takeo and Kompong Cham, MSF 890 children were on treatment by the end of provided assistance to victims in some of the project in the Teknaf region at the border with access to healthcare is improving. A better provides ART including second line treatment 2007. remote areas using mobile clinics. By Myanmar in 2006, MSF in 2007 focused on infrastructure allows people to reach existing for those who do not respond well to standard December, MSF had provided medical care improving access to healthcare, particularly for health structures and more assistance is (first line) treatment. Counselling, treatment MSF continues to support the local health © Eddy Van Wessel to over 7,600 patients, most of whom had the 9,000 people living in the makeshift ‘Tal coming into the region. of opportunistic infections and information authorities’ response to seasonal epidemics diarrhoea and skin infections. In addition MSF camp’. MSF has also advocated on the plight of on HIV/AIDS are also provided. A total of 360 such as dengue fever. The 2007 dengue out- distributed 4,000 household kits. the Rohingya to encourage other international Cyclone Sidr killed With the government now offering better patients are on second line treatment. break was particularly severe, with 35,000 actors to recognise their vulnerable situation more than 3,000 people accommodation to the people living in Tal cases and 190 deaths reported nationwide. Severe floods increased diarrhoea risk and take action to help. Camp, MSF plans to hand over its project there In Phnom Penh, MSF is working in the Khmer MSF provided assistance to Cambodian Cases of diarrhoea increased following the and made hundreds of to another organisation. MSF is intending to Soviet Friendship Hospital, one of the largest medical staff in Takeo and Kompong Cham. early severe flooding in July and August. Throughout the year, MSF carried out medical thousands homeless. leave the country by the end of 2008. public hospitals in the city. Alongside its HIV/ MSF initiated a severe watery diarrhoea activities through an outpatient clinic, under- AIDS care, which began in 1997, MSF has been MSF has worked in Cambodia since 1979. MSF has worked in Bangladesh since 1985. 60 61 Médecins Sans Frontières S CHINA GEORGIA As tuberculosis numbers grow, Due to the growing epidemic and the lack of UC AS U Reason for Intervention • Endemic/ MSF implements programmes access to affordable treatment, MSF plans to Reason for InterventioN • Endemic/Epidemic Epidemic disease According to the recent World Health launch TB treatment programmes in colla disease • Social Violence/Healthcare exclusion Field Staff 63 Organisation Global Tuberculosis report, boration with the provincial and central Field Staff 202 China had 4.5 million cases of tuberculosis in authorities. In Inner Mongolia Autonomous

MSF is providing free HIV/AIDS 2006, with an estimated 1.3 million new cases Region and Jilin province, two northern Activity Report treatment to complement the national each year. The spread of drug resistant TB is of provinces where government statistics indicate government programme, which still even greater concern, with over 130,000 new the situation to be more severe, MSF has A s i a ND THE C patients estimated each year. At least half of engaged in in-depth negotiations to establish | has significant gaps. In addition,

cases of drug resistant TB are on the drug resistant patients in China have never a drug resistant TB prevention and manage- 2007 E u r ope a nd the Middle Eas t taken TB drugs before, a population equal to ment programme.

increase, and this trend needs to | be addressed using affordable, acces- 10 per cent of the global burden. sible drugs. MSF has worked in China since 1988.

Addressing gaps in HIV/AIDS treatment Official figures indicate that some 700,000 people in China were infected with HIV/AIDS R LD S AR OUND THE WO

s | T he A m e r ic as at the end of 2007. Of the 85,000 needing anti-retroviral treatment (ART), fewer than half, including 600 children, are actually

uc as u receiving the drugs they need. Through a national programme, the government has MSF P R OJECT provided free testing and medication, including ART drugs, to people living with HIV/AIDS and schooling for children infected with or affected by HIV/AIDS. © Jean-Marc Giboux

Nevertheless, HIV/AIDS treatment and care are not integrated. ART drugs are delivered at the In Sukhumi (Abkhazia) and Zugdidi (West Georgia), MSF treats multi-drug In Abkhazia, MSF has supported the local TB Chinese Centre for Disease Control, whereas resistant (MDR) tuberculosis (TB). The estimated prevalence is over 10 per control service since 1999. MSF rehabilitated a treatment for opportunistic infections is cent of new TB cases and 57 per cent of re-treatment cases. The daily intake TB hospital near Sukhumi and supplies it A fr icA | s i a nd the Ca provided at a designated county hospital. of dozens of medicines and the extremely prolonged treatment are difficult to with drugs, materials and laboratory equip- Tuberculosis (TB) treatment is provided in endure and patients’ adherence to the treatment course is generally poor. ment. Since 2001, the programme has focused another structure. Some patients also face on drug-resistant tuberculosis and by end of high treatment costs, including the HIV Patients find it hard to stay isolated in hospi- support is another integral part of the pro- 2007, 166 drug resistant TB patients had been confirmation test, medical consultations, tal for several months. Many are from poor gramme, as is the additional resources pro- started on treatment. MSF also introduced the laboratory tests, drugs to prevent and treat families and cannot afford to stay too long in vided to families to help fill the economic gap life-prolonging anti-retroviral treatment for opportunistic infections, hospitalisation and hospital when their dependants are relying caused by the patient’s incapacity. TB/HIV co-infected patients. transportation. Many do not seek or receive on them for financial support. MSF has tack- comprehensive care due to the stigma led this problem by reducing the period in In 2007, 78 MDR-TB patients were enrolled on In early 2007, MSF handed over its regular associated with their situation. hospital from between six and eight months the programme in Zugdidi. Since the start of TB programme to the health authorities of to an average of just two. In this pilot project, the programme in November 2006, no patient Abkhazia but continued to support TB The free HIV/AIDS comprehensive care and as soon as the sputum smear test shows a has dropped out of the treatment. MSF activities in Dranda. The health access treatment provided by MSF aims to address patient negative for active TB bacilli, he or she renovated the TB facility and provides a programme for vulnerable people has also some of these problems. After five years, the can leave hospital and be cared for through constant supply of drugs and medical materi- been considerably downsized, although MSF project in Xiangfan, Hubei Province in Central a mobile service that provides follow-up als. MSF has also been working closely with mobile teams in Sokhumi and Tkwarchili China, will be handed over to local health treatment and support. the Georgian national TB control services continue to provide care to a group of vulner- authorities in March 2008. Another project in providing technical assistance and training in able elderly patients who have no means or Nanning, Guangxi Zhuang Autonomous MSF also helps to improve patients’ homes, the management of MDR-TB. The Zugdidi access to basic healthcare.

Region will continue. By the end of 2007, © Joanne Wong which often do not provide good enough project is expected to be used as a model for almost 1,500 HIV/AIDS patients were registered infection control or comfort. Mental health the Georgian national TB programme. MSF has worked in Georgia since 1993. in the Nanning and Xiangfan MSF projects China had 4.5 million cases of tuberculosis (TB) and over half received ART drugs and other services. in 2006, with an estimated 1.3 million new cases Patients find it hard to stay isolated in each year. hospital for several months. 62 63 Médecins Sans Frontières S INDIA INDONESIA In the heart of India, clashes between Responding to emergencies UC AS U Naxalites, the local Maoists rebels, and the Reason for Intervention • Social Violence/Healthcare exclusion MSF responded to a measles outbreak in Indian government have displaced tens of • Natural disaster Mamuju District, West Sulawesi, and worked thousands of people. Caught in the fighting, Field Staff 174 with the local health authority to set up a an estimated 56,000 people have been forced mass vaccination campaign reaching over

to move to government-run camps in Located on the ‘Ring of Fire’, Indonesia is prone to natural disasters such as 7,000 children. Activity Report Chhattisgarh. Thousands of others are hiding earthquakes, volcanic eruptions, floods and landslides. MSF began working in in the dense forest of southern Chhattisgarh the country in October 1995. After the 2004 Tsunami, MSF set up a clinic MSF treated 1,132 cases of malaria in South A s i a ND THE C in Naxalite-controlled areas or have taken Halmahera and distributed 3,701 bed nets in | in Aceh and ran projects in eight affected districts providing medical care

refuge in settlements for the displaced around including surgery, vaccinations and psychological support. MSF continues to Buano Island of Maluku Province. MSF also 2007 E u r ope a nd the Middle Eas t villages across the border in Andhra Pradesh. provided healthcare to 1,291 miners in Mimika

assist victims of natural disasters through its emergency programmes and | provides healthcare in remote areas. in Papua after a high number of cases of MSF tries to reach all those who have been meningitis was reported. isolated by the conflict, providing medical assistance including primary healthcare and a MSF intervened after floods in Jakarta and a mobile therapeutic feeding programme for series of earthquakes that jolted West moderate and severely malnourished children. Sumatra, in Bengkulu, Muko Muko and MSF works in three camps and has mobile Mentawai Island. The teams ran mental health R LD S AR OUND THE WO

s | T he A m e r ic as clinics in Chhattisgarh and Andhra Pradesh. activities providing psychological support to Services provided include ante- and post-natal 29,000 people. care. A total of 22,700 consultations were

uc as u conducted. After the March earthquake in West Sumatra, MSF set up four hospital tents to support MSF P R OJECT MSF began an HIV project in Mumbai in 2006, Padang Panjang hospital and Puskesmas with a specific focus on treating HIV/tubercu- Lunang Silaut and donated medical supplies losis (TB) co-infected patients and other people to the local health authority. The teams excluded from the national healthcare conducted 5,110 medical consultations and programme. The project offers counselling, distributed 43,600 blankets, 24,600 plastic treatment for opportunistic infections and sheets, 1,400 cooking sets and 22,000 anti-retroviral treatment (ART) to the trans hygiene kits. gender community and commercial sex workers. By early 2008, over 530 patients were Providing healthcare in remote areas A fr icA | s i a nd the Ca registered at the clinic, with 259 patients on Following a measles vaccination campaign on ART and 23 on second-line treatment. MSF has the remote island of Papua in May 2006, MSF © Jean-Marc Giboux also started treating multiple drug resistant launched a primary healthcare programme in MDR-TB and currently has 19 MDR-TB patients. Asmat, southern Papua, in partnership with By the end of 2007, MSF had treated 675 patients the Ministry of Health. The programme aimed In Bihar, MSF opened a project at the Hajipur to improve mother and child healthcare and with kala azar in Bihar. referral hospital to tackle the growing access to basic and emergency medical care for problem of visceral Leishmaniasis or kala azar, these isolated communities. In 2007, over 5,500 of which India has 80 per cent of the world’s consultations were conducted, 269 babies were Reason for Intervention • Armed In Manipur, MSF runs integrated basic cases. Ninety per cent of cases are in Bihar. In delivered in the supported health facilities and conflict • Endemic/Epidemic disease healthcare clinics with an emphasis on the July, MSF began treating this neglected disease an obstetric referral system was set up in case • Social Violence/Healthcare exclusion diagnosis and treatment of HIV/AIDS. MSF is with a simpler, shorter and more effective of emergency. Other activities in Asmat includ- • Natural disaster also studying the extent of mental health treatment than the one to which patients had ed the rehabilitation of the surgery room, the Field Staff 446 needs arising out of the low-intensity conflict grown resistant. By the end of 2007, MSF had donation of surgery and medical materials and and continuing violence and has appointed a treated 675 patients with kala azar. water and sanitation activities. In 2007, MSF worked in the states mental health officer. In total over 61,000 of Kashmir, Manipur, Assam, consultations were conducted. During the rainy season, MSF mobile clinics In June, MSF handed over its tuberculosis Chhattisgarh and Bihar, providing also provided medical and humanitarian activities in Ambon, in the Moluccan islands, basic healthcare to communities in In October, MSF closed a basic healthcare assistance to some 30,000 people affected by to the local health authorities. This pilot conflict-ridden areas. project in Assam, as the Ministry of Health was the floods in three isolated districts of Bihar. project focused on a patient-centred approach able to cover the needs. A key focus had been © Véronique Terrasse and provided fixed drug combinations. It In Kashmir, MSF continues to provide commu- to optimise management of falciparum MSF has worked in India since 1999. improved patients’ adherence to treatment nity-based psychosocial support and basic malaria with Artemisinin-based combination MSF teams ran mental health activities providing and strengthened the counselling skills of healthcare to those affected by years of therapy (ACT). A total of 58,971 consultations psychological support to 29,000 people. local health staff. violence, including over 12,000 consultations. were conducted. MSF has worked in Indonesia since 1995. 64 65 Médecins Sans Frontières S KYRGYZSTAN MYANMAR

UC AS U Reason for Intervention • Endemic/ Reason for Intervention • Armed Epidemic disease conflict • Endemic/Epidemic disease Field Staff 46 • Social Violence/Healthcare exclusion Field Staff 1,200

Since 2005, MSF has worked to address Activity Report tuberculosis (TB) in two of The population endures widespread Kyrgyzstan’s prisons, where incidence and often hidden suffering. Controlled A s i a ND THE C

| rates were estimated to be 25 times by a military regime since 1962 and higher than in civil society. MSF largely cut off from the outside world,

supports TB detection and administers the health and welfare of people in 2007 © Alexander Glyadyelov TB treatment in the prisons. Together Myanmar is affected by repression and with national institutions and other low intensity conflict. Ethnic minori- international organisations, such Many prisoners get sick in prison, while others patients with different resistance patterns ties, many of whom are displaced and as the International Committee of learn they have TB only when they arrive. from recovering patients. MSF provides TB care live in border regions, are particularly © MSF the Red Cross, MSF is also trying to Prisoners used to be kept in crowded cells, with for 550 patients a year and nutritious food to vulnerable. Provisions for healthcare respond to the alarming rate of drug poor ventilation and scarce light. To change support recovery. are inadequate, with 80 per cent of resistant TB. this MSF has implemented early detection of people living in malaria risk areas and transmitted infections. Almost half a million In Myeik, south of Dawei, MSF has run a R LD S AR OUND THE WO TB in the pre-trial detention centres and has To help alleviate the stigma, MSF organised a thousands going without treatment for patients were tested for malaria and 210,000 malarial control and treatment project since The Ministry of Justice has initiated a penal rehabilitated medical rooms and the cells of TB photography exhibition depicting the lives and conditions such as tuberculosis (TB) were treated. 2002, including surveillance and emergency reform process but the prisons remain among patients. MSF also undertakes infection control treatment of TB patients ‘behind bars’. It was and HIV/AIDS. response for epidemic diseases. Four mobile the most overcrowded in the former Soviet and the separation of sick inmates. the first such event to unveil this hidden world In Yangon, Kachin and Shan, MSF provided clinics provide care in three townships of states. Despite high TB prevalence, cumber- to the wider public. MSF is also lobbying In 2007, MSF continued its medical aid projects medical care for 16,000 HIV/AIDS patients, half Thanintharyi. At the end of 2007, the project MSF P R OJECT some bureaucracy makes it extremely difficult MSF refurbished and maintained the labora- respective authorities to take responsibility for in areas where it had secured humanitarian of whom were receiving anti-retroviral treatment was handed over to another international to set up mechanisms of TB control. Continuity tory and rehabilitated the hospital in one of solving the problem of TB in prisons, particu- access: Rakhine, Kachin, Shan and Kayah states, by the end of the year. Focusing on high-risk non-governmental organisation (Aide Médicale of treatment when a patient is transferred or the prisons. The new facility ensures the larly by providing sufficient human resources. as well as Yangon and Thanintharyi divisions. groups including sex workers, intravenous drug Internationale). released is questionable and those leaving isolation of highly infectious and drug- users and migrant workers, MSF also provided prison often face stigma and discrimination. resistant patients and the separation of MSF has worked in Kyrgyzstan since 2005. In Rakhine state, MSF provides basic health- health education, distributed over 3.5 million In Kayah state, a pocket of ongoing civil strife care with a focus on malaria, TB and sexually condoms and provided needle exchanges. previously off-limits to international aid, MSF

MSF also provided health education, distributed Laos from the north of the country were pro over 3.5 million condoms and provided needle gressively transferred from Savannakhet to Reason for Intervention • Endemic/ the hospital at Setthathirat in the country’s exchanges. Epidemic disease capital, Vientiane. In 2007, this HIV unit Field Staff 36 began receiving new patients and by December, 300 patients were being cared for. In Thanintharyi division, southern Myanmar, provides primary healthcare and TB treatment The gradual introduction of a decen- MSF runs a project aimed at controlling and for people trapped in poverty, low-level conflict tralised cost-recovery system over the MSF is progressively working towards a hand treating malaria. The goal was to ensure and inadequate healthcare. A total of 22,350 past 10 years means there is no univer- over of all HIV activities to the Lao authorities. adequate infrastructure for the screening consultations were provided through three sal access to quality healthcare in Laos. Most medications are supplied by the Global and treatment of malaria. There are now clinics in the north of the state, one in the Access to treatment for people with Fund and other non-governmental organisa- seven fixed structures integrated into public south and a new clinic that opened in mid- HIV/AIDS has been particularly lacking. tions (NGOs) are becoming involved in treat- clinics, a private clinic and several mobile 2007 to care for those living in the eastern ment and there have been positive develop- clinics. part of Kayah. When MSF opened its HIV/AIDS project in ments within the government. This represents Savannakhet in 2001, there was little a major improvement compared to previously, In Dawei, Thanintharyi division, MSF has During the year, MSF advocated for its patients © Bruno Stevens / Cosmos recognition of this disease in Laos. The medi- when HIV/AIDS was not even officially recog- developed a more integrated approach to the nationally and internationally, raising cal centre became the first and only in the nised. However, technical capacity and train- treatment of TB, malaria and sexually trans- awareness of the situation faced by Rakhine country to offer care for people with HIV. By the end of the year over 600 patients were ing infrastructure remain inadequate, making mitted infections including HIV, illnesses Muslims, Kayan and Karen minorities, as well Along with providing urgently needed treat- receiving care with 490 on ART in Savannakhet. further external assistance from donors and previously addressed through separate projects. as the vulnerability of HIV/AIDS patients in ment, the project aimed to sensitise the gener- development NGOs still necessary. Gaps in Care is provided through two fixed clinics and Myanmar. One of few international NGOs in al public and the authorities to the existence costs of laboratory testing and certain medi an additional health centre focusing specifi- the country, MSF has urged and helped other of HIV/AIDS and the need for specialised care. inces. In Savannakhet, southern Laos, MSF counselling services had been handed over to cations still exist and will need to be covered cally on HIV/AIDS and TB. In total, 914 patients actors to become more engaged with the provides prophylaxis and treatment for oppor- the hospital. By the end of the year, 608 if access to treatment is to be assured. were receiving HIV/AIDS treatment and 586 humanitarian crisis in Myanmar. MSF’s project offers a free service for patients, tunistic infections and anti-retroviral patients were receiving care, with 490 on ART. people were treated for TB. who until recently travelled from all prov- treatment (ART). By 2007, HIV testing and In August 2006, about 100 patients originally MSF has worked in Laos since 1989. MSF has worked in Myanmar since 1992. 66 67 Médecins Sans Frontières S NEPAL women have little access to routine reproduc- UC AS U Child malnutrition Reason for Intervention • Armed tive care or emergency obstetrical surgery. conflict To maintain health and growth, young children need 40 essential nutrients. Those who Field Staff 125 In May, MSF organised and supervised a do not get them become malnourished, a condition that contributes to more than five women’s ‘surgical camp’ in partnership with

million deaths in children under five each year. The World Health Organisation esti- People living in the mountainous the Nepalese Ministry of Health and the Public Activity Report mates there are 178 million malnourished children worldwide, all of whom are less able regions of Nepal suffer a wide range Health Concern Trust. The project provided to fend off disease and 20 million of whom are at risk of death. In an international of preventable illnesses associated surgery for women suffering from uterine- A s i a ND THE C campaign launched in October 2007, MSF advocates for crucial change in the response to vaginal prolapse, often caused by obstetrical | with poor living conditions including

childhood malnutrition. respiratory infections, skin ailments trauma during labour and delivery. The con

and diarrhoeal diseases. Health dition results in a variety of debilitating and 2007 The critical age is between six and 24 months. At six months, mothers usually start structures are poor and dilapidated, difficult symptoms including pain, discharge © P.K. Lee supplementing breast milk with other foods. Yet, in ‘malnutrition hotspots’, such as with blocked and unusable sanitary and bladder infections. Successful surgery was Africa’s Horn and Sahel regions and South Asia, adequate food is either too expensive or facilities, no healthcare waste provided to over 80 women. responded to numerous cholera outbreaks. people’s ability to reach healthcare services. simply not available. Ensuring a complete balanced diet for children is a significant management, inadequate staffing Despite the conflict between Maoists and the By mid-year, marked improvements in the challenge that requires an urgent response. levels and a lack of medical supplies. MSF also expanded its Kalikot project, which government being officially over since security situation of certain areas allowed MSF focuses on women’s health as well as offering November 2006, sporadic fighting has continued to hand over three projects. Health authorities MSF and several other NGOs working in resource-limited settings have seen excellent MSF initially began working in Nepal to care general primary and secondary care. Almost to threaten the fragile peace. MSF opened a new took over the work in Khotang, while activities R LD S AR OUND THE WO results over the past five years through treating malnourished children with ready-to- for those isolated by the Maoist conflict. 20,000 patients were seen. The infrastructure project in the Central Terai, Rauthahat district, in Rukumkot and Arviskot were transferred to use foods (RUFs). These deliver all the nutrients a child needs in an energy-dense paste However, projects are increasingly focusing on and operating procedures of the hospital were where the local population lives amid fighting local non-governmental organisations. made with milk powder. They are easy to eat and require neither refrigeration nor upgrading basic healthcare and establishing improved and MSF opened a day centre between Madheshi armed groups and govern- preparation. A mother can effectively treat the child herself so only the most severe services for women. Often excluded from the providing therapeutic feeding for over 100 ment forces. The violence has resulted in MSF has worked in Nepal since 2002. cases need to be hospitalised. It is therefore easier to reach many more children, most of healthcare system by social discrimination, malnourished children. The team also severe restrictions on movement, limiting MSF P R OJECT whom recover remarkably quickly. Despite all this, only five per cent of the 20 million children at risk of death receive RUFs.

There is less certainty about how best to approach less severe forms of malnutrition PAKISTAN and different strategies will work in different contexts. Yet the success of RUFs is treatment unit in Ormara and a chlorination Sectarian violence undeniable and MSF would like to see a dramatic expansion of this response. Reason for Intervention • Armed unit in Pasni were established to provide safe MSF teams also provided emergency medical conflict • Social Violence/Healthcare drinking water. MSF also provided relief and support and surgical supplies during sectarian exclusion • Natural disaster medical supplies in Jaffarabad, Jhal Magsi, violence in March and distributed relief supplies A mother can effectively treat the child Field Staff 413 Nasiribad and Turbat. Doctors and nurses were to displaced families. herself so only the most severe cases need sent to provide additional support and ran Life in Pakistan is slowly returning to mobile clinics to target isolated communities. In December, fighting in Swat district, north © MSF to be hospitalised. normal after the devastating earth- of Malakand, left many people injured and quake of 2005. However in June, this Improving maternal health many more were forced to flee. MSF donated progress was hampered by cyclone In October 2006, MSF started a project in drugs and materials to the emergency room of MSF treated over 1,000 Yemyin that caused widespread Malakand district, North West Frontier Mingora hospital and began a mobile clinic in Wealthy countries must do more to prevent childhood malnutrition and stop donating patients for diarrhoea, damage in the South. MSF responded to Province. The project aimed to support Agra partnership with a local ambulance service foods that are inadequate for small children. Food aid must include specific products this crisis, and continued to provide hospital and a series of health centres in during curfew hours. Working together with malaria and skin that meet the nutritional needs of children below two years of age. Equally, other health services in the country, delivering primary healthcare, with a local non-governmental organisations, MSF governments of affected countries must prioritise malnutrition and ensure acutely infections. particularly around maternal health. particular emphasis on maternal health. By also distributed food, hygiene and shelter malnourished children receive RUFs or other effective supplements. RUFs have to be December 2007, MSF had conducted some materials to displaced people. However, more affordable, available from more producers and in a wider range of products that The aftermath of Cyclone Yemyin 6,300 consultations at the hospital, assisted the security situation prevented the full population, refugees and patients coming meet local needs and address different levels of malnutrition. Heavy monsoon rains exacerbated by cyclone over 60 deliveries and admitted 100 patients, deployment of MSF emergency operations. from neighbouring Afghanistan. In May, MSF,

Yemyin, which swept through the southern many with respiratory infections, trauma and therefore, started supporting Chaman hospital Most important, however, is the will to challenge the status quo so that children in part of the country in June, caused flooding chronic diseases. Assisting Afghans in Balochistan in Balochistan through a reproductive health developing countries have equal access to nutritional food. This is a crucial step towards and displaced thousands of people in the province project that includes emergency obstetric dramatically reversing the number of children dying from malnutrition. western province of Balochistan. MSF Delivering care in the federally administered MSF provides care in a rural health centre and surgery and neo-natal services. responded to the emergency, complementing tribal areas since March 2006, MSF has provided supports maternal and child care in Kuchlak, a the activities of the Ministry of Health. up to 1,000 paediatric consultations a month largely Afghan refugee settlement just north Earthquake project transfer in the Alizai hospital in Kurram Agency. of Quetta, Balochistan. Over 5,000 medical In October 2007, MSF transferred the only MSF treated over 1,000 patients for diarrhoea, The project has been extended to cover repro- consultations are conducted every month, remaining project related to the 2005 earth- malaria and skin infections in the first weeks ductive health, including emergency obstetric including mental health support. Health quake, a 60-bed temporary hospital in Bagh, of the floods and set up two cholera treatment surgery and neo-natal services in Alizai and services in the border town of Chaman are to local authorities. centres in Turbat and Jhal Magsi. A water Sadda hospitals. over-stretched, providing for the local MSF has worked in Pakistan since 2000. 68 69 Médecins Sans FrontièresFronti è S Papua new Guinea THAILAND Thailand has announced the repatriation of UC AS U Reason for Intervention • Armed overall estimated HIV prevalence of two per quality healthcare services and provide a Reason for Intervention • Endemic/Epidemic disease • Social Violence/ Hmong refugees and is screening the pop conflict cent among adults and pockets of much high- model of care for others. An additional new Healthcare exclusion ulation without involving an independent Field Staff 163 er prevalence in some communities, AIDS has facility was also built and the staff started Field Staff 225 party. MSF has urged Thailand not to repatri-

become a significant health issue. Violence seeing patients in December 2007. The team ate refugees without proper guarantees of res Activity Report 06|07

Papua New Guinea’s circumstances are occurring at all levels of society causes an provided comprehensive outpatient medical their well being on return to Laos. MSF is also Activity Report fairly unique. The island country has enormous amount of harm, with physical and and psychosocial care to survivors of gender- asking for an independent third party, such as only been independent for 30 years sexual violence against women and children based violence, including rape. The MSF team UNHCR, to monitor the situation. A s i a ND THE C (particularly girls) being extreme. Currently, also worked closely with staff from the | and is comprised of hundreds of tribes

(speaking more than a total of 860 the country’s health services cannot handle Ministry of Health in Lae Hospital, in an effort In Mae Sot, on the Thai-Burmese border, MSF 2007 E u r ope a nd the Middle Eas t the tremendous need for care. to improve hospital services for victims of began treating tuberculosis (TB) among

languages). | violence, particularly those services offered in unregistered migrant workers from Burma and The inhabitants are still unfamiliar with the Assessment the emergency department. refugees in Mae Lae camp in 1999. The project idea of being one nation with a central govern- In mid-2007, a second assessment confirmed also offers counselling and health education. ment and much of the country is struggling to that women and children continued to suffer New project sites In 2007, there were 5,234 consultations adjust. The country’s population of approxi- from massive levels of domestic and social In 2008, MSF plans to further develop and involving 581 TB patients, 70 per cent of whom mately six million people predominantly lives violence and that appropriate medical and expand the existing clinic’s services while also successfully completed treatment. Twenty-one in rural and often very remote areas of the psychosocial assistance for its survivors was looking for potential, new project sites in the patients have drug-resistant TB. MSF also R LD S AR OUND THE WO

s | T he A m e r ic as island. almost entirely absent in most parts of the country. When appropriate, MSF will carry offers ART for those co-infected with TB and country. Based on these findings, MSF began out advocacy work to help establish national HIV and had 115 patients under ART at the end Significant health issues supporting the Women and Children’s Support protocols and service guidelines to better of the year.

uc as u Papua New Guinea has some of the worst Centre in the city of Lae. The clinic, founded meet the needs of those harmed by gender-

health statistics in the Pacific region. Maternal by Soroptomists International, was handed based violence. © Espen Rasmussen / Panos In Phang Nga, thousands of undocumented MSF P R OJECT and infant mortality rates are high, and treat- over to MSF by the signing of an agreement migrant workers from Burma are still crossing able diseases such as malaria, pneumonia and with the Morobe province Angau Memorial MSF has worked in Papua New Guinea since 2007. In Mae Sot, there were over 5,000 consultations the border to seek jobs in Thailand. As they tuberculosis (TB) remain common. With an Hospital. This programme aims to establish have no official access to heathcare, MSF involving over 500 patients, 70 per cent of whom provides mobile clinics, health centres and successfully completed treatment. Burmese-speaking medical staff. The primary SRI LANKA healthcare services include mother-child Mannar, all government-controlled areas close healthcare and treatment of communicable Reason for Intervention to the frontline of conflict where the diseases including HIV/AIDS. MSF carried out MSF provides medical care, including MSF began screening and treating patients • Armed conflict population is particularly at risk. Working over 4,500 consultations and some 200 women

A fr icA | s i a nd the Ca HIV/AIDS treatment and prevention, for retinitis CMV, a dangerous opportunistic Field Staff 163 with local staff, MSF offers quality general and were assisted to give birth safely in hospital. for vulnerable groups, ethnic infection that can lead to blindness and death. emergency surgery and obstetrics assistance. minorities and migrants. Twenty-eight patients have received treatment. Whilst a cease-fire agreement MSF performed more than 6,000 surgical Providing healthcare to excluded © Henk Braam / HH was signed between the warring procedures. populations Establishing non-discriminatory care In Chiang Saen and Mai Sai hospital, in Chang factions in 2002, conflict erupted Drug users are among the highest risk for HIV/AIDS Rai province on the Thai-Lao border, MSF offers again in 2006. Daily life is dominated MSF was also able to extend activities in groups for HIV infection. MSF provides health MSF began its first anti-retroviral treatment cross-border HIV/AIDS treatment and care to conflict and LTTE-controlled areas. MSF holds a education and trains peer workers in one of by the conflict. (ART) programme in Thailand in 2000 and unregistered minorities from Myanmar and In 2007, war escalated in the northern and surgical outpatient clinic in Point Pedro and Bangkok’s drop-in centres. has since worked closely with the health Laos. MSF has also strengthened the capacity eastern parts of the island. Daily life is domi- supports the Vavuniya district hospital, which authorities and local partners to support of three Lao hospitals and Lao patients can nated by the conflict, with fighting at the Minister of Health authorised the teams to also serves as the referral hospital for people MSF is progressively handing over its project in people living with HIV/AIDS and improve now be referred and treated in their country. frontlines, aerial bombings (sometimes on start providing care. MSF offers surgical, living in the LTTE-controlled area. In May, MSF two prisons in Bangkok to the Department of treatment and care. Currently, 100,000 civilian settlements), roadside mines, obstetric/gynaecological and paediatric care in launched a project in Kilinochchi, in the heart Correction. The project, which began in 2003, patients receive free first-line ART through the Providing healthcare to migrants and restrictions on movements, suicide bombings, government-controlled and LTTE-held zones in of the LTTE-held region. However, due to the offered HIV prevention information and national health security scheme. Second-line minorities abductions, judicial executions, disappear- the northern part of the island. fighting in Mannar district, MSF was unable to treatment to prisoners. MSF also trained prison treatments are also available free. In Petchabun, northern Thailand, MSF has ances and arbitrary arrests. start supporting Adampan hospital, also medical staff and covered laboratory costs. MSF been ensuring adequate medical care, water The conflict and resulting insecurity have led situated in a LTTE-held region. is working with the Department of Correction In Kalasin province, north-east Thailand, MSF supply and sanitation in the Lao Hmong Insecurity seriously hampers access to people many health workers to flee and there is now a to develop a training curriculum, which will be is working in partnership with Kuchinarai refugee camp since 2005. In late June, 7,900 affected by the conflict but so do the serious shortage of health specialists in con- MSF established a project in Batticaloa to used to extend these services to all Thai prisons. district hospital and support groups to refugees were relocated to a bigger holding government restrictions on humanitarian flict areas. In government hospitals, MSF assist 12,000 internally displaced people by strengthen and maintain first-line ART camp. MSF continued its medical and water assistance. Few humanitarian organisations nurses and doctors are filling health staff gaps conducting mobile clinics and providing relief MSF has worked in Thailand since 1983. through viral load monitoring and community and sanitation services in the new camp and are in a position to address needs and people to assist victims of the conflict. supplies. However, as the situation improved, by activities. Currently, 220 patients receive began food distribution. Mental health are left without access to healthcare. the end of the year MSF handed over the project. first-line treatment and five patients are on activities began in November, with the main Although MSF returned to the country in MSF has started three programmes in Point second-line treatment. diagnoses including anxiety, depression and 2006, it was not until January 2007 that the Pedro (east of Jaffna Peninsula), Vavuniya and MSF has worked in Sri Lanka since 2007. post-traumatic stress disorders. 70 71 Médecins Sans Frontières S TURKMENISTAN The Americas intensive care and maternity wards of the UC AS U Reason for Intervention Magdanly Town hospital. The project has set 72 | BOLIVIA • Social Violence/ up an intensive baby care room and child 72 | Brazil Healthcare exclusion screening facilities and makes regular 73 | COLOMBIA Field Staff 68 outreach visits to primary healthcare posts 74 | GUATEMALA

around Magdanly. MSF also built and 74 | HAITI Activity Report equipped a TB laboratory to help tackle the 76 | HONDURAS rising number of cases. 76 | PERU A s i a ND THE C

While MSF is attempting to improve

paediatric care in the city, its ability to 2007 provide meaningful care has been hampered by the fact that all healthcare services in this district face bureaucratic obstacles and a lack of political commitment. Despite © James Kambaki these frustrations, MSF’s programme managed to support more than 4,000 hospital- High mortality rates among newborns, infants based consultations, about 15,000 outpa- R LD S AR OUND THE WO and young children is a serious issue. tient visits and over 1,000 deliveries.

MSF’s ability to work closely with patients, MSF is working to advance the quality of healthcare for children and pregnant local healthcare workers and healthcare women in Magdanly – an impoverished area on the Eastern frontier of managers, enabled the team to gain an MSF P R OJECT Turkmenistan, predominantly populated by ethnic Uzbek communities. Despite understanding of the country’s most acute some bureaucratic problems improvements in paediatric care have been made. healthcare needs.

Overcoming bureaucratic obstacles illness and death caused by disease has In 2008, MSF plans to expand its activities to High mortality rates among newborns, led to a downward spiral in the quality of other regions and will remain on standby infants and young children is a serious issue healthcare. for any health-related emergencies. and the prevalence of communicable diseases such as tuberculosis (TB) and sexually MSF started working in the eastern MSF has worked in Turkmenistan since 1999. transmitted infections are also of grave Magdanly district in 2004 and supports the concern. The lack of accountability on general paediatrics, infectious disease,

UZBEKISTAN Inappropriate and inadequate treatment of effects. After six months in hospital, patients Reason for Intervention • Endemic/ common sensitive TB increases drug resistance. need to continue on medication for another 18 Epidemic disease MSF has seen many alarming practices in the months supported by a mobile DOTS-Plus clinic Field Staff 81 local healthcare system that fuel this epidemic, or home visits from an MSF nurse. In 2007, MSF from poor infection control in TB facilities and enrolled 265 patients, compared to 150 in 2006. The ex-Soviet republic of Uzbekistan inappropriate use of first and second-line drugs, Since the start of the programme in late 2003, has a high tuberculosis (TB) incidence to self-treatment with anti-TB medicines easily MSF has enrolled over 617 patients. rate and one of the world’s highest available on the market. MSF is now seeing a levels of multi-drug resistant (MDR) number of cases of extensive drug resistant At the end of the year, MSF signed a memoran- TB, a strain that is resistant to the (XDR) TB. dum of understanding with the Ministry of most powerful anti-TB drugs. MDR-TB Health of Karakalpakstan on the gradual rate accounts for 13 per cent of all In a joint MSF and Ministry of Health pro- handover of the MDR-TB treatment programme new TB cases and 40 per cent of gramme, MSF has set up a reference laboratory over the next three years. MSF still has major re-treatment cases. in Nukus where MDR-TB is diagnosed by testing concerns about the sustainability and future of sputum for sensitivity to certain drugs. the project and plans to address these by invest- MSF has been treating TB in Uzbekistan since ing in local capacity-building and advocacy. 1998, initially using the directly observed Patients from Nukus and Chimbay region treatment short course (DOTS) and more receive DOTS-Plus treatment in a renovated MSF has worked in Uzbekistan since 1997. recently DOTS-Plus for treating MDR-TB in the MDR-TB hospital. The treatment is complex and autonomous region of Karakalpakstan. lengthy. Some patients suffer unpleasant side

An MSF psycho-social team works with children and adults to help them recover from the August earthquake that rocked the Peruvian coast. © Jodi Hilton / Corbis 72 73 BOLIVIA Colombia Médecins Sans Frontières

Reason for Intervention • Endemic/ Reason for Intervention • Armed conflict Epidemic disease • Social Violence/Healthcare exclusion • Natural disaster Field Staff 35 Field Staff 312 T he A m e r ic as

The Chagas parasitic infection affects Activity Report some 18 million people in Latin America, with the highest prevalence in Bolivia. Transmitted by blood- sucking insects commonly found in

impoverished areas and rural dwellings, 2007 Chagas can debilitate the heart and intestinal systems, shortening life

expectancy by about 10 years. © Juan Carlos Tomasi R LD S AR OUND THE WO

Chagas has attracted little investment in terms Initially, the chagas projects treated children of diagnostics and drug development. The only treatment is based on two older-class drugs only but a new project has opened in Cochabamba that risk many side effects and make patient MSF P R OJECT for adults also. monitoring and follow-up essential. The main target for medical interventions has always © Espen Rasmussen / Panos been children as treatment for adults has like any other disease at the primary care level. MSF works with national and international never proved completely successful. While the Chagas National Programme started organisations to raise awareness of Chagas and diagnosing and treating patients under 15 encourage more research and development Hundreds of thousands of Colombians are displaced, trapped, isolated and im- In August, MSF began a new project for IDPs MSF has undertaken several projects to prevent years old in various municipalities in the into effective diagnostics and drugs. MSF has poverished by the conflict that has ravaged their country for the past 45 years. on the Venezuelan border, in Tame, Arauca and treat Chagas in Bolivia. Initially, the country in 2006, access remains unavailable been a partner of the Pan American Health Guerrilla groups, government forces and paramilitary groups continue to fight department, where nearly 1,500 consultations projects treated children only but a new for the majority and MSF has been increasing Organization and participates in the Global in many areas. The violence has caused widespread physical and psychological were carried out in the first two months. project opened in Cochabamba in August also its advocacy within the country to improve Network for Chagas Elimination launched at distress, yet many victims continue to be overlooked by their government and Delays in receiving government social benefits treats adults and is integrated into six urban this. Research has also been a key part of the the World Health Organization in July. the international community. Healthcare access is difficult and dangerous for leave IDPs with gaps in healthcare coverage, health centres. The need to work with and Chagas projects in Bolivia, and further those in rural conflict zones and those forced to seek refuge in urban slums. which MSF covers by providing medical care to train health workers meant a slow start but research into new diagnostic tools and MSF has worked in Bolivia since 1986. all recent IDPs. Mental health consultations Chagas is now a step closer to being treated treatments is planned for the coming year. Delivering healthcare in conflict In Buenaventura (Valle del Cauca), one of the are also complemented with training and stricken areas most violent cities in Colombia, where access support for local mental health institutions. MSF has a wide range of healthcare projects to healthcare is limited by the dangers of Efforts to address mental health are made in across the country particularly in areas travelling in the city, MSF has established Caquetá department through mental health Brazil affected by violence and conflict. Mobile mobile clinics to provide urgent medical care. centres in Florencia and adjacent municipa violent and accidental injuries, respiratory clinics provide primary care, sexual and MSF has also opened a centre to assist lities. During 2007, 9,540 people were seen. Reason for Intervention • Armed tract infections and suspected dengue fever. reproductive healthcare and mental health patients who cannot access other health conflict Across Brazil, MSF offers training to munici- care to patients in the rural areas of Norte de facilities for financial or security reasons. Prioritising maternity needs Field Staff 42 palities, mainly on security risk management Santander , Sucre/Bolívar, Chocó, Córdoba, In Quibdó, Chocó, MSF focuses on the maternity in violent settings. Over 600 staff from the Nariño, Cauca, Putumayo, Arauca and Caquetá. Supporting IDPs needs of women and babies by providing direct Complexo de Alemão is a deprived and family health programme in Rio, Belo MSF also supported the internally displaced support to the maternity ward. MSF also violent neighbourhood of Rio de Horizonte and other municipalities followed In July, MSF began to provide medical populations (IDPs), seeing over 9,000 patients provides sexual, reproductive and mental Janeiro. The area is well known for this training programme during the year. healthcare using mobile teams to assist the in the urban clinic in Sincelejo, Sucre. On the healthcare using mobile clinics in the IDP regular clashes between local armed populations in the rural areas of Cartagena del outskirts of Bogotá, Colombia’s capital, MSF areas of the city. Over 17,600 consultations groups and with the Rio de Janeiro In partnership with the Oswaldo Cruz Charia and San Vicente de Caguán. Inhabitants works with the displaced in Soacha, conduct- were carried out, with particular attention police forces. The local population, Foundation, MSF has a Chagas diagnosis in southern Colombia are also suffering the ing medical consultations and providing paid to the medical and psychological needs of estimated to be around 150,000, lives project in the Amazon region. The project effects of the conflict, with Cauca and mental health support for those excluded victims of sexual and domestic violence. trapped in the violence. aims to train health professionals to Putumayo witness to frequent fighting. In from the public health system. The team also identify the parasite that causes the disease March MSF began working in the area, sup- tells families about their right to national Projects closed in Tolima and Huila Since October, MSF has been providing emer- while screening for malaria. The project, porting health facilities and providing healthcare and provides information on gain- After seven years, MSF has begun closing gency and mental health services to those implemented in 12 health centres so far, has healthcare through mobile teams. ing access to the government-run health projects that provided primary and mental living in Complexo do Alemão. MSF runs an © MSF identified some 200 cases of Chagas. The system. Some 2,700 patients were seen in 2007, healthcare in rural Tolima and Huila and to emergency room in Fazendinha, at the heart project will expand in 2008, to include more MSF also gained access to the Montes de Maria many suffering from skin diseases, respiratory displaced people in Ibagué as there is now a of the neighbourhood, offering emergency practiced by medical staff, establishing an health centres. region following a three-year blockade of all infections and psychological distress. lesser need for mental health consultations as care, mental health services, MSF ambulatory efficient triage system for the quick diagnosis international organisations. the displaced population has decreased. referrals and an advisory service. Techniques of patient needs. By December, MSF had MSF has worked in Brazil since 1991. such as advanced trauma life support are treated around 2,000 patients, mainly for MSF has worked in Colombia since 1985. 74 75 Médecins Sans Frontières GUATEMALA MSF started a project to Such shortages were mainly due to low treat- Reason for Intervention • Endemic/Epidemic disease • Social Violence/ treat survivors of sexual ment targets that did not reflect the actual Healthcare exclusion violence in zone 18 of number of people in need, budgetary issues, Field Staff 44 inadequate coordination between the T he A m e r ic as

| national HIV/AIDS programme and the Global

Guatemala City.

Poverty in Guatemala is widespread in the countryside and amongst indigenous Fund’s implementing partner and the late Activity Report communities. Child mortality and malnutrition rates are the highest in the procurement of drugs. MSF raised these region, and life expectancy is the lowest. The country is plagued by organised to transfer its remaining HIV/AIDS projects in concerns publicly, including to representatives crime and violent street gangs. Coatepeque, Puerto Barrios and Guatemala of the Ministry of Health. City to health authorities.

Not enough medical attention has been paid Healthcare is also provided by MSF through a In September, MSF also highlighted gaps in 2007 to victims of sexual violence in Guatemala. mobile unit working with several non-govern- The national health service has taken over support for the HIV/AIDS department in A protocol for addressing these patients in mental organisations (NGOs) throughout responsibility for HIV/AIDS care at the hospital Coatepeque hospital and the risks associated health structures approved by the Ministry of Guatemala City. The project also aims to raise in Coatepeque, where 900 patients were treat- with anti-retroviral drug shortages. MSF R LD S AR OUND THE WO Health in 2005 has yet to be implemented. awareness of the violence and the importance ed, and treatment for most of the 750 patients believes the Global Fund should work with and availability of specialised care. in the Guatemala City programme will now be its implementing partner to set realistic MSF started a project to treat survivors of provided by a local medical NGO called treatment targets and use its financial leverage sexual violence in zone 18 of Guatemala City. Handover of HIV/AIDS treatment Fundación Marco Antonio. to lower drug prices. MSF also advocated for This is one of the ‘barrios’ most affected by projects the Guatemalan government to take advantage MSF P R OJECT violence and organised drug crime. MSF activi- Increased support from international donors However, issues of scale-up and continuity of of World Trade Organization mechanisms to ties included reproductive healthcare and and gradual improvements in healthcare care remain major challenges in Guatemala. purchase the most effective medicines at the psychological services in a Ministry of Health services, funded and delivered through MSF supplied anti-retroviral drugs to treat- best prices. primary care clinic and maternity clinic. Guatemalan government structures, led MSF ment centres experiencing drug shortages. MSF has worked in Guatemala since 1984.

© Juan Carlos Tomasi HAITI Reason for Intervention At the end of 2007, MSF handed over its project Throughout the year, MSF medical teams 72 hours resumed in July in the shantytowns • Armed conflict in the slum of Cité Soleil, where the security focused on improving quality of care, working and city centre. • Social Violence/Healthcare exclusion situation has improved, to the Ministry of to perfect the recently introduced surgical Field Staff 794 Health. The project started in July 2005 to technique of orthopaedic internal fixation. Maternal health needs guarantee access to care for victims of the A total of 205 patients benefited from this Maternal mortality rates in Haiti are the Large sections of Haiti’s population, violence. The ongoing presence of MSF teams, technique, which sharply reduced their length highest in the western hemisphere particularly in the capital, Port-au- even during the most intense fighting, result- of stay in hospital. (approximately 630 women die for 100,000 Prince, live in precarious conditions ed in 72,000 consultations at the primary births), mainly due to eclampsia. The insecure due to poverty, neglect, urban violence health centre of Chapi and 32,000 at Choscal MSF also operates a physical rehabilitation urban slum environment where many women and lack of access to basic healthcare. hospital, where more than 13,000 patients centre where patients needing specialised live limits their access to healthcare as physi- Violence continues, especially in were hospitalised. However, since April the post-operative treatment can receive physical and sexual violence, extortion and com- Martissant, where MSF treated over situation has got better, with no patient with a otherapy and psychological care. mon crime are serious threats. 200 gunshot injuries. An MSF survey bullet wound seen at the Choscal hospital and between January 2006 to July 2007 people in the neighbourhood no longer living In June, MSF increased its capacity to treat In 2006, the emergency maternal Jude Ann showed that nearly one in four deaths in fear and isolation. victims of sexual violence in the capital, hospital was opened in Port-au-Prince, the only in Martissant was related to violence. offering comprehensive psychological and hospital in Haiti to offer free emergency MSF continued to provide medical and surgical medical treatment. The programme treated obstetric care. By the end of 2007, over 13,000 Violence and conflict care at its Trinite trauma centre in Port-au- 242 victims between July 2006 and June 2007. women had given birth here. MSF also started Since December 2006, MSF has operated an Prince, admitting more than 14,000 patients Awareness campaigns emphasising confiden providing services in fixed clinics in selected emergency health centre in Martissant, a compared with 11,000 in 2006. The number of tiality and the need to seek treatment within slum communities, with ante- and post-natal neighbourhood characterised by daily violence admissions for gunshot wounds fell from 1,300 care and a referral service in the three slums and a lack of medical facilities. Every day, in 2006 to 500 in 2007, although the number of La Saline, Pelé Simon and Solino. Mental patients are referred from the emergency of victims of stab wounds, rape and beatings health services will be added in 2008. health centre to the other hospitals where MSF continued to rise. In total, 2,847 patients were MSF mobile teams offer works. MSF established a number of mobile admitted for violence-related trauma. primary healthcare to MSF has worked in Haiti since 1991. clinics in the heart of the Martissant neighbourhoods, with medical teams offering some 400 patients a primary healthcare to some 400 patients a day.

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84 |P 83 |Yemen 82 |IRA 81 |IRAN 81 |SWITZERLAND 80 |RU 79 |MOLDOV 79 |IT 78 |FRaNCE 78 |BELGIUM Europe andtheMiddleEast ALESTININ TERRitories ALY SSIAN FEDERA Q A TION Thousands of Somali and Ethiopians risk their lives every year to cross the Gulf of Aden to escape from conflict and extreme poverty. poverty. extreme and conflict from escape to Aden of Gulf the cross to year every lives their risk Ethiopians and Somali of Thousands © MSF

77 Frontières Sans Médecins 2007 Report Activity 78 79 BELGIUM FRANCE ITALY MOLDOVA Médecins Sans Frontières and home to a large number of illegal Reason for Intervention • Social Reason for Intervention • Social migrants who live in extremely difficult con Reason for Intervention • Social Reason for Intervention • Social Violence/Healthcare exclusion Violence/Healthcare exclusion Violence/Healthcare exclusion ditions. The MSF project focuses specifically Violence/Healthcare exclusion Field Staff 17 Field Staff 5 Field Staff 32 on women migrants employed as sex workers. Field Staff 28 It includes outreach activities and medical

2007 has seen an increase in the The plight of migrants arriving and care for sexually transmitted infections and HIV patients in Transnistria, the Activity Report number of illegal immigrants deported living Italy continues to be worrying. HIV/AIDS prevention. More than 7,000 breakaway republic of Moldova, have from France and new attempts to MSF provides medical care, but for consultations were performed in the MSF limited access to quality healthcare. reform asylum policies. In addition, many the reality of life in Italy is clinics in 2007. MSF is providing life-prolonging anti- access to the French and European more precarious than expected. retroviral treatment (ART) for HIV- 2007 E u r ope a nd the Middle Eas t Many thousands of migrants move around

territory is becoming more difficult positive patients as well as supporting | and administrative procedures for Every year, thousands of migrants arrive in southern Italy to work as seasonal farm work- local health authorities in introducing those seeking refuge are increasingly Italy having made the precarious boat journey ers in the fields. Most are young men from HIV/AIDS care into the primary complex. Psychological assistance for across the Mediterranean sea to Europe. Many Africa with no permit to stay in Italy. Between healthcare system. homeless and non french speaking lives are lost. Survivors arrive exhausted and July and November 2007, at the same time as refugees in France remains extremely dehydrated, suffering from respiratory infec- providing medical services, an MSF team MSF is one of few agencies providing direct limited. tions and skin complaints, caused by over- interviewed over 600 seasonal workers. A full assistance to people living with HIV/AIDS in exposure to salt and water and burns from report of the results will be issued in 2008 but this isolated region. According to official © Dieter Telemans In March, MSF opened a centre in Paris fuel accidents. MSF has established a base at the initial picture is one of poor living, work- statistics, the prevalence of HIV/AIDS in targeting particularly those without valid one of the most used landing points on the ing and health conditions. Transnistria is four times higher than in the

R LD S AR OUND THE WO MSF continues to provide medical and psychosocial immigration papers who have sought refuge Island of Lampedusa, providing medical help rest of Moldova. The region is not recognised consultations in Brussels and Antwerp. after fleeing conflict, violence or persecutions to more than 12,000 migrants in 2007. After five years of carrying out programmes in by the international community and little in their home countries. These people are Sicily, MSF handed over all clinics for undocu- international aid has reached here despite the likely to be suffering psychological distress. MSF continues to work in the Campania re- mented migrants to the Ministry of Health. enormous amount of assistance given to Everyone in Belgium is entitled to healthcare. This includes undocumented Their precarious living conditions only in- gion, in Caserta and Naples provinces, running Moldova by international institutions to tackle

MSF P R OJECT migrants and asylum seekers, although in practice their access to health crease their anxiety. Psychological care is various clinics for undocumented migrants. MSF has worked in Italy since 1999. the HIV/AIDS epidemic. services is restricted by numerous administrative obstacles. MSF assists essential to avoid deterioration leading to The area is one of the most deprived in Italy migrants in Belgium by providing medical care and advocating for government suicide attempts. Most do not speak French In May, MSF started HIV-positive patients on services to face up to their responsibilities. and, without valid papers, have little access to ART. In August, after rehabilitation and in healthcare. close collaboration with the local health MSF continues to provide medical and psycho- Brugge where illegal migrants are kept before authorities, MSF opened an outpatient social consultations in Brussels and Antwerp to their expulsion. Most of the 206 people seen At its centre, MSF provides refugees with department in the main hospital of the capi- people who cannot access these through nor- since May 2006 were suffering from stress- psychological and medical care and advises tal, Tiraspol, and trained Ministry of Health mal channels. More than 5,000 consultations related psychosomatic problems. MSF them on the social and legal aspects of their medical staff to enable the integration of HIV/ were conducted in 2007, with the majority of published a report highlighting the negative situation. The multidisciplinary team of AIDS treatment into the primary healthcare patients being undocumented migrants and impact of the detention centres on health and doctors, psychologists and social workers system. In September, the programme was asylum seekers. Rather than creating a parallel more particularly on mental health. conducted some 2,700 consultations, includ- extended into the prison system, where HIV/ system, the aim is to direct people towards the ing 1,300 for psychological distress. AIDS prevalence is significantly higher than official system, which is supposed to provide MSF has also witnessed the human cost of deten- average. The rate of co-infection is also much the service. tion for critically ill patients, including women MSF has worked in France since 1987. higher, with TB being the main cause. with complicated pregnancies, people living When necessary, MSF advocates for patients with HIV, diabetics and acute psychiatric cases, The MSF team also visits Bender TB hospital both with the social services and within many of whom remain in detention centres for every week to treat co-infected patients and political spheres that has led to improvements several months. MSF has called for a major Slobozia, the region’s only inpatient HIV/ in access to national health services. As a review and changes to the detention policies for AIDS facility. In December, the programme result, MSF will hand over its activities to undocumented migrants in Belgium. expanded its activities to Ribnitza in the north another organisation in April 2008 because of the country and began operating a weekly although the situation has improved, there MSF provides information to people who face clinic in the city’s hospital. remains a need for a focal point to help mi- expulsion and who will not have access to the grants and asylum seekers find their way treatment they need in their country of origin. By the end of 2007, in partnership with the through the complex health system. A website, www.ithaca-eu.org, has been Ministry of Health, MSF had enrolled over launched making the information easily acces- 360 patients on the programme and 65 had © Lorenzo Maccotta Until the end of May, MSF also provided sible to lawyers and other organisations trying started ART. MSF is now working to make psychological and medical consultations in to contest expulsion on medical grounds. the programme sustainable so that it can be the five detention centres in Vottem, MSF provides medical care, but for many the reality handed over to the local authorities by the Melsbroek, Steenokkerzeel, Merksplas and MSF has worked in Belgium since 1987. of life in Italy is more precarious than expected. end of 2008.

MSF has worked in Moldova since 2007.

© Julien Lévèque 80 81 RUSSIAN FEDERATION SWITZERLAND IRAN Médecins Sans Frontières to find their homes in ruins. In an attempt to Reason for Intervention • Armed conflict • Social Violence/Healthcare exclusion solve the IDP problem, the local authorities Reason for Intervention • Social Reason for Intervention • Armed conflict Field Staff 74 attempted to close these centres but with no Violence/Healthcare exclusion Field Staff 78 alernative housing available, they remain and Field Staff 7 MSF’s focus is on the post conflict North Caucasus region, treating trauma-related are now called ‘communal hostels’. The MSF

injuries, providing mental health support, healthcare for women and children mobile team conducted around 38,000 medical In January 2006, MSF launched the Activity Report and tuberculosis (TB) care. consultations in 2007. ‘Meditrina’ project in Zurich. Free consultations are provided to anyone Healthcare in Chechnya has been crippled by Chechen staff, supported by the international MSF rehabilitated two clinics in Grozny where who has no access to the public health more than a decade of war. The majority of team based in Moscow. it runs free pharmacies. MSF doctors also services because they have no medical 2007 E u r ope a nd the Middle Eas t E u r ope a nd the Middle Eas t doctors have fled and the security situation for provided women’s health and paediatric medi-

insurance or the means to pay for | | hundreds of thousands of civilians and inter- In the Chechen capital, Grozny, MSF provides cal care in four clinics and reproductive health, medical consultations and treatment. nally displaced persons (IDPs) remains precari- primary healthcare to the most vulnerable family planning consultations and medical ous. MSF has responded by providing basic communities with limited or no access to equipment to the capital’s maternity hospital. The centre has focused primarily on primary healthcare, surgery and mental medical services. Mobile medical teams Outside Grozny, MSF supports district hospitals undocumented foreign nationals living in health services, as well as supporting consisting of a therapist, gynaecologist, in the mountainous villages of Shatoy, Sharoy unstable circumstances and unable to access Chechnya’s TB programme. For security paediatrician and psychologist served six and Itum-Kale, and has set up a primary health medical care through the Swiss healthcare reasons, there are few international staff on temporary accommodation centres for clinic in remote Shelkovskoy district. system. Homeless people and asylum seekers

s | T he A m e r ic as site. Instead, programmes are run by national Chechen IDPs who returned from Ingushetia have also used the service. Gynaecological and MSF runs a medical centre in Nazran, the dental problems, as well as diseases of the

R LD S AR OUND THE WO capital city of neighbouring Ingushetia, skeletal system, are the most common com-

uc as u providing medical and mental health consulta- plaints. By December, some 70 consultations a tions. Some 17,000 IDPs from the conflict in month were being provided. Chechnya and 18,000 from the Ossetian conflict of the early 1990s still live in Nine community ‘mediators’ of various

MSF P R OJECT Ingushetia. They lead difficult lives with little nationalities have been integrated into the © Siavash Maghsoudi support and largely without access to health community of migrants living and working in services. MSF conducts up to 1,200 consulta- Zurich. These mediators have taken on the role In 2007, an economic crisis in Iran led to tions a month for IDPs and the few locals who of raising awareness of this free service. also use MSF’s clinic. increased resentment towards refugees.

As Chechnya’s TB services were largely

A fr icA | s i a nd the Ca Free consultations are destroyed during the war, MSF supports the Since 2001, MSF has been assisting Afghan refugees in Zahedan, capital of implementation of a directly observed provided to anyone the Iranian province of Sistan-Baluchistan, where they have been crossing the treatment short course (DOTS) programme in who has no access to border for the last 30 years. In 2002, despite a deterioration of conditions in four TB hospitals serving around 350,000 Afghanistan, the Iranian government adopted a policy of forced repatriation. people. Since the beginning of the programme the public health Many are reluctant to return to Afghanistan, some even returning to Iran in 2004, more than 1,500 patients have re- services. after deportation. ceived treatment. The programme enrolled 455 patients in 2007. The success rate of over In 2007, an economic crisis in Iran led to consultations and nutritional support for 80 per cent is made possible by the work of The Meditrina service now offers HIV increased resentment towards refugees. Some children. MSF also refers patients to secondary MSF health educators and counsellors who counselling and voluntary screening. As with 150,000 Afghan refugees were expelled health facilities and covers costs for specialist help patients adhere to the lengthy treatment. the detection of other medical conditions between May and August but over half a consultations, treatments and hospitalisation. The programme plans to double by extending requiring more specialised treatment, patients million remain in Sistan-Baluchistan and an A team of social workers identify those in need to the main TB hospital in Grozny. may be directed towards other local medical average of 34 new families arrive at Zahedan of medical care and ensure they get access to facilities after their initial examination. every week. With Iranian restrictions on work, consultations. A total of 18,000 people were MSF continued to perform violence-related Meditrina works with a network of national educational opportunities and health services, assisted through this programme. reconstructive surgery in Grozny’s hospital doctors, chemists, hospitals and laboratories living conditions for refugees are difficult but No.9, the main republican trauma hospital. to ensure consultations and to enable such remain better than in Afghanistan. Iranian New project in Mehran MSF has also been supporting the neuro referrals. authorities estimate that the majority of Given the extreme difficulties in accessing

© Misha Galustov / agency.photographer.ru surgical and trauma wards, which performed Afghans are economic migrants and, there- patients and providing healthcare inside Iraq, around 600 emergency surgeries throughout MSF has worked in Switzerland since 2003. fore, not entitled to legal status or access to a project started at the end of 2007 in Mehran, In the Chechen capital, Grozny, MSF provides the year. free healthcare. close to the Iraqi border, to provide surgical care for victims of violence coming from Iraq. primary healthcare to the most vulnerable MSF has worked in the Russian Federation since In response, MSF provides primary and This project plans to receive between 30 and communities. 1988 and in North Caucasus since 1995. secondary healthcare to this population. 50 patients each month. MSF runs three medical clinics in Shirabad, Karimabad and Besat, offering free medical MSF has worked in Iran since 1996. 82 83 IRAQ Yemen Médecins Sans Frontières Yemen, some 650 died and the same number Reason for Intervention • Armed conflict Reason for Intervention • Armed conflict • Healthcare exclusion went missing. The death toll is probably much Field Staff 249 Field Staff 44 higher. Since September, MSF has been assisting refugees who have survived this risky Since the reunification of its northern and southern parts in 1990, the Republic of voyage, providing medical and humanitarian

Yemen has been exposed to political and social tensions and sporadic waves of assistance to over 3,000 refugees and migrants. Activity Report violence. The Saada province in the north-west has been particularly affected by The MSF mobile team offers survivors tensions between governmental and rebel forces since 2004. MSF began working in emergency medical treatment, food, water Yemen in September 2007, supporting health structures in the Saada province and and relief items on arrival. MSF also provides assisting migrants and refugees in the Abyan and Shabwah governorates. counselling, as many migrants arrive exhausted 2007 E u r ope a nd the Middle Eas t E u r ope a nd the Middle Eas t and emotionally shattered. In 2008, MSF will

| | Supporting health infrastructures fleeing fighting in their country and continue to provide medical assistance to this In the first half of 2007, some 56,000 people Ethiopians who cannot find employment back population, notably at a new reception centre fled their homes temporarily when violence home for political reasons or due to the con- opened recently by UNHCR in Ahwar. once again erupted in Saada province. In flict in the Ogaden region. In 2007, although September, following the signing of a ceasefire 28,000 people reached the southern coast of MSF has worked in Yemen since 2007. agreement, MSF began working in Haydan hospital to improve access to healthcare.

s | T he A m e r ic as It is the first time since the beginning of the fighting that an international relief organisa-

R LD S AR OUND THE WO tion other than the International Committee

uc as u of the Red Cross has been authorised to work © MSF in the region. The team supports inpatient and outpatient services, antenatal and maternity Four years into the conflict, the gap between emergency medical needs and the required to restore functionality and a units, and the emergency room of the hospital.

MSF P R OJECT capacity of Iraq’s medical infrastructure persists. Bombings and lesser reported minimum quality of life. The project treated On several occasions in November, MSF had to sectarian violence result in devastating injuries requiring immediate and 281 patients but its potential capacity is temporarily evacuate Haydan as fighting re- intensive medical attention, yet skills and supplies in many areas are limited. limited by administrative obstacles and sumed, although activities were sustained by The economy has collapsed and approximately 50 per cent of Iraqi doctors have impositions on bringing patients to Jordan national staff. In 2008, activities at the hospital fled the country. The high-level insecurity and ongoing violence reduces direct from Iraq. will be expanded to cover surgery. access to civilian victims. At the end of the year, MSF launched a recon- During the fighting of 2007, the hospital A fr icA | s i a nd the Ca Movements are dangerous and people cannot these provinces with materials and drugs and structive surgery project in Mehran, Iran. of Razeh, west of Haydan, which serves a access medical care or may receive limited and enables referrals of severely injured war The objective is to care for patients from the population of 75,000, was looted and partially insufficient care leading to life-threatening victims to hospitals in Kurdistan. MSF is also eastern provinces and south of Baghdad. destroyed. MSF repaired it and in December complications. Unable to run direct medical evaluating the situation of displaced people resumed medical activities in the emergency programmes with a permanent presence of and providing basic humanitarian assistance Confusing political and humanitarian room and in the inpatient, maternity, staff in violence-affected areas, MSF has sought particularly in the governate of Dohuk, where objectives antenatal and family planning services. viable ways to provide assistance to Iraqis some 1,000 families received support during Security issues make Iraq an exceedingly within and outside the country. the harsh winter. difficult context for independent humanitar- The volatile security situation makes ian interventions. The US-led coalition and UN movement difficult in some areas so an MSF In the Kurdistan area, programmes have been Operations in Jordan and Iran in system blurring roles demand a reaffirmation team goes six days a week to the town of established in three hospitals in Dohuk, Erbil support of Iraqi population of MSF’s strictly impartial and humanitarian Dhayan, home to 25,000 people in the rebel and Sulemaniyah to deliver surgical assistance An MSF team based in Amman, Jordan, began character and an insistence on the need to zone. On average, 120 consultations are car- and psychological support. One of the most offering limited support to five Iraqi hospitals preserve, defend and protect the integrity of ried out each day, mainly focused on children common medical problems is skin burns in zones severely affected by the violence. This humanitarian action from political and mili- and women’s healthcare. MSF is also contribut- caused by domestic accidents, failed suicide involved providing essential medical supplies tary objectives. MSF struggles to reassert and ing to the rehabilitation of the hospital of Al attempts or explosions. In Erbil, over a including anaesthetics, analgesics and surgical gain recognition for its identity as an inde- Talh, close to Dhayan, which will reopen in hundred operations a month were carried out, equipment. Some Iraqi staff also visit Amman pendent humanitarian organisation, separate April 2008 after seven years of closure. about half of which were war-related. In July, regularly for training on life support protocols from any political, commercial, religious or MSF opened a programme in Sulemaniyah to and mental healthcare in emergencies. personal interests. In November, MSF Providing assistance to migrants and © MSF care for burn patients and provide orthopaedic reinforced dialogue with all key stakeholders refugees surgery. By December, 738 patients had been In Amman, MSF runs a surgical programme in and warring factions to secure safe space in Every year, thousands of people risk their lives MSF supports health structures in the Saada treated, many for severe burns. partnership with the Red Crescent, staffed which to carry out its work. to cross the Gulf of Aden, the dangerous mainly by Iraqi surgeons performing maxillo- stretch of water between Yemen and Somalia. province and assists migrants and refugees in the The adjacent provinces of Tameem and facial, plastic and orthopaedic surgery. MSF has worked in the current Iraqi conflict This treacherous journey is taken by Somalis Abyan and Shabwah governorates. Ninevah experienced an upsurge of violence in Patients have complicated bone and wound since 2006. 2007. MSF supports healthcare structures in infections and six or seven operations are often 84 85 PALESTINIAN TERRITORIES Gaza strip Reason for Intervention • Armed conflict Field Staff 91 As with the whole of the Occupied Palestinian Territories, the often issuing contradictory instructions. Disputes result in Gaza strip had been subject to an international embargo since political appointments, strikes and a demoralised staff. early 2006. The already difficult situation deteriorated signifi- With the embargo making the re-supply of hospitals with drugs cantly in mid-2007 when Hamas took control after weeks of bitter and equipment highly problematic and a general economic col- internal fighting. With an array of security services and militia lapse, access to healthcare has been significantly reduced. MSF allied along factional lines, the bloody takeover was the culmina- has, therefore, expanded its activities beyond the mental health tion of an increasingly intense Hamas-Fatah rivalry. The remain- sphere to include post-operative care in addition to rehabilitation

E u r ope a nd the Middle Eas t der of 2007 saw violent repression of anti-Hamas demonstrations and paediatrics.

| and an emerging insurgency by disgruntled members of the former security establishment. The increased need for external medical assistance is a result not only of the violence and reduced capacity of secondary medical While Israel and international donors quickly recognised and structures but also of the political climate. As the positions of the engaged the new Palestinian government in the West Bank, the main antagonists become increasingly polarised, individuals with Gaza strip effectively remained under Hamas control and subject specific or perceived affiliations have correspondingly limited to tougher sanctions. Israel limits passage into Gaza to basic food access to health services. and medicine and the number of medical referrals abroad is de- creasing. Fuel and electricity supplies have been reduced in an The parallel Ministries of Health and many local organisations are

R LD S AR OUND THE WO attempt to pressure the Hamas regime, which the Israeli cabinet seen as directly influenced by Hamas or Fatah while some interna- officially labelled a ‘hostile entity’ in September. tional non-governmental organisations, particularly those funded by key institutional donors, are believed to have wider political Alongside the political and economic isolation of the Gaza strip, motives. Therefore, being financially independent as a medical the Israel-Palestinian conflict fluctuates. Hamas and smaller relief organisation is not just relevant but also necessary in order

MSF P R OJECT groups continueMSF began to target neighbouringworking Israeliin communities and to operate in Gaza. MSF repeatedly explains and highlights this militaryY basesemen with inrocket September and mortar-fire. 2007, Targeted air strikes independence to the recognised Palestinian authorities in the and limited incursions from the Israeli side ostensibly aim to West Bank, the Israelis and, of course, local actors on the ground, limit thesupporting rocket fire but inevitably health lead struc to civilian- casualties. in an effort to gain as much access as possible to the communities in need. © Valerie Babize tures in the Saada province During the peak of internal Palestinian clashes in May and June, at least and200 people assisting were killed migrantsand some 1,200 andinjured. However, Disputes continue however, and healthcare becomes simply an- Poverty, restricted movement and increasing violence in the Palestinian physiotherapy for several hundred people. As the subsequent split in the Palestinian Authority has had the other political tool through which pressure can be applied. As Territories have inflicted a tremendous toll on mental health, yet there are few well as meeting medical criteria, patients were refugees in the Abyan and most far-reaching consequences. The already fragile health sector positions remain entrenched, health services are likely to deterio- trained psychologists. MSF focuses on supplying psychological support to victims admitted to the programme as a result of has becomeShabwah highly politicised, governorates. with the two opposing parties rate further, making independent humanitarian action increas- of violence in the Israeli-Palestinian and intra-Palestinian conflict. MSF also financial, security or mobility problems. ingly relevant and important. provides medical assistance to people without access to health services. Teams work in the West Bank and Gaza. Supplying drugs and medical material The 2006 embargo by western states has led to Patients live in exposed and insecure condi- able context. Travel is difficult due to closures a general deterioration in the health system tions such as refugee camps or areas where and restrictions, so consultations and therapy and numerous strikes by health workers. The they are subject to frequent incursions, often are often provided through home visits. A Ministry of Health is completely dependent on close to checkpoints and Israeli settlements. total of 4,617 consultations (1,284 in Hebron, donations from the international community. People suffer from depression, anxiety, post- 1,851 in Nablus and 1,482 in Gaza) were pro- Although a mechanism is now in place to traumatic disorder and psychosomatic trou- vided in 2007. Almost half (42 per cent) of alleviate financial pressures and supply bles. They are burdened with symptoms such patients were under 12 years old. medical materials, health workers still do not as disrupted sleep, flashbacks and nightmares. receive full salaries and recurrent strikes in Emergency post-operative programme the public sector have disrupted healthcare MSF supplies psychologists to provide indi- Following violent clashes with the Fatah in access, particularly in the West Bank. MSF vidual and group therapy for children, adoles- May and June, Hamas took control of the Gaza made periodic drug donations in Hebron to cents and adults. This clinical care is aimed at Strip. The violence left more than 1,200 people help cover critical shortages, as well as reducing symptoms and helping people injured and several needing specialised care. donations of drugs and emergency medical develop coping mechanisms. Teams comprise a By July, MSF had established a post-operative material to hospitals in Gaza. psychologist, medical doctor and social care programme to help people recover from worker. The programme has remained flexible their injuries and gain maximum mobility. MSF has worked in the Palestinian Territories since and reactive in order to meet patient needs The service included follow-up consultations, 1988. while operating in a volatile and unpredict- pain management, antibiotic supply and

Sources of Income Medecins Sans Frontieres Audited FACTS AND FIGURES 2007 2006 As part of MSF’s effort to guarantee its independence and strengthen the organisation’s link with society, we strive to maintain a high level of private income. Médecins Sans Frontières (MSF) is an international, medical Programme expenses by country/region Income In Me In % In Me In % In 2007, 90.9 per cent of MSF’s income came from humanitarian organisation that is also private and not-for-profit. Countries/Regions in Me Countries/Regions in Me private sources. More than 3.8 million individual

s a nd f igu r e It is comprised of 19 national branches in Australia, Austria, Belgium, Private Income 518.7 87.6% 488.4 85.9% donors and private funders worldwide made this

ct Canada, Denmark, France, Germany, Greece, Holland, Hong Kong, Africa Asia/Middle East Public Institutional 54.2 9.1% 61.8 10.8%

possible. Public institutional agencies providing Activity Report 06 | Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, the Sudan 40.9 Iraq 10.0 Other Income 19.8 3.3% 18.5 3.2% funding to MSF include, among others, ECHO, the United Kingdom, the United States, and with an international office Democratic Republic Myanmar 8.9 governments of Belgium, Canada, Denmark, Ireland, in Geneva. of the Congo 39.9 India 5.9 Total Income 592.7 100.0% 568.7 100.0% Luxembourg, The Netherlands, Norway, Spain, Chad 25.3 Cambodia 4.9 Sweden, Switzerland and the UK. Audited fa Audited

The search for efficiency has led MSF to create specialised organisa- Somalia 21.9 Thailand 4.2 tions – called satellites - in charge of specific activities such as human- Niger 15.8 Pakistan 3.9

How was the money spent? 07 Expenditure itarian relief supplies, epidemiological and medical research studies, Kenya 13.1 Sri Lanka 2.9 Operations* 439.1 76.1% 431.2 77.0% Expenditures are allocated according to the main and research on humanitarian and social action. They include: Liberia 10.1 Indonesia 2.8 Témoignage 19.4 3.4% 18.0 3.2% activities performed by MSF. ‘Operations’ includes Epicentre, Etat d’Urgence Production, Fondation MSF, MSF Assistance, Uganda 9.8 Palestinian territories 2.4 Other humanitarian activities 9.1 1.6% 7.9 1.4% program-related expenses as well as the headquarters’ MSF Enterprises Limited, Médecins Sans Frontières - Etablissement Ivory Coast 9.0 Georgia 2.3 Total Social Mission 467.6 81.0% 457.1 81.6% support costs devoted to operations. All expenditure d’Utilité Publique, MSF-Logistique, MSF-Supply, SCI MSF, SCI Sabin, Zimbabwe 9.0 Bangladesh 2.1 Fundraising 76.9 13.3% 71.8 12.8% categories include salaries, direct costs and allocated and Wali-Nawaz. As these organisations are controlled by MSF, they Malawi 8.6 Uzbekistan 2.1 Management, general & administration 32.9 5.7% 30.9 5.5% overheads. are included in the scope of the financial statements presented here. Mozambique 8.3 Yemen 1.7 The figures presented here describe MSF’s finances on a combined Central African Republic 8.1 Armenia 1.6 Total Expenditure 577.4 100.0% 559.9 100.0% Permanently restricted funds may either be international level. The 2007 combined international figures have Ethiopia 7.3 Nepal 1.5 Net exchange gains & losses capital funds, where the assets are required by the been set up in accordance with MSF international accounting stand- Sierra Leone 5.3 China 1.5 (realised and unrealised) -3.2 -4.5 donors to be invested, or retained for actual use, ards which comply with most International Financial Reporting Burundi 5.3 Iran 1.3 Surplus/(deficit) 12.1 4.3 rather than expended, or they may be the minimum Standards (IFRS). The figures have been jointly audited by the account- Nigeria 4.9 Other countries* 3.0 compulsory level of retained earnings to be ing firms KPMG and Ernst & Young, in accordance with international Burkina Faso 4.7 * Programs & HQ program support costs Total 62.9 maintained by some of the sections. auditing standards. A copy of the full 2007 financial report may be Guinea 3.5 obtained from the International Office upon request. In addition, each Republic of the Congo 3.0 Americas Unrestricted funds are unspent non-designated national office of MSF publishes annual, audited financial statements South Africa 3.0 Haiti 12.6 Balance sheet In Me In Me donor funds expendable at the discretion of MSF’s according to its national accounting policies, legislation and auditing Zambia 2.9 Colombia 7.5 (year-end financial position): trustees to further our social mission. rules. Copies of these reports may be requested from the national Angola 2.4 Peru 1.7 Non-current assets 37.1 35.8 offices. Cameroon 2.4 Guatemala 1.5 Current assets 61.0 66.2 Other retained earnings represent foundations’ Rwanda 1.2 Other countries* 2.4 Cash & equivalents 350.2 347.5 capital as well as technical accounts related to the The figures presented here are for the 2007 calendar year. All amounts Mali 1.2 Total 25.8 combination process, including the conversion are in millions of euros. Other countries* 1.7 Total assets 448.4 449.5 difference. Europe Permanently restricted funds 2.5 2.5 Total 268.7 NB: Figures in these tables are rounded off and this may result in Chechnya / Ingushetia / 6.3 Unrestricted funds 402.2 389.4 MSF’s retained earnings have been built up over slight addition differences. Russia 2.0 Other retained earnings -14.6 -7.1 the years by surpluses of income over expenses. Italy 1.1 Total retained earnings and equities 390.1 384.7 As of the end of 2007, their available part (the Kyrgyzstan 1.1 Non-current liabilities 3.4 3.7 unrestricted funds decreased by the conversion Belgium 1.0 Current liabilities 52.5 55.5 difference) represented eight months of activity. The Other countries* 1.1 Unspent donor-restricted funds 2.3 5.6 * “other countries” combines all of the countries purpose of maintaining retained earnings is to meet for which program expenses were below 1 Total 12.7 the following needs: future major emergencies for million euros. Total liabilities and retained earnings 448.4 449.5 Where did the money go? which sufficient funding cannot be obtained, and/or a sudden drop of private and/or public institutional Program expenses* by nature Program expenses* by continent HR Statistics funding, and the sustainability of long-term programs (e.g. ARV treatment programs), as well as International departures (full year): 4,134 100% 4,623 100% National Staff | 28% Africa | 72% the pre-financing of operations to be funded by Medical pool 1,117 27% 1,292 28% International Staff | 25% Asia | 17% upcoming public funding campaigns and/or by Nurses & other paramedical pool 1,303 32% 1,500 32% Medical & nutrition | 20% Americas | 7% public institutional funding. Non-medical pool 1,714 41% 1,831 40% Transport, freight, storage | 13% Europe | 3% Logistics & sanitation | 6% Non-allocated | 1% Unspent temporarily restricted funds First time departures (full year): 1,152 (*) 28% 1,332 (*) 29% Operational running costs | 5% are unspent donor-designated funds, which will (*) in % of total international departures Training & local support | 1% be spent by MSF strictly in accordance with the Other expenses | 1% donors’ desire (e.g. specific countries or types of Field positions: 24,348 100% 26,981 100% interventions). International staff 1,994 8% 2,022 7% National staff 22,354 92% 24,959 93%

Pr President | GD General Director | SG Secretary General The Médecins Sans Frontières Charter About this Book

Spanish Edition Coordinator Javier Sancho Translator Pilar Petit Editor Eulalia Sanabra

Graphic Design Studio Roozen, Amsterdam, The Netherlands Printing Kunstdrukkerij Mercurius, Westzaan, The Netherlands

cover Photo Nurse working with MSF treating baby with severe dehydration in Pieri, in Jonglei State (South Sudan) © Sven Torfinn 2007 t MSF Activity Activity MSF Repor

MSF Activity Report 2007