International Activity Report 2013

www.msf.org The MÉdecins Sans Frontières Charter

Médecins Sans Frontières is a private international association. The association is made up mainly of doctors and health sector workers and is also open to all other professions which might help in achieving its aims. All of its members agree to honour the following principles:

Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions.

Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.

Members undertake to respect their professional code of ethics and to maintain complete independence from all political, economic or religious powers.

As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout the world between January and December 2013. Staffing figures represent the total full-time equivalent positions per country at the end of 2013.

Country summaries are representational and, owing to space considerations, may not be comprehensive. For more information on our activities in other languages, please visit one of the websites listed on p.100.

The place names and boundaries used in this report do not reflect any position by MSF on their legal status. Some patients’ names have been changed for reasons of confidentiality. Contents 2 MSF programmes Around The World

4 t he Year in Review Dr Joanne Liu, International President Jérôme Oberreit, Secretary General 4 The year in review 8 overview Of activities

10 Glossary of Diseases and activities

14 South Sudan: A country gripped by violence

16 Addressing Women’s Health Needs

18 CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS

14 South Sudan: A country gripped by violence 22 A Day in the Life: médecins Sans Frontières (MSF) clinic at Dera Murad Jamali, Balochistan, Pakistan

24 Overcoming challenges to meet MSF’s vaccination ambitions

27 activities by country

95 special reports 2013 16 Addressing women’s health needs 96 Facts and figures

100 contact MSF

18 CAR: Descent into chaos

27 Activities by country

Contents 1 MSF programmes around the world

2 MSF programmes around the world 28 Afghanistan 58 Kenya

30 Armenia 60 Lebanon

30 Bolivia 62 Lesotho

31 Bangladesh 63 Libya

32 Bulgaria 63 Madagascar

32 burkina Faso 64 Malawi

33 Burundi 65 Mali

33 cameroon 66 Mauritania

34 Cambodia 66 Morocco

34 China 67 Mexico

35 Colombia 68 Mozambique

36 Central 69 Myanmar African Republic 70 Niger

38 Chad 72 Nigeria

40 Congo 73 Palestine

40 Côte d’Ivoire 73 papua New Guinea 41 Democratic 74 Pakistan People’s Republic 76 Philippines of Korea 78 Paraguay 41 Egypt 78 Russian 42 Democratic Federation Republic of Congo 79 south Africa

44 Ethiopia 80 Somalia

46 France 82 south Sudan

46 Georgia 84 Sudan

47 Greece 85 Swaziland

47 Guinea 86 Syria

48 Haiti 88 sIerra Leone

50 Honduras 88 Tajikistan

50 Iran 89 Turkey

51 Italy 89 Ukraine

51 LAOS 90 Uganda

52 India 91 Uzbekistan

54 IRAQ 91 Zambia

56 Jordan 92 Zimbabwe

57 Kyrgyzstan 94 Yemen

MSF programmes around the world 3 Médecins Sans Frontières The Year in Review Dr Joanne Liu, International President Jérôme Oberreit, Secretary General

In August 2013, Médecins as Central African Republic (CAR) and our time in Somalia, but it was when it South Sudan. Sans Frontières (MSF) pulled became apparent that the parties with whom we were negotiating were in some Since its founding, MSF has faced different out of Somalia after working cases actively involved in, or complacent forms of violence against its patients, staff, towards, violent actions directed against in the country continuously health facilities and medical vehicles, and MSF that we had no choice but to draw for 22 years. has also witnessed targeting of health systems in general. The situation in Somalia, the line. A lack of respect and deliberate The last year has been one of exceptional however, became untenable in 2013 as the violations of medical humanitarianism for circumstances, decisions and compromises, balance could no longer be found between political and financial profit were putting particularly with regards to Somalia and the risks involved, the compromises we the lives of our patients and staff at risk. Syria. We have again seen profiteering from had to make – such as hiring armed guards We withdrew with heavy hearts. humanitarian organisations, in the form and implementing remote management to of robberies and the looting of medical support national staff – and our ability to In Syria, the civil war continued into its third structures, but the most striking thing we provide medical care to the Somali people. year and it is estimated at present that nine have witnessed is the failure of the global Staff members had been threatened, million people are internally displaced in the humanitarian aid system in countries such attacked, kidnapped and even killed during country or have fled abroad as a result of © Giulio Di Sturco

A staff member surveys what remains of the MSF office in Kitchanga, Democratic Republic of Congo, after a wave of violence engulfed the town.

4 The Year in Review Iraq, Turkey and Jordan, MSF continued to continued MSF Jordan, Turkey and Iraq, Lebanon, In purposes. political for used and conflict the in involved those by targeted directly cases many in and respected not large and by was care medical to access how of reminder aforceful limited; extremely manner to the enormous needs remained atimely in respond to and people reach to opportunities the programmes, medical largest our of some running been have should we where acountry in However, undertaken. were vaccinations and MSF by provided were care obstetric and maternal surgery, consultations, andoutpatient wards, Inpatient networks. medical Syrian to given was support and challenge, a constant opposition-held areas where instability was in namely negotiated, be could agreements working where programmes aid operated MSF diseases. chronic or infections of care, immunisations and management the antenatal like requirements everyday for services without are and treatment, medical access to desperate are Syrians Countless polio. and measles as such diseases preventable of outbreaks in resulting collapsed, has system healthcare The and entire cities have been decimated. violence, incessant and ongoing endure to had have Syria in remaining Those homes. their from forced been have Syrians of cent per 40 over that means This violence. the have fledtoneighbouringcountriesescapetheconflict. A youngSyrianrefugeeisexaminedbyanMSFpaediatricianatthemobileclinicinVoenna RampacampinSofia.Thousands ofSyrians

throughout the country. consultations had been provided to people medical 800,000 over and programmes, alongside sevenhealthcare in ongoing CAR MSF emergency were projects delivering 2013, of end the By nine sites. displacement in living were others and bush the in sheltering were people of thousands of Hundreds Cameroon. and Chad as such the border into neighbouring countries crossing them of 245,000 homes, their fled had people million one over that estimated 2014, was it January By divisions. religious throughout the and country inflamed spread clashes political subsequent and March in coup apresidential was there CAR, displacingSudan thousands. In and CAR, South both in violence brutal and instability into adescent marked events Political humanitarian needs of the people affected. other the also but medical the just not tackling alone itself found often MSF yet and lifeline only their was assistance external cases, some In help. medical skilled little with vulnerable, communities entire left that crises acute numerous by punctuated was year The camps. the refugee outside and inside Syrians for healthcare provide Internati onal A

violence, are largely neglected. In 2013, In neglected. largely are violence, banditry, widespread abuse and sexual conflict, increasing to subjected are people where DRC, eastern of areas remote more the stable, considered country the of areas and Goma in focused is it of much DRC, in community aid alarge is there While (DRC). Congo of Republic Democratic in healthcare of lack appalling the and people of displacement repeated the to aresponse was expenditure programme year, MSF’s this largest again Once Sudan. South in suffering human and war civil violence, of crisis agrave become to was what of beginning the only was December refugees. the to aid provide to Uganda as such countries in neighbouring opened programmes and war-wounded; emergency further displaced the for care to opened were projects emergency three and states, nine in 16 programmes operate to continued staff MSF 3,000 than More country. nascent the for stability of hopes destroying and homes their flee to people causing states, five throughout spread quickly army the of factions different between displacement, and in December, fighting caused year the in early Jonglei in violence healthcare, for MSF on part large in rely to come have people where Sudan, South In iv ct i ty R ty eport 2013 T he Y he ear i ear n R ev i e

w 5 © Jodi Hilton 6 T a fast-growing team of international and and international of team a fast-growing had MSF mark two-week the by so, even days; first the within encountered Numerous logistical challenges were while also rebuilding healthcare capacity. providing medical care and relief supplies, by Filipinos the assist to sought MSF feared. than smaller much were needs of the Department of Health, medical preparedness the and workers health local of experience the to due but facilities, health public destroyed followed, that surge storm the and storm, the of force great The November. in Haiyan Typhoon Philippines’ the of survivors assist to pockets their into dug quickly worldwide war, of individuals victims for support financial raise to struggle to continue fundraisers While disaster. anatural of wake the in as strong as never is others of plight the for sympathy public that again once shown were we year This Responding in the Philippines were vaccinated against measles. 15 and years months six between aged children 1.2 million than more total, in vaccination and in campaigns country the and projects emergency of a number undertook MSF rampant. were measles and cholera malaria, as such diseases meant conditions living inadequate and displacement massive caused fighting heavy S Médecins he Y he MSF doctors at Kunduz trauma centre in Afghanistan perform surgery onamanhitbystray bullet. surgery MSF doctorsatKunduz traumacentreinAfghanistan perform ear i ear n R ev i e w ans Frontières ans

been seen at the MSF-supported hospitals. hospitals. MSF-supported the at seen been had what –detailing lightly undertaken not action –an astatement released we and country the in developed had we link through the reliable doctor-to-doctor was the most independent direct witness displaying neurotoxic MSF symptoms. cared for approximately 3,600 people directly had they that Syria of governorate Damascus the in locations three in based doctors MSF-supported from received was 2013. in information out 21 August, On speak and statements public make to MSF compelled that events many were There years. the over positioning public MSF’s of foundation the and movement the by faced challenges operational around debates internal the into awindow offer writings These movement. the of history the through crises different on documents témoignage MSF accessible publicly making website Out ( Speaking the launched MSF October, In situations. extreme in witness bearing about also is it care; of delivery the at stop not does work our but organisation amedical is MSF healthcare to access for out Speaking 37 locations. in clinics mobile running was and centres, health eight and hospitals four in staff local speakingout.msf.org ), ),

respect human dignity. dignity. human respect that conditions living provide to responsible those urging while the all Bulgaria, and Greece Italy, in migrants undocumented for healthcare provide to continued MSF and the Lampedusa centre in Italy was heeded of refurbishment and closure the for calling release press ADecember health. mental and physical residents’ in deterioration to detention centres that are contributing ill-equipped overcrowded, several in migrants Teams treated have states. EU in policies migration repressive and restrictive the about out spoke also MSF East, Middle the and Africa in conflicts from flows refugee steady Witnessing cross-border efforts. obtain the assistance they needed through could aid Damascus-controlled receiving from blocked people that so action take to them urging Geneva, in meeting Syria’ on Group Level ‘High the of states member to letter open an later, sent MSF a week than Less assistance. widespread provide to it possible was humanitarianism, principled with that shown had aid of delivery and staff of MSF’s deployment life. human or for ensure minimum requirements respond adequately to the emergency to failure system’s humanitarian UN the and CAR in situation the about General, Under-Secretary- UN Amos, Valerie to letter open an 12 published On MSF December,

© Mikhail Galustov malaria in areas of high seasonal transmission. in of areas highmalaria seasonal severe from risk at children of health the protect to useful proving is SMC programmes, the of basis the remain sprays and nets of use the including prevention, bite mosquito of methods usual while and treatment antimalarial of acourse received children season, rainy the during months four For 2013.in time first the for Niger in used was Mali, and Chad in effective proven has which measure preventive a WHO-recommended (SMC), Chemoprevention Malaria Seasonal Tackling malaria, tuberculosis and (TB) HIV survival. and treatment their for people in the developing world depend on that and patients of millions for purchases MSF that –drugs HIV including diseases for medicines generic to access blocking extending patents drug and effectively standards for intellectual property, include aggressive agreements trade these launched campaign in 2010.Medicine Both our Off Hands the continuing agreement, trade Commission India–European the as well as nations, 11Rim and Pacific (TPP) being negotiated between the USA Agreementof Transpacific the Partnership light in patients for advocating tirelessly, worked also Campaign MSF’s Access PCV wasusedinthecountry. Children undertwowerevaccinatedwiththepneumococcalconjugatevaccine(PCV)inYida refugeecampinSouthSudanthisyear. Itwasthefirsttime refugee camp in 2011. The issue of incidents 2011. in camp incidents of issue refugee The Kenya’s Dadaab from abducted been had They 21 for months. captivity in held been having after released were Thiebaut Blanca and Serra Montserrat colleagues our note, positive amore On them. for searching actively still is team dedicated a writing, of time the July. At in mission evaluation an on while group armed an by abducted Romy, and were Richard Philippe, Chantal, staff, MSF Congolese four DRC, In Yemen. and Syria Sudan, South Pakistan, Nigeria, Afghanistan, as such places in incidents security localised withstood Teams benefit. own their for a target aid medical make to choose some that reminder aharsh were events year’s The Fire under Care Medical continued.effort early’ treat and early ‘test the Swaziland year, in and this Mozambique of areas in introduced was apatient, in virus HIV of amount the monitors which technology, load Viral TB. and HIV of co-incidence high the tackle to introduced was project Curves the Bending the Africa, South Natal, KwaZulu- In Caucasus. southern the in TB drug-resistant to respond to continued MSF In collaboration with the health authorities, Internati onal A made our work possible over the last year. last the over possible work our made has who everyone thank to opportunity this take to like We would need. of hour their in people million eight than more to care medical delivered world the around teams and of our conflict – supporters uncertainty and losses violence, the by traumatised –many year this crises in caught people of number sheer the and however, challenges, the Despite struggle. uphill an 2013 in like MSF’s work times at felt national teams. medical and international andhealthcare structures of security the and healthcare to access safe patients’ improve to ways identify to hope We project. Fire under Care Medical the in and our impact their response incidents, such 2013,In researching began MSF help. to aim we people the of survival and health the on –have services medical of revocation or suspension – temporary consequences their and events these impact ultimate the for also but security, for only not isconcern, of significant organisations MSFtargeting and other humanitarian iv ct i ty R ty eport 2013 T he Y he ear i ear n R ev i e w 7 © Yann Libessart / MSF Médecins Sans Frontières Overview of activities

Largest country programmes Programme locations based on project expenditure Number of programmes 1. Democratic Republic 6. Niger Africa 240 Americas 24 of Congo 7. Somalia Asia * 108 Europe 11 2. South Sudan 8. Iraq 3. Haiti Pacific 4 9. Chad * Asia includes the Middle East 4. Syria 10. Zimbabwe and the Caucasus 5. Central African Republic

The total budget for our programmes in these 10 countries is 323 million euros, 53 per cent of MSF’s operational budget. 62 % 1 % 2.8 % Percentage of 6.2 % programme Staff numbers portfolio Largest country programmes based on the number of MSF staff in the field. Staff numbers measured in full-time equivalent units. 28 % 1. Democratic Republic of Congo 3,604 2. South Sudan 2,854 3. Haiti 2,324 4. Niger 1,879 5. Central African Republic 1,631 Context of intervention

Number of programmes

Stable 161 Internal instability 88 Outpatient consultations Armed conflict 117 Post-conflict 21 Largest country programmes according to the number of outpatient consultations. This does not include specialist consultations.

1. Democratic Republic of Congo 1,654,100 2. South Sudan 981,500 30 % 3. Niger 916,000

4. Central African Republic 816,300 42 % Percentage of 5. Myanmar 519,100 programme 6. Kenya 415,700 portfolio 7. Afghanistan 370,000 5% 8. Somalia 318,400 9. Mali 308,100 23 % 10. Swaziland 287,800 28 %

8 Overview of activities International Activity Report 2013 2013 activity highlights 9,029,100 18,500 14,200 Outpatient PMTCT – mother Mental health (group) Number of outpatient consultations Number of HIV-positive pregnant Number of group counselling or mental women who received prevention health sessions of mother-to-child transmission 477,70 0 (PMTCT) treatment Inpatient 27,9 0 0 Number of admitted patients 16,800 Cholera Number of people treated for cholera PMTCT – baby 1,871,200 Number of eligible babies born in 2013 Malaria who received post-exposure treatment 2,497, 2 50 Total number of cases treated Measles vaccinations 182,200 Number of people vaccinated against measles in response to an outbreak 233,800 Births Therapeutic Number of women who delivered feeding centres babies, including caesarean sections 129,900 Number of severely malnourished Measles treatment children admitted to inpatient or Number of people treated for measles outpatient feeding programmes 77,350 Surgical interventions 17,10 0 Number of major surgical interventions, 162,400 including obstetric surgery, under Meningitis vaccinations Supplementary general or spinal anaesthesia Number of people vaccinated against feeding centres meningitis in response to an outbreak Number of moderately malnourished children admitted to supplementary 11,100 feeding centres Sexual violence 1,750 Number of patients medically treated Meningitis treatment for sexual violence 341,600 Total number of people treated HIV for meningitis Number of HIV patients registered 29,900 under care at end 2013 Tuberculosis (first-line) Number of new admissions to 325,500 tuberculosis first-line treatment Antiretroviral treatment (first-line) 1,950 Number of patients on first-line antiretroviral treatment at end 2013 Tuberculosis (second-line) Number of new admissions to MDR tuberculosis treatment, second-line drugs 5,500 Antiretroviral treatment 141,100 (second-line) This data groups together direct, remote support Number of patients on second-line Mental health (individual) and coordination activities. Note: these highlights give an overview of most MSF activities but cannot antiretroviral treatment at end 2013 Number of individual mental health be considered exhaustive. (first-line treatment failure) consultations

Overview of activities 9 Médecins Sans Frontières Glossary of diseases and activities Chagas disease Vibrio cholerae bacterium. It is transmitted HIV/AIDS by contaminated water or food, or direct Chagas disease is found almost exclusively The human immunodeficiency virus (HIV) is contact with contaminated surfaces. In in Latin America, although increased transmitted through blood and body fluids non-endemic areas, large outbreaks can global travel and migration have led and gradually breaks down the immune occur suddenly and the infection can spread to more cases being reported in North system – usually over a three- to 15-year rapidly. Most people will suffer only a America, Europe, Australia and Japan. period, although 10 years is more usual mild infection, but the illness can be very Chagas is a parasitic disease transmitted – leading to acquired immunodeficiency severe, causing profuse watery diarrhoea by triatomine bugs, which live in cracks syndrome, or AIDS. As the virus progresses, and vomiting that can lead to severe in the walls and roofs of mud and straw people begin to suffer from opportunistic dehydration and death. Treatment consists housing. It can also be transmitted through infections. The most common opportunistic blood transfusions or to the foetus during of a rehydration solution – administered infection that leads to death is tuberculosis. pregnancy, and, less frequently, through orally or intravenously – which replaces organ transplants. A person with Chagas fluids and salts. Cholera is most common in Simple blood tests can confirm HIV status, but often feels no symptoms in the first, acute densely populated settings where sanitation many people live for years without symptoms stage of the disease. Then the chronic is poor and water supplies are not safe. and may not know they have been infected with HIV. Combinations of drugs known as stage is asymptomatic for years. Ultimately, As soon as an outbreak is suspected, antiretrovirals (ARVs) help combat the virus however, debilitating complications develop patients are treated in centres where and enable people to live longer, healthier lives in approximately 30 per cent of people infection control precautions are taken without their immune systems deteriorating infected, shortening life expectancy by an to avoid further transmission of the rapidly. ARVs also significantly reduce the average of 10 years. Heart complications disease. Strict hygiene practices must be likelihood of the virus being transmitted. such as heart failure, arrhythmia and implemented and large quantities of safe cardiomyopathy are the most common water must be available. As well as treatment, MSF’s comprehensive cause of death for adults. HIV/AIDS programmes generally include MSF treated 27,900 people for cholera in 2013. education and awareness activities, condom Diagnosis is complicated, requiring distribution, HIV testing, counselling and laboratory analysis of blood samples. There prevention of mother-to-child transmission are currently only two medicines available (PMTCT) services. PMTCT involves the to treat the disease: benznidazole and Health promotion administration of ARV treatment to the mother nifurtimox, which were both developed during and after pregnancy, during labour and over 40 years ago. The cure rate is almost Health promotion activities aim to improve breastfeeding, and to the infant just after birth. 100 per cent in newborns and infants, but health and encourage the effective use of health services. Health promotion is a two- as the gap between the date of infection MSF provided care for 341,600 people living way process: understanding the culture and and the beginning of treatment lengthens, with HIV/AIDS and antiretroviral treatment for practices of a community is as important as the cure rate declines. 331,000 people in 2013. providing information. The treatment currently used can be toxic and can take longer than two months to During outbreaks of disease or epidemics, complete. Despite the clear need for more MSF provides people with information on Kala azar (visceral leishmaniasis) efficient and safer medication, there are few how the disease is transmitted and how Largely unknown in high-income countries new drugs in development. to prevent it, what signs to look for, and (although it is present in the Mediterranean what to do if someone becomes ill. If MSF basin), kala azar – Hindi for ‘black fever’ – MSF treated 4,500 patients for Chagas disease is responding to an outbreak of cholera, is a tropical, parasitic disease transmitted in 2013. for example, teams work to explain the through bites from certain types of sandfly. importance of good hygiene practices, It is endemic in 76 countries, and of the because the disease is transmitted through estimated 200,000–400,000 annual cases, contaminated water or food, or direct Cholera 90 per cent occur in Bangladesh, India, contact with contaminated surfaces. Ethiopia, South Sudan, Sudan and Brazil. Kala Cholera is a water-borne, acute azar is characterised by fever, weight loss, gastrointestinal infection caused by the

10 Glossary of diseases and activities International Activity Report 2013

enlargement of the liver and spleen, anaemia and immune-system deficiencies. Without treatment, kala azar is almost always fatal.

In Asia, rapid diagnostic tests can be used for diagnosis of the disease. However, these tests are not sensitive enough for use in Africa, where diagnosis often requires microscopic examination of samples taken from the spleen, bone marrow or lymph nodes. These are invasive and difficult procedures requiring resources that are not readily available in developing countries.

Treatment options for kala azar have evolved during recent years. Liposomal amphotericin B is becoming the primary treatment in Asia, either alone or as part of a combination VII therapy. This is safer and involves a shorter course of treatment than previously used medication. However, it requires intravenous administration, which remains an obstacle to its use in local clinics. In Africa, the best © Seamus Murphy/ available treatment is still a combination of The triatomine bug, also known as the ‘kissing bug’, carries the parasite that causes pentavalent antimonials and paromomycin, Chagas. The disease can be asymptomatic for years but can be fatal if left untreated. which requires a number of painful injections. Research into a simpler treatment is underway and it is hoped it will soon be available. Malnutrition Measles Co-infection of kala azar and HIV is a major A lack of food or essential nutrients causes Measles is a highly contagious viral challenge, as the diseases influence each other malnutrition: children’s growth falters and disease. Symptoms appear between in a vicious spiral as they attack and weaken their susceptibility to common diseases eight and 13 days after exposure to the the immune system. increases. The critical age for malnutrition virus and include a runny nose, cough, is from six months – when mothers eye infection, rash and high fever. MSF treated 5,300 patients for kala azar in 2013. generally start supplementing breast There is no specific treatment for measles milk – to 24 months. However, children – patients are isolated and treated with under five, adolescents, pregnant or vitamin A, and for any complications: breastfeeding women, the elderly and these can include eye-related problems, Malaria the chronically ill are also vulnerable. stomatitis (a viral mouth infection), Malaria is transmitted by infected mosquitoes. dehydration, protein deficiencies and Symptoms include fever, pain in the joints, Malnutrition in children can be diagnosed headaches, repeated vomiting, convulsions in two ways: it can be calculated from respiratory tract infections. and coma. Severe malaria, nearly always measurements of weight and height, Most people infected with measles recover caused by the Plasmodium falciparum parasite, or by measurement of the mid-upper within two to three weeks, and mortality causes organ damage and leads to death if arm circumference. According to these rates in high-income countries are low. left untreated. MSF field research has helped measurements, undernourished children In developing countries, however, the prove that artemisinin-based combination are diagnosed with moderate or severe mortality rate can be between 3 and 15 per therapy (ACT) is currently the most effective acute malnutrition. treatment for malaria caused by Plasmodium cent, rising to 20 per cent where people falciparum. In 2010, World Health Organization MSF uses ready-to-use food (RUF) to treat are more vulnerable. Death is usually guidelines were altered to recommend the use malnutrition. RUF contains fortified milk due to complications such as diarrhoea, of artesunate over artemether injections for the powder and delivers all the nutrients that dehydration, encephalitis (inflammation of treatment of severe malaria in children. a malnourished child needs to reverse the brain) or severe respiratory infection. deficiencies and gain weight. With a long Long-lasting insecticide-treated bed nets are shelf-life and requiring no preparation, A safe and cost-effective vaccine against one important means of controlling malaria. these nutritional products can be used measles exists, and large-scale vaccination In endemic areas, MSF distributes nets to in all kinds of settings and allow patients campaigns have significantly decreased pregnant women and children under the age to be treated at home, unless they are the number of cases and deaths. However, of five, who are most vulnerable and have suffering severe complications. In situations coverage remains low in countries with the highest frequency of severe malaria. Staff where malnutrition is likely to become weak health systems and in areas where advise people on how to use the nets. severe, MSF takes a preventive approach, there is limited access to health services, distributing nutritional supplements to leaving large numbers of people susceptible In 2012, MSF used a seasonal chemoprevention at-risk children to prevent their condition to the disease. strategy for the first time, in Chad and from deteriorating further. Mali. Children up to five years old took oral MSF treated 129,900 patients for measles antimalarial treatment monthly over a period or MSF admitted 250,900 malnourished patients and vaccinated 495,250 people in response three to four months during the peak season for to nutrition programmes in 2013. to outbreaks in 2013. the disease. In 2013, this was introduced in Niger.

MSF treated 1,871,200 people for malaria in 2013.

continued overleaf

Glossary of diseases and activities 11 Médecins Sans Frontières

continued Glossary of diseases and activities Relief items distribution often results in increased levels of violence, including sexual violence. Sexual violence is MSF’s primary focus is on providing particularly complex and stigmatising and has medical care, but in an emergency teams long-lasting consequences and can result in Meningococcal meningitis often distribute relief items that contribute important health risks. Meningococcal meningitis is a bacterial to physical and psychological survival. Such infection of the thin membranes surrounding items include clothing, blankets, bedding, MSF medical care for victims of sexual violence the brain and spinal cord. It can cause shelter, cleaning materials, cooking utensils covers preventive treatment against sexually sudden and intense headaches, fever, nausea, and fuel. In many emergencies, relief transmitted infections, including HIV, syphilis vomiting, sensitivity to light and stiffness of items are distributed as kits – cooking kits and gonorrhoea, and vaccinations for tetanus the neck. Death can follow within hours of contain a stove, pots, plates, cups, cutlery and hepatitis B. Treatment of physical injuries, the onset of symptoms. Up to 50 per cent of and a jerrycan so that people can prepare psychological support and the prevention and people infected will die without treatment. meals, while a washing kit includes soap, management of unwanted pregnancy are also shampoo, toothbrushes, toothpaste and part of the systematic care. MSF provides a Six strains of the bacterium Neisseria laundry soap. medical certificate to all victims of violence. meningitidis (A, B, C, W135, X and Y) are known to cause meningitis. People can be Where people are without shelter, and Medical care is central to MSF’s response carriers without showing symptoms and materials are not locally available, MSF to sexual violence, but stigma and fear may transmit the bacteria when they cough or distributes emergency supplies – rope and prevent many victims from coming forward. sneeze. Cases are diagnosed through the plastic sheeting or tents – with the aim of A proactive approach is necessary to raise examination of a sample of spinal fluid and ensuring a shelter. In cold climates more awareness about the medical consequences treatment consists of specific antibiotics. substantial tents are provided, or teams try of sexual violence and the availability of care. However, even with treatment, 10 per cent to find more permanent structures. Where MSF sees large numbers of victims or more patients will die and as many as one – especially in areas of conflict – advocacy in five survivors may suffer from after effects, MSF distributed 146,650 relief kits in 2013. action aims to raise awareness among local including hearing loss and learning disabilities. authorities, as well as the armed forces when Meningitis occurs throughout the world, they are involved in the assaults. but the majority of infections and deaths are Reproductive healthcare MSF medically treated 11,100 patients for in Africa, particularly across the ‘meningitis Comprehensive neonatal and obstetric sexual violence-related injuries in 2013. belt’, an east–west geographical strip from care form part of MSF’s response to any Ethiopia to Senegal, where epidemics are emergency. Medical staff assist births most likely to be caused by meningococcus A. and perform caesarean sections where A new vaccine against this strain provides necessary and feasible, and sick newborns Sleeping sickness protection for at least 10 years and even and babies with a low birth weight receive (human African prevents healthy carriers from transmitting medical care. the infection. Large preventive vaccination trypanosomiasis) campaigns have now been carried out in Many of MSF’s longer-term programmes Generally known as sleeping sickness, human Benin, Burkina Faso, Cameroon, Chad, offer more extensive maternal healthcare. African trypanosomiasis is a parasitic infection Ghana, Mali, Niger, Nigeria, Senegal and Several antenatal visits are recommended transmitted by tsetse flies that occurs in Sudan and have resulted in a decrease in the so that medical needs during pregnancy sub-Saharan Africa. In its latter stage, it attacks number of new cases. are met and potentially complicated the central nervous system, causing severe deliveries can be identified. After delivery, neurological disorders and frequently death. MSF treated 1,750 patients for meningitis and postnatal care includes medical treatment, More than 95 per cent of reported cases are vaccinated 162,400 people against the disease counselling on family planning and caused by the parasite Trypanosoma brucei in response to outbreaks in 2013. information and education on sexually gambiense, which is found in western and transmitted infections. central Africa. The other 5 per cent of cases are caused by Trypanosoma brucei rhodesiense, Mental healthcare Good antenatal and obstetric care can which is found in eastern and southern Africa. prevent obstetric fistulas. An obstetric Traumatising events – such as suffering or fistula is a hole between the vagina and During the first stage, the disease is relatively witnessing violence, the death of loved ones rectum or bladder that is most often a easy to treat but difficult to diagnose, as or the destruction of livelihoods – are likely result of prolonged, obstructed labour. symptoms such as fever and weakness are to affect a person’s mental wellbeing. MSF It causes incontinence, which can lead to non-specific. The second stage begins when provides psychosocial support to victims of social stigma. Around two million women the parasite invades the central nervous system trauma in an effort to reduce the likelihood are estimated to have untreated obstetric and the infected person begins to show of long-term psychological problems. fistulas; there are between 50,000 and neurological or psychiatric symptoms, such as 100,000 new cases each year. A number poor coordination, confusion, convulsions and Psychosocial care focuses on supporting of MSF programmes carry out specialist sleep disturbance. Accurate diagnosis of the patients to develop their own coping strategies obstetric fistula repair surgery. after trauma. Counsellors help people to illness requires a sample of spinal fluid. talk about their experiences and process MSF held more than 703,900 antenatal Nifurtimox-eflornithine combination their feelings so that general stress levels are consultations in 2013. therapy or NECT, developed by MSF, Drugs reduced. MSF also offers group counselling, for Neglected Diseases initiative (DNDi) as a complementary approach. and Epicentre, is now the World Health Organization recommended protocol. NECT MSF staff held 155,300 individual and group Sexual violence counselling sessions in 2013. is much safer than melarsoprol, the drug that Sexual violence occurs in all societies and in all was previously used to treat the disease, and contexts at any time. Destabilisation of contexts which is a derivative of arsenic. Melarsoprol

12 Glossary of diseases and activities is now being used, but it is costly and still still and costly is it but used, being now is resistance drug of level acertain detect and hours two just after results give can that test molecular A new children. from obtain to difficult be can which sample, fluid gastric or asputum on depends TB of Diagnosis HIV. with people among death, of cause aleading is and higher, much is incidence TB death. to lead-up the in breathlessness and pain chest loss, fever, weight cough, apersistent include Symptoms lungs. the affects often most disease The lives. their in point some at TB active develop will cent 10 but ill, per becomes TB with infected everyone Not sneeze. or cough people infected when air the through spread is TB it. from die 1.5 and million TB active develop people million nine year, about Every bacillus. (TB) tuberculosis the with infected currently is population world’s the of One-third Tuberculosis sickness treatment in 2013. in treatment sickness sleeping 1,800 for MSF admitted patients orally. administered be can that disease the of stages both for treatment effective asafe, of development the to lead will trial clinical under currently molecules new the that hoped is It patient. the kill even can and effects side many causes Supplies areunloadedatMSF’s tenthospitalinGuiuantheaftermathofTyphoon HaiyaninthePhilippines. conjugate, polio, rotavirus, rubella and and rubella rotavirus, polio, conjugate, pneumococcal measles, papillomavirus, human tuberculosis), BCG (against (Hib), Haemophilius B, influenzae hepatitis pertussis), tetanus, are DTP (diphtheria, World Health Organization. Currently, these the by children for recommended vaccines of aseries by preventable are that diseases from year every die people million two approximately that estimated is it However, health. public in interventions medical cost-effective most the of one is Immunisation Vaccinations for MDR-TB in 2013. in MDR-TB for 1,950MSF 29,900 and treated TB for patients limited. are XDR-TB for options treatment The MDR-TB. for administered drugs line second- the to resistance show patients when identified is (XDR-TB) tuberculosis drug-resistant Extensively effects. side many causing and years two to up taking arduous, is regimen drug the but treat, to impossible not is MDR-TB (MDR-TB). TB multidrug-resistant have to considered are they antibiotics, first-line powerful most two the to resistant are patients When months. six of aminimum takes TB uncomplicated for treatment of A course reliable power supply. a as well as sample, aphlegm requires Internati type b type onal A facilities and ensure hygiene good practices. of use the promote to campaigns information conduct Staff in. trucked is containers in by, close water found be cannot source water safe a Where priorities. first the among are disposal waste and water Drinking sanitation. adequate and water safe of provision the in assists MSF emergencies, In it where works. facilities health the all in system management waste a and supply water aclean is there sure make teams MSF activities. medical to essential are sanitation good and water Safe Water sanitation and hundreds of thousands of people. people. of thousands of hundreds reach can and weeks three and two between lasts campaign Atypical gather. to likely are people where places in posts vaccination of set-up the as well as immunisation of benefits regarding the activities awareness-raising vaccination campaignsinvolveLarge-scale meningitis. and fever yellow measles, of outbreaks to MSF’s of response part key a forms also Vaccination programme. healthcare basic its of part as possible when five under children for vaccinations routine offer to strives low, MSF generally is coverage vaccination where countries In recommended everywhere. are vaccines all not –although fever yellow iv ct G lossary o lossary i ty R ty f d i seases and act and seases eport 2013 i v i t i es © Francois Dumont / MSF 13 Médecins Sans Frontières South Sudan: A country gripped by violence South Sudan gained independence from Sudan in July in hiding though, requests for government permission to travel to opposition-held 2011, becoming Africa’s first new country since Eritrea in territory were repeatedly denied. 1993. Since then, however, hopes for the future of the young December violence state have slowly crumbled and in 2013, as the government In Juba, amid a power struggle inside the collapsed and intercommunal violence reached explosive ruling Sudan People’s Liberation Movement levels, South Sudan edged towards civil war. (SPLM), South Sudan’s president, Salva Kiir, sacked his cabinet in July and so rid himself Jonglei state has seen some of the worst South Sudan, and what takes a matter of of his main political rival, vice-president violence since independence, a result of hours to destroy can take months or even Riek Machar. What started as a political conflicts that are rooted in cattle raiding. years to reconstruct, leaving many thousands dispute exacerbated ethnic tensions in an In March, however, the situation became of people without adequate healthcare. already divided country. On 15 December, even more unstable as the army launched an fighting broke out between battalions of offensive against a rebel group led by David As the fighting in Jonglei state intensified, the Sudan People’s Liberation Army (SPLA), Yau Yau. In April, Médecins Sans Frontières almost the entire population of Pibor county spilled onto the streets of the capital and (MSF) was forced to suspend activities in sought refuge in the bush. People were resulted in Kiir accusing Machar of an Pibor because of threats against staff and too afraid to leave their hiding places to attempted coup d’état. Conflict subsequently patients and was preparing to return in May, seek medical attention, and so MSF went spread throughout the country, between having secured the necessary assurances, to them: a small clinic was set up in Boma those loyal to the government and those when the hospital in Pibor was looted and town, staff continued to run a health post in supporting the former vice-president. rendered unusable. This was the sixth time Gumuruk, and mobile clinics – some carried Civilians sought shelter in UN bases and an MSF medical facility had been looted or out by helicopter – conducted hundreds of in the bush, and many others crossed into damaged in Jonglei state in two years. It is consultations in the bush in southern Pibor. neighbouring countries such as Uganda, difficult and expensive to build hospitals in Before MSF could deliver assistance to those Ethiopia and Kenya. © Corinne Baker / MSF

A hepatitis E ward at MSF’s hospital in Batil refugee camp, Maban county.

14 south Sudan: A country gripped by violencE of who fled conflict in Sudan’s South Kordofan Kordofan South Sudan’s in conflict fled who of majority the refugees, Sudanese of thousands of hundreds to home also is Sudan South that 2013, in forgotten be country could it nascent the of hold took that instability and displacement internal mass the Amid Sudanese refugees flood. to begin settlements and starts season rainy the once exacerbated be only will situation the and large loomed Minkamman and Awerial as such camps makeshift in disease of risk the population, weakened already an and place, in infrastructure little very With a priority. were children for vaccinations measles and water Clean drinking donating medicines. and care obstetric and consultations providing by clinics Health of Ministry two supported team MSF’s and emergency state, Lakes in Nile the of banks the on Awerial, of town the to fled civilians of Thousands violence. December the after rebels the to fall to area major first the was It control. for battled (SPLM-IO) SPLM-in-Opposition and troops government as year the of end the by town aghost become had state, Jonglei of capital bustling once Bor, the concerns.safety to owing hospital Leer from evacuated be to had staff month, same the In violence. of outbreaks to due access safe gain to unable were staff because state, Nile Upper Malakal, in hospital the at days two for activities suspended MSF deteriorated, Sudan South in situation the As supplies. medical and drugs with Hospital Teaching Juba provided also and camps, both in clinics up set MSF compounds. UN two in sheltered and lives their for fled 15 on people Juba December, of vicious fighting eruption in the Following The MSFhospitalinPiborafterithadbeenpurposefullydamagedtorenderinoperable.

South Sudan for 30 years and even before before even and years 30 for Sudan South now is what in working been has MSF August. in state, Unity camp, Yida in Sudan South in time first the for used was vaccine conjugate pneumococcal The location. a remote such in scale, large a such on measure apreventive as vaccine oral two-dose the used had MSF time first this was the immunised against cholera; were county Maban of 27,500 residents and refugees Sudanese 105,000 than more 2013. in April, campaigns In vaccination of anumber ran MSF Sudan. with border the near camps in mortality on impact a major had have Eoutbreaks hepatitis and a threat, all are measles and malaria cholera, states, Nile Upper and Unity in camps refugee In 2011 in states 2012. and Nile Blue and The conflictinSouthSudanhasdisplacedhundredsofthousandspeople. Internati

onal A

S outh S outh –83 pp.82 report, country the see Sudan, MSF’s South of in details response more For worse. dramatically become to poised was Sudan South in situation the aclose to 2013 as December, in drew organisations international of departure the to due scarcer resources and ever-greater growing needs people’s interethnic increasing, tensions With acute needs. on focused projects long-running ongoing, leaving staff meant it if even accordingly where needs were greatest, and responding identifying became year, MSF’s priority the of end the By roads. any barely and swamps, rivers, with region, abarren is This achallenge. was it providing and limited was healthcare to access conflict latest this country gr Acountry udan: iv ct i ty R ty eport 2013 i pped by v by pped i olenc .

© Jean-Pierre Amigo / MSF © MSF E 15 Médecins Sans Frontières Addressing women’s health needs Pregnancy and birth do not Sexual violence occurs everywhere, after birth is recommended, either at the but it tends to be more prevalent in maternity unit or in the community. stop because of a conflict crisis situations. The majority of people or crisis, and neither do any presenting after incidents of sexual violence Consequences of unwanted pregnancy of the associated medical in MSF projects are women and children, and unsafe abortion but men are also coming forward. All MSF Of the four main causes of maternal complications. Pregnant operations are prepared to provide medical mortality, unsafe abortion is the one that is women make up five per cent and psychological care to victims of sexual entirely preventable. Worldwide, it accounts violence, as well as medico-legal certificates. for approximately 13 per cent of all maternal of a general population at deaths; the figures are much higher in any given time but among Complications during and after birth some regions such as Latin America and refugees and displaced Most maternal deaths occur during or in areas where the population is living in immediately after birth, and MSF’s primary displacement camps. people, the percentage is commitment, therefore, is the provision often higher. In general, there of skilled obstetric and neonatal care. Girls and women with complications resulting are more women in displaced In 2013, over one-third of MSF projects from unsafe abortion frequently arrive in the offered obstetric care, and half of them had emergency rooms of MSF facilities. Some come populations because often the the surgical capacity to perform a caesarean in bleeding and distressed, rather than in any men are fighting or have stayed section when needed. Maternal mortality real danger, and counselling and support behind to protect property. in the maternity wards supported by MSF is will be all that they need. Others arrive with low, which shows that even in remote areas life-threatening complications and may require of Afghanistan, for example, obstetric and antibiotics, surgery, blood transfusions or time Over the last 20 years, aid organisations neonatal care can and should be provided. in intensive care, or all of the above. have learned that the specific needs of MSF also treats women who have given women have to be addressed as part of an birth at home and who arrive with postnatal Experience shows that many women and emergency response. Trends in maternal complications such as a retained placenta, girls will seek unsafe abortion to terminate mortality1 reveal a 47 per cent reduction in severe bleeding or infection. an unwanted pregnancy if no safe abortion the number of maternal deaths worldwide care is available. They will do so risking between 1990 and 2010. This data is Most post-partum complications for both their life, sometimes knowingly, because the encouraging, but the reality of girls and mothers and newborns occur in the first alternative is unbearable. MSF provides safe women in many parts of the world has 24 hours, and for this reason MSF encourages abortion care to women and girls in need, changed little. Differences between areas of women to stay in the maternity unit for whenever this is feasible. the world are huge: in developed regions one day after delivery. This allows for early one in every 3,800 women risks dying diagnosis and treatment of complications, MSF also makes a choice of contraceptives from pregnancy- or childbirth-related and also supports the breastfeeding mother. available and provides information and complications, while in developing regions, At least one follow-up visit in the first week counselling to girls and women who want to it is one in 180 women, and in sub-Saharan Africa, one in 39 women.

In many situations where Médecins Sans Frontières (MSF) works, obstetric care is in a constant state of emergency; national © Laurence Geai health systems are disrupted, there are staff shortages, low salaries and little or no supplies. Conflict and crises further exacerbate the situation.

MSF’s work with regards women’s health focuses primarily on action that directly impacts mortality and suffering: obstetric and newborn care, postnatal care and safe abortion. MSF also offers a range of preventive actions that are known to contribute significantly to the reduction of maternal morbidity and mortality: antenatal care, the provision of contraceptives, prevention of mother-to-child transmission (PMTCT) of HIV/AIDS, and cervical cancer screening and treatment in pilot projects. Sonia is resting with her newborn baby, after delivering in the MSF hospital in M’Poko camp, In some programmes, MSF provides Central African Republic. obstetric fistula repair.

16 Addressing Women’s Health Needs offer obstetric care. obstetric offer they longer term or emergency projects, be interventions, Today, MSF all of athird possible. whenever care necessary the provides and needs, medical specific very have girls and women that recognises MSF no access to healthcare. quality is there where especially mortality, maternal high to contribute that factors all are these multiple sexual pregnancies, violence: pregnancy, teenage mutilation, genital female marriage, Early women. and girls to attribute communities and societies that roles the of aresult are death maternal prevent to drive the in challenges major the of Many The challenge of societal roles hospitalisation. for need the without visit, same the in removed be can through a simple colouring method colouring asimple through eye the to visible made are cells Abnormal treating cervical cancer in its early stages. early its in cancer cervical treating and screening started has MSF projects, AIDS are particularly vulnerable. particularly are AIDS HIV/ with those and countries, developing in live cancer cervical from die who women of majority The worldwide. women in death cancer-related of cause main the is cancer cancer, cervical breast After Cervical cancer babies. their for care follow-up have and finished arranges breastfeeding they after care HIV continuous for women refers also MSF possible, Wherever birth. and their babiesimmediately treats after positive tested have who women to treatment is possible, and MSF provides appropriate PMTCT infants. in infection HIV of source main the –is breastfeeding through and birth and pregnancy –during baby to mother from virus HIV the of transmission The birth. after or during also but care, antenatal their of part as primarily women, pregnant all to testing HIV, offers of MSF rate ahigh with areas In unit. maternity the at deliver to women encourage to and preparation birth discuss to conditions the mother and that baby, affect medical treat and manage diagnose, to opportunity this uses MSF pregnancy. their in late clinic, MSF an at consultation antenatal one attend only may women Some mothers. expectant with connect to staff health for way important an is it but death, maternal prevent not does alone care Antenatal care antenatal of role The child. another carrying risk to willing are they not or whether decide also can complications life-threatening experienced have who Women one. next their of timing the plan to children have and women who enables alreadypregnancy first their delay to women young allows of preventing unwanted It pregnancies. method best the is Contraception so. do to aposition in are and pregnancies, their plan 2 In some 4 and and 3

1  WHO, UNICEF, UNFPA and The World Bank estimates – WHO 2012. –WHO estimates Bank World The and UNFPA UNICEF, WHO, more frequent and develops much faster. faster. much develops and frequent more After thetyphoon,hismotherwalked forseveraldaystoreachmedicalhelp. A babyboydeliveredbycaesarean sectionatBethanyhospital,Tacloban, inthePhilippines. femmes inAbéché,Chad. Having successfullyundergoneobstetricfistulasurgery, Nafissarecuperatesinthevillagedes © Mikhael De Souza / MSF Internati 3 Pre-cancerous lesions. lesions. Pre-cancerous onal A Obstetricfistularepair Safeabortioncare(providedor PMTCT Sexualviolencecare Postnatalcare Contraception(consultations) Caesareansections Vaginal deliveries Antenatalcare(1stvisit) referred toaqualityprovider) iv ct A ddress 4 VILI/VIA diagnosis VILI/VIA 2 In HIV-infected women, cervical cancer is cancer cervical women, HIV-infected In i ty R ty i ng Wo ng m eport 2013 en’s H en’s ealth N ealth

114,356 138,069 164,553 340,306 18,489 11,062 17,681 eeds 17 eeds 804 683 © Yann Libessart / MSF

CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS

Central African Republic (CAR) has known decades of violence, displacement and lack of medical access, and Médecins Sans Frontières (MSF) has been working there since 1996. This year, however, the country was confronted with a massive humanitarian crisis to which many in the international community, and the world in general, remained largely indifferent.

Towards the end of 2012, the Séléka – left for Cameroon (he himself had taken shortages and malnutrition, and with an a coalition of rebel groups mainly from the power by force in 2003), state security forces increased threat of malaria. Despite the north and east of the country – made their were disbanded, and rebel Michel Djotodia huge rise in people’s needs, however, way towards the capital, Bangui. En route proclaimed himself president, suspended the humanitarian presence in the country they took control of numerous towns and the constitution and dissolved parliament. reached an almost record low. Many UN villages, forcing residents to flee into the In August he was officially sworn in. agencies and NGOs withdrew to the capital bush to escape the violence. The presence of The coup left the country in chaos, and due to the lack of security, leaving much the Séléka exacerbated the ongoing conflict widespread violence and looting ensued as of the country without aid. In light of the between farmers and pastoralists, and CAR’s CAR remained at the mercy of armed groups. situation on the ground MSF felt compelled armed forces, FACA, withdrew from areas to publish an open letter to Valerie Amos, where they had been integral to keeping Djotodia announced in September that he UN Under-Secretary-General, on the situation under control. The anti-balaka had officially disbanded the Séléka coalition, 12 December, citing the ‘unacceptable (anti-machete) traditional self-defence but many fighters refused to put down their performance of the United Nations groups started fighting the Séléka whom weapons. They committed atrocities against humanitarian system in the Central African they perceived as pro-Muslim for favouring civilians, and the anti-balaka – its ranks swelled Republic over the last year’ and Arjan the pastoralists from the north. with former soldiers, gangs and other self- defence groups – reciprocated with attacks on Hehenkamp, General Director of MSF Despite signing a peace deal with the members of the Muslim community. in the Netherlands, wrote a piece for government in January, the Séléka marched The Guardian newspaper stating that on Bangui in March and seized power Displaced people found themselves living ‘The aid world has failed the people of claiming unfulfilled promises. President Bozizé without access to safe water, facing food the Central African Republic’. © Camille Lepage / Polaris

Thousands of people fled to M’poko airport in Bangui to escape Séléka gunmen in August, blocking the runway and preventing flights from landing. By December MSF’s airport clinic was addressing the medical needs of more than 100,000 displaced people who had taken refuge in the makeshift camp.

18 CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS Bossangoa, 30,000 people sought refuge in the grounds of the Catholic mission, mission, Catholic the of grounds the in refuge sought people 30,000 Bossangoa, homes to escape vigilantes armed with machetes and guns. In September in September In guns. and machetes with armed vigilantes escape to homes Since the start of the conflict, tens of thousands of people have fled their their fled have people of thousands of tens conflict, the of start the Since and 8,000 people from the Muslim community sheltered in a mosque. amosque. in sheltered community Muslim the from people 8,000 and A CENTRAL F R I REPUBL CAN I C I : DESCENT burned to the ground. ground. the to burned Once the violence had had violence the Once shelter in the Catholic Catholic the in shelter subsided, MSF helped helped MSF subsided, 400 families who had had who families 400 On 9 September, the the 9September, On anti-balaka targeted anti-balaka mission compound. compound. mission were executed, and and executed, were and buildings were were buildings and the bush or sought sought or bush the Cmle Lepage /Polaris Camille © the town of Bouca Bouca of town the lost their homes. homes. their lost civilians fled into into fled civilians Séléka fighters fighters Séléka CHAOS NTO

19 © Juan Carlos Tomasi / MSF 20

interrupted and levels of malnutrition and malaria have increased. increased. have malaria and malnutrition of levels and interrupted been have regimens treatment HIV place, taken not have vaccinations routine as civilians, of healthcare the impacted heavily has crisis the world, the in indicators health worst the of some has already which people, million 4.5 over of acountry In facilities. sanitation to access little with conditions precarious in living are all –but killer one number –CAR’s malaria contracting of risk at particularly are bush the in Those airstrip. the to next and aschool in hospital, the in compound, mission Catholic the in safety, for groups large in sheltering are People treatment. for hospital MSF-supported the to Bossangoa in church the at acamp from rushed being is above pictured woman The A CENTRAL © Marcus Bleasdale / VII F R I REPUBL CAN I C I : DESCENT CHAOS NTO

© Camille Lepage / Polaris “ Bria bush, the in refuge took who person Displaced Josianne four residents of Bangui had been displaced. displaced. been had Bangui of residents four in one that estimated Affairs Humanitarian of Coordination the for Office UN the began, unrest the after days Ten threats. amid fled staff health and looted, and attacked was hospital, main Bangui’s Hospital, Amitié arms. and hands heads, their to injuries defensive with presented people many and hospital, the at seen were beaten and tortured been and machete wounds. Patients who had gunshot for predominantly December, early during aday 15 wounded 20 to treating were teams MSF Hospital, Community the At MSF treated hundreds of wounded people. ex-Séléka. the for bases political potential as areas these saw they as country, the of west and north the in communities Muslim against of number the increased attacks anti-balaka The withdrew. ex-Séléka the as country the around place took Muslims followed by against killings revenge Christians Attacks on ex-Séléka. the disarm to troops French of arrival the after offensive an through Bangui groups as armed launched swept violence of awave 5December, On yourself what state we are in. We want peace. We want in. are we state what yourself for You see can running. always We are illnesses. many too are There mosquitoes. by bitten are we well, eat don’t we bush, the in sleep we flee, we started, all this Since

” For more details on MSF’s response in CAR, see the country report, pp. 36–37. pp. report, country the see CAR, in MSF’s on response details more For fear. in live CAR of population the and continues violence The needed. is intervention international more However, even operations. and expand to crisis, the throughout CAR in working keep to possible is it that shown have organisations other of ahandful and MSF country. the in 300 than international more has MSF writing staff of and time 2,500 the at Central people; of African staff working displacement massive the to respond and wounded the treat to continues MSF civilians Cameroon. or Chad as such Muslim countries attacking neighbouring to began flee to forced militias were many and Christian January, in power left Djotodia When CAR. for 2014 of respite no brought beginning The A CENTRAL

F © Marcus Bleasdale R I REPUBL CAN This patient in the Community Community the in patient This calls for those engaged in the the in engaged those for calls All humanitarian organisations organisations humanitarian All “ Community Hospital, Bangui the at doctor MSF SabineDr Roquefort to the leg. Despite repeated setting where I have worked. I have where setting conflict other any in than powerfully more me struck has suffering and violence of level The me. shocked kill and wound mutilate, to intent wilful organised, but this environments, violent very in working to accustomed We are fighting to respect medical on healthcare facilities and facilities on healthcare medical personnel andmedical personnel the received a gunshot wound wound agunshot received hospital. On 29 December working in CAR have been been have CAR in working workers continued and on robberies, and staff have staff and robberies, more than one occasion, occasion, one than more they threatened to threatened they lynch ill and wounded, attacks attacks wounded, and ill structures, ambulances, structures, armed men entered the the entered men armed Hospital in Bangui has has Bangui in Hospital victims of and looting victims I some of the patients. C I : DESCENT been threatened. CHAOS NTO

”

© Juan Carlos Tomasi / MSF 21 Médecins Sans Frontières A Day in the Life: médecins Sans Frontières (MSF) clinic at Dera Murad Jamali, Balochistan, Pakistan

Purchaser Mohammad Aslam sees the impact of Dera Murad Jamali’s isolation every time he places an order for supplies. “We can’t buy medicines locally – we have to order them from Islamabad every three months,” he explains. “Sometimes we have a problem with international cargo and we have to ask other MSF hospitals or clinics in the country. Just this week we needed some injections and we asked Islamabad, who asked the MSF team in Chaman, who sent it to the MSF team in Quetta, and then Quetta sent it to us – it took more than two days.”

There are few options for quality healthcare in the area, with the nearest major centre of Jacobabad about 40 kilometres away, and private clinics – of which there are only a small number – charging tens of thousands of rupees for caesarean sections, for example, an impossible cost for most families. As well as being excluded from medical care, the

people here have been displaced by internal © Sheeba Hanbi conflicts and affected by social violence. As Australian nurse David McGuinness says, there are many challenges when working Mohammad Aslam for MSF in a location like Dera Murad Jamali: Before MSF, I was working as a receptionist for an organisation that supported education “Stories of loss, tales of terror, another bomb in Nasirabad and Jaffarabad. The organisation also provided some voluntary support to blast, another kidnapping, and children the basic health units in the region. literally starving to death [but] the work being done here is invaluable and the I joined MSF in April 2009, for the professional experience and to help people in need. impact it has on people is undeniable.” I was still getting to know the job and the organisation when MSF launched its response to the 2010 flood emergency. We had around 45 international and around 350 Pakistani Dr Raj Batra was working for a public staff working in Dera Murad Jamali. I realised the international staff and national staff hospital before he joined MSF. “There had the same objective: to help those people affected by the floods. were poor people who couldn’t access healthcare and were being denied the proper A typical day treatment,” he said. “When I read about We start our working day at 8am with a meeting. I then spend time each day working MSF’s independence and impartiality, I said I on the project’s medical supplies, receiving requests, organising quotations and making wanted to join.” As the medical focal person the purchases. in MSF’s Dera Murad Jamali clinic, Dr Batra Once a month, I receive the medical orders from the teams in Dera Murad Jamali and supports all the departments, including send them supplies from our store. Once every three months, we send a big order for maternal and child health, the feeding both medical and non-medical items to the capital, Islamabad. The medical team leader programme for malnourished children and will talk to the logistics team about what’s needed, and then logistics will talk to me the mobile clinics. He explains: “The biggest about how we can arrange the supplies. challenge is that people in this area are not educated about health issues and often When we receive cargo from Islamabad, we enter it into the system and make sure that depend on home remedies. For example, anything needing to be refrigerated is placed in the cold chain. Sometimes I’ll also fill in with breastfeeding, women often avoid as the assistant to the project coordinator. using the first milk from the mother. But we know how important that first milk is – with nutrition and antibodies for the baby.”

22 A Day in the Life: médecins Sans Frontières (MSF) clinic at Dera Murad Jamali, Balochistan, Pakistan International Activity Report 2013

In charge of the maternal and child health Dr Raj Batra departments at the clinic is midwife Dr Raj Batra grew up in Jacobabad, where he completed his pre-medical studies. He was one Gaudesia Waitherero Kimani from Kenya. of just 31 candidates (out of 1,650 applicants) from his district chosen to complete a Bachelor She is responsible for the birthing unit, of Medicine at Chandka Medical College in 2001. After further training in Karachi, he began antenatal and postnatal care, and the working as an ambulance paramedic with a Pakistani NGO (the Aman Foundation). nursery. She draws on her experience working as a midwife with MSF in South After he was injured in a road traffic accident, he began working as a doctor in telehealth Sudan to advise co-workers on the best and began an MBA in Health Management. He oversaw a project mapping all healthcare medical treatment. facilities in Karachi and neighbouring districts – the first of its kind in Pakistan – to make it easier for people to access health services. “We have many cases of pre-eclampsia and mothers haemorrhaging, which is Next he took a job looking after the health of workers in the textile industry in Karachi, and life-threatening. In the nursery, it takes time then in December 2013 joined MSF as the medical focal point in Dera Murad Jamali. and you have to be patient. The prognosis A typical day of the babies is very poor, due partly to lack A normal day starts with a meeting, where we share security updates such as any bombing of hygiene in the community and because incidents overnight or other incidences of violence. From the project side, we also discuss many parents don’t come to the antenatal each team’s plans for the day. After that, I usually go to my office and might need to make clinic for vaccinations, which would protect a supply order, prepare a report or arrange reimbursements for staff. These jobs are really the baby.” important to help with the smooth running of the project.

I’ll then join the staff doing the morning medical round of the hospital and take the Gaudesia Waitherero Kimani opportunity to ask patients for feedback on our services. I might need to prepare short reports for the relevant staff to pass on any comments from patients. This is my third mission with MSF. I’m also responsible for the weekly medical meeting, where we gather and review cases, discuss I have also worked as a midwife in medical issues and try to reach a consensus. If we can’t reach agreement on a medical issue, South Sudan, first for six months in the we might involve the project coordinator. I will work with the medical team leader to respond to township of Raga and then for a year health, operational, management and supply issues. I make sure that every protocol and policy at a huge MSF project working with is being followed in the project. I’m also responsible for the health of our Pakistani staff. If they refugees in Maban. In South Sudan, are sick, I might need to refer them to the best facility for treatment. Basically I’m the person MSF provides maternal and reproductive who works to coordinate all the medical teams. Coordination is the thing that holds us together. health services, including looking after mothers with complicated births and mothers with hepatitis E, which is a serious health issue there. In between my MSF missions, I work at a private hospital in Nairobi, Kenya.

When an emergency situation arises, the team pulls together – such as when fruit seller Shair Khan and his family were rushed to the MSF clinic with serious burns. Shair Khan had been awakened by his daughter’s shouts to find his tent engulfed by flames. His first thought was for his six children inside. “I went to the side of the tent and tore it, and took my children out,” he recalled. “Nine people, including me, were living in that tent – we were using candles for lighting.”

Once at Dera Murad Jamali hospital doctors began treatment and extra staff were called in. The mother – who had the worst burns – and one child were transferred to another hospital six hours’ drive away. Sadly the mother died but all the children were eventually discharged, and Gaudesia Waitherero Kimani still remembers the way the staff worked together that night. “Everyone still talks about it and how happy we were with the way we responded.” David McGuinness agrees, saying: “As I have seen on many occasions, the MSF staff worked through these difficulties together and committed themselves to the patients,

to help achieve the best outcomes.” © Abdul Majid

A Day in the Life: médecins Sans Frontières (MSF) clinic at Dera Murad Jamali, Balochistan, Pakistan 23 Médecins Sans Frontières Overcoming challenges to meet MSF’s vaccination ambitions Today, 10-month-old Roni will Sudan: pentavalent and the pneumococcal to find those children over the age of one conjugate vaccine (PCV). MSF projects are who haven’t completed the recommended be vaccinated against one of also rolling out innovative strategies, seeking immunisation series and need to ‘catch up’. the world’s biggest killers of to show in Guinea, for instance, that a new children his age: pneumonia. oral cholera vaccine is effective in responding However, these new vaccination plans are in to outbreaks and even works as a useful danger of being thwarted by the issue of price, He waits patiently, perched on preventive tool where cholera is endemic. and by the very nature of the vaccine product his mother’s hip, as she gives itself. MSF, through specific campaigning his name and date of birth to MSF’s renewed commitment to vaccination and advocacy, needs to address these issues, as a medical priority centres on the ambition while also focusing on innovative operational the Médecins Sans Frontières to strengthen routine immunisation, that activities and research. (MSF) team working in Yida is to say, the vaccines the World Health refugee camp in South Sudan. Organization (WHO) recommends all children When price curtails ambitions should receive. Four priority countries have The GAVI Alliance – the foundation that While immunisation has always been a major been chosen: Central African Republic (CAR), procures vaccines on behalf of many part of MSF operations – with more than two Chad, Democratic Republic of Congo (DRC) developing countries – has been instrumental million people protected against measles in and South Sudan. There are many aspects in negotiating substantially lower vaccine 2013 alone, for example – the organisation to this work, and one is reducing ‘missed prices for the world’s poorest countries. recently upped its vaccination ambitions. This opportunities’ in MSF projects by screening This has helped to improve availability of the involves, in part, using the newest vaccines eligible children for their vaccination status newest vaccines in countries hardest hit by more systematically in MSF operations, during clinic visits. Another is integrating diseases like pneumonia. including in emergencies, where children immunisation into other paediatric are at their most vulnerable. For example, programmes. MSF projects in Niger, Mali and These lower prices are, however, only available Roni was one of several thousand children Chad, for example, are already combining through specific purchasing channels, and vaccinated by MSF in the Yida camp between routine vaccination activities with other health MSF has not been able to systematically July and September 2013 with two new measures such as seasonal malaria prevention. access the ‘GAVI price’. Nor does GAVI have vaccines that were not yet available in South A third strategy is pursuing opportunities policy provisions that cater to emergency

WE NEED EASIER-TO-USE VACCINES Five Vaccination Visits are Required Before a Baby’s First Birthday. This can be Difficult for Caregivers in Developing Countries

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Schedule is WHO-recommended routine immunisations for children – http://www.who.int/immunization/policy/Immunization_routine_table2.pdf

24 Overcoming challenges to meet MSF’s vaccination ambitions double the lowest global price paid by GAVI. by paid price global lowest the double –still dose per US$7 of aprice at PCV access to able was MSF Ultimately, organisations. humanitarian other and MSF to prices discounted its up open to alliance the urging campaign, media social GAVI 2013 Dear its with April in public went Campaign Access MSF the price, GAVI the at PCV purchase to inability the at MSF’s and frustration crisis refugee growing the With processes. procurement lengthy and Alliance, GAVI the with and Pfizer, and GSK companies pharmaceutical were complicated price negotiations with reasons The long? so take it did why So response. emergency an for timeline accessing vaccines, the an untenable problems of because campaign the organise 11 took to It months pneumonia. against vaccinate children camp in Yida vulnerable to sought MSF Sudan, South in crisis humanitarian the of escalation the With ahurdle. remains manner atimely in and price affordable an at vaccines accessing yet vaccinating in emergencies, humanitarian recommend which year last guidelines on released WHO Immunization new (EPI). Programme Expanded WHO’s the on focusing as itsituations, organisation is a development ideally between2and8° Ice packsarepreparedforthevaccinationsthatneedtobekeptincoldchain.Vaccinations mustbekeptcoldbutnottoocold, C. C. – are feasible. – are –immunisation schedule a minimum of five a complex complete to needed visits multiple the that meaning point, avaccination reach to caregivers most for ease relative the and syringes; of dispose safely to means the injections; deliver to able workers health qualified refrigerated; vaccines keep to electricity constant and reliable mind: in developed with wealthy-country conditions Vaccines challenging. are usuallyremarkably is areas remote to products these delivering recommended by WHO, largely because vaccines of package basic the without go 22 than millionMore each children year ice on Vaccines and access.affordability greater for advocate to continues Campaign Access the so price, possible cheapest the at MSF to vaccines their sell to – refuse decisions for pricing responsible ultimately companies. companies These – who are pharmaceutical from directly price global lowest the at vaccines purchase to push channels, procurement MSF still will its use they if organisations to humanitarian available prices its making to committed publicly has GAVI while and results, mixed brought campaign GAVI Dear The Internati O verco mi ng challenges to m to challenges ng onal A for the vaccine to be re-labelled, allowing it it allowing re-labelled, be to vaccine the for push to it use to possible be should it released been has data the once and promising, are far so results The days. 30 to up for 40°C to up of temperatures ambient at chain’ temperature a‘controlled in kept was that vaccine toxoid tetanus of a efficacy continued and stability the determine to astudy out carried Epicentre arm research its and MSF 2013, in research: clinical and operational through part in achieved being is This patient. the to centre ahealth from journey their of stages last very the for heat of tolerant more are that vaccines particularly products, use easier-to- for campaigning therefore is MSF points. vaccination to way their on while packs ice against stored they’re when freeze accidentally can –vaccines cold too not but cold, kept be to need vaccines that complexity added the is there Then rooms. freezer three and 18 freezers involved this and required, were 21,500 packs ice example, for Chad, in For an MSF vaccination measles campaign to expandingbarriers the reach of vaccinations. ‘cold biggest chain’, the of one aconstant is in temperatures, right the at kept be to vaccines for need the that say logisticians field MSF live. countries where the most children vulnerable developing many to applies this of Little iv ct eet M eet i S ty R ty F’s vacc F’s eport 2013 i nat i on a on m b i t i ons 25 ons

© Ikram N’gadi / MSF 26

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© Ikram N’gadi / MSF © Yasuhiko Okuno © Yasuhiko

An MSF Community Testing Counsellor in Swaziland explains what HIV is, how it is transmitted and how it can be prevented. Activities by country 28 Afghanistan 41 Egypt 60 Lebanon 78 Russian 30 Armenia 42 democratic Republic 62 Lesotho Federation 30 Bolivia of Congo 63 Libya 79 south Africa 31 Bangladesh 44 Ethiopia 63 Madagascar 80 Somalia 32 Bulgaria 46 France 64 Malawi 82 south Sudan 32 burkina Faso 46 Georgia 65 Mali 84 Sudan 33 Burundi 47 Greece 66 Mauritania 85 Swaziland 33 cameroon 47 Guinea 66 Morocco 86 Syria 34 Cambodia 48 Haiti 67 Mexico 88 sIerra Leone 34 China 50 Honduras 68 Mozambique 88 Tajikistan 35 Colombia 50 Iran 69 Myanmar 89 Turkey 36 central African 51 Italy 70 Niger 89 Ukraine Republic 51 LAOS 72 Nigeria 90 Uganda 38 Chad 52 India 73 Palestine 91 Uzbekistan 40 Congo 54 IRAQ 73 papua New Guinea 91 Zambia 40 Côte d’Ivoire 56 Jordan 74 Pakistan 92 Zimbabwe 41 democratic People’s 57 Kyrgyzstan 76 Philippines 94 Yemen Republic of Korea 58 Kenya 78 Paraguay Médecins Sans Frontières afghanistan The number of people receiving critical medical care at Médecins Sans Frontières (MSF) hospitals has nearly doubled over the last two years, a clear indication of the medical needs in the country.

In 2013, the ongoing war and its consequences continued to restrict people’s access to quality medical services – in particular to specialist healthcare.

Private clinics are unaffordable for most Afghans and many public hospitals are understaffed Cities, towns or villages with MSF activities and overburdened. Many rural health clinics Key medical figures: are dysfunctional, as qualified health staff • 370,000 outpatient consultations • 48,000 patients admitted to hospital have left the insecure areas, and the supply • 32,800 births assisted of reliable drugs and medical materials is irregular or non-existent. Insecurity can also prevent entire communities from travelling to Ahmad Shah Baba hospital, Kabul and MSF so that they can provide emergency hospitals. Afghanistan has some of the worst The number of people in Kabul has and maternity services around the clock. health indicators in the world according to the increased significantly as a result of World Health Organization, and is still one of migration, displacement and repatriation. Major work completed in 2013 included a the riskiest places to be a pregnant woman or In eastern Kabul, MSF has been upgrading new waiting area, the relocation of the female a young child. MSF focuses on ensuring people Ahmad Shah Baba hospital to become a outpatient department and the opening of have better access to free, quality healthcare in reliable district hospital, and has trained a new maternity ward with 21 beds offering some of the most conflict affected areas. Afghan staff from the Ministry of Health labour, delivery and post-delivery care. This year, Noor Images / © Andrea Bruce

A woman delivers a baby via emergency caesarean section at the Ahmad Shah Baba hospital, Kabul.

28 afghanistan No. staff end 2013: 1,526 |Y 2013: 1,526 end staff No. outpatient and physiotherapy departments The completed. also was theatre operating athird and treatment, and triage better enabling available made was space More roof. one under accommodated be to theatres operating and room emergency the allowed building hospital old the of refurbishment Extensive construction continued, and medical protocols and techniques. relevant the in trained were members staff and facilities, fixation internal with January in equipped was It injuries. head severe and moderate with patients admitted also hospital year, the this of As wounds. gunshot like injuries conflict-related as well as accidents, traffic as such trauma general of victims to care surgical free provide to continued 2011 in opened which centre trauma MSF the Kunduz, of province northern the In Trauma centre, Kunduz children. for vaccinations and consultations, postnatal and antenatal out carry to area Baba Shah Ahmad the in clinics mobile operated MSF April, From period. athree-month over consultations 2,000 conducted and camps six in worked team winter. The harsh Kabul’s of aresult as suffering people displaced assist to clinic amobile launched MSF January, In to the therapeutic feeding programme. children 500 children, admitting malnourished for treatment provided also hospital The month. every births 1,000 approximately assisted staff At aclinicontheeasternoutskirtsofKabul,Afghanmengettheirdrugprescriptionsfilled. ear MSF first worked in the country: msf.org/afghanistan | 1981 country: the in worked first MSF ear a general lack of skilled female medical staff staff medical female skilled of lack a general is There achallenge. been has Khost in staff medical female qualified of recruitment The or labour. pregnancy complications during had who women 2,000 than more helped and 12,000 babies of delivery the in assisted Staff offer. on care high-quality free, the access to distances long travel patients Many province. the in deaths neonatal and maternal of number high the reducing on and deliveries complicated with assisting on particular in focuses It birth. give to women for environment healthy and asafe provide to aims it and area, the in hospital maternity specialised only the is Khost in hospital 83-bed The hospital maternity Khost 2012. in than more times three procedures, surgical 4,500 performed and injuries, conflict-related from suffering were whom 17,000 of 10of cent per about people, atotal treated Staff increase. to continued centre the visiting patients of number The for and patients their caregivers. hospital the in activities promotion health started also MSF bereavement. and events traumatic with coping families and patients to support 2013in psychological provide to launched was programme health A mental year. the during conducted were sessions 12,000 physiotherapy than More visits. follow-up for returning patients for access facilitating building, the into moved also were Internati onal A in locations where teams operated in 2013. in operated teams where locations in Afghanistan, in to Healthcare Access Struggle Ongoing entitled areport 2014, published MSF February In available. now were services health basic 2013, of end the at as department outpatient general hospital’s the close to decided MSF area, Lashkargah the in resources healthcare of evaluation an Following monthly. admitted were children 200 approximately and patients paediatric90-bed ward overflowed with 2010 in 2011, and extensions Despite the 2013. in children malnourished 3,200 treated The hospital’s therapeutic feeding centre province. Helmand in mortality child of causes main the of one remains Malnutrition performed. were procedures surgical 5,600 and room emergency the in treated were patients 66,000 of Atotal monthly. patients 1,300 of average an admitted hospital 250-bed intensive care and emergency The services. paediatric, maternal, and medicine, internal surgery, with Afghanistan, southern in hospitals referral functioning two only of one hospital, Boost support to continued team MSF An Helmand province Boost hospital, Lashkargah, provide training. also and gap the fill help staff international MSF cities. big the in work and live to prefer in Afghanistan and many specialists qualified iv ct Between Rhetoric and Reality: The Reality: and Rhetoric Between based on information collected collected information on based i ty R ty eport 2013 a fghan i stan

© Robert Nickelsberg / Getty 29 Médecins Sans Frontières armenia arduous treatment. MSF has also helped implement infection control policies, measures and practices.

MSF worked with the Ministry of Health’s programmes for DR-TB and nontuberculous mycobacterium infection (the same © MSF bacteria family but not classic TB) in A member of the MSF flying TB surgery Yerevan, Armavir, Ararat, Shirak, Lori, team examines a patient. Regions where MSF has projects Kotayk and Gegharkunik. A team also Cities, towns or villages where MSF works assisted the programme in Karabagh.

Key medical figures: The National Tuberculosis Programme’s Tatev • 119 patients under treatment for MDR-TB ‘compassionate use treatment’ for patients 17-year-old MDR-TB patient from Yerevan with extensively drug-resistant TB (XDR- TB) was supported by MSF in 2013. As of At first, I had difficulty accepting that I Armenia has one of the December, 26 patients were receiving the needed to go to hospital, or that I had highest rates of drug-resistant treatment. Also this year, in a collaborative the disease even. I think most of all I was undertaking, a team of MSF and Ministry of scared of taking the drugs. Maybe that’s why I reacted as I did. tuberculosis (DR-TB) in the world. Health TB pulmonary surgeons successfully operated on seven patients. The first two days I took the drugs TB has become a significant public health normally, but it got harder when I realised concern in Armenia. Since 2005, Médecins The MSF team aims to enhance the I would be taking them long term. It was Sans Frontières (MSF) has been working national programme’s capacity to a difficult period but I forced myself to in the country to improve diagnosis implement DR-TB response plans and believe the treatment would work, and that and treatment of DR-TB, and to support enable the gradual handover of existing I would get rid of TB. That’s my dream. patients so that they can complete the MSF activities in Armenia.

No. staff end 2013: 98 | Year MSF first worked in the country: 1988 | msf.org/armenia bOLIVIA Médecins Sans Frontières live in remote areas far from the urban hospitals and health centres that offer (MSF) handed over its Chagas treatment, and which often charge a fee. programme in Aiquile after In 2009, MSF began an integrated Chagas successfully establishing an programme in the communities of Aiquile, integrated prevention, diagnosis Omereque and Pasorapa. Working through and treatment strategy. community clinics and health centres, teams diagnosed and treated people aged Regions where MSF has projects Chagas, a parasitic disease endemic one to 60 for Chagas, and trained local in Latin America, is most commonly health staff. Significant efforts were made transmitted through the bites of infected to raise awareness and the communities vinchuca bugs, which are often found in were involved in surveillance and control cracks in the walls and roofs of rural adobe of Chagas through educational workshops, houses. The disease can be asymptomatic weekly meetings and a radio show. for many years, but if left untreated it may affect internal organs and can lead to heart In September 2013, the project was handed failure and even death. over as planned to the Departmental Chagas Programme of the Ministry of Treatment for Chagas in Narciso Campero Health and the province’s Health Network province, where disease prevalence is Management. MSF is planning a new

© Juan Renau estimated to be as high as 40 per cent, has project in Aiquile, which will implement a always been difficult both geographically sustainable treatment model that can be In Bolivia, significant efforts are made to raise awareness of Chagas. and financially. The majority of inhabitants replicated in other locations.

Year MSF first worked in the country: 1986 | msf.org/bolivia

30 armenia | bOLIVIA International Activity Report 2013 bangladesh

Cities, towns or villages where MSF works

Key medical figures: • 135,650 outpatient consultations • 2,300 births assisted

People of the Rohingya ethnic and religious minority continued to cross into Bangladesh in 2013, fleeing severe discrimination and © Alfons Rodriguez sporadic violence in Myanmar. Mothers and children waiting to be seen at the clinic in Kamrangirchar.

More than 200,000 Rohingya have Many people living in the slum suffer from escaped to Bangladesh from Myanmar diarrhoea and skin conditions resulting Noor over the past four decades and are losing from poor water quality and unhygienic 30 years old, brought her children to hope of ever returning home. They suffer living conditions. The MSF programme is the MSF clinic in Kutupalong widespread discrimination, and as the therefore also developing a stronger focus majority are undocumented they are on environmental health. I live with my husband and my five excluded from healthcare. At Cox’s Bazar, children in a house in the camp. Médecins Sans Frontières (MSF) continues The project in Fulbaria treating primary We arrived five years ago from to provide comprehensive medical kala azar began in 2010, and successfully Myanmar because the situation was assistance, including basic healthcare and introduced a treatment with liposomal not good there. My three youngest maternal and mental health services, for amphotericin B. The project was handed children were all born here in the both the host community and the 30,000 over to the Ministry of Health in March this camp. The youngest was born in the MSF clinic nine months ago. Both mine unregistered Rohingya in the makeshift year, as they were in a position to manage and my husband’s parents live in camp at Kutupalong. The clinic also has a it. MSF is currently awaiting permission Myanmar so we are all alone and have stabilisation unit for severely malnourished from the ministry to start treating post-kala children, a small inpatient department and to fend for ourselves. My husband can azar dermal leishmaniasis. a diarrhoea treatment centre. MSF has an sometimes find work as a day labourer, as a rickshaw puller or carrying things, ambulance to transport severely ill patients Emergency interventions but sometimes this is difficult and then to hospital for specialised treatment. On 24 April, an eight-storey building More than 74,300 patients were treated we do not have anything. housing garment factories that employed at the clinic in 2013. thousands of people collapsed in Savar, Dhaka, the capital city, has a population a subdistrict of Dhaka. Many of those of 15 million. In Kamrangirchar, the city’s who survived experienced symptoms largest slum, half a million people live on of psychological trauma. An MSF team the bank of the Buriganga River, with provided mental health support to 413 very little access to the city’s overstretched survivors and rescuers. MSF also gave healthcare system. An MSF team runs a psychological first aid to 28 people who health centre in the slum, providing free, had suffered burns from fire bombs thrown basic healthcare, and sexual and reproductive on public transport during pre-election health services to young women. violence in Dhaka on 12 December.

No. staff end 2013: 311 | Year MSF first worked in the country: 1985 | msf.org/bangladesh

bangladesh 31 Médecins Sans Frontières bULGARIA More than 8,000 refugees, 70 per cent of sanitation facilities. Medical care was also them Syrians, crossed into Bulgaria this year insufficient, with only emergency ambulance and were transferred to various detention referrals to hospitals available. Consultations and reception centres. In November, were provided on an ad hoc basis and there Médecins Sans Frontières (MSF) began was no consistent supply of drugs. working in these centres, in close collaboration with the State Agency for Refugees, Responding to the gaps in care, to respond to the humanitarian needs MSF started working in the Vrezdevna of the refugees. MSF has not worked in and Voenna Rampa centres in Sofia, Regions where MSF has projects Bulgaria since 2005. and in Harmanli camp close to the Turkish Cities, towns or villages where MSF works border. Basic healthcare was provided, The influx of refugees resulted in pressure Key medical figures: including antenatal care and midwifery. on the state system and a dramatic drop • 2,200 outpatient consultations Mental health consultations were in standards of healthcare and hygiene at organised for those showing symptoms of the centres. Vulnerable groups, including psychological distress. Tools and procedures pregnant and breastfeeding women, children The sudden increase in under five, patients with chronic diseases for medical and vulnerability screening refugee numbers in Bulgaria or mental health issues, disabled people were introduced, a system of access to healthcare was implemented and critical in 2013 led to overcrowding and the elderly, needed to be identified on arrival and fast-tracked in order to guarantee work to improve hygiene and sanitation in accommodation centres, them access to specialised care, food and was undertaken. MSF also ensured that and a shortage of adequate suitable accommodation. During the cold services were available for those asylum winter months, MSF teams witnessed a lack seekers living outside the Vrezdevna and healthcare. of accommodation, electricity, bedding and Voenna Rampa centres.

Year MSF first worked in the country: 1981 | msf.org/bulgaria burkina faso The relocation of Malian refugees within Burkina Faso resulted in a reduction in Médecins Sans Frontières (MSF) activities in 2013.

The stream of Malians fleeing violence working – Ferrerio, Dibissi and Ngatourou- and attacks in their home country began Niénié – had been moved to the inland in February 2012, and an emergency camps of Goudoubo and Mentao. As a programme was opened by MSF to help Regions where MSF has projects consequence, MSF scaled down its activities. meet their healthcare needs. Initially, Key medical figures: most refugees gathered in camps near In April, MSF began a twice-weekly mobile • 18,800 outpatient consultations the Malian border, within the province clinic for people who remained in Dibissi • 7,000 patients treated for malaria of Oudalan. Later that year though, the • 1,300 antenatal consultations camp, as well as the 6,200 residents Burkina government moved the camps in Gandafabou health district. The team further inland to ensure increased safety provided basic healthcare consultations, for the refugees. vaccinations – primarily for tetanus and At the beginning of 2013, due to deteriorating measles – and referrals to the hospital in Dori. security in the Sahel zone, the authorities once again decided to relocate refugees. An estimated 43,000 refugees from Within six months, 11,300 people who had Mali were present in Burkina Faso at been living in the camps where MSF was the end of 2013.

No. staff end 2013: 91 | Year MSF first worked in the country: 1995 | msf.org/burkinafaso

32 bULGARIA | Burkina Faso International Activity Report 2013 burundi Women with obstetric complications in Urumuri health centre in Gitega. Fistulas, a Kabezi had little access to appropriate consequence of birth complications, cause healthcare until Médecins Sans Frontières not only pain but incontinence, which in (MSF) launched an emergency programme, turn often leads to social exclusion and the Centre for Obstetric Emergencies sometimes rejection by friends and family. (CURGO), in 2006. Located in Kabezi The package of care at Urumuri includes hospital, the project offered free, surgery, physiotherapy and social support, high-quality emergency and surgical and is offered around the clock. obstetric services. Referrals and ambulances Regions where MSF has projects were also provided so that women from Malaria Cities, towns or villages where MSF works 24 health centres were able to reach the In 2013, MSF staff at the Kirundo malaria CURGO, which admitted an average of project continued to support 44 health Key medical figures: • 3,500 patients treated for malaria 250 women per month in 2013. centres and two hospitals with diagnosis • 380 fistula repair operations and treatment of severe malaria. After an MSF study in 2012 entitled Safe Delivery: Reducing Maternal Mortality in Improved access to Sierra Leone and Burundi showed these efforts had reduced maternal deaths by Séverine emergency medical care 74 per cent, the team trained and coached an obstetric fistula patient in Burundi’s rural Kabezi Burundian medical staff, and handed the programme over to local authorities in 2013. The MSF team welcomed me to the district has markedly women’s village. I feel good here; we reduced maternal deaths. Providing fistula care dance together often. All the women here An MSF team continued to provide suffer from the same thing, and that helps obstetric fistula treatment this year at the us cope. I’m having the surgery in a week. I hope it will go well; I’m confident it will. No. staff end 2013: 233 | Year MSF first worked in the country: 1992 | msf.org/burundi cameroon Buruli ulcer is a tropical disease that to have HIV, nearly triple the estimated destroys skin and soft tissue, usually population prevalence. Those who test on a person’s arms and legs. This can positive receive comprehensive care for cause secondary infections, restrict their both diseases. In total, the team treated movement and cause permanent disability 188 people with chronic wounds resulting and scarring if left untreated. If the disease from Buruli ulcer, applied more than 15,800 is detected early enough, the majority of surgical dressings, admitted 48 new patients patients can be cured with antibiotics, and carried out 78 surgical procedures. although surgery may also be necessary. It Regions where MSF has projects is still not known exactly how Buruli ulcer Since November 2011, research has been Cities, towns or villages where MSF works is transmitted. About half of those in Africa underway to facilitate diagnosis of Buruli Key medical figures: suffering from the disease are children. ulcer in those resource-limited countries • 2,800 patients on first-line ARV treatment where it has a high prevalence. The aim is People with suspected Buruli ulcer in to provide health professionals with an Cameroon are examined and laboratory easy-to-follow diagnostic grid for The centralised system and tests are performed. When positively identifying cases. The first phase of the diagnosed, they receive antibiotics, wound treatment costs pose barriers study was completed this year, and in dressing, surgery and physiotherapy at the total 370 patients have been enrolled. to healthcare for many people Buruli ulcer ‘pavilion’ run by Médecins Sans in Cameroon. Those with Frontières (MSF) in Akonolinga hospital. The HIV programme in Douala was handed HIV testing is routinely offered to all over to the Ministry of Health in April, neglected diseases such as patients; 12.5 per cent of people entering with tenofovir having been adopted as Buruli ulcer, seen mostly in the programme during the year were found the first-line treatment.

No. staff end 2013: 91 | Year MSF first worked in the country: 1995 | msf.org/burkinafaso rural areas, are particularly disadvantaged. No. staff end 2013: 79 | Year MSF first worked in the country: 1984 | msf.org/cameroon

burundi | cameroon 33 Médecins Sans Frontières cambodia are very high. It is therefore essential to find new methods for better and earlier detection. In 2013, the TB department of Kampong Cham provincial hospital became fully operational, and offered detection, diagnosis and comprehensive care for TB patients and those suspected of having the disease, whether it was drug-sensitive, complicated or drug-resistant (DR-TB). People from around Cities, towns or villages where MSF works

the province come to the hospital for testing. © Philippe Bosman / MSF MSF also supports the diagnosis and follow-up Key medical figures: of TB patients in Choeung Prey district. In Participants of the PCR Detection Rate • 1,150 patients under treatment for TB Study being registered. Tboung Khmum district, MSF is aiming to screen all inhabitants aged over 55. strain of malaria in their blood and more In Phnom Penh and Kandal provinces, specifically at artemisinin resistance. In The prevalence of tuberculosis MSF worked with a local organisation, 2014, a project with a specific treatment (TB) in Cambodia is one of the Cambodia Health Committee, and the protocol will be developed with the aim of the highest in the world, with national programme CENAT to treat demonstrating that artemisinin-resistant 20 DR-TB patients and will continue to malaria can be eliminated. more than 0.8 per cent of the provide follow-up until they finish their population already infected treatment. Thanks to this collaboration, Handover of prison project MSF monitored almost half of the diagnosed MSF started working in two Phnom Penh and more than 60,000 people DR-TB patients in Cambodia in 2013. prisons in 2006, in response to high HIV newly infected every year. mortality rates. At the end of June 2013, the Malaria in Preah Vihear district TB and HIV projects were handed over to two Fewer than 20 per cent of the people in MSF carried out a baseline survey this year, national programmes and other local partners Cambodia infected with TB are diagnosed looking at the percentage of inhabitants in as a result of improvements in care and the each year, and as a result of this morality rates the district with the Plasmodium falciparum implementation of a long-term approach.

No. staff end 2013: 159 | Year MSF first worked in the country: 1979 | msf.org/cambodia china Although the prevalence of HIV in China and influence reforms that will make care is low, providing an adequate response more widely available. In October 2011, to people needing treatment remains a at the request of ACC, Médecins Sans challenge. China initiated the ‘Four Frees Frontières (MSF) started supporting a clinic and One Care’ policy in December 2003, near the China–Myanmar border in Jiegao, providing HIV counselling and testing, Yunnan province, where there are high antiretroviral treatment, prevention of numbers of Chinese and Burmese injecting mother-to-child transmission and schooling drug users with HIV or HIV–TB and for children orphaned by AIDS, all free of HIV–hepatitis C co-infection. In September, Regions where MSF has projects charge, but many people with the disease a four-person MSF team began providing have not benefited from these measures. medical expertise and staff management According to the Ministry of Health, some under a one-year agreement. People living with HIV/AIDS regions and departments are not sufficiently in China face difficulties concerned with HIV, and there is still Flooding in Guangxi widespread discrimination and stigma. accessing the necessary care. In August, more than 127,000 people were A Chinese NGO, Aids Care China (ACC), affected by flooding and a landslide in is developing quality care and treatment Guiping, Guangxi province. MSF distributed through private clinics, hoping to show the hygiene kits, buckets, plastic sheeting and impact this can have on people’s health mosquito nets to 950 households.

No. staff end 2013: 5 | Year MSF first worked in the country: 1989 | msf.org/china

34 cambodia | china International Activity Report 2013 COLOMBIA

Cauca Buenaventura

Caquetá Nariño

Regions where MSFColombia has projects Cities, towns or villages where MSF works

Key medical figures: • 36,200 outpatient consultations • 3,600 individual and group mental health consultations

The testimonies of 4,400 Médecins Sans Frontières (MSF) patients revealed © Aurelie Baumel / MSF As part of MSF’s support of the national TB programme in Buenaventura, a couple receive that 67 per cent of people health education in their home. in Colombia seeking mental health support had In July, MSF published The Less Visible Programme closures experienced at least one Wounds: Mental health, violence and conflict In February, given improvements to the violence-related event. in southern Colombia, a report based on health system in the area, MSF closed a the testimonies of patients treated in the project focused on reproductive healthcare mental health component of the above in Buenaventura. In December, activities The Colombian armed conflict has programmes in 2012. The report drew in rural Nariño were handed over to local inflicted a heavy toll on people’s health. attention to the debilitating effects of the health institutions due to better availability In addition to the historic confrontation violence and the fact that people caught of healthcare. between the military and FARC and ELN up in armed conflict and other forms guerrillas, new paramilitary groups and drug-trafficking cartels have appeared in of brutality lack critical state support to Colombia recent years, creating different dynamics address their psychological needs. A 50-year-old displaced woman from of violence. Most armed activity is Cauca describes how her family has Focus on tuberculosis (TB) changed as a result of violence. registered in the southern departments of TB has emerged as a major public health Caquetá, Cauca, Putumayo and Nariño, concern, particularly in the crowded seaport I haven’t been able to sleep in several where civilians witness massacres and nights; I have dreams where I see the of Buenaventura, where 9.5 per cent of new are subjected to threats, extortion, faces of my neighbours. I see them crying, cases are found to be drug-resistant. displacement, injuries caused by mines, pleading, asking for mercy. I wake up MSF works in two health facilities, and torture, sexual violence, forced recruitment crying. I start thinking about our farm, and other human rights violations. teams oversee an additional 15 medical about my plants in the garden, about stations. In 2013, 218 drug-sensitive TB my hens, and the cattle, and my dogs Medical and psychological support is critical patients began treatment, and 47 patients that wanted to come with us but that we in such a context, yet healthcare access in were included in the programme for drug- had to scare away with stones so that these geographically remote areas is limited. and multidrug-resistant TB. they wouldn’t follow us. I have never felt MSF has a long-standing programme of like this. I have never seen my husband mobile clinics and health posts to provide In addition to providing support to so quiet; I have never seen him mourn healthcare and mental health consultations the national strategy for TB detection in silence. And what can I say about my to people in need. Basic medical care, and treatment, MSF started advocacy son? The boy is not the same as he was. a referral system for emergencies, initiatives and discussions with partners Now there is no tenderness in his eyes; sexual and reproductive health services and authorities to introduce bedaquiline there is only anger and hatred. including family planning, antenatal care, as a treatment for patients with extremely immunisations and check-ups for children resistant forms of the disease. Workshops and all available. and negotiations are ongoing.

No. staff end 2013: 180 | Year MSF first worked in the country: 1985 | msf.org/colombia

COLOMBIA 35 Médecins Sans Frontières CENTRAL AFRICAN REPUBLIC dysfunctional healthcare system, prevents When 2013 began, the rebel group Séléka people from obtaining the treatment they had recently seized several strategic towns, Regions where MSF has projects need. Many die from easily preventable and in March they took the capital Bangui, and treatable illnesses such as malaria, leading to a presidential coup and the Key medical figures: • 816,300 outpatient consultations respiratory infections and diarrhoeal gradual destabilisation of the country over • 3,300 surgical interventions diseases. Prior to the current conflict, the course of the year. Increased tensions • 24,300 measles vaccinations mortality rates in some regions were up and violence, including assaults on civilians, to five times the emergency threshold. spread into previously peaceful areas. In early September, armed self-defence In response to this chronic medical crisis, Escalating and extreme groups, the ‘anti-balakas’, started to attack Médecins Sans Frontières (MSF) was Séléka forces and civilian populations in violence in the Central providing basic healthcare through seven the northwest. African Republic (CAR) comprehensive projects – at Batangafo, Boguila, Carnot, Kabo, Ndélé, Paoua and Throughout this period, MSF provided free over the year resulted in a Zémio – when the current emergency medical care to people wounded in attacks massive, acute humanitarian began to unfold. Despite some interruptions or displaced by violence. Mobile clinics were due to insecurity, these projects have launched and teams supported government crisis in addition to an adapted and continue to provide medical healthcare facilities, providing emergency existing chronic medical one. care to people in the communities, and to aid to people wounded in attacks or in need respond to localised emergencies caused by of medical attention. Additional activities For over 20 years, the small landlocked population displacement. Teams offer basic were started to ensure access to clean country of CAR has witnessed many political and specialist healthcare, mental health drinking water and improve hygiene for and military crises. Continual population consultations, maternity, paediatric and the displaced population. displacement caused by pockets of armed nutritional services, surgery and HIV and conflict, combined with a poorly resourced, tuberculosis (TB) care. MSF / © Juan Carlos Tomasi

Violence in Bouca forced many people to leave their homes, which were later destroyed, and seek refuge where they could.

36 CENTRAL AFRICAN REPUBLIC No. staff end 2013: 1,631 end |Y staff No. (15,000). Centre Bosco Don the and (15,000) Boy-Rabé of monastery the people), (100,000 ingathered camps including airport Bangui and homes their fled people of thousands of Hundreds conflict. the by displaced were 214,000 people some that estimated UN the alone, month that of weeks two first the In and reprisals. lynchings attacks, daily clashes, were there capital, the in forces international of arrival the Despite Bangui. in hold took chaos and violence December, in Beginning and malnutrition. diseases diarrhoeal infections, skin and respiratory malaria, for wounded, and teams regularly treated patients the for available were healthcare basic and surgery Bouar. Emergency Yaloke and visited teams medical emergency and Gadzi, and Bangui, Bria, Sibut, Bouca, Bossangoa, Damara 2013 in opened in also projects Emergency outwere through carried projects. these 12,800 consultations than More bush. the into fled temporarily had who people to treatment hospitals.local Damara The team also offered at services outpatient supporting Sibut, and Damara in year the of half first the in closed Short-term emergency opened projects and Thousands ofBanguiresidentstookrefugeinM’pokoairport2013,settingupamakeshiftcamp. ear MSF first worked in the country: 1996 | msf.org/car | 1996 country: the in worked first MSF ear measles vaccinationmeasles programme. Health of aMinistry supported also MSF weeks. three just in cases trauma 465 to responded surgeons Bangui, in centre health At Castor organisations. humanitarian other by mobilisation insufficient was there as unmet remained CAR in people displaced the of needs However,consultations. basic the health basic and surgery trauma providedBangui. MSF medical staff tosupplies displaced the of population relief distributed also and day per water drinking clean of litres 600,000 produced that plant treatment water a ran MSF addition, In camp. airport M’Poko in 350 latrines afurther and there, 150 built latrines later a day. They water of metres cubic 30 provided and latrines trench emergency 20 dug a team site, Bosco Don the at disposal: waste basic standards of hygiene and human supply, water aclean ensure to work extensive MSF undertook assistance, organisations providing emergency deplorable. With hardly any other are, still and were, conditions Living Internati

onal A

crossed into neighbouring countries. had 75,000 afurther that and CAR inside displaced were Africans Central 700,000 over that estimated was it end year’s By CAR. in employer largest the is MSF writing, of time the At posts. health 40 and centres health two hospitals, seven in people 600,000 approximately to care medical free providing staff African Central 2,500 and international 250 than more had MSF year, the of end Towards the needs. human extensive the to response appropriate an provide –to organisations aid other and UN the –from resources and means more of deployment the for called and agencies humanitarian UN of mobilisation of lack the MSFhealthcare facilities. also denounced in staff and patients and civilians, against violence the to end an for calling and wounded and sick the for care medical to access allow conflict the in involved parties all that asking out, spoke repeatedly MSF iv ct i ty R ty A CENTRAL eport 2013 F R I REPUBL CAN

I © Juan Carlos Tomasi / MSF C 37 Médecins Sans Frontières cHAD At Massakory hospital, Hadjer Lamis region, where MSF provided support in paediatric care, teams treated 36,600 patients during an acute peak in malaria cases between July and December. Children also received treatment for malnutrition in the hospital and surrounding health zones. A large water sanitation campaign for people’s homes was launched to help prevent outbreaks of diarrhoea. This activity currently reaches 900 families in 20 villages.

From August to October there was an emergency intervention in response to high levels of malaria in the Salamat region. Based at Am Timan hospital, outreach activities expanded to ensure people in remote areas of the district could get the medical care Regions where MSF has projects Key medical figures: they needed. An MSF team in Am Timan Cities, towns or villages with MSF activities • 183,350 outpatient consultations hospital also continued to provide basic • 113,900 patients treated for malaria and specialist care with a focus on women • 20,850 patients treated in feeding centres and children. Reproductive healthcare, emergency obstetric care and treatment for tuberculosis and HIV, including prevention Although the Chadian malaria unit. MSF also supported health of mother-to-child transmission of the centres and community health workers in virus, was offered. Teams carried out 5,280 government has promised rural areas with drug supplies and staff. outpatient consultations, assisted 1,895 to increase investment in Seasonal Malaria Chemoprevention – the births and tested 2,050 people for HIV. healthcare, the quality of distribution of antimalarials as a prevention A paediatric nutrition programme based strategy – was organised for children at the hospital and in nine outreach sites care and health indicators admitted 9,990 children for treatment. Six of under five and pregnant women during these outreach sites were handed over to the are still poor, particularly for the high season (July to October). The Ministry of Health at the end of the year. rural communities, children strategy had previously proven effective in and refugees. reducing the number of people developing Providing assistance to Sudanese refugees severe malaria. In 2013, prophylaxis was Renewed clashes in Darfur, Sudan, led to an The mortality rate for children under five distributed to 53,000 children and teams influx of refugees in the Tissi area of Chad is high, and routine vaccination coverage recorded an overall reduction in malaria of early in the year. MSF launched activities in is low. People often die from malnutrition 60 per cent in Moissala when compared to Tissi town, establishing an emergency room and preventable diseases such as malaria the previous year. to treat victims of violence, a health centre and cholera, and disease epidemics are recurrent. Instability in the surrounding countries also means Chad is host to a high number of refugees. In 2013, some 60,000 new refugees arrived in the country, with urgent needs for basic and specialist medical care.

Focusing on malaria Malaria, a mosquito-borne disease, is one of the main causes of death for children under five, but deaths can be prevented with simple measures such as the use of mosquito nets, preventive medicine and early detection and treatment.

For the past few years, teams from Médecins Sans Frontières (MSF) have worked on preventing and treating malaria in the Moissala and Bouna districts,

Mandoul region. Teams focused on © Samantha Maurin / MSF children with severe and complicated A child being vaccinated as part of expanding coverage for displaced people. cases of the illness in Moissala hospital‘s

38 cHAD and vaccination organises campaigns collaboration with the Ministry of Health, routine vaccinationexpanding coverage in in involved been has MSF malnourished. also are they if fatal be can consequences the and infection, of risk greater at are children vaccinations, routine Without E improve conditions. living to kits washing and blankets as such supplies relief distributed and water drinking to access provided consultations, healthcare out basic carried ateam Beida, Goz In camp. Gadam Ab in hygiene basic improve to latrines built and water drinking clean provided MSF malaria. for 10,400 people treated and consultations 52,820 outpatient out carried team The malnutrition. and diseases, skin and diarrhoeal infections, tract respiratory malaria, from mainly suffering were People Doukhum. Um in post ahealth and camp, Gadam Ab in of Sudaneserefugees. An MSFnursestabilisesapatientinTissi earlyintheyearresultedaninflux hospitalpriortohisevacuationAbéché.RenewedclashesinDarfur No. staff end 2013: 1,039 end |Y staff No. xtensive vaccination campaigns ear MSF first worked in the country: msf.org/chad | 1981 country: the in worked first MSF ear offering nutritional support to 2,630 children, 2,630 to children, support nutritional offering and consultations, health 12,200 basic out Yaroungou and Moula camps, carrying in living Republic African Central from refugees to assistance provided MSF region, Moyen-Chari Maro, in flooding Following Responding to emergencies and 26,800 against meningitis. measles against 12,250 people vaccinate to MSF led outbreaks region, Salamat In vaccinated. 161,300 of were Atotal death. people and disease liver severe cause can that disease viral fever, amosquito-borne yellow of outbreak an for Beida Goz in out carried was campaign inBeginning February, a vaccination September. in Iriba in 68,100 children and Guéréda in May,in children 102,000 and reaching 257,000 region in children Ouaddai vaccinationmeasles in campaigns 2013, three were There disease. of outbreaks to response in and people displaced for Internati onal A the health ministry in February. in ministry health the to over handed was Lamis, Hadjer Bokoro, in programme nutrition emergency An care. post-operative and surgery hadpatients from benefited rehabilitative and total, in women 850 around welcomed village des 2013.of femmes 45-bed The end the at began Health of Ministry the to handover programme The family. and friends by rejection sometimes and exclusion social incontinence, leads which in to often turn but pain only not cause complications, birth of a consequence Fistulas, fistulas. obstetric with women to care psychosocial and rehabilitative medical, provided Abéché in 2008 in started programme MSF An Programme handovers in Koldaga and Moissala. refugees to provided also was assistance August, In immunisations. as well as iv ct i ty R ty eport 2013 had had cHAD

39 © Ritu Gambhir / MSF Médecins Sans Frontières congo More than 36,000 refugees were repatriated from Congo to their home province of Équateur, Democratic Republic of Congo (DRC), in April.

In 2009, Médecins Sans Frontières (MSF) to improve national control programmes opened an emergency programme to meet against tuberculosis, HIV, leprosy and yaws. the medical needs of refugees and the host community in Bétou district, Likouala, by Yaws treatment Regions where MSF has projects expanding and strengthening services in Yaws is a contagious but treatable bacterial Cities, towns or villages where MSF works Bétou hospital and health centres in the infection that causes skin lesions and can lead area. Some 450 patients were admitted to disfigurement and disability. In the rainforest Key medical figures: of northern Congo and in Bétou district, where • 18,000 outpatient consultations to the hospital per month, and between November 2012 and May 2013, 9,800 yaws is endemic, MSF carried out a second people were treated for malaria alone. round of treatment in April and May, targeting Aka pygmies in remote areas who had not As many children were suffering from received treatment in the first round. preventable diseases such as tetanus, polio and measles, 13 teams carried out a district- Cholera emergency response wide, door-to-door vaccination campaign The cholera emergency response that began between December 2012 and May 2013, in Pointe-Noire in November 2012 was providing 97,500 vaccinations. With the completed in May. In addition to opening improvement of the security situation in a cholera treatment centre in Loandjili DRC and subsequent repatriation, MSF hospital and five rehydration centres, MSF closed the Bétou project in June. The team trained medical staff and helped authorities had also worked with health authorities implement preventive measures.

Year MSF first worked in the country: 1997 | msf.org/congo Côte d’ivoire Médecins Sans Frontières (MSF) has closed the last of its emergency programmes launched to meet healthcare needs during the Ivorian post-electoral crisis of 2010–2011.

Overall, the security situation has stabilised Work undertaken by teams in Duékoué and 2013 was declared ‘the year of health’. and Abobo during the crisis resulted in a However, although there has been an need for lifesaving maternal healthcare increase in investment in healthcare, gaps being identified. Women generally deliver Regions where MSF has projects persist, due to a lack of qualified staff and their babies at home with traditional birth Cities, towns or villages where MSF works outdated technologies. attendants and without effective emergency obstetric care when there are complications. Teams from MSF gradually ceased activities This results in unnecessary suffering and the that were originally set up to address the death of mothers and babies. needs of people displaced during the 2011 armed conflict. Only the programme in MSF is preparing to open a mother and Taï, along the border with Liberia, which child health programme with the Ministry consisted of support to the Ministry of of Health in Hambol region in 2014. Care Health teams in outpatient, paediatric and will be provided for complicated deliveries, maternity services in a 20-bed hospital, and antenatal and neonatal emergencies at continued until the end of March. A total of the hospital in Katiola. 27,338 consultations were carried out.

No. staff end 2013: 74 | Year MSF first worked in the country: 1990 | msf.org/cotedivoire

40 congo | Côte d’ivoire International Activity Report 2013 DPR KOrea After developing an agreement and child health in the district hospital of Anju, South Pyongan province. A with the government in May, memorandum of understanding was signed Médecins Sans Frontières in May, outlining the framework of the (MSF) opened a programme collaboration between the government and MSF, and MSF’s activities in the country. in the Democratic People’s Republic of Korea (DPRK). In February, a team travelled to DPRK to start updating the medical knowledge of Regions where MSF has projects staff through training. The first module Medical assistance is not considered a top Cities, towns or villages where MSF works covered was ‘Management of dehydration priority in DPRK and most help is steered and shock among children’, and then in towards self-sufficient food production, June the team returned to complete the food aid and disease prevention strategies. second training module, ‘Life support in Only a few international aid organisations obstetric services’. In October, the third are present in the country, and these face restrictions on their movements and on free module, ‘Management of malnutrition, access to patients. respiratory and neurological diseases among children’, was completed. The drugs and In this context, MSF has employed an medical materials related to the modules adapted approach. After a long absence, were provided during each visit, as well MSF started working in the country again as food for the hospitalised patients, their in 2012, and from the beginning of 2013, caregivers and the hospital staff. Follow-up made visits on a regular basis to upgrade monitoring and supervision was carried out some medical practices related to mother during field visits.

No. staff end 2013: 5 | Year MSF first worked in the country: 1995 | msf.org/dprk egypt consultations were carried out each hepatitis C project aiming to improve month; 70 per cent of patients were young patient adherence to treatment by children suffering from respiratory tract decentralising their medical care. In rural infections, intestinal parasites, skin diseases areas in particular, overcoming cost and and diarrhoea. MSF also provides transport distance could markedly improve patients’ and covers hospital costs for pregnant cure rates. Approval was received in early women in the clinic’s 24-hour emergency 2014 to launch the first phase of the project referral system. in Fayoum governorate, south of Cairo.

Cities, towns or villages where MSF works Assistance for vulnerable groups Winter relief and medical training

Key medical figures: Many migrants and refugees living in During the especially harsh 2013–2014 • 18,750 outpatient consultations Egypt are victims of violence. In 2013, winter, MSF teams in Cairo and Alexandria • 3,300 individual and group mental MSF continued to offer mental healthcare supported vulnerable families who had health consultations (742 new patients, 2,530 follow-up sessions) been identified by local health partners, and treatment to victims of sexual violence providing medical and psychiatric Migrants and people living (305 new cases, 960 follow-up sessions) at consultations and distributing washing in remote areas of Egypt the Nasr City mental health clinic in Cairo. kits and blankets. have difficulty accessing Expanding treatment for hepatitis C MSF also trained a number of volunteer medical services. There is a very high prevalence of hepatitis Egyptian doctors in Cairo, including some C in Egypt; it is estimated that around Egyptian Ministry of Health personnel, At Abu Elian clinic, on the outskirts of 12 per cent of the general population so that they could respond quickly and Cairo, Médecins Sans Frontières (MSF) are infected. For the last two years, MSF effectively to medical needs on the spot offers healthcare to mothers and children has been in discussions with the National during demonstrations. Training included under five. In 2013, an average of 1,700 Committee for Viral Hepatitis about a how to deal with large numbers of wounded. No. staff end 2013: 74 | Year MSF first worked in the country: 1990 | msf.org/cotedivoire

No. staff end 2013: 85 | Year MSF first worked in the country: 2010 | msf.org/egypt

DPR Korea | egypt 41 Médecins Sans Frontières Democratic republic of congo

Key medical figures: • 1,654,100 outpatient consultations • 106,600 patients admitted to hospital • 1,223,300 measles vaccinations (outbreak) • 10,900 patients treated for cholera

Owing to a dysfunctional health system, people in Democratic Republic of Congo (DRC) lack basic healthcare, and in 2013 suffered numerous, preventable outbreaks of cholera, malaria and measles. The conflicts in the eastern provinces were also Regions where MSF has projects ongoing, displacing thousands.

Decades of conflict, lack of investment in In the hospital in Rutshuru territory – a and integrated psychosocial care were the healthcare system and ongoing violence region controlled by M23 rebels until provided in Pinga. A security threat caused cause extreme hardship. Humanitarian they were forced to pull out in October the suspension of the project there in aid is concentrated around big cities and – MSF continued to offer comprehensive July and activities had not resumed by places that are considered secure, but there healthcare, including surgery, intensive and year’s end. More than 34,389 outpatient is a need for a rapid, flexible humanitarian emergency care, and treatment for victims consultations, 5,100 consultations for response to acute needs throughout the of sexual violence. More than 7,600 surgical malaria and over 900 mental health east of the country. Teams from Médecins procedures were performed during the year. sessions had been conducted in Pinga. Sans Frontières (MSF) are working to increase the availability of healthcare and In Masisi, MSF provides full support to the In March, an emergency measles respond to health emergencies. general hospital (internal medicine, surgery, vaccination campaign in Vuhovi reached gynaecology, maternity services, paediatrics more than 51,000 children. While on an exploratory mission in July, and neonatology) and to two health centres Chantal, Philippe, Richard and Romy, four in Masisi and Nyabiondo. There is a 76-bed South Kivu Congolese MSF staff, were abducted by an maternity village for women in their third South Kivu hosted more than 800,000 armed group during an attack on Kamango, trimester of high-risk pregnancies. MSF displaced people in 2013, most of them in North Kivu. At the time of writing, a dedicated also works with community advisors to the Kalehe and Shabunda territories, where team is still actively searching for them. counsel victims of sexual violence. Until MSF provides basic and specialist healthcare June, healthcare was provided to people in In 2013, measles epidemics continued in Kalonge, Shabunda and Matili hospitals Rubaya camp and to the host population. to proliferate. Some health zones were and in 15 health centres in the surrounding overwhelmed by the number of cases, Comprehensive healthcare is provided at areas. MSF supports a hospital and three and MSF launched emergency campaigns, Mweso hospital, with psychiatric services health centres in Minova, an area regularly vaccinating more than 1.2 million children integrated into the basic healthcare affected by conflict and influxes of displaced aged between six months and 15 years. programme. The nearby Kitchanga project people, and conducts mobile clinics to assist closed mid-year. The mental health and victims of violence. North Kivu sexual violence programmes were absorbed In Fizi territory, MSF provides A health centre in Mugunga III camp for into the Mweso-based project, which also comprehensive basic and specialist displaced people provided basic healthcare, took over activities in Mpati and Bibwe. healthcare, including surgery, reproductive dressings and aftercare for victims of sexual Other activities were handed over to Merlin. health services, neonatal treatment, violence, carrying out more than 41,800 Security incidents caused the suspension of prevention of mother-to-child transmission consultations and treating some 840 people the Mweso project twice in 2013, but the of HIV, tuberculosis and cholera treatment, for injuries resulting from sexual violence. teams at Mweso hospital provided more vaccinations, nutritional support and sexual A team focused on cholera prevention and than 140,000 consultations, carried out violence aftercare at Baraka and Lulimba treatment in Goma treated 1,660 patients. more than 1,300 surgeries and assisted hospitals and six health centres. In addition, Displaced people at spontaneous sites around more than 4,500 deliveries. Bulengo also received healthcare from MSF, MSF supports two permanent cholera including psychosocial support for victims of Basic healthcare, including the prevention treatment centres (CTCs). A new 100-bed sexual violence wanting to take legal action. of, and response to, epidemic outbreaks, hospital was also built in Lulimba.

42 Democratic republic of congo children against measles inchildren Moba. against measles 150,300 over vaccinated and Lukanzola and Kaiseng in outbreaks cholera to responded Shamwana and the surrounding area. Teams in continued services health Comprehensive patients. 5,904 of atotal treated and CTC 80-bed an built team The November. previous the begun had that Lubumbashi in intervention acholera completed MSF April, In outpatient feeding centres were opened. one inpatient and three malnourishment, extensive indicated survey a nutritional a vaccination targeted campaign. When undertook and treatment hospital provided MSF Kabalo, in outbreak a measles of result a As malaria. for mainly centres, health 15 and peripheral hospital Kabalo of unit paediatric the in children treats MSF afford. cannot they fees and services health quality of alack from suffer and aid humanitarian little very receive province Katanga in Those Katanga 2013. in Kivu South in completed were consultations outpatient 565,000 than More area. Shabunda isolated the in 43,000 and Fizi in treated were patients 64,000 outbreak, malaria the vaccinated During against rabies. were 100 people over Lemera in and measles, 160,000 children were vaccinated against than more province, the in out carried were interventions cholera Six Kivu. South in cholera and rabies measles, malaria, of outbreaks of anumber to responded teams emergency MSF No. staff end 2013: 3,604 |Y 2013: 3,604 end staff No. A residentofRubayacampinMasisi,NorthKivu,looksoutoverthemakeshifttents. ear MSF first worked in the country: msf.org/drc | 1981 country: the in worked first MSF ear Likati, Titule and Poko, and vaccinated vaccinated Poko, and and Titule Likati, Bondo, Aketi, Buta, Ganga-Dingila, of zones health the in patients 30,200 treated MSF Bas-Uélé, in measles of outbreak an During were screened and 1,358 received treatment. 73,336 Some people Bas-Uélé. Ango, and Ganga-Dingila at sickness sleeping for people Ministry of Health staff, screened and treated with and hospital, Dingila at department emergency the in work to continued MSF under 15. 42,567 of children atotal reaching campaigns, vaccination measles two conducted and kits relief 10,000 distributed people, displaced for hygiene and water improved clinics, mobile two ran also MSF injuries. conflict-related with patients 106 on trauma operated and 726 births assisted teams time, this During patients. of number increasing an for hospital to guarantee adequate healthcare Geti of theatre operating and unit maternity the supported MSF September, from and displacementmassive population in area, the caused August in forces rebel and government between clashes year. Violent previous the on 41 cent of per increase an 59,567 consultations, provided and centre health the support to continued MSF Irumu, South Geti, In Orientale vaccination campaign was also cancelled. MSF. on Acholera attacks consecutive two cholera was suspended in November after reducing at aimed Kalemie in A project Internati onal A

More than 5,500 patients are on treatment. treatment. on are patients 5,500 than More medication to patients. stabilised (ARV) of antiretroviral distribution the manages programme and a community-based hospital has been increasingly decentralised Kabinda at based programme HIV The Kinshasa Likati. and Bondo Aketi, Buta, Ganga-Dingila, of zones health the in 189,000 children my job back. job my me gave and that, to to like talk him Icame that brave it thought boss The free drugs and had regained strength. the HIV, Iwas taking with that sick but Iwas that him Itold explain. and ex-boss to to me go my advised to Afriend eat. nothing I had But health. my I regained gradually ARVs, Istarted When home. at stayed I Iwas So fired. useful. longer no Iwas time, the all Iwas sick but before, shop this in working I was already son. my and daughter my wife, my I feed is this how astore; in asalesman I am care. free for [to MSF] US$10. even money, not me referred Adoctor no Ihad But US$200 treatment. treatment, to start Ihad screening, the After status. HIV my about to want anyone tell not I did 52 years old Popol iv ct D e i m ty R ty ocrat i c republ eport 2013 i c o congo 43 f congo

© Colin Delfosse Médecins Sans Frontières ethiopia Nomadic people, refugees, people in conflict-affected areas and those located in the remotest parts of Ethiopia lack access to health services.

Responding to the lack of medical services for pregnant women and young children, Médecins Sans Frontières (MSF) runs a programme focused on maternal and child health in Sidama, Southern Nations, Nationalities and People’s Region (SNNPR). People are seen at Mejo and Chire health centres, and through outreach activities in 15 locations. A maternity waiting home offers women with high risk births Regions where MSF has projects a place to stay for one to two weeks before delivery, so that they are close to Key medical figures: emergency obstetric services. In 2013, the • 120,800 outpatient consultations • 600 patients under treatment for TB team provided 10,460 ante- and postnatal • 9,900 patients treated in feeding centres consultations, assisted 800 deliveries and vaccinated 19,260 children. The inpatient department saw 3,000 patients. © Faith Schwieker-Miyandazi / MSF

In Teru Woreda, Afar, which is affected by an ongoing drought, MSF provided medical care to 1,880 children.

44 ethiopia Somali region. Services include an inpatient inpatient an include Services region. Somali zone, Liben Ado, Dolo in population host the and refugees Somali for healthcare specialist provide to Teams continued Critical refugee assistance assisted 325 deliveries. and care antenatal with 2,242 women provided malnutrition, 1,467 for children Teams treated 12 villages. another served and immunisations. A ambulance free antenatal care, therapeutic feeding provided and locations outlying nine to Additionally, travelled clinics mobile regular to population. surrounding the services health quality provide to training and supplies medical staff, of form the in support received Yucub and Danod in centres health two and post, health Yucub at offered was healthcare Basic treatment. TB and services maternity children, malnourished or ill severely for care specialist on focusing hospital, Wardher supported MSF area, Wardher the In ofBureau Health. vaccinationmeasles the with campaign a completed ateam and facilities health MSF-supported in supply and quality water in made were Improvements provided. also were activities health of management the for materials and Drugs hospitalisation. requiring children for care better provide to built was ward 35-bed equipped fully A treatment. TB began 430and patients people, 890 by attended were groups, including counsellingactivities, and therapy health Mental programmes. nutrition in 960consultations and children enrolled antenatal 3,460 out Teams carried woredas. Degehabur and Ararso Birqod, in clinics mobile through provided was healthcare Basic TB. and malnutrition for treatment of violence including sexual violence, mental healthcare, for assistance victims hospital with emergency obstetric services, Degehabur, MSF supported the regional In region. Somali the in healthcare to barriers pose all groups anti-government armed and forces government between conflict and workers health senior qualified Underdevelopment, of a shortage region Somali in gaps healthcare Filling five. under children malnourished for treatment and patients for support nutritional offers also programme 2013. in Health Abdurafi of The Bureau the to HIV simple with patients of handover the completed MSF (TB). tuberculosis with co-infected those for and HIV/AIDS, and azar kala with people for treatment provides MSF region, Amhara Abdurafi, In Ethiopia. in sandfly, is endemic and sometimes epidemic infected an of bite the by transmitted disease azar, or kala leishmaniasis, a parasitic Visceral No. staff end 2013: 1,226 |Y 2013: 1,226 end staff No. ear MSF first worked in the country: 1984 | msf.org/ethiopia | 1984 country: the in worked first MSF ear

an inpatient unit, and carried out mobile mobile out carried and unit, inpatient an and programme feeding a supplementary up set Staff support. development lacks that area reach to difficult and aharsh Woreda, Teru to ateam sending by responded MSF April, In nutrition. and health people’s on impact asevere had region Afar in years recent in recorded drought worst The Responding to drought and deportation and 1,980against measles against meningitis. 1,280 children vaccinated and consultations, 5,500 out carried had year, teams the of end the By region. Gambella Raad, of community host the in people 3,000 and refugees 3,000 estimated an to assistance providing started MSF Sudan, South in violence of outbreak an July,In following camps. three all across programmes children to supplementary feeding 21,02523,170 admitted and consultations Teams undertook camp. Ashura new the at Tongo and Bambasi, in services nutritional to improve authorities local healthcare and with work to continued MSF improved. that people’s nutritional status had greatly showed 2012 camp in Bambasi in started emergency nutrition programme that the of evaluation An refugees. Sudanese South to aid provided ateam Gumuz, Benishangul- of region western the In out rounds several of polio vaccination. carried also Health, of Bureau Regional the and,against measles in with collaboration children. Teams vaccinated 12,180 children for centre feeding atherapeutic and emergencydepartment, obstetric surgery An arrivalsiteinGambellaregionforrefugeesfromSouthSudan. Internati onal A

consultations, and assisted 170 and assisted consultations, births. 33,140 out antenatal 650 and carried health year, the teams of half first the In June. city, in Gambella of north Mattar, in centre health a at care nutrition and maternity inpatient, providing project the over handed also MSF April. in closed was camp refugee Buramino in centre feeding therapeutic the and March, in Health of Bureau the to over handed was region, Imey, Somali East in clinic The stay. hospital alengthy without treatment undergo could they that so homes people’s and ward TB the to modifications fine-tuningmedical protocols and making equipment, donating diagnostic after project the over handed team The Dawa. Dire in treatment TB for programme innovative an establishing in Health of Bureau the assisted MSF rise. the on are disease the of forms drug-resistant that indications are there and malaria, after Ethiopia in death of cause common second-most the is TB Programme closures further treatment. for Ababa Addis in hospital psychiatric the to referred were 40 and illness a mental have to found were consultations individual 15,673 people. of One-fifth those receiving to support psychosocial provided MSF December. of end the by airport Bole at children and women men, Ethiopian 154,837 of arrival the in resulting workers, foreign ‘illegal’ deporting began Arabia In November, the government of Saudi care. medical received children treatment activities. More than 1,880 iv ct i ty R ty eport 2013 iop eth

i © Francois Servranckx / MSF a 45 Médecins Sans Frontières France Médecins Sans Frontières (MSF) closed its programme for asylum seekers in Paris this year.

Since 2007, MSF has been providing medical both at home and in exile. A particular and psychological care as well as social emphasis was put on providing support to asylum seekers in Paris. Many have psychological care to those who did not fled conflict zones or political persecution speak French and could not access the at home and find themselves living on necessary help elsewhere. Cities, towns or villages where MSF works the streets in France. Most have no health insurance and it is very hard for them to MSF, after assessing the limitations, decided access any kind of medical care. Furthermore, to close its programme in France at the many of them cannot speak French. end of May 2013. The most pressing issues encountered by migrants in France are those In 2013, an MSF team of nurses, doctors, linked to administrative and social problems, psychologists and social workers continued and these are currently beyond the remit of a to treat and support asylum seekers who medical humanitarian organisation. had suffered repeated traumatic experiences

Year MSF first worked in the country: 1987 | msf.org/france georgia Lack of access as well as poor adherence The Georgian national TB programme is to TB treatment were at the origin of well organised, and MSF is currently in the emergence of multidrug-resistant TB discussions with the Georgian Ministry (MDR-TB), a form of the disease that does of Health regarding clinical trials for two not respond to standard first-line drugs new MDR-TB drugs which will shorten the as the bacteria is resistant to two main length of treatment and should result in antibiotics. Today, MDR-TB also spreads fewer side effects. from one patient to another. Treatment for MDR-TB is available, but it takes up to two Care for the elderly Regions where MSF has projects years on a course of several drugs to be An MSF team continued to provide medical Cities, towns or villages where MSF works cured. People must also tolerate difficult assistance to vulnerable people in an access side effects, such as depression, loss of to care programme that started in 1993. Key medical figures: Most of the 50 patients are now aged 70 • 169 patients under treatment for TB hearing, nausea and vomiting. or older, and live in Sukhumi, Abkhazia Médecins Sans Frontières (MSF) treats and Tbilisi. They are bedridden and Tuberculosis (TB) remains a patients with MDR-TB in the autonomous isolated, and suffer from serious chronic republic of Abkhazia, and is also assisting diseases. MSF offers eye care, as well as major challenge in Georgia, with the development of the Abkhazian material support such as wheelchairs, and with many people suffering national programme. Activities include an MSF doctor carries out home visits. training, writing medical care protocols, from multidrug-resistant laboratory support and the supply of strains of the disease. equipment and drugs.

No. staff end 2013: 39 | Year MSF first worked in the country: 1993 | msf.org/georgia

46 France | georgia International Activity Report 2013 greece Migrants and asylum seekers of all ages rapidly in crowded conditions – in the can find themselves summarily arrested detention facilities. More than 2,000 people and confined in detention centres for were treated between January and April and up to 18 months. They have little or no September and December. opportunity to communicate with their families, and their physical and mental Healthcare out of reach health often deteriorates. The financial crisis in Greece has led to the country’s health budget being cut by Médecins Sans Frontières (MSF) has almost 40 per cent, and state funds for Regions where MSF has projects responded to the situation by providing medication have also been almost halved. Cities, towns or villages where MSF works medical consultations and psychosocial As a consequence there is limited availability support to people being held at detention of medicine, not only for vulnerable groups Key medical figures: centres in Komotini, Filakio and Drama, and like the unemployed and the uninsured, but • 2,900 outpatient consultations in the police stations of Feres, Soufli, Tychero also for the general population. In October, • 200 individual and group mental and North Iasmos. Items including clothes, an MSF team began assisting people in need health consultations sleeping bags, towels and soap have also of healthcare at food distribution centres been distributed in centres to help people in Athens. On-the-spot care, including maintain a basic level of hygiene, health and medical consultations, hospital referrals and Undocumented migrants and dignity. These activities were handed over to psychosocial referrals for shelter and legal asylum seekers in Greece face the Hellenic Center for Disease Control and assistance were provided. Many patients Year MSF first worked in the country: 1987 | msf.org/france Prevention in April. Five months later, MSF were unemployed or elderly. long periods of detention in resumed assistance at Filakio and Komotini, centres with limited access to and Feres, Soufli and North Iasmos as no Freezing temperatures in early 2013 led basic services and healthcare. medical or humanitarian assistance was authorities to open temporary emergency being provided by the authorities. The team shelters to accommodate homeless people also responded to two outbreaks of scabies in Athens, and MSF launched an emergency – a parasitic skin infestation that spreads intervention in January.

No. staff end 2013: 12 | Year MSF first worked in the country: 1991 | msf.org/greece guinea Malaria is a preventable and treatable illness health centres supported by MSF, offers a transmitted by infected mosquitoes, and is free, comprehensive health package that a leading cause of illness and death in the includes psychosocial care, tuberculosis country. Médecins Sans Frontières (MSF) treatment for co-infected patients and has continued to work with the Ministry of prevention of mother-to-child transmission Health on malaria prevention and treatment of the virus. in Guéckédou, and the programme now The HIV programme in Guéckédou was supports the district hospital, seven health handed over to the Ministry of Health in centres and 12 health posts. The MSF team 2013, as was the Matam maternal health Regions where MSF has projects has also trained 53 community health programme. Cities, towns or villages where MSF works workers so that they can screen and treat people with uncomplicated malaria. Responding to cholera and Key medical figures: meningitis outbreaks • 179,400 outpatient consultations HIV • 94,400 patients treated for malaria During an outbreak of meningitis in May, Although the prevalence of HIV is relatively • 13,600 patients on first-line ARV treatment an MSF team treated 132 patients, provided low in Guinea, people who have the drugs to medical facilities and trained illness often cannot afford to pay the No. staff end 2013: 39 | Year MSF first worked in the country: 1993 | msf.org/georgia local staff. In June, an emergency cholera fees that are charged for antiretroviral The healthcare system in treatment centre was set up on Memgbe drugs. Many HIV-positive people also fear Island, Conakry. Eighty people who had Guinea is currently unable disclosing their status due to the social contracted the water-borne disease were stigma, and this creates another barrier to to meet all the needs of its treated. There were no new cases or deaths treatment. The HIV programme based in after assistance had been provided. people. Malaria remains a the capital Conakry, comprising one MSF particular concern. ambulatory treatment centre and five

No. staff end 2013: 327 | Year MSF first worked in the country: 1984 | msf.org/guinea

greece | guinea 47 Médecins Sans Frontières haiti Healthcare in Haiti remains largely water chlorination points and educational privatised and most people do not have activities. In 2013, more than 85,000 people the financial means to pay for it. In 2013, learned about cholera prevention and 5,240 Médecins Sans Frontières (MSF) continued disinfection kits were distributed. to provide urgently needed free services to help fill some of the gaps. Historically there has been little emergency care available for people in Haiti unless Cholera, a water-borne infection that can they can afford to pay for it. MSF runs lead to rapid dehydration and sometimes the Centre de Référence en Urgence Cities, towns or villages where MSF works death, remains a health threat where there Obstétricale (CRUO), a 130-bed hospital

Key medical figures: is poorly managed water and sanitation. in Port-au-Prince providing free, 24-hour • 6,550 births assisted Overall, living conditions in Haiti have obstetric care for pregnant women suffering • 13,600 surgical interventions improved over recent years, but in camps from complications such as pre-eclampsia, • 7,400 patients treated for cholera hygiene standards remain extremely poor eclampsia, obstetric haemorrhage and and some people are without access to uterine rupture. A full range of reproductive affordable drinking water. health services, including family planning, More than three years postnatal care and prevention of The cholera crisis that began within months mother-to-child transmission of HIV is also after Haiti’s devastating of the 2010 earthquake persists, particularly offered. A 10-bed unit, the ‘Cholernity’, earthquake, the few public during the rainy season, when the number is available for pregnant mothers with medical facilities in the of patients reaches epidemic levels. Since cholera within the CRUO. Teams assisted October 2010, more than 700,000 people 5,450 births during the year. country do not have the have been infected with cholera. One- resources to meet the third of these have been treated by MSF. Decentralising care needs of most Haitians. Teams continued to run cholera treatment MSF continued to manage the 160-bed centres (CTCs) in Delmas and Carrefour, temporary container hospital in the city Emergency services are in Port-au-Prince. Preventive measures of Léogâne, which had originally been set particularly lacking. included distribution of hygiene kits, up to provide emergency services after © Diana Zeyneb Alhindawi

A mother feeds her premature baby in an MSF hospital in Port-au-Prince.

48 haiti No. staff end 2013: 2,324 |Y 2013: 2,324 end staff No. wounds bullet with patients 50 (around violence of victims were one-fifth accidents, road in been had 2013. one-third than More in treated were 13,200 people Some offered. are physiotherapy and care, burn and slum. Surgery, intensive care, orthopaedic Soleil Cité to close Port-au-Prince, in hospital Drouillard 130-bed the at violence, sexual and burns violence,accidents, including of victims to care trauma provides A team Drouillard hospital complicated cases. handle to partners potential identify to started has MSF facilities. health local canpregnancies already be managed in uncomplicated for care antenatal and deliveries straightforward and hospital, the in activities its reduce to begun has MSF unit. treatment acholera run to primarily for obstetric emergencies, and services, specialist as year, well as this children and women for healthcare basic provide to continued hospital The region. the in level pre-earthquake the to services restoring of aim Health’s of Ministry the support to order in programme its extend to decided MSF disaster, the after system healthcare the of fragility the of Aware earthquake. the The specialistburnsunitinPort-au-Price’s DrouillardhospitalistheonlyoneinHaiti. ear MSF first worked in the country: 1991 | msf.org/haiti | 1991 country: the in worked first MSF ear for people in eastern Port-au-Prince. Port-au-Prince. eastern in people for care post-operative and physiotherapy orthopaedics, services, and trauma continued to provide free emergency Tabarre in centre surgical Kenbe Nap The Tabarre 2013. in daily seen were 100 patients than More treatment. for hospitals appropriate to patients situation. transports ambulance An service medical emergency of kind any in people to care free offering clock, the around open is centre The centre. stabilisation and caregivers at the Martissant emergency and patients for support psychological as well as services, maternity and medicine internal care, paediatric provides MSF stabilisation centre Martissant emergency and required. if CTC, a130-bed into transformed be quickly can that hospital the in a unit unitburns in country. the MSF also maintains aspecialist with facility only the is hospital Drouillard five. were under children accidents domestic in burns suffered who patients domestic accidents. A large percentage of in injured were one-quarter and monthly) admitted were wounds knife 100 with and Internati

onal A

going to offer to do washing for people. for to washing do to offer going Iam milk. breast for is old too he once son to my feed Iwon’t able be worried I am … birth the remember not could to but me next baby the Isaw MSF an hospital. in up woke and consciousness Ilost day one and worsened health My to swell. began feet my until pregnancy my in problems no I had me. to help came passersby. one of No were anumber there and 8pm was It around times. many me hit and to tightly on me held other The left. them of one so loudly I shouted tent. empty into an me dragged water. some and Twocollect arrived men to Iwent night, One to work. out went cousin my while food, prepared tent and the in Istayed earthquake. the after cousin my with camp Canaan in I was living 19 years old Manise iv ct

i ty R ty eport 2013 hai

ti © Yann Libessart 49 Médecins Sans Frontières honduras The public healthcare system in Honduras cannot keep pace with victims of violence, leaving the most vulnerable people deprived of much-needed services. Cities, towns or villages where MSF works

Survivors of criminal violence in Honduras reorganise services and is working on Key medical figures: rarely seek medical or psychological help, improving emergency management • 1,500 individual and group mental fearful of their aggressors and deterred by to better deal with large influxes of health consultations the many barriers to healthcare. There are patients and to reduce chances of death • 720 people treated after incidents of sexual violence frequent shortages of skilled personnel and or permanent disability arising from supplies at public hospitals and clinics, and inadequate trauma care. health staff are reluctant to treat victims of violence for fear of repercussions. A large street-based population, consisting There is no national protocol for the treatment of homeless people and people who work of victims of sexual violence in Honduras and Aiming to improve access to emergency informally, such as street sellers and sex this means that victims do not have access to adequate medical care. MSF is part of a medical care, Médecins Sans Frontières workers, are hyper-exposed to violence (MSF) continued to run a comprehensive Ministry of Health committee working to and are excluded from the health system. programme offering quality treatment develop national health guidelines for the Mobile teams consisting of a social worker, and follow-up to victims of violence in the treatment and care of victims. a psychologist and a clinician visited capital city of Tegucigalpa. Teams worked 25 sites around the city each week in to increase vulnerable people’s access to Dengue emergency 2013, identifying inhabitants’ medical, emergency healthcare for trauma, medical In San Pedro Sula, the country’s second city, psychological and social needs. The teams emergencies, sexual violence and mental MSF responded to an epidemic of dengue provided on-the-spot first aid, preventive healthcare for victims of violence. haemorrhagic fever and treated more than care and mental health support. More than 600 children in the paediatric ward of Mario The emergency room of the university 1,040 victims of violence, including 725 Catarino hospital between August and hospital Escuela, the main public hospital in victims of sexual violence, were identified November 2013. MSF also donated drugs the country, is always extremely busy, seeing and treated across four MSF-supported and medical supplies to the hospital for the some 260 patients per day. MSF helped health clinics. treatment of adults affected by dengue.

No. staff end 2013: 57 | Year MSF first worked in the country: 1974 | msf.org/honduras IRAN Rates of drug addiction in Iran Sans Frontières (MSF) continued to run a health centre dedicated to women and remain high, yet many addicts children under five who are excluded have difficulty accessing the from healthcare, including undocumented medical and psychological refugees. Together with Iranian authorities care they need. and local organisations, MSF offered free, basic healthcare, including medical consultations for women and children, The Iranian authorities have recognised that drug addiction and HIV infection are gynaecological care, family planning Cities, towns or villages where MSF works a growing public health concern, and have and postnatal care. A mental health programme started in September, with Key medical figures: taken significant steps to initiate harm • 5,800 outpatient consultations treatment and support provided by a reduction and HIV/AIDS prevention among • 1,200 antenatal consultations injected-drug users. However, the broad psychiatrist and a psychologist. • 60 individual and group mental medical needs of high-risk groups remain health consultations Iran’s Bureau for Aliens and Foreign acute, especially in Tehran, where drug Immigrants’ Affairs estimates that the users, sex workers and street children are stigmatised and are therefore unable to country hosts 850,000 refugees, most of access the general health system. them Afghans. While registered refugees are granted private health insurance, In Darvazeh Ghar, one of the poorest those who are undocumented have neighbourhoods in Tehran, Médecins limited access to healthcare.

No. staff end 2013: 30 | Year MSF first worked in the country: 1990 | msf.org/iran

50 honduras | IRAN International Activity Report 2013 italy Migrants and asylum seekers standards and respect for human dignity. The authorities closed the centre and began face many health challenges making upgrades. upon arrival in Italy, in both MSF continued a pilot project for the early Cities, towns or villages where MSF works reception and detention centres. diagnosis and treatment of tuberculosis among migrants hosted in reception and Key medical figures: Victims of torture, human trafficking, sexual detention centres. • 6,750 outpatient consultations violence and people with mental health issues are particularly vulnerable on first arrival in MSF teams also worked in Milan, Trapani, Italy, but there are insufficient services to Caltanissetta and Rome, in collaboration meet their needs. Crowded reception centres with the Ministry of Health, the Ministry A Syrian refugee whose family had and poor living conditions in facilities for of Foreign Affairs and private companies escaped a chemical weapons attack migrants pose further health risks. responsible for managing reception and and had travelled through Lebanon, detention centres. In Lombardy, an MSF Teams from Médecins Sans Frontières (MSF) Egypt and Libya before arriving in provide medical and mental healthcare to team worked with the NGO OIKOS in the Pozzallo, Italy. migrants and asylum seekers in reception Latin American migrant communities to centres on Sicily and in Calabria. Basic ensure access to diagnosis and treatment of The trip was organised by armed men … healthcare is offered to undocumented Chagas disease, which is endemic in their on board we had no water or food. migrants in Ragusa province, Sicily. In home countries. Thirsty, we drank the used engine water. Pozzallo, MSF supports the local health We stayed three days at sea before we authorities with medical triage of migrants A team also completed a three-month were rescued near the Sicilian coast. All I on arrival. In December, MSF called for assessment of the ongoing healthcare want is a safe place for my family. Many the temporary closure of the Lampedusa needs of homeless patients discharged Syrians are stuck in hell: caught between reception centre so that it could be from hospitals in Milan, Rome and Palermo. the battles, without doctors and food. refurbished to ensure minimum reception A project will be launched in Milan in 2014.

No. staff end 2013: 11 | Year MSF first worked in the country: 1999 | msf.org/italy Laos as the number of deaths during pregnancy and childbirth, and an MSF team worked with the hospitals and health centres of XiengKhor, Sop Bao, Ett, Xamtai and Kuan districts. Mobile medical clinics reached some of the most remote and disadvantaged communities in the province, and MSF worked to improve

Regions where MSF has projects laboratory and pharmacy facilities in the area, as well as water, electricity and sanitation infrastructure.

Médecins Sans Frontières The team found that low patient attendance (MSF) stopped working in rates, the scattered nature of the health facilities in the province, and the difficulties Laos in December 2013. in recruiting qualified Lao staff and In 2011, MSF decided to launch a programme importing the necessary drugs meant that to provide obstetric and neonatal support goals were not met and expected outcomes for training medical staff and treating

and paediatric care for children under five, © Takuro Matsumoto / MSF in five district hospitals and 10 health posts patients were not reached. The decision in Huaphan province, northeastern Laos. was made not to continue the programme A midwife examines a patient, in the The aim was to reduce infant mortality, as well beyond the end of the year. presence of her family.

No. staff end 2013: 46 | Year MSF first worked in the country: 1989 | msf.org/laos

italy | Laos 51 Médecins Sans Frontières india

Key medical figures: • 93,100 outpatient consultations • 1,500 patients on first-line ARV treatment • 820 patients under treatment for TB

Healthcare remains difficult to access for India’s most isolated and marginalised populations.

Longstanding, low-intensity conflict in Chhattisgarh and Andhra Pradesh has led to population displacement and reduced access to healthcare. Médecins Regions where MSF has projects Sans Frontières (MSF) teams continued Cities, towns or villages where MSF works to bring basic healthcare to people in The maps and place names used do not reflect any position by MSF on their legal status. villages through weekly mobile clinics in southern Chhattisgarh, and those living in displacement camps on the Andhra Pradesh side of the border. Patients suffered mainly co-infections who have been excluded TB hospital with infection control and from skin infections, general body pain, from government health services. In 2013, counselling services. Approximately respiratory tract infections and malaria. however, the focus shifted to responding 300 patients received treatment in A mother and child health programme to the public health crisis posed by DR-TB 2013, including nearly 160 patients on offered antenatal care, immunisations and in the city. MSF treated patients with the second-line and third-line HIV regimens, nutritional support for pregnant women and most severe forms of DR-TB. The strategy approximately 50 patients with HIV and children in Bijapur, Chhattisgarh. Screening, is to treat a small but acute group of DR-TB co-infection, and about 80 patients diagnosis and treatment for tuberculosis patients who cannot access the government with DR-TB. (TB) were also available. In November, healthcare system, and to use evidence a clinic providing basic healthcare was from operational research to encourage In the northeastern state of Manipur, where opened in Mallampeta, a remote village the government to find ways and means the prevalence of adult HIV infections is the on the border of Andhra Pradesh and to provide treatment for these people. highest in the country, MSF offers HIV and Chhattisgarh. In 2013, MSF carried out TB care in three clinics in Churanchandpur nearly 52,600 consultations and treated MSF runs a clinic offering outpatient care and Chandel districts. One of the clinics approximately 8,465 people with malaria that provides third-line antiretroviral (ARV) is situated in the town of Moreh, right on in the region. therapy for patients with second-line ARV the border with Myanmar. More than 560 failure and treats patients co-infected patients started treatment for HIV this year Healthcare in Nagaland with HIV and hepatitis B or C, or DR-TB. (a total of 1,244 patients were receiving Until recently there had been few health In addition, MSF supports a government treatment by the end of 2013), 299 people services available in remote Nagaland state, where the years of insurgency had stunted the area’s development. Since 2010, MSF has supported Mon district hospital by refurbishing the buildings and upgrading key services including pharmacy and medical waste management, the laboratory, infection control measures, and water and sanitation. MSF has also provided staff training to improve medical management, with special focus on sexual and reproductive health and TB. The team carried out 30,365 outpatient consultations, assisted more than 680 deliveries and treated 15 patients for drug-resistant TB (DR-TB) in 2013. The project has been recognised by the government and local community for the significant impact it has had on people’s access to healthcare in Mon district.

Improving access to HIV and TB care © Azzurra D’inca / MSF In Mumbai, MSF continued to provide An MSF mobile clinic in a Chhattisgarh village. treatment for patients with HIV and

52 india No. staff end 2013: 672 |Y end staff No. working population local the and India over all from pilgrims were lives their lost who people 10,000 estimated the of majority the and sites Hindu holy many to home is state The and districts. Rudraprayag Pithogarh Chamoli, Uttarkashi, in flooding flash significant caused in mid-June state Uttarakhand in landslides and rains Heavy programme. the across provided were 2,530 individual mental health consultations of Atotal June. in Pattan in launched were services Counselling met. being were needs material and social psychological, basic ensuring – aid first psychological provided of violence invictims Srinagar hospitals and visited Teams also districts. Baramulla and Srinagar in locations fixed five at continued programme health mental MSF established Awell- support. psychological for persist needs and health, mental people’s on a toll taken have Kashmir in conflict of Decades Mental healthcare multidrug-resistant TB (MDR-TB). for 30 and TB for treatment began the circumference ofachild’s upperarm. There arehighlevels ofmalnutritioninchildrenaged betweensixmonthsandfive yearsinBihar. Malnutrition braceletslikethisonemeasure ear MSF first worked in the country: 1999 | msf.org/india | 1999 country: the in worked first MSF ear as well as an alternative, single-shot dosage dosage single-shot alternative, an as well as therapies, combination two of effectiveness and safety the examining project a pilot implementing initiative (DNDi), Diseases collaborated with the Drugs for Neglected 2012, Since cent. has per MSF 98 of rate cure initial an with treated, were patients than 10,000 More clinics. health five and hospital district Sadar at treatment afirst-line as B) amphotericin (liposomal 20mg/kg 2007, L-AmB in azar introducing kala to responding began MSF untreated. left if fatal always almost is infection The endemic. is sandfly, infected an of bite the by transmitted disease a parasitic leishmaniasis), (visceral azar kala area where an in Bihar, live district, Vaishali in People in Bihar Treating kala azar and malnutrition were provided. sessions 37 and group sessions individual 440 than More district. Rudraprayag in distress acute from suffering those support to programme athree-month up set MSF them. with Internati onal A

treated in Darbhanga since 2009. since Darbhanga in treated been have five of age the under children 13,000 Over system. health public the malnutrition that can be implemented within acute severe with children for care of model a define to authorities health with work to continues MSF cases. severe most the treat to Darbhanga in hospital ateaching inside unit care intensive amalnutrition building began also MSF blocks. four additional an cover to expanded programme the 2013, In block. Biraul in programme a through community-based malnutrition acute severe with children for treatment MSF weekly crisis. teams provide health under-reported and achronic is malnutrition Bihar, child of district Darbhanga the In disease. the for protocols treatment national change potentially could research the safe, and effective proven are regimens drug new these If districts. additional to expand will programme pilot the and encouraging were outcomes Initial L-AmB. of iv ct i ty R ty eport 2013 i nd i

a © Angel Navarrete

53 Médecins Sans Frontières iraq There was a dramatic increase in violence in in order to try and reduce the number of Iraq in 2013, and this further undermined neonatal deaths. Along with training and the capacity of health facilities to respond supervision, MSF placed an emphasis on adequately to medical needs. Médecins infection control, pharmacy standardisation, Sans Frontières (MSF) is focusing on filling sterilisation procedures and data collection. some of the gaps in care, training staff and In 2013, 23,627 deliveries were registered at sharing knowledge at several hospitals. the hospital, with more than 6,000 infants requiring intensive care. Child and maternal health Regions where MSF has projects In January, MSF began working with Hawijah hospital Cities, towns or villages where MSF works the neonatal care unit at Kirkuk general More than 300 emergency surgical hospital, providing training and supervision Key medical figures: procedures were performed each month to ensure basic standards of care for • 193,800 outpatient consultations at the hospital in Hawijah, the only facility • 10,800 individual and group mental newborns and their mothers. health consultations offering specialist services in the entire The Al-Zahra hospital is the main referral district. In addition to providing hands-on hospital for obstetrics, gynaecology and emergency surgical services around the Thousands of Iraqis endure paediatrics in Najaf governorate. An clock, an MSF team conducted training in MSF team trained doctors and nurses, the management of emergency cases and a lack of basic healthcare implemented treatment protocols and infection control intervention. MSF also services, and access is further introduced documentation and analysis carried out assessments of health centres hampered by chronic insecurity. methods. Support was also provided in in Hawijah district to ascertain whether hospital management, infection control, basic healthcare was available for the rural War has affected medical structure rehabilitation and maintenance. MSF communities, and this information will be infrastructure in some areas. trained hospital staff in case management used as a reference to develop new activities. © Diala Ghassan / MSF

The Syrian crisis has resulted in a massive flow of refugees into Iraq, and more than 200,000 Syrians crossed into the Kurdish region of Iraq by the latter half of 2013.

54 iraq No. staff end 2013: 526 |Y 2013: 526 end staff No. needs with pace keep cannot services camp authorities, local the of efforts the Despite people. 45,000 to swollen has population camp the families, 1,000 host to designed Initially camp. Domiz in provider healthcare main the also is MSF groups. age all across consultations for were main the infections cause Respiratory five. under children for were these of cent per 30 and refugees, with conducted were 18,900 consultations than More December 2013. in Health of Department the to over handed was province, Erbil in also refugees), (3,000 camp Qushtapa smaller the in September late from ran that clinic Amobile refugees. 12,500 hosts which province, Erbil in camp Kawargosk the at September in healthcare mental and basic offering clinic a health opened MSF mid-August. in days a few just within arrived refugees 50,000 than more and intermittently only opened are 2013. of half latter Borders the by Iraq of region Kurdish the into crossed had Syrians 200,000 than more agency, refugee UN the to According Iraq. into refugees of flow amassive in resulted has crisis Syrian The camps refugee in Syrians for Caring A sickbabywithhismotherandsiblingsinthepaediatricwardofHawijahhospital. ear MSF first worked in the country: 2003 | msf.org/iraq | 2003 country: the in worked first MSF ear

support based in based Baghdad, managed the support administrative with together MLOs, The support. psychosocial and physiotherapy plastic reconstructive surgery, along with and maxillofacial receive orthopaedic, Patients Jordan. Amman, in programme surgery MSF’s to reconstructive patients refer and identify They Diyala. and Basrah Al- Al-Anbar, Salah ad-Din, Al-Qadissiyah, in Baghdad, Najaf, Erbil, Ninewa, Kirkuk, located (MLOs) officers liaison medical of anetwork runs MSF country. the the specialised care they need within cannot access injuries other traumatic and burns from suffering patients Many reconstructive surgery Referring victims of violence for year. the of half first the in completed were ensure minimum of hygiene standards to activities sanitation and water and kits Targeted ofhealth. washing distributions diseases, health reproductive and mental chronic for treatment provides also MSF but diarrhoea, watery acute and infections tract respiratory upper from suffer patients Many consultations. medical 2,400 some out carries MSF week Each health. people’s in adeterioration to led have conditions and overcrowding and poor living Internati onal A

physiotherapy is being organised. is being physiotherapy in Baghdad, for and training inpatient made to various rehabilitative departments were physiotherapy.concerning Visits collaboration apossible for Rehabilitation health ministry’s Department of Medical the from arequest to responded also exchange of scientificknowledge. MSF the and antidotes of donations the through Baghdad in (PCC) Center Control Poisoning national the supported MSF services health in expertise Sharing in June. Health of Ministry the to over handed was programme the before sessions, counselling 2,027 in 775 people treated psychologists 2013, In offered. were helpline a telephone to reduce stigma. Individual counselling and aiming and needs to 2009, responding since mental healthcare in Baghdad and Fallujah providing been had MSF Iraq. in treated or discussed openly not is illness Mental illness mental of stigma the Reducing 2013. in Iraq in patients 400 almost for follow-up provided and 185 of patients, discharge and admission iv ct i ty R ty eport 2013 i ra © Diala Ghassan / MSF q 55 Médecins Sans Frontières JORDAN Médecins Sans Frontières an MSF rehabilitation centre. Surgeons performed 1,370 operations on patients (MSF) continued a from Syria, Iraq, Yemen and Gaza in 2013. reconstructive surgery programme in Jordan for In addition, MSF conducted around Cities, towns or villages where MSF works 300 medical and surgical consultations Key medical figures: victims of conflict, opened a per month for Syrian refugees at a special • 320 individual and group mental trauma programme for war health clinic within the hospital compound. health consultations wounded from Syria, and Physiotherapy services were also offered expanded activities to help and a team provided physiotherapy and specialist referrals. Maternal and child health in Irbid meet the needs of Syrian Irbid has one of the highest concentrations refugees and ease pressure In August, MSF opened an emergency of Syrian refugees outside of the camps – on host communities. trauma project in the Ministry of Health there were over 120,000 in the governorate hospital in Ar Ramtha, less than five by the end of 2013. An assessment of their kilometres from the border with Daraa health situation conducted by MSF in May In Amman, MSF runs a regional governorate in Syria, an area which has and June showed that mothers and children reconstructive surgery programme for seen some of the heaviest fighting in the were not getting adequate healthcare. MSF patients suffering from severe injuries conflict. Severely wounded patients crossing opened a programme in October offering that require a level of integrated and the border here are taken to Ar Ramtha consultations and inpatient care for refugees specialised care that is difficult for them and people in need in host communities. to access anywhere else. Many people hospital. They are the victims of bombings initially receive treatment for wounds at and shellings, and are caught in the middle Filling a gap in paediatric care at Zaatari other hospitals, and a network of doctors of the violence and left with limited access refugee camp, an MSF team ran a 24-hour refers them to the reconstructive surgery to medical care. Since the project opened, hospital for children aged one to 10 from March hospital. Orthopaedic, maxillofacial and the team has admitted 181 patients and to November. The project was closed when plastic reconstructive surgery is offered performed 336 major surgical procedures. other health providers were able to meet the with essential complementary care that The facility also offers individual and group children’s needs. More than 17,500 patients includes physiotherapy and psychosocial mental health and physiotherapy sessions. were treated over the course of the programme. support. Patients are also provided with transportation and are accommodated at No. staff end 2013: 72 | Year MSF first worked in the country: 2006 | msf.org/jordan © MSF

MSF runs a regional reconstructive surgery programme in Amman.

56 JORDAN International Activity Report 2013 KYRGYZSTAN

Regions where MSF has projects Cities, towns or villages where MSF works

Key medical figures: • 300 patients under treatment for TB

Médecins Sans Frontières (MSF) estimates the incidence of tuberculosis (TB) among

prisoners in Kyrgyzstan to be Tremeau © Vincent 20 to 30 times higher than in A doctor explains a lung x-ray to an XDR-TB patient in Kara-Suu hospital. the general population, with mortality rates as much as 60 times higher. Promoting ambulatory care for TB In Kara-Suu district, Osh province, where Mukhtar MSF continued to offer TB care to prisoners rates of TB are among the highest in the in the penitentiary system in Bishkek, country, MSF supported the Kara-Suu I still remember the day in the TB centre the country’s capital, which holds up to hospital, which has 80 beds for TB and when my MSF doctors told me that I No. staff end 2013: 72 | Year MSF first worked in the country: 2006 | msf.org/jordan 9,000 inmates. In the institutions where DR-TB patients. This project aims to become was cured and could stop the treatment. prisoners are detained until sentencing, a model for effective walk-in treatment. I had a strange feeling of happiness, teams provided full health screening and Whenever possible, patients receive care which I really cannot find any words put identified TB patients on treatment through the community-based healthcare to describe. I still can’t believe that the straightaway. Staff also diagnosed and system, with ambulatory or home-based treatment has finished. I have conquered treated inmates with multidrug-resistant treatment, rather than being hospitalised. death. I want to thank you all and to say that good people can save the world. TB (MDR-TB). Psychosocial counselling for patients and their families, and social packages Using a comprehensive approach to TB (nutritional support, hygiene kits and patient management, MSF also supported transport money) are provided to help Advocacy work has resulted in policy treatment for co-occurring illnesses, and patients adhere to treatment. change and acceptance of the community- offered screening and vaccination for based treatment model by the Ministry of hepatitis B. Uninterrupted completion of Rehabilitation of the hospital and basic Health as the future strategy for TB care in treatment is crucial in order for it to be health facilities was supported by MSF the country. successful, and the team ensured follow- to ensure optimal infection control and ups once individuals were released from better sanitary conditions for the patients. prison. Having helped establish protocols, Teams also worked with health centre increased infection control and improved staff to improve clinical case management, access to care, MSF plans to hand over the and the detection of people suffering penitentiary project by the end of 2014. from TB, DR-TB and HIV–TB co-infection in the district. Comprehensive care was MSF has also actively supported the provided to people with drug-resistant development of a newly constructed forms of TB, and those with certain national reference laboratory in Bishkek. co-occurring illnesses.

No. staff end 2013: 130 | Year MSF first worked in the country: 2005 | msf.org/kyrgyzstan

KYRGYZSTAN 57 Médecins Sans Frontières kenya

Key medical figures: • 415,700 outpatient consultations • 13,200 patients on first-line ARV treatment • 2,000 patients treated after incidents of sexual violence

Médecins Sans Frontières (MSF) continued to fight HIV and tuberculosis (TB), and in the camps growing insecurity affected healthcare access for refugees.

In the Dadaab refugee camps, home to over Regions where MSF has projects Cities, towns or villages where MSF works 340,000 Somalis, the general level of security has steadily deteriorated since the end of 2011. This has reduced access for aid workers, and MSF is unable to maintain a permanent non-communicable diseases. More than 330 chronic diseases such as HIV, and any other presence of international staff in its hospital people sought assistance at MSF’s 24-hour illnesses, makes it a one-stop service, thus in Dagahaley. Many aid organisations have clinic for victims of sexual violence. Services easing patients’ access to medical care experienced a decrease in funding, leading to included post-exposure prophylaxis, and facilitating early diagnosis, treatment an overall reduction in assistance for refugees psychological support and medical and follow-up. Health education sessions, in Dadaab. The impact is visible: there is a treatment. In 2013, teams working in Kibera counselling and social support are also lack of maintenance and investment in camp completed more than 142,000 outpatient offered to empower patients to manage hygiene and shelter, which raises major health consultations, and provided antiretroviral their own health. concerns and increases the risk of epidemics. (ARV) treatment to over 4,300 HIV patients. More than 60 per cent of all consultations MSF manages a 100-bed hospital in In February, MSF opened a new clinic in at MSF’s Kibera clinics were for respiratory Dagahaley, providing adult and paediatric Kibera South that has been set up with the infections and diarrhoeal or skin diseases, a care, maternity services, emergency aim of gradually handing over management result of the poor hygiene and sanitation. surgery and treatment for HIV/AIDS and to the Ministry of Health over a period of TB. Antenatal care, surgical dressings five years. It is equipped to provide residents The Eastlands area of Nairobi, composed of and mental health support are available with basic healthcare and maternity services. poor suburbs and informal settlements, is through four health posts. Each month There is an inpatient maternity ward, and an home to a population of about two million. in 2013, on average, 18,000 outpatient ambulance service for obstetric and other An average of 150 people who had been consultations were carried out and over emergencies. Integrated management of the victims of sexual violence came to the 700 people were admitted to hospital. More than 2,580 babies were delivered and some 4,100 children received treatment through outpatient and inpatient feeding programmes. Over 10,800 mental health consultations were also conducted.

In November, a Tripartite Agreement was signed by the UN refugee agency and the Kenyan and Somali governments, outlining practical and legal procedures for the voluntary return of hundreds of thousands of refugees to Somalia. An assessment conducted by MSF among patients in its medical facilities in Dagahaley camp in August found that four out of five people would choose not to return to Somalia given the current climate of insecurity.

Free healthcare in slum settlements Three MSF clinics continued to provide

free basic healthcare in the Kibera slum © Phil Moore in Nairobi, as well as integrated Residents of the Kibera slum in Nairobi wait to be seen at an MSF clinic. treatment of HIV/AIDS, TB and chronic

58 kenya No. staff end 2013: 789 |Y 2013: 789 end staff No. 2013 response in the increase to programme anew up set –MSF world the in HIV of incidences highest the of one found which – Bay Homa Ndhiwa, in survey population in impact MSF’s of HIV aresult as However, sinceprogramme 2001. the in care received have people 25,000 2015. by process Some the complete to expects and partners, its and Health of Ministry the to Bay Homa at programme HIV the of handover the continued MSF Homa Bay Addressing the HIV epidemic in Foundation.Healthcare AIDS the to over 2001, handed since was care HIV providing been has MSF where clinic, 2014. in House Blue The completed be will programme the expand to proposal A area. the in violence sexual of extent the explore to and needs other evaluate to Eastlands in assessment ahealth out carried team MSF An TB. drug-resistant with 40 and TB with 476around patients treated also Ateam aftercare. psychological and medical for month each clinic MSF An MSF team assistingflood victimsinthe Tana Riverregion. ear MSF first worked in the country: msf.org/kenya | 1987 country: the in worked first MSF ear

destroyed and looted. An MSF team team MSF An looted. and destroyed were May, in houses militias armed local between clashes intense during county, and Mandera of area Rahmu the in year the throughout violence sporadic was There services. sanitation and treatment water construction, distribution of relief items, latrine as such people, displaced for camps the within activities 830 community than more organised also Staff out. carried were consultations health mental family and health consultations and 160 individual Pokomo communities. More than 4,900 and Orma the both from people to support health mental and medical Teams provided and many communities were displaced. April in flooding heavy to subject was area the when expanded was response the of intercommunalvictims violence, but assisting year the of beginning the since region delta Tana the River in underway An MSF emergency intervention had been E 2014. of half first the in open will It epidemic. this to mergency interventions Internati onal A was completed in August. in completed was aid emergency This staff. Health of Ministry for training conducted also and referrals were treated.wounded MSF facilitated several where hospital, Rahmu to material medical and drugs donated and affected people the to items relief distributed need treatment can access it. it. access can treatment need who Kenyans to all ensure that policies better for to lobby Icontinue activist, an MSF. by As offered services health free good the of abeneficiary now I am and to hopeless the hope gave treatment ARV girl. five-year-old apretty and wife one with man afamily away. now fade Iam neighbours and friends my witnessed Ihad like just to wait die and was hide do Icould Ithought all MSF came, Before high. was very discrimination and 2003. in stigma HIV was when with This diagnosed been having after hopeless I felt 43 years old Charles iv ct

i ty R ty eport 2013 kenya 59 kenya

© Francis Eiton / MSF Médecins Sans Frontières LEBANON

Key medical figures: • 114,200 outpatient consultations • 6,700 individual and group mental health consultations

An estimated one million Syrian refugees have made their way to Lebanon, a country with a population of only four million.

Despite tremendous efforts by the Lebanese authorities and the provision of

international aid, the various structures and Regions where MSF has projects schemes put in place to assist refugees are Cities, towns or villages where MSF works unable to cope with their numbers.

As a consequence of the huge increase in new arrivals, tensions grew in 2013 and implemented psychosocial activities Corps in September. Treatment for acute refugees were living in dire conditions with for Syrian refugees living in unfinished diseases, reproductive healthcare and very little assistance. According to Médecins buildings in the area. routine vaccinations were available at the Sans Frontières (MSF) assessments, access to Jabal Mohsen and the Bab el Tabbaneh hospital care and free medicines for Syrian In Tripoli, Lebanon’s second largest city dispensaries. refugees were severely limited, and obstetric and home to most of the Syrian refugees, care was not available. It was difficult MSF provided medical care for acute and Bekaa Valley for them to benefit from health services chronic diseases, reproductive healthcare A large number of Syrians crossing into because of the charges they had to pay – and routine vaccinations at Dar al Zahraa Lebanon enter through the Bekaa Valley. most had left everything behind and were hospital in Abou Samra district. Clinicians, Many people arriving here have suffered struggling to support themselves. staff training, emergency management as a result of disrupted treatment for and donations of medical supplies were chronic diseases such as hypertension, In 2013, MSF was present in Tripoli, the provided to the Tripoli government asthma and diabetes. Those who stay in the Bekaa Valley, Beirut and Sidon (Saïda), hospital. A mental health programme region live in overcrowded conditions with delivering medical care to people directly run out of the government hospital was host families or in scattered settlements or indirectly affected by the Syrian crisis, handed over to the International Medical in unheated abandoned or unfinished including Syrian refugees, irrespective of registration status, vulnerable Lebanese, Palestinian refugees, and Lebanese returnees from Syria.

The majority of Palestinian refugees from Syria have gathered in Sidon at the vastly overcrowded Ein-el-Hilweh refugee camp, where there are regular security incidents and clashes between political factions. The camp has existed since 1948 and is the largest Palestinian refugee camp in Lebanon, with an estimated population of 75,000. As many people are experiencing symptoms of trauma and distress, an MSF mental health programme at Human Call hospital and two clinics in the camp provide psychological support. They also offer medical and psychological care for victims of sexual violence. In June, a MSF team began to carry out consultations for / people with chronic diseases at Human Call hospital. Outside the camp, MSF offers mental healthcare to Palestinian and

Syrian refugees, as well as local residents, © Nagham Awada at the Saïda governmental hospital and the An MSF staff member visits a Palestinian family living in Ein-el-Hilweh refugee camp. Palestinian Red Crescent hospital. A team

60 LEBANON msf.org/lebanon Y 2013: 127 end staff No. there is another influx of refugees. refugees. of influx another is there if expand to ready is project This refugees. for healthcare basic provide to February in Lebanon Southern in itself based team A small agreements. has MSF which with hospitals two to them refers and needs, surgical emergency with patients supporting for asystem up set team The diseases. chronic from suffering patients and women pregnant of children, needs healthcare mental and basic the on focusing refuge, sought have Syria from Palestinians many where Beirut, in camp Shatila the in works MSF Beirut sheltering Syrian families. already were which of year, two the of end the by finished were buildings Five arrivals. new accommodate to order in Aarsal in Teams buildings public refurbish also helped arrivals. new vulnerable most the to stoves and kits washing vouchers, fuel blankets, winter approached,MSF distributing As began and returnees. Lebanese included Syrian and refugees, Palestinian Patients healthcare. reproductive as well as diseases, chronic and acute for treatment providing Bekaa), (North Hermel and Aarsal and Bekaa), (West Anjar Majdel Baalbek, in worked MSF tents. and courtyards buildings, ear MSF first worked in the country: 1976 country: the in worked first MSF ear So we left. weSo left. targeted. be would children and women even that we understood then But service. army the for men young were after they we thought move; we didn’t days of couple first The dangerous. to very be was going situation The to leave. Qara all in other each on were calling People ago. 10 old) years days two and (four children two our with avan Itook and husband border. to My the them cross was for safe to another until itone neighbourhood from moved 18 They here. to get days way. the them on took It constant shelling wasthere because journey difficult very a had She Qara. from brothers younger two my with yesterday came mother My refugee Syrian old, 23 years Malak

A youngLebanesegirlhashertemperaturetakenatBabelTabbaneh inTripoli. dispensary These two Syrianfamilies liveinanunfinished buildingin thesuburbsof Arsal. Internati onal A iv ct i ty R ty eport 2013 LEBANON

© Alla Karpenko / MSF © Baozhu Wei / MSF 61 Médecins Sans Frontières lesotho There is also a shortage of skilled Several advances in the programme were healthcare workers. made during 2013. Beginning in April, all women who tested positive for HIV were Médecins Sans Frontières (MSF) aims put on antiretroviral treatment to prevent to close some of the gaps in care by the transmission of HIV to their babies. providing integrated HIV and TB care in A community adherence group was also a programme focused on maternal and piloted in one health centre. Here, patients child health. Antenatal, postnatal and get together to discuss concerns and pool emergency obstetric care are offered at St resources so that only one of them, on a Regions where MSF has projects Joseph’s district hospital in Roma, six basic Cities, towns or villages where MSF works rotating basis, has to collect the medicines healthcare clinics in the lowland area and for the entire group. Technological three clinics in the more remote Semonkong Key medical figures: improvements were made with the • 1,300 patients on first-line ARV treatment area. An ambulance and maternity lodge installation of CD4 testing machines • 1,400 births assisted provided by MSF, where women can (the CD4 count is an indicator of an HIV come to give birth, have also improved patient’s immunity level) in nine health emergency care. centres, and the introduction of a rapid TB test (GeneXpert). More than half of all Increased decentralisation of the HIV and TB maternal deaths in Lesotho component of the programme is providing MSF was also granted permission to people with the specialised care they need expand viral load monitoring within its are attributed to HIV and closer to their homes. In order to meet programme ahead of changes in the tuberculosis (TB). staffing needs, nurses have been trained to national protocol. Measuring the amount initiate and follow up HIV and TB treatment of HIV virus in the blood is used to Although basic healthcare is free, accessing with the supervision of doctors, and village ascertain when first-line HIV treatment has it is not easy in this mountainous country, health workers and lay counsellors have failed and a patient needs an alternative where many people live far from facilities. been trained in key support roles. drug regimen.

Year MSF first worked in the country: 2006 | msf.org/lesotho © Peter Casaer / MSF

Ha Seng is one of the clinics supported by MSF, and woman come for ante-, postnatal and emergency obstetric care.

62 lesotho International Activity Report 2013 LIBYA Libya’s health system is Designed to provide comprehensive care for a broad spectrum of mental disorders, gradually recovering from the the centre takes a multi-disciplinary 2011 conflict, but the violence approach across psychiatry, psychology has had a lasting effect on and medical services. The team also trains doctors from the Ministry of Health and many people’s mental health. has established a referral system from basic healthcare facilities and from Libyan and The World Health Organization estimates international NGOs. Cities, towns or villages where MSF works that more than a third of Libyans were directly and/or indirectly exposed to the Emergency support Key medical figures: conflict. The prevalence of severe post- An outbreak of methanol poisoning in • 300 individual and group mental traumatic stress disorder was estimated March killed approximately 90 people in health consultations at 12.4 per cent and severe depression Tripoli and resulted in the hospitalisation of at 19.8 per cent in 2012. around 1,000. MSF sent toxicology experts from Norway to offer technical assistance to A team provided support to the Sebha In August 2013, Médecins Sans Frontières the Libyan Ministry of Health and provided Medical Center in the south of the country (MSF) opened a mental health centre in supplies of the antidote fomepizole, which in September, when the facility treated a Tripoli, the country’s capital, to help people acts by blocking the toxin produced by number of migrants suffering from burns suffering from physical and mental health methanol poisoning. MSF toxicologists also as a result of a traffic accident. Medical problems related to violence. The centre carried out training for medical staff at supplies and materials needed for burn treats people who have been affected Tripoli Medical Center and Tripoli Central management were delivered, and staff by any form of violence, be it physical, Hospital to improve diagnosis and treatment received training in the appropriate clinical psychological, sexual or conflict-related. in case of future outbreaks. management of burn patients.

No. staff end 2013: 35 | Year MSF first worked in the country: 2011 | msf.org/libya MADAGASCAR People in the cities of Tuléar and Morombe Improving healthcare in Androy region were particularly affected by the cyclone. Since 2011, an MSF team has been Several aid agencies responded, including improving patient care in the remote a team from Médecins Sans Frontières Androy region. Clinical care and drugs (MSF) that ran mobile clinics and donated are dispensed through Bekily hospital’s drugs to facilities in the cities and to health emergency room, inpatient department, centres in the surrounding areas until and antenatal and maternity unit. mid-April. From February to May, a team Medicines, staff training and consultations also helped health authorities respond are also provided in two health centres. Regions where MSF has projects Cities, towns or villages where MSF works to a spike in malarial infections in Tuléar, Patients receive treatment for a range Morombe and Betioky. A total of 5,761 of health concerns such as malaria and Key medical figures: consultations were carried out. tuberculosis, as well as for schistosomiasis • 900 births assisted (bilharzia), a curable parasitic disease • 4,800 patients treated for malaria Governmental budget cuts to social endemic in Madagascar. In addition, MSF services following the 2009 presidential works with the Centre for the Testing and Tropical cyclone Haruna coup have severely affected the country’s Treatment of Tuberculosis, testing, raising health sector. A policy of free healthcare awareness and carrying out consultations. struck the southwest access for those in need was officially During 2013, 70 new patients were coast of Madagascar on 22 abolished in 2012. International donors admitted for treatment. also remain reluctant to release funds for February, causing extensive non-emergency situations. Meanwhile, flooding and resulting in the people in remote regions are unable to displacement of more than access the services they need because of 10,000 people. the distances to health facilities.

No. staff end 2013: 118 | Year MSF first worked in the country: 1987 | msf.org/madagascar

LIBYA | MADAGASCAR 63 Médecins Sans Frontières malawi

Regions where MSF has projects

Key medical figures: • 75,100 patients on first-line ARV treatment • 5,900 women enrolled on PMTCT treatment

Malawi is largely dependent on international aid for healthcare. Seventy per cent of general

health services and 99 per cent © Sydelle WIllow Smith of antiretroviral (ARV) coverage Marita Saga’s HIV status is classed as undetectable after she successfully adhered to her ARV are donor-funded. treatment regimen.

Malawi’s HIV rates are among the 10 highest in the world: more than one in 10 people Nsanje project for Heath (HRH) Scholarship Programme. are estimated to be infected. The healthcare MSF started providing mentorship and With this programme, MSF addresses system is chronically underfunded and there is improving health services in Nsanje and the shortage of health workers in the a severe shortage of skilled workers – a 61 per Chikhwawa districts in the far south of the understaffed, hard-to-reach areas of cent vacancy rate for clinical staff. Médecins country in 2010. In 2013, MSF withdrew Thyolo, Nsanje and Chikhwawa districts Sans Frontières (MSF) has therefore been from Chikhwawa and expanded its work by recruiting local students and paying for supporting the HIV response, improving care in Nsanje, focusing on the needs of their training as mid-level health workers. for patients, and also aiming to strengthen specific vulnerable groups. Early treatment In turn, the students agree to work for the the existing health system through staff through a ‘test and treat approach’ was health ministry in their home areas for at training and technical support, innovative implemented for sex workers, couples least five years. and progressive treatment models, and by where only one partner had HIV, and HIV- implementing operational research. positive breastfeeding women. Prevention of mother-to-child transmission of HIV was Chiradzulu programme David also fully integrated in all 14 health clinics. Chiradzulu The HIV programme based in Chiradzulu A total of 50 health workers were mentored district, and decentralised via 10 health in 14 sites and 88 per cent of them I have been on antiretroviral treatment centres, had more than 28,000 patients completed the mentorship programme. since February 2002. Two months ago receiving ARV treatment this year. In was the first time I got my viral load mid-2013, the first point-of-care viral Thyolo programme handover measured. Before, I only had my CD4 load test was installed in a rural health The scheduled handover of first-line HIV cells counted. So after more than 11 centre, thanks to a UNITAID grant. This treatment in Thyolo was completed, with years, I am happy to know that my test measures the amount of HIV virus in the bulk of the HIV services now being viral load is undetectable and that my the blood, which increases when first-line delivered by the Ministry of Health. MSF treatment is working. I am also only treatment fails, so patients can be switched remains in Thyolo to conduct operational taking one drug a day now and I feel to a different drug regimen. research, to help expand community ARV very good! treatment groups, and to provide technical An MSF study in Chiradzulu showed that 65.8 and clinical services for people in need of per cent of people needing ARV treatment were advanced or specialised HIV care. receiving it, and a population-based survey revealed that there was also a very low level Developing capacity for hard-to-reach of new infections (0.4 per cent), suggesting rural areas that the large distribution of HIV treatment By the end of 2013, 49 students had has played a role in reducing transmission. enrolled in MSF’s Rural Human Resources

No. staff end 2013: 706 | Year MSF first worked in the country: 1986 | msf.org/malawi

64 malawi International Activity Report 2013 MALI health situation. It is difficult for people to full package of vaccinations. Teams have reach health facilities, particularly when observed a reduction in acute severe they have to travel along roads targeted by malnutrition and stunting in the children armed gangs. MSF works in all departments participating in the programme. of the 60-bed Timbuktu hospital, Niafunké hospital and five outlying health centres. MSF implemented Seasonal Malaria A total of 91,975 consultations were Chemoprevention during the high conducted for patients mainly suffering transmission period between July and from malaria, pregnancy complications, October. On average, around 163,000 Regions where MSF has projects respiratory infections and chronic diseases. children were given treatment at each Cities, towns or villages where MSF works of the four rounds and it is estimated Paediatric care that approximately 87 per cent of Key medical figures: children received at least three of the • 308,100 outpatient consultations In the south, MSF continued a • 2,400 births assisted comprehensive paediatric programme in four distributions. The number of Koutiala, Sikasso state, in conjunction with children suffering from uncomplicated the Ministry of Health. A free healthcare malaria in 2013 was 31 per cent less package is aimed at ensuring children’s when compared to the previous year. Although the situation growth and development and reducing stabilised somewhat in Mali hospitalisation. MSF manages the paediatric Severely malnourished children received unit in Koutiala hospital, where over medical care from MSF in Mopti region. in the second half of the year, 5,300 patients were admitted, including The project, which had opened in 2012, many people are still afraid to more than 5,000 children with severe was handed over to Save the Children in return home. The 2012 crisis or complicated malnutrition. Teams also March. Before, during and after the provide basic healthcare in five peripheral fighting erupted in northern Mali, MSF has furthered weakened health centres, where some 82,000 medical worked in Mopti and Douentza districts, the healthcare system, consultations were undertaken, more than a where the focus was on maternal and child health, basic healthcare and surgery. particularly in the north. third involving malaria, and 3,460 children with severe malnutrition received treatment. Teams worked in a referral centre in Douentza and in five basic healthcare Many health workers have fled the country Preventive and curative paediatric care centres: Konna, Boré, Douentza, Hombori and access to adequate medical care remains is also offered in the Konseguela health and Boni. These activities had all been a significant issue throughout Mali, even area, where children receive healthcare handed over to the Ministry of Health in the south. Malnutrition and malaria are and preventive measures, including a by late November. persistent health concerns. No. staff end 2013: 610 | Year MSF first worked in the country: 1992 | msf.org/mali Early in the year, sporadic attacks and fighting around Gao caused people to flee in fear of air strikes and reprisals. Some families left the country while others found shelter in small villages or withstood harsh living conditions in the bush. Médecins Sans Frontières (MSF) provided basic healthcare at several health clinics in the region. At the beginning of the year, teams were working in Chabaria, Wabaria and Sossokoira and services began at Bazi Haoussa health clinic in June. All these activities had been handed over to other NGOs and development agencies by the end of the year.

A team also worked in the 39-bed Ansongo hospital, south of Gao, vaccinating children and providing outpatient and inpatient services, reproductive healthcare and emergency surgery. More than 8,500 children were vaccinated against measles.

Healthcare in Timbuktu © Paolo Marchetti Insecurity in and around Timbuktu Waiting to be seen at the MSF-supported health centre in Konna. contributed to a deteriorating food and

MALI 65 Médecins Sans Frontières mauritania In January, another 15,000 refugees escaping violence in Mali crossed into Mauritania, joining those already settled in precarious conditions at Mbera camp. Regions where MSF has projects Cities, towns or villages where MSF works The presence of armed groups in Mali has a report calling on aid organisations to instilled fear and pushed thousands of meet the basic needs of refugees in Mbera. Key medical figures: refugees into Mauritania. By early 2014, The majority of the diseases treated inside • 168,600 outpatient consultations over 59,000 people had settled in the the camp are preventable, and are primarily • 3,900 people treated in feeding centres middle of the desert, and ethnic tensions caused by a lack of clean water and food. in northern Mali have quashed any hopes A comparative data analysis revealed that of a swift return home. children developed malnutrition after six Azarra* Refugees receive healthcare through a to eight weeks in the camp, and an average 40 years old, from Timbuktu health post at the border in Fassala – of 300 severely malnourished children were which also screens children aged from six treated there every month. It took us two days to arrive in Fassala; we months to five years for malnutrition – and were tired but we were alive and safe. That through three health centres in Mbera MSF also supports Bassikounou health centre, was the most important thing. Now, we camp, all supported by Médecins Sans where an operating theatre was set up to have to adapt to life in Mbera camp but it Frontières (MSF). Teams carried out some provide emergency surgery for refugees and is very difficult for us … I was poor in Mali 1,800 consultations each week in 2013. but here it is even worse, I have absolutely the host population, and to stabilise patients nothing and I feel like a complete stranger, for referral to the hospital in Néma. MSF The living conditions in the camp are very far from my own country. I want peace to difficult and people rely on aid to survive. carried out 160 interventions this year, the return to the north so that I can finally go In April, MSF released Stranded in the Desert, majority of them emergency responses. back home.

* Name has been changed. No. staff end 2013: 307 | Year MSF first worked in the country: 1994 | msf.org/mauritania

MOROCCO however, has meant that the country has to close the Morocco programme was based become an unexpected and sometimes on the fact that access to healthcare for difficult final destination for many of them. sub-Saharan migrants has improved, and that local organisations have emerged to help Médecins Sans Frontières (MSF) opened ensure that migrants get the healthcare they a programme in 2002 to address the need and that their rights are respected. poor access to healthcare and inhumane treatment that migrants experience, and has spoken out about their plight on several Cities, towns or villages where MSF works occasions, including in a report published Beatrice in 2013, Violence Vulnerability and Migration: 52 years old Trapped at the Gates of Europe. They sent us to Médecins Sans Frontières, MSF handed over its migrant In 2012, MSF started winding down a project who told us we should do the tests for health projects in Morocco. in Rabat which supported trafficked people HIV. It’s me who is a victim; my children – mainly women, and many the victims are in good health. When I started to There is a steady flow of migrants from of sexual violence – and the programmes cry the doctor encouraged me. She told Africa – many of them coming from facilitating access to healthcare for migrants me that it’s good to know, because now war-torn countries – making their way in Oujda and Nador. The handover process to that we know they can help me with the to European countries through Morocco. local health and human rights organisations treatment. The reinforcement of European borders, was completed in February 2013. The decision

No. staff end 2013: 7 | Year MSF first worked in the country: 1997 | msf.org/morocco

66 MAuritania | morocco m No. staff end 2013: |Y 62 end staff No. The estimated countries. and attacksintheirhome and peoplefleeingthreats including economicmigrants vulnerable populations, health consequencesfor the drugtrade,hasserious organisations involvedin mainly linkedtocriminal Ongoing violence, cases were followed up. The programme in programme The up. followed were cases hospital referrals and ensured emergency 1,389 also made Staff consultations. trauma were there year the –during healthcare mental and services, health sexual and included basic healthcare, reproductive activities The state). (México Tultitlán and Apaxco and state), (Hidalgo Bojay state), continued this year in Ixtepec (Oaxaca violence. Programmesand indirect direct of victims of needs psychological and medical the addressing are (MSF) Frontières Sans Médecins Teams from unmet. largely go needs health mental their and violence, sexual of particularly violence, of victims for scarce generally are emergency Healthcare services. resources overwhelmed to part in due care, medical to access of alack from suffer also violence by affected areas in living People murder. and/or violence sexual torture, abduction, assault, of victims become Many risk. particular at are States, United the reach to year, each hoping train freight by Mexico across journey who America Central •  •  •  Key m sexual violence of incidents after treated patients 22 consultations health mental group and individual 1,600 consultations 12,700 outpatient Cities, towns or villages where MSF works MSF where villages or towns Cities, e dical ex 1 91,000 migrants from from 91,000 migrants fig u r e s : ico ear MSF first worked in the country: 1985 | msf.org/mexico | 1985 country: the in worked first MSF ear

1 the end of the year. the of end the at up set being was state, Oaxaca Pochutla, de Pedro San of network healthcare public health authorities and integrated into the with coordination in designed project, Chagas MSF An government. the by priority ahealthcare as recognised now is untreated, left if death and complications debilitating cause may but years for asymptomatic be can that disease aparasitic Chagas, Chagas disease fumigating 7,200 houses. and area the from 140 people training and dengue prevention and education, hiring promote to church the as such institutions local with worked MSF October, In incidents. security of because Acapulco of areas vulnerable most the of some in suspended later were but illness the combat to place in put were programmes Health mosquitoes. by spread infection aviral cases, dengue of number the in apeak saw Acapulco of city the particularly and Guerrero of state year, the the in Early Dengue emergency handed over to the government. were migrants for services healthcare as April, in closed was state, Chiapas Arriaga,  and Antonio Guevara. Landa y redes estrategias rutas, problemáticas, nuevas México: por paso su en Migrantes Migrants fromCentralAmericatravelacrossMexicobytraininabidtoreachtheUS. Internati . Ana María Chávez Galindo Galindo Chávez María . Ana onal A * into Mexico. later, crossing Iwas again 15 and, to Guatemala I returned days … hospital to nearest me the took and me helped people Some atown. reach to night to all walk Ihad then and day all hill the Iwas on bodies. over our all bruises with and clothes without Cerro del Boca us in dumped they was paid, ransom the Once us to go. let order US$5,000 in asked for family. They our of numbers phone the them give us to forced as they brother-in-law, my with talked Tenosique …They 16 for near days I was kidnapped A Guatemalan transmigrant  name has been withheld. hasname been person’s the reasons, security For iv ct i ty R ty eport 2013

m ex

* i co 67 co © MSF Médecins Sans Frontières MOZAMBIQUE

Regions where MSF has projects Cities, towns or villages where MSF works

Key medical figures: • 55,100 patients on first-line ARV treatment • 4,000 patients under treatment for TB • 1,700 women screened for cervical cancer

Médecins Sans Frontières (MSF) has been supporting the Ministry of Health to

increase the number of © MSF

people on antiretroviral There was extensive flooding at the beginning of the year in Gaza province and health facilities (ARV) treatment for HIV. were disrupted. MSF supported the Ministry of Health with extra staff and medical supplies.

Despite progress in Mozambique’s national In Chamanculo, MSF worked in five health affected, and health facilities, including response to HIV/AIDS, the virus still centres and in one referral centre for the main hospital, were disrupted. MSF accounts for 40 per cent of adult deaths and complex HIV/AIDS cases, all run by the deployed an emergency team to support 14 per cent of child deaths in the country. Ministry of Health. MSF also supported the the health ministry with extra staff Mavalane project which registered patients and medical supplies. During the two- One significant barrier to people getting on ARV treatment in four health centres and month emergency programme the team appropriate healthcare is a lack of skilled one health post; six per cent of the patients carried out more than 23,000 medical medical professionals. MSF has developed who registered were under 15. MSF has consultations. Almost half of these related innovative solutions in the management another team supporting the Primeiro de to HIV/AIDS and TB. The rest of the patients of HIV to overcome this obstacle, by Maio health centre, which provides services were mainly suffering from respiratory empowering patients as well as lower level specifically for adolescents. More than 600 infections, diarrhoea and malaria. healthcare workers. young people were offered counselling, peer education, testing and linkage to care Comprehensive treatment for HIV each month. patients co-infected with tuberculosis Carla (TB) was provided through programmes Viral load technology, considered the ‘gold Cured of multidrug-resistant TB in Maputo in Chamanculo and Mavalane districts standard’ for monitoring the amount of HIV in the capital city, Maputo, and in Tete. virus in a patient’s blood, was introduced in I feel like I was born again. It was more Specialised care was given to people with Maputo and Changara district in 2013. An than two years of treatment, which finally more complex conditions, such as drug- MSF team provided staff training in support has ended. I thought about giving up resistant TB (DR-TB), and those who had of the Ministry of Health’s Acceleration Plan the treatment and I even thought about not responded to first-line ARV treatment, to make ARV treatment available to more suicide. Today I have hearing problems and or had Kaposi’s sarcoma or cervical cancer. people in need. I am forced to use a hearing aid to be able Treatment for children was also included to listen. Besides that, my vision problem in the programmes. MSF is supporting Flooding in Chokwe got worse. It was a big challenge for me, implementation of a policy to provide all At the beginning of the year, heavy rains but now I am cured of drug-resistant TB and I can proceed with my dreams. HIV-positive pregnant women, and children caused extensive flooding. Gaza province under five, with ARVs. and the city of Chokwe were particularly

No. staff end 2013: 327 | Year MSF first worked in the country: 1984 | msf.org/mozambique

68 MOZAMBIQUE International Activity Report 2013 MYANMAR

Regions where MSF has projects

Key medical figures: • 519,100 outpatient consultations • 33,200 patients on first-line ARV treatment • 13,600 patients treated for malaria • 3,300 patients under treatment for TB

There is an ongoing medical humanitarian crisis in Rakhine state, and there are concerns about the increasing challenges faced © Eddy McCall / MSF by those assisting people in A drug-resistant TB patient receives treatment at MSF’s clinic in Lashio, Shan state. need of healthcare. organisations to ensure that all patients in While violence and segregation continue need of emergency medical services could Ko Min Naing Oo access the necessary care, regardless of their in Rakhine state, more than 100,000 37 years old, Yangon. background or ethnicity. people remain displaced, living in appalling TB first came into my life in June 2000 conditions in camps, and almost entirely cut HIV and TB programmes off from healthcare and other basic services and kept coming back over the next 13 MSF is the largest provider of HIV/AIDS care including clean water. Communities living years, getting harder and harder for the in Myanmar, treating over 33,000 patients in isolated villages and townships, most doctors to treat it. I took many different in a country where fewer than one in three kinds of pills and injections over the years in Northern Rakhine state, also face great people who need antiretrovirals receive but nothing seemed to get the disease difficulty in accessing medical services. As them. People with HIV are more likely to out of my body for good. the minority Rohingya remain extremely have active TB, and multidrug-resistant TB vulnerable, Médecins Sans Frontières (MSF) (MDR-TB), which is harder to diagnose and Before I started, I was able to carry out is striving to overcome significant challenges requires two years of arduous treatment, is normal physical activities, but after I felt and obstacles and provide free, high-quality also an emerging health problem. tired and exhausted. The side effects from medical assistance to those most in need. the treatment were strong and it was MSF runs projects treating HIV and TB really difficult to manage. I felt dizziness, Working closely with local communities, patients in Kachin, Shan and Rakhine pain in my buttocks from all the injections the team has offered basic healthcare, states, as well as in Yangon and in Dawei and had problems with my hearing. I felt obstetric services, mental healthcare, in Tanintharyi region. After three years of nauseous when I smelled cooking, found treatment for HIV/AIDS and tuberculosis collaboration with the prison department myself easily getting angry, constantly weak and tired, always having diarrhoea, (TB), and supported emergency referrals. in Yangon, MSF officially closed its HIV and experiencing hallucinations. MSF also treated 10,816 malaria patients, project in Insein prison in December. MSF 84 per cent of the nationwide total. Staff had provided counselling and testing to I tried to forget my emotional pain by realising worked in 10 townships across the state, 1,400 prisoners and conducted more than that there are other people who were more in fixed and mobile clinics in 24 camps 15,000 outpatient consultations since the socially, economically disadvantaged and with for displaced people and in a number of programme began in 2010. worse health than I was. I often reminded isolated villages. myself that I needed to get back my good In 2012, MSF started a programme in health in order to save my family from a Throughout 2013, MSF continued to urge Yangon in conjunction with the Ministry of miserable situation. the government and the communities of Health, which continued this year, treating Rakhine to work together with international 58 patients with MDR-TB. From the MSF blog, ‘TB & Me’

No. staff end 2013: 1,299 | Year MSF first worked in the country: 1992 | msf.org/myanmar

MYANMAR 69 Médecins Sans Frontières niger

Key medical figures: • 916,000 outpatient consultations • 425,100 patients treated for malaria

Seasonal Malaria Chemoprevention (SMC) was used for the first time in Niger in 2013. Combined with malnutrition screening and treatment, this strategy aims to reduce suffering and child mortality. Regions where MSF has projects

During the months between harvests, there is a period known as the ‘hunger gap’, during which there is a steep rise in the number of children suffering from acute malnutrition. Children under five are particularly affected, as their young bodies have specific nutritional needs for proper growth and development and few reserves. The rainy season, which causes a proliferation of malaria-transmitting mosquitoes, also occurs during the hunger gap. This represents a dual threat to young children: malnutrition weakens their immune system, which makes it more difficult for them to cope with the malaria that causes anaemia, diarrhoea and vomiting, and that then leads to, or complicates, malnutrition. The combination of malaria and malnutrition is often fatal.

Aiming to shift from malaria treatment to prevention as much as possible, teams from Médecins Sans Frontières (MSF) widened the scope of prevention activities in 2013. SMC, a new strategy which has proven effective in Chad and Mali, was used in © Narcisse / MSF Wega Niger for the first time. For four months Children waiting with their mothers for a course of antimalarial medication. during the rainy season, children received a course of antimalarial medicine in the districts of Guidan Roumdji and Madarounfa Teams involved in the SMC campaign diagnosis and treatment for pregnant (Maradi region), Bouza and Madaoua undertook it alongside activities for women and children through community (Tahoua region) and Magaria (Zinder children with malnutrition. MSF has health workers based at 111 health posts. region). On average, around 225,000 ongoing nutrition programmes providing These staff are trained by doctors to detect children received treatment at each of the mobile screening and treatment, as well as and diagnose malaria, treat simple cases and four rounds and dependant on location hospitalisation for severely malnourished refer complicated ones. They also examine coverage has been estimated at between children, in all these regions. children’s nutritional and vaccination status. 94 and 99 per cent. Following a measles outbreak in March in Delivering essential healthcare closer to While the usual methods of mosquito bite Madaoua and Sabon Guida, MSF launched a prevention, including the use of nets and home is the goal of all MSF’s malaria and vaccination campaign in May which reached sprays remain the basis of the programmes, nutrition programmes, a strategy known 84,460 children under the age of 14. SMC is proving useful to protect the health as PECADOM (Prise en Charge à Domicile). of children at risk from severe malaria where In Bouza and Madaoua districts, Tahoua A new approach is also being adopted to there is limited access to care. region, MSF provided home-based malaria help prevent severe acute malnutrition in

70 niger No. staff end 2013: 1,879 |Y 2013: 1,879 end staff No. to travel to need their eliminating homes, people’s in and huts’ ‘health at held were children more accessible. Consultations malnourished for treatment making thus care, of points decentralising on focus to In region, Zinder Magaria, MSF continued 6,630 to people. blankets and soap cans, water nets, mosquito with kits distributed and crops in Madarounfa in July, MSF homes destroyed that rains heavy Following and children received routine immunisations. distributed, were nets mosquito provided, health areas. Nutritional supplements were five the of three in old years two under malaria prevention for programme children a ran also ateam Niger), Santé (Forum FORSANI organisation Nigerien the with care inMSF paediatric conjunction provides region, where Maradi In Madarounfa district, villages. their in peers with learn they what share turn, in mothers, The nutrition. maximal for food prepare to how lumières mamans The Tahoua in region. villages some prevention, particularly inmalnutritionandmalaria. In Bouzadistrict, MSFisworkingtoimprovehealthcare forchildrenunderfive andpregnantwomen,focusing onearlytreatmentand receive training from MSF teams on on teams MSF from training receive ear MSF first worked in the country: 1985 | msf.org/niger | 1985 country: the in worked first MSF ear The team responded to a cholera outbreak outbreak acholera to responded team The out. carried were 57,500of consultations Atotal region. Tillabéri in community host the and refugees Malian to immunisations care,specialist maternal healthcare and and basic provided teams MSF safety. of search in borders national cross people to massive population displacement as 2012 since Mali led in has conflict Armed refugees Malian for Caring malnutrition. of periods peak during centre treatment 450-bed additional an open to ready 2013. of end the at Teams remain Health of Ministry the to over handed was this and years, many for hospital Zinder at centre feeding inpatient an supported also has MSF hospital. to referrals of number the reduced and triage improve to staff enabled Bangaza and Dungass Magaria, in centres health at observation and treatment intermediate of their own communities. The development in care obtain to people vulnerable most the of some allowing and facilities larger Internati onal A district hospital. district surgical emergencies were referred to the and Obstetric residents. local 33,000 some and camp the in refugees 14,000 Malian to provided was care specialist and Basic capital. Niger’s Niamey, of north kilometres 250 about camp, Abala the in worked also MSF September. in Cross/UNHCR Red Qatar the to over handed was healthcare Refugee patients. 1,500 May,in treating fewer malaria cases. malaria fewer are …there year This diarrhoea. and fever, with vomiting seizures, burn causing bodies their Then malaria. have usually to here children take come My it. people is so this many why is and treatment this important how realised We now have medicine. prevention malaria the for here us told to come workers MSF community 26 years old, Tounfafi village, Madaoua Mariana Assoumane iv ct i ty R ty eport 2013 n i ger © Ramón Pereiro / MSF 71 Médecins Sans Frontières NIGERIA remaining villages – for example remove Emergency care in Borno lead-contaminated soil and mining waste The ongoing violence in the northeast from villages, wells and ponds – and treat caused population displacement to other the children affected by lead poisoning states, including Abuja, and people also fled who live there. to countries such as Niger and Cameroon. MSF provided medical care to 3,750 people Providing maternity care and in Baga and Chibok. The team ended the fistula surgery intervention, which lasted for 10 weeks, in Pregnant women in Jigawa state have October because of insecurity. limited access to maternity services, and

Regions where MSF has projects deaths due to pregnancy and childbirth Measles and cholera Cities, towns or villages where MSF works are high. It is also estimated that between A measles outbreak spread through Katsina 400,000 and one million Nigerian women state in January and MSF donated medicine Key medical figures: live with obstetric fistula, a consequence to 300 public health clinics, thus providing • 18,600 outpatient consultations of birth complications that causes not only treatment for 14,290 people. More than • 6,400 births assisted pain but incontinence, which in turn often • 1,500 surgical interventions 217,490 children were vaccinated against results in social stigma. MSF’s programme measles in Bakori, Sabuwa, Funtua, in Jahun hospital cares for women with Dandume and Faskari. obstetric emergencies and offers surgical Health indicators for people repair of fistulas. More than 8,390 women Between March and July a team responded living in northern Nigeria were admitted to the obstetrics unit and to a measles outbreak in Kebbi, Sokoto and 370 women underwent surgery for fistulas. Zamfara states, treating 47,585 people and remain poor and there are donating 3,600 treatment kits. Over 2,000 frequent outbreaks of measles, A maternal and child health programme people received cholera treatment in Rini meningitis and cholera. continued in Goronyo, Sokoto state, where and Gusau between September and the end many people suffer from malaria. The of December. An upsurge in violence in 2013 added to the project closed in June due to insecurity. difficulty of obtaining adequate healthcare. Threats posed by Ansaru and Boko Haram No. staff end 2013: 649 | Year MSF first worked in the country: 1971 | msf.org/nigeria are affecting security for Nigerians as well as aid organisations.

Where possible, teams from Médecins Sans Frontières (MSF) continued to deliver specialist healthcare to vulnerable people and responded to outbreaks of disease.

Lead poisoning in Zamfara The rising price of gold has led to renewed interest in mining in Zamfara state, where unsafe practices have resulted in a number of villages being contaminated with lead. The gold deposits contain unusually high concentrations of the metal, and as the rocks are ground into sand highly contaminated dust fills the air. Lead can enter the body through the lungs or digestive tract and is particularly harmful to children, potentially causing brain damage, kidney problems and death. MSF MSF teams screened more than 1,570 children / in 2013 and provided some 10,800 basic health consultations for children under

five. Since the beginning of the project, © Ruth Grace 4,804 children have been screened and Obstetric fistula patients holding up their art projects on the grounds of Jahun hospital, where 4,306 treated. MSF continues to lobby at women with obstetric emergencies are cared for and surgical repair of fistulas is available. federal government level to remediate the

72 NIGERIA International Activity Report 2013 PALESTINE The Israel–Palestine conflict and dressings, to help patients rehabilitate from inter-Palestinian violence has increased their surgery. people’s need for medical and psychological care, and has reduced the availability of In 2013, MSF started supporting the drugs, medical equipment and services to Ministry of Health on intensive care, treat them. Médecins Sans Frontières (MSF) by implementing training programmes runs programmes in the Occupied Palestinian for medical and paramedical staff. An Territory aimed at meeting the needs not MSF medical team is working in close covered by the Palestinian health system. partnership with Nasser hospital medical Regions where MSF has projects staff, providing bedside clinical instruction, Cities, towns or villages where MSF works In Gaza, MSF focuses on plastic surgery, mentoring and technical support. reconstructive surgery and hand surgery for Key medical figures: Mental health support • 160 surgical interventions patients suffering from serious burns, trauma • 7,200 individual and group mental and other debilitating injuries. MSF specialist Exposure to conflict violence has a severe health consultations surgeons, anaesthetists and operating impact on people’s mental health. In Nablus, theatre nurses work alongside Palestinian Hebron and East Jerusalem, MSF teams colleagues in the two main public hospitals. continue to provide psychological and Unrelenting violence in Gaza Most patients are children with burns injuries social support to direct and indirect victims and the West Bank continues caused by domestic accidents, as electricity of violence. Almost half of the patients to have medical, psychological shortages force people to find alternative are under 18, and most are suffering from means of cooking and heating their homes. anxiety-related conditions. Depression, and social consequences MSF runs a clinic in Gaza City offering post- behavioural issues and post-traumatic stress for Palestinians. operative care, including physiotherapy and disorder are common.

No. staff end 2013: 94 | Year MSF first worked in the country: 1989 | msf.org/palestine

No. staff end 2013: 649 | Year MSF first worked in the country: 1971 | msf.org/nigeria Papua New Guinea Domestic and sexual violence is a medical-humanitarian emergency in Papua New Guinea (PNG), with consequences at individual, family and national level.

There are very high levels of sexual, covered during one appointment: emergency domestic, social and tribal violence medical care for wounds, psychological first throughout PNG, and yet care for victims aid, preventative drugs for HIV and other remains inadequate and, in many places, sexually transmitted infections, emergency Cities, towns or villages where MSF works nonexistent. A durable model for prevention contraception and vaccinations to prevent or treatment has yet to be identified, and hepatitis B and tetanus. The aim of the project Key medical figures: survivors need access to free, quality, • 34,700 outpatient consultations is to help more people experiencing domestic confidential and integrated medical care. • 3,600 individual and group mental and sexual violence to access the care they health consultations need through health centres and family In June, MSF handed its project treating support centres throughout the country. people suffering from high levels of intimate partner violence and sexual violence back Buin Health Centre to Angau Memorial General Hospital in Lae, Access to healthcare in Buin district has but continued to provide technical support. The MSF team at Tari hospital in the southern improved significantly in recent years, highlands performed 830 major surgical and this combined with increased support procedures this year, and also continued from the provincial health services and to run a family support centre where 1,231 AusAID (Australian Agency for International consultations were conducted. March marked Development) means that MSF is starting to the launch of the Port Moresby Regional plan the closure of its project there. Teams

© Kate Geraghty / Fairfax Treatment and Training project, where staff carried out 3,894 antenatal consultations, were trained to provide the integrated care 979 family planning consultations and assisted This patient at Tari hospital was attacked by her husband. available in Lae. Five essential services are 870 births at the Buin Health Centre this year.

No. staff end 2013: 214 | Year MSF first worked in the country: 1992 | msf.org/png

PALESTINE | Papua New Guinea 73 Médecins Sans Frontières pakistan

Key medical figures: • 252,500 outpatient consultations • 3,900 surgical interventions • 22,700 births assisted • 8,400 individual and group mental health consultations

Providing comprehensive emergency healthcare to people in remote regions of Pakistan is a priority, yet accessibility and security

are a constraint for both Regions where MSF has projects The maps and place names used do not reflect Médecins Sans Frontières any position by MSF on their legal status. (MSF) and the patients.

In addition to the general gaps in the In Lower Dir, there was a dramatic increase for cases of infectious illnesses such as healthcare system, people living in remote in patient numbers in the emergency and measles and diarrhoeal diseases. areas and those displaced or directly resuscitation rooms at Timurgara district affected by conflict suffer from a critical hospital. More than 100,000 patients came Balochistan lack of medical services, in particular to the emergency room, an increase of 33 Pakistan’s largest province is remote and emergency treatment and maternal and per cent over 2012, and more than 22,000 rural, and hosts many Afghan refugees. child care. MSF runs programmes to try patients were treated in the resuscitation Healthcare indicators are among the to address these needs. room. MSF provides obstetric care with country’s worst, as delays in obtaining a focus on complicated deliveries, and medical help are common and are accounted Khyber Pakhtunkhwa province assisted around 7,000 births in 2013. Teams for by geography, insecurity in the region Hangu district borders three tribal agencies, also support the blood bank, improve and a low density of medical services. North Waziristan, Orakzai and Kurram. sterilisation and waste management, and These areas are among those most exposed organise health education activities – some In Quetta, the paediatric inpatient medical to violence since military operations were 56,000 health and hygiene education care provided by government and private launched by the government in response sessions were carried out. In addition, hospitals is insufficient to meet the to an aggressive campaign by the Pakistani MSF conducted more than 5,300 mental population’s needs and many people cannot Taliban, which started in 2007. There are health consultations and 26,900 mother afford the fees charged. MSF offers medical also sporadic clashes between the Sunni and child sessions. care in Quetta paediatric hospital, and treats and Shia communities in the district. MSF malnourished children in ambulatory and teams manage the emergency and surgical Federally Administered Tribal Areas (FATA) inpatient feeding programmes. Neonatology services in the Hangu Tehsil Headquarters Conflict in Kurram Agency has led to the services, and family and individual hospital. They admitted more than 25,000 isolation of local communities, closure of counselling sessions are also available. patients to the emergency room and supply routes and the near-collapse of the performed 1,407 surgical procedures in state-sponsored healthcare system. Measles An MSF team runs a mother and child 2013. Within the hospital’s maternity unit, is very common in Kurram, highlighting health centre in nearby Kuchlak, offering MSF midwives support Ministry of Health gaps in basic health services such as outpatient treatment, including nutritional staff, assisting with complicated deliveries, vaccination. The area is hardly accessible to support, for children under five. There and providing training on obstetric international staff, and local MSF personnel is a birthing unit, and a system to refer procedures and hygiene protocols. provide paediatric services at hospitals in complicated emergency obstetric cases to the Sunni enclave of Sadda and the Shia Quetta. Other services include psychosocial MSF runs a 32-bed private women’s hospital community of Alizai. In 2013, a military in Peshawar, which opened in 2011. It offers offensive launched against the Tirah Valley support and counselling, and screening and free, emergency obstetric care, including in the neighbouring Khyber Agency led to treatment for cutaneous leishmaniasis. surgery. A third of the 3,717 admissions the displacement of thousands of families Comprehensive emergency obstetric, this year were displaced or refugee women. to New Durrani camp, and around Sadda. A referral network has been developed neonatal and emergency care is provided among the district’s rural health centres, In Bajaur Agency, years of violence have left at the Chaman District Headquarters communities and camps for displaced the population with limited access to basic hospital, where 17 per cent of patients people or refugees, and is expanding to healthcare. In March, a team of local MSF treated in the emergency room in 2013 the neighbouring tribal agencies. A five- personnel began running mobile clinics were victims of conflict. More than 2,500 bed newborn unit opened, and a further to facilities in Talai, Kotkay and Derakai, measles vaccinations were given, in close 10 beds will be added in 2014. providing basic healthcare and monitoring collaboration with the Ministry of Health.

74 pakistan This unhappypatient isbeingtreatedinaclinicon theoutskirtsofKarachi. |Y 2013: 1,528 end staff No. free basic, emergency and obstetric services providing Trust, Welfare and Education Health SINA with clinic healthcare abasic runs MSF who cannotmigrants access care. medical undocumented many to home is slum Colony Machar the Karachi, of outskirts the On Healthcare in Karachi out. carried were consultations antenatal 6,000 and hospital, Jamali Murad Dera the at programme were treated in the therapeutic feeding 7,500 9,600 than children. More children reached and Health of Ministry the with vaccination aconducted measles campaign team low. is The coverage vaccination and displacement has exacerbated malnutrition, four Conflict-related centres. health and hospital Jamali Murad Dera in programmes in health child and maternal on focus to continued MSF Nasirabad, and Jaffarabad of districts eastern the In ear MSF first worked in the country: 1986 | msf.org/pakistan | 1986 country: the in worked first MSF ear Balochistan in April. MSF was ready to ready was MSF April. in Balochistan of district Mashkel the in earthquake an July, and and June in Dir Upper in outbreak ameasles Swat, and Timurgara in diarrhoea watery acute and fever dengue both of outbreaks to responded teams November, and August Between of violence. the victims primary the were May. in Non-combatants days FATA and four over Pahktunkhwa Khyber resulting from election-related violence in injuries blast 110 bomb for treated people MSF staff, Health of Ministry with Together responses Emergency inparticipated health education sessions. people 80,000 over and malnutrition for in 2013, 7,600 were children screened were conducted consultations healthcare basic 35,000 than More available. also is support health Mental clock. the around Internati onal A not think it necessary for MSF to intervene. to MSF for necessary it think not did government Pakistani the but province, same the in September, in earthquake Awaran the following assistance provide have the best treatment for my baby. my for treatment best the have Icould hospital, MSF the Quetta at that said he and driver taxi] a tuk-tuk [small Iasked treatment. medical –for anywhere – somewhere take child the I would husband my Itold morning the in night, the during was unwell baby the when and is away far house My lethargic. became then and was wheezing and days two for fever ahigh had He pneumonia. with sick been has boy baby one-month-old My Quetta of west village, Kirani Faiz Bibi iv ct i

ty R ty eport 2013 pak i stan 75 stan

© Haroon Khan / MSF Médecins Sans Frontières PHILIPPINES

Key medical figures: • 72,100 outpatient consultations • 290 surgical interventions • 29,100 relief kits distributed

The strongest typhoon ever recorded at landfall struck the storm-prone Philippines on 8 November, killing over 6,000 people and displacing more than four million others.

A massive local response had already begun as international aid flowed into the country, Regions where MSF has projects including a team from Médecins Sans Frontières (MSF) who arrived in Cebu on 9 November. Typhoon Haiyan destroyed hospitals and clinics and disrupted the public the hard-hit Eastern Visayas, which still had a outlying areas and assess people’s needs. health system. Assistance was needed to partially functioning airport and one partially Teams set up medical activities and delivered treat the wounded and provide relief over a functioning hospital. Damaged and blocked relief supplies to typhoon survivors on the wide area. It was decided that MSF would fill roads, fuel shortages and congested airports principal islands of Leyte, Samar and Panay, gaps in emergency care and help rehabilitate in the country posed logistical constraints as well as smaller outlying islands, adapting hospitals and clinics so services would be and there were delays in getting supplies to aid to fill emerging healthcare gaps as the available for ongoing healthcare needs. people in need, particularly during the first situation evolved. 10 days. As many aid organisations were Initially most aid activity was centred around present around the city, MSF used trucks, Immediately after the typhoon, MSF Tacloban, on Leyte island, the main city in boats, planes and helicopters to reach provided surgery and wound dressings, MSF / © Laurence Hoenig

People affected by the typhoon on North Gigante island queue to receive shelter material and cooking and hygiene kits.

76 PHILIPPINES No. staff end 2013: 89 |Y 2013: 89 end staff No. than 25,200 people received healthcare, More distress. severe experiencing people to healthcare mental offered and water drinking clean supplied nets, mosquito and kits washing tents, as such supplies reliefhealth distributed standards. Staff meeting and place in were disposal waste and water that ensured and supplies and staff with hospital district the supported ateam Leyte, of area Burauen the In families 3,000 to items relief essential Talosa, distributing in and Tacloban of south Tanauan, of town the in worked teams district, Palo In centres. health the visit not could who people reach to city the around clinics mobile Teams took services. health mental and maternal surgical, provided room and outpatient department, inflatable hospitalwith an emergency a60-bed erected MSF Tacloban, of city the In island Leyte support. health mental for needs substantial were there that meant homes and ones loved of loss the of and itself storm the of impact psychological The crucial. also was diabetes, and hypertension kidney failure as such diseases chronic for treatment undergoing people for Healthcare event. the after weeks several wounds infected with presenting patients treated also and Typhoon anddestroyed hospitalsandhomes. Haiyanresultedinthedeathofthousandspeople,displacedmorethanfourmillionsurvivors ear MSF first worked in the country: msf.org/philippines | 1987 country: the in worked first MSF ear support tosupport 3,290 people. health mental given and consultations 12,675 out 2014. Teams carried medical had January in MSF from activities Panay over take to able was Health of Ministry The in the surrounding area. families vulnerable assisted also and centre, evacuation an to relocated people to tents 1,500 some and items relief care, medical provided ateam and harbour Estancia the in spill oil an caused typhoon The water. of chlorinated litres 1.2 over million as well as 11,000 families, for food and 11,000 kits than more relief 14,990 distributed Staff against measles. vaccinated 4,650 children against polio, and MSF islands, offshore the On need. in those to services medical provide to able and functional them render to islands, offshore the on and mainland Panay the of areas coastal the along 13 facilities health islands. MSFon 21 rehabilitated offshore residing people to aid delivered also and San on Dionisio Panay municipalities island and Estancia Carles, in based Teams were Panay and offshore islands 11,470 support. health mental accessed and supplies relief obtained 48,500 Internati

onal A and psychological support. psychological and hospitals providing surgery, inpatient care medical inflatable of out work to continued MSF rehabilitated. completely yet not and diminished were severely services health where areas in presence a strong maintained 2014, teams yet January by completed Many acute emergency were activities homes. their reconstruct to begin could people so Victory, and Sulangan Homonhon, Manicani, of islands nearby four the on communities isolated among distributed were kits shelter and washing and equipment day. each cooking Tents, people 20,000 to up for water clean supplied and disposal, waste proper was there that ensured experts sanitation and MSF’s water sessions. therapy and children through group and individual adults to support psychosocial offered teams MSF and distress health mental suffering were people Many Guiuan. of south islands smaller the on clinics mobile regular ran and Samar on centres health rural in consultations medical out Teams carried room. isolation and unit maternity room, delivery theatre, replacement, equipped with an operating atemporary as hospital tent a 60-bed up set MSF so and typhoon the by repair beyond damaged was island, Samar Guiuan, in hospital Memorial Abrigo Felipe The E astern Samar Samar astern iv ct i ty R ty eport 2013 PH I L I PP I NES © Julie Remy 77 Médecins Sans Frontières paraguay Medical services for the potentially fatal staff (through workshops and academic Chagas disease, caused by a parasitic meetings) and those undertaking infection transmitted by the triatomine entomological surveillance of the bug. bug, are particularly lacking in remote, A Chagas School Guide was created in rural areas such as the Paraguayan Chaco. collaboration with groups of teachers, and 196 people were trained to use it as a tool In Boquerón, Médecins Sans Frontières in health education. (MSF), in collaboration with the Ministry of Health, piloted an intervention strategy In total, over the course of the project, Regions where MSF has projects to bring diagnosis and treatment closer 15,330 people were tested for Chagas to Chaco’s most isolated communities. and 1,632 received treatment. Activities were integrated into Boquerón regional hospital, two smaller hospitals, and MSF continues to support Paraguayan In December, a three-year 15 health centres and health posts. Mobile health authorities from a distance in the teams also visited 120 remote communities development of a national protocol for project helping to develop that lacked a local health infrastructure. Chagas diagnosis and treatment. MSF better awareness, diagnosis advocates the delivery of Chagas care within The project was complemented by the basic healthcare system, integrated with and treatment of Chagas community education activities throughout community education and entomological disease came to an end. the country and the training of medical surveillance and control.

No. staff end 2013: 55 | Year MSF first worked in the country: 2010 | msf.org/paraguay Russian Federation Years of conflict in the North Caucasus medical services do not meet the needs have left gaps in many areas of the of those with acute coronary syndromes health system, resulting in a resurgence and other cardiovascular emergencies. of TB, especially DR-TB. Poor diagnosis, In Grozny, Chechnya’s capital, MSF is interrupted treatment and the questionable improving the cardiac unit in the Republican quality of the TB drugs available on the Emergency Hospital through staff training open market are some of the factors and the purchase of medical equipment contributing to high drug-resistance levels. and medicines for specialised treatment. During 2013, the team conducted further Regions where MSF has projects In 2013, MSF, together with the Chechen training on fibrinolysis (the breakdown of Cities, towns or villages where MSF works Ministry of Health, continued to implement fibrin, or clots) and improved laboratory Key medical figures: a comprehensive TB diagnosis and procedures, as well as the quality of • 6,100 individual and group mental treatment programme for patients with consultations pre- and post-admission. health consultations both TB and DR-TB. The programme • 430 patients under treatment for TB Providing mental health support promotes a patient-centred approach, and as the treatment is arduous and the An MSF team continued to offer counselling to patients in Grozny and communities in management of side effects an important Médecins Sans Frontières the mountainous districts of Chechnya, component, MSF health educators and who are still experiencing the psychological (MSF) is working with adherence counsellors provide psychosocial effects of exposure to violence and death. Russian health authorities support to all TB patients and their families. to address tuberculosis (TB) Expanding cardiac care and drug-resistant TB (DR-TB) There is a high rate of heart disease in in Chechnya. Chechnya, but the scale and quality of

No. staff end 2013: 153 | Year MSF first worked in the country: 1992 | msf.org/russianfederation

78 paraguay | Russian Federation International Activity Report 2013 south africa

Regions where MSF has projects Cities, towns or villages where MSF works

Key medical figures: • 26,500 patients on first-line ARV treatment • 1,500 patients under treatment for TB

South Africa remains at the centre of the worldwide

HIV/AIDS epidemic. More © Peter Casaer / MSF No. staff end 2013: 55 | Year MSF first worked in the country: 2010 | msf.org/paraguay than six million people in These Community Health Agents are doing door-to-door HIV testing. the country live with HIV.

Innovative models of care have been January 2011 and September 2013, 231 ARV plan. These strategies include: the rapid introduced over the past decade and clubs were established at 10 health facilities in expansion of community-based testing, 90 per cent of patients with HIV now Khayelitsha, enrolling a total of 7,733 patients. greater continuity of ARV and TB treatment, receive treatment through the public faster TB diagnosis and treatment, and sector. The projects run by Médecins Research by MSF has found that 97 per cent the aggressive promotion of prevention of adherence club members continued their Sans Frontières (MSF) in 2013 continued methods, including voluntary male treatment, compared with 85 per cent for to support the empowerment of people circumcision and earlier treatment of HIV. living with HIV, by giving them more patients who qualified for membership but flexibility in treatment approaches and remained in mainstream clinic care. Club Integral to these goals are mobile one-stop enabling them to obtain drugs and patients were also 67 per cent less likely to shops, where people get rapid HIV testing support in their home communities. experience treatment failure. and treatment in a single location, at the heart of the community. In 2013, teams Khayelitsha In September, the clubs were handed over started an outreach programme of testing Khayelitsha, a poor township on the outskirts to local health authorities and are being and health promotion targeted at mobile of Cape Town, was the site of the first scaled up, thanks to a US$15 million Global populations on farms around Eshowe and primary-level antiretroviral (ARV) treatment Fund grant. Community-based clubs are Mbongolwane. A stronger focus was also programme in South Africa in 1999, and currently undergoing trials. placed on measuring patients’ HIV viral load subsequent innovations include the ARV to monitor the effectiveness of ARV treatment, adherence clubs, introduced by MSF in 2011. KwaZulu-Natal nurse-initiated management of ARV and the One-to-one appointments at the health KwaZulu-Natal has the highest tuberculosis centre are time consuming for patients (TB) incidence of all the provinces in promotion of ARV adherence clubs. who may not have the time to queue for South Africa and TB remains the leading Improving access to generic drugs hours to pick up their drugs, and are an cause of death for people with HIV. It is added workload for health professionals also the epicentre of the HIV epidemic MSF is actively involved in the Fix the Patent in a country where medical facilities are in the country, with one in four adults Laws campaign in South Africa, which aims chronically understaffed. As an alternative, infected. The Bending the Curves project to tighten the law so that it only grants MSF pioneered adherence clubs that offer that was introduced in 2013 seeks to patents to drugs that are truly innovative. people living with HIV the opportunity to implement multiple strategies to address This in turn would facilitate the production combine peer support with check-ups and the high co-incidence of HIV and TB, and and/or importation of generic drugs, thus drug refills at bi-monthly meetings. The reduce the number of incidences in line making them more affordable to people model quickly became popular and between with the South Africa National Strategic seeking treatment.

Year MSF first worked in the country: 1999 | msf.org/southafrica

south africa 79 Médecins Sans Frontières somalia

Key medical figures: • 318,400 outpatient consultations • 6,150 births assisted • 15,600 patients treated in feeding centres • 28,600 routine vaccinations

In August, Médecins Sans Frontières (MSF) closed all of its projects in Somalia after 22 years of continuous operations.

Leaving Somalia was an extremely difficult decision to make. A series of violent attacks on MSF personnel took place with the Regions where MSF has programmes tacit acceptance – or active complicity – of armed groups and civilian authorities. The minimal conditions necessary for operations were not respected, and hence To improve access to quality basic and from these clinics were donated to other MSF ceased supporting health facilities in specialist healthcare for children, MSF ran aid organisations in Mogadishu, and the Somalia by mid-September 2013, handing the only paediatric hospital in Mogadishu, Dharkenley clinic has continued operations. them over to government entities and in Hamar Weyne. The hospital had isolation Bay region humanitarian organisations where possible. wards for children suffering from measles or acute watery diarrhoea and a nutrition MSF began supporting Dinsor hospital in Although the humanitarian situation has centre that treated 3,800 children between Bay region in 2002. It is the main referral improved since the nutritional crisis of 2011, January and August. hospital for the entire region, and is the ongoing conflict in the south-central especially active in providing maternity regions, together with natural disasters and MSF also ran health clinics for displaced services and treating malnutrition, seasonal outbreaks of disease, put huge populations and residents in the Wadajir, tuberculosis (TB) and kala azar (visceral strains on the weak healthcare system. In Dharkenley and Yaaqshiid districts. These leishmaniasis). In 2013, the team at the many parts of Somalia, access to healthcare focused on maternal and child health and 60-bed hospital performed 16,208 is extremely limited and mortality rates for were able to respond to sudden outbreaks outpatient consultations, around 1,458 pregnant women and young children are of disease such as cholera, treat peaks of antenatal consultations, and treated among the highest in the world. Hundreds malnutrition through feeding programmes, more than 680 malnourished children. of thousands of Somalis remain displaced and participate in mass vaccinations against Lower Shabelle region inside the country and in refugee camps polio, which had made a resurgence in the across Somalia’s borders, living a precarious country. Over 100,000 consultations were The Afgooye district hospital serves existence exposed to many forms of carried out at these health facilities prior displaced people and residents of the violence and extortion. to MSF’s departure. All drugs and supplies Afgooye Corridor with an outpatient

MSF did not want to leave Somalia but was left with little choice, and continues to support Somali refugees in Ethiopia, Kenya and Yemen.

In and around Mogadishu Nine kilometres northwest of Mogadishu,

in Dayniile, MSF supported a 60-bed © Muhammad Daoud / MSF hospital with an emergency room, operating theatre, intensive care unit, paediatric unit, feeding centre and maternity facilities. The team performed 646 surgical procedures and over 8,272 consultations in 2013.

MSF’s 40-bed hospital in the Jaziira district of Mogadishu, which mostly catered to displaced populations, carried out some 25,700 consultations and 2,200 hospital In many parts of Somalia, access to healthcare is extremely limited and mortality rates for admissions this year, and treated over 330 pregnant women and young children are among the highest in the world. severely malnourished children.

80 somalia No. staff end 2013: 1,188 end |Y staff No. asatellite ran 2013. MSF in addition, In 33,824 out consultations carried teams MSF treatment. TB and programmes feeding services, maternity care, inpatient and North, MSF offered paediatric outpatient Galkayo in hospital referral Health’s of Ministry the In Galkayo. of city divided the in hospitals referral two in projects ran MSF Mudug region vaccinations.and received children 8,447 women and assisted, 1,040 deliveries performed, were consultations 60,000 than More September. in (IMC) Corps Medical International the to over handed were clinics other the and insecurity to due 2013 March in closed clinic Mahaday TB. treated also facilities Gololey and Mahaday The Mahaday. and Balcad Gololey, Sheik, Bulo Kulmis, in centres health and hospital maternity Jowhar the at support nutritional and vaccinations services, health child and maternal care, outpatient provided MSF Middle Shabelle region MSF’s withdrawal. following hospital the of support assumed Society Crescent Red Qatar The 953 of babies. delivery the assisted and wards its to patients 738 11,408 admitted consultations, medical and September, the hospital conducted January feeding programme. Between outpatient an and facility maternity room, inpatientand 30-bed emergency department, A childbeingtestedformalnutritioninHamarWeyne district. ear MSF first worked in the country: msf.org/somalia | 1979 country: the in worked first MSF ear cholera. Over 68,000 medical interventions interventions medical 68,000 Over cholera. and to measles treat malnutrition, facilities had Jilib in clinic fixed small A five. under children care to malnourished nutritional 12 under and children to healthcare basic delivered and Moto Osman and Ketoy of towns the covered teams mobile addition, In population. catchment ahuge to care nutritional and services emergency obstetric specialist healthcare, TB treatment, and regions, Gedo providing basic and Juba Lower and Middle of whole the for hospital referral the as served Marere of town rural small the in MSF’s hospital Middle Juba vital services. these continue to organisations medical international two with partnership in works Development Organisation, which now Mudug the to passed was hospital the January and September. Management of between clinics the and hospital the through assistance received 44,071 people Some region. Galmudug in healthcare primary provided also clinics mobile treatmentTB and immunisations. Two programmes, nutrition services, maternity care, paediatric and surgery provided MSF South, Galkayo in hospital the In region.Nugal in Burtinle in treatment TB for programme Internati onal A facilities and relief supplies. distributing consultations, improving water and sanitation medical out carrying Somaliland, in prisons three in intervened also MSF of 720the birth babies. in assisted and department inpatient the to 1,602 people admitted interventions, 775 surgical conducted MSF withdrawal, 2011. since its to Somaliland of Prior region Togdheer the in hospital Burao 160-bed the of facilities surgical and maternity inpatient, the supporting been had MSF Somaliland MSF’sfor withdrawal. compensate to October in hospital Kismayo at structure asimilar opened Cross Red the of Committee 2013. International The treatment between January and September 5,183of thereafter: children received 2011 stream of asteady crisis saw and facility opened during the nutritional This cholera. and measles from suffering those for wards special with five, under children for programme nutrition inpatient an ran MSF Kismayo, of city port the In Juba Lower August. and January between programme this through out carried were iv ct i ty R ty eport 2013 som al i a 81 © Muhammad Daoud / MSF Médecins Sans Frontières south sudan people, mostly women and children, fled the capital of Jonglei state, Bor, for Awerial, Lakes state.

Refugee assistance In Yida camp, Unity state, MSF provided basic and specialist healthcare, ran nutrition centres and helped ensure adequate water and sanitation for 70,000 Sudanese refugees. Teams delivered the same services to more than 110,000 refugees across four camps in Maban county, Upper Nile state. In cooperation with the Ministry of Health, MSF staff vaccinated 132,500 people against cholera in the camps and the surrounding area. Regions where MSF has projects Cities, towns or villages where MSF works Teams began providing Sudanese refugees

Key medical figures: from South Kordofan with basic and • 981,500 outpatient consultations • 50,000 patients admitted to hospital specialist healthcare in Pamat, northern • 4,700 surgical interventions • 2,750 patients treated for kala azar Bahr El Ghazal, in February. In October, staff in Upper Nile state offered medical and nutritional assistance to around 5,000 Escalating violence in South On 15 December, fighting broke out in refugees in Fashoda, and carried out Juba between different army factions and Sudan increased the need for surgery and post-operative care at the violence spilled onto the streets. Some hospital in Malakal. emergency medical aid as the 40,000 people fearing for their lives sought year progressed. refuge in two UN compounds, where MSF Basic and specialist health services set up clinics and provided 1,890 health MSF teams continued to offer a full consultations. A high number of people range of services at clinics and hospitals During clashes between the government were treated for acute diarrhoea, a direct throughout the country, including and militia in Jonglei state in April, staff and result of poor water and sanitation. MSF surgery, maternal and child healthcare, patients at Pibor hospital were subjected also provided drugs and medical supplies vaccinations, emergency obstetric services to threats and intimidation and Médecins to the Juba Teaching Hospital. Sans Frontières (MSF) was forced to suspend and treatment for malnutrition, kala azar, activities. In May, the hospital was looted Fighting spread quickly through several HIV and tuberculosis (TB). They also and severely damaged, and fighting in the states causing displacement, and 70,000 responded to outbreaks of disease. area caused Pibor residents to flee into the bush or hide in malaria-infested swamps without access to safe water or food. As the MSF hospital was the only one in the county, 100,000 people were deprived of healthcare. Thousands of people emerged 40 kilometres away to attend MSF’s small clinic in Gumuruk village, where teams carried out over 100 consultations per day for patients suffering from pneumonia, respiratory diseases, malaria, diarrhoea and malnutrition. During the first few weeks, a team set up a surgical unit at Gumuruk and performed 49 surgical procedures. To address the needs of the displaced people, a second clinic was opened in Dorein, south of Pibor town, and a helicopter was used to run mobile clinics in the bush in Pibor county. More than 26,500 consultations were provided across Pibor county over a six-month period. The team also conducted 1,468 antenatal consultations and offered

mental health support through individual © Isabel Corthier / MSF and group sessions. In Gogrial town, Warrap state, MSF runs a small hospital that provides a full range of basic healthcare services.

82 south sudan exacerbated oncetherainy seasonstarts. This motherinYida refugeecamphasjusthadher daughtervaccinated.Infectious diseasesrelatedtothecamp’s poorhygieneconditionsarefurther |Y 2013: 2,854 end staff No. 13,394 place; these took of consultations outpatient 68,000 than More healthcare. specialist and basic offered MSF state, Unity in Leer, also In area. surrounding the and town the in HIV and TB with people treat to aproject opened and February in ministry health the to programme nutrition a over handed MSF state, Unity Bentiu, In Ethiopia. of areas border the and counties surrounding from referred patients for cared and treatment, TB and HIV including services specialist and basic of range afull provided state, Nile Upper hospital, Nasir The August. and July in out broke that violence the during hospital Health of Ministry the at MSF from care emergency received Bor, in 177 south, patients Yuai. Further in clinic outreach an and hospital Lankien the at services of spectrum afull among were provided consultations outpatient 71,000 than more state, Jonglei In ear MSF first worked in the country: 1983 | msf.org/southsudan | 1983 country: the in worked first MSF ear an inpatient maternity department. Staff has also hospital The units. isolation and tetanus neonatal, and victims, burn of include intensive care, surgery, treatment Services Ghazal. El Bahr Northern hospital, 15 of civil age Aweil at the to up children for available is care Around-the-clock healthcare and referrals. maternal and basic access could regions remote in people ensure to clinics mobile and weight lowoperated birth babies. Staff accommodate high the of number premature to September in ward maternity a new constructed MSF care. TB and HIV including services comprehensive area, providing the in hospital only the runs MSF Abyei. of city the from kilometres 40 Agok, in nomads and people displaced internally residents, to offered are services Health interventions. 336 surgical performed also MSF malaria. with patients for were Internati onal A measles in Lakes state. Lakes in measles 41,000 children were vaccinated against In November and December, more than women. pregnant including children and adults, HIV-exposed for care HIV comprehensive deliver to staff technical key deploying and training recruiting, by programme HIV Health’s of Ministry the to support its reinforced MSF state, Equatoria Western hospital, Yambio At and diarrhoea. infections tract respiratory malaria, with people of numbers large treating clinics, mobile ran also team The family. and friends by rejection sometimes and exclusion social to leads often turn in which incontinence, but pain only not cause complications, of birth consequence a Fistulas, to women. 55 surgery fistula In November and December, MSF provided year. this hospital to children 4,600 over admitted and 6,100 than births more assisted iv ct i ty R ty eport 2013 south sudansouth 83

© Yann Libessart Médecins Sans Frontières sudan

Regions where MSF has projects

Key medical figures: • 130,000 outpatient consultations • 470 patients treated for kala azar • 319,200 measles vaccinations (outbreak)

In Sudan, Médecins Sans Frontières (MSF) focuses on providing medical assistance © Sharafeldin Magzoub in remote regions with poor In Al-Gedaref state in eastern Sudan, an MSF doctor explains to a group of schoolchildren access to healthcare, and to why they should be vaccinated against measles. people affected by conflict, outbreaks of disease and in 2013 in collaboration with the Ministry Vaccination campaigns natural disasters. of Health. In January, MSF assisted the Sudanese health authorities in preventing a yellow In July, an MSF team started supporting the Treating tuberculosis in Jebel Awlia fever epidemic. Over 750,000 adults and health centre in El Serif displaced person In February, MSF started diagnosing and children were vaccinated over nine months camp near Nyala in South Darfur. treating tuberculosis (TB) in five health in four localities in Central Darfur state. centres in Jebel Awlia, a large slum on In West and Central Darfur, 256 patients In North Darfur, MSF continued working the outskirts of the capital, Khartoum, suspected of having yellow fever were in Tawila but due to insecurity the project where crowded living conditions increase treated. From early March to May, MSF was limited to basic healthcare activities people’s risk of contracting the disease. emergency teams carried out a measles within the town and the implementation The team is training Ministry of Health vaccination campaign in five locations in of a referral system to hospitals in El Fashir Al-Gedaref state. A total of 306,400 people staff and working with patient groups in for specialist treatment. The focus in Dar were vaccinated. Zaghawa was also on basic healthcare. the community to develop counselling and Teams supported two health centres support systems that will help patients Emergency flood response and two health posts, and carried out adhere to treatment. Heavy rains in August caused flooding postnatal home visits. Projects in Kaguro, which affected 150,000 people. Khartoum Reproductive healthcare in Tabarak Allah, including vaccination campaigns, were state was particularly hard hit, and MSF Al-Gedaref state under remote management, as no access launched an emergency intervention, was available to international staff. An MSF began supporting the Ministry of providing 228,600 litres of clean water emergency intervention in El Sireaf started Health’s reproductive health activities in and carrying out 654 mobile clinic in 2013 after tribal clashes displaced an July. The main objectives are to reduce consultations in the Sharag Alniel locality. estimated 65,000 people. Two mobile maternal and neonatal mortality, and to Most patients had respiratory tract clinics provided outpatient consultations, ensure patients who need fistula repair and infections, gastritis or diarrhoea. therapeutic feeding programmes and reconstructive surgery are appropriately Kala azar reproductive healthcare. Referrals were referred. Comprehensive emergency made to the MSF-supported El Sireaf MSF continued its kala azar work in Tabarak obstetric services are offered, and women hospital. In July, two mobile clinics Allah, Al Gedaref state, and treated 470 also receive follow-up services including started providing care to people in people in 2013. The Shangyl Tobaya basic postnatal consultations and family planning two displacement camps in El Serif. healthcare programme was handed over to support. MSF renovated and equipped the Ministry of Health. Aiming to improve access to emergency the maternity wing and refurbished the healthcare, MSF launched the North Darfur operating theatre in Quresha hospital. Emergency Response (NDER) programme Children were also referred for vaccinations.

No. staff end 2013: 1,120 | Year MSF first worked in the country: 1979 | msf.org/sudan

84 sudan International Activity Report 2013 swaziland

Regions where MSF has projects

Key medical figures: • 20,100 patients on first-line ARV treatment • 1,900 patients under treatment for TB

The decentralisation of medical services in Swaziland is helping people with

HIV, tuberculosis (TB) and © Sven Torfinn

multidrug-resistant TB (MDR- Treatment for drug-resistant TB involves swallowing 20 pills a day and receiving a painful TB) get the care they need. daily injection that makes it difficult to sit or even lie down.

Swaziland has high rates of HIV–TB In 2013, the MSF team continued to community treatment supporters (CTS). co-infection and the number of people improve infection control and provided This is a new approach and an analysis of with drug-resistant forms of TB (DR-TB) is psychosocial support for patients in the effectiveness of the CTS programme is rising. Médecins Sans Frontières (MSF), in Mankayane hospital and in community- currently underway. collaboration with the Ministry of Health, based clinics. They also trained staff at A ‘test early and treat early’ effort began has been integrating HIV and TB services at the TB National Reference Laboratory last year as a preventive measure against basic health clinics and in the community. in Mbabane, where MSF assists with the transmission of HIV. It ultimately aims Further strategies have included advocating TB cultures and drug-sensitivity testing. for the introduction of shorter, more to put everyone testing positive for HIV on tolerable treatment regimens for DR-TB Patient-centred HIV and TB care ARV treatment, regardless of how far the and the promotion and implementation of in Shiselweni virus has progressed. The first phase, which started in January 2013, involved putting outpatient DR-TB care. After five years of increasing the number all HIV-positive women on treatment, and of HIV and TB services, Shiselweni, One-stop, comprehensive care for HIV this work continues, along with routine viral formerly the most disadvantaged region and TB is provided in Matsapha, Manzini load testing. for healthcare, now has multiple HIV and region, an industrial town that attracts TB service points. MSF provides treatment migrant workers. The clinic here offers A voluntary door-to-door HIV-testing and psychosocial support for HIV and TB HIV counselling and testing, diagnosis campaign was also conducted in patients in 22 basic health clinics and and treatment of TB, and sexual and August, which resulted in 6,452 people three specialist facilities. Teams also work reproductive healthcare services, including being screened. ante- and postnatal care. The clinic on infection control and improving provides victims of violence with medical adherence to treatment. and psychosocial care, and consultations In 2013, there was a strong focus on and treatment for common illnesses, improving access to DR-TB diagnosis and as well as immunisations for children, care. Locating laboratories at points of are also available. care was an important component, and In Mankayane, MSF works closely with rapid diagnostic technology (GeneXpert) the Ministry of Health’s HIV and TB was distributed throughout the region; department to improve diagnosis and 20 primary clinics now have their own treatment of patients suffering from mini-labs. Furthermore, patients who HIV–DR-TB co-infection. Antiretroviral cannot come to their nearest facility (ARV) treatment has been integrated for daily injections during the intensive with that for TB and DR-TB. treatment phase are now visited by

No. staff end 2013: 439 | Year MSF first worked in the country: 2007 | msf.org/swaziland

swaziland 85 Médecins Sans Frontières SYRIA

Key medical figures: • 108,300 outpatient consultations • 4,900 surgical interventions • 1,800 births assisted • 18,700 relief kits distributed

Against a backdrop of relentless violence, the Syrian people endured food shortages, disrupted power and water supplies, and the collapse of the healthcare system in 2013.

Regions where MSF has projects The conflict in Syria has decimated what was previously a well-functioning healthcare system. With regions of the country inaccessible to humanitarian organisations, In late 2012, a field hospital in a cave acute and chronic diseases. Mental health the huge medical needs that are indirect was relocated to a converted farm in the services were launched in July. consequences of the conflict remain largely mountainous region of Jabal Al-Akrad. unreported and unseen. The initial focus for More than 520 surgical procedures and With needs steadily rising, MSF opened Médecins Sans Frontières (MSF) was providing 15,550 emergency consultations were another hospital in the governorate in emergency and trauma surgical care in performed there in 2013. When security May. Services include surgery for trauma, the north of the country. As the situation allowed, MSF ran mobile clinics in the area, including burns, and obstetric care. deteriorated, activities were extended to provided medical facilities with essential Consultations are provided for adult and include basic and mental healthcare, maternal drugs and equipment, and distributed basic paediatric outpatients and there is also an health services and measles vaccination relief items. Over 30,600 consultations were inpatient department. Between May and campaigns. MSF also donated medical carried out at mobile clinics and the hospital. December, staff performed more than 1,300 supplies and drugs to treat communicable Two additional basic healthcare clinics were surgical procedures and carried out 14,300 diseases such as typhoid, chronic conditions opened in the area in June. consultations. such as asthma and diabetes, as well as cardiovascular and kidney diseases. Aleppo governorate In July, MSF opened a third hospital on The hospital MSF opened in 2012 in Aleppo the outskirts of Aleppo city, providing care In Idlib governorate, MSF continued to run governorate continued to treat children and to patients with conflict-related injuries a trauma surgical unit set up in a house, the wounded. The team also performed and those indirectly affected by the war. where patients suffering from shrapnel surgical procedures, provided maternity and There is an emergency room, an outpatient wounds, bullet wounds and burns were obstetric care, and treated patients with department and a 12-bed ward. treated. Physiotherapy and post-operative care were provided. Given the many people exhibiting psychological distress, mental health services were added in February.

More than 60,000 people have settled in displacement camps in the area around the hospital. MSF staff built 60 latrines and 40 showers to improve hygiene, and distributed supplies such as tents, blankets and plastic sheeting. The conflict has disrupted essential preventive care and between February and May, teams vaccinated children in the camps, immunising 3,137 against measles and more than 3,300 against polio. Routine childhood vaccinations started in November in partnership with two local NGOs, with an average of 1,000 children immunised per month. Seventy community health workers undertook outbreak surveillance and health education activities in the camps. Two outpatient clinics were also opened in November. © Anna Surinyach / MSF A transit camp in Aleppo governorate, home to thousands of people.

86 SYRIA No. staff end 2013: 621 |Y end staff No. families. vulnerable to distributed were kits hygiene and stoves blankets, as such items through several health centres. Non-medical vaccinated 27,000 children against measles and consultations 12,600 outpatient than schoolempty buildings, conducted more emergency assistance to people living in provided teams Mobile care. in interruption no was there broke chain supply the when that so patients, dialysis of treatment the cover to made were Donations facility. the in ward paediatric MSF-supported an been has there July since and Tal Abyad, in hospital Health of Ministry the in clinic healthcare abasic May,In opened ateam governorate Ar-Raqqah governorate. Aleppo in hospital Al-Bab at ward paediatric the reopen to provided was support Further people. displaced to sheeting plastic and tents winter distributed conduct a vaccination campaign and helped also MSF Manbij. in centre health volunteers treating displaced people at a Syrian supported ateam attacks, violent after north fled people When medicines. and tents donated MSF October, in and area Safira Al the in camps in live people displaced of Tens thousands of sterile environment. In whatusedtobeachickenfarm,MSFsetupmakeshifthospitalwithaninflatableoperatingtheatre–efficientwaymaintain ear MSF first worked in the country: 2009 | msf.org/syria | 2009 country: the in worked first MSF ear that more than four million Syrians were were Syrians million four than more that estimated was it year the of end the By governorates. seven across posts health 60 and hospitals 40 of network a to daily donated were material medical non- and medical of tons three of average 2013, Throughout an offered. are support andequipment, technical advice and medical drugs, government, the by access denied being or insecurity of because teams own its send cannot MSF Where in assistance Syria.medical-humanitarian delivering to obstacles major are security about concerns and access on Restrictions Donations and remote support casualties. of influx large apossible for prepared also MSF Hasakah. Al in year the of end the by conducted been Approximately 3,110 consultations had decreased. arrivals of number the but villages, nearby in people leaving September, of end the at again closed border The Syria. leave to waiting those assist to post health a up set MSF and August in reopened Iraq with border The drugs. and staff skilled with Hasakah Al in ahospital in ward trauma the support to July, started In MSF governorate Hasakah Al Internati onal A

Syrians in Lebanon, Iraq, Jordan and Turkey. and Jordan Iraq, Lebanon, in Syrians to aid medical emergency provided also MSF had crossed into neighbouring countries. million two and country, the inside displaced patients immediately, everything. ambulances capable of transporting doctors, medication, in support need We here. know, nothing weyou have As care, drugs. doctors, case, needs she sister’s my care. In We medical need died. she’d hospital, were no there If have the bleeding. Her situation is stable now. stopped they where to hospital, her the nearby. We was one there took Thankfully acar. …We for shouted neck her of out was coming Blood face. her hit had shrapnel that saw and towards her ran I “Yes, Iam!” replied: She sister?” hurt, “Are you Ishouted: covered rubble. in her. near was She landed Abomb metres. five about me, was She behind was close. shelter, sistermy find to and move itas …Itold explosions of sound the We heard hospital field MSF toan sister his brought who A man iv ct i ty R ty eport 2013

SYR

I © Robin Meldrum / MSF A 87 Médecins Sans Frontières sierra leone More than a decade has passed since the Ministry of Health, with staff, medicines end of the civil war, but Sierra Leone is and medical materials. still recovering. Healthcare gaps are systemic and nationwide, and access MSF plans to build a 160-bed hospital to quality healthcare remains a major closer to Bo town that will provide better challenge for the population. Although access for patients, staff and supplies. the government initiative offering free The new, more spacious facility will also healthcare to pregnant women and children allow for better infection control protocols, is improving access, many people still die and will include a proper isolation ward Regions where MSF has projects from treatable diseases such as malaria, and a modern laboratory. measles, acute respiratory infection and Key medical figures: Lassa fever, a viral haemorrhagic fever • 73,300 outpatient consultations • 2,200 births assisted endemic in the country.

In Bo district, MSF runs the Gondama referral centre, a 220-bed hospital offering MSF Médecins Sans Frontières emergency paediatric and obstetric / services. In 2013, ambulances transported (MSF) has begun reorienting patients from nine community health its work to focus on improving centres to the hospital, and an additional

medical care for children and ambulance service took patients with © Aisha Dodwell Lassa fever to Kenema hospital for A Clinical Health Officer examining a child its capacity for diagnosing treatment. MSF also supports Gondama at Gondama referral centre in Bo. Lassa fever. health centre, a nearby clinic run by the

No. staff end 2013: 619 | Year MSF first worked in the country: 1986 | msf.org/sierraleone tajikistan In 2011, MSF started a paediatric TB The diagnostic tools and treatment programme to improve access and quality currently used are not adapted for children. of care for children with drug-sensitive TB, MSF is hoping to find ways to better drug-resistant TB (DR-TB) and multidrug- diagnose DR-TB and MDR-TB and produce resistant TB (MDR-TB). The team continued paediatric formulations of the drugs, for to support the paediatric TB hospital in example syrups. Dushanbe in 2013, offering diagnosis and comprehensive care to children who were Kala azar admitted. Their family members were also Following an outbreak of kala azar (visceral Cities, towns or villages where MSF works tested and treated, and MSF worked with leishmaniasis), MSF trained 200 Ministry the Ministry of Health to diagnose and treat of Health staff and introduced a rapid Key medical figures: test. Kala azar is a parasitic disease that is • 220 patients under treatment for TB, those who had come into close contact with of which 28 for MDR-TB the children. almost always fatal if left untreated, and the specialist facilities and expertise required MSF provided outpatient care for children for reliable diagnosis are often missing in Improving children’s access and their families wherever possible, areas where it is prevalent. At the request of to tuberculosis (TB) treatment along with nutritional and psychosocial the Tajik Ministry of Health, MSF developed support to help them adhere to the treatment guidelines for the national kala continued to be the main focus difficult treatment. Hospitalised children azar programme. of Médecins Sans Frontières took part in MSF-organised activities to aid their development, and teams also (MSF) in Tajikistan in 2013. conducted activities to decrease the stigma surrounding the disease.

No. staff end 2013: 64 | Year MSF first worked in the country: 1997 | msf.org/tajikistan

88 sierra leone | tajikistan International Activity Report 2013 TURKEY The poor living conditions and lack of outside of the camps and may not have access to medical care endured by many access to services or aid distribution. of the predominantly Syrian refugees in Turkey remain concerning, and this year A health needs assessment conducted by Médecins Sans Frontières (MSF) launched MSF among migrants revealed no access several humanitarian interventions to to healthcare, as well as financial barriers deliver assistance to those in need. and poor living conditions. The response by humanitarian organisations was found Many Syrians have settled in the southern to be inadequate. MSF provided support Cities, towns or villages where MSF province of Kilis, along the Syrian–Turkish to an HCA psychosocial project assisting supports projects border. The NGO Helsinki Citizens’ mixed migrant communities in Istanbul. Assembly (HCA), in collaboration with Turkish psychologists, community health Key medical figures: • 29,000 outpatient consultations MSF, is running a clinic in Kilis aimed at workers and interpreters supported referral • 6,800 individual and group mental providing quality healthcare, including activities in 10 municipalities. The project health consultations mental health services, to this vulnerable was closed at the end of the year, as MSF population. The main goal of the mental decided to focus its interventions on Syrian health activities in Kilis is to help refugees refugees in Turkey. Over half a million Syrian war cope and adjust to their new situation, regardless of whether they live inside or refugees were living in Turkey outside the camps. Unregistered refugees by the end of 2013. are a priority for MSF since they live

No. staff end 2013: 29 | Year MSF first worked in the country: 1999 | msf.org/turkey UKRAINE and treatment of the disease in Ukrainian Some have psychological disorders, and many prisons is limited. suffer from drug and alcohol addictions.

Since 2012, Médecins Sans Frontières (MSF) MSF provides laboratory services for rapid, has provided DR-TB treatment to prisoners accurate TB diagnosis, adverse effects and ex-prisoners in eastern Ukraine’s Donetsk diagnosis and management, and guarantees region. DOTS (directly observed treatment, an uninterrupted quality-assured drugs short course), the treatment recommended supply is available. MSF also lobbies the by the World Health Organization, is State Penitentiary Service of Ukraine and the Regions where MSF has projects provided in a special prison TB hospital Ministry of Health, at regional and national and in three pre-trial detention centres. levels, for the integration of TB and HIV Key medical figures: Antiretroviral (ARV) therapy is given to DR- services and multidisciplinary, patient-oriented • 250 patients under treatment for MDR-TB TB case management in penal facilities. • 43 patients on first-line ARV treatment TB patients co-infected with HIV. After the prisoners are released, MSF works to ensure that they complete their DR-TB treatment. The dual drug-resistant The course of treatment for DR-TB takes up tuberculosis (DR-TB) and HIV to two years and can result in a number of MSF epidemics in the Ukrainian side effects, some of them severe, including / penitentiary system are an vomiting, nausea, depression and loss of hearing. Counselling is an important part urgent public health issue. of the patient-centred programme, to help people cope with their diagnosis and adhere to

Overcrowded prison environments and the treatment. Inmates often come from deprived © Niklas Bergstrand inadequate healthcare provided to inmates environments, with difficult family histories MSF provides drug-resistant TB treatment exacerbate the spread of DR-TB. The diagnosis and experiences of social marginalisation. to prisoners in Donetsk region.

No. staff end 2013: 62 | Year MSF first worked in the country: 1999 | msf.org/ukraine

TURKEY | UKRAINE 89 Médecins Sans Frontières uganda After several years of progress in the fight After a 12-year presence in Arua, MSF has against HIV, and large increases in the started to hand over medical activities to local number of people being tested and treated authorities and their partner SUSTAIN, and for the virus, the rate of new infections has will close the project in July 2014. This follows risen since 2010. Test kits and condoms both an increase in the local ability to provide are difficult to obtain in several areas of medical care for people with HIV and TB and the country; meanwhile it is estimated that a reorientation of MSF’s work in the country. one-third of women and half of men with HIV are not aware of their status. Specialised Emergency care for refugees Regions where MSF has projects care, such as prevention of mother-to-child The conflict in North Kivu province, DRC, Cities, towns or villages where MSF works transmission (PMTCT) and the combined caused between 40,000 and 50,000 refugees treatment of tuberculosis (TB) and severe to cross into western Uganda between May Key medical figures: malnutrition, is often unavailable. and the end of July. An estimated 22,000 • 52,900 outpatient consultations • 6,500 patients on first-line ARV treatment people reached the Bubukwanga transit In West Nile region, the prevalence of HIV • 570 patients under treatment for TB camp, near Bundibugyo. Originally designed among adults aged 15 to 49 is about five per for 12,500 people, the camp lacked sufficient cent and has almost doubled since 2005. shelters, latrines and drinking water for the Médecins Sans Frontières (MSF) has been increased numbers. MSF began providing In Uganda, the rate of HIV working in the region to help improve access medical care in July. Patients were suffering to care and reduce HIV-related mortality. infection is on the rise again, mainly from respiratory infections, malaria after decreasing for many For several years, MSF teams have treated and diarrhoea. Teams also built latrines and years. The country has also people with HIV and TB through a trucked in water. Some refugees have since programme based at the Arua regional been transferred by the Ugandan authorities had to host large numbers referral hospital. Care is provided to people to the Kyangwali camp to ease pressure on of refugees arriving from living in the district as well as to a significant resources. MSF provided healthcare to the Democratic Republic of Congo number of patients from neighbouring 33,000 people in Kyangwali camp from DRC. Activities include PMTCT and ensuring September to the end of November. A total (DRC) and South Sudan. people infected with both HIV and TB receive of 25,000 consultations were conducted and the necessary integrated care. 1,500 people were admitted to hospital.

No. staff end 2013: 358 | Year MSF first worked in the country: 1986 | msf.org/uganda © Fulvio Bugani

Family and friends visiting patients at the health centre in Bubukwanga transit camp, near Bundibugyo.

90 uganda International Activity Report 2013 UZBEKISTAN Uzbekistan is one of many countries in nearly two-thirds of the DR-TB patients Central Asia with high levels of drug- began ambulatory care. In September 2013, resistant TB (DR-TB), a form of the disease 16 MDR-TB patients were enrolled in a pilot that does not respond to the standard project in which the often arduous treatment first-line drug regimen. Access to proper that usually takes up to two years was diagnosis and care is still limited and the shortened to nine months. vast majority of people with DR-TB remain undiagnosed and untreated. The DR-TB project expanded this year into the districts of Chimbay, Shumanay and Regions where MSF has projects In the Autonomous Republic of Kanlikul, while activities in the districts of Cities, towns or villages where MSF works Karakalpakstan, Médecins Sans Frontières Khodjeily, Takhiatash and Nukus region were (MSF) has been running a TB programme handed over to local health authorities. Key medical figures: in collaboration with the Ministry of Health • 2,200 patients under treatment for TB, In Tashkent, Uzbekistan’s capital city, an MSF of which 516 for MDR-TB since 1997. In 2013, 1,212 patients were • 200 patients on first-line ARV treatment enrolled for first-line TB treatment, as well team continued to work at the Republican as 677 for DR-TB. Many patients underwent AIDS Centre, and activities began at the treatment on an outpatient basis, so they Tashkent City AIDS Centre in September. A pilot project to shorten avoided the additional stress of hospitalisation Psychosocial activities such as counselling treatment time for people and could remain at home close to their were also provided as an additional support families and social support network. Overall, for people living with HIV. with multidrug-resistant

tuberculosis (MDR-TB) No. staff end 2013: 184 | Year MSF first worked in the country: 1997 was launched in 2013. msf.org/uzbekistan

No. staff end 2013: 358 | Year MSF first worked in the country: 1986 | msf.org/uganda ZAMBIA opened its programme in 2010. Residents donated medicines, medical equipment and had to travel long distances for appropriate an ambulance. More than 400 pregnant health services and there were reports of women referred from villages to health high maternal mortality because of the centres travelled by Zambulance, a covered poor availability of care. Although the trailer pulled by a bicycle – a viable means HIV rate among pregnant women was low of transportation in this setting. in the district, it was difficult for those with the disease to obtain antiretroviral The decision to close the programme was treatment because of a lack of resources based on the improvement of medical Regions where MSF has projects at the district hospital. processes and came after a gradual handover to the Zambian Ministry of Key medical figures: In close collaboration with Zambian health Health. Medical activities ended in June • 4,000 antenatal consultations authorities, MSF established comprehensive 2013, the project closed in mid-September • 770 births assisted • 380 postnatal consultations sexual and reproductive health services in and MSF withdrew from Zambia in October. the Luwingu district hospital and several rural health centres. These included In September, a three-year family planning, ante- and postnatal care, prevention of mother-to-child transmission project aimed at improving of HIV and assisted births. Emergency MSF access to reproductive health obstetric referrals were also made from / services in Luwingu district rural centres to the district hospital, and 56 women with obstetric fistulas were came to an end. identified and referred to Chilonga district hospital for surgery.

Luwingu, a remote and rural area, was © Sophia Apostolia underserviced in terms of health facilities Over the course of the project, MSF Patients waiting at Luwingu district hospital. when Médecins Sans Frontières (MSF) first improved facilities, trained local staff and

No. staff end 2013: 42 | Year MSF first worked in the country: 1999 | msf.org/zambia

UZBEKISTAN | ZAMBIA 91 Médecins Sans Frontières ZIMBABWE

Key medical figures: • 64,500 patients on first-line ARV treatment • 3,200 patients under treatment for TB, of which 63 for MDR-TB

Although Zimbabwe has made significant progress, gaps in treatment for HIV/ AIDS and tuberculosis (TB), including drug-resistant TB (DR-TB), remain. The needs of children and teenagers are

particularly overlooked. Regions where MSF has projects Cities, towns or villages where MSF works Treatment for HIV is reportedly widely available but there are still areas where coverage is extremely low. The main barriers include a lack of human resources, The Gokwe North project made progress TB training was provided for 16 nurses treatment fees, clinic hours and the long with its approach in 2013, increasing from Harare, thereby preparing for distances people must travel to reach decentralisation of services through training nurse-led treatment to be implemented facilities. Patients with multidrug-resistant and mentorship. Treatment for HIV and TB in these facilities. The HIV and TB TB (MDR-TB), where standard first-line and for victims of sexual violence is being programme in Epworth was integrated drugs have failed, lack access to the best integrated into two rural hospitals and into the Epworth polyclinic at the end of available treatment. Integration of TB and 16 rural health centres. Eleven facilities the year, with clinical responsibilities HIV care, ensuring treatment is available currently provide care for people with handed over to ministry of health staff. at a more local level, and moving tasks HIV, and four are treatment initiation The Tsholotsho project is also in the process over from doctors to nurses are all key sites. The Gutu/Chikomba programme has of being handed over, having achieved 98.7 strategies being undertaken by Médecins decentralised care to 28 facilities in Gutu per cent coverage of all people in need of HIV Sans Frontières (MSF) in collaboration with and 31 in Chikomba. Support groups have treatment in the district. Provision of ARVs, the Ministry of Health. This streamlining also been established. treatment of opportunistic infections and enables more people to obtain the medical MSF pushed for seven health facilities within prevention of mother-to-child transmission care they require. high-density suburbs in Harare, including the (PMTCT) of HIV continued at Nyamandhlovu MSF supported HIV and TB projects Caledonia Farm clinic, to be accredited as hospital as part of the decentralisation of ARV treatment and follow-up sites. HIV and the project. The standard implementation of throughout the country in 2013: in Harare (Epworth and Caledonia Farm), Gokwe North, Tsholotsho, Beitbridge, Buhera, Gutu and Chikomba. A new project also opened in Nyanga district, after an assessment revealed that only five per cent of people were getting the antiretroviral (ARV) treatment they needed for HIV.

The emphasis in Nyanga is on paediatric ARV care. The strategy used aims to increase patient access to treatment by providing quality HIV and TB care using existing healthcare facilities and human resources. Services in Nyanga are being integrated into the district hospital and nine health clinics, with nurses undergoing training to initiate treatment. MSF supports the health team with the organisation of services, patient records and patient flow, so facilities can manage the additional workload. Community ARV treatment refill groups and

the provision of a three-month drug supply © Julie Remy for healthy patients reduce the number of A 14-year-old patient being shown his x-ray. visits to busy clinics.

92 ZIMBABWE No. staff end 2013: 604 |Y 2013: 604 end staff No. it and Gutu, and Buhera in used being already –was patients HIV monitoring for standard gold –the monitoring (VL) load viral yearly Routine Zimbabwe. in care patient HIV improve will that technology modern implement to striving is MSF Implementing newer technology year. the of course the over sessions counselling for 16,300 people saw specialists health Mental DR-TB. for these of five treatment, TB started 853 patients 2013, In treatment. ARV started patients 7,590 project, the of course the Over area. the in patients HIV of healthcare future the for concerned remains but treatment, their of interruption postpone to patients for buffer drug athree-month arranged MSF leaving, Before activities. continue to team the allow to not decided authorities the after Africa, South with border the on Beitbridge, in project the close abruptly to forced was MSF December, of end the At Zimbabwe. in generation HIV-free an achieving in strategy akey is PMTCT An MSFTBnurse injectinganMDR-TBpatientin their home. ear MSF first worked in the country: 2000 | msf.org/zimbabwe | 2000 country: the in worked first MSF ear to inmates in 10 prisons, including Harare Harare including 10 in prisons, inmates to support psychiatric provide to continued professionals health mental MSF of A team care psychiatric Prison Africa. South in alaboratory to sent being of instead country the in with dealt be to more for way the paving processed, were September and December 11,500 samples Between country. the throughout analysis VL provide to aims ministry, health the and NMRL with collaboration close in run and UNITAID by funded project, This hospital. Harare in (NMRL) Laboratory Reference Microbiology National the at platform NUCLISENSE the May,In installed MSF healthmost facilities. MSF-supported in MDR-TB and TB for diagnosis of speed the improve to introduced was (GeneXpert) technology diagnostic New results. VL send to sites potential as included were these and hospital, and Parirenyatwa Chitungwiza), (Harare Harare in hospitals three at trained were technicians and scientists Laboratory Chikomba. in January in introduced was Internati onal A accommodate growing the programme. to construction under is building A new follow-up. for 920 people than more saw 2013 in centre team the to the and came patients 1,220 of new Atotal care. medical immediate of seeking importance the and community, the in violence sexual of awareness raise to conducted were activities promotion Health Harare. in Mbare of suburb high-density the in violence sexual of victims for provided were support legal and psychosocial psychological, for referrals and counselling care, medical Free violence sexual of victims for Care sessions. inpatients individual and group counselling 1,880 treated team The available. also was therapy Occupational wing. psychiatric a in care receive inmates female 30 and male 250 where prison, security maximum iv ct i ty R ty eport 2013 Z IMBAB

W © Julie Remy E 93 Médecins Sans Frontières YEMEN

Amran

hajjah Sana’a

Ad-Dali Abyan Lahj ADEN

Regions where MSF has projects Cities, towns or villages where MSF works

Key medical figures: Yemen • 102,600 outpatient consultations • 4,100 surgical interventions • 3,400 births assisted MSF / There was a significant deterioration in living

conditions in parts of Yemen in © Anna Surinyach 2013, and insecurity towards An MSF staff member talking to migrants living in the Sana’a detention centre. the end of the year affected availability and accessibility at MSF’s emergency surgical unit, which a stabilisation centre for managing large treated victims of violence from Aden as well influxes of wounded people, providing of healthcare. as the nearby governorates of Lahj, Abyan, emergency care and a referral system. Shabwah and Ad-Dali. A weekly clinic was Insecurity affected programmes supported run for inmates at Aden central prison, and To assist the communities in remote areas by Médecins Sans Frontières (MSF), further Yemen 80 patients were seen each month. with very limited access to healthcare, teams cutting people off from healthcare, and ran mobile clinics in the Osman and Akhraf activities had to be suspended twice in Staff support and supplies were provided valleys, carrying out 5,350 consultations and Amran and once in Aden. to hospitals in Lawdar and Jaar in Abyan treating 427 patients for malaria. governorate. Teams also trained emergency Over 150 Yemeni patients were sent from room staff and sterilisation technicians. Caring for migrants in Sana’a Yemen to MSF’s reconstructive surgery MSF began providing HIV care to people in programme in Amman, Jordan, which Amran governorate Sana’a in 2013. A mental health programme provides orthopaedic, maxillofacial and Access to healthcare decreases progressively for migrants in detention also started in April. reconstructive plastic surgery (for more in the rural areas of Amran governate details, see the Jordan country report, p.56). and ceases to exist for communities in Programme handovers the valleys. At Al-Salam hospital, Khamir, In February, MSF handed over activities Ad-Dali MSF is involved in the emergency, at the Radfan hospital, Lahj governorate, MSF continued to work in Ad-Dali surgery, maternity, paediatric, inpatient to the Ministry of Health. A programme governorate, but problems with security and intensive care departments, and offering healthcare at Haradh, Hajjah caused significant disruptions to the collaborates closely with the Ministry of governorate was closed in August. provision of healthcare there at the end of Health to improve medical services. Support the year. Food shortages and maternal and is also provided for the blood bank and child health are of great concern in the area. laboratory. There was a dramatic rise in surgery patients towards the end of the year Teams worked with local communities, Mohamed after violence intensified in the governorate. both rural and urban, providing care for Shabwah More than 1,940 surgical procedures victims of violence and trauma. Emergency were performed, and 4,080 people were My nephew was shot during gunfire services, including surgery, were available at admitted to hospital. Teams carried out in Shabwah. There was no hospital … the Al Naser general hospital, Ad-Dali city, 21,980 emergency consultations. nothing in the area. The only place we and patients received basic healthcare and could bring him was here [MSF hospital lifesaving surgery in Al Azaraq and Qataba’a MSF resumed its support of the Huth in Aden]. We sincerely thank MSF for the districts. More than 41,704 consultations health centre in March, after six months’ unconditional medical care they offered were carried out. suspension for security reasons. A team to him and to everybody in this hospital. provided emergency, maternity and Aden and the south inpatient care. In September, Huth became In Aden, more than 2,500 surgeries were performed and 860 patients received post-surgery follow-up and physiotherapy No. staff end 2013: 459 | Year MSF first worked in the country: 1994 | msf.org/yemen

94 yemen special reports 2013 Hear my voice: Somalis on living in a humanitarian crisis

FEBRUARY

Misery beyond the war zone: Life for Syrian refugees and displaced Violence, vulnerability populations in Lebanon and migration: Trapped at the gates of Europe

MARCH

Syria two years on: the failure of international aid so far Stranded in the Desert

Untangling the Web APRIL of Antiretroviral Price Reductions: 16th Edition Healing Iraqis: The challenges of providing mental health care in Iraq Putting HIV Treatment to the Test

JULY The illness of migration

DR-TB Drugs Under the Microscope:3rd Edition Central African Republic: OCTOBER abandoned to its fate?

Hepatitis C: The Hidden Epidemic

NOVEMBER

Improving paediatric TB care in Tajikistan HIV status? Undetectable

DECEMBER

How low can we go? All these reports are available at www.msf.org/reports

special reports 2013 95 Médecins Sans Frontières Facts and Figures Médecins Sans Frontières relief supplies, epidemiological and jointly audited by the accounting firms medical research, and research on of KPMG and Ernst & Young, in accordance (MSF) is an international, humanitarian and social action. These with International Auditing Standards. independent, private and satellites, considered as related parties to A copy of the full 2013 Financial Report non-profit organisation. the national offices, include: MSF-Supply, may be obtained at www.msf.org. MSF-Logistique, Epicentre, Fondation MSF, In addition, each national office of MSF Etat d’Urgence Production, MSF Assistance, publishes annual, audited Financial It is made up of 23 associations (2013): SCI MSF, SCI Sabin, Ärzte Ohne Grenzen Statements according to its national Australia, Austria, Belgium, Brazil, Foundation and MSF Enterprises Limited. accounting policies, legislation and Canada, Denmark, East Africa, France, As these organisations are controlled by auditing rules. Copies of these reports Germany, Greece, Holland, Hong Kong, MSF, they are included in the scope of may be requested from the national offices. Italy, Japan, Latin America, Luxembourg, the MSF Financial Report and the figures Norway, Southern Africa, Spain, Sweden, presented here. The figures presented here are for the 2013 Switzerland, UK and the USA. MSF’s calendar year. All amounts are presented in day-to-day activities are managed by 19 These figures describe MSF’s finances on millions of euros. national offices and nine branch offices a combined international level. The 2013 Note: Figures in these tables are rounded, (see page 100 for contact details). combined international figures have been prepared in accordance with MSF which may result in apparent inconsistencies in totals. The search for efficiency has led MSF international accounting standards, which to create 10 specialised organisations, comply with most of the requirements called ‘satellites’, which take charge of of the International Financial Reporting specific activities such as humanitarian Standards (IFRS). The figures have been

Where did the money go?

Programme expenses by nature Programme expenses by continent

Locally hired staff 33 % The biggest category of expenses Africa 62 % International staff 23 % is dedicated to staff working in the Asia 28 % Medical and nutrition 18 % field: about 56 per cent of expenditure Americas 7 % Transport, freight and storage 12 % comprises all costs related to Europe 2 % Logistics and sanitation 6 % locally hired and international staff Oceania 1 % Operational running expenses 5 % (including plane tickets, insurance, Unallocated 1 % Consultants and field support 2 % accommodation, etc). Training and local support 1 % The medical and nutrition category includes drugs and medical equipment, vaccines, hospitalisation fees and therapeutic food. The delivery of these supplies is included in the category of transport, freight and storage.

Logistics and sanitation comprise building materials and equipment for health centres, water and sanitation and logistical supplies.

96 Facts and Figures International Activity Report 2013

Countries where we spent the most

Countries where MSF expenditure is more than 10 million euros 80

60

40

in millions of euros 20

0 n i a c a n a r n a n raq DRC Hait Syri Niger I eny Mali me Chad Suda K Ye Somali yanma Pakista Ethiopia Nigeri Zimbabwe M Philippines South Suda Afghanistan

entral African Republi C 2013 2012 2011

80 AFRICA in millions of E ASIA AND THE AMERICAS in millions of E 70 Democratic Republic of Congo 78.3 THE MIDDLE EAST in millions of E Haiti 33.3 60 South Sudan 51.1 Syria 29.5 Colombia 5.5 50 Central African Republic 26.0 Iraq 20.4 Mexico 2.0 40 Niger 24.4 Afghanistan 18.7 Paraguay 1.6 Somalia30 21.2 Myanmar 16.4 Honduras 1.4 Chad20 20.0 Philippines 15.8 Other countries * 0.2 Zimbabwe10 19.9 Pakistan 14.2 Sudan0 17.1 Yemen 10.5 Total 44.1 Kenya 16.9 India 9.1 Ethiopia 12.0 Lebanon 6.3 EUROPE in millions of E Mali 10.6 Uzbekistan 6.3 Russian Federation 4.8 Nigeria 10.5 Palestine 3.5 Ukraine 3.3 Swaziland 9.9 Bangladesh 3.2 Other countries * 1.6 Malawi 8.5 Kyrgyzstan 3.0 Mozambique 7.8 Jordan 2.8 Total 9.8 South Africa 7.3 Cambodia 2.5 Sierra Leone 6.6 Turkey 2.3

Guinea 5.8 Armenia 2.2 OCEANIA in millions of E Uganda 5.0 Tajikistan 1.7 Papua New Guinea 4.4 Mauritania 4.1 Laos 1.0 Burundi 3.7 Iran 1.0 Total 4.4 Cameroon 2.0 Other countries * 1.8 Egypt 2.0 E Madagascar 1.5 Total 172.4 UNALLOCATED in millions of Libya 1.5 Other 3.2 Congo 1.4 Transversal activities 3.1 Côte d’Ivoire 1.2 Zambia 1.0 Total 6.3 Other countries * 1.8

Total 379.1 * ‘Other countries’ combines all the countries for which programme expenses were below one million euros.

Facts and Figures 97 Médecins Sans Frontières

WHERE DID THE MONEY COME FROM? 2013 2012 in millions of e percentage in millions of e percentage Private 899.7 89% 838.9 89% Public institutional 93.0 9% 82.7 9% Other 15.9 2% 16.1 2%

Income 1,008.5 100% 937.7 100%

HOW WAS THE MONEY SPENT? 2013 2012 Private income 89 % in millions of e percentage in millions of e percentage Public institutional income 9 % Programmes 615.4 65% 619.4 66% Other income 2 % Headquarters programme support 108.8 11% 103.9 11% Témoignage/awareness-raising 30.2 3% 31.7 3% Other humanitarian activities 9.3 1% 7.4 1%

Social mission 763.7 80% 762.4 81%

Fundraising 131.6 14% 124.8 13% Management and general administration 57.1 6% 56.6 6% Income tax 0 – 0.1 – 5 Other expenses 188.8 20% 181.5 19% million Expenditure 952.5 100% 943.9 100% private donors Net exchange gains/losses -7.9 -4.8 Surplus/deficit 48.1 -11.1

YEAR-END FINANCIAL POSITION 2013 2012 in millions of e percentage in millions of e percentage Cash and cash equivalents 616.3 81% 551.4 79% Other current assets 87.3 11% 91.1 13% Non-current assets 61.7 8% 57.4 8%

Assets 765.3 100% 699.9 100%

Permanently restricted funds 3.1 0% 3.4 – Unrestricted funds 627.7 83% 580.2 83% Other retained earnings and equities 3.4 0% 15.0 2%

Retained earnings and equities 634.2 83% 598.6 85% Income 1008.5 Expenditure 952.5 Current liabilities 131.1 17% 101.3 15% Surplus 48.1

Liabilities and retained earnings 765.3 100% 699.9 100%

98 Facts and Figures International Activity Report 2013

HR STATISTICS 2013 2012

Medical pool 1,593 26% 1,548 26% Nurses and other paramedical pool 1,892 30% 1,785 30% Non-medical pool 2,714 44% 2,622 44%

International departures (full year) 6,199 100% 5,955 100%

no. staff percentage no. staff percentage Locally hired staff 29,910 85% 29,228 86% International staff 2,629 8% 2,592 7%

Field positions 32,539 93% 31,820 93% Locally hired staff 85% International staff 8% Positions at headquarters 2,493 7% 2,326 7% Headquarters staff 7%

Staff 35,032 100% 34,146 100%

The majority of MSF staff (85 per cent) are hired locally in the countries of intervention. Headquarters staff represent 7 per cent of total staff.

Sources of income Permanently restricted funds may be capital funds, where donors As part of MSF’s effort to guarantee its independence and require the assets to be invested; funds retained for actual use, strengthen the organisation’s link with society, we strive to maintain rather than expended; or the minimum level of retained earnings a high level of private income. In 2013, 89 per cent of MSF’s income that is compulsory for certain sections of MSF. came from private sources. More than 5 million individual donors Unrestricted funds are unspent, non-designated donor funds and private foundations worldwide made this possible. Public expendable at the discretion of MSF’s trustees in furtherance of our institutional agencies providing funding to MSF included, among social mission. others, the European Commission’s Humanitarian Aid Department (ECHO) and the governments of Belgium, Canada, Denmark, France, Other retained earnings represent foundations’ capital as well as Germany, Italy, Ireland, Luxembourg, Norway, Spain, Sweden, technical accounts related to the combination process. Switzerland and the UK. MSF’s retained earnings have been built up over the years by Expenditure is allocated according to the main activities performed surpluses of income over expenses. At the end of 2013, the available by MSF. All programme expenditure categories include salaries, portion (excluding permanently restricted funds and capital for direct costs and allocated overheads. foundations) represented 7.9 months of the preceding year’s activity. The purpose of maintaining retained earnings is to meet Social mission includes all costs related to operations in the field the following needs: future major emergencies for which sufficient (direct costs) as well as all the medical and operational support from funding cannot be obtained, a sudden drop in private and/or public the headquarters directly allocated to the field (indirect costs). Social institutional funding, the sustainability of long-term programmes mission costs represent 80 per cent of the total costs for 2013. (e.g. antiretroviral treatment programmes), and the pre-financing of operations to be funded by forthcoming public fundraising campaigns and/or public institutional funding.

The complete Financial Report is available at www.msf.org

Facts and Figures 99 Médecins Sans Frontières Contact MSF International Médecins Sans Frontières Greece Médecins Sans Frontières / UK Médecins Sans Frontières / 78 rue de Lausanne Case Postale 116 Doctors Without Borders 1211 Geneva 21 Switzerland 15 Xenias St. 115 27 Athens Greece 67–74 Saffron Hill London EC1N 8QX UK T +41 22 849 84 84 F +41 22 849 84 04 T + 30 210 5 200 500 F + 30 210 5 200 503 T +44 20 7404 6600 F +44 20 7404 4466 www.msf.org [email protected] www.msf.gr [email protected] www.msf.org.uk

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100 Contact MSF About this report

Contributors Corinne Baker, Igor G. Barbero, Aurélie Baumel, Niklas Bergstrand, Pierre Borelle, Talia Bouchouareb, Andrea Bussotti, Brigitte Breuillac, Amandine Colin, Lali Cambra, Giorgio Contessi, Stefan Dold, Silvia Fernández, Isabelle Ferry, Sarah-Eve Hammond, Solenn Honorine, Karem Issa, Nicole Johnston, Joanna Keenan, Aurélie Lachant, Sophie-Jane Madden, Samantha Maurin, Sally McMillan, Robin Meldrum, Isabelle Merny, Agustin Morales, Rebecca Murray, Heather Pagano, Nondas Paschos, Catrin Schulte-Hillen, Faith Schwieker-Miyandazi, François Servranckx, Sandra Smiley, Shumpei Tachi, Clara Tarrero, Fiona Terry, Frank Theunissen, Ann-Marie Wilcock, Pascale Zintzen.

Special thanks to Valérie Babize, Kate de Rivero, François Dumont, Marc Gastellu Etchegorry, Silvia Fernandez, Nicole Johnston, Erwin van ’t Land, Caroline Livio, Jérôme Oberreit, Emmanuel Tronc.

We would also like to thank all the field, operations and communications staff who provided and reviewed material for this report.

English Edition Managing Editor Sara Chare and Linda Nagy Editor and Writer Caroline Veldhuis Editorial Support Robert Bartram Photo Editor Bruno De Cock Copyeditor Kristina Blagojevitch

French Edition Editor Laure Bonnevie, Histoire de mots Translator Translate 4 U sarl (Aliette Chaput, Emmanuel Pons)

Spanish Edition Coordinator Silvia Fernández Translator Pilar Petit Editor Cecilia Furió

Arabic Edition Coordinator Jessica Moussan-Zaki Translator Bruno Barmaki Editor Jessica Moussan-Zaki

Designed and produced by ACW, London, UK www.acw.uk.com Afghanistan • Armenia • Bangladesh • Bolivia • Bulgaria • Burkina Faso • Burundi • Cambodia • Cameroon • Central African Republic • Chad • China • Colombia • Congo • Côte d’Ivoire • Democratic People’s Republic of Korea • Democratic Republic of Congo • Egypt • Ethiopia • France • Georgia • Greece • Guinea • Haiti • Honduras • India • Iran • Iraq • Italy • Jordan • Kenya • Kyrgyzstan • LAOS • Lebanon • Lesotho • Libya • Madagascar • Malawi • Mali • Mauritania • Mexico • Morocco • Mozambique • Myanmar • Niger • Nigeria • Palestine • Pakistan • Papua New Guinea • Paraguay • Philippines • Russian Federation • Sierra Leone • Somalia • South Africa • South Sudan • Sudan • Swaziland • Syria • Tajikistan • Turkey • Uganda • Ukraine • Uzbekistan • Yemen • Zambia • Zimbabwe

Médecins Sans Frontières (MSF) is an international, independent, medical humanitarian organisation that delivers emergency aid to people affected by armed conflict, epidemics, exclusion from healthcare and natural disasters. MSF offers assistance to people based on need and irrespective of race, religion, gender or political affiliation.

MSF is a non-profit organisation. It was founded in Paris, France in 1971. Today, MSF is a worldwide movement of 23 associations. Thousands of health professionals, logistical and administrative staff manage projects in 67 countries worldwide. MSF International is based in Geneva, Switzerland.

MSF International 78 rue de Lausanne, CP 116, CH-1211, Geneva 21, Switzerland Tel: +41 (0)22 849 8400, Fax: +41 (0)22 849 8404

COVER PHOTO Critically ill child being cared for by MSF at M’poko camp, Bangui airport. © Pierre Terdjman / Cosmos