> N° 143 / November 2006 / Médecins Sans Frontières internal newsletter www.msf.fr DOSSIER PANDEMIC DESPERATELY SEEKING SOLUTIONS - Inventing as we go along P2 - The Ugandan model: reportage P4 - Arua Meeting: discussions between AIDS 3 heads of mission P6 - Prevention of mother-to-child transmission P10 Pandemic - Interview with Professor Win Van Damme of the Institute desperately of Tropical Medicine P12 - MSF treatment of Aids patients seeking > Map P14

MISSIONS solutions - Sri Lanka: MSF withdraws from the Jaffna Peninsula P16 - Southern Sudan: what role is there for NGOs in a region undergoing reconstruction ? P18

DEBATES © Julie Rémy - May 2006 - Darfur :

Humanitarian aid held > Malawi hostage P20 - Somalia : Should MSF open a programme ? P22

INFOS - Watch and read - Seventh volume of the “MSF Speaking out” collection P24 AIDS

DOSSIER Inventing as we Pandemic desperately MSF/November 2006/Translated by Alison Quayle seeking solutions “To treat as many of the AIDS patients who come to us as we possibly can.” This is the objective of our HIV/AIDS programmes, especially in Africa. We must now turn our efforts towards covering the needs as widely as possible. It is a very unusual concept for Médecins Sans Frontières to say, and above all a radical step forward, five years on from the start of our first AIDS programmes. Number 143 WE CAN ALWAYS DO BETTER In late 2000 and early 2001, MSF’s For MSF, two years on from the first trouble getting enough funding to objective was to start treating AIDS patients, the objective was no longer match the needs, and national Although we procrastinated at length patients with antiretroviral (ARV) starting individual treatment, but programmes were taking a long time before starting, MSF is among the therapy, and to show that it was moving on to “scaling up”, increasing to set up, or were even non-existant. ‘pioneers’ treating Aids in developing perfectly possible to treat poor the number of patients on ARV “The World Health Organisation’s countries. Thanks to its experience patients in developing countries. At therapy. This meant identifying all the “3 x 5” initiative launched in December MSF, alongside other organisations, the time, patent-protected triple bottlenecks that were preventing us 2003 – 3 million patients under helped initiate a response to the therapies cost over 10,000 dollars per from making the move to treating treatment by 2005 – certainly gave it a pandemic and compelled others to person per year. And there were many larger cohorts. It led to a simplifica- boost by mobilising the various become actively involved in the fights sceptics – major sponsors in particu- tion of treatment: initiating therapy players” says Annick Hamel from the against Aids. MSF is now innovating lar – who believed that it was impossi- without a CD4 count1, longer periods Operations Department. Even if the an approach to try and treat as many ble, and even pointless. Then the between patient visits, new allocation WHO “3 x 5” was widely disparaged, patients as possible. Our teams are context changed. The Global Fund to of tasks, with a start on training and not only by MSF (see the Win Van already helping 60,000 patients to Fight AIDS, Tuberculosis and Malaria nurses to take responsibility for some Damme interview on p. X), there were survive. was set up in June 2001. With generic patients. more and more initiatives being set up versions coming onto the market, in in the field, and national programmes Ok, but what next? ‘No hailing of 2001 triple therapy was available for In parallel, the “global response” to are gradually starting up. victory” is the message in this less than 350 dollars per patient per the pandemic was making slow dossier. Above all we must not fall year. progress: the Global Fund was having “Decentralisation of care is now into the trap for which we criticised under way in a great many countries, the WHO concerning tuberculosis: in the sense of increasing the number soothing self-satisfaction in order to EPIDEMIOLOGICAL RESEARCH of places where treatment is conceal our failures and difficulties. available, to get closer to the patients Our programmes have their failures, TRANSLATED BY AARON BULL and offer therapy to everyone who and they are considerable: treatment needs it. It’s the only way to cope with We are conducting a series of cross-sectional surveys to determine the is given priority over prevention, the high demand, especially in high- efficacy of treatment for patients being treated by MSF. MSF has a especially in mother-to-child trans- prevalence countries”, Annick Hamel responsibility to be credible, demonstrating that its treatment strategy is mission, the ever neglected element effective. explains. The question is therefore: of our Aids programmes. The how should it be done? In MSF treatment of TB/HIV co-infected Our work involves taking a blood sample of patients who have been programmes, implementing decen- patients is the next challenge for receiving antiretroviral treatment for 12, 24, 36, or even 48 months. If the tralisation also depends on the MSF. A complex challenge that will viral load is detectable, we study the genotype of the virus in order to political will shown by the countries call us to rack our brains. determine the most frequent viral mutations. At the same time, we try to and the constraints they have to face. measure how consistently patients have been following the treatment and “Some countries, such as Uganda, It is because we have made progress assess the side effects they have experienced. We also try to identify have set up a decentralisation policy clinical signs of treatment failure by comparing viral load values with that our weak points and where we that is mainly aimed at meeting target possible clinical signs that may appear during treatment. need to better ourselves are all the figures. Here it is harder for MSF to more visible. That’s all par for the get involved in the process because it This will allow us to make more accurate assessments of our programs, course. MSF can only be considered a i.e. to measure treatment failure rates, adherence problems and has to be done by improving the ‘pioneer’ if it continues to break new treatment toxicity. For patients experiencing treatment failure, analysis of existing system. In Malawi, where ground and improve treatment for the genotype allows us to determine the most suitable second-line there is a willingness at national level, patients. MSF must not be a hero combination. The first studies on adults show immuno-virological results the government is encouraging MSF clinging to past success, but a that are comparable to those in economically developed countries, taking to implement the decentralisation so clinician in the field continually into account the patients’ health condition when MSF began administering they can learn from our experience.” inventing new approaches. their treatment. But in practical terms, the dynamic is Dr Mar Pujades, epidemiologist, Epicentre. the same as for “scaling up”. “It’s only Interview by Olivier Falhun the scale that changes. And one of the

P2 messages MSF N°143 November 2006 go along

> Nigeria © Ton Koene - July 2006

main issues is the lack of medical reliable supply of drugs, and so on. able to transfer our activities to experience of the first few years. Even personnel. But it’s possible to care for While quality of care is of vital impor- national programmes that are if some teams still feel that treating more patients by asking for help from tance, it is not incompatible with capable of offering good-quality care Aids is complicated, treating a few other patients or people in the quantitative objectives. for stabilised patients, we hope MSF patients as part of their programme is community, to look after the patients will be further ahead: for instance in no longer anything out of the ordinary. close to their home.” Hence the And what about tomorrow? What is treating children, or complicated What is extraordinary is having to experiments in Malawi, for instance, the future for MSF programmes once medical cases in outlying health ‘make it up as we go along’. There is or in Kenya (see also p. 4). all the requirements for treatment at centres. no care model for large cohorts of patients. There has never been a Nevertheless, not everyone wants to There remains the question of chronic disease quite like this, so treat all patients and provide every- treating patients outside the vertical there is no referring back to earlier thing needed to ensure they survive. There has never been a chronic HIV/AIDS programmes. Although MSF practice. We have to invent it, country “We must keep repeating that disease quite like this, so there says it wants to treat HIV/AIDS by country, to suit their specific requi- everyone must be treated. And at the is no referring back to earlier patients within other programmes rements and constraints, so we can same time, it’s important not to forget practice. We have to invent it, where possible, this is still not treat all the patients who come country by country... that treating an AIDS patient is not happening everywhere. At the knocking on our door”. ■ just a matter of making drugs moment it is done in Liberia, Sudan, available”. It also involves making a the Democratic Republic of Congo, Caroline Livio diagnosis, being able to treat opportu- Thailand, Georgia and Ivory Coast. But nistic infections, detecting and population level are covered? “It will as Annick Hamel points out, “treating dealing with treatment failure, never be MSF’s job to treat all a AIDS patients is not that complicated. 1- the CD4 or T-lymphocyte count adapting therapy if there are side country’s patients”, Annick Hamel There are guidelines2 available now, indicates the level of immunosuppression. effects, working on compliance, insists. MSF has a clear lead over which the teams have found very 2- ARVs for dummies, available on MSF having enough trained staff, having a national programmes. Once we are helpful. We have learnt from the medical service.

P3 messages MSF N°143 November 2006 DOSSIER Pandemic desperately seeking solutions

> A showcase which suits everyone

In the fight against Aids, Uganda has often been presented as a model, not without an ideological ulterior motive. The national prevalence has been reduced from 28% in 1988 to 6.4% in 2005, even if large regional disparities still persist. This success has been attributed by some to abstinence and fidelity, whereas the credit should rather go to increased > Uganda © Jean-Marc Giboux - July 2006 use of condoms and the death of a large number of patients. The moralistic approach THE UGANDAN MODEL to prevention has concrete repercussions. Last year there A reality check was a period when Uganda ran out of condoms. And between Translated by Penny Hewson 2003 and 2005 the prevalence of AIDS in the country went Often quoted as an example, Uganda is showing a declining prevalence and more than back up from 5.6% to 6.4%. 80 000 patients on treatment. This outward appearance masks a more complex reality. The other trump card which The hospitals and health centres are short of staff, financial means and materials. Never- Uganda has in terms of image theless, MSF is treating 2 700 patients in Arua and supports the decentralization of HIV is to have exceeded the objec- care by the State in the West Nile region. Report. tives assigned by the WHO’s "3 by 5" plan, which was a point of optimism in the It is 5pm in the HIV clinic of Arua In 2002, MSF started treating aids time. On her desk, between the school overall results of failure. hospital in the north west of Uganda. patients here. “We are have 4 603 HIV exercise books which are used for There are now over 80 000 Patients have been there since early positive patients on our registers, of health records, sits a yellow flag with patients on treatment, and this morning; and the public is a bit whom 2 704 have begun triple the MSF logo where you can read “2 the rhythm of inclusion is tired. But when Helen begins to therapy,” explains William pills a day, treat HIV/AIDS now!” accelerating with more than harangue those present in Lugbara Hennequin, field coordinator in Arua. Sometimes patients turn up who do 200 district hospitals and interspersed with English words, she This Tuesday, more than 150 patients not have appointments but whose achieves the feat of making laugh have appointments. They come to health has suddenly got worse. Such health centres giving out ARVs. everyone by deploying her acting collect their medication for the month as this man, being treated since There are doubts however talents. “The main thing, insists Helen or months to come, and for a medical October 2004, who is continually about the quality of care who has herself been undergoing consultation. They can also discuss convulsing and will die two hours dispensed. treatment for two years, is to leave with a counsellor any difficulties they later. A sad reminder that AIDS still with your medication. Interrupting may have in taking their treatment kills. your treatment is just too dangerous. regularly and see how they can Since the launch of the project, 244 Do not let yourself be discouraged by remedy it. A young woman on patients have died (i.e. 7% of the the wait." reception calls 4 or 5 patients at a patients having started treatment has

P4 messages MSF N°143 November 2006 sick people who need ARV ARVs – and counselling was kept to a treatment," notes William. Working minimum. The overburdened medical better with the paediatric service staff give reminders about the impor- would allow us to increase the tance of taking the treatment properly number of children treated with ARVs but have scarcely the time to give which is still too small (only 3%). more advice. “To reinforce the MSF tries to reinforce the different counselling, patient associations is a wards with MSF stuff, but without new route,” considers Patrick succes. “We would prefer the Anguzu, the Director of Health for the medical staff at the hospital to come Arua district. to the MSF clinic for training in the care of opportunistic infections, Another difficulty is supplying the explains William. But we are having health centres with medication. “In difficulty in setting it up." the West Nile region, there have been incomplete courses of treatment > For lack of treatment For it would first be necessary to delivered and supply shortages, and available in their reorganize the MSF clinic to reduce this is very dangerous for patients, area, 600 Congolese the work load and be in a position to says William. To limit the damage, we come to Arua. take in more patients. At the moment, have given several loans or one-off about 3 600 patients come every Marie-Jeanne’s t-shirt reads month for their follow-up appoint- “Sida nous te vaincrons” ment. “We are beginning to space out Caring for AIDS patients well (“Aids, we will beat you,”). the appointments of stable patients involves giving them antiretrovi- To come to her follow-up every 2 or 3 months, and we are rals, making sure of their appointment in Arua, for this hoping that they will be followed up by compliance – regularly taking the Congolese woman it took first the nursing staff to ease the burden prescribed medication – but also of all a day to get from her on the clinicians, explains William. timely diagnosis and treatment village to Aru, the border town. That will also allow us to devote more of any opportunistic infections. Then, this morning, she time to complicated cases." pedalled for 3 hours to get to the clinic. “Of course, I would For a long time, Arua hospital was the like health centres near my only facility in the West Nile region donations thanks to our emergency home to give free ARVs, she offering free antiretroviral treatment. stocks.” At national level, following said, but that isn’t happening well as, doubtless, some of the 426 Patients flooded in from all over the management errors, the central for the moment,” patients lost to follow up (12%). region and even beyond, since more purchasing agency National Medical The Ugandan government agreed to accept a few years Caring for AIDS patients well involves than 600 patients live in DRC and Store (NMS) was in September ago that Congolese patients giving them antiretrovirals, making some of them have more than a day’s relieved of supplying ARVs to the could be treated in Arua, but sure of their compliance – regularly journey every month to come and get benefit of the World Health Organiza- on the condition that, taking the prescribed medication – their medication. But things have tion’s office in Kampala. It remains to beginning in 2006, they would but also timely diagnosis and begun to change. The process of be hoped that the ordering system be referred to facilities set up treatment of any opportunistic infec- decentralization of HIV care launched which is finally starting to work in the in their own country. tions. The work carried out to improve by the government goes as far as the health centres will not be changed The process however has not follow-up compliance is beginning to West Nile where ten or so public completely. started yet. And the team at bear fruit. The proportion of patients facilities are putting patients on ARVs. Arua is trying to support the lost to follow up has fallen, as also has Indeed, the rhythm of patient Medication for opportunistic infec- setting up of treatments the death rate. The team has also inclusion is accelerating. But the tions poses another acute problem. in Aru, on the other side of the renovated the tuberculosis clinic and quality of care dispensed leaves a lot The health facilities purchase border, without yet sending has started providing integrated care to be desired. A visit to some ARV medication for opportunistic infec- patients there. to co-infected patients. On the other centres in the West Nile region is tions from the NMS. Not without hand, MSF no longer intervenes enough to see that the difficulties problems. “Deliveries are late and you directly in the other departments encountered in the MSF project in are lucky if you get 50% of what you whose functioning is burdened with Arua are there multiplied tenfold by ordered,” deplores a district doctor in many problems: the roof of the main lack of means. First of all, the lack of the West Nile region. At the end of building containing 80 beds which has staff limits the number of patients September it was supplies of Cotri- been threatening to cave in for four who can be treated. “We have only six moxazole which were beginning to years, the paediatric ward where the qualified staff for the whole hospital. run out. Cotrimoxazole is a the women are all piled together, minis- If the HIV clinic opened more than one preventive treatment which is given to terial credits which are a long time day a week, the other departments all HIV-positive patients followed up in coming… could not function,” states the public hospitals. In theory, the money Director of the Hospital of Nyapea. from the Global Fund should also be "We need to strengthen our links Because of this, the number of HIV- used for the purchase of medication with the other hospital departments, positive patients followed up in July for opportunistic diseases and make to improve the quality of care of the 2006 in the whole of the West Nile up for the deficiencies of the NMS, but patients in hospital and identify other peaked at 3 000 of whom 800 were on this funding is only just being set up. ••• P5 messages MSF N°143 November 2006 ••• But this is still not the case and there financed by PEPFAR (The Quality Ministry of Health who are putting is resistance on the part of the NMS Assurance Project) are working on patients on ARVs. “I shall go regularly which is afraid of losing part of its two different systems of data collec- to 4 centres to share with the care revenue with the reduction of its tion. staff my experience of the care of prerogatives. “We will have to make AIDS patients," explains Julien, a DOSSIER up for the lack of medication that is In Uganda, and perhaps even more so doctor. The support will also apply to essential to treat opportunistic infec- in the North and the rural areas, the the organization of the counselling for Pandemic desperately tions,” thinks William. quality of care for HIV-positive compliance and the administration of seeking solutions Furthermore, the ARV programmes patients must improve quickly before the pharmacy. A few months from do not include an evaluation or a they die of opportunistic infections now, the impact of this aid will be precise follow-up of the results which could be treated. Before incom- evaluated for the possible redirection obtained. There are said to be 80.000 plete or intermittent ARV treatments of our support to other facilities. “The patients on ARVs in the country, but it accelerate the appearance of resis- objective is that the quality of HIV care is impossible to know the exact tances, making it necessary to becomes good enough to transfer the number of patients who have died or prescribe second-line treatments patients being followed up in the MSF lost to follow up. Very few treatment which are more complex and more clinic to hospitals or health centres centres study the levels of viral load expensive. In the West Nile region, in nearer where they live," concludes or the resistances developed by their addition to prompt donations of William. ■ patients. The initiatives in this area medication to prevent stock are manifold and sometimes concur- shortages, the Arua team is thus rent. The WHO and the programme supporting the facilities of the Rémi Vallet

> Participants present ARUA MEETING at the meeting in Arua

Present at the meeting were Doing more, Renaud Leray, William Hennequin and Johnny without sacrificing quality Byarugaba, head of mission, field coordinator and assistant Translated by Nina Friedman medical coordinator, The first regional field meeting dedicated to AIDS took place on 27 – 29 September in respectively, in Uganda; Uganda. The heads of mission and coordinators for our three AIDS programs in sub- Christine Genevier, head Saharan Africa met in Arua for discussions; here we present the main points of these of mission, Isabelle Gerneron, discussions. field coordinator in Mathare, and Bintari Dwihardiani, medical coordinator, repre- At first glance, things seem to be off to the quality of care in national health ral neuropathies). And resistance to senting Kenya; Chantal Saint- a good start. The number of patients on care systems. treatment can develop after several Arnaud, head of mission, antiretrovirals (ARVs) continues to grow years, requiring a switch to second- and Sylvie Goossens, medical a bit faster, and the dropout rates Our projects’ goal is to continue line therapy. For now, only about a coordinator, from Malawi, observed in 2004 no longer apply. In improving treatment for our patients, hundred patients in our four sub- as well as Annick Hamel, MSF projects, the number of patients to keep them alive as long as possible. Saharan Africa projects are on second- wearing her two hats from under treatment—and still alive—has But also, if conditions are right, to the Operations department markedly increased: 2,704 patients in maximize the number of patients and the Essential Medicines Arua, Uganda; 5,293 in Malawi’s being treated. There is much to be Chiradzulu district; and 4,886 in our done. Our projects’ goal is to continue Campaign; the Epicentre team two projects in Homa Bay and Mathare, improving treatment for our in Kampala, represented patients, to keep them alive as Kenya. And the virologic results are > A DIFFERENT by Laurence Ahoua, long as possible. comparable to those obtained in the COMBINATION DRUG epidemiologist, and William developed world (see sidebar, page 2). THAN TRIOMUNE? Watembo, regional manager for AIDS projects. The discussions at the Arua meeting The first-line ARV for the vast majority line treatment. This number could go showed, however, that we can’t claim of our patients is Triomune, a generic up, though. More than ever, we need a victory yet. Presentation of the many drug that combines d4T, 3TC and more effective first-line drug—one that advances quickly gave way to concerns nevirapine in a single tablet. We aren’t is less toxic, and delays resistance for and questions. Questions about our questioning this choice—overall, the as long as possible. To improve the own work, first of all: how do we results are satisfactory. The tablet, quality of the ARVs we prescribe, AIDS improve patient follow-up and quality taken twice daily, makes it easier to program coordinators expect the of care, and how do we get the follow the treatment. Medical department, with help from resources needed to treat more In some patients, however, d4T causes the Essential Medicines campaign, to patients? Next came questions about loss of sensation in the limbs (periphe- be on the lookout for new drugs, so

P6 messages MSF N°143 November 2006 > Monitor patients closely to assess the quality of care

Monitoring & Evaluation— M&E to insiders—is of major concern to everyone. Detailed follow up of patient outcome (prescribed treatment, side effects, opportunistic infec- tions, etc.) is the only way to evaluate program quality. MSF

> Kenya © Andrew Njoroge - January 2003 uses cards, which are quick to fill out and easy to enter in the FUCHIA software. With the that our patients can benefit from the process of decentralization, most effective treatments. MULTI-DRUG RESISTANT TUBERCULOSIS: this system—very thorough, THE NEXT BIG THREAT > STEP UP TB DETECTION but cumbersome to manage with increasing numbers of Two confirmed cases in Arua, three in Homa Bay (two of whom died before Better management of opportunistic the results came back), six in Mathare. The appearance of patients coinfec- patients to follow—cannot be infections remains a priority for us. ted with the AIDS virus and the multi-drug resistant form of TB is worrying maintained. Should we create Operational research projects on teams in the field. “It’s the next big threat,” says Annick. “MSF can’t fight it a light version of FUCHIA, or Kaposi’s sarcoma and cryptococcosis alone, we have to push for a stronger international response.” In the think about a new tool…or rely are now underway. On the other hand, meantime we have to try to treat our patients. on the monitoring systems our programs for TB—the most In Mathare, a Nairobi shantytown, MSF is trying to set up an outpatient treatment system, asking patients to come to our HIV clinic twice a day. In used by the national common opportunistic infection—are this precarious social context, the most vulnerable are offered shelter, on a programs? Ultimately, this last farther along, though much remains to case-by-case basis, for the duration of their treatment. “It’s a gamble, option seems inevitable— be done, particularly on management because we’re not sure how effective such an approach will be,” Christine which is why we have to of multidrug-resistant tuberculosis. explains. “But we really don't have a choice, because there are no advocate for high quality treatment programs for multi-drug resistant tuberculosis in Kenya. The monitoring systems in the The three AIDS programs have government has a waiting list of 50 patients. It has the funding, but setting integrated care so that patients with up a dedicated inpatient unit in the national reference hospital will take a countries where we work. HIV/TB coinfection can use a “single year or two, at least.” counter.” Instead of going to the TB clinic, and then going to the HIV clinic, patients receive treatment and follow- up for both diseases in a single facility. team’s efforts to step up TB detection Mathare, in 2006, to find a more (routine screening of our patient effective technique. One method— This new approach may seem simple, cohort, better quality lab tests) has FASTPlaque—was evaluated, but as it but it’s running into resistance. In quickly paid off. “The number of stands doesn‘t seem to be an attractive Kenya, for example, it took two years patients in whom coinfection was option. A new study to look at bleach for the team to persuade all of the diagnosed went from 256 in 2005 to 712 plus auramine is planned. actors—that’s how firmly entrenched for the first 9 months of 2006,” notes habits were. Yet the impact on patients William Hennequin, field coordinator in And the results from Homa Bay can be dramatic; separate treatment Arua. highlight the importance of detecting sometimes leads to serious confusion, AIDS in TB patients. “The national even a total lack of understanding, And TB diagnosis in AIDS patients program in the district, which gets a lot about the drugs to be taken for one continues to be a problem. Microscopic of MSF support, puts an average of 218 disease or the other. examination of sputum doesn’t always patients on TB treatment each quarter. diagnose the disease in AIDS patients. Of these, 72% agree to the HIV This integrated approach is now Caregivers must have a faster, simpler screening test, and 90% turn out to be showing convincing results. The Arua diagnostic tool. A study was done in positive,” explains Bintari, the medical ••• P7 messages MSF N°143 November 2006 ••• coordinator in Kenya. “At the moment, we’re only managing to test five patients a month in the Arua hospital’s TB unit," regrets William.

DOSSIER Finally, six-month TB treatment (instead of eight) has been in place in Pandemic desperately Chiradzulu since April, and Malawi seeking solutions adopted it as its national protocol in July. In Arua, the Ministry of Health has agreed to let us use this protocol for our patient cohort, and wants to follow the results closely, though for the time being it continues to use the standard DOTS (Directly Observed Treatment) > Lost to follow up protocol for its own patients. The situation in Kenya is more complicated, In addition to the adherence because local authorities would be on effort, better monitoring board if we committed to providing this involves quickly looking for treatment regimen to all TB patients patients who don’t show up for treated in the district. Negotiations their visit. Because interrup- have just gotten underway. ting ART for a few days can be dangerous, the projects in > INTEGRATE NUTRITIONAL SUPPORT Kenya, Malawi and Uganda are setting up an early search All four AIDS programs now include a system in the days following a nutritional component for malnouris- missed visit. hed patients or those at risk for malnu- trition: children, and certain extremely vulnerable adults, such as hospitalized > Malawi © Julie Remy - May 2006 > Local organizations patients. Prescription of Plumpy’nut— and patient groups: a ready-to-use therapeutic food—is flaws, our system functions well already support the district’s ten public precious allies aimed at reducing the mortality rate. overall. But this argument doesn’t health centers, with mobile teams and "This is an issue that MSF has been sweep aside all doubt, especially a training plan for these centers’ To cope with the shortage of slow to address,” emphasizes regarding long-term adherence; when nursing staff, so that eventually they’ll medical personnel, all the Christine Genevier, head of mission in patients feel better, they might be be able to initiate ART and follow stable projects believe it necessary Kenya. This effort is too recent to allow tempted to become more lax. “It would patients,” explains Sylvie Goossens, to strengthen their networking its impact to be measured, but all the be interesting to look at what’s being medical coordinator. A pilot project— efforts with local organizations projects will be closely following the done in countries that started ART a the “village unit”—goes even further by results. long time ago," suggests Annick identifying, at village level, a person or patient groups, for help with Hamel. “We should take a look at with no medical background who is adherence counseling and > PROMOTING ADHERENCE adherence practices for other chronic capable of re-supplying very stable locating patients lost to diseases, as well.” Diabetes might be a patients with their drugs, and referring followup. In Kenya, they plan to Adherence—that is, strict compliance particularly interesting example, them to a medical facility if their health hire a social worker trained in with the prescription (the amount and because it too affects children, and deteriorates. “This will allow us to focus community organization to timing of medication taken), is adherence is even less well controlled on the complicated cases, while at the identify and train local helpers. essential to maximizing the effective- in children than in adults. same time increasing treatment In the Arua region of Uganda, ness of ART and delaying the appea- capacity,” she adds. But for the time MSF supports four patient rance of resistance. Unfortunately, for > LAUNCHING being, the inclusion rate has topped out organizations. lack of a magic recipe for convincing DECENTRALIZATION at between 150 and 200 patients a patients to follow their treatment to the month. “We should also be treating letter, and reliable tools for measuring While improving the quality of more children, approaching them by adherence, our practices provoke a treatment and follow-up, increasing way of their family, get more involved in mixture of anxiety and confusion. “Pill the number of patients who receive mother-to-child transmission preven- counts, patient interviews, and the treatment is our only other weapon tion, and figure out why only half of adherence scale are biased methods; against the epidemic. This means patients diagnosed as HIV-positive patients may be tempted to cheat out getting involved in a process of decen- come in for treatment,” Sylvie reckons. of fear of being reprimanded by the tralization, and coping with the lack of doctor or counselor,” Christine qualified medical personnel. This project, with its goal of covering explains. overall needs, truly reflects MSF’s In Malawi, for example, we would have 2005-2008 AIDS objectives. In several Encouraging results on survival rates to accept 250 patients a month to cover ways, however, Chiradzulu remains a indicate, however, that despite its needs in the Chiradzulu district. “We special case.

P8 messages MSF N°143 November 2006 KAPOSI’S SARCOMA AND CRYPTOCOCCOSIS: TWO OPPORTUNISTIC DISEASES

Kaposi’s sarcoma is a cancer that exists in endemic form in Africa, and develops especially in individuals coinfected with HIV. In 2005, more than 8% of patients seen in our African AIDS projects had it. It usually occurs in the form of skin lesions, and is thus relatively easy to diagnose. To treat it we use ARVs in combination with a single chemotherapeutic agent, bleomycin, administered by intramuscular injection once every two weeks, 20 injections maximum. After this treatment, however, we have nothing else to offer, because there is a very high risk of pulmonary fibrosis, and relapses are common. MSF wants to test another drug, taxol, although it’s cumbersome to administer (several IV injections that must be administered in a hospital setting), and expensive (1,600 euros). The feasibility study will start off in Ouganda and Malawi.

Cryptococcosis is a mycosis that occurs in very immunocompromised individuals, and often manifests as meningitis. Its prevalence among patients admitted to the Phnom Penh hospital, in Cambodia, is 30%. While diagnosis, by lumbar puncture, is relatively simple, its treatment with Amphotericin B causes significant side effects. Above all, it is very hard to implement, because it requires a two-week hospital stay and is toxic. Doctors therefore have a tendency to rush the switch to the second, oral, phase of treatment, which is less effective. In view of this, MSF should be starting a clinical trial in Cambodia to test a new two-drug oral protocol (high dose of fluconazole + fluocytosine).

The situation in Uganda and Kenya But it is still going slowly, and there are seems more complex. “In Homa Bay, doubts about the quality of care. So it’s still premature to talk about we’ve started by supporting four covering needs. With projects centers, in order to assess the impact focused on the hospital and a preva- after three months and, if necessary, lence of over 30%, the demand for redirect our support to other centers. treatment greatly exceeds the capacity of MSF and the Ministry of In the end, to varying degrees, all the Health combined,” points out national programs are running up Christine Genevier, head of mission. against the same obstacles: a lack of For the past three years, MSF has qualified personnel, inadequate been providing nursing staff follow- public health infrastructures up of stable patients in three decen- (especially in rural areas), problems tralized health centers. “The Kenyan ensuring a regular supply of ARVs and authorities are interested in this drugs to treat opportunistic infec- approach, but it's taking a long time tions, etc. We have advocated for a to turn talk into concrete decisions," greater global response to the crisis, Christine continues. So delegating repeated over and over the slogan responsibility to nurses, so that they “two pills a day,” and documented the can follow patients on ARVs, is not results from our programs to prove always formalized by directive. “The that rapid “scaling-up” was possible. Ministry of Health very much needs Now that the number of HIV our support, but wants to know the treatment centers is increasing, our extent to which MSF is planning to teams’ goal is to continue to come up commit. It’s up to us to decide if we with innovative approaches, to show want to get involved in new health that quantity and quality can go hand- centers, and if we’re ready to train in-hand. And to take up this demand public health personnel.” for quality in both our speaking out and in our relationships with the In Uganda (see report), decentraliza- national programs. ■ tion has been underway in the West > Malawi © Julie Remy - May 2006 Nile region since the summer of 2005. Rémi Vallet

P9 messages MSF N°143 November 2006 CAMBODIA, A LOW-PREVALENCE COUNTRY, WHERE WE MUST CONCENTRATE ON THE MOST DIFFICULT CASES - TRANSLATED BY ALISON QUAYLE

With prevalence in the country at A major problem remains: are access to first-line therapy in good 1.9%, the Cambodian National patients surviving after a year of conditions. In parallel, MSF is Programme estimates that out of therapy? “There’s still a skills gap concentrating on treating the more DOSSIER 120,000 people with HIV, between in all aspects of quality of care and difficult cases – children, pregnant 25,000 and 30,000 urgently need keeping patients alive”, Jean- women, or patients on second-line Pandemic desperately ARV therapy. At the end of 2006, François Corty adds. therapy (around a hundred people) seeking solutions taking all programmes together, – and on monitoring hospitalised 16,000 patients have access to Nearly a thousand NGOs are patients, particularly those who are triple therapy. Nearly 7,000 are working in Cambodia, including 200 coinfected with HIV and TB, who receiving treatment in Médecins involved with AIDS, most of them make up 60% of the hospitalised Sans Frontières programmes concentrating on preventive patients in our two programmes. (MSF-France and MSF-Belgium). programmes or support for “Especially because we’re now orphans. MSF still has an important seeing cases of multiresistant TB – “Cambodia is going through a role in the treatment and follow up three patients have been on MDR transition period in the fight against of AIDS patients and in treating therapy since July and there is a AIDS”, says Dr Jean-François tuberculosis. fourth suspected case. No-one else > To be continued? Corty, deputy programme manager. is working on multiresistant TB, “When we started our programme, “We are thinking about gradually which is a real time-bomb in this we were more or less the only handing over part of our activities country. Tuberculosis is not being The Arua meeting provided an people involved. Now there’s a to the National Programme” says adequately treated, and there are opportunity to share an overall political readiness to commit to the Jean-François Corty. The first an estimated 2000 cases of multi- view of the problems, and the issue, and national policy is stage is to assess the treatment resistant TB. So our involvement in teams from Kenya, Malawi and becoming a reality, particularly capacity of the Cambodian organi- this area is vital.” Uganda would like to continue with large numbers of health sations, so that stable patients can centres introducing ARV therapy”. be referred to them, and have C.L. this exchange on prevention of mother-to-child transmission, pediatric care, treatment adherence, the role of local and patient organizations, and training. A second regional meeting may take place in January, in Nairobi, with members of the Medical department, Operations, or outside participants invited to contribute to the discussions. © Juan Carlos Tomasi - february 2006 - february Tomasi © Juan Carlos

Press Contact: [email protected] [email protected] > Cambodge

For further information:

- on the activities of the French section of MSF: www.msf.fr - on the activities of the other MSF sections: www.msf.org

P10 messages MSF N°143 November 2006 PREVENTION OF MOTHER-TO-CHILD TRANSMISSION A weak link in our programmes

MSF/November 2006/Translated by Alix Hague

Reducing child mortality due to AIDS requires addressing mother-to-child transmission as well as screening and treating infants. These two approaches are essential but little implemented in our programmes. An interview with Dr Myrto Schaefer, paediatrician at the Medical Department of MSF, and head of the project unit in MSF Sydney.

> Nine out of ten children with presently working. In certain areas, After birth, we need to provide tested. Unfortunately, this number HIV contracted the AIDS virus from we are already conducting mother- prophylactic treatment for one week is probably not representative of the their mothers. What can MSF do to to-child transmission prevention for to these babies, then monitor them whole, but it shows that we can do combat the problem? pregnant women we are treating in for infection. If, despite everything, something against transmission. These children contract the AIDS our AIDS program. The new these babies are infected, we must virus during pregnancy and above challenge will be to establish contact be able to offer treatment. In > In your opinion, does MSF do all during labour and delivery, as with those women who do not know enough to prevent mother-to-child well as during breastfeeding. And if they are HIV positive or not. transmission? almost one out of two children who We are doing something. But it's not contracts the HIV virus during Once a diagnosis has been made, « [...] Treating children with HIV enough. A few years ago, it was too pregnancy or at birth dies before the appropriate care can be offered to is therefore a challenge for MSF, complicated to set up ARV age of two. This is what happens if women, including triple-therapy, but we must also try to combat treatment for adults. But we did it we do not diagnose early enough in prenatal care and advice on breast- mother-to-child transmission by anyway. And I think that we have order to provide appropriate feeding. There are also women who breaking the "transmission what it takes to deal with mother- chain ». treatment. Treating children with are not at a point in their illness to-child transmission of the virus HIV is therefore a challenge for requiring triple-therapy. In this during pregnancy and for the MSF, but we must also try to combat case, prescribing ARVs can put treatment of newborns. ■ mother-to-child transmission by them at risk of side-effects of these breaking the "transmission chain". drugs. In order to prepare for this, Mathare, in Kenya, where we do Otherwise, we are only dealing with we can implement a strategy mother-to-child transmission one side of the problem. consisting in reducing mother-to- prevention, we have begun testing Interview by child transmission during labour babies whose mothers are HIV Sally McMillan and > What exactly can we do? and delivery and providing care for positive. At present, we have found Philippe Tanguy, We need to do two things. First of newborns from birth. one HIV positive baby out of 26 MSF-Australia all, we must reduce mother-to-child transmission. Secondly, we must identify HIV children early enough along to provide appropriate treatment. Otherwise, we are not attacking the problem completely, and we will not be able to keep the majority of infected children from dying.

The new challenge will be to establish contact with those women who do not know if they are HIV positive or not.

In order to reduce mother-to-child transmission, action must be taken during women's pregnancies. This will not be easy, as there are very few centres for prenatal care in the countries where we work. Yet I think that we should, first of all, offer AIDS tests in the prenatal consultation > Malawi © Julie Remy - May 2006 centres around where we are

P11 messages MSF N°143 November 2006 A COMPREHENSIBLE RESPONSE “There is a glaring lack of long-term political vision” DOSSIER MSF/October 2006 Pandemic desperately seeking solutions Over the years the battle against AIDS has seen considerable changes. The comprehen- sive response to the epidemic seems to be stalling, despite the optimistic statements of international organizations. Below is an interview with Professor Win Van Damme of the Institute of Tropical Medicine in Antwerp, Belgium, by Dr Arnaud Jeannin, MSF Deputy Programme Manager in charge of Malawi.

> Money from the > Arnaud Jeannin : What actions are And promises and funding are like Brazil, are deemed more “ Global Fund and currently being taken at internatio- reviewed every year. The system is profitable” because they have imple- PEPFAR nal level against the HIV epidemic? therefore very unstable. There is no mented a national policy for treating With regards to funding, has the assured continuity over the years. The all people living with AIDS with the emergence of bilateral and multi- prevailing global funding strategy is a idea that it’s in the economic interest • Global Fund to Fight AIDS, lateral funding sources produced any very short-term one, which is of the country - the treated people Tuberculosis and Malaria sustainable solutions? dangerous. no longer being a burden to society Since its creation in 2002, Win Van Damme : Funding remains an because they can re-enter the 3.1 billion dollars have been important issue. For the treatment of > A.J. : Can the situation change? labour market. Doesn’t this model allocated to programs people living with AIDS, the two main W.V.D. : The percentage of total North- demonstrate the effectiveness of conducted in 127 countries. In funding sources today are the Global South international aid (i.e. approx. 80 large-scale national treatment the latest allocation decision, Fund to Fight AIDS, Tuberculosis and billion dollars a year) allocated to AIDS policies? total funds to be allocated Malaria (see inset) and PEPFAR (Presi- is still low—about 5%. UNAIDS, W.V.D. : The Brazilian authorities were were increased to 1.039 billion dent's Emergency Plan for AIDS notably, argues that this percentage not thinking in terms of profitability but dollars distributed among 52 Relief), launched by George W. Bush. must increase radically by pointing out rather of how to manage Ministry of countries. Programs specifi- The Bill and Melinda Gates Foundation the uniqueness of the battle against Health money better. The cost/effecti- cally related to HIV/AIDS is becoming an important actor, too AIDS. But other problems exist. Other veness argument is meaningless (allocating 100 million dollars to the actors receiving international aid also anyway because it is very short-term increased to 469 million Global Fund in 2006, for example), but claim unique measures for education, thinking. Some studies, like the one dollars in 27 countries. it invests more in the search for a water or the reconstruction of Iraq. At published in The New England Journal vaccine and on microbicides. The the same time for international institu- of Medicine dealing with 10,000 hospi- • PEPFAR Global Fund intervenes in all countries, tions like the World Bank, AIDS and talized AIDS patients, make that clear. (President's Emergency Plan while PEPFAR concentrates on 15 health in general do not merit a unique Calculating the cost of taking care of for AIDS Relief) countries where the prevalence of status because they are not profitable these patients for a year—not treated In 2006, PEPFAR’s budget HIV/AIDS is very high. with ARVs—is simple, and so is calcu- increased to 3.2 billion lating how much their ARV treatment dollars, 868 million of which The problem with PEPFAR funding, would cost, which is almost the same The system is therefore very which was stated from the start, is that or even less. That’s the “honeymoon” is dedicated to antiretroviral unstable. There is no assured treatments. 561,000 people its funding operations cover a limited continuity over the years. The period, when it is worthwhile to treat are currently being treated period of only five years. The US prevailing global funding with ARVs. In the second year, the president is probably convinced that calculation is different. Non-treated through this funding in strategy is a very short-term this type of action is necessary for the one, which is dangerous. patients don’t cost anything because 15 countries: South Africa, national security of the United States. they’re dead. Treated patients cost Botswana, Ivory Coast, And US evangelical Christian organiza- money. They can develop opportunistic Ethiopia, Guyana, Haiti, Kenya, tions have seized the opportunity to illnesses and resistances and will cost Mozambique, Namibia, exert their influence with, for example, investments. Therefore, there is an even more then. So, of course, treating Nigeria, Uganda, Rwanda, the “ABC” strategy: Abstain, Be especially fragile balance of forces more and more patients is far from Tanzania, Vietnam and faithful, and Correct and consistent between those who argue for profitable. The cheapest… is that Zambia. use of condoms, which is at the heart increased aid and those who believe patients die. To find solutions, we can’t of PEPFAR-funded prevention actions. that this type of aid is a bottomless think in economic terms. With regard to the Global Fund, the well. The danger is that sooner or later funding dilemma is twofold. It funds a donors will stop increasing their aid > A.J. : Today, nearly 1.6 million high number of countries that are and could even decrease it, especially people living with AIDS are under largely dependent on those funds for now when embezzlement scandals at treatment. Looking back over the their national programs. At the same the Global Fund have started to appear. past few years, what lessons can be time, Global Fund donors do not learned from implemented interna- provide sufficient funds to cover the > A.J. : Speaking of “investment tional strategies, in particular the estimated needs (5-10 billion per year). effectiveness,” some countries, World Health Organization’s (WHO)

P12 messages MSF N°143 November 2006 > Malawi © Julie Remy - May 2006

“3 x 5” initiative (3 million patients on However it seemed as if talking about relationship.” Two years ago, nobody program, despite enormous restric- ARVs by the end of 2005)? reality were censored. There was a was thinking in terms of global tions (lack of medical personnel and an W.V.D. : In the long term, the most glaring lack of long-term political coverage (treating all those suffering under-developed health system), has important variable is the number of vision. It was a little like, well, we have with AIDS in a given area). The clini- set up an extremely simplified system: patients being treated who survive. to convince the international cians developed responses, but they no laboratory, the same first-line And the news is good there. Where it community to continue to contribute, did not consult public health experts, treatment for everyone. In a health isn’t good is in the disease’s expansion but let’s avoid talking about the bad for example, to imagine more compre- centre I visited in August, they are because infections continue to news that won’t serve our cause. hensive solutions. However, few public treating 800 patients. Consultations increase. In the future, there will be ten health actors are interested in AIDS… take place three mornings a week. In or twenty million people in need of > A.J. : However, ARV delivery Even at the WHO. Uganda, the national program is treatment. I have criticized the 3 x 5 models are essential in order to treat certainly poorly coordinated, but there initiative from the start because it is a patients on a large scale and for > A.J. : To what extent do technical are interesting initiatives, like “expert very short-term strategy as far is coming up with more comprehensive difficulties affect the search for patients,” patients who are stable in funding is concerned. It was necessary political solutions. Are things comprehensive solutions? their treatment and who monitor other to find some way to start the process, progressing in this direction? W.V.D. : At first, the price of medica- patients, or “field officers,” treated but the initiative was presented as a W.V.D. : Up to now it has mainly been tions was the main obstacle, but then patients who distribute ARVs to homes final objective without anticipating the clinicians who have started treatment prices decreased. Pilot projects each month. future or providing the means to reach programs, focusing on the doctor- showed that it was possible to treat that objective. And this strategy has patient relationship. These first patients in developing countries, and But, in fact, it is MSF and what it’s shown its limits. treatment programs had limited objec- so then the issue of funding arose. doing in Thyolo and Chiradzulu in Today, money is no longer a problem, Malawi that is cutting-edge. It is based > A.J. : In fact, isn’t it three million although it will become one again in a on the experience of pilot projects, in people who need to start treatment few years. The main issue is rather the which the work was done on a district every year? It is MSF and what it’s doing in lack of human resources to register, level and that could result in really W.V.D. : Yes, or 10 million in 2010 and Thyolo and Chiradzulu in Malawi treat and monitor thousands of innovating responses. MSF may 20 million in 2020. that is cutting-edge. It is based patients. There the solutions are yet to propose innovations, but it may also be on the experience of pilot be found. But it will difficult to apply restricted by its own limitations. In an > A.J. : Nothing long-term has been projects, [...] that could result in comprehensive responses because organization of doctors, any methods considered? really innovating responses. each country’s problems are specific. that do not put doctors at the centre of W.V.D. : There aren’t any long-term the process may generate internal strategies or funding initiatives. In > A.J. : Are there any national resistance. However, we must continue Toronto [at the 16th International AIDS programs proposing innovative to consider other methods to achieve Conference in August 2006], the tives, such as: “to treat 1,000 patients solutions? real advances. ■ discussions mainly focused on and then stop taking new ones W.V.D. : Malawi and Uganda, with very technical aspects: resistance because it would not be possible to different environments, are good phenomena, HIV/TB co-infection… maintain a good doctor-patient examples. Malawi, in its national Transcribed by Caroline Livio

P13 messages MSF N°143 November 2006

> Sri Lanka © Yann de Fareins/MSF - January 1989

SRI LANKA MSF withdraws from MISSION SRI LANKA Jaffna peninsula All medical activities of MSF are suspended in Sri Lanka

MSF/October 2006

An increase in violence and fighting in 2006 led Médecins Sans Frontières to return to Sri Lanka to provide medical assistance to the war affected population. Since August of this year, approximately 200,000 people have been displaced by the fighting. Despite requests from the Ministry of Health for MSF to provide assistance to several hospitals in the North, we had so far only been allowed to start activities in Point Pedro Hospital on the Jaffna Peninsula. However, MSF teams have now had to suspend their medical activities and withdraw from the only hospital we had been permitted to work in. Explanation by Dr Guillermo Bertoletti, director of operations.

P16 messages MSF N°143 November 2006 > Why has MSF suspended nally recognized, independent and national organizations, states, or its activities and withdrawn from neutral medical-humanitarian international NGOs, are all grouped POINT INFO Jaffna Peninsula? organization. Without these assuran- together and perceived as being pro- Since the 30th of September, false ces, we cannot send our teams to LTTE (Tamil Tiger) or as profiting > 20 october 2006 allegations have been leveled in the provide medical assistance to those from the war. This is why it is Niger : 61 000 Sri Lankan media accusing MSF in need. extremely important for us to explain admissions since the teams of participating in the conflict. our action and to be publicly and beginning of the year We have been cited as a ‘threat to > Why were these accusations officially recognized as being The number of admissions national security’ and have been leveled against MSF? Maybe this is independent, neutral and impartial. is not decreasing but is accused of actively supporting the just an misunderstanding? Finally, it may be that the govern- stable, with 2300 admissions Tamil Tigers. Simultaneously we The accusations are absurd and ment does not want an international for the month of September, received a letter from the govern- completely unfounded! MSF has a presence in the areas where war is and a total of 61,000 admis- ment canceling our existing visas long record of impartial and indepen- being waged. sions since the beginning of and asking us to leave the country, dent action in all the major armed the year. The great majority followed shortly by a second official conflicts of the last 30 years. We > Following your visit, do you think are moderately malnourished letter saying we could stay in the speak out on the humanitarian this situation will be resolved? children. This corresponds country until ‘further notice’ stating issues we face, but we don’t take What will MSF do if there is no to the number of admissions we are under investigation. sides in a conflict. We worked in Sri progress? we had excepted for the Though we have not been officially Lanka during 17 years of armed We have made a commitment to whole year, between accused of anything, the false allega- conflict, and have proved that we are work in Sri Lanka, and are prepared 75,000 and 80,000 for 2006. tions made in the media combined a medical emergency organisation to honour that commitment. We have with a lack of clear support from the grave concerns for the population government as a whole, have made living in the war affected areas. the risk for our personnel unneces- Fighting is increasing. Heavy > 3 November 2006 Many foreign entities [...] are CAR : Explo mission sarily high. As a result, our team in perceived as being pro-LTTE bombing has displaced tens of Point Pedro has ceased providing (Tamil Tiger) or as profiting from thousands of people who are in need to Birao medical assistance, and has left the the war. This is why it is of assistance. Hospitals are in need On Monday 30 October, the Jaffna Peninsula. extremely important for us to of support in order to meet the city of Birao – located in the explain our action and to be demands. It is deplorable that we north-east of the Central > Seeing as the government has publicly and officially recognized are not allowed to bring medical African Republic, the region now said MSF can stay, isn’t it as being independent, neutral assistance to the population living in on the border with the south- and impartial. an overreaction to stop medical areas where heavy fighting is east of Chad and the west activities just because of some underway. of South Darfur – fell into the articles in the media? hands of rebels. Birao is a city This is not a decision we have taken responding to the needs of the Following several meetings we had in of 15,000 people, and there lightly! It was extremely hard to leave population. This situation is all the Colombo, the capital of Sri Lanka, I are about 50,000 people living the patients and to stop the collabo- more puzzling taking into account believe there are members of the in the zone. A team is going ration with our colleagues in the that the hospitals we had proposed to government who are concerned by to try to go to Birao. This is hospital, knowing that the situation support are all government the need for medical assistance in not easy, as the zone is on the peninsula continues to hospitals, in government controlled the north and east, and would like difficult to access whether deteriorate and that currently there areas, following requests made by MSF to provide this assistance. by road or air. is heavy bombing in the area. Throu- the Ministry of Health. Yet, thousands However, this needs to translate into ghout 2006 the security situation in of people living in the LTTE controlled concrete actions. MSF surgeons, Around Paoua, where we’re the country has greatly degraded, areas are also in desperate need of nurses and other staff have been on undertaking our activities, creating acute needs for the civilian assistance. standby for months in Colombo and violence erupted again at the population as well as increasing the in Europe, ready to provide care to Sri end of the rainy season and risk taken by humanitarian organiza- However, there are a series of factors Lankans. Nevertheless, we cannot there have been more villages tions. The assassination of 17 that may help to understand why this keep our teams on standby indefini- burned down. People are members of ACF was a terrible has happened. The accusations and tely. Today our name is not cleared leaving again to hide in the shock to us and illustrates how restrictions on MSF, and other up and we are not granted permits bush, and the number of dangerous the situation can be for humanitarian organizations, are and authorizations to carry out our consultations in our clinics humanitarian workers also. occurring in a context of increasing work. This means that we remain is slightly decreasing. Within this context, like in any armed distrust and sometimes outright blocked, with no security for our However, our activities conflict, our independence and rejection of the involvement of inter- teams and no humanitarian space to within the Paoua hospital neutrality must be respected. If we national actors in Sri Lanka. On the carry out our activities. If this doesn’t itself remain consistent are to help the civilian population one hand the general disappointment change soon, if the government as a and for now, admissions affected by the conflict, we need the and frustration with the reconstruc- whole doesn’t show that we are haven’t declined. false allegations and inaccurate tion efforts following the tsunami has welcome to work in Sri Lanka, then I statements made in the media translated into a profound disap- will consider that we will be forced to cleared up. We need a strong pointment and mistrust of NGOs. On leave the country. ■ message that the government as a the other hand, there is a strong whole and that authorities at all opinion against the involvement of levels are ready to welcome and foreign organizations in the conflict. Dr Guillermo Bertoletti facilitate the work of an internatio- Many foreign entities, be they inter- Transcribed by Kate de Rivero

P17 messages MSF N°143 November 2006 SOUTHERN SUDAN “NGOs and the United Nations cannot serve as subcontractors MISSION SOUTHERN SUDAN for this enormous reconstruction project"

MSF/October 2006

Dr Rony Brauman, former president of Médecins Sans Frontières (MSF) in France and POINT INFO research director of MSF Foundation , recently returned from Southern Sudan. He describes the situation nearly two years after the peace agreement was signed, and also raises > 13 october 2006, questions about the position aid organizations have taken in the context of reconstruction. DRC – North Kivu, opening of an emergency project in Nyanzale Since August the number In January 2005, after 20 years of war teeming. That is all as it should be. a huge undertaking, most of which of victims of sexual violence interrupted occasionally by short-lived The city’s population has doubled in a remains to be carried out. coming to our programme ceasefires, the south Sudan rebels year, so merchants are pleased, but in Rutshuru has increased and Sudanese government signed a housing has not kept pace and rents The new government authorities must considerably. From an peace agreement. It took three years have skyrocketed. organize a power-sharing arrangement average of 60 new cases per of negotiations, sponsored and guided among the movements that fought in month the first 7 months, by the U.S. government, to reach a > HUMANITARIAN the war or that have substantial forces we’re now up to 220 cases compromise acceptable to both AGENCIES HAVE A at their disposal. These talks are tense, for August and 316 cases parties. Trust is hardly to be expected MASSIVE AND VISIBLE particularly when long-serving comba- for September. among former warring parties, parti- PRESENCE tants are pushed aside latter day A large proportion of the cularly in a country so deeply wounded supporters. The authorities are also victims are referred from by an endless history of violence. The massive international presence is working as best they can to establish an Nyanzale health centre. Indeed, the human cost of the war has visible as soon as your plane touches administration, which for the moment is Violence broke out in the yet to be determined: One million down and you set foot in Juba interna- periphery of Nyanzale, in the people, perhaps more, have died, and tional airport. More than 10 huge white north and south-east, during three to four million have been trucks bearing the logos of various U.N. fighting between various displaced, mostly around the capital agencies are parked outside. Everyone armed groups in the area city, Khartoum. These numbers begin is here: from the World Food Program after the first round of the to describe the disaster from which (WFP) to UNICEF, the UN High elections on 30th July 2006. Southern Sudan is emerging and the Commission for Refugees to the World The population sleep in the problems that await it. Health Organization (WHO), as part of bush and return to their the United Nations Mission in Sudan villages during the day. (UNMIS), a major deployment of 6,000 50 severely malnourished The new government authorities Blue Helmets and 4,000 civilians. They children were registered. must organize a power-sharing have been assigned to back up the We will start by providing arrangement among the peace accord, and, more specifically, to treatment for rape victims in movements that fought in the support the integration of rebel forces Nyanzale, and will carry out war or that have substantial and the regular army, to help refugees forces at their disposal. further evaluations of the return home, to participate in protecting nutritional situation. civilians and to restore part of the road system. However, Juba, the southern political and administrative capital, is not in Dozens of NGOs and government aid mourning. The city is very much alive. agencies are here, too, based in Juba A match has been scheduled between and operating throughout the South. two local soccer teams and their Hospitals, schools, roads and bridges respective supporters spill out into the have been rebuilt, thanks in part to aid streets, wearing team jerseys, blowing groups and, also, to oil companies whistles and waving flags. We could be (primarily Chinese) that are prospecting in Nantes or Manchester. Shops and and drilling in the major oilfields restaurants have multiplied, the located on the border between the markets are well-stocked and North and South. However, these > Sudan © Kevin Phelan/MSF - April 2006 crowded and the bus stations are projects constitute only a small share of

P18 messages MSF N°143 November 2006 non-existent, in the ten states that form education and other community facili- It calls to mind the unrealistic state- the new South. The distribution of jobs ties—cannot be cobbled together from ments issued by the same actors after is, naturally, the subject of difficult piecemeal contributions from aid the tsunami. One might well suggest negotiations. organizations, whether private or U.N.- that the country consider recruiting the based. These groups have neither the managers it needs from today’s very Nonetheless, everything remains to be mandate nor the means to become the open international labor market. Such (re)built from scratch. This is the government’s human resources agency an approach would certainly be more program to which NGOs have been or its operational administrators. The expensive but thanks to oil income and invited to contribute. Some have outside aid, government coffers are not POINT INFO already gotten down to the job. empty—not by a long shot. Norwegian People’s Aid (NPA) flags and > 3 november 2006, stickers are visible on many public MSF has not yet determined > ADAPTING OUR Chad - Extensive fighting buildings and an endless fleet of what form our activity will take. PROGRAMS TO THIS NEW However, it is already clear that in the east vehicles. This large NGO has decided to CONTEXT we must avoid the trap of invol- In the last week of October serve as the Juba government’s inter- vement in public health systems, a rebel division made mediary for a range of functions, from Does this mean that aid organizations despite their deficiencies. an incursion in Chad and de-mining to rebuilding hospitals, are no longer necessary? Certainly penetrated as far as the supporting the press and providing not. They provide a range of services centre of the country, without professional training. This is a paradoxi- and will continue to be useful in encountering opposition. cal choice for a non-governmental supplementing government activities. But even though this armed organization. Where is the “non- government would be unable to orches- MSF has not yet determined what group then retreated towards governmental” in this role? However, it trate such a disparate collection, with its form our activity will take. However, it the border, it was ambushed is a respectable position because it is host of constraints and diverse skills— is already clear that we must avoid the by the Chadian National being done openly. and not only for lack of resources. trap of involvement in public health Army. Extensive fighting took Rather, the more important reason is systems, despite their deficiencies. place, causing many wounded > RECONSTRUCTION that it is impossible to coordinate a The government and the WHO would who flocked towards Goz THROUGH THE AID group of heterogeneous institutions. very much like us to respond to Beida and Abéché. Some SYSTEM IS AN ILLUSION These are not temporary employment chronic and acute epidemics, given of these wounded have now agencies. It is also impossible to our expertise in this area. That is been referred to N’Djamena Despite appearances, however, NGOs exercise real authority over them. where we can provide concrete assis- after they stabilised. and the United Nations cannot serve as However, this illusion that the interna- tance, particularly because it would In Adré, the situation has subcontractors for the enormous tional aid system will carry out recons- involve adapting and refocusing been rather calm and in the reconstruction project facing the South truction seems to be one of the most existing programs. Regardless, we will main part, the city is empty Sudanese. Public goods—health, widely-held beliefs in South Sudan. have to make major changes to our of soldiers, who have left programs as they are no longer appro- for the front. priate to the population’s needs. In Koloye, where the team has been preparing to close As mentioned above, the political the project, the renewal context has, indeed, changed. And of tension has accelerated even though peace is the order of the our retreat and the team day, the future remains unclear. has been evacuated towards Hatreds and resentments have not Dogdoré. In Dogdoré the disappeared, violent incidents are team has been reduced for frequent, oil income stirs up envy, and security reasons. They the various armed forces throughout received a few wounded the South have not been integrated. In patients, but were able to short, the political outcome of the run activities almost peace accords is unknown. Critical normally. moments are already on the horizon, In Goré, the hospital including the census and elections in continues to operate and 2007 and the referendum in 2011. the number of admissions Violent flare-ups—and worse—could is more than significant. occur, but as of now, there is no way to know what course events will take. This uncertainty alone is hardly a reason to remain in South Sudan because humanitarian aid focuses on today, not on the future. But it does offer one more reason. Let’s hope that this one remains in the realm of the hypothetical. ■

Rony Brauman

P19 messages MSF N°143 November 2006 DARFUR Humanitarian aid held hostage MSF/October 2006

> Sudan, Darfur © Michael Zumstein/L'Oeil Public - August 2004

Humanitarian organisations find themselves hostages between the Sudanese government and the international community. Op-ed Fabrice Weissman, CRASH.

The intensification of fighting in wounded has increased sharply. responded to United Nations’ threats Darfur and the general increase in Other assistance missions in the of military intervention with DEBATES insecurity have forced Médecins government-held region have had to xenophobic propaganda, likening all Sans Frontières (MSF) to drastically close. Vital services, like the foreigners to "new crusaders" reduce its activities over the last transfer, via roads, of patients who motivated by hatred of Arabs and three months. require emergency hospitalization, Islam. In all likelihood, the increased Since July 2006, gangs and militias have been suspended. However, operating in cities and along govern- MSF can still work in the large A shorter version ment-held roads have stepped up displaced persons’ camps, which The Sudanese government bears of this article was their death threats, beatings, sexual together house close to 2 million grave responsibility for the published, under assaults and killings, along with the people who are almost entirely mounting insecurity along roadways and in towns it ransom of aid organizations. The dependent on outside aid. a different title, controls. in Le Monde dated army and paramilitary forces control roads providing access to the Jebel > XENOPHOBIE 3 November 2006. Marra mountains, but they have PROPAGANDA become so dangerous that MSF and violence of the attacks against other humanitarian organizations The Sudanese government bears humanitarian workers is part of a have had to suspend activities in the grave responsibility for the mounting government strategy to confine aid mountain regions under rebel insecurity along roadways and in organizations to garrison towns. control. At least 100,000 people, towns it controls. First, the serious, That way, the government can including a large number of repeated attacks underway could conduct its counter-insurgency displaced persons, have been only be carried out with the compli- campaign without hindrance or deprived of assistance, while several city—if only passive--of the regime’s witnesses and resist the threat of cholera outbreaks have been imposing security structure that international intervention by holding recorded and the number of war- controls Darfur. Second, Khartoum humanitarian workers hostage. “If

P20 messages MSF N°143 November 2006 you move ahead with the plan to those who refuse to accept its > A WAR AGAINST SUDAN fighting and the opposition of many send in blue helmets, you will the authority. armed groups to the U.N.’s deploy- pay the price in the deaths of aid Khartoum now refuses to accept this ment, it is difficult to imagine how workers.” That, in so many words, is In the face of this renewed, widesp- deployment. At this phase, Resolu- the blue helmets will carry out their what the gangs and militias read violence, the United States, tion 1706 provides for a war against mission. As deputy U.N. secretary- operating with the regime's endor- Great Britain, France, the European Sudan and military invasion of its general for peacekeeping Jean- sement have said. Union, the African Union, the highest western region. However, no nation Marie Guehenno emphasized on leadership in the United Nations and appears ready to take that on. October 4, “When peacekeeping is Fighting has resumed in western many Western advocacy groups Assuming that the Sudanese govern- confused with enforcing peace, you and northern Darfur, outside the believe that sending U.N. troops is ment ultimately agrees to accept run into major problems… Anyone areas under Khartoum’s control. The the best way to assist the Darfur U.N. troops, no country is willing, who tells me that a 500,000-kmÇ hostilities pit supporters of the populations. The war has left either, to provide the 20,000-person area can be pacified by a foreign Darfur Peace Agreement against its 200,000 victims, one-quarter to one- force that Resolution 1706 calls for. force, and that law and order can be opponents. The government and just third of whom have died in the Nearly 80,000 blue helmets are restored that way, is mistaken.” one rebel faction signed the violence. According to U.N. Security already deployed around the world Countries are well aware of that and agreement under strong internatio- Council Resolution 1706, approved and the U.N. is struggling to find an balk at providing troops to a U.N. nal pressure on May 5. In the Korma on August 31, the 7,000 soldiers additional 15,000 soldiers to streng- mission that they voted to support. and Tawilla regions, that faction has currently deployed by the African then UNIFIL contingents in southern Despite its own doubts, the interna- killed more than 70 civilians. Up to Union are to be replaced by 20,000 Lebanon. tional community continues to now, the areas currently affected by blue helmets. The latter will be suggest to the people of Darfur that fighting are those that have been authorized to use force to implement But most importantly, nearly all the their salvation will come from a U.N. less dependent on international aid. their mandate, defined as ensuring rebel factions—as well as the military intervention—one that, However, the resumption of violence compliance with the peace displaced populations—reject the today, is highly unlikely to be could produce many wounded agreement, protecting displaced peace agreement whose implemen- deployed or to succeed. Some people, as well as new population persons and international workers tation the U.N. troops are supposed humanitarian actors, like Jan displacements. and disarming the belligerents. to guarantee. With the resumption of Egeland, U.N. deputy secretary- general for humanitarian affairs, are It has been nearly impossible to participating in this campaign. conduct an independent evaluation Moreover, they are embroiling aid of needs because effective security organizations in the “just war” camp guarantees are lacking. The splinte- and contributing to exposing them ring of the opposition into some 10 further to reprisals by Khartoum and factions, often without logistical its militias. networks and operational chains of command, requires aid organiza- The neutrality required to intervene tions to negotiate with a growing in a war zone prohibits aid workers number of fluctuating territorial- from making judgments about the and militarily-based groups more recourse to force or from speaking interested in pillaging aid resources out on the international pressure than in setting up aid operations. that could prompt warring parties to respect the requirements of interna- We wish to emphasize that the tional humanitarian law. Further- current situation involves resumed more, the international community’s hostilities, not the implementation current strategy cannot stem the of a program intended to systemati- resumption of violence against cally exterminate a portion of the civilians as long as it endangers the Sudanese population. From a purely vital aid operations that more than legal perspective, the atrocities one out of three Darfur residents committed in Darfur may fall under depend on. This observation is not, the 1948 Genocide Convention. of course, intended to exonerate the However, historically speaking, they warring parties from their primary are more akin to “pacification responsibilities. They alone can campaigns” carried out by ensure that the lives of non-comba- European armies during periods of tants are respected and that colonial conquests than to the humanitarian agencies can provide Rwandan state apparatus’ methodi- impartial assistance to the victims of cal destruction of part of its the conflict. ■ citizenry in 1994. As the war in southern Sudan illustrated, Khartoum has always managed its outlying areas with the brutality of a colonizer--destroying villages, burning harvests, killing men and > Sudan © Hugues Robert/MSF - August 2004 rapid women--to punish and control Fabrice Weissman

P21 messages MSF N°143 November 2006

N°143 November 2006 November N°143 MSF messages P22

tations are offered to indigents. It’s a It’s indigents. to offered are tations water the find to basis daily a on fight for the French section. French the for

the one day a week when free consul- free when week a day one the to have Somalians of majority great and Guillermo is operations director director operations is Guillermo and

completely unaffordable, except on except unaffordable, completely The control”. without but “remote, charge of coordinator follow-up follow-up coordinator of charge

commercial clinics are obviously are clinics commercial than more anything be to claim can manager (in New York), Denis in in Denis York), New (in manager

one and a half million) and the private the and million) half a and one NGOs isolated few a and sections MSF - Marie Noëlle is programme programme is Noëlle Marie - 1 MSF sections: www.msf.org sections: MSF

- on the activities of the other the of activities the on - Mogadishu, out of a total population of population total a of out Mogadishu, other ICRC, the Only rare. are projects

(200,000 displaced persons in persons displaced (200,000 relevant on working and populations section of MSF: www.msf.fr MSF: of section

Denis Gouzerh Denis populated by displaced persons displaced by populated local the with involved organisations - on the activities of the French the of activities the on -

buildings, either entirely empty or empty entirely either buildings, aid Emergency unabated. continues

For further information: information: further For

ne’s commitment to the project. project. the to commitment ne’s enormous just now are in-patients, also civilians against Violence ■

as it did in the 90s, requiring everyo- requiring 90s, the in did it as 500 over accommodate to able were mission. the of charge in teams

ping a special operational framework operational special a ping past the in which hospitals public the of part the on vigilance cular [email protected]

concerns, even if this means develo- means this if even concerns, The beds). hundred one (around parti- require and operations have we Reactions and contributions: and Reactions

should be at the core of MSF’s of core the at be should where countries other in those from

[email protected] There can be no doubt that Mogadishu that doubt no be can There significantly differ They changed.

[email protected]

seen, working conditions have not have conditions working seen, to treat them is so limited. so is them treat to

Press Contact: Press

difficult. difficult. be can as far As country. the in project many requests and the capacity the and requests many

the morning as there are so are there as morning the for survival will be made more made be will survival for a reopening propose to visit the of

registrations at three o’clock in o’clock three at registrations the fighting and again their struggle their again and fighting the charge in members two the allowed

hospital in the town begins town the in hospital the populations will be caught up in up caught be will populations the which expression evasive deliberately

The only private not-for-profit private only The

few key towns will return. Once again Once return. will towns key few

« A context”. Somalian the in footing

Mogadishu and for the control of a of control the for and Mogadishu our “regain to sent was mission

threat still exists that fighting in fighting that exists still threat exploratory an later years ten Almost

of the new régime can be felt. The felt. be can régime new the of limited so is them treat to capacity the

away from the capital, but the fragility the but capital, the from away and requests many so are there as ended. war

notch and the fighting has moved has fighting the and notch morning the in o’clock three at tions civil the if permanent be only could

violence has suddenly dropped a dropped suddenly has violence registra- begins town the in hospital departure Our project. MSF’s of heart

provinces: the Islamic tribunals. Daily tribunals. Islamic the provinces: not-for-profit private only The the at mission Somalian the put which

Mogadishu and a few neighbouring few a and Mogadishu interruption, without almost Somalia

has taken military control of control military taken has houses. their in dying simply to tives in present been had MSF however,

Since June 2006 a new political power political new a 2006 June Since alterna- few have ill severely are who necessary. Since the early 80s, early the Since necessary. for

by various warlords for years, those years, for warlords various by was mourning of period a – leave to us

no better. no apart torn city capital the Mogadishu, forced MSF of member a of death The

gloomy picture and the future looks future the and picture gloomy In survive. to need they food and

their adversary. adversary. their

conquer a few square metres from metres square few a conquer

> Somalia > © Espen Rasmussen - May 2006 May - Rasmussen Espen ©

between opposing warlords trying to trying warlords opposing between

respite, even between two skirmishes two between even respite,

of Somalian citizens. It gave them no them gave It citizens. Somalian of

extortion, marked the daily existence daily the marked extortion, ting of rapes, kidnappings and kidnappings rapes, of ting

population. Everyday violence, consis- violence, Everyday population. «

90s was still weighing heavily on the on heavily weighing still was 90s

civil war in progress since the early the since progress in war civil

its staff in the hospital in Baidoa, the Baidoa, in hospital the in staff its

following the assassination of one of one of assassination the following

its projects in Somalia in July 1997 July in Somalia in projects its

Médecins sans Frontières closed all closed Frontières sans Médecins

TODAY. When the French section of section French the When

PRESENT IN MOGADISHU IN PRESENT

TION LIKE OURS SHOULD BE SHOULD OURS LIKE TION

I THINK THAT AN ORGANISA- AN THAT THINK I

conditions are still uncertain and the proposed activities are little relevant. little are activities proposed the and uncertain still are conditions

after withdrawing from the country. Dr Dr country. the from withdrawing after does not agree: the security the agree: not does Bertoletti Guillermo

Marie-Noëlle Rodrigue Marie-Noëlle , lobbies for the French section to return to Mogadishu, 10 years 10 Mogadishu, to return to section French the for lobbies ,

1

Denis Gouzerh Denis returning from an exploratory mission to Somalia, accompanied by by accompanied Somalia, to mission exploratory an from returning DEBATES

MSF/October 2006 2006 MSF/October

Debate on Somalia : should MSF should : Somalia on Debate FOR OR AGAINST OR FOR

N°143 November 2006 November N°143 MSF messages P23

Interview by Olivier Fahlun Olivier by Interview it. This means that we need experienced need we that means This it. is – problem resources human internal

Dr Guillermo Bertoletti Guillermo Dr human resources capable of sustaining of capable resources human an to than religion to less related Print: Artecom. Print:

Design: Exces communication Exces Design: intervention is not possible without the without possible not is intervention been have to appear which reasons for –

TC Graphite TC

Finally, I must stress that this type of type this that stress must I Finally, Mogadishu in care free offering hospital

Layout: Sébastien Chappoton / Chappoton Sébastien Layout:

tion of a nun working at the only private only the at working nun a of tion

Translation : Caroline Serraf/TSF - Serraf/TSF Caroline : Translation

to Mogadishu. Mogadishu. to project. assassina- recent The withdrawal. our to Photo librarian: Alix Minvielle Alix librarian: Photo ■

Breuillac Breuillac responsibility for the return of our teams our of return the for responsibility a open to decide to us allow tation, led which 1997, in volunteers our of one

Editing: Caroline Livio, Brigitte Livio, Caroline Editing:

director of operations I will not take not will I operations of director presen- the seen having not, does MSF, of death tragic the of think first I teams,

Bénédicte Jeannerod Bénédicte

given in the operations meeting, as meeting, operations the in given like organisation an by satisfied be can the for danger the mention I When

Editor in chief: chief: in Editor

moment and looking at the presentation the at looking and moment that “needs” medical the and Mogadishu www.msf.fr

Fax : +33 (0) 1 48 06 68 68 68 06 48 1 (0) +33 : Fax a feeling of omnipotence. Because at the at Because omnipotence. of feeling a in team a of presence the to connected it. fill to needed resources the ultimately

Tél: +33 (0) 1 40 21 29 29 29 21 40 1 (0) +33 Tél:

in greater detail if we’re not to fall prey to prey fall to not we’re if detail greater in risks the between relation the words, and environment working our teams, the

75544 Paris Cedex 11 Cedex Paris 75544

the questions that need to be examined be to need that questions the other In them. with deal to required by taken risks the concerning questions

8, rue Saint Sabin Saint rue 8,

What for? And at what price? Those are Those price? what at And for? What means the and taken risks the mind of number certain a avoid cannot Médecins Sans Frontières Sans Médecins

mission of this kind to our volunteers. our to kind this of mission in bearing intervene, to us allow would intervene to decision this surrounding

them, I can’t see myself suggesting a suggesting myself see can’t I them, that assistance providing for motives the

« discussion the MSF, of perception

tions, which are fully compatible with my with compatible fully are which tions,

But beyond these operational considera- operational these beyond But > Somalia > © Espen Rasmussen - May 2006 May - Rasmussen Espen ©

territory, devoid of any humanitarian aid. aid. humanitarian any of devoid territory,

So we wouldn’t be going into virgin into going be wouldn’t we So

become involved in situations of conflict. of situations in involved become

proof of an operational willingness to willingness operational an of proof

capital, their presence is nevertheless is presence their capital,

Even if they are not all present in the in present all not are they if Even

already four MSF sections in Somalia. in sections MSF four already

First of all I should stress that there are there that stress should I all of First

would justify our intervention. intervention. our justify would

population – displaced or not – which – not or displaced – population

information on the health situation of the of situation health the on information

don’t work, it doesn’t give us precise us give doesn’t it work, don’t

describes the way the hospitals work, or work, hospitals the way the describes

Although the presentation clearly presentation the Although

Without a magic wand to propagate to wand magic a Without and stake at issues the defining reliably MSF. like organisation aid emergency

areas, in Darfur, in Congo or in Haiti. in or Congo in Darfur, in areas, and clearly of today capable are we an for exists that manoeuvre” for “room

already sufficiently exposed in other in exposed sufficiently already that think not do I meeting, operations the and stake at issues the on than

These resources are rare, and are and rare, are resources These the in made presentation the of view – Somalia in footing” our “regain to us

working environment comes up, and in and up, comes environment working allow would which and Rodrigue Noëlle

This is where the question of our of question the where is This Marie and Denis by up brought idea an

department of a hospital in Mogadishu – Mogadishu in hospital a of department «

us to decide to open a project. project. a open to decide to us

then this concept also becomes relative. relative. becomes also concept this then maternity the in project a opening for tion like MSF, does not [...] allow [...] not does MSF, like tion

armed guards accompanying our teams, our accompanying guards armed proposal the on less focused deliberately can be satisfied by an organisa- an by satisfied be can

[...] and the medical “needs” that “needs” medical the and [...] any intervention would have to be with be to have would intervention any was discussion The length. at matter the

[...] the relation between the risks the between relation the [...] independence, but when one knows that knows one when but independence, discussed however, have, we mission

different, especially in terms of our of terms in especially different, exploratory the of return the Following

INTERVENE IN SOMALIA. IN INTERVENE Of course one can say that we are we that say can one course Of

WHY WE SHOULD DECIDE TO DECIDE SHOULD WE WHY country long enough, despite the risks. the despite enough, long country changed. not has capital the in situation

CLEAR VIEW OF THE REASONS THE OF VIEW CLEAR armed guards and of staying in the in staying of and guards armed the that believe to me leads least

TANCES, I DO NOT HAVE A HAVE NOT DO I TANCES, more or less permanent protection of protection permanent less or more at hurdle, insurmountable an constitute IN THE CURRENT CIRCUMS- CURRENT THE IN

individuals, capable of working under the under working of capable individuals, doesn’t it if which, factor, additional an

against open a programme? a open MSF SPEAKING OUT Violence against Kosovar Albanians, NATO’s intervention INFOS 1 WATCH AND READ 1998-1999 MSF / September 2006

The “just published” seventh volume of the “MSF Speaking out” collection’s case study2 is 6TH SURGICAL DAY dedicated to the dilemmas met and to the stances during the 1998-19999 Kosovo crisis. MSF is organising its 6th Surgical Day on the 9th December 2006 on its Paris premises. The topic will be training. assets as a means of organising and - Should MSF take a position on the controlling aid. NATO intervention, or not? Presentations and debates: • Surgeon training on mission In April and May 1999, MSF on several • Getting across knowledge in occasions publicly denounced both the - What sort of relationships (financial, humanitarian situations or co- control being exercised over the refugee cooperation, etc) should be establis- building ? Transcultural camps by NATO - which was a party to hed with countries that were aspects the conflict - and the marginalisation of committed either militarily (such as • Developing self-evaluation the United Nations High Commission NATO members) or politically (Greece) • Choosing what to teach/train ? for Refugees (UNHCR). MSF underlined in the conflict? • E-training in surgery • The point of view of the the need to provide refugee protection surgeon being trained and warned about what was happening - By raising the alert about UNHCR’s • Hand trauma resulting from to the Albanian Kosovars who were still absence/withdrawal/lack of effective- mine explosions in the province, under the control of ness in managing the refugee camps, • Training in Africa: the paradox Serb forces. Throughout the period of was not MSF taking the risk of reinfor- of vesico-vaginal fistulas military operations, MSF managers cing this marginalisation? • The art of surgical companionship From March 1998, attacks on Albanian actively refuted the notion of “humani- • The difficulties of training villages by the Federal Yugoslav army tarian war” promoted by NATO. - Is it justifiable, by invoking an interpre- programmes: the case of and the Serb police increased: the tation of the impartiality principle that Ethiopia violence was exacerbated by the On 30 April 1999, MSF published a implies a responsibility to assist guerrilla action of the Kosovo Liberation report entitled “Kosovo: Accounts of a victims on both sides of a conflict, to 9th December 2006, Army (UCK). Several thousand people Deportation.” Compiled on the basis of carry out an exploratory mission that MSF, 8 rue Saint Sabin, 75011 Paris. were killed and tens of thousands more refugee accounts and an epidemiologi- sacrifices the principles of operational For further information, and to fled into the interior and over the border. cal study, this report showed that the independence? confirm attendance, please contact Kosovar Albanians were the victims of a Dr. François Boillot, MSF medical In autumn 1998, conscious of the systematic process of terror and Your comments are very welcome: department. Email : [email protected] deteriorating situation, MSF, which had expulsion, described by MSF as “depor- [email protected] ■ been working in Kosovo for several tation.” DOCUMENTARY years, decided to inform European Laurence Binet « L’AVENTURE MSF » public opinion and to increase These different stances were taken in (THE MSF ADVENTURE) awareness by publishing communiqués the context of an armed conflict in Following her book on Médecins and refugee eyewitness accounts. This which western countries were partici- 1- « Violences against Kosovars Albanians, Sans Frontières, Anne Vallaeys has campaign was widely reported in the pating directly and which they justified NATO’s intervention 1998 – 1999 » MSF now released a documentary called, L’aventure MSF , which press. by evoking human rights and humanita- Speaking Out – Laurence Binet – covers the main events in the world rian requirements. CRASH/MSF International, September in the past 35 years viewed through In Spring 1999, after several months of 2006, 324 p, internal document. the eyes of MSF. Following field fruitless negotiations, violence and This particular political environment 2- In the same collection “MSF Speaking teams, Anne Vallaeys shows how MSF “sharpens its criticial analysis population movements continued considerably reinforced the dilemmas out “ : “Salvadoran refugee camps in through its activities and the increasing. and difficulties for MSF: Honduras (1988) “; Genocide of Rwandan conflict situations it is confronted Tutsis (1994) ; Rwandan Refugee camps with “. In two parts, the first On 24 March 1999, NATO began aerial - Should it speak out to denounce Zaïre and Tanzania (1994-1995); “The retraces the period between 1968 and 1989 (from Biafra to the end bombardments of Serbia and Kosovo. violence being committed against the violence of the new Rwandan regime (1994- of the cold war) and the second The Serb forces responded by increa- Kosovars, at the risk of seeing itself 1995) ; “ Hunting and Killings of Rwandan covers the 90’s (Rwanda, Kurd sing terror, forcing hundreds of excluded by the Serb authorities from Refugee in Zaïre-Congo ( 1996-1997) ; exodus, Somalia, war in thousands of Albanian Kosovars to flee access to these people? “Famine and forced relocations in Ethiopia” Afghanistan and Iraq). to neighbouring Albania, Macedonia (1984-1986). Available in English and in To be shown on France 5, 17th and Montenegro. MSF organised a - By denouncing and describing the French through the documentation center, December at 8.40pm. number of relief operations for these violence against Kosovars, was not the CRASH – distributed in the field and refugees at the borders of Kosovo. At MSF a party to encouraging/suppor- headquarter – orders through the opera- the same time, NATO mobilised military ting the NATO intervention? tional library strongly encouraged.

P24 messages MSF N°143 November 2006