> N° 142 / September 2006 / Médecins Sans Frontières internal newsletter www.msf.fr

DOSSIER > Palestinian territories © Alan Meier - September 2005 FREUD IN THE FIELD - Round table P1 - The limits of the PTSD concept P13 - Other notions questioned P15

MISSIONS - Liban: first review P18 - Meanwhile in Gaza P20 - New programme in Jordan P22 - The question of rape in the DRC P24 MENTAL HEALTH ACTIVITIES - Our intervention in the CAR P25 - MSF’s reaction Freud in the field after the assassination of ACF members in Sri Lanka P26 MSF / July 2006 / Translated by Nina Friedman Number 142 The editors of Messages decided to contribute to the On August 6th the bodies of seventeen DEBATES reflection currently underway on the relevance of MSF Sri Lankan members of Action Contre La Faim were found in Muttur. - Dangers and risk taking: mental health programs by holding a round-table 1 They had been murdered, like the Realities that need to be discussion on July 7. The purpose of this debate was to expose the issues, criticisms, difficulties and limits local population there had been trying accepted P27 to help. In the face of this massacre, surrounding our mental health programs in their - A critical look at surgery: almost without precedent in the current form. The discussion centred on two major Surgery off track? P29 history of modern humanitarianism, themes: operational policy, and the tools used to recent press releases calling for the implement it. What follows is a partial transcript2 of respect of security for humanitarian this lively debate: workers –in Darfur and Lebanon to mention but the latest– strike a INFO particular chord. Danger is intrinsic to many of our - “MSF Logistique” > Moderators3: What factors illustrated recently in Pakistan activities. Although it is impossible to is 20 years old lead us to set up mental health and Indonesia. The questions totally protect ourselves from it, we Log Story P30 programs, and what questions raised today concern operational can try and evaluate the impact of our - Keeping in step P31 do they now raise? relevance and the mental health actions in order to ask ourselves: is it - Watch and read P33 Graziella Godain: Our mental care approach we offer, particu- worth it? The question comes up health care programs were once larly in our vertical programs. frequently, and may well come up oriented toward social violence Perhaps these issues come up again soon after a new assessment and exclusion, four years ago less when these activities are mission in Somalia. But in Colombia RESOURCES however there was a shift ancillary to a medical program, and Palestine, where the risks - Turnover and —reflecting the shift in the opera- like in Haiti, or when mental our teams take are coupled with the tional plan— toward contexts of health care is part of expanding difficulty of evaluating our mental training courses P36 instability: war zones, of course, treatment for the wounded— from health activities, we find ourselves but also natural disasters —as war or other forms of trauma The incapable of answering the question. ••• ••• problem we have in the operations MRM: Yes, Poland — Palestine isn’t also contexts in which we have department, however, is our inability the only one. But in Indonesia, for decided to stay on just for that. to interpret, criticize, and challenge example, where we have opened a Bosnia, for five years, and also these choices, and thus assess the mental health activity, we still do Kosovo. So you can’t really say these impact of such activities. Because surgery, even though there’s little are exceptions. DOSSIER we still don’t have any real tools for comparing diagnoses, treatment Pierre-Pascal Vandini: The Field Freud in the field responses, or the different approa- Coordinator decides on the response. ches of the different actors (psycho- So doing mental health alone is Because to start with there are logists or psychiatrists) — which not a goal in and of itself. several possibilities. And the decision moreover vary from one mission to But the teams sometimes is a tactical one. Bosnia is a good another. swallow goals like that! example, because we were doing >PPV anesthesia there for a long time. Marie-Rose Moro: Still, the very first Once the Dayton Accords were programme was Armenia—i.e. after signed, the question was, do we do an earthquake, when the doctors reconstruction, something else, or realized that the help people were interaction between the two activi- leave...? At the time, the Belgian asking for was clearly more psycho- ties (it would be better if there were section in particular threw itself into logical. I would also like to add more!). reconstruction, using funds from that—aside from Palestine—when institutional donors. That bothered mental health becomes the primary, GG: One of the big problems is us—not for so-called “humanitarian” or majority, activity in the field, it maintaining the connection I think reasons or because of expertise, but usually has more to do with how a necessary between the medical for tactical reasons! And what we program evolves than with an initial approach and mental health care. found in Gorazde was, primarily, decision. There are exceptions, Because, quite often, we find enormous needs of a psychological though. ourselves with two "sub-activities,” nature—the response had to be along which causes real problems with those lines. As for Palestine, from GG: Poland! relevance and choice. But there are what I remember, the first program— in Jenin—was very theoretical. There was a war, which caused mental OUR OPERATION IN ARMENIA (1988-1989)… health problems. We found the problems and responded to them, MSF / July 2006 / Translated by Frank Elliott after having explored all the other medical needs. So we focused on We delved into the MSF archives to look up the records of our operation in Armenia after the 7 December 1988 helping children at a centre for earthquake. What were the driving forces of our intervention? Here are two elements of the reply: an excerpt families and children. from the editorial of Messages dated 14 February 1989, some two months after the disaster. The second is an excerpt from Psychiatrie humanitaire en ex-Yougosalvie et en Arménie (Humanitarian psychiatry in former Yugoslavia and Armenia) published in 1995 under the direction of Marie-Rose Moro and Serge Lebovici: MRM: And the first children were suffering from enuresis. It wasn’t until we began treating bed-wetting « 7 December 1988 : one of the largest seismic « Right from the start of the humanitarian operation, shocks to take place this century wiped out the lives the doctors reports’ mentioned signs of psychological that children who had experienced of several thousand people. Unbelievable, distres- problems amongst the affected population, especially extremely severe situations came in. sing, shocking images (…). The Brussels, Paris, amongst the children. An MDM study noted, though the So it happened very gradually. Amsterdam, Barcelona and Geneva sections has semiology was not clearly defined, that 70% of the mobilised all possible resources, with the assistance children in the affected zone presented serious signs PPV: The second project we started of the EEC Emergency Fund. An all-out effort has of trauma. Reports from psychologists and psychia- was in the Terre des Hommes been launched jointly with SOS Armenia and the trists sent by MSF in the field at the time confirmed feeding centre. They told us, “The Union of Armenian Doctors in France. After the initial this. It quickly transpired that the psychological therapy mothers are crying, the children emergency phase, Médecins Sans Frontières administered on a one-off basis was insufficient. The aren’t gaining any weight.” So our proposed a medium and long-term aid programme. It Armenians asked MSF to consider setting up a health- objective was to make the link with has been agreed with the Soviet authorities. 38 MSF care facility that could provide longer term healthcare malnutrition—an objective that got doctors are still in Armenia. It is impossible to for children and their families that had been victims of summarise in just a few lines everything we have felt, the earthquake. But what kind of arrangement could lost somewhere along the way. So experienced or shared. Soon a book containing a we set up in this particular context? That’s how I was doing mental health alone is not a collection of personal accounts is to be published. If I asked to set up a healthcare facility that was able to goal in and of itself. had to encapsulate everything we have experienced respond to such an acute situation and to the specific But the teams sometimes swallow since the 7th December 1988 in one word, this word needs of the Armenian people. (…) This was the first goals like that! And there are other would be ‘emotion’». time MSF had decided to mount an operation to provide examples! I’ve visited villages where treatment for psychological problems. This need was the Field Coordinator said, “We’re dictated by the amount of psychological distress found here to do mental health,” leaving Antoine Crouan in the field». out the medical activities. That’s a Editorial of Messages – 14 February 1989 departure from the objective, too. Marie-Rose Moro, in Psychiatrie humanitaire en ex-Yougosalvie et en Arménie – PUF publications, December 1995. Rony Brauman: It’s clear what leads us to set up mental health

P2 messages MSF N°142 September 2006 programs. It’s no mystery; it’s an initial traumatic event that leads to a series of symptoms grouped under the name “post-traumatic stress disorder,” or PTSD. What Marie- Rose said is that we began with the earthquake in Armenia, that that was an event that could indeed be described as traumatic. After that, if we look objectively at MSF’s history, ignoring the particularities of the various missions, we see primarily that category of pathology. — In passing, we should note that this traumatic event is even theorized, since in Soigner malgré tout4, which is like MSF’s mental health bible, it is even recommended that popula- tions in danger be classified as level 1, 2, or 3, according to the intensity of the violence they were exposed to. Now, there’s a problem right from the start, and it’s a problem for which I feel partly responsible for; I had a different take on Armenia than Marie-Rose, because what I saw at the time was MSF asking to stay in what was an extremely compelling situation emotionally both for the French, with regard to Armenia, and for MSF, with regard to the teams. The emotional commitment took place within a new framework that was starting to emerge, and which took shape at that moment—victi- mology. That’s what led us to set up this type of activity. Moreover, we can draw a parallel with surgery. If, at certain times in our history, surgery has been part of a greater whole, integrated into other medical activities, it can also from time to time become autonomous, and exist •••

1- Participants: Rony Brauman (Fondation MSF), Graziella Godain (deputy director of operations), Annette Heinzelmann (deputy programme manager), Marie-Rose Moro (mental health advisor), Claire Reynaud (mental health officer) and Pierre-Pascal Vandini (member of the Board of Directors). 2- We were unable to reprint the entire discussion here for lack of space. In the interest of readability and coherence, we have summarized the original transcript. The entire transcript of the debate is available on the Association website at www.msf.fr/asso.

3- Bénédicte Jeannerod and Olivier 2005 - August Bolesch © Sebastian Falhun 4- Soigner malgré tout T1 et 2 MSF/Editions La Pensée sauvage - 2003 > Indonesia P3 messages MSF N°142 September 2006 ••• on its own—there are, after all, for those assessments. We’re in a precisely that it still works even reasons for making that choice. And black hole! years later! e.g. the intervention in in the same way, we do this kind of Sierra Leone in 2000. And you can’t “mental surgery”—that is how I RB: That’s just what I meant! There’s say that Gorazde is an area that has describe it critically—on its own, in a sort of growing conflict between been free of violence. So any event— DOSSIER various missions. Besides, unlike these figures, this highly construc- not necessarily violent—any trauma- Graziella, I do think we assess it, ted, even soothing, discourse, and a togenic, inaugural event, is enough Freud in the field because I read the articles! We reality of questioning, of doubts on to provide an almost automatic justi- assess, and we find excellent fication. results—results that should be the envy of everyone! On average, two > Moderators: What do you think [...] we truly have invented a thirds of our results are good or very magical treatment, because about Rony’s criticism, and about good; we truly have invented a getting such good results with the issue of trauma, the basis of magical treatment, because getting no side effects, that’s really our mental health activity? The other 'vulnerable' group such good results with no side remarkable. There’s a method we should be sharing! “most targeted by humanita- effects, that’s really remarkable. PPV: I have a problem with it. And There’s a method we should be Obviously, I’m being ironic… with how the debate is being rian aid agencies is sharing! Obviously, I’m being ironic… handled! We all began by saying that >RB 'traumatized children.' that wasn’t MSF’s history. I also gave However, Richman (1993) MRM: That’s an understatement… examples, adding that we do not observes that the emotional Because no one said we weren’t focus on trauma every time, and that well-being of children trying to assess… the content, form, methods—in it isn’t a question of MSF asking to remains reasonably intact short, a general uncertainty. If there do it, but of responses to requests if the parents, or the other RB: What I mean is, my response to wasn’t all this uncertainty, there coming from elsewhere. And Rony people they know, are with what Graziella said when she stated wouldn’t be so many of us around comes in saying “I say that it’s the them and offer a reasonably that we had a problem with assess- this table! other way around,” without any reassuring and stable ment is that, judging from what we explanation; that’s why I asked the presence. If they lose this write, it doesn’t look like there’s a PPV: In that case, Rony, can you tell question about Gorazde, because presence, the well-being problem. me what you think the traumatic there were thousands of traumatic event was that pushed us into the events, so he needs to define exactly of the children can rapidly GG: I was talking about the opera- Gorazde program? what he is talking about, to support deteriorate and the rates tions dept., because we’re not his hypothesis—especially since we of child mortality increase. comfortable with that kind of RB: Of course! In the framework of intervened at a time of peace. It is not so much about assessment. Right now, the opera- this magical treatment, we realize knowing whether the tions dept. is not capable of that early intervention is admittedly RB: Just like in Sierra Leone! “Inter- orphans and other children accepting and taking responsibility preferable. But what’s magic is venir à distance du trauma, une without protection need attention, but to ensure that this attention is provided on IN SUDAN, AMONG THE ABANDONED CHILDREN OF MYGOMA a social rather than psycho- logical level." "Mygoma is a broad medical care programme to the individual care given to the children once they (nutrition, psychosocial...) aimed at abandoned have been targeted. Derek Summerfield in “ babies and children under six years old. The mental So we must define the initial objective and the L’impact de la guerre et des health activity is defined by the very nature of our approaches, to identify the populations and their atrocités sur les populations programme. We came to the orphanage of Mygoma specific psychological needs and to adapt the objecti- civiles : principes fondamen- because infant mortality was very high, particularly ves according to the priorities. In the Darfur region, taux pour les interventions because of problems of malnutrition. But treating for example, there are definitely psychological needs des ONG et une analyse these children by simply giving them food would not in the people we are treating. But in this case psycho- critique des projets sur le have been enough. We knew that the problems of logical needs do not seem to us to be a priority today. traumatisme psychosocial – malnutrition were also connected with the situation In contrast to these adults, the children of Mygoma (The impact of war and atroci- and the environment of these orphans. Furthermore, do not have the means to overcome their difficulties ties on civilian populations: the orphanage represented an institution, which, by on their own. fundamental principles for its very nature, did not offer them the mother-child NGO interventions and a contact which is essential to their development. It As this programme is closing at the end of 2006, we critical analysis of psychoso- was, therefore, unimaginable not to include a mental are going to transfer our activities to the authorities. cial traumatism programs)– health aspect in our care package. So right from the The psychological treatment must continue after we Emergency Aid and Rehabili- start we chose a multidisciplinary approach. have left. That is why we have established links with tation Network, Thematic the university medical faculties and the students and report #14 – April 1996 The first objective was to optimise the environment we hope that the authorities will take over our team of the child in order to avoid delayed psychomotor of psychologists." development or emotional difficulties. That can be achieved through prevention. Indeed we encourage the nannies to detect difficulties in the child but also Dr Pauline Horrill, programme manager – to stimulate the infant. The second objective relates Interview by Irene Nzakou.

P4 messages MSF N°142 September 2006 The question of témoignage “is an important one. In fact, there are several kinds of témoignage. … We try to find forms adapted to the experience of the place, the time, and the environment: accounts, films, expositions of children’s drawings, anything that can enable the witnessing to be as close as possible to what we have seen, heard, and understood. Furthermore, there is direct testimony that the people themselves confide in us as witnessing. > Sudan © MSF/Caroline Livio - May 2004 In this case, the NGO, the entirety of the association, tries in a multidisciplinary urgence en Sierra Leone [“Interve- the same thing you did. The request Secondly, yes, we go places because way to find a possible form ning long after trauma, an was extremely clear, both from MSF there are events, like war, a string of for these words, drawings, emergency in Sierra Leone.”] That’s and the people themselves, who acute events or chronic break- or denunciations; for what it says in Soigner malgré tout! easily identified the issue, in direct downs… But these interventions are instance, when there is an relation to the event. And then, closely linked to MSF policy. In the official report or when PPV: You can argue with the book if gradually, we began to see cases of same way, if MSF decides to stop someone has witnessed you want, but here this is a debate depression, or anxiety that was focusing on exclusion, we’ll stop something very serious. The with people who are telling you getting worse, rather than better. We doing mental health in situations of form has to be reinvented something different, and you’re not exclusion. every time as a function of listening to us… As for the trauma issue, unlike other the content, and as a When psychotherapists tell you actors or other sections, we have GG: About Gorazde, if you say that that they’re busy trying to fit always favoured carrying out thera- function of what we there were many, many traumas and patients into a grid, rather than peutic consultations to deal with imagine is capable of giving having a grid that corresponds that wasn’t why we intervened, then situational suffering, which excludes account and of touching to the state of the patients, I why did every other page in the serious, structured psychiatric those who were not that in have a real problem with that, report, signed by Karine Le Roch, too. And yet that’s what we’re disorders. But while there are, in that place, at that time. say we were working with trauma? being told. fact, things directly related to In most of today’s projects, the traumatic events, and we probably Marie-Rose Moro, extract teams and the psychotherapists are >GG should have done a better of job of from Soigner malgré tout – “ focused on trauma—that’s what I resisting the pressure to want to put Volume 1 have a problem with! When psycho- everything under the heading of MSF / La pensée sauvage – therapists tell you that they’re busy have never said we were doing victi- trauma, Karine’s report [after April 2003 trying to fit patients into a grid, mology! And in my first meetings for Gorazde – ed.] shows that treatment rather than having a grid that the programme, there was nothing was not limited to post-traumatic corresponds to the state of the emotional going on. Rony says that situations… patients, I have a real problem with the teams absolutely wanted to that, too. And yet that’s what we’re stay—that’s not true! MSF was PPV: That “traumatic event/response” being told. monitoring the situation, and mental logic is just what I’d like to pull apart. health care became conceivable for Because in Gorazde, in the beginning, MRM: First of all, I want to respond MSF when it started considering we were responding to people who to Rony’s criticisms, because feasibility and available resources. It were having problems, not to an event. otherwise it’s not really a debate. was only afterwards that we looked One doesn’t rewrite history. I was in for the human resources to support RB: Psychiatry is the only treatment Armenia, too, and I really didn’t see the programme. technique at MSF where we put out ••• P5 messages MSF N°142 September 2006 ••• ready-made lists of signs and > Moderators: Is it the mental example to me—I think we are symptoms. And while Graziella health program itself that’s being fundamentally off the mark. Which talked about psychotherapists in the called into doubt, or is it not, more leaves unanswered the basic field having to tailor their practice to broadly, MSF’s presence in this question of whether there is a conform to certain categories, type of context? possible humanitarian response in DOSSIER personally I have a bit harsher view this type of context? of this carving away at psychological GG: Both! The purpose of our being Freud in the field signs so that they fit into the in Colombia is, above all, to provide PPV: Like you, I think it’s not the category of trauma. And we really do assisatance to a population that is psychotherapists who have insisted have to talk about the consequences victim to war. Yet most of the on trauma and who read every event of this, because it has enormous problems with which the teams are in terms of it, it’s MSF in general and consequences… it’s historical, just like we’ve gone in search of physical trauma, as in > On the discontinuity of care in Gaza: It is PPV: In that case, I’d really like to “war equals surgery!” important that the absence know what our tools for malnutrition […] we’re asked to take opera- are, if not a list of tables and Claire Reynaud: The trauma be explained, and that the tional responsibilities and techniques? It’s useful, because make operational decisions, diagnosis is something that I wasn’t absence is justified (the after your training in France, you’ve based on data that, to me, don’t acquainted with in my prior practice. absence must also be unders- never seen a malnourished child! mean very much. I learned of it at MSF, unwillingly— tood and accepted by us, so It’s the same thing for mental >AH because I was not comfortable with as to avoid any inner health. the notion, or with the victimological conflicts we might face). approach. My goal, when MSF began However, there are paradoxi- > Moderators: Annette, based on collecting accounts (I participated) cal situations where one is your experience in Colombia and confronted are socioeconomic in was rather to show the operations not able to respond to the Palestine, for example, what is nature, and are not specifically war- dept. what we were doing and tell most obvious needs. The your view of these programs? related—though the war doesn’t them how we were doing it, by help matters. This insistence on describing the suffering that the premise of quality that MSF Annette Heinzelmann: The questions treating, no matter what—which in patients were experiencing and how has made its own - reaching I have are less about Palestine— this case involves mental health we were treating it—were we going inaccessible populations - where there’s a much clearer care, but which could just as easily to see them individually, in small ‘may’ at times not exist. We humanitarian issue—than Colombia: involve mobile medical clinics— groups (for children, for example), must consider this and take are we relevant there? Does what we results in care that is inappropriate as a family, etc.? Were we going to it as it is. offer correspond to the needs of the and ill-suited to the context. The do psychotherapy or psychological All this to say that the ideal population? Do the results justify the people who pass through the support...? The idea was to have has always been and risks that our teams are taking? Etc. mission say they’re looking for something concrete, to have remains to try to be in the trauma, since the original objective feedback on our activity, and then to right place, which will allow This is where I concur with Graziella: was war, and “war equals trauma!” be able to analyze it. The list of signs we feel that the means at our And they realize that they don’t have comes from the DSM-IV (American us to reweave the symbolism disposal don’t allow us to evaluate much trauma! But it’s the whole classification system of mental and give meaning back…. these questions. And there’s also MSF organisation—not just mental disorders – editor’s note), and it’s the issue of knowing how. health—that bears responsibility for true that there are problems with this excessively interventionist, the DSM-IV. Maryvonne Bargues MSF Psychiatrist in Gaza – Because we’re asked to take opera- trauma-oriented interpretation, Palestinian Territories tional responsibilities and make which has now created a significant > Moderators: Which brings us operational decisions, based on data rift. Because once again—and back to the notion of PTSD, which that, to me, don’t mean very much. Colombia seems like a good is also being questioned. Rony, what, in your opinion, are the consequences of using an MENTAL HEALTH CARE PROGRAMMES MAINTAINED IN GAZA approach based on such notions?

Translated by Penny Hewson made their way to us, asking to start consultations RB: PTSD is a very unique psychia- “Despite the deterioration in security conditions again as soon as possible. These had been broken off tric classification in that it’s the only (there are fewer and fewer foreigners in Gaza), we when the expatriates who were in Jerusalem at the one—and this is what distinguishes have decided to maintain our mental health activities. beginning of the military operations had not been able Because the targeted assassinations cause a lot of to return to Gaza. They have been taking place again it—that is entirely defined by its civilian casualties, people being in the wrong place at since 18 July which saw the return of our psycholo- etiology, that is, by its origin. There the wrong time, stress and nervousness are making gists and the resumption of the treatment – at home is a causal event, a situation deemed themselves felt more and more within the population. and at fixed points – when security conditions allow. profoundly abnormal, and then the The noise of explosions is constant and terrifying, Nevertheless, access remains particularly problema- individual’s reaction. PTSD is what particularly for children. The violence, the consequen- tic in the zones to the north of the Gaza strip near the some have called a normal response ces of daily incursions and shell fire can generate bombardment zones. “ to an abnormal situation. While psycho-pathological reactions which need to be dealt we’re at it, we might well wonder at with quickly. Thus, despite how difficult it is to travel Laura Brav, Head of mission the objective of going to the other around, some patients – particularly those from the in the Palestinian Territories side of the world to tell someone areas most affected by Operation Summer Rain – have Interview by Isabelle Merny that what he has is normal. But on

P6 messages MSF N°142 September 2006 > Palestinian territories © Alexandre Sargos - May 2004 the theoretical level, since what A PROJECT CALLED INTO QUESTION IN POLAND defines PTSD is the event, the unconscious is taken out of the "In October 2004, MSF carried out an exploratory from the viewpoint of integration into Polish society reaction—which puts us in the mission in Poland, a country that had just joined the than with a will to grant refugee status. The category of what’s called cognitive, European Union, to assess the situation of the Chechens are not being sent back to Russia or turned or cognitive-behavioral, therapy. But Chechen populations who were arriving in Europe to back at the Polish border; they are not stigmatized, what I don’t like is trying to have it request asylum there. they are not in danger. both ways at once. That is, we claim In August 2005, we decided to open a mission and to On the other hand, the Chechens do not wish to stay to take a psychodynamic approach, develop a psychological assistance program there in in Poland, and are trying to reach the more Western therapeutic listening to patients, but the 14 centers for asylum seekers spread across countries, particularly Germany, Belgium, and at the same time we’re developing three geographical regions (Warsaw, Lublin, and France. Despite their efforts, more and more of them techniques that belong to CBT— Bialystok). This intervention was justified because it are being sent back to Poland under the Dublin II cognitive-behavioral therapy—and in was aimed at Chechen refugees who were fleeing regulation. For this population, Poland is an isolated from the violence they had suffered in Chechnya, but country, surrounded on the East by the new reinfor- my opinion, it’s this sort of clumsy also because their mental suffering had not been ced European border between Russia and Poland, syncretism that makes this treated, neither by the Polish authorities nor by and on the West by the Schengen border with approach seem fairly shaky... anyone else. Germany. We are facing the issue of European policy Because I don’t know how we can In February 2006, I wanted to question not only the on controlling immigration flows and asylum talk about analytic listening when relevance of the MSF operation, but also the program seekers, and its consequences in terms of travels, the unconscious is disregarded, and that we chose to develop, namely a vertical mental confinement, etc. we give a series of 4 or 5 sessions on health program. Beyond the question of vertical mental health average. But what’s also annoying is Although I did not in any way deny the mental programs, what place is there for MSF in the twists that the conscious mind is disregar- suffering of this population, it was our "raison d'être" and turns of policies on asylum seekers? ded, too! Since when you read about in Poland that posed a problem for me. Where is the The Poland mission will be closing at the end of Indonesia, for example, you read issue? To my eyes, it is elsewhere. 2006." The Polish authorities, with the resources they have that there were 500,000 potential available, are providing the Chechens with assistance victims of trauma, among whom we – medical care, lodging, food, social services – more Malika Saïm, programme manager had to go find the ones who were asking for help. And we realize that ••• P7 messages MSF N°142 September 2006 MOBILE “MEDICO-PSYCHOLOGICAL” CLINICS IN THE REGION OF TOLIMA (COLOMBIA)

“In 2001 MSF opened a programme of mobile clinics several times to the same place when we registered DOSSIER to supply the people affected by the conflict which is patients who had been psychologically affected by the raging in the region of Tolima. The objective was to violence and whom we needed to follow up. The Freud in the field go places that the hospital staff cannot reach, unless choice of intervention zones was made according to an international organization can ensure their the violent events which had recently taken place protection. there. The trend was therefore reversed. At present, In 2003, the conflict evolved. The intensity of fighting it is the medical care which goes with the psychologi- between the armed combatants decreased and the cal and which serves to “identify” the patients. But health services were able to reach rural areas more the interaction between the medical and mental easily. Nevertheless, the climate of generalized health activities is interesting. It allows us to treat the violence against civilians, used as a means of control- pain and distress of the same patient, even if the M. is a woman who ling territory, continued. It was during this period diseases are often benign. “experienced a violent that the doctors reported that behind the everyday Regarding the impact which we are having on the incident four years ago. In ailments they treated were hidden the effects of people in our mental health activities, we offer them violence (somatic illnesses). Indeed, a study carried the opportunity to unburden themselves by offering her village, many people out by our doctors, and confirmed by an evaluation them a space for talking and listening, taking into were murdered, including carried out by a psychiatrist, showed that 10 % of the account the suspicion and mistrust which exists (…) her friend and the patients presented significant signs of psychological between the members of a community, sometimes godfather of her son (…). distress, most of them linked to a trauma or a direct even within a family. As for the patients who are Three months ago, there event of the conflict. followed up, we help them to connect their suffering was armed fighting in her Thus, since the end of November 2003, a psychologist with an event or a situation which caused it, in order has been part of each mobile team in order to be able to try to alleviate some of their distress. Although it is village. This had a strong to treat patients suffering from problems connected little when viewed on the level of a department, it is a emotional impact on her with the conflict. This objective was, however, limited lot when one puts oneself in the position of the whole family. She was since the clinics only went to a zone once and patient who comes through the door of our surgery discouraged, suffered from therefore there was no possibility of follow-up of with this enormous need to get rid of his distress and insomnia, had breathing patients. Given the situation, we rectified our mode of when he no longer knows how to deal with it.” operation in 2005. Thus, we doubled our psychologi- problems, and ‘psychosis’, a cal team to meet demand and started returning Stéphane Doyon, Head of Mission in Colombia term that she used to describe a state of anguish and permanent concern at ••• the idea that more armed we’re going out looking for clients! as a whole, on this point: at some simply would not allow us to work on fighting could break out at So I have a theoretical/practical moment in time we have to describe unconscious fantasy and to offer any moment. During problem with that. where we start from with patients interpretations on unconscious consultation, M. realized The second thing that seems and where we end up—it’s the same fantasy, it’s just not possible! the benefit of being able to questionable to me is that all this is for all the missions. I well Besides, the 500,000 people Rony talk to and especially to be based on the liberating power of remember countless meetings on mentioned is a figure I took from the able to place trust in talking, which several studies are the subject, which Epicentre later WHO for one of my exploratory someone. When she was calling into question. Armed with this joined in on. Of course, they [these mission reports, but we never set up instrumental technique of using talk lists – transl.] are open to criticism, a system for 500,000! We set up an asked at the end of psycho- as a release, we can intervene indefi- but they aren’t intended to describe extremely individualized system: a therapy if she understood nitely. This explains the widely-held the whole of one’s mental life. They consultation, attached to a hospital the reason for her improve- impression that when we don’t know supplement the record, the clinical internal medicine service, where ment, she responded that if what to do, we do mental health! history. either patients or doctors requested one does not let go of what mental health care. Let me also is attached, one cannot MRM: I don’t agree that we let remind you that the only condition relax confusion take root. With regard to for going is to treat—unlike, for Colombia, if we think that the risks With regard to Colombia, if we example, the Dutch, who do preven- are too great and the benefits think that the risks are too tion. They are the ones, for example, Diego Fernando Mercado, “ secondary, then it is urgent that we great and the benefits who give out little sheets saying MSF Psychologist in the ask ourselves about the humanita- secondary, then it is urgent that "These are normal reactions to an Tolima region in Colombia. we ask ourselves about the rian response overall. Because this abnormal event." We have always Extract from “La psychologie humanitarian response overall. clinique auprès des popula- issue isn’t just about mental health, offered individual therapy, or group tions affectées par le conflit it’s about MSF’s ability, will and >MRM therapy in certain cases, and we Colombien.” (Clinical policy in this particular context. An don’t impose any conditions other psychology among popula- issue which is also evolving. than that of the clinician. The tions affected by the On the question of lists, we have used psychotherapists can have different Colombian conflict.) lists throughout our history—lists of As for the unconscious, of course it’s types of training. If they don’t symptoms, for example. Some are not disregarded! Each person has a agree—that is, if they don’t feel obsolete; others have stood up quite mental representation that includes qualified to provide individual well. We have also evolved, with MSF all dimensions, but the framework therapy, then they don’t go.

P8 messages MSF N°142 September 2006 > Indonesia © Sebastian Bolesch - August 2005

Finally, there’s the issue of libera- RPs when it comes to making centered on a single issue, involving because it made things simpler for tion through talking... It’s not about decisions and choosing directions? operational choices with which we’re us, and allowed a direct relationship liberation through talking; it’s about You get the impression from this extremely uncomfortable. Most of with the operational reorientation. the importance of narrative. To debate that the psychotherapists the time, we’re faced with no-choice The fact that, afterwards, the opera- establish a relationship with a have taken over MSF! The implica- situations, which are unacceptable, tions dept. pressed to get tools, patient—which is the basis of all tion is that MSF has allowed itself to since I myself am incapable of didn’t follow the tools that were individual psychotherapy—you must be manipulated! This denies MSF's having either a positive or negative created, wasn't necessarily involved share a narrative. Of course, the involvement and history, by ignoring or didn’t involve itself in those tools, patient will often say to you, “It does the responsibility and the uncertain- that’s a reality, too! What we can say me good to talk.” There are also ties—both past and present—of the now about the dynamic between the patients who say, “I can’t talk about heads of mission, the RPs, the MSF You get the impression from operations dept. and psychothera- that!” But it’s less a question of actors. this debate that the psychothe- pists at MSF is that it doesn’t exist. obligation than of necessity, in order rapists have taken over MSF! We can’t say that the work we're The implication is that MSF has to begin a therapeutic consultation. RB: I began by saying that it was a doing on this issue, together, is allowed itself to be manipula- Yet is everything based on the notion question of collective responsibility, adequate. And we will already have ted! This denies MSF's involve- of talking that frees? Yes, in the and I include myself, because back ment and history, by ignoring accomplished something if this sense that it is necessary for the then in Armenia, I thought this the responsibility and the debate helps us re-establish a patient to be able to say a certain approach had some validity. I also uncertainties—both past and number of ties—specifically, one: number of things related to what he said that there was a problem with present—of the heads of operational aims and why we do this has experienced, his suffering, etc. the fundamental concept upon which mission, the RPs, the MSF program; two: how we do it; three: There again, however, we respect we have based a whole series of actors. how we assess it; and four: when do the fact that, in certain cases, in the interventions and operations, that’s >PPV we stop doing it... interest of self-protection, it is all! Because up until now, we never better not to talk, and to be able to close because we think we’ve develop inner resources. MRM: But we didn’t base it on a treated the people we wanted to concept of diagnosis. That’s just opinion on the impact of our activi- treat, or because we’ve gone all the PPV: I find it outrageous to focus the where I don’t agree either with what ties. That’s the reality! Though it’s way to the end of our intervention. debate on the issues that Rony is implied... also true that when the concept of brought up, which are theoretical trauma came along, it made PPV: I agree with the problem as issues for specialists. Where is GG: Be that as it may, all this has everyone more comfortable— you’ve stated it. But what does the MSF’s responsibility, where are the brought us to a rigid interpretation including the operations dept.— notion of the liberating power of talk ••• P9 messages MSF N°142 September 2006 DOSSIER Freud in the field

What should we do if “certain patients, despite everything, through every- thing, remain the same and slowly die before our eyes? Well, at least we will have succeeded in alleviating their suffering and not profiting from the care we gave them, compelling them to face ‘normalisation’ obligations that overtake them and wound them. Let > Haiti © Dieter Telemans - October 2004 us not add to their pain and accept, humbly, as health- ••• care workers, to comply have to do with this debate? This is national health staff have a problem than 72 hours I’ll give her with the first Hippocratic an attack, which doesn’t resolve the with trying to get a woman to talk— emergency contraceptives, but I’ve principle: First, do no harm problem and which implies that particularly about what she’s been got a real problem with the rest!” So there’s a malign psychiatric through—and that the benefits of there’s a real problem of commit- Extract from Patrick influence at MSF. this talking are questioned by these ment to these issues. Declerck: Les naufragés, “ expatriates or national staff who (The shipwrecked), Terre GG: Yet these are day-to-day issues! believe, on the contrary, that it is PPV: That makes me wonder about Humaine collection, Pocket, For example, as part of the operatio- counterproductive. People today tell the training that doctors are getting, Plon - 2001 nal plan we are now looking to treat me, “Sorry, a rape victim, I’ll do a more than anything else! victims of sexual violence. The medical examination, I’ll do a gynae- reality is that some expatriate or cological examination, if it’s less > Moderators: For those of you in the operations dept., what, in IN OUR TUBERCULOSIS PROGRAMME IN ABKHAZIA: practical terms, are your expecta- tions from the psychotherapists?

“Psychological counselling began in the second half MDR patients suffer from severe anxiety and 58% AH: First, there’s a real need to seek of 2005 in Abkhazia, where we were running two from moderate depression. The main goal of this out a dialogue, and to have a closer programmes: one providing access to health care, psychological support is to help patients overcome relationship with the psychiatrists mainly for the elderly, and the other concerning the these problems. and psychologists, similar to that treatment of tuberculosis, including multi-drug- We have just begun and are counselling patients who which we have, as a matter of resistant tuberculosis (MDR). Initially, MDR patients have been receiving medical care for more than two were to be the primary focus of psychological years. We should therefore wait a little longer to course, with the medical dept.. For therapy, with some therapy devoted to the health care evaluate the impact of psychological support on their the moment it feels like our discus- access programme, particularly palliative care for quality of life. The patients are, however, very inter- sions just go round and round, patients in the last stage of their illness (such as ested in working with psychologists and are happy without any resolution of recurring cancer). But at the present time, we are mainly with this new aspect of the programme. I think that issues. Result: our actions suffer, concentrating on the TB/MDR programme. counselling plays a key role in resolving problems between the fear of setting up some The major objective of psychological counselling for related to TB patients adhering to their treatment excuse for a program and not MDR patients is to help them scrupulously follow regimen and preventing others from abandoning knowing which elements would their treatment regimen and handle all the difficul- treatment.” allow us to stop our activities. We ties imposed by this chronic disease. The drugs they also need to demystify the mental take have many side effects. Recent analyses Dr Babak Abbaszadeh – health programs. We don’t really conducted by our psychologists show that 77% of Medical coordinator in Georgia know what’s going on, how it’s happening, etc., or why it is that

P10 messages MSF N°142 September 2006 these programs occupy such a specific place within the projects. If IN HAITI, MENTAL HEALTH INTEGRATED INTO THE PROJECT we want to do it—and here I’m getting away from any theoretical “Psychological assistance for patients emerged no sense in my opinion. To recognise and treat the discussion—in that case, what is the naturally in March 2005 thanks to a local partnership mental distress of victims who have undergone great best way to get there, and to with the organization Healing Hands for Haiti (HHH) physical traumas seems to me to be ethically very integrate it? And why is it so hard, which had a Haitian psychologist at its disposal. MSF relevant and allows us to widen the range of care we wanted to further in the care provided to its patients, provide and therefore the quality of the medical like this discussion? The fact is we whom were mostly victims of serious traumas. The treatment. Furthermore, this significantly improves wouldn't be fighting so much if we creation of the Pacot rehabilitation centre, combining the patient/carer relationship by humanizing it, which were talking about malaria! psychological help and physiotherapy, has allowed is obviously important in a humanitarian approach. this ambitious step to become reality in terms of One can however question the limits of the psycholo- GG: The various RPs involved in medical quality and complements our traumatology gical intervention. I think it would be difficult to these projects also do comparisons, centre opened in 2004. include mental illnesses of a psychiatric nature in the and when they compare Colombia The first objective was to create an environment programme, although we frequently come across and Palestine, saying, “Marie-Rose which would promote the physical and mental rehabi- them. On the other hand, I am personally sceptical told us that in Colombia, two or litation of our patients. The centre was installed in an about the universality of mental health practices, three sessions do the trick!” Then enormous Creole building from the beginning of the even more so in a country where voodoo beliefs are we plan eight to ten sessions in last century, situated in the heart of the residential widespread. That is why I am not sure that this district of Pacot. Moving the patients into this relati- activity would have been able to function without the Palestine, etc. We can’t work that vely calm place – most of them come from shanty presence of local psychologists, which are not way! The operations department towns where violence is omnipresent – helps create a available in all our intervention countries. Some of can’t play its critical role, can’t beginning of serenity which is ideal for this type of the victims are also perpetrators of violence. Apart assess the quality of what’s being care. Psychological support, based on listening, is from the problems of cohabitation between victim done, or make real choices on given to the victims of trauma (victims of aggression, and aggressor which sometimes occur, I wonder operational strategy, it’s not gunshot wounded, amputees, raped women), and what our mental health options are in trying to possible. This leads the operations also to their families. This helps to alleviate some of address the perpetration of violence in a healthcare dept. to throw up its hands, leaving their distress and to reassure patients who have been approach. Can violence be cured? ’’ the psychotherapists free to practice particularly badly affected. as they like, and no one understands The mental health care activity in Haiti is integrated anything about what they’re doing. into the traumatology centre; otherwise it would have Yann Libessart, Head of mission in Haiti That’s where things stand!

MRM: But the conditions in which we be resolved. Unlike the psychodynamic MRM: Is it a problem that there are various therapies have in common, work in Colombia are different! approach, which depends much more people with different training? than on specific factors, such as on the individual’s reaction and What’s an even bigger problem are training in psychoanalysis, CBT, or CR: I think we should to try to come commitment, the cognitive therapies actually the personalities! And that’s something else... So I think we need up with treatment diagrams or are presented as extremely structu- why we need a serious effort—not to make an effort on the common methods. It’s true that these books red, with a beginning, an end, a specific to mental health, but really factors and objectives. It’s obvious have a lot of theoretical stuff in progression, a practice, a tactical very important for mental health in that there’s a real need for the them, but there are few practical approach that’s highly compatible with terms of the recruitment issue— operations dept., for links, interac- elements. We’ve put together a measurement, assessment, forecas- while still being somewhat practical. tions and discussions on these working group with the operations ting, predictability—everything the There is, though, something that issues. But it has to go both ways, dept. that should improve the psychodynamic approach is not! But I and I think that if this debate interface between the two entities. don’t see MSF choosing one method actually contributes to that, it will be Because there are many experien- over the other. I think a certain eclecti- a good thing. For the moment it feels like our ces, and many issues for which we cism is possible, and that there should discussions just go round and There is another element implicit in should try to offer some guidelines. be a certain pragmatism, as well. round, without any resolution of this debate, which is—I’ve had this And there will no doubt be some Because it seems to me that the recurring issues. Result: our position for a long time at MSF— debate. For example, I am more person doing the therapeutic work is actions suffer, between the fear having to defend psychology as part comfortable talking about distress, more important than their theoretical of setting up some excuse for a of medical action. I agree completely or suffering, but perhaps we'll have origins. However, in terms of prepara- program and not knowing with Pierre-Pascal when he says to talk disease... The working group tion, training, or recruitment, these which elements would allow us that it’s part of medical training! I’m to stop our activities. consists mainly of physicians. approaches raise a lot of questions for going to take the example of talking >AH me. when caring for a woman who has > Moderators: What, exactly, are the suffered sexual violence. Of course different approaches? And what is PPV: But that’s the way it is at MSF! you can refer her to the specialists, MSF’s approach? The guidelines have been very but that comes later. In the useful, and have absolutely not connects us all—the psychothera- beginning, it’s up to everyone. Even CR: There are big debates, at the stopped any doctor leaving for the pists, the RPs, etc.—and that’s the with drugs, I hear remarks all the international level, regarding the most field from questioning their matter of providing treatment. If, for time such as, “I don’t want to effective approach. Is it the cognitive contents, when treating a case of example, an American tells us that prescribe antidepressants, because therapies (more Anglo-Saxon in origin) malaria or pneumonia. Practices he wasn’t trained to do individual I’m not a specialist.” Yet antidepres- or psychoanalysis-inspired psychody- differ from one doctor to another in a therapy, then he won’t go. In other sants are available and easy to namic therapies (more francophone in given mission, and it’s the same for words, our actions will be based prescribe. That’s something that is origin)? Personally, I don’t think it can mental health. more on the goal, and factors the everyone’s problem—improving our ••• P11 messages MSF N°142 September 2006 ••• ability to practice medicine in all its little while ago. Confronted with this one of the services we provide. dimensions. The psychological mélange where two incompatible That’s not what this discussion is dimension is part of medicine, too— approaches are artificially made to about. What it is about is our ability general medicine! You can’t say that be compatible, we end up choosing to think much more collectively it’s the realm of specialists only. the easiest, the one that squares about the issues raised earlier. And DOSSIER As to talking, don’t we use talking best with MSF, based on the causal we won’t move forward on this if we when dealing with someone who has event, using the DSM-IV for think of it as just the psychothera- Freud in the field been through something really diagnosis, and brief individual, pists’ problem, and frame the debate serious? We inevitably incorporate family or group therapy. It’s the type ideologically, as Rony is doing. talking, in wondering how far to go and Besides, the positive feedback from when to ask for a specialist—that is, in the people in the field and from the deciding at what point we think the populations—I’m thinking of These kind of activities need to be patient’s suffering—and the quality of Guatemala, for example—should better integrated into MSF’s our actions—demands further action operational plan. There also needs calm, to some extent, these ideolo- We seem more comfortable on the part of a psychologist or to be discussion and exchange on gical quarrels. “in our missions when we psychiatrist. But before getting to that this subject. This is a goal to which that point, the question is, “Should we I’m going to devote myself at MSF, GG: I don’t agree with your apparent offer mental health care in or shouldn’t we try to get this person starting from the principle that assessment of our action in the same way that we do to talk?” That depends. It’s true that mental health care isn’t just the Guatemala. other care included in the you can’t generalize. It’s true that you psychotherapists’ problem. >CR wide range of health care must be willing to hear difficult things PPV: Just recently, when listing the we provide, which is what in order to have a relationship in which topics to be discussed at the Board of we seek to develop in the the person can say what’s hurting him. Directors meeting, the wording used future. We are less comfor- Again, this comes up before the of treatment that I oppose at the in talking about mental health table when a project is question of technique. very root. But there’s no doubt, in my programs was really different from based only on mental health As for deciding when to stop our activi- mind, that there’s a place for the rest, which shows that they are care. This is perhaps an ties, it’s true that this needs to be psychiatric treatment at MSF in poorly integrated within MSF. It was arguable statement, but it is discussed; not because there is no “multidisciplinary” programs. I want Marc Le Pape [member of the BoD – as if this reminds us that longer a need for mental health care, to say it again, because we’re almost ed.] who pointed out that we were but because there are no longer at the end of the discussion. talking about the problem of psychia- mental health care by itself enough reasons to stay. I repeat: we trists/psychologists at MSF, and not cannot be the reason for will never be able to say that a need no GG: For me, this debate is a prelimi- about mental health care at MSF, beginning a project in situa- longer exists. But when we close a nary to the working group. The idea before also mentioning some work tions where the needs are tuberculosis program, it’s not because isn’t just to discuss the question of that Rony is currently doing. Again, to difficult to define: this may there’s no more tuberculosis. We stop technique, but also to explore the me it seems that that’s ignoring the be because the humanita- because the conditions are no longer original intention; to see why we program managers, Claire’s rian nature of our actions is sufficient to continue. Otherwise, it choose to intervene and treat existence, and our presence here at difficult to prove, or because goes from being rigorous to being people, and how we might assess this table. And again, I agree with the other local and internatio- extremely rigorist—it would be these interventions and improve operational assessment, with the fact nal actors are present and rigidity! them. For years there hasn’t been that the RPs cannot monitor, that they active. (…) We must also the space or the time for this discus- don’t have tools to help in decision- not forget the other domains > Moderators: To conclude, how sion. Result: from the field to the making... But I also think there’s a do you see the position of mental program managers, more and more recurrent problem at MSF, of no of our medical practices in health care at MSF? people want to stop taking responsi- longer knowing how to make which mental health is not bility for this type of activity. And decisions. The fact that we’re yet very developed, which RB: I’d like to go back to the while I think that these programs demanding to make them is rather seems unacceptable. I am question of the general choice made have a place, it is important that they positive, at least. Now we’ll have to thinking of treatment for by MSF. It was not completely made, have the same place as others—that find ways of working together that will HIV patients or victims of since there was actually a desire to is, that they are debated, critiqued, allow us to share our experiences. sexual violence. These are take into account the specific and looked at in the same way as examples that merit discus- constraints on an NGO that recruits others. The same is true for commu- CR: It seems to me that MSF has sion. Is the mental health on an international level—Marie- nication around mental health failed to take ownership of mental approach as well integrated Rose was right to emphasize the activities. The “technique, communi- health, and that it has been kept as we would like? It is personality issue—but that is practi- cation, operation” triptych has not outside a bit. These kind of activities doubtful cally an unsolvable issue. On the worked, at least not well enough, need to be better integrated into other hand, what is solvable, in a from my perspective. How do we talk MSF’s operational plan. There also way, is the choice of framework. about these activities, how do we get needs to be discussion and Pierre Salignon, This choice was made, and one of my them across, and how do we explain exchange on this subject. This is a General director“ criticisms is that the consequences them? The working group needs to goal to which I’m going to devote are not accepted. We are driven to deal with these questions, too. myself at MSF, starting from the make a choice, without which we principle that mental health care end up with this sort of theoretical MRM: I don’t think the issue of isn’t just the psychotherapists’ ambiguity, causing the anger and whether MSF should do mental problem. ■ irritation that Annette spoke of a health is really up for debate. It’s Summarized by O.F.

P12 messages MSF N°142 September 2006 ON TRAUMA…. The limits of the PTSD concept

MSF / August 2006 / Translated by Anne Wiles

Although humanitarian psychiatry and emergency intervention provide fertile ground for development of a response focused on post-traumatic stress disorder (PTSD), they also experience the risks and limits of its implementation. With extensive field experience, Jacky Roptin, a psychologist working with MSF since 2002, tells us about the risks of overusing this concept at MSF.

Right from the start the concept of it is not uncommon to see organiza- PTSD came up against an impasse. tions like MSF centre on PTSD to DIAGNOSTIC CRITERIA FOR POST- Encompassing all trauma situations, initiate, legitimize, or perpetuate TRAUMATIC STRESS DISORDER (PTSD) it tended to give all suffering the same action or to justify definition of a target (SOURCE: SOIGNER MALGRÉ TOUT, T1. MSF – LA PENSÉE SAUVAGE, APRIL 2003) significance without differentiating population. Although it may seem between the nature and issues of logical to pay more attention to violent natural violence and inter-human events, the “race to the event” A. The subject was exposed to 3) Unable to recall an violence. resulting from the trauma approach a traumatic event that included important aspect of the the following two factors: trauma. By focusing the description of trauma presents real risks to our programs. 1) The subject experienced, 4) Clearly less interested in on the fact that “the patient conti- Crisis intervention is not always witnessed, or was confronted important activities or less nually re-experiences the traumatic appropriate for the circumstances. with an event or events in participation in the same event,” PTSD made it the common Again with the example of Palestine, which individuals died or were activites. denominator for trauma (by citing our intervention is sometimes very seriously injured or were 5) Feels detached from others nightmares, for example) and extremely close to the violent and threatened with death or or becomes estranged from relegates many other psychological media-generating event and can serious injury or in which the others. and social consequences to the hinder periods of mourning for subject or others were physi- 6) Restricted range of affect. background. It does not represent all families and contribute to talk of victi- cally threatened; 7) Sense of foreshortened post-traumatic pathologies however; mization or martyrs or the construc- 2) The subject reacted to the future. far from it. For example, after five tion of good victims. event with intense fear, helplessness, or horror. D. Persistent symptoms of years of continuous violence in increased arousal as indicated Palestine, the symptoms have moved This leaves aside those who are B. The traumatic event is by at least two of the following away from the PTSD model. sometimes more vulnerable but persistently re-experienced in manifestations: suffer far from the media and out of one or more of the following 1) Difficulty sleeping or staying The problems faced by teams can take sight of the community.. ways: asleep. the form of severe parental depres- 1) Recurrent, intrusive, distres- 2) Irritability or outbursts of sion (with possible outbursts of > CONTROVERSIAL sing recollections of the event anger. violence) as much as severe CONCEPTS AND CONTRO- including images, thoughts, or 3) Difficulty concentrating. emotional deprivation in children or VERSIAL THERAPY perceptions. 4) Hypervigilance. risk-taking behaviors in adolescents, 2) Recurrent distressing 5) Exaggerated startle sometimes with clearly expressed Trauma and PTSD became the choice dreams of the event. response. 3) Sudden feeling or acting-out talk of suicide. We can also cite the concepts through their “easy” as if the event would reoccur. E. The disturbance (criteria B, program for victims of sexual violence diagnosis and consequent action. In 4) Intense psychic distress C, and D symptoms) lasts more in Congo-Brazzaville, where we have an organization like MSF, and beyond when exposed to cues evoking than a month seen a high rate of anxiety and major the oversimplified and reassuring or resembling an aspect of the depression, a low rate of reliving the view that these concepts can bring, traumatic event. trauma, and significant somatic they presuppose the idea of action 5) Physiologic reactivation F. The disturbance causes clini- complaints associated with an intense based on treatment that functions like when exposed to cues resem- cally significant suffering or a decrease in libido. Here also, for lack a protocol – the “short-term trauma bling an aspect of the traumatic change in social, work, or other of a match with certain symptoms therapy.” As soon the notion of PTSD event. important area functioning. described in PTSD, we risked was defined, psychic trauma very inferring that there were no problems quickly benefited from development of C. Persistent avoidance of stimuli associated with the Specify if: and denying very real suffering. therapeutic practices that were trauma and numbing of Acute: for symptoms lasting supposed to respond to PTSD, or at general responsiveness as less than three months. > THE THRESHOLD EFFECT least to prevent it. From there came indicated by at least three of Chronic: for symptoms lasting the recommendation for early inter- the following manifestations: three months or more. By focusing on the symptoms consi- vention whose aim, beyond the triage 1) Avoids activities, places, or dered specific to trauma, one also function, is long-term prevention of people that arouse memories Specify if: risks brushing aside any other form of more disabling symptoms. These of the trauma. Delayed occurrence: for psychological injury and making PTSD practices have found some legitimacy 2) Avoids thoughts, feelings, or symptoms starting at least six a diagnosis that highlights a deeper in specific situations such as natural conversations associated with months after the stress factor. suffering and legitimizes therapeutic disasters or accidents, because the the trauma. action. After a war or natural disaster, events are acute, time-limited crises. ••• P13 messages MSF N°142 September 2006 > TOWARDS A NEW DESCRIPTION OF SUFFERING

In its most ideological version, the DOSSIER trauma approach approved and implemented by a professional or an Freud in the field institution can result in the de-politi- cization of suffering by diluting its political or social origins in individual psychic functioning. The Vietnam War demonstrated this. The request that > The consequences of was made to us in Palestine by the identifying Vietnam Minister of Health demonstrated it again when it meant managing veterans' psychiatric adolescents who were throwing disorders as PTSD. stones on the Israeli forces and the Minister considered them “traumati- ‘For the first time in the zed by war.” Here again, the trauma history of post-traumatic approach tends to place the pathology disorders, the authors of label on behavior whose logic can also aggression figure beside be in keeping with both political 'their' victims as victims analysis (response to the violence and themselves. PTSD offers this the occupation) and sociocultural possibility of diagnosing analysis (adult ambivalence when anybody presenting a faced with violence, which is psychological disorder after condemned within the family but sometimes contradictorily legitimized an abnormal event, whether > Colombia © Stephan Vanfleteren - October 2005 on the outside). he be the aggressor or the victim. The auto-traumati- ••• The trauma and PTSD approach thus sed aggressor, to use The psychological practices in difficult in practice to act immediately finds its source not only in the Young's wording, is a question would therefore only be of after the event. dominance and diffusion capabilities victim practically like any interest in the time immediately of DSM-IV (U.S. system for classifica- other. The parallel with following these events. With the > FROM REALITY TO MYTH tion of mental disorders) but also in medical trauma also works, exception of these specific situations, the tacit complicity that our institutio- to the extent where a north many MSF patient injuries stem from Early and specific situation (described nal constraints impose on us American psychiatrist chronic crises or chaotic lives. It thus above) intervention aside, are short- (urgency, transparency, and optimiza- publicly affirmed that the seems difficult if not illusory to distin- term therapies a myth? Not if we tion). By succumbing to the current question of the direction of guish the psychological suffering consider that they do not draw their climate and sometimes becoming the related to a recent event from conse- legitimacy from this concept (PTSD) fascinating mirror of reality and the violence -i.e. whether quences related to a course of life and that our practice is primarily vocabulary of war and emergency, inflicted or suffered- was events. defined by its goal – to care, to provide this approach functions as circular not any more relevant to a relief, and to console. From a thera- self-justification. psychiatrist than to a In the case in point, the suffering of peutic standpoint, however, our inter- surgeon, as 'the treatment these patients cannot be reduced to ventions are structured around Freezing the perspectives of humani- of a fractured leg is the PTSD grid and to therapeutic defining priorities and viable tarian psychiatry, it reduces the identical - whether the methods that are more like a magic treatment objectives for the patient, approach while magnifying the effects patient has inflicted or formula in their situation. With an taking into account the operational of the response it generates. If we do received the blow'. approach focused on PTSD and crisis constraints of insufficient resources, not wonder about the motives of our intervention, the ability of Palestinians the need for minimum impact, and the mental health programs, this to grasp the clinical aspects short length of missions of psycholo- approach can therefore go from R. Rechtman in Etre victime, described above in the opening gists. opening doors for our operations to généalogie d’une condition paragraph was quickly limited or Consequently, our ambition for action hindering our mental health activities, clinique – L’évolution psychia- exceeded. In the case of Congo- cannot exceed the associated where psychological practice is trique, éditions scientifiques et ■ médicales Elsevier SAS - 2002. Brazzaville, the social and family constraints. In its unifying tendency alienated and devitalized. disruption after rape was considered and simplified descriptions, however, one of the main sources of suffering the trauma and PTSD approach opens Jacky Roptin for many women seen between 2002 up the prospect of a perfect match and 2004. In addition, a study of 178 between our mental health activities 1- With overdeveloped diagnosis, patients during the same period and epidemiological principles1 - at development of therapy that resembles showed that 80% of them had been the risk of distorting reality and protocols, defining the number of seen more than a month after the overestimating the impact of our sessions, or evaluation and optimization aggression, demonstrating that it is intervention. of programs.

P14 messages MSF N°142 September 2006 OTHER NOTIONS QUESTIONED… From victim status to the notion of resilience

MSF / August 2006 / Translated by Alison Keroak

Other questions are regularly debated and raise, particularly in specialized literature, a certain number of criticisms. From the victim's condition to the limits of témoignage, while touching on the notion of resilience, here is a glimpse of some of the criticisms levied, some of which go beyond the framework of our mental health programmes. We have attempted to summarize them here succinctly. "Saida remains standing “and screams to resist. She relates that sometimes she screams, even alone, to release the anger and the agony that seize her. There was this one time when a young neighborhood boy, who could have been her son, the son she never had, this young boy set off a land mine left voluntarily by the Israeli military during one of their so-called "punitive" nighttime forays. His body flew through the window of Saida’s house. … It was upon her return that she discovered the body, the blood, the horror. She had > Palestinian territories © Alan Meier - September 2005 seen far worse things, but this event made all the rest One of themes addressed in the > THE CONDITION OF THE psychiatric clinician". An echo of this unbearable. … According to debate, which we were not able to VICTIM can also be found in an anecdote her own terms, she had lost publish in full due to lack of space, provided by Derek Summerfield2, her dignity – as a woman, concerned the issue of témoignage. Beyond the question of témoignage, psychiatrist and expert council for as a wife, as a Palestinian, Rony Brauman points out the affinity there is the larger issue of the role of Oxfam. He cites the example of an and doubtless as a potential that exists between psychiatric psychiatry and of its possible [editor’s expatriate fro ••• mother…" practice and témoignage, in order to emphasis] ‘traps’. Richard Rechtman, highlight their limitations. Drawing psychiatrist and anthropologist, in his Marie-Rose Moro, extract from an example in Soigner malgré article entitled "Etre victime, généa- 1- In an example from Soigner malgré 1 from Soigner malgré tout – “ tout , he laments that the psychologi- logie d’une condition clinique" (Being tout (see in margin), Rony Brauman, Volume 1 cal reality of the patient is sometimes a victim, genealogy of a clinical without denying the psychological reality MSF / La pensée sauvage – transformed by psychologists into a condition), recalls the beginnings of of Mrs. Saida's remarks, criticizes how April 2003 historical fact, leading to significant an approach focused on PTSD, which, they were used. He claims that the mines theoretical confusion "between the according to him, changed the way in left voluntarily by the Israeli army in sign and the event, the view and the which we set about trauma victims. Gaza, and the effects that they produce facts". Marie Rose Mono challenges For Rechtman, the process of legiti- when a child steps on one – projected as if this analysis, clarifying that it is only a mizing victimology " is based more from a catapult – are two facts that could matter of "retracing the patient’s and more on the clinical approach to not exist, and thus he disputes the way in theory, retranscribing the patient’s the victim. … From the certainty of a which Marie Rose expresses them. psychological life in order to give it a human condition, we have passed to a 2- "L’impact de la guerre et des atrocités (sometimes partial) meaning, but that diagnostic certainty ... at the cost of a sur les populations civiles : principes allows the patient to rediscover his or profound change from the system of fondamentaux pour les interventions des her life force" [Marie Rose discussed truth attached to the narration of the ONG et une analyse critique des projets at length the question of témoignage trauma". Thus, according to sur le traumatisme psychosocial", by in a chapter of Soigner malgré tout, Rechtman, the condition of the victim Derek Summerfield – Réseau Aide an excerpt of which has been printed depends now on the event and on "the d’urgence et réhabilitation, Dossier on page 5. – Editor’s note]. granting of victim status by the thématique n°14 – April 1996

P15 messages MSF N°142 September 2006 m an NGO in Rwanda who strove to difficulties when applied to other vable for believers in resilience, who gather information on sleep distur- populations. While a certain number favor instead a tendency to sublimate bances (one of the characteristics of of safeguards exist to compensate for the subject, drawing from its traumatic neurosis), while the local this problem, Summerfield relates symptoms "resources for the benefit population believed that no matter nonetheless the words of one his of society". DOSSIER what the response, that was not the colleagues, close to MSF, who issue, anyway. observed that the local staff often had > MOURNING Freud in the field a tendency to "overemphasize In their 1994 article, Kleinman and > "NEITHER PATIENTS Western psychology and underesti- Desjarlais mention mourning to point NOR VICTIMS" mate their own cultural contexts". out that, according to the DSM, Noting that the local professionals suffering must necessarily come to an This is what both Arthur Kleinman had received—almost by definition – a end. "We must come to the end of and Robert Desjarlais tell us3, both of mainly Western education, this everything, even memory," they write. whom are activists "for an ethnogra- colleague presumed that "this brings The two anthropologists questioned phy of political violence". The two them closer to their Western collea- this, suggesting that it would be prefe- Freud in a famous observa- anthropologists sometimes blame gues, but alienates them from the rable to "celebrate the memory of “tion described the game of a psychologists and psychiatrists for communities that they serve". traumas rather than to evade them". child who was trying to creating "the notion of violence as an Summerfield carries the criticism They continued that "commemorating control his anguish linked event that can be studied indepen- even further: while affirming that collective traumas is one of the ways to the absence of his dently of the context in which it Western psychology concepts are by which countries cultivate memory". 5 mother. The child was happened, under the pretext that its presented as authoritative knowledge, Assoun also comes back to this idea throwing a bobbin, that he effects on people are supposedly he stresses "the risk of unintentio- of "successful mourning", or of universal". Kleinman and Desjarlais nally perpetuating the colonial "mourning well done"; a believer in held by a thread, far away ask the question: "What sense is mindset in the Third World". resilience will give substance to the out of sight. The child there in conferring a victim status or a According to him, the irony of history idea that the work needs to be done shouted, in German, “fort” patient status on those who have been is that patients bet on receiving aid by for the subject to heal. However, (far, gone). Then, pulling on subjected to political violence?" For presenting themselves as a "moder- drawing from the works of Freud6, the thread, he would make them, it is more a question of viewing nized" victim, by minimizing their own Assoun insists on the fact that the bobbin reappear. When those who suffer from violence as knowledge, their own potential, or mourning is done in any case. It is a he saw it reappear he "social sufferers" in order to, in parti- even their own fury... reactive and unconscious process of laughed and cried “da” cular, "clarify the way in which large- disinvestment from the lost object, (there, here). scale forces alter interpersonal > RESISTANCE TO subjected to the vagaries of narcis- 4 Through this observation relations". While they do not dispute RESILIENCE ? sism and the relation to the lost Freud asked what sense the need for medical institutions to Paul-Laurent Assoun, psychoanalyst, object. We would not know how to could a repeated consider those who suffer as patients addresses the question of "resilience attempt to mourn "well", he tells us. first, they are nevertheless skeptical put to the test by psychoanalysis" in And rather than "crow about the microtrauma have, in the when "the medicalization of suffering his October 2003 article "La résilience expression of pathological mourning" framework of the theory of goes beyond the hospital compound, à l’épreuve de la psychanalyse" in regarding a subject who has the a psychic functioning of the and becomes an integral part of Synapse. Going back to the metallur- tendency to relive the original loss in primacy of pleasure. ordinary discussion on violence and gic definition of résilience as the such-and-such context, we must This led him to rethink the its consequences". According to them, ability of a material to withstand question precisely what conditions psychoanalytical theory the wounds and scars or the tragedy shock, he notes that the notion of cause the subject to relive the initial and, later, the formulation of suffering then become the object of resilience, which has now found its grief. For a psychoanalyst, the ideal of of a hypothesis on the appropriation for others, which allows way into everyday usage, emphasizes resilience reinforces itself at the cost death wish. them to be made visible according to the possibility of the individual to not of a distortion of the Freudian the criteria imposed by the media, only resist a traumatogenic event, but theory. ■ who have a taste for the sensational, to derive suggestions from it on the O.F. Patrick Declerck,“ excerpt at the risk of "masking the common- individual's capacity for post- 3- "Ni patients ni victimes – Pour une from: Les naufragés, place forms of daily violence". traumatic restoration, and on his or ethnographie de la violence politique." collection Terre Humaine, her potential for "creativity"; in other Arthur Kleinman and Robert Desjarlais, Pocket, Plon - 2001 > "UNIVERSAL" words, on his or her capacity to "make Actes de la recherche en sciences RESPONSES TO the best out of a bad situation". For sociales, n°104 – 1994. "UNIVERSAL" EFFECTS him, Nietzsche’s famous expression, 4- The French word résilience only "Whatever does not kill us makes us translates to "resilience" in English Another striking point raised by stronger" is given a new twist by within the context of psychiatry. The Summerfield concerns the origins of believers in resilience, since rather French word is usually translated as the elaborating the response to trauma- than see a "will to power" (title of a technical term "impact resistance". The togenic situations. For a psychiatrist, work by Nietzsche), which could very French term as used in psychiatry seems the majority of projects are in fact well express itself as a death wish to have taken on the connotations of the inspired from the hypothesis of a (see in margin), they only see in it a English "resilient", as in a material that "universal" response. He says, life force. By turning the former can not only withstand or resist the shock "Western diagnostic systems, mainly towards the exterior, one of the most of an impact, but also "bounce back" from concerned with classifying illnesses successful forms of resilience would it. – translator's note rather than patients", pose serious be delinquency and crime, inconcei- 5- Op. cit.

P16 messages MSF N°142 September 2006 > To read:

We drew from a number of articles and publications to write this article:

- Psychiatrie humanitaire en ex- Yougoslavie et en Arménie, by M.-R. Moro et S. Lebovici – Presses universitaires de France, December 2005

- Soigner malgré tout, Volume I et II, by T. Baubet, K. Le Roch ; D. Bitar, M.-R. Moro – MSF, éditions La pensée sauvage, April and october 2003

- L’impact de la guerre et des atrocités sur les populations civiles : principes fondamen- taux pour les interventions des ONG et une analyse critique des projets sur le traumatisme psychosocial, by Derek Summerfield – Réseau Aide d’urgence et réhabilitation, Dossier thématique n°14 – April 1996

- Effects of war : moral knowledge, revenge, reconci- liation and medicalised concepts of « recovery », by Derek Summerfield – Article in le British Medical Journal – November 2002. (sélection du Crash)

- La résilience à l’épreuve de la psychanalyse, by P.-L. Assoun – Article in Synapses n°198, october 2003

- Ni patients ni victimes – Pour une ethnographie de la violence politique, by Arthur Kleinman et Robert Desjarlais – Article in Actes de la recherche en sciences sociales, n°104 – 1994.

- Etre victime, généalogie d’une condition clinique, by R. Rechtman – Article in L’évolution psychiatrique, éditions scientifiques et médicales Elsevier SAS - 2002.

- De la charité hystérique à la fonction asilaire, Patrick Declerck, extract from Les naufragés, Patrick Declerck, collection Terre Humaine, Pocket, Plon - 2001. © Thierry Buignet / September 2003 © Thierry Buignet / September (sélection du Crash) > Guatemala

P17 messages MSF N°142 September 2006 LEBANON EMERGENCY First assessment after the ceasefire MSF / 14 August 2006 / Translated by Steven Durose © Kadir Van Lohuizen/Agence VU - August 2006 VU - August Lohuizen/Agence © Kadir Van > Lebanon

A ceasefire recently brought relative calm to Lebanon and Israel, one month after the outbreak of hostilities. Just hours after the agreement came into force, thousands of people started the journey back to their home regions. Mercedes Tatay, a doctor and Emergency Desk manager, looks back on the work of the French section of MSF during the month-long conflict.

MISSION > What were our main priorities in Lebanon? LEBANON A few days after the Israelis first bombed Beirut airport, we sent a team into the area, although we were aware that the Lebanese, [who LEBANON disposed of] support networks, a healthcare system, and Lebanese medical teams, had adequate Beirut resources for responding to this type of crisis, and that we would only play a Aley supporting role. And that’s what happened: most displaced people Joub were given shelter by their families or Jannine Sayda SYRIA were housed by communities in Jezzine Quaraaoun public buildings and reception Nabatiye centres, while overall the medical system continued to function. After MSF activities up to 8 August 2006 Sour assessing the needs not being met by Tibnin all sections: (before the ceasefire) the Lebanese on the ground, we Bent Jbail Places where MSF focused our operations on two areas: is running a project we supplied equipment to displaced Places where MSF is supporting existing medical assistance families who had been hit the hardest in the Aaley and Chouf regions, where

P18 messages MSF N°142 September 2006 certain villages – such as Kayfoun – PRESS had seen their population triple in REVIEW OF MSF ACTIVITIES 14 AUGUST 2006 (ALL SECTIONS): size; in addition, we administered REVIEW follow-up medical care to people 310 tonnes of relief supplies were sent by MSF to Lebanon and neighbou- MSF / 21 August 2006 / O.F. suffering from chronic conditions. ring countries to help displaced Lebanese populations. These people had fled their homes > Speaking out and The supplies included a variety of equipment: and were no longer in a position to keeping silent in - hygiene kits receive care from their treating physi- - kitchen utensils Lebanon cians… We therefore provided them - blankets, mattresses and tents Just before the ceasefire in with a bridging service and supplied - dialysis equipment, medication, surgery kits Lebanon, Jan Egeland, Under any necessary medication. - sanitation equipment for ensuring a supply of water, water tanks, Secretary General for Humani- vehicles, etc. tarian Affairs at the UN stated > What role do you expect the MSF indignantly, “it’s an absolute to perform now that a ceasefire is 6 teams have been deployed on the ground: in place? - in Beirut disgrace.” Egeland was quoted Since the ceasefire took effect, large - in Aaley, in the Chouf region in the Dauphiné Libéré on 11 numbers of displaced persons have - in Sidon and Tyr August. The newspaper was - in Jezzine quickly returned to their regions, reporting on his comments that - in Damascus, Syria including villages in the south, some humanitarian organisations - in Cyprius of which have been partly destroyed, were unable to gain access to while others have been completely An estimated total of around 45,000 displaced people in Lebanon and 8,500 southern Lebanon. A journalist flattened. The Lebanese have refugees in Syria have received cooking equipment, mattresses, blankets, writing in the same edition responded well to this latest develop- cooking stoves and hygiene kits containing soap, rasors, tooth brushes, etc. quoted an MSF press release ment, just as they did at the start of from the day before, which the crisis. Those who have lost their reported MSF’s intention to homes will be taken in by their family “work around the Israeli or neighbours. Both doctors and the we intervened in two highly specific populations with access to medical health service were able to operate areas of the crisis, and I think that we care during the fighting. The embargo on travelling around throughout the conflict, so there’s no provided a really useful service. Lebanese people we met told us that southern Lebanon”. At the reason why they shouldn’t do so now. the presence of these international same time, the president of the There’s also a very strong political Our activities had a far from insignifi- teams was a source of comfort for Secours Populaire described interest for the Lebanese government cant impact in another respect: by them. By working in close cooperation the conflict as a “humanitarian and political organisations such as transporting large amounts of with populations and providing a tsunami”, a statement that was Hezbollah to occupy the area and to equipment into the interior of the supportive presence, while maintai- ellipitical, to say the least, but ensure these people are resettled as country, the MSF movement managed ning a space in which to carry out our at any rate effective, since it efficiently as possible. to break the blockade of Lebanon and work… it seems to me that we fulfilled was taken up by numerous ■ weakened the stranglehold on the our humanitarian role. media organizations. It did not, The United Nations is also currently country. We also tried to make the however, prevent the organisa- deploying major resources in the belligerents respect a space for Dr Mercedes Tatay tion from delivering 80 tonnes area. If the truce holds, Lebanon will medical care and to provide civilian Interview by B.J. soon enter a period of reconstruction of relief supplies… by boat. during which, as an emergency medical organisation, we won’t have a major role to play.

> Does that mean that we’re leaving Lebanon? It’s still too early to say, but our teams in Chouf have wrapped up their activi- ties for the time being. We’re going to monitor the situation and keep an eye on families as they return to see if the medical support we provide is still required. As for the future, we’re still ready to intervene in any new emergency that arises before a multi- national force is deployed in the area.

> What’s your take on the MSF operation? Did we provide real added value? We have reason to be humbled by the Lebanese who, once again, provided the lion’s share of the response. But > Lebanon © Kadir Van Lohuizen/Agence VU - August 2006

P19 messages MSF N°142 September 2006 MISSION PALESTINIAN TERRITORIES

> Is it difficult not to take sides in a conflict? Taking Lebanon as an example, doesn’t Israel need assistance too?

We asked the Israeli autho- rities if they needed outside > Palestinian territories © Laura Brav/MSF - November 2005 assistance in providing MEANWHILE… relief to displaced popula- tions. But knowing the situation in Israel, we were New incursion in Gaza acting out of principle, because fortunately the MSF / 2 August 2006 / Translated by Colin Smith Israelis are able to manage Following the kidnapping of one of its soldiers, the Israeli army has once again entered their own assistance to the the Gaza strip. This operation, referred to as ‘Summer rain’, started on 28th June 2006 civilian population and and has caused extensive damage to people and property. Our head of mission Laura wounded military reports: personnel, and it works pretty well. Lebanon, on the other hand, is experiencing “On the 6th of July I managed to get electricity supply has still not been themselves cut off from the grid for interruptions in relief into the Gaza Strip with our field fully restored (the power lines have days at a time (Rafah was without th th supplies, while shortages of coordinator, one doctor and a logistics been repaired but are regularly power between the 7 and 13 July). medication, food and fuel specialist. We evaluated the situation destroyed again) some areas find Without electricity or fuel, water can in order to plan the assistance are starting to be felt almost required. CONCERNING THE SITUATION IN GAZA AND everywhere… Operation ‘Summer rain’ is still underway, with movement of Israeli OUR ACTIVITIES (AS OF 2 AUGUST 2006) Jean-Hervé Bradol, President tanks and heavy shelling of the north of MSF, interviewed on the of the Gaza strip. Meanwhile, - Power is restored, on average, for 6 to 8 hours per day; water for radio station, RMC, 10 August ‘Qassams’ (home-made Palestinian 2 to 3 hours per day 2006 rockets) are being fired daily into - There are 22 hospitals and 58 Health centres in Gaza. 75% of hospital services are operational, 22 centres have their own Israel from Gaza. generators, 21 have been set aside for emergencies, 12 are working > THE RAVAGES OF around the clock, 4 for 12 hours per day. - MSF has made donations to the main hospitals and specific orders ‘SUMMER RAIN’ (especially for treatment of chronic psychiatric conditions) have In addition to loss of life (between the been placed. Urgent medicines and medical equipment have been 28th of June, when ‘Summer rain’ donated or lined up for hospitals located in the front line and th started, and the 18 of July, 101 handling the injured. people were killed in Gaza, more than - Storage tanks and water have been supplied to a group of half of them civilians; more than 300 refugees (40 families, about 400 people) fleeing the shelling of Al have been injured during the incur- Shoka (a district close to the airport). A water supply system (two sions and attacks) ‘Summer rain’ has storage tanks connected to a well) is going to be installed for a caused extensive damage to infras- community at risk in the north-east of the Gaza strip. Food supplies tructure. Gaza’s only power station, will be distributed by UNRWA, the WFP and the ICRC. which feeds the hundred or so water - A surgeon will be dispatched to Gaza in order to provide short and pumps supplying the area, was medium term support to hospitals in the area. destroyed in the bombing. Since the

P20 messages MSF N°142 September 2006 neither be pumped nor stored. problem of dealing with the chroni- by the incursions – within the Gaza Supplies to the north-west of the Gaza cally ill (cancer, diabetes, etc.) also strip – and to some communities strip were suspended for a long time arises, since these cases can no affected in particular by the lack of after pipes were destroyed: with each longer be referred to neighbouring water and electricity: in the El Fara incursion, new water storage tanks countries such as Egypt, Israel or towers, where we had already worked are destroyed and access to wells Jordan for treatment with the appro- in 2005, in the Bedouin village of Siafa, made impossible. The reservoir priate equipment or medication, situated next to the waste water holding waste water (in the north) is which doesn’t exist in Gaza. We have reservoir and cut off from the electri- full as it can no longer be drained made contact with the hospitals in the city grid, and in the north-east, where (again due to lack of fuel and electri- region. For the time being, electricity a community is unable to move due to city). Nor has refuse been collected generators allow hospitals to continue continuous shelling. for several weeks in some areas. to operate. The injured receive correct medical attention, operating theatres At the beginning of June we met and > SUPPLY PROBLEMS are functioning and surgeons are assisted 200 families living on or near The Karni Crossing, a major transit available… We have made some the front line and shelling zones. point for goods, is not always open, donations, but it is difficult for the Since then they have been regularly and all the junctions are partially or hospitals to operate in this manner, under shelling and explosions. completely closed. Under pressure waiting for the next donation, without from the US and the UN, access has knowing when it will come and what it Today, MSF is monitoring the situation been improved, but remains never- will consist of. We are maintaining closely (numbers of injured, houses theless strictly controlled by the close contact with the hospitals, so destroyed, people fleeing the region, Israeli army, which maintains a that we can respond to medical patients suffering in particular from constant presence around Karni. shortages, and any requirements for psychological problems and people Health workers have not been paid for medical staff, emergency services, or who have received – or not –food and five months. In spite of this, and supplies for intensive care units. equipment) and remains ready to shortages of medical equipment, intervene.”■ electricity and fuel, doctors and > AMONG THE POPULATION nurses carry on working. However it From a logistical point of view, on is difficult to provide care at all levels, occasions MSF comes to the aid Laura Brav, especially for less urgent cases. The certain groups of population displaced interview by Isabelle Merny

> Palestinian territories © Bruce Frank / MSF - August 2005

P21 messages MSF N°142 September 2006 JORDAN / IRAQ Amman, a window to Iraq

MSF Amman, Jordan – July 2006

MISSION On August 3rd our teams in Jordan went to Amman airport to pick up the first seven JORDAN / IRAQ patients from Baghdad. The first plastic surgery operation was carried out three days later. A look back at how this project came about and how MSF is back in Iraq, without being there….

> Iraq © MSF / Ismaël Fouad - July 2006

THE CHOICE OF JORDAN Three years after the Iraq war of 2003, and therapeutic equipment resulting the evolution of the situation in the in the loss of lives that could be saved. Although Syria, Kuwait and the Iraqi Kurdistan all represent potential inter- country and the increasing violence Due to insecurity, lack of access, vention countries, the choice of Jordan as a base of operations was made for has had dramatic consequences on limited ability to collect reliable infor- many reasons. The principle factor was that Jordan already has a high level the population. The situation in Iraq mation, inadequate emergency of medical care that has been developed in this country over many years and has deteriorated, especially following response capacity of national and it undeniably represents a platform for professional exchanges especially the bomb attack in February this year local institutions and lack of adequate with MSF’s new surgical approach. Moreover, due to this level of medical care, Jordan offers possibilities of locally available quality drugs and medical against the Shiite mausoleum of funding, the collective national and materials. The implementation of the MSF free of charge surgical platform Samara that further marked the road international response to emergency will also be accessible to the most vulnerable patients who would not have to civil war and sparked a particularly health needs in Iraq remains insuffi- access to the hospitals in Jordan as they remain expensive. In addition, the large outbreak of violence. This cient. Hundreds of civilians have been partnership that we have established with the Jordan Red Crescent hospital violence varies from medium to large- killed or wounded because of blind will make it acceptable and possible for Iraqis to come and be treated in a scale armed conflicts in certain attacks, targeted murders and culturally friendly environment. These first contacts have paved the way for localized areas, to terrorist bombings military operations. Many people have a fruitful ground for common understanding. Last but not least, within the in crowded areas that result in mass had to leave their homes, displaced by framework of this project we aim to assist patients coming from the Palesti- casualties. According to evaluations force or by fear of sectarian violence. nian Occupied Territories who may need the same kind of reconstructive by health professionals from Iraq, the In addition, this trend of deterioration surgery. The proximity of Jordan and the willingness of the authorities to public health facilities, emergency of the health system coupled with the facilitate the implementation and operation of this project make it easier to envisage its establishment in the Hashemite Kingdom where 60% of the rooms and key hospitals are finding it increasing violence is pushing a population is of Palestinian origin. Although we have chosen to base our difficult to deal with the increasing growing number of highly qualified operations in Jordan, we will not exclude the fact that we will need to further numbers of causalities. The operation doctors to leave the country. Those develop constructive relations with each of these countries, to reactivate our rooms, the specialized medical, remaining in Iraq are in need of ties where possible and to develop field contacts in order to study other surgical, gynaecological and paedia- support in order to accomplish their potential intervention areas. tric departments all over the country medical endeavours in assisting the continue to lack sufficient diagnostic victims of violence.

P22 messages MSF N°142 September 2006 > RETURNING TO IRAQ IN PARTNERSHIP THE ORGANISATION OF THE SURGICAL PLATFORM MSF established a coordination office in May 2006 in Amman. It has signed a Although MSF withdrew from its memorandum of understanding with the Jordan Red Crescent (JRC) in order to activities in Iraq in November 2004, it establish the surgical platform within the operation theatre of the Jordan Red remained in contact with members of Crescent Hospital (JRCH) which is based in Al Wahdat, a popular Palestinian quarter PRESS the Diaspora, especially through the of Amman city. The cooperation with the President of the JRC, who is also the UAE office. Through these regular Chairman of the Standing Committee of the Red Cross and Red Crescent in Geneva, REVIEW contacts, MSF was contacted in seems very promising. MSF have already undertaken in-depth evaluations of the operation theatre (OT), the intensive care unit (ICU), and the recovery rooms with an November 2005 by a number of Iraqi (CONTINUED) anaesthetist doctor and an OT nurse. The JRCH will make available 20 permanent surgeons and medical doctors who beds in the in-patients ward, which can be extended by an additional 60 beds if offered to provide their services to needed. The MSF team has evaluated the hospital capacity of accommodating a help during the earthquake in maxillofacial, plastic and orthopaedic surgical platform from a technical, protocol > Darfur: still a cause Pakistan. These same doctors were and human resource point of view. It has negotiated all the administrative, logistical for concern met by MSF teams in Pakistan where and legal issues that will allow the smooth transport, entrance to Jordan and stay of “Forgotten causes” was a first discussion was held to assess the patients and the people accompanying them. The team has evaluated and the headline of an article the possibility of working together in studied the importation and local purchase possibilities for the drugs and medical featured in the 17 August the Iraqi context. By April 2006, a materials needed for the project. edition of the French meeting was organised between MSF members and certain doctors who > A POSSIBILITY FOR This will also be possible thanks to weekly La Vie devoted to had worked in Pakistan. These PALESTINIAN PATIENTS the Memorandum of Understanding the crises currently doctors told us that it was not Coupled with this project, which is that was signed between MSF and the “causing concern for advisable for MSF to open a project geared towards Iraqi patients, and Iraqi MOH allowing this framework, humanitarian inside Iraq, given the violent security taking into account the recent provided that the MOH is informed organisations”. Although situation that is a risk for foreigners evolution in the Palestinian Occupied about the evolution of the project. the article makes no and Iraqis alike. We discussed possi- Territories after the election of Hamas Several hospitals are already doing mention of the nutritional bilities of collaborating together and and the subsequent decision of the this type of direct supply. situation in Niger, or the came up with the idea of a partners- donor community to restrain from prevailing climate of hip, with MSF covering administrative cooperating with the newly elected This project set-up may seem atypical insecurity in North Kivu and logistical matters and our Iraqi government, MSF is also envisaging compared to other MSF projects. We colleagues the operational side. The the possibility of setting up a referral are far from the ‘proximity to the (DRC) and northern CAR, it project would also include a surgical system to Jordan for Palestinian patient’ interventions that characteri- does refer to the conflict in project in Amman for patients that patients who might need corrective ses MSF’s programmes. But at the Darfur; a crisis described cannot be treated in Iraq, due not only surgical treatments. Meanwhile, the same time, the current situation, as being “held at arms to lack of surgical material but also to MSF mission in Palestine has especially in Iraq, does not allow any length by international the violence and forced departure of conducted a similar survey and is immediate in-country intervention for relief efforts” and which, qualified human resources to treat assessing the eventual medical MSF. Nevertheless, through this new quoting Guillermo Berto- patients requiring orthopaedic, plastic needs. Once the initial phase of the working framework, we are aiming to letti, “will not be resolved and maxillofacial reconstructive project established, we could –if the assist patients in need of reconstruc- until a political solution is surgery. Militiamen do not respect the event arises- work closely with the tive surgery but who do not have found to the conflict”. Ten right to treatment of the wounded, MSF teams in Palestine for the access to it due to the non-respect of and they indiscriminately burst into referral of Palestinian patients who health facilities by warring factions in days earlier, the UN hospitals to arrest patients or health might need this kind of surgery. Iraq today. Furthemore, through the expressed its concern “in professionals. These patients cannot supply of emergency medical material the face of rising violence therefore be properly treated because > THE CONSTRAINTS and drugs to pre-selected hospitals in in Darfur, in the west of they prefer to leave the hospitals as It was quickly decided to set up our Iraq we will be able to help our Iraqi Sudan, which has caused soon as they have received the first reconstructive surgery programme in colleagues carry out their medical the death of more humani- treatments. Jordan. Given the insecurity and duty in this volatile context. This type tarian workers in the last Within this partnership agreement chaos in Iraq, it was impossible to of partnership will open the door to two weeks than in the there is also the project of supplying envisage referring patients requiring new interventions in the region. So previous two years”, much needed basic surgical and emergency attention. In order not to far, the first contacts in the region has reported the French daily emergency medical material and endanger further our Iraqi collea- proven positive. The Emirates Medical drugs to selected hospitals in gues, who are already risk their lives Association has also expressed its Le Monde in an article Baghdad to start with and later daily, we will have to develop at least interest in the project and other published on 8 August. gradually to hospitals in other areas at the beginning, simple and discreet supports are in the process of being “Increased insecurity in Iraq. This component of the project mechanisms for the identification and explored. This initial phase should hampers MSF medical is as important as the surgical referral of patients. The same will be give us the opportunity to broaden our assistance in Darfur,” component. Refurbishing the set up for the supply of the pre- network of contacts within the Iraqi declared MSF in a press hospitals will give our colleagues in selected hospitals, for which we will communities, which, if the possibility release dated 3 August. Iraq better means to address have to find suppliers who have arises, will help us intervene in Iraq emergencies and to tackle the offices and warehouses in Amman itself. ■ growing demand for treatment of and Baghdad. Using these suppliers, wounded people and of casualties due we will have a direct line of supply Ismaël Fouad to violence. from the suppliers to the hospitals. Head of Mission MSF-Amman

P23 messages MSF N°142 September 2006 DEMOCRATIC REPUBLIC OF CONGO: Rape as a Weapon in North Kivu

MSF / July 2006 MISSION DEMOCRATIC In the Democratic Republic of Congo (DRC), rape forms part of the daily reality for REPUBLIC women living in the North Kivu province, where violence has reigned for several years. OF CONGO In 2005, Médecins Sans Frontières (MSF) teams admitted 1,292 women who were victims of sexual violence and as many again in the first six months of 2006. These figures are extremely disturbing; however they only reflect a very small part of reality in this eastern region. Malika Saim, MSF programme manager for the DRC, outlines the response our teams are providing to the situation..

Rape is used as a tool to terrorize within five days, we offer the the population, and the number of morning-after pill to avoid unwanted cases increases with each new pregnancy. Medical treatment also outbreak of fighting and attacks. involves prophylactic antibiotics While young girls under 18 are parti- against the most common sexually cularly targeted (close to 40 transmitted infections (syphilis, percent), the most affected age gonorrhea, and chlamydia), and group is between the ages of 19 and 45 (53.6 percent). These are the women who work in the fields in order to provide for their families. […] several aspects are still to The acts of aggression against them be improved and questions take place mainly in the fields but remain concerning the need to test —or not — the victim's also on the roads used to get there. serology before giving an ARV Consequently, women limit their prophylaxis, the addressing of travel. Thus, in our supplementary psychological suffering within feeding centers in Kayna, mothers medical treatment, and also the have preferred to find accommoda- limits we apply regarding legal tion in the direct vicinity rather than procedures. returning each week to get rations for their children. In the eastern regions of the DRC, while rape is etched into the general framework tetanus and hepatitis-B vaccina- of violence, it's also seen as fully tions. The treatment of physical legitimate "additional retribution" by trauma such as lesions, wounds, or the armed groups. other injuries is also recommended. Follow-up is extensive and the total > What is MSF's response to this duration of medical treatment is at > Democratic Republic of Congo © Jodi Bieber - October 2003 violence? least six months. When setting up On an operational level, we must this type of medical care, it is > How do you explain the extent of adopt a transversal approach and essential from the very outset to sexual violence in the North Kivu systematically try to offer specific identify a facility where women can province? care in all our medical programs be referred to for an abortion. Sexual violence is embedded within (whether primary or secondary Abortion is illegal in DRC, so we the general context of violence care). To begin with, it's essential to have negotiated the possibility of perpetrated by the several armed work with community groups and carrying it out at local level, with the groups present in this region. This existing health facilities to increase head doctors in the health zone, as violence takes many forms: rape, awareness about the issue. On a well as also with our practitioners. but also looting, crime, and armed medical level, early consultation fighting for the control of villages or after rape is vital, and must be Additionally, on a legal level and for roads. In this environment, where undertaken within 72 hours. In this reasons of protection, a medical armed groups are always harassing period of time, it's actually possible certificate attesting rape is systema- the population, women are particu- to administer to the woman an tically issued and offered to the larly at risk. More than three antiretroviral (ARV) prophylaxis, patient. In 2005, in our North Kivu quarters of the women that we have which makes her less susceptible to projects, 17 percent of women treated have been raped by unknown HIV infection —a very significant risk accepted the medical certificate and armed soldiers. factor to take into account. Then, 21 percent filed a complaint with the

P24 messages MSF N°142 September 2006 local authorities. It is essential we increased— it is access to treatment an ARV prophylaxis, the addressing raises the issue of its political strive to guarantee our two main that has improved. The message is of psychological suffering within objective. Abortion is an issue that principles — confidentiality and free beginning to be delivered widely. The medical treatment, and also the remains completely unresolved in a health care. proportion of treatments in the 72- limits we apply regarding legal country like the DRC. Abortion — hour period is also clearly increa- procedures. systematically available in all our > What is your assessment of our sing, reaching 47 percent in certain projects— is nonetheless forbidden activities? projects, like in Rutshuru. But beyond these recurrent issues, in this country, as is the importing In 2004 we treated 270 rape victims this type of response in a context like and usage of the abortion pill. ■ in one year in North Kivu —today this However, several aspects are still to that of North Kivu creates other figure corresponds to the average be improved and questions remain problematic questions. For example, number of cases we receive in one concerning the need to test —or not rape, considered a weapon of war Malika Saïm. month. The number of rapes has not — the victim's serology before giving against civilian populations, also Interview by Kate de Rivero

CENTRAL AFRICAN REPUBLIC In the midst of turbulence in the northern CAR1 MISSION MSF / August 2006 CENTRAL Médecins Sans Frontières has been working since March 2006 to improve access to AFRICAN medical care in the area around the town of Paoua in the northern Central African REPUBLIC Republic (CAR), where residents are victims of a conflict between rebel groups and government forces. Our teams face a difficult situation and security is a major concern. Francisco Diaz, MSF logistics director, spent a week in the CAR to meet the authorities and groups in the region and evaluate the security risks. > Is the Lebanon context more dangerous than > What is the current situation in > After four months of work where when the significant increase in the any other war? the northern CAR? are we in operational and medical mosquito population sharply terms? increases the risk of transmission to No, there are currently a The northern CAR is a politically- humans. The other reasons are number of other very charged region. The border with In operational terms, the team is in parasites, non-bloody diarrhea, dangerous wars. Seventeen neighboring Chad is open, which the consolidation phase. At the Paoua various kinds of infections as well as a colleagues from “Action makes it easy for poorly-identified hospital, we still need to organize the small proportion of other diseases. contre la faim” (Action armed groups to filter into the CAR. To pharmacy management, set up a cold More than half the hospital admis- against Hunger) have been combat this development, the Central chain, and review the collection and sions are to the pediatrics depart- African government has authorized compilation of medical statistics. With ment. assassinated in north- Chadian soldiers to enter the CAR. respect to the mobile clinic, we need eastern Sri Lanka. This is There are often, therefore, many to make improvements at the sites we > One of the goals of your visit was the most shocking massacre armed men on the roads of the CAR: visit by building latrines and basic to evaluate the security conditions in the history of modern Chadian, Central African Republic, or shelters, for example, for patients in in which our teams are working. Can humanitarian action. rebel soldiers etc. Confrontations case of rain. We also need to take a you tell us more about that? Operations in Darfur are between rebel groups and govern- close look at how transport logistics The civilian population in this also very dangerous. While ment troops create a climate of and installations are organized at northern CAR region is experiencing a it has been less in the news warfare that has forced part of the each site. very difficult situation. Soldiers lately, there has recently population to take refuge outside regularly carry out reprisals against been an increase in the villages to escape the violence. Our medical activities give priority to villages suspected of harboring rebels number of attacks against the most vulnerable individuals and the residents must thus flee to relief workers in Darfur. These individuals are living in difficult (primarily children, pregnant women, find shelter. There are also a great conditions and lack access to the and the elderly). The goal is to provide many armed bandits on the roads in health care system. Our work thus access to emergency care to people the region. These groups—primarily Jean-Hervé Bradol, President follows two tracks. One team who have taken refuge outside the former mercenaries or soldiers—add of MSF, interviewed on RMC conducts medical consultations at villages by referring them, if to the confusion and create additional radio, 10 August 2006 several sites (schools and other necessary, to the Paoua hospital. For risk for our activities. For all these locations) via mobile clinics. A second now, the main reason for coming to reasons, regular skirmishes occur. team works at the 70-bed Paoua the outpatient consultations is While they are not a direct threat to hospital, including treating patients malaria (more than 50 percent), which our teams for now, they create a referred by the mobile clinics. makes sense during the rainy season context of insecurity that we must ••• P25 messages MSF N°142 September 2006 take seriously. Several weeks ago, an transparent with respect to our activi- measures that will considerably ICRC vehicle was fired on along a road ties and objectives and restating our reduce the risk of incident. near Paoua. Luckily, no one was principles of impartiality and neutra- injured. While the circumstances do lity will make it easier for us to do our Last, it is essential that the work of not suggest a premeditated act work and reduce the risks of misun- our teams not expose civilian popula- MISSION against the ICRC as a humanitarian derstanding. We must also regularly tions to additional danger. Recently, organization, such an action is still explain to the populations themselves on two occasions, residents of Betoko CENTRAL unacceptable. It is very important to why we are there so that they unders- were attacked by official armed troops AFRICAN explain the principles of our work very tand our operational choices. For after our mobile clinic had stopped clearly so that the civilian and military example, our priority of assisting the there. Perhaps this was just an unfor- REPUBLIC authorities understand that treating most vulnerable often raises tunate coincidence, but it reminds us patients does not mean supporting questions, so we have to know how to that we need to take maximum the rebels. The message seems to respond. precautions and communicate with have gotten through. the population about these risks. ■ The second key point involves the > What are the main conclusions of concrete measures that can be taken Francisco Diaz. your visit? to limit risks during our daily activities Interview by Renaud Cuny Regarding the current tensions, it is and, in particular, when we travel by critical that we understand the larger road. We must not travel at night, context. First, I would point to the always include an expatriate in a 1- Other MSF sections present in CAR need to constantly explain our work vehicle making a long trip and follow - Dutch section: Markounda, Boguila and engage in dialogue with the the teams’ movements by radio. - Joint Spanish-Belgian mission: Kabo- various actors in the area. Being These are relatively simple security Batangafo axis

SRI LANKA Sri Lanka: MSF is deeply shocked by the killing of members of MISSION Action Against Hunger

SRI LANKA MSF / August 2006

Médecins Sans Frontières (MSF) is deeply shocked and outraged by the news that 17 members of Action Against Hunger have been murdered in Sri Lanka. MSF is concerned about the turn this conflict is taking. Since hostilities resumed, the level of violence directed at civilian populations and humanitarian aid workers has increased daily. Gabriel Trujillo and Denis Lemasson, program officers of MSF missions in Sri Lanka, react to the news.

> What was your reaction to the Since the conflict resumed, the general to provide assistance in the area. murders of the Action Against Hunger climate in Sri Lanka has been extremely Several tens of thousands of people members in Sri Lanka? tense, with suspicions and accusations are still there, without medical care. Everyone at MSF is stunned and on all sides. There are tight restrictions MSF has been trying to set up two horrified. This concerns the entire and draconian controls on aid organiza- emergency projects for more than two international humanitarian community. tions in the field. After these killings, we months. One is a surgery project at These targeted killings are unprece- are worried about how this conflict is the Point Pedro hospital on the Jaffna dented in the contemporary history of going to evolve: it has already reached a peninsula and the other would provide humanitarian work, and words are not very serious level of violence affecting medical assistance to people living strong enough to describe these odious civilian populations and humanitarian between Muttur and Batticaloa. As acts. We share the pain of the victims’ organizations. yet, however, government authorities families and that of all members of have not granted the authorizations Action Against Hunger. We strongly > Is MSF prevented from working required to carry out these programs. hope that an independent investigation with the victims of the conflict? It is currently impossible for us to will quickly bring the circumstances Over the last two weeks the popula- access the civilian populations in the and the people responsible for this tions in the Muttur region, in eastern eastern part of the country. ■ tragedy to light. Sri Lanka (where the bodies of the 17 Action Against Hunger members were Gabriel Trujillo > What was the context in which found), have been victims of military and Dr Denis Lemasson. these killings occurred? incursions and it has been impossible Interview by Isabelle Ferry

P26 messages MSF N°142 September 2006 DANGER AND RISK TAKING Realities that need to be accepted © MSF / 2006 - February Serrano Oscar > Angola

MSF / August 2006

Thierry Allafort, head of emergencies, and Gaelle Fedida, programme manager, continue the debate on risk taking at MSF. They discuss, in particular, the role of individual risk taking in our work and the fashion in which the association decides on rules about it.

Risk is intrinsic to MSF mission work proposed and rejected at the Mancha taking and lack of security. The given its medical nature and the that the association would not accept former is active and the latter passive, RESSOURCESDEBATES complicated contexts in which it takes individual risk taking appears so out but to avoid or escape poor security place. Not all medical workers expose of touch with reality. Risk taking is may depend upon the individual’s themselves to Marburg or blood everyday practice in the field. capacity to take risks. exposure accidents; special determi- nation and precautions are required. The security of an action is a function Different situations are not necessa- Over and above the collective decision of the individual qualities of MSF rily comparable and each must be to intervene in these kinds of personnel, starting from their sense evaluated as though unique. One must programs, field teams are made up of of responsibility. One important avoid evaluating risks run in purely members that have engaged objective during volunteers’ apprenti- political analysis, not forget our past themselves as individuals. ceship of security is performing the experiences, build pertinent networks The second category of risks concerns most objective evaluation possible of and relevant activities and adapted the conflict contexts in which we the situations they are confronted teams both in head office and in the work. In and around war zones we with. The apprenticeship of risk taking field. take special precautions. Once again and active security planning occur Better-guaranteed security demands field team members must engage through confronting reality and that each individual proposing a themselves individually. through the acquisition and mastery project prove its risk limitation to the For these reasons the motion of skills. One should not confuse risk group. It is imperative to limit, ••• P27 messages MSF N°142 September 2006 ••• framework, or hinder certain poten- is absurd. Its like the “twelve angry to define risk-taking criteria from the tially dangerous actions without men”; the subject is too grave and the point of view of organisation waiting for the danger to be precisely sharing of responsibility within the hierarchy. The security of our teams evaluated. This process applied association must be without ambiguity, would suffer as a result. broadly and maximally could provoke a unanimous vote must support the One fundamental dimension of MSF is DEBATES inaction. How far to go in risk taking, decision, and over and above institutio- the individual’s engagement that but also why? The limits are linked to nal responsibility, it is about members builds the collective. It is the essential the efficacy of the action that is engaging their individual responsibility. pillar – each one of us constructs MSF possible given the constraints, To caricaturise Pierre Salignon in his over the years. Profound uneasiness otherwise it is no more than bluff or article, he opposes a reckless volunteer occurs with expressions such as empty declarations that have no with a wise institution. In giving a “exposing teams” or “temptation of concrete impact on patients. Delega- maximum of decisions to the latter martyrdom”. If some members are PRESS REVIEW tion and confidence are primordial. MSF’s actions would be less at risk. But motivated and competent to confront Overly strict mechanisms of risk to agree that the board could be an extreme security situations without (CONTINUED) authority in better understanding of recklessness and of their own will, risks might be dangerous. The board then the association should listen to serves to accept risks together or not; it these initiatives. It would be unhealthy > Elections in the DRC: [...] to agree that the board could is the safeguard of the principle of if our missions only depended on The Democratic Republic of be an authority in better unders- precaution. individuals. And it would be just as tanding of risks might be On the contrary the institution may irresponsible not to do some opera- Congo is preparing to live dangerous. The board serves to sometimes incite its volunteers to tions when we have the required through a second round of accept risks together or not; it is presidential elections, the safeguard of the principle of take disproportionate risks, notably resources that are voluntary and scheduled for 29 October. precaution. during media exposed political crises. capable of putting the action in The president, the communications place. ■ This follows the provisional officer, the operations director and results of the election super- the emergencies director leave during Thierry Allafort Duverger, vised by MONUC (the UN management between the field, the the first days of the Kosovo war. They Gaëlle Fedida Mission in DR Congo), executive, and the board should be get lost in the middle of shellfire and announced on 20 August by avoided, and should permit those didn’t treat many people.… and at the 1- From taking risks to putting lives in an Independent Electoral involved to improve their understan- same time the MSF institution refused danger? by Pierre Salignon, general Commission, which placed ding of the contexts and situations letting a nurse and a doctor go to director of the French section of MSF. Joseph Kabila in the lead with they are working in, and to have Congo Brazzaville on the pretext that Contribution to La Mancha, October more than 44% of the vote, to maximal support when decisions are that the zone was dangerous…. 2005 Jean-Pierre Bemba’s 20%. taken collectively. Thousands of living dead are coming 2- Of Measles Stalin and Other Risks by The board plays its role when it speaks out of the forest every day… Kenny Gluck, director of operations of “UN Secretary-General Kofi out about the return of MSF teams to Kenny Gluck is right when he states the Dutch section of MSF. Contribution to Annan welcomed the Chechnya, but that the decision is voted that MSF must be careful not to wish La Mancha, September 2005 announcement of the provi- sional results of the presidential election on A CRITICAL LOOK AT SURGERY Sunday evening, describing it as an historic event representing a vital step in Surgery off track? the country’s peace process MSF / August 2006 / Translated by Aaron Bull (…), but the announcement of the results saw an outbreak Xavier Lassalle, advisor for anaesthesia in the medical department, looks at our directions of violence in Kinshasa,” and operational choices in the area of surgery. He is not convinced about the relevance and noted the daily Le Monde in quality of our surgical programmes, or how they are evaluated, and as a result, he questions its on-line edition dated 21 our practices, calling for greater cohesion in our surgical activities. August. At least three people were thought to have been Because the need for “medical improving quality of life. > ELECTIVE SURGERY killed and ten or so wounded treatment” throughout the world is Like the mental health and pain Surgery in the broad sense of the word, in Kinshasa, according to the infinite, the operations department management programs, the surgical including anaesthesia, resuscitation journalist. “There is every is required to select for MSF, based programmes were developed and post-operative care, is a high-risk reason to fear that the on the priorities set by the associa- with this in mind. However, the rapid activity (in terms of mortality and tion, the areas where we wish to growth in surgical activities morbidity). Follow-up of peri-operative campaign for the second intervene and the types of activity we and MSF’s introduction of elective mortality, conducted for the first time round will become even more will carry out there. For a number of surgery and surgery aimed by MSF last year based on mortality bitter than in July,” notes for years, in addition to its initial at improving quality of life (not reports provided by teams of anaes- its part the daily Libération, objective of providing treatment for directly related to a life-threatening thetists and surgeons in the field, also on 21 August. life-threatening emergencies, MSF condition) raises a number of revealed very high figures: 1 death in has been offering programs aimed at questions. 34 procedures [see margin – ed.].

P28 messages MSF N°142 September 2006 Given the many constraints related dures. The equation surgery (+ safety conditions (no functional both to resources (e.g. human anesthesia) = benefit for the patient recovery room, no pain management, resources, budgets) and conditions simply does not always hold true. We etc.) reflects a worrying lack of (particularly with regard to security), must document early and late medical responsibility. Is it really we have had to adopt a minimal operative complications, such as MSF’s role to treat congenital malfor- technical and organizational standard infection, morbidity, mortality, in mations, when there are many > On peri-operative that seems to be an acceptable order to assess whether a specialized international teams mortality compromise for life-saving surgery. programme has genuinely been already involved in this work, such as However, what may appear to be beneficial for the target population. Chaîne de l’Espoir or Operation Between January and acceptable for “vital” surgery is much Primum non nocere. Smile? Is it worth performing these September 2005, of 7,698 less acceptable when it comes to Unfortunately, it seems that within high-risk complex elective procedures surgeries performed, 4,712 elective surgical interventions and MSF, evaluation is still seen by some (66%) were followed up for those aimed at improving quality of as putting a damper on enthusiasm or mortality. It was found that 138 life. So we need to ask the question: simply adding another level of red Personally, I am not convinced of the 4,712 patients, or 1 in what level of risk do we accept for our tape. Personally, I am not convinced that there is the will at MSF to 34, had died. patients to be exposed to when they that there is the will at MSF to carry carry out a systematic evaluation - for emergency surgery (60% undergo an operation for an inguinal out a systematic evaluation of our of our activities. of our activity), there were 136 hernia, or reconstructive orthopaedic activities. In many respects, the surgery? problem of evaluation parallels that of deaths in 2,830 procedures, or pain management: naturally, 1 in 20. Emergency surgery > A QUESTION OF QUALITY everyone is for it, but among the in makeshift conditions just to included what are called Unfortunately, an increase in the desks or in the coordination team, maintain a presence in the region? “acute” emergencies (e.g. volume of activity without a strategic how many people are actively More generally, what resources are uterine rupture, multiple plan has resulted in a decrease in promoting it? we able and prepared to invest in trauma) and “tepid” emergen- quality. This is clearly the case with How can we make decisions today order to perform this specialized cies (e.g. procedures regard to anaesthesia. In contrast to about expanding our surgical surgery in more appropriate condi- secondary to emergency earlier years, the past few months missions — particularly where they tions? surgery, dressing under have seen missions opened with no involve elective surgery — without Clearly, when an activity is developed, anaesthesia, skin grafts). consultation and without meeting our first having assessed the risk and there needs to be a balance between - for scheduled, elective defined minimum acceptable standard. benefit for the patient and established those who push for going ahead (“the surgery (e.g. hernias, varicose We have also noted a reduction in pain the means for evaluating it? details will look after themselves”) management (from 60% of patients in and those who are often seen as veins), which made up 40% of February/March to 30% in May/June), > SPECIALIZED SURGERY naysayers, who want to put certain our activity, there were an increase in the interim periods AND THE RESOURCES facilities in place first. Unfortunately, 2 deaths in 1,888 procedures during which anaesthesia is adminis- NEEDED FOR IT it does not follow that a surgical or 1 in 944. These deaths could tered by unqualified staff, and a decline The development of specialized programme will benefit all patients. have been avoided. surgical programmes without first The capacity to do great harm must be There were a variety of causes setting up the necessary technical understood. The “technical” prerequi- connected with the patient’s […] what level of risk do we conditions in terms of both human sites are not designed just to put general condition, insufficient accept for our patients to be resources, equipment and organiza- obstacles in the way of our teams, but resources, the surgery, tion, and alternative solutions for to ensure the well-being of our exposed to when they undergo the anaesthesia, or more an operation for an inguinal surgical activities in the community, patients. They have proven themsel- often all these factors. hernia, or reconstructive ortho- raises serious ethical problems. ves in developed countries, and it has The anaesthesia-related paedic surgery? Take Sigli, for example. In May, been demonstrated that they can be general surgery was suspended to adapted to the conditions we work in, causes were analysed in a make way for reconstructive surgery, and are effective there. These technical presentation given at the last in the follow-up of mortality. In this in theory to address the needs of constraints (as defined by the consul- surgery day. context, what is MSF’s strategy for the victims of the tsunami and of the tants) need to be accepted, and the development of surgical programmes? violence that had occurred over the programmes must be not viewed Xavier Lassalle Furthermore, in this environment of previous few years. In the first stage purely from a quantitative perspective. expansion what is our mechanism for of this reconstructive programme, a Furthermore we must provide the assuring quality? maxillofacial surgeon specializing in means to measure their quality in a treating children born with cleft lips completely transparent way. > EVALUATION and palates was sent, without liaison Let’s stop spreading our limited The lack of evaluation of surgical with our specialist advisors. This type surgical resources too thin, and start activities poses a real problem. Last of surgery is not at all straightforward having a meaningful discussion year, there was a discrepancy of 20% when performed on young children, together around how we can set up in the figures reported by the depart- and it cannot be done without teams the management and evaluation ment of operations and the medical of specialised professionals (surgeon, systems we need, without diminishing department regarding the number of paediatric anaesthetist, post- the professionals’ enthusiasm and surgical procedures performed. With operative physician and nurse). responsiveness, which are vital to our this level of inaccuracy, it is difficult to Planning and conducting this activity work.■ imagine what criteria could be used to at a hospital with very low overall evaluate the usefulness of our proce- standards, under very unsatisfactory Xavier Lassalle

P29 messages MSF N°142 September 2006 MSF LOGISTIQUE’S ANNIVERSARY It’s not everyday INFO you’re 20 years old MSF / August 2006 / Translated by Penny Baker

She may have put on some weight but there’s not a wrinkle in sight. Born 1986, MSF > The Gulf War Turning Logistique celebrated its 20th birthday on the weekend on the first of July. Several of Point local representatives, who had helped to buy the site, came to Merginac to join in the celebrations. The Boards of Directors of MSF-France and MSF Logistics took the oppor- In 1991, the Iraq War marked tunity to meet and discuss MSFLog’s activities and to debate its future. The next day an important moment. A large there were games, stalls, refreshments and dinner infront of the stage set up for the operation, involving all MSF occasion. sections, was launched to To celebrate this anniversary, we would like to recall the genesis of MSF Log, which has assist Kurdish refugees near grown and diversified continually since its creation and to look at the challenges with the Turkish border. For two which it is confronted today. months, MSF Logistique managed the dispatch of 56 planes. Most of them left directly from the country where the necessary equipment was available: Log story… Germany for blankets, Pakistan for tents, Denmark MSF / August 2006 / Translated by Penny Baker for Compact Food. For several 1 days, a regular service ran Jacques Pinel participated in the birth and growth of MSF Logistique. He describes us its between MSF Log and the history, from the purchase of its first vehicles in the eighties to the impressive logistic field: orders from the field platform that it is today. Its 20 years of existence have made MSF Logistique “much more were sent in the afternoon, a than just a purchasing centre.” plane was loaded by MSF Log the same evening which took off from Toulouse in the night > Before it used logisticians, who assistance to Cambodian refugees), missions from Paris. In Africa, unlike and arrived at the Iraqi border was in charge of logistics on the first these posts were relatively straight- in Thailand, the phone network was the next morning. Demands MSF missions? forward because the country was almost non-existent and problems in were extremely changeable Until 1980, members of the medical already well developed. It took half an finding vehicles and equipment, or because of the refugees’ team took it in turns to take care of hour for us to hire or buy a vehicle for even basic drugs, held up the work of changing situation, but also logistics. In Thailand, MSF’s first the teams, the local telephone the medical team. large-scale mission, we started to network worked and drugs were because of the launching of a create ‘supervisor’ positions- we available locally. To begin with, we concentrated on massive, but anarchic didn’t call them logisticians at that communications, provision of response, by the international time- in the nine camps where we > How did logistic arrangements medicines and vehicles. We set up a community. Adapting itself were active to support the teams’ evolve after this? radiocommunications network, extremely quickly to the work. In fact, despite the size of the In 1982, headquarters asked me to standardised lists of drugs and evolving situation, avoiding mission (100 expatriates providing structure logistics for all of our constituted a vehicle pool - limiting duplication… I think that MSF, ourselves to Toyota Land Cruisers, a is a model to emulate in this model used by ICRC and the UN. Not type of situation. The joint MSF LOGISTICS: CHRONOLOGY so we could be like them, but so we working of ground and the could use their garages! logistics teams was a key part 1980 : first supervisors in Thailand 1986 : Birth of MSF Logistique in Narbonne of this flexible response.” > When did MSF Logistique come 1989 : Pre-storage of drugs into being? 1992 : MSF Logistique moves to Bordeaux-Mérignac Between 1982 and 1986, it became Jacques Pinel 1993 : Bonded warehouse clear that to conduct emergency 1999 : MSF Logistique is licensed to stock pharmaceuticals by the Ministry operations we not only needed of Health financial resources and a pool of 2003 : Extension of the warehouse from 2 000m2 to 5200 m2 people available, we also needed

P30 messages MSF N°142 September 2006 © MSF / 2006 - July Nzakou Irène > Bordeaux - Mérignac > Bordeaux

suitable equipment. So on 19 October not to go for the gigantic sites like MSF LOGISTIQUE 1986, we created MSF Logistique, Paris-Roissy, because we would have which we envisaged as a procurement been drowned in the plethora of and pre-storage centre for logistics companies already located there. The Keeping In Step equipment. Three people were based Bordeaux-Merignac site offered the MSF / August 2006 / Translated by Chrissy Schmiedel in Narbonne in the south of France, most advantages, particularly concer- and then in Lezignan, where we were ning customs and transport, and also supposed to stay for a year. In the end, offered good installations for the 30 as one emergency mission followed people who worked there. As operational activities increase, MSF Logistique (MSF- another, we stayed several years. Log) has no choice but to keep up the tempo set by opera- > How has MSF Log evolved? tions. The question is: how will it keep it up, and for how > What were MSF Logistique’s initial MSF Logistique has had to adapt to much longer? Site director Gérald Massis and Supplies activities? the change in the type of missions Coordinator Philippe Cachet sat down with us to talk We started to stock ready-to-go carried out by MSF. As well as about it. vehicles. Toyota made solid vehicles supplying medical teams, MSF Logis- which were well adapted to the tique has expanded to respond to the difficult conditions of Africa, but they basic needs of populations in crisis: > What are the difficulties facing that storage is not a magic solution. were only available on order. the provision and treatment of water, MSF Logistique today? So we constantly have to strike a So MSF Logistique pre-brought the sanitation, shelter, food…It’s a lot MSF-Log always keeps pace with balance between the constraints vehicles and parts in Japan. For more than a procurement centre! growth in the operational sections, inherent to the supplies, the diversity several years, the procurement centre which has been booming across the of products and sources, and our was not involved in pharmaceuticals Today, MSF operations have a genera- board. Our volume of activity has operational needs. We expanded the and therefore turned to turn to large list operational tool at their disposi- therefore been rapidly increasing. warehouse in 2002 and already we are NGO’s like IDA, Action Medeor for tion, designed to respond to the needs Because of our operational restric- running out of space again, not to these. In 1989, we started to stock in the field. But to keep this tool up to tions, we can’t take a just-in-time mention that the MSF-Log staff are drugs and hired a pharmacist to work date, a direct and permanent link approach like some logistics firms do. stretched to capacity. on site. between the operations departments, We have to operate on a stock system missions and MSF Logistique is (including MSF-France, MSF-Switzer- > What approaches are being > Why did it move to Merignac? needed.■ land and MDM emergency stocks), considered to keep up with this At the beginning of the 90s, we looked which brings with it a whole host of growth? for a new site, more suitable to what Jacques Pinel. management restrictions. These For the logistics products, decentrali- MSF Logistique had become. We Interview by Irène Nzakou supplies have to be consolidated, so zation is a possibility. We could pre- wanted to be close to an international that we can be sure all of our store the equipment that doesn't need airport, but we also wanted to be missions will have what they need, to be ordered or prepared in large enough to benefit from the flexi- 1- Jacques Pinel now works particularly in terms of specialty Bordeaux. We already run a decentra- bilities necessary to deal with for the Access to Essential Medicines items that are harder to procure (TB, lized storage facility in Dubaï (Arab emergency operations. We decided Campaign neglected diseases), keeping in mind Emirates) that we could make greater ••• P31 messages MSF N°142 September 2006 he called the "automatic French MSF LOGISTIQUE IN FIGURES (2005) autarky". Is that still the case today? Gérald: I'll admit it was a bit inflam- - 15,200 tons dispatched to 70 countries matory--but I wanted to remind people 3 INFO - 165 tons (750m ) of emergency supplies that the center is not, statutorily, a tool - 14,100 listed items meant for the sole use of the French - 2,500 items stored section, but rather that it is supposed - 3,801 kits assembled in-house to be used by all sections in the same - 350 orders per month, on average way. For the record, six years ago 70% - 66 salaried employees of MSF Logistique turnover was devoted to the French section. Today, its portion represents less than 60%. ••• So, things have changed in a funda- use of. We're looking into a couple of taking a more international approach mental way. Now, it is a given that all possibilities. We also need to develop to our supply policy and consolidating sections are entitled to the same MSF our intelligence on suppliers in other cross-center collaboration, particu- Logistique services, and everyone at countries and set up a network that larly with MSF Supply (supply center MSF knows that there is a lot more to delivers supplies quickly and in accor- in Belgium). Should we be moving our day-to-day work than talking to dance with our own quality standards. towards a common supply policy for Operations at the French section. This Our Bordeaux facility will also need to each product type? Should we is the direction in which the center will be expanded. outsource our products? This is the be moving in the future, and the inter- > VOLUME Supervision of kit assembly opera- kind of food for thought that should national framework is one of the OF ACTIVITY (2005) tions, which represent a strong added rapidly lead to action. strategic points that should be mapped value, requires our continued out fast. ■ 45 million Euros (33.3% presence at the site. Human > When he first became head of Gérald Massis Medical, 19.3% Logistics, resources will need to be stepped up. MSF Logistique in 2003, Gérald and Philippe Cachet. 30.1 Freight and 17.3% Food) We have also been thinking about made a statement denouncing what Interview by Irène Nzakou

> RATIO BY SECTION, OTHER NGOS

59 % MSF- France 20.9 % MSF- Switzerland 8.6 % MSF- Spain 9.7 % Other MSF Sections 1.8 % Other NGOs

> Bordeaux - Mérignac © MSF / Irène Nzakou - July 2006

P32 messages MSF N°142 September 2006 INTERNAL PUBLICATION Finally a document on nursing care!

MSF / August 2006 / Translated by Frank Elliott

We were somewhat «has been» when it came to good nursing care. There was even practically nothing on the subject in the Field Library. Comments made by nurses who PRESS shared their views with the medical department were to provoke a response. A project started two years ago has now been completed. After the recent publication of the steri- REVIEW lisation guidelines, - «Nursing care: a handbook for MSF missions» will be available in November. About time too ! (CONTINUED)

>THE AIDS EQUATION Our health care practices in the field improve the standard of care by carrying out rapid tests, as well as In relation to patients have developed in line with the type of replacing obsolete items useful annexes on daily nursing care. projects undertaken by MSF: an These guidelines should come out in The document will be accompanied suffering from AIDS and increasing number of hospital November in French, then in English, by a CD-ROM with technical who are treated by MSF, projects have opened, leading to field and will be included in the Field procedure sheets; this will provide “immune system restora- staff frequently asking for previously Library. They describe basic nursing nursing staff with a basis from which tion is equivalent to that in non-existent documents on nursing care procedures such as observation to start and which they can then wealthy countries. Survival care and which required time to and monitoring, administration of adjust to their specific operational rates are at 74% after two answer. One of the many comments drugs, transfusion, emergency setting. years,” explains Dr was the fact that equipment for procedures, hygiene, dressing of Also, a DVD film called « Healthcare Alexandra Calmy to a carrying out increasingly complex acute wounds, taking samples and Techniques » will be available for the journalist from the daily medical treatment was either ••• Libération, in the newspa- obsolete, unsuitable, or quite simply lacking. Could it be that nursing was per’s 17 August edition. the last thing to be considered by Coinciding with the Inter- MSF? Not quite, but it is a rather national AIDS Conference neglected area where the consequen- held in Toronto, the ces of minimal care do not seem to pandemic has been the present too many problems. You subject of many articles could overstate the case by saying: « this month. In an interview no deaths occurred ». How many with the daily La Croix, nurses in the field have found Dr Arnaud Jeannin notes: themselves in the in the situation “Do the maths yourself: if where they have had to create make shift solutions or approximating there are three to five procedures, while at the same time million new cases to treat, MSF insisted - and with good reason - something like 230-380 on ACT or ARV treatment procedu- million euros need to be res? In the end you tend to forget the provided annually. And as standard benchmarks: « it’s normal more people are saved to work like this on humanitarian expenditure rises from missions; it’s not like at home ». year to year, which means there is an increasing need > THE OBJECTIVES for funding.” He is worried The aim of «Nursing care: a handbook for MSF missions», is to: about the cost of medicine, - help nursing teams provide quality but also about industrial care by, for example, providing field property laws, which staff with technical procedure sheets. constitute “a major source - define set quality standards for of uncertainty.” certain techniques –e.g asepsis criteria– using as a basis internatio- nal recommendations - assess existing equipment, identify > Democratic Republic of Congo © MSF / Pascale Zintzen - March 2006 what materials are lacking and

P33 messages MSF N°142 September 2006 ••• training of staff. Produced by a team contribute significantly to nosocomial These will include the dressing of of specialists from Belgium, the film infections. chronic wounds, monitoring of deals with certain aspects of nursing - Infusions: certain pathologies frequently care (intravenous injections, insertion - 3 way taps (at last !) to avoid encountered in the field (malaria, of a urinary catheter etc). «injecting» into the tubing , meningitis, tetanus, etc..), post- INFO - Occlusive catheter dressings (being operative care and everything relating > FROM THE THEORETICAL tested in the field) so as not to have to hospital management and health- WATCH AND READ TO THE PRACTICAL catheters held in place with bits of care organisation. The medical The work to produce the document sticking plaster… department welcomes any sugges- has helped us assess our procedures. - Where dressings are concerned, we tions. It seems that hygiene is somewhat should choose two kinds, one for Nursing care has long had a low neglected by field nurses, and we acute wounds (alginates) and another profile, it must develop according to MSF / Alix Minvielle / August 2006 therefore felt it important to stress type for chronic wounds (hydrocol- the types of field programmes, Available at the photo this aspect by devoting a chapter to it. loid). A number of tests in the field practices and equipment must be library As far as equipment is concerned, the should help us to respond more continually adapted to the specific MSF catalogues now include several effectively to the needs and kind of settings we work in and new New photos sent new items: equipment required according to the resources must be made available to ■ to international Database - Alcohol based solutions for disin- type of mission (surgery as opposed the teams. fecting hands. These will be introdu- to outpatient services for example). ced gradually over the next few Emmanuelle Chazal1, > Palestine months, with written instructions on > THE FIELD’S ROLE Training Advisor Destructions of Beit Lahya how to use them. This document is the result of several (and on occasion nursing and social worker, July - Sterile urine bags. Although their months’ work. It must now be put to care advisor) in the medical 2006, (c) Laura Brav / MSF (15 images) use and the insertion of a catheter test in the field and we are relying on department and a « closed system » bag have you in the field to send us your Mental health care, medical been recommended by international comments and criticisms so that we 1- With Sophie Lauzier, Florence care and social work, protocols for some ten years now, we can improve it and update it on a Fermon, Coralie Léchelle, Marie-Noëlle September 2005, (c) Alan were still inserting catheters with regular basis. Rodrigue, Véronique Grouzard, Geza Meier (29 images) non-sterile bags, even though the Other nursing care practices will be Harci, Thomas Diste, Corinne Lejeune, insertion of urinary catheters can added to the document in the future. Laurence Bonte > Thailand Maesot, tuberculosis, April 2006, (c) Antoine de Changy (27 images)

Hmong refugees, July- NEW EDITION December 2005, (c) Sylvie Cusset / MSF (22 images) Practical dictionary > Indonesia Inflatable hospital in Iogia- karta and mobile clinics of humanitarian law around Bantul, Island of Java, June 2006, (c) Kaltoum Romdhani / MSF (18 images) and lawyers, but also for those who recent legal and political changes want to understand the issues related specifically to the war against Inflatable hospital in Iogia- involved in this new law and the terrorism and the operation of inter- karta and mobile clinics resources it offers. national tribunals. It now includes around Bantul, Island of From Adoption to Wounded and Sick summaries of recent international Java, June 2006, (c) MSF (13 Persons, this dictionary delineates case-law, included at the end of the images) the field of humanitarian activity and key relevant headings. A cross- the responsibility of the various actors referencing system, bibliography, > Niger who manage crises and conflicts. It organisations’ contact information, Treatment of malnutrition in offers a legal definition and practical indexes and a list of relevant texts for the region of Maradi, June 2006, (c) Anne Yzebe / MSF analysis of more than 300 key each country complete this essential (28 images) concepts, including assistance, tool for humanitarian actors, decision Central Tracing Agency, children, makers and concerned individuals. > Sudan civilians, detention, embargo, The dictionary has been translated Orphanage of Mygoma, genocide, Human Rights Council, into seven languages. ■ March 2006, (c) Stephan Françoise bouchet-Saulnier, Legal International Criminal Tribunals, Oberreit / MSF (8 images) Director of MSF, has developed a medical duties, peacekeeping, Practical Dictionary reference work for professionals in prisoners of war, refugees, terrorism, of Humanitarian Law the field of international relations and United Nations, war crimes, weapons, -Françoise Bouchet-Saulnier, humanitarian action (including non- and women. Legal Director of governmental and international This new edition, which has been Médecins Sans Frontières, organisations), journalists, students updated and expanded, incorporates La Découverte publications.

P34 messages MSF N°142 September 2006 FILMS AND DVD News from EUP

MSF / August 2006 New photos sent to Two important pieces of news this and deserves to be discovered by Hollywood, nor are we condemning international Database time round : medical teams far and wide. the fact that Johnny Depp and Uma (cont.) The much awaited film « Organising The ‘Operational Video Library’ Thurman appear on your screens an emergency mass vaccination equally took a while to see the light of from time to time… we’re simply > France campaign » is now available on DVD in day but we got there in the end. It is a offering an alternative and an oppor- Full charter in Bordeaux French and English. Clearly presented collection of 65 films - medical and tunity for all our staff to enhance their Mérignac leaving for and brilliantly filmed, training films training films, reports on MSF knowledge and understanding of MSF Indonesia, 30 May 2006, take on a whole new meaning with programmes, documentaries on and the environment we working in. (c) Laurent Theillet this state-of-the-art ‘A to Z’ on how to humanitarian aid… All the films are The collection will be arriving on all (5 images) set up and carry out successfully a presented on DVD ; all are in French field programmes in September. ■ Mission among illégal vaccination campaign. Let word and over half are in English too. François Dumaine immigrants in Calais, spread of this film’s release, it should We’re not trying to compete with and Sara Mc Leod February 2006, (c) Julien Lévêque (10 images)

AVAILABLE IN THE DOCUMENT LIBRARY > Southern Sudan meningitis vaccination campaign around Akuem, Acquisitions July 2006 April 2006, (c) Kevin Phelan / MSF (6 images) Christine Pinto (01 40 21 27 13) > DRC, Katanga Upemba, distribution of > MEDICAL OMS. Guide to Health Workforce Development in Post- NFI kits, March 2006, (c) Conflict Environments. Genève: OMS, 2005, 141 p. Bruno Berson / MSF DEVEAUD, B.,LEMENNICIER, B. L'OMS: Bateau ivre de la (13 images) santé publique: les dérives et les échecs de l'agence des > GEOPOLITIC Nations Unies. Paris: L'Harmattan, 1997, 177 p. Upemba, cholera + health IACHOURKAEV,S. Survivre en Tchétchénie. Paris : Gallimard, centre, February-March LOVELL,A-M. Santé mentale et société. Paris: La Documen- 2006, 383 p. 2006, (c) Hichem tation française, 2004,119 p. Demortier / MSF + MSF (9 images) LACOSTE,Y. Géopolitique: la longue histoire d'aujourd'hui. OMS, MSF, and UNHCR. Malaria Control in Complex Paris :Larousse, 2006, 335 p. MSF moble clinic in Mitala Emergencies: an Inter-Agency Field Handbook, Genève: OMS, Zambia et Kisungi, février 2006. 218 p. TISHKOV,V. Chechnya : Life in a War-Torn Society. Berkeley: 2006, (c) Corentin Fleury / University of California Press, 2004, 284 p. Deadline Photo Press (23 images)

> Sudan, Darfur Election of the president of the I.O. refugee camps, February 2006, (c) Stephan Oberreit MSF / August 2006 / MSF (24 images) Dr Christophe Fournier has been elected president of the International Office of MSF, replacing Dr Rowan Gillies Photo library who is at the end of his mandate. Christophe started working in the humanitarian field with Médecins du Monde > Armenia in 1989 as field doctor on a six month mission in Peru, then Erevan dispensary in repair, as field coordinator in Chili until 1993. MDR TB, February 2006, After four years working as a general practitioner in (c) Elisabeth Poulet / MSF France, he joined the French section of MSF in July 1997. > Nepal 2006 + Niger 2005 After various field positions –medical coordinator in (c) William Martin / MSF Burundi, head of mission in Uganda and Honduras, then two assessment missions in Mexico and Venezuela- Chris- tophe joined the headquarters staff in May 2000 as programme manager. Four years later he joined the decentralised desk in New-York as programme manager there before becoming Programme Director in July 2005. Aged 42, Christophe will officially start his new position at the beginning of December 2006. © MSF DR

P35 messages MSF N°142 September 2006 TURN OVER AT HEADQUARTERS

FUNDRAISING & COM DPT > Gilles FASBENDER ended his contract on 02/06/2006

> Nathalie RESOURCES CAILLOT-TRANCHARD left her position as Assistant on 14/08/2006.

> Brigitte BREUILLAC started as communications officer on 4/08/2006. She is replacing Isabelle MERNY- ENGEL who is away on maternity leave.

IT > Nadia AYANE left her position as headquarters IT officer on 30/06/2006.

FINANCE DPT > Mickael LE PAIH left his position as Field Financial Controller on 03/08/2006.

> Thierry LE GALLAIS left his position as Head of Field Financial Management on 13/07/2006. Chantal MIR, who has replaced him, started on 26/06.

> Francie SADESKI started as Field Financial Controller on 21/06/2006. She is replacing Irina LARGUIER who is on maternity leave.

> Clémentine THENAULT started as assistant field financial controller on 20/07/2006.

> Anne EVENO started as Field Financial Controller on 10/07/06.

LOGISTIC > Gwenaël BERRANGER started as Logistics supervisor on 16/08/2006.

MEDICAL DPT > Milton TECTONIDIS left his position as doctor in the medical department on 20/07/2006.

> Sophie LAUZIER ended her contract on 23/06/2006.

OPERATIONS > Filipe RIBEIRO let his position as deputy programme manager on 13/07/2006.

Press Contact: FIELD HR [email protected] > Franck ELOI ended his contract on 30/06/2006. [email protected]

Reactions and contributions: [email protected] TRAINING COURSES For further information: > POPULATIONS IN PRECARIOUS SITUATION > NUTRITION / VACCINATION - on the activities of the French section of MSF : www.msf.fr From 17 September to 1st October 2006 in Saint-Prix (Val From 8 to 15 November 2006 in Spain d’Oise), near Paris Duration : 6 days, Language: English - on the activities of the Other Duration : 12 days , Language: English MSF Sections: www.msf.org > TARGET POPULATION > GOAL OF THE PSP Medical background staff who will be involved in nutritional Train participants to answer to medical humanitarian emergency programs and/or take part in the setting up of vaccine activities. situations in an appropriate way and in accordance with MSF policies. By the end of the training course, trainees should be able to:

> TARGET POPULATION > EPIDEMIOLOGY - Priority to expatriate medical personnel who are or could - Define, calculate and use epidemiological indicators become field coordinator and national deputy coordinators (field or capital coordination) > NUTRITION - Second line of recruitment : medical coordinators and head of - Set MSF actions in the general context of food crisis mission - Diagnose acute malnutrition among children - Between 12 and 20 months of MSF experience within at least - Discuss the different types of nutritional programmes Médecins Sans Frontières two different types of intervention, one of which in emergency - Ensure management of children with acute malnutrition 8, rue Saint Sabin - Committed for at least another 12 months (for the expatriate in - Ensure functioning of the feeding centre (intensive and/or one or several missions). supplementary) 75544 Paris Cedex 11 Tél. : +33 (0) 1 40 21 29 29 > TRAINING OBJECTIVES : > IMMUNIZATION Fax : +33 (0) 1 48 06 68 68 By the end of the PSP trainees should be able to: - Describe the basic principles of vaccination www.msf.fr - Evaluate the population needs (medical and essential: WatSan, - Supervise the validity of the cold chain Editor in Chief : Bénédicte shelter, food, security) - Plan and implement vaccination activities in an emergency Jeannerod - Define intervention strategies adapted to health problems, to situation Editing : Olivier Falhun the context, to the population and to MSF objectives and policies - Monitor the activities within a vaccination campaign, analyse Translation : Caroline Serraf / TSF - Plan the implementation of program’s activities the results and define the actions to implement - Ensure follow up of population health status Photo librarian : Alix Minvielle - Ensure program monitoring and re-orientation according to Layout : Sébastien Chappoton / context evolution tcgraphite Design : Exces communication For further information and to apply: contact your desk or EPICENTRE Print : Artecom. Isabelle Beauquesne (01 40 21 29 27) or Danielle Michel (01 40 21 29 48) actions to implement

P36 messages MSF N°142 September 2006