Activity Report Activity MSF

T (+41-22) 8498 400, F (+41-22) 8498 404, E [email protected], www.msf.org [email protected], E 404, 8498 (+41-22) F 400, 8498 (+41-22) T Office International MSF MSF was awarded the 1999 Nobel Peace Prize. Peace Nobel 1999 the awarded was MSF countries. 70 over in aid medical provide to staff hired locally 25,850 approximately joined administrators and engineers sanitation and water experts, logistical professionals, medical other nurses, doctors, volunteer MSF 2225 over 2005, In countries. 19 in offices branch with movement humanitarian medical international an is MSF Today helps. it people the of plight the to witness bear publicly to and assistance medical needed urgently provide to organisations nongovernmental first the of one was MSF relief. emergency to access have should people all that believed who by 1971 in founded was (MSF) Frontières Sans Médecins

a small group of doctors and journalists journalists and doctors of group small a

Rue de Lausanne 78, Case Postale 116, CH-1211 Geneva 21, Switzerland 21, Geneva CH-1211 116, Postale Case 78, Lausanne de Rue

06 20 July – 2005 July t Repor Activity MSF MSF Activity Report Activity MSF

2005/06

The Médecins Sans Frontières Charter About this publication

FEATURE WRITERS Médecins Sans Frontières is a private international association. Nathalie Borremans, Leopold Buhendwa, Dieudonné Bwirire, Fabien Dubuet, Margaret Fitzgerald, The association is made up mainly of doctors and health C. Foncha, Moses Massaquoi, Marilyn McHarg, Dalitso Minsinde, Rodrick Nalingukgwi, Fasineh Samura, Milton Tectonidis, Emmanuel Tronc sector workers and is also open to all other professions which might help in achieving its aims. COUNTRY TEXT AND SIDEBAR MATERIAL WRITTEN BY Emma Bell, Claude Briade, Lucy Clayton, Gabi Faber-Weiner, Petrana Ford, Stephan Grosserueschkamp, All of its members agree to hounor the following principles: Lisa Hayes, Jean-Marc Jacobs, Anthony Jacopucci, James Lorenz, Alessandra Oglino, Susan Sandars, Diderik van Halsema, Erwin van ‘t Land

Médecins Sans Frontières provides assistance to populations SPECIAL THANKS TO in distress, to victims of natural or man-made disasters and Anne Ameye, Laure Bonnevie, Marine Buissonnière, Anouk Delafortrie, Rowan Gillies, Tory Godsal, Olivier Guillerminet, Lisa Hayes, Myriam Henkens, Florence Licci, Miquel Maldonado, Barry Sandland, to victims of armed conflict. They do so irrespective of race Miriam Schlick, Nicolas de Torrente, Emmanuel Tronc, and all the field, operations and communications religion, creed or political convictions. staff who reviewed material for this report.

EDITOR Caroline Veldhuis Médecins Sans Frontières observes neutrality and impartiality PHOTO EDITORS Bruno de Cock, Sofie Stevens COPY EDITOR Melissa Franco in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in ARABIC EDITION COORDINATOR Mohamed Naji the exercise of its functions. TRANSLATOR Brahim El-Khazrouni EDITOR Mohamed Naji

Members undertake to respect their professional code of ethics FRENCH EDITION and to maintain complete independence from all political, COORDINATOR Corinne Cecilia TRANSLATOR Emmanuel Pons economic or religious powers. EDITOR Corinne Cecilia

ITALIAN EDITION As volunteers, members understand the risks and dangers of COORDINATOR Barbara Galmuzzi the missions they carry out and make no claim for themselves TRANSLATOR Selig S.a.S. EDITOR Barbara Galmuzzi or their assigns for any form of compensation other than that which the association might be able to afford them. SPANISH EDITION COORDINATOR Mar Padilla TRANSLATOR Pilar Petit EDITOR Eulalia Sanabra

GRAPHIC DESIGN Studio Roozen, Amsterdam, The Netherlands PRINTING Drukkerij Mercurius, Wormerveer, The Netherlands

The country texts in this report provide descriptive overviews of MSF work throughout the world between July 2005 and July 2006. Staffing figures represent the total of full-time staff equivalents per country for 2005. Country summaries are representational and, owing to space considerations, may not be entirely comprehensive.

COVER PHOTO Patients in the post-operation ward at the MSF Bon Marché Hospital, Bunia, Democratic Republic of Congo, May 2005. © Gary Knight (VII) Contents Contact MSF Contact Figures and Facts Audited of Overview Handovers Project East Middle the and Europe Americas The Caucasus the and Asia Africa World the around Projects MSF MSF by Treated Frequently Conditions Medical Essay War Photo Forgotten Congo: of Republic Democratic International MSF Coordinator, Advocacy and Tronc, Policy Emmanuel and Officer Liaison UN Reforms? Dubuet, Fabien Humanitarian Deceptive Nations: United Minsinde, Dalitso Bwirire, Dieudonné Foncha, C. Malawi: Thyolo, in Malawi Team MSF Rural in Care HIV/AIDS Decentralising Less: Doing by More Doing expert nutrition MSF Tectonidis, Milton Disease Neglected Fatal, Treatable, Frequently Imminently Prevalent, Highly A Malnutrition: Acute Canada MSF Director, General Flux McHarg, in World Marilyn a in Emergency an of Challenge The General Secretary MSF Buissonnière, Marine and Council International MSF President, Gillies, Rowan Review in Year The World the around Missions MSF

MSF Operations Operations MSF Moses Massaquoi, Nathalie Borremans Nathalie Massaquoi, Moses

Fasineh Samura, Rodrick Nalingukgwi, Nalingukgwi, Rodrick Samura, Fasineh Leopold Buhendwa, Leopold

Margaret Fitzgerald, Fitzgerald, Margaret 16 13 10 88 85 84 83 75 67 53 27 25 18 7 4 2

2005/06 MSF Missions around the World

POLAND P.80

BELGIUM P.76

LUXEMBOURG P.78

SWITZERLAND P.80

FRANCE P.76 ITALY P.77

LEBANON P.81

PALESTINIAN TERRITORIES P.82

MOROCCO P.42

NIGER P.44

MALI P.42

BURKINA FASO P.30

GUINEA P.37

GUINEA-BISSAU P.38

SIERRA LEONE P.46

LIBERIA P.40 GUATEMALA P.73 IVORY COAST P.38 HONDURAS P.69 BENIN P.29 HAITI P.72 NIGERIA P.44 ECUADOR P.68 CAMEROON P.32 COLOMBIA P.70 REPUBLIC OF CONGO P.34 PERU P.74 DEMOCRATIC REPUBLIC OF CONGO P.34 BOLIVIA P.68 ANGOLA P.28

SOUTH AFRICA P.50

2 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 RUSSIAN FEDERATION P.78

IRAN P.59 TURKMENISTAN P.65 ARMENIA P.54 UZBEKISTAN P.66 GEORGIA P.54 KYRGYZSTAN P.61 PAKISTAN P.63

JAPAN P.59

SOUTH KOREA P.66

CHINA P.56

CHAD P.32 LAOS P.61 SUDAN P.48 NEPAL P.62 MALAYSIA P.61 ETHIOPIA P.36 INDIA P.58

CENTRAL AFRICAN REPUBLIC P.31

SOMALIA P.47 BANGLADESH P.55

KENYA P.39 MYANMAR P.60

UGANDA P.50 THAILAND P.64

RWANDA P.45 CAMBODIA P.56

BURUNDI P.30 INDONESIA P.57

TANZANIA P.46

MALAWI P.41

MOZAMBIQUE P.43

ZAMBIA P.52

ZIMBABWE P.52

LESOTHO P.40

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 3 The Year in Review

In July 2006, amid intensifying armed conflict between Israeli Defense Forces (IDF) and Lebanese Hezbollah fighters, MSF launched an emergency intervention to help address medical-humanitarian needs. Assistance was offered on the Israeli side dealing with civilian deaths and injured from rocket attacks; however the nature of the conflict was such that there were greater needs and less available assistance in Lebanon. © Zohra Bensemra/REUTERS

With a high intensity bombardment cutting demands, MSF retained its neutrality by The difficulties reaching people in need in major roads and bridges throughout the refraining from commenting on specific Lebanon are illustrative of a growing prob- country, transportation was difficult and military decisions of either side. This inde- lem of access that MSF has confronted over dangerous, compelling MSF to make public pendent and impartial approach to the pro- the past year. Despite the relative simplicity statements reminding those engaged in the vision of aid allowed us to move and assist of our mission – to provide impartial medi- conflict that they had a responsibility to in a context where almost all movement was cal-humanitarian assistance to those in allow assistance to reach civilians caught in prevented. need and prevent loss of life – our ability to the fighting. Though vociferous in such obtain access to patients can rarely be

4 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Many of the people we help are trapped within highly charged and complex social and political contexts that create significant barriers to the provision of aid.

diminishing and underfunded aid made available to them. Outside the camps, especially in West and North Darfur, violence against civilians continues, accompanied by a significant increase in targeted attacks against aid workers including MSF staff, making land travel and logistical assistance close to impossible.

MSF has been working in Darfur since early 2004 and intends to stay as long as we are able to be effective, although the situation is becoming increasingly precarious. Serious security incidents have forced us to reduce activities in the Jebel Marra region, despite an ongoing cholera outbreak, and we can no longer send surgical referrals by road for emergency care. This reduction in the ability to provide basic assistance is likely to have a critical impact on an already fragile health situation.

Likewise in Sri Lanka, a country where we worked for many years during the conflict, seventeen aid workers from the NGO Action Contre la Faim were executed in July 2006. The perpetrators of this outrage have not been identified. With such attacks on clearly identified aid workers, there is a grave concern for the future of assistance in this country. MSF is struggling to get access to areas where there is no humanitarian assistance at all in this brutal civil war.

An unhealthy mix Over the past year, there has been a mounting distrust toward aid organisations by those who have the power to grant us access. This mistrust is not always mis- placed. The practice of some nongovernmental organisations (NGOs), private contractors and many governments doing ‘humanitarian’ work with a specific political aim causes confusion, and reduces the acceptance of the universal nature of An MSF convoy transporting emergency medical supplies and fuel remained stuck north of the Litani humanitarian assistance. This contributes River after an airstrike destroyed the last bridge. Four tonnes of supplies were carried by hand over 500 to a climate where groups opposed to any metres using a human chain. A tree trunk spanning the river was used as a makeshift bridge. underlying political aim use confusion as an excuse to attack aid workers. assumed. Many of the people we help are or pulling out of Darfur, Sudan. Over a This mounting distrust is just one of the trapped within highly charged and complex million people have been living a survival ongoing challenges of providing emergency social and political contexts that create sig- existence with ‘adequate’ health parame- assistance discussed in an article in these nificant barriers to the provision of aid. ters for over two years in camps in Sudan pages by Marilyn McHarg, who underscores and Chad, disguising an utter lack of hope our need to adapt to and anticipate not only Security concerns and despair that pervades these islands of a changing humanitarian landscape, but At the time of writing, humanitarian assistance. These are the lucky ones who also dynamic social, political and even geo- organisations have been reducing activities manage to have sustained contact with the graphical environments in order to identify

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 5 Numbers mean little without reflecting on the relevance of the assistance and the quality of our work.

where and how we can best provide effec- 26,000 people with cholera in Angola in the our interventions in 2005/2006, we also tive assistance. Addressing the problem of spring of 2006, the largest outbreak of this recognise that MSF can only offer immedi- access, she proposes that new strategies disease in that country in over a decade. ate and time-limited solutions. It must be must necessarily be developed to carry out But these numbers mean little without clear that the modest improvements we can our work. As this report goes to press, we reflecting on the relevance of the assistance make should be viewed neither as an oppor- are launching a new project to provide and the quality of our work: each patient is tunity for governments and international reconstructive surgery for wounded Iraqis much more than a statistic and we must be organisations to abdicate their responsibili- in Jordan and working with Iraqi medical sure that if we treat someone for malaria, ties, nor an alibi for political inaction. groups to assist them in responding to the for example, that they get a humane consul- Speaking out and raising awareness of this effects of daily violence in that country. tation, the right diagnosis and treatment. neglect is how we avoid covering up the problem. This year, we include in this Coordination: not a panacea Particularly when we have access to field- report a selection of photos of people from With an ever-growing number of aid organ- appropriate medical and logistical tools, we the Democratic Republic of Congo – where isations, there are now increasing attempts are able to adopt new methods of treatment human needs have largely been ignored by to coordinate humanitarian assistance to to provide relevant and quality care. A nov- the international community. control and direct this assistance in a cer- el approach to an old problem of treating tain direction. Superficially coordination malnourished children, mobile feeding cen- Self-criticism is an essential element of MSF can have positive results allowing various tres and the availability of an effective, and the 19 sections of MSF went through an agencies to use their strengths within a portable nutritional rehabilitation product internal process this past year aimed at comprehensive response; however, “lack of helped MSF carry out its largest and most improving our operations and governance coordination” is currently used as a blanket successful response to child malnutrition structure. Developing from this is a com- excuse for every failing of aid assistance. In in Niger in 2005. 63,000 severely malnour- mitment to maintain the transparency of some cases, it is not a failure of aid but ished children were admitted to pro- our actions and concretely increase the rather a deliberate and politically motivated grammes, where record cure rates were accountability we display to those we assist lack of access to aid for people in need. The achieved. Dr. Milton Tectonidis explains and the donors that generously assist our intricacies and potential dangers of coordi- this intervention and its importance in an work, for it is reliance on individual donors nation being provided as a sole response to essay within this report – an undertaking that allows us to act quickly and independ- the failures of aid in the past is discussed in that allowed us to demonstrate that death ently and in response to human needs. this report by Fabien Dubuet and by malnutrition is not necessarily inevitable Emmanuel Tronc, who outline MSF’s posi- and can more and more be equated with We see this accountability as a potent tool tion whilst the UN implements changes in death by neglect. to reflect openly on our operations and its system of aid assessment and delivery. improve them significantly as we meet new MSF remains careful to separate itself from Similarly, as we continue to provide a full challenges and obstacles. MSF will continue these processes, instead relying on inde- package of HIV/AIDS prevention and treat- to look for new ways to manoeuvre past pendence of assessment and action to ment to people and communities in 32 whatever barriers may arise, logistical, respond to specific needs of specific popu- countries, our developing strategy is to security or political and assist those who lations, rather than contributing to a global decentralise care and increase the number are being neglected – firmly grounded in framework of dubious origins and effective- of sites where treatment is available – an our identity, and our intention to provide ness. Independent and impartial assessment approach described in this report by our quality medical care for people who would is not only a principled, but also a practical team in Thyolo, Malawi. The size of scale- otherwise have none. approach that allows us safe and rapid up that is truly needed, however, continues access to people in need. to be limited by a shortage of human Rowan Gillies, M.B.B.S. resources and the state of health systems in President, MSF International Council Effective responses many countries. It is unrealistic to believe Marine Buissonnière Despite our concerns around these issues, that these issues will be solved sufficiently MSF Secretary General our records over the past year show a mas- to treat everyone with HIV/AIDS. A com- sive volume of medical care to individuals prehensive response to this epidemic is pre- and families around the world: this cluded by a disgraceful lack of drugs, diag- includes doing more life-saving surgery, nostics and monitoring tools developed for treating more malaria, and offering mental resource-poor countries, who instead must health support to more people than ever make do with the detritus of western- before. MSF in 2005 provided medical- focused research. More appropriate tools humanitarian assistance to over 10 million are urgently needed to address this crisis people, including assistance in major emer- head-on, to treat many more people despite gency responses following an October the human resources and structural crises. earthquake in Asia, and treatment for While we are buoyed by the outcomes of

6 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 BY MARILYN MCHARG, GENERAL DIRECTOR, MSF CANADA © Bruno Stevens/Cosmos The Challenge of an Emergency in a World in Flux

As the world has changed, so has our response to emergencies. In the past, a typical MSF emergency intervention saw us responding to refugees within defined camps bordering war zones, to malnourished children located in geographic pockets, to communities suffering from cholera outbreaks or meningitis epidemics, and other emergency situations such as periodic floods, droughts or earthquakes. © Didier Lefevre / imagesandco.com

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 7 With the effects of the tsunami, malnutrition in Niger and cholera in DRC, among many others, MSF has continued to focus on responding to those most in need.

As a medical-humanitarian organisation, emergencies within crisis identification and response more difficult. In Colombia, for exam- situations have always been at the heart of our action, and our ple, ongoing conflict has caused the displacement of over two mil- response has focused on medical interventions. With time and lion people and many are in need of medical and psychological care; experience, our technical capacity to respond to urgent medical however, these people are scattered and sometimes hidden within needs has improved. Our inflatable hospital in Mansehra, Pakistan, urban centres, requiring us to seek out those needing assistance and an earthquake setting where pre-existing infrastructure had col- launch multiple projects to reach a more diffuse population. lapsed, is but one example of the evolution of emergency medical action and resulting capacity to implement highly developed medi- More recent global developments have also impacted on needs and cal, surgical, and intensive care services. our capacity to respond. As polarisation between various funda- mentalist western elements and extremist Islamic groups intensi- Although these types of emergencies continue, the character and fies, the capacity for organisations such as MSF to independently complexity of our contexts places new demands on us. To a large respond to any humanitarian needs, free from any falsely based extent, more conventional wars between states have been replaced accusations of political alliances, becomes increasingly limited and by internationally influenced guerrilla wars fought within coun- poses greater security risks. Aid workers are not in these contexts tries. Underlying these conflicts, ideological motivations or territo- to choose sides or to die, rather they are there to save others’ lives, rial gains are more the exception, with economic motivations and as global polarisation becomes more entrenched, overcoming becoming more the rule. Civilians, normally seen as those to be these barriers in order to respond to emergencies becomes increas- protected in conflicts, are often used as commodities of war and ingly difficult. become trapped or targeted as a result. The violence against civilians is frequently used as a means of diminishing opposing ele- Assisting in middle-income countries ments, meanwhile abduction or looting of civilians – sometimes As major humanitarian crises occur more in middle-income coun- children, as in Uganda, where up to 20,000 children have been kid- tries, the type of our emergency response has required adaptation. napped and inducted into the Lord’s Resistance Army – have Historically, MSF has mostly responded to situations in sub- become standard strategies in gaining strength against an enemy. Saharan Africa, where infrastructure collapse has meant few staff were available and disease patterns typically included tropical ill- Changing perceptions nesses such as malaria, diarrhoea and many other infectious dis- With this degradation, there has been a weakening of respect for aid eases. Within middle-income countries such as Lebanon and Iraq, and humanitarian interventions. Increasingly, belligerents of war our classic emergency response has been tested with the presence of perceive us as either feeding into or aggravating warring agendas, sufficient numbers of capable staff and epidemiological patterns much the same way they view the civilians we aim to support. With that are more typical of western countries, with chronic diseases many warring actors fragmented along various lines, it has become being among the most urgent. Our medical policies, supplies and increasingly difficult to negotiate our presence and also to maintain protocols need to encompass chronic diseases such as cardiac dis- the security of MSF staff in areas where access is accomplished. ease, diabetes, asthma and epilepsy, among others.

Added to this, there are more and more aid organisations and agen- These middle-income contexts have also challenged MSF to devel- cies involved in the business of aid. Many have different values, op new strategies and play a more secondary role whilst engaging in goals and strategies that confuse the perception of MSF. We have more partnerships. In the summer of 2006 our medical activities in always believed that our reliance on principles such as impartiality Lebanon were in some ways unusual for MSF, conducted alongside and independence secures our capacity to safely intervene where well-developed medical resources and included helping provide needs are greatest. However, the multiplicity of actors has blurred supplies and treatment for chronic diseases, kidney disease in par- our distinction and with it, increased the risk of being erroneously ticular. It is likely we will be called upon to assist in this manner in seen as part of political or even military agendas. This limits our the future. capacity to engage in unhindered action for those most in need. Learning from natural disasters Displaced within borders MSF has responded to a number of natural disasters through the Accessing populations also becomes more difficult with the changes years, but these emergencies have not been seen as one of our main in population movements. In the past, populations facing war would interventions. Usually, MSF has struggled to find a role, as the most displace themselves to safer areas beyond their borders and cluster urgent needs tend to be related to rescue, followed by logistical sup- into camps. The classic situation was characterised by groupings of port. Most needs are answered by armies, national actors, and people in distinct locations where health risks were increased through local solidarities. The incredible local response of Sri because of the stress of displacement and crowding under austere Lankans to the 2004 tsunami limited our need to intervene there. conditions. We have increased our capacity to clearly identify those Similarly, the Pakistani army was highly effective in its activities fol- in need and quickly provide needs-based responses in these situa- lowing the October 2005 earthquake in southern Asia. tions. But today, more and more people displace themselves within their borders, integrating into cities, smaller communities or other The needs for medical response in these situations, although present, open settings so their locations are not as evident, making needs do not always amount to substantial medical interventions. Pakistan

8 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 © Bruno Stevens/Cosmos

was an exception. With destruction of small buildings in remote are- orrhagic diseases such as Ebola in parts of Africa have demanded as, there were relatively more injured demanding a medical response, highly specialised and culturally adapted responses, which so far and fewer deaths. But usually this is not the case – survivors of have been limited in success due to the complexity resulting from earthquakes and other natural disasters usually present limited inju- the interplay between cultural orientations and needed medical ries, whilst their major needs include shelter, water, sanitation, and interventions. In Angola in 2005, an outbreak of Marburg haemor- food. All interventions MSF can do, but usually on a small scale and rhagic fever required us to wear bio-safety gear, which frightened in support of medical interventions. local community members. Further, people with the illness had to be isolated to prevent the spread of this highly infectious disease. In the future, however, factors including increasing environmental Many of these patients died, so it was perceived that people sepa- degradation and climate change may well contribute to changes in rated out by MSF were meant to die, and community members epidemiological patterns and a greater number of natural disasters became reluctant to seek help for those who were sick. Such misun- such as droughts and floods. Although these events are highly derstandings underscore the need for cultural sensitivity in situa- unpredictable in nature, we should be aware of what exactly we are tions where we cannot anticipate how our tools and approaches able to provide to people in distress and be ready to respond with the may be received. strengths we have developed. Likewise, a recent MSF intervention in a plague outbreak in Ituri, By accepting our limits, but continuing to develop our core Democratic Republic of Congo (DRC) highlighted the need for strengths, we can advance our response. It is clear there are others MSF to continue in its pursuit of understanding such diseases, better able to respond in the first phase of natural disasters and their spread, and necessary treatment within various contexts – in intervening in the very first hours of a rescue phase requires an this case, an isolated war setting. Emerging diseases such as avian expertise and logistical capacity that MSF does not have. We are flu also demand highly specialised responses. But like any inter- better placed to direct our efforts in the survival phase – this work vention by MSF, choices must be made and an avian flu outbreak has synergies with interventions in other settings and facilitates the highlights this dilemma more than ever. Our capacity to take on development of our specialities instead of potentially diluting them such a pandemic will be limited, though it should not inhibit our by broadening our scope. Emergency surgery is a particular activity preparedness to do what is possible, where it is possible. we have identified as a focus area. We are increasing our capacity for emergency surgery and other specialised medical services – for 2005 has been a demanding year for MSF in terms of emergency example we now routinely send nephrologists to the field to treat response. With the effects of the tsunami, malnutrition in Niger crush syndrome, a condition characterised by renal (kidney) failure and cholera in DRC, among many others, MSF has continued to and often seen in people who have survived a building collapse pre- focus on responding to those most in need. Although these cipitated by earthquakes or bombings. Mental health, nutrition and responses in their own right were of value and laid further founda- monitoring for epidemics amongst displaced persons in crowded tion to whatever emergency responses are required in the future, living spaces are also areas that overlap with our medical interven- the challenges ahead in this changing world will place further tions elsewhere. These are aspects we need to further build up and demands on us. Ours is a challenge of continued adaptation and adapt to evolving situations. evolution in order to ensure we are assisting those most in need on a medical basis and to the best of our abilities. Treating emerging diseases Changes in epidemiological patterns are among the greatest challenges ahead for MSF. Recent increases in frequency of viral haem-

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 9 BY DR. MILTON TECTONIDIS, MSF NUTRITION EXPERT

Acute Malnutrition: A highly prevalent, frequently fatal, imminently treatable, neglected disease

“ …‘regular’ starvation has to be distinguished from violent outbursts of famines… Problems of: (i) existence of much regular starvation, (ii) worsening trend of regular starvation, and (iii) sudden outbreak of acute starvation, are quite distinct…” (Amartya Sen, Poverty and Famines 1981)

How is it that MSF managed to admit 63,000 severely malnourished children into its programmes in Niger in 2005, the largest nutritional intervention in the organisation’s history? Niger is not the image most would associate with recent famines – civil war, violence, population displacement, severe food shortage, massive malnutrition (including adults), disease and epidemic – the typical picture of excess death due to catastrophic famine in the 20th century .

10 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Acute Malnutrition: A highly prevalent, frequently fatal, imminently treatable, neglected disease

Regular starvation in Niger and on the role played by micronutrient die- beyond tary deficiencies, typically associated Debate ensued over the nature of the with the monotonous, cereal-based diets Niger crisis in 2005 and the appropriate- of rural-poor populations, in growth fail- ness of the response, as international ure and malnutrition. Deficiencies in relief efforts were finally stepped up in trace metals, sulphur, phosphorus, cer- July. There were objections to the use of tain vitamins and other micronutrients the term famine to describe the emergen- have particularly deleterious effects on cy, and resistance to providing free food young children in the first two, critical © Henk Braam aid as a response until late into the hun- years of life.3 Many easy-to-use, fortified, ger gap period, when food reserves from nutrient-rich products specifically the previous year’s harvest were exhaust- malnutrition (wasting) at any given designed for this age group to help pre- ed, and the steep price of staple food moment. Thirteen million of them are vent deficiency exist on the market in items on the market had broken all previ- severely wasted, whilst many others are developed countries for those with the ous records. affected by Kwashiorkor. Acute malnutri- means to purchase them. Any attempt to tion is implicated in over five million reverse the high rates of malnutrition in Niger is a country with chronically high preventable deaths yearly amongst young countries such as Niger has to address the levels of what Nobel Prize winning econ- children.2 difficulty poor, rural populations face in omist Amartya Sen calls “regular starva- The Maradi region alone accounted for providing a sufficiently nutrient-rich diet tion”. Other terms used are chronic hun- 39,353 admissions for severe malnutri- for their young, rapidly growing children. ger or under-nutrition. The Food & tion to MSF therapeutic feeding pro- Agricultural Organization estimates grammes in Niger in 2005. Over 95% of Stepping up the treatment of there are over 800 million undernour- cases occurred amongst children less acute malnutrition ished, having access to less than their than 30 months old, and the majority Results obtained in Niger in 2005 in daily requirement in food energy to be (over 60%) were admitted during a rehabilitating large numbers of severely normally active. Economists view chron- three-month period between mid-July malnourished children are exceptional. ic food shortage in such large popula- and mid-October corresponding to the Over 91% of severely malnourished tions as a failure of development. Many classic hunger gap (over 80% between patients from Maradi region (34,247 chil- public health advocates actually play June and November). Yearly admissions dren) exited the programme cured, that down the link between food scarcity and in Maradi were four times higher than is, no longer acutely malnourished. childhood malnutrition in poor coun- the number admitted into the MSF pro- Providing individualised, therapeutic tries, insisting instead on “inadequate gramme in 2004. In some southern, rural treatment to such large numbers of infant and young child feeding practic- cantons of Maradi in 2005, almost half patients had never been accomplished in es”, or, to a lesser extent, on poor access the children between six and 24 months the large famines of the recent past in to health services or clean water. Outside of age developed severe acute malnutri- Ethiopia, Somalia and Sudan. What has of major crises, the usual proposed pack- tion during the year and were admitted changed? Until recently the World Health age of preventive and curative child to an MSF therapeutic feeding pro- Organization (WHO) recommended that health interventions rarely includes the gramme. all cases of severe acute malnutrition be treatment of even the severest cases of treated with therapeutic (high energy, acute malnutrition.1 It is inconceivable that infant and child nutrient fortified) milks, in therapeutic feeding practices can account for such feeding centres or inpatient wards of hos- Severe acute malnutrition defines a form large seasonal and yearly variations in pitals.4 Although high cure rates are of malnutrition that bears a particularly admissions for severe acute malnutrition obtained by humanitarian agencies using high risk of death but which nevertheless in Niger. Nor can this variation be therapeutic milks in feeding centres dur- responds rapidly to treatment. Individual explained by increased exposure to dis- ing major crises, such specialised centres cases are diagnosed either on the basis of ease and poor access to healthcare or represent a significant investment in staff the degree of emaciation or “wasting,” as clean water. Such variations are largely and infrastructure, are costly, and have measured by the weight to height ratio, due to nutritional stress in the hunger limited capacity at any one time.5 or by the circumference of the mid-upper gap period, particularly in years follow- Moreover, demands on a patient’s family arm (marasmus); or by the presence of ing poor harvests. At these times, the posed by prolonged inpatient feeding “water in the tissues” (oedematous mal- quality and limited diversity of the diet is (generally several weeks) discourages nutrition or Kwashiorkor). Moderate cas- often even more limiting than the caloric participation, lowers programme cover- es of acute malnutrition are those with a and protein content of available food. age and increases the number of children slightly less abnormal weight to height who default before cure. ratio. Unicef estimates there are over 60 Over the past 20 years, clinical nutrition It is not completely surprising then, that million children suffering from acute research has increasingly concentrated outside large emergencies, the treatment © Didier Lefevre / imagesandco.com

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 11 consuming procedure of taking each child’s height and rely on the measurement of the mid-upper arm circumference (MUAC) and weight alone. Some of these new ideas are currently being implemented in northern Kenya, where three years of drought have led to high malnutrition rates amongst pas- ©Vincent Maure toral populations. Blanket Feeding, Tanout, Niger, October 2005. Food assistance ( enriched wheat and oil) is provided for families identified with malnourished children. Clearly, efforts to address the underlying causes of malnutrition are critical and must of severe acute malnutrition has not been treatment. Almost 85% of all admissions be supported. However, new therapeutic seen as a priority by international public finished their treatment as outpatients. The products and outpatient treatment strate- health consultants, and that few countries average time to cure was less than a month. gies make it possible to offer curative treat- with limited resources have made attempts Inpatient units are needed to handle refer- ment now, to much larger numbers of to integrate the treatment of acute malnutri- rals for complications such as anorexia, patients, including in situations of chronic tion into their healthcare services. In the weight loss, severe infection or anaemia. hunger, where most cases of acute malnu- case of Niger, a country where there are, There were almost 1000 deaths amongst trition and excess death are occurring. This depending on the season and year, between patients admitted to MSF inpatient centres will be all the more true if RUTF products 250,000 and 500,000 acutely malnourished in Maradi in 2005; however, over 6200 oth- can be made less costly and more widely children at any given time, no effective ers were discharged cured or referred back available. There is no reason why this can’t nutritional rehabilitation programmes for to an outpatient programme after having be done. As treatment of acute malnutrition severely malnourished patients existed out- spent less than two weeks on average as becomes simpler and cheaper, it may no side the MSF Maradi programme until July inpatients. longer be perceived exclusively as a tragic 2005. dilemma requiring sustained, long-term The availability of a simple to use and effec- efforts and solutions, but also as a highly The introduction of Ready to Use tive therapeutic product permitted MSF to prevalent, frequently lethal, neglected and Therapeutic Foods (RUTF) over five years admit record numbers of patients into its imminently treatable disease, calling for ago is changing perceptions and practices.6 feeding programmes in Niger in 2005. Such immediate and effective medical care. These nutrient-rich products designed for new products and strategies open new pos- rapid weight gain do not require prepara- sibilities for nutritional intervention in large tion or the addition of water, and the ener- emergencies, and in situations with high gy-dense paste is impossible to contami- levels of childhood malnutrition. In Maradi nate. They are tailored for malnourished in 2006, MSF is treating all malnourished, children with poor appetites and small severe and moderate, with the same thera- stomachs who need to consume high quan- peutic treatment regimen. The severely mal- tities of calories. Small, severely malnour- nourished have higher rates of mortality, ished children can gain one to two kilo- but most malnutrition-related deaths occur grams in a few weeks. amongst the far more numerous, moderately malnourished group. On an individual level, These factors make such products ideal for all are at increased risk of death and disease, outpatient use, and mothers quickly grasp and most can be quickly cured when the the therapeutic nature of the product. The best available therapeutic, nutritional prod- MSF experience in Niger in 2005 shows that uct is given to them. MSF is looking at ways most cases of severe, acute malnutrition can to further simplify outpatient management be cured through attendance at outpatient of acute malnutrition. By reducing the fre- centres at regular, weekly intervals. Over quency of follow-up visits, it is possible to 65% of severely malnourished children further increase capacity and efficiency, were admitted directly into outpatient care, helping mothers who have to travel signifi- and the majority never required hospitali- cant distances to attend scheduled consulta- sation during the entire course of their tions. It may be possible to bypass the time © Paul Grover

1. Jones G et al. How many child deaths can we prevent this year? 4. Golden MH, Briend A. Treatment of malnutrition in refugee camps. Lancet 2003; 362: 65-71. Lancet 1993; 342:360. 2. Black RE et al. Where and why are 10 million children dying every year? 5. Collins S. Changing the way we address severe malnutrition during famine. Lancet 2003; 361: 2226-2234. Lancet 2001; 358: 498-501. 3. Shrimpton R et al. Worldwide timing of growth faltering: Implications for 6. Briend A et al. Ready-to-use therapeutic food for treatment of marasmus. nutritional interventions. Pediatrics 2001; 107: e75. Lancet 1999; 353: 1767-1768

12 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 BY MSF TEAM IN THYOLO, MALAWI: FASINEH SAMURA, RODRICK NALINGUKGWI, C. FONCHA, DIEUDONNÉ BWIRIRE, LEOPOLD BUHENDWA, MARGARET FITZGERALD, DALITSO MINSINDE, MOSES MASSAQUOI, NATHALIE BORREMANS Doing More by Doing Less Decentralising HIV/AIDS care in rural Malawi

The Thyolo region of southern Malawi is a Despite this grim statistic, concerted efforts are being made verdant area of tea estates. Bright green tea to provide treatment in this district of 575,000 residents. The Malawian Ministry of Health (MOH) has a national pro- fields are cut through by reddish tracks, linking gramme to address HIV/AIDS, there is currently a supply of the many communities spread out in small drugs for patients, and MSF has been present in the Thyolo health district since 1997, helping to organise and provide villages. One of 28 districts in the country, it is effective care for those suffering from the disease. also the area that is perhaps hardest hit by HIV/ Whilst have had many successes, establishing an efficient sys- AIDS, with 20% of people now testing positive tem of treatment delivery has been challenging, particularly for the HIV virus. given the rising number of people presenting themselves for treatment. HIV/AIDS education, testing, and successful treatment of opportunistic infections – conditions such as pneumonia that can claim the lives of people with HIV – have led to more people surviving the virus and there are now over 10,000 people without access to antiretroviral treatment (ART) who urgently need these life-prolonging drugs.

Accessing ART has not been easy for everyone here with an HIV+ test result, particularly with the initial national strategy of providing the drugs only at hospital-based clinics. The two hospitals in Thyolo district are now grossly insufficient to handle the thousands of people who need ART. For many, hospital-based care has also proven to be inconvenient and cumbersome. Long trips by foot to the hospital are unrealistic for people who aren’t feeling well, are expensive, and increase the risk of people discontinuing or not even initiat- ing treatment. © Julie Rémy

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 13 © Julie Rémy © Julie Rémy

One patient living in Namileme, 25 kilometres from the nearest Offering patient-centred care hospital, describes her experience: Our solution was to decentralise antiretroviral treatment, moving follow-up for stabilised patients on ART out of the hospitals and “I left at 3:30 am on foot to Thyolo hospital to try to get antiretro- into nine local heath centres. viral medicine (ARVs), arriving at 9:30 am after four hours of hard walking. I waited in the group counselling room until 12:00 pm To maintain quality care, we developed criteria to define eligible and as I was very hungry and thirsty, left to the market to find patients and to identify the necessary characteristics for the selec- something small to eat. When I returned, I was told the session was tion of health centres. All staff who would be providing ART were already over and I must return one week later. I now had to walk also required to undergo training. These workers are supported by back home for another four hours without anything! Now I must a mobile MSF team that travels to the health centres for supervision walk back twice to Thyolo hospital, once for a group counselling of treatment and counselling and dispensing ARV drugs. The session and then again for an individual counselling session before health centre teams continue the regular follow-up activities with I can get ARVs. The nurse says this is to make sure I will be com- continuous support from MSF. mitted to taking ARVs, but I already know very well that I really need the ARVs and I am ready to take the medicines. It’s just so This approach is helping to “demedicalise” HIV, empowering indi- hard to get them.” viduals and community members to be more involved in caring for those who have the virus. Communities are embracing this whole- The usual process for obtaining antiretrovirals involves education- heartedly, developing networks that engage in a range of supportive al group counselling, followed by a one-week period so patients can and innovative activities, such as checking in with peers at commu- consider making the commitment to treatment. Patients then nity meetings to make sure pills are being taken properly, and doc- return for individual counselling to understand how to take their umenting life-affirming “before and after” photographs of people ARVs properly. With such activities based at the hospitals, many on treatment and living with HIV, which helps to reduce the stigma people lose valuable hours they need to earn a living. On children’s of the disease. clinic days, both mothers and children were exhausted upon arrival, practically falling asleep during counselling sessions! Motorised Today there are over 2000 people who have formed an association transportation is a quicker way to get to the hospitals, but costs are linked to the National Association of People Living with AIDS prohibitive for most, and during the heavy rainy season, transpor- (NAPWA). Members are identifying ways they can help each other, tation is also difficult as the dirt tracks turn to mud, often dou- undertaking projects such as organising vegetable, maize and fish bling travelling time or stopping service altogether. farms to help feed people who are poor and unwell, and creating vocational training and income generation activities for HIV/AIDS When less is more orphans. This community involvement has been a positive force in Having set a goal of providing ART to 10,000 people by the end of our efforts at decentralisation. 2007, it became clear we needed a new approach. Our motto became “do more by doing less.” We needed to get drugs to many A dearth of human resources more people before their disease progressed to the point where they The numbers show that decentralisation is working – in one village required more intensive medical care. We also needed a faster, less alone we rapidly went from 20 to 150 patients on ART. But this new cumbersome and more patient friendly system. approach also comes with its own challenges, the most serious impediment being the lack of adequate and well-trained medical personnel. As in many other African countries, there is a chronic “ I always used to go to Thyolo hospital with my shortage of human resources here. Malawi graduated only 16 new guardian, a relative who helps me comply with doctors in 2005, and only one remains in the country. The government is permitting us to train medical assistants to provide ART at my treatment, and it was expensive to pay for the health centre level because there simply are not enough medical two transport fees. Now I get exactly the same doctors or clinical officers to do so. service at my local health centre”. The pre-existing health centre staff who are now involved in decentralised HIV activities are understandably feeling overstretched. Patient at Konjeni health centre, a decentralised site. HIV care is an added activity when they have many other responsi-

14 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 bilities and administration duties. Other priorities – primary those who need to change drugs will really help us leap forward. healthcare, vaccination programmes, training workshops or pro- But despite our limitations and multiple constraints on resources, viding relief for colleagues on annual leave – compete with HIV this is proving to be a good approach for getting treatment into the care and sometimes result in health centre clinics not opening hands of more people who, quite literally, will not live without it. when they are supposed to. Absenteeism amongst medical staff is Our staff sees a visible difference in the health and vibrancy of the also a problem and can be attributed, in part, to low salaries. patients we treat, as a result of being able to access the care they Although we have topped-up health staff salaries as a compensation need. From one of our patients at a decentralised site in Milongwe: for the increased workload, there is a limit to how much work one can do in one day. The lack of human resources is the most crucial “I have spent a lot of money trying to access ARVs at Thyolo but I obstacle to our decentralisation effort. did not succeed. The first two weeks of taking ARVs are wonder- ful. I felt the difference. I actually can feel life coming back.” These difficulties are compounded by a poor health infrastructure. Operating ART clinics and general outpatient consultation simultaneously in the same room with a lot of staff and patient movement can compromise confidentiality, and some patients have com- plained about sitting with other patients from the same areas in their health centre. We have tried to put up partitions to split rooms in two, but this does not always work because rooms are small to begin with. We now need to refurbish and rehabilitate some of the nine public health centres and in some cases, build extensions to accommodate clinic rooms. For now, we are simply doing the best we can with what we have.

Simplified treatments are key As we now begin to initiate treatment at local sites, simplified treatments will be the backbone of successful decentralisation. It is the most practical response in the face of human resource shortages, and gives patients and caregivers as much control as possible for their care. Antiretroviral drugs must be effective and of acceptable international standard, easy to administer with a light pill burden (twice a day, triple drug combination), and child friendly for young patients – easily breakable, for example. In this resource-poor setting, drugs requiring no refrigeration are needed, as well as a sched- ule of drug intake that has no relation to food.

Other avenues exist for simplification. In Malawi, laboratory services to do a CD4 count (an index of immune system function) are a rare commodity and are usually not available in decentralised sites. We have found that with treatment provided far away from labs, blood specimens sometimes “spoil” before they can get to the lab to be analysed. Sometimes blood must be collected twice for a single analysis.

Though a baseline CD4 count is normally required as a pre-condi-

tion to start antiretroviral treatment, most patients we see are in © Julie Rémy advanced stages of the illness (WHO stages III & IV) and exhibit clinical symptoms that can lead to a decision to initiate ART without a blood analysis. In this environment, a thorough medical history and physical examination are a reliable way to select patients To participate in decentralisation in Thyolo, needing ARV treatment. patients must: • have been on standard firstline ART for a minimum Reaching more patients, saving more lives of 3 months Scaling up ART to treat more people is a challenge, especially as the • demonstrate good treatment adherence caseload increases. Decentralisation is not an easy process and it is • be stable on ART without opportunistic infections not a cheap venture to provide patients with treatment. Research • not have any specific psychosocial considerations and development into paediatric diagnostic tools and drugs, simpli- • live at least 10 km or more from the main Thyolo ART fied treatment protocols, and affordable secondline medications for Clinic, but close to the approved health centre

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 15 BY FABIEN DUBUET, UN LIAISON OFFICER AND EMMANUEL TRONC, POLICY AND ADVOCACY COORDINATOR, MSF INTERNATIONAL United Nations: deceptive humanitarian reforms?

Responding to many of the same crises and often working along- humanitarian coordinators nor be accountable to them. In the face side United Nations relief efforts within the field, Médecins Sans of the challenges to be met, however, we can only welcome the will- Frontières has given much consideration to the nature of humani- ingness of the United Nations to improve their humanitarian tarian aid offered under the UN relief system. Increasingly, there response. has been a feeling of a great discrepancy between the needs to be covered quickly and the effectiveness of the UN response. We must also take a critical look at the possible effects of the reforms on the effectiveness of aid. While it is doubtless too soon to The past two years have raised many questions regarding the opera- fully evaluate the impact of proposed changes, the slowness of the tional engagement of the United Nation’s agencies: there have been UN response to the recent cholera outbreak in Angola, including at inappropriate or slow UN responses to emergencies in Niger, the the peak of the crisis in May 2006, or in the face of the latest popu- Eastern Democratic Republic of Congo, Sudan and Somalia; diffi- lation displacements in Katanga province, Democratic Republic of culty understanding strategies and agendas, such as in Northern Congo (DRC) makes one wonder whether the reform will deliver Uganda, the Caucasus and in Colombia; poor coordination of their better assistance for those most in need. In DRC, the military opera- delivery partners in Indonesia following the tsunami or more tions launched in November 2005 by the Congolese armed forces recently the earthquake in Pakistan, and the virtual absence of UN against certain Mai-Mai groups resulted in the displacement of sev- aid in very fragile regions such as the Central African Republic. eral tens of thousands of people, yet the World Food Programme needed several months to become fully operational. In Northern Spurred on by increasingly public failures to adequately respond to Uganda, chosen as a pilot country for the implementation of the needs of displaced persons in various contexts – Darfur being reforms, the needs for water and latrines were not always met in the most egregious example, the UN, on occasion of its sixtieth most districts more than six months after the reforms came into anniversary, initiated a series of reforms intended to improve its effect. response to humanitarian crises. Marked by the modification of its emergency fund to establish the Central Emergency Response Fund Placed respectively in charge of the nutrition and health clusters, (CERF) in December 2005, these changes fall within the scope of a Unicef and the World Health Organization (WHO) have a chance wider process of organisational reform proposed by the UN to play a leading role promoting and adopting new strategies for the Secretary General under pressure from many Member States.1 treatment of malnutrition, following the discovery of a new therapeutic product (in the form of an enriched ready-to-use paste). MSF and current reforms: independence and prag- Given this possibility, their position and operational decisions sur- matism rounding this issue will also constitute a full-scale test to see if the Officially, reform aims to increase the role and authority of new coordinated cluster structure results in any real improvements humanitarian coordinators in the field to better defend humanitar- in meeting human needs. ian space and principles. Everything rests on two pillars. The first is financial resources that are more predictable and more readily Whilst determined to retain its independence in the face of current available in emergency situations through the new CERF. The sec- reforms, MSF will continue a dialogue with the UN operational ond is a mechanism (“cluster system”) allowing the humanitarian agencies and also accepts the need for context-related, operation- coordinator in a given country to clearly identify and quickly oriented coordination between the head offices as well as in the mobilise the agency responsible for overseeing a response to par- field. MSF will maintain its independence of analysis and action ticular needs, with the aim of eliminating any gaps between sec- and resources so as not to jeopardise the strictly humanitarian and tors. This “cluster lead” then relies on the other members of its impartial nature of our organisation, particularly in conflict situa- cluster to carry out a response: the UN operational agencies and tions, where it is critical to keep the trust of the belligerents to be NGOs it will mobilise to address an identified need. able to reach those who require our assistance.

MSF continues to follow this process of reform with attention to its Coordination: to what end? potential implications for the organisation of emergency relief and Coordination cannot be an end in itself; it must be useful, guided the response to humanitarian needs in the field. We have abstained by the reality of the situation on the ground and directed toward from publicly taking position on the current reforms, as we consid- concrete action. The limits of the mechanisms of coordination ered it did not fall within the competence of a medical-humanitar- must be recognised: faced with political interference in humanitarian organisation to comment on, or make proposals regarding the ian aid, the solution resides not in multiplication or strengthening internal workings of the UN. The current reforms are also a UN of technical measures, but rather in the need for humanitarian process: clearly stated, we will not be a member of the clusters and organisations and the international community to highlight politi- the action of MSF will not be placed under the responsibility of UN cal constraints and ascribe responsibilities. The setting up of coor-

1. “In larger freedom: towards development, security and human rights for all”, Report of mittee. This body is made up of the most senior officials of the worldwide organisation the Secretary-General, 24 March 2005 (A/59/2005). and is responsible for advising the Secretary General and strategic decision making. 2. Tsunami Evaluation Coalition, Joint evaluation of the international response to the Indian 4. Faced with the increase in the number of peacekeeping operations in the 1990s and the Ocean tsunami, July 2006. failure of the international community in the management of certain internal conflicts, a 3. “Note of Guidance on Integrated Missions”. This document issued by the General number of analyses concluded that there was a need for better coordination between Secretary of the United Nations was adopted on 17 January 2006 by the UN policy com- the different aspects of crisis response through the creation of suitable institutional

16 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Nine different clusters have been validated by the members of the Inter-Agency Standing Committee (IASC) in the UN’s cluster system. These clusters are: • Nutrition • Water and hygiene • Health • Coordination and camp management for displaced people • Emergency shelters dination structures at national (Joint Monitoring Committee) and • Protection decentralised (District Disaster Management Committees) levels • Logistics did not, for example, help to improve the quality of assistance pro- • Means of communication vided in Northern Uganda. • Re-launch of the economy in the post-conflict stage This organisation applies mainly to relief efforts in favour It is also crucial not to maintain the illusion that a unified aid sys- of internally displaced populations. tem steered by the UN Office for the Coordination of Humanitarian Affairs (OCHA) or any other agency would lead to an automatic significant improvement in the efficiency of relief efforts. Presented as by the peacekeeping missions. The DRC provides a perfect illustra- a model of coordination, the international response to the tsunami tion of this: the weakness of the international assistance given to at the end of 2004 was nonetheless severely criticised by an interna- Katanga and the slow response of the UN’s operational agencies to tional evaluation mission.2 According to the conclusions of that the renewed displacements of populations that occurred at the end investigation, the international relief effort did respond to the actual of 2005/ beginning of 2006 were linked to the reticence of the needs of the affected populations, but was driven more by political Security Council and donors to examine the situation in this and media considerations. Faced with the scale of the public “Presidential province”, for highly diplomatic reasons. response, the humanitarian organisations spent the money “quickly and ostentatiously” and “to find something to do”. MSF has on a number of occasions publicly stressed the risks of the politicisation and the militarisation of the system of aid brought The humanitarian landscape is currently made up of a large about by the “coherence agenda”4 and integrated missions, in par- number of actors with widely differing aims, resources and modus ticular in conflict situations. This approach has notably led in the operandi. It is not only impossible and unrealistic to believe that all past to certain groups in need being excluded from immediate these actors can work in perfect synergy under a single banner, but assistance in Angola, Sierra Leone and Burundi5. In Sierra Leone, it can also be at times perilous, as some actors operate with mixed for example, the UN in 1997 withdrew staff and cut off emergency agendas, the humanitarian goals falling second to political, security assistance to support its political aim of weakening the AFRC/ or developmental objectives and resulting in unmet needs. The RUF, the result of which was deliberate and unnecessary suffering existence of a diversity of approaches is what helped save the lives of and starvation of the population. This year, Darfur and the occu- thousands of children in Niger in 2005, illustrating that independ- pied Palestinian Territories served once again to remind us that ent actors may well offer people in need the best chance at effective humanitarian action constitutes a crisis management instrument. assistance. Further, diverse approaches to humanitarian aid help In April 2006, the World Food Programme (WFP) announced a assure that if one strategy fails, all do not fail, with deadly conse- halving of food rations to the people displaced by fighting in quences. We have already seen this to be the case in contexts such Darfur because of a lack of finance. This was brought about as East Timor and Angola. because the donor countries had decided to make assistance to populations conditional upon the signing of a peace agreement. The increasing politicisation of humanitarian action According to United Nations official line, the reforms initiated in Following the victory of Hamas in the January 2006 parliamentary 2005 should better defend the humanitarian space and principles election, several countries including the United States and the and improve the efficiency of the UN’s crisis response. This can be European Union decided to suspend their bilateral financial aid to doubted, however, in light of the UN Secretary General’s note on the Palestinian Authority whilst proposing to redistribute these integrated missions, adopted on 17 January 2006.3 This document funds towards international relief organisations. Humanitarian reaffirms the central role of integration for the mounting of UN action thus became a palliative for a retaliatory measure and was peacekeeping missions. It is not only a matter of achieving “a more effectively asked to act as a substitute for the Palestinian Authority. consistent UN system” in the field, but also of “ensuring efficient coordination between the peacekeeping mission, the UN’s opera- Improving the effectiveness of relief actions depends mainly on tional agencies and non-UN partners.” The note also specifies that upholding and implementing humanitarian principles by the oper- the UN presence must be based on a clear and shared understand- ational agencies of the UN (WFP, Unicef, HCR) and by the NGOs, ing of the priorities and the willingness of all actors to contribute in other words, strengthening the impartiality and independence to the achievement of shared objectives – subject to reorientation of humanitarian action. The increasing politicisation of the inter- based on the global objective of the UN mission. national system of aid over the past few years does little to inspire This document clearly shows that in the UN’s view, humanitarian optimism, particularly as the majority of humanitarian relief action remains subordinate to the UN’s political arm and that actors are actively contributing to the process – or do not have the humanitarian aid comes second to the political objectives pursued means to escape from it.

mechanisms. Within the UN system, this dynamic led to the implementation of “integrat- 5. For more information, see in particular “Angolans left to die: abandoning the humanitarian ed missions” consisting in placing all UN activities in the field under the authority of the imperative”, MSF report, 30 October 2003 and Nicolas de Torrenté, “Humanitarianism UN Secretary General’s Special Representative. See in particular “Renewing the United Sacrificed: Integration’s False Promise”, in Ethics and International Affairs, volume 18, 2004. Nations-A Programme for reform”, A/51/950 and “Report of the Panel on United Nations Peace Operations” (the Brahimi report), A/55/305-S/2000/809.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 17 Democratic Republic of Congo: Forgotten War

As a medical-humanitarian organisation, MSF seeks to help people most in need, and for years the DRC has been at, or near, the top of our list. The longstanding war and the collapse of the public health system have resulted in widespread acute medical needs. MSF teams, composed of international and Congolese aid workers, are active in all corners of this huge country striving to reach those most at risk.

It is a struggle to do anything other than respond to the most serious emergencies. The complex and diverse nature of the violence, neglect, and discrimination in the DRC challenges any notion of simple, blanket solutions to redress even the immediate causes of so much death and suffering. Whilst MSF does not purport to provide a solution, we want to draw attention to what the Congolese people are enduring.

More than 3.8 million people have died in the Congo conflict since 1998. The majority of people die from disease and malnutrition.

Bon Marché Hospital, Bunia, May, 2005

18 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Democratic Republic of Congo: Forgotten War © Ron Haviv

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 19 Internally displaced people of the Hema tribe at the Tche camp, Ituri District. In January 2003, renewed fighting forced tens of thousands of people to flee for their lives into the surrounding forests and abandon their few possessions to local militias, with some 80,000 finding precarious refuge in Djugu territory north of Bunia. MSF carried out an emergency intervention in four displacement camps in Gina and Tche, in the highlands, and Tchomia and Kakwa, on the shores of Lake Albert. © Ron Haviv/VII VII / James Nachtwey ©

At a hospital in Bunia, a mother tries to soothe her two young children suffering from malaria and dysentery.

20 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 © Joachim Ladefoged/VII

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 21 22 © Antonin Kratochvil/VII MEDECINS MEDECINS

Kinshasa are living with HIV/AIDS and few have access to treatment. In addition to providing antiretroviral therapy to over 1300 1300 HIV/AIDS. over have to who therapy workers sex commercial antiretroviral treating at providing to aimed in addition project In people new a 160,000 treatment. to to Up started has access MSF have Kinshasa. few in patients, and workers sex HIV/AIDS with commercial living nine by are shared Kinshasa compound a inside net mosquito a behind girl A © Joachim Ladefoged/VII S ANS FRONTIERES ANS

ACTIVITY REPORT 2005/2 REPORT ACTIVITY 00 6 comprehensive healthcare. comprehensive to access no or little have people many and HIV/AIDS with living are Congolese million 1.1 estimated an country the Throughout 2005. June Congo, Bukavu, of town eastern the in pital hos a at doctors MSF by for cared being patient AIDS An - © Gary Knight/VII

An MSF patient recovers at Bon Marché Hospital. A former coffee warehouse, the Bon Marché is the only fully functioning medical facility for hundreds of kilometres, offering free healthcare to all indigenous tribes. A range of medical care is provided here, with a particular focus on surgery for the war-wounded. Sexual violence is especially prevalent, and MSF has treated more than 3500 rape survivors since June 2003. © Antonin Kratochvil/VII

A guard at the entrance of an AIDS clinic run by MSF in Bukavu, June 2005.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 23 © Gary Knight/VII

A young child with high fever and many medical complications awaits emergency surgery at Bon Marché Hospital, Bunia. Whilst many people have lost their lives in the violence, the great majority have died from preventable diseases like malaria and measles.

Pictures can help. Their essential quality is to go behind the headlines to offer glimpses of ordinary people’s lives – reminding us, and the world at large,

that we must refuse to let the unacceptable

become

normal.

Photos are part of a touring exhibition by the world-renowned VII Photo Agency photographers, who travelled with MSF in the Democratic Republic of Congo in 2005. The exhibit has visited

Bon Marché Hospital, Bunia

24 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 MSF Projects around the World Africa Paolo Pellegrin/Magnum Photos ©

A child with cholera and his mother in an MSF-run cholera treatment centre in Malenje, Angola, May 2006.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 27 INTERNATIONAL STAFF 100 NATIONAL STAFF 962 Africa Angola

After three decades of civil war, reconstruction of Angola’s health infrastructure is starting to take the place of medical emergency assistance. The country’s current health system, however, remains woefully inadequate and in February 2006 was challenged by the worst cholera outbreak ever recorded in the capital city of Luanda.

MSF, already present with numerous proj- introduced new malaria treatment proto- ects throughout the country, responded by cols using highly effective artemisinin- setting up 10 cholera treatment centres based combination therapy (ACT) and is (CTCs) in Luanda, receiving up to 400 urging the government, who has adopted admissions daily at the height of the out- ACT as its new treatment protocol, to make break. Another 15-20 treatment centres the drugs available across the country.

were set up to deal with the spread of the Paolo Pellegrin/Magnum Photos bacterial illness in other provinces. MSF also supports the health centre in © Treatment efforts were complemented by Cuemba, Bié province, which provides water and sanitation activities. medical care for approximately 84,000 local residents and Angolan refugees returning The required medical care for cholera from other countries. In 2005, more than includes the immediate replacement of flu- 40 patients were treated for TB at this loca- ids and electrolytes. MSF organized 40 “oral tion. MSF also supports the TB programme Inside a Cholera Tr eatment Centre Luanda, Angola, March, 2006 rehydration salt points” in Luanda, where at the provincial hospital in Kuito, which patients could receive rehydration and serves approximately 500 patients receiv- The atmosphere inside the cholera treat- more severe cases could be immediately ing directly observed tuberculosis treatment centre (CTC) is somewhat chaotic. referred to the closest CTC. This also ment. All the beds are full and some patients helped reduce pressure on CTCs by offer- have to share a bed. Both medical and ing effective treatment for those not need- In Luau, Moxico province, MSF supports logistical staff are working flat out, the ing hospitalisation, whilst reducing time the 53-bed hospital, which conducted logisticians hastily putting up another between cholera detection and necessary more than 20,000 outpatient consultations tent to house twenty more beds, but the referrals. in 2005 and admitted approximately 125 truth is they are running out of space. patients monthly. MSF also provides assis- The CTC itself is quite basic: at the An educational component was part of the tance at five area health posts, using entrance there is a disinfection area where emergency response, including a cholera mobile medical teams in this sparsely pop- everyone is sprayed with chlorine, to kill song broadcast by national and local radio ulated area. During 2005, teams performed the bacteria that cause cholera. Cholera is networks. The number of cholera cases over 30,000 medical consultations. highly contagious so it’s crucial that began to decline by mid-May and MSF infected people are isolated and anyone started handing over the treatment centres Numerous projects close who comes into contact with them is dis- to the Ministry of Health (MOH). The country’s stabilising situation has led infected. There is also a triage area for MSF to hand over many of its activities, newly arrived patients, a pharmacy, water More than 53,000 people were infected including projects in Mussende, Kwanza points, latrines, and several large tents and an estimated 2100 people died Sul province (March 2006); Kuvango and with rows upon rows of beds. Each bed between mid-February and early Vikungo, Huila province (March 2006); has a hole in the middle and two buckets September 2006. During its intervention, Cangola, Uige province (July 2006); underneath, one labelled ‘vómito’ the MSF treated more than 26,000 people and Macocola and Buengas municipalities, Uige other ‘excremento’. sent more than 400 tonnes of medical and province (December 2006); Caxito, Bengo logistical supplies to affected areas. province (January 2006); Mavinga, Cuando It would be easy to be shocked by the Cubango (September 2006) and the Luau indignity of it all, but the only way to Treating people with HIV/AIDS, transit centre (September 2005). treat cholera is to allow patients to flush tuberculosis and malaria the bacteria out of their bodies and to In the provinces of Malanje, Lunda Norte MSF has worked in Angola since 1983. rehydrate them as quickly as possible. For and Bié, MSF in 2005/2006 continued to those who reach a centre in time, recovery assist thousands of people with HIV/AIDS, is fast. tuberculosis (TB) and malaria. MSF has also

28 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Inside a Cholera Tr eatment Centre Centre eatment Tr Cholera a Inside port, getting to the CTCs is not always easy: easy: always not is CTCs the to getting port, trans public limited with that find ment, treat receiving is son old five-year whose Mateus, Florinda as such parents Yet severe. most been has outbreak cholera the where areas slum biggest Luanda’s of one Vista, Boa from are centre this in patients Most surroundings. their or them, around people the of recognition no show that eyes sunken – eyes’ as ‘cholera describes nurse one what by identifiable easily affected severely most the with ed, infect be will centre the to coming of people majority The necessary. hardly are tests such up, set is CTC a that time the By ness. ill the diagnose to used are samples stool suspected, first is outbreak cholera a When dehydration. from die could they adult, an to enough quickly not is it given If lungs. their flooding of risk the is there child, young a to given is much If too monitored. constantly be must they drips the on are patients Once morning. in one IVs fifty to up do might doctor a drips, these on people putting clock the around work staff MSF them. rehydrate to fluid lactate Ringer’s containing drips venous intra on put are centre the at patients Most Luanda, Angola, March, 2006 March, Angola, Luanda, - - - - - tion is not just a question of knowledge. As As knowledge. of question a just not is tion preven cholera unfortunately but illness, the of spread the prevent help to response, cholera a into integrated is education Public them. for can done be little that centre the at arrive they when dehydrated so are patients means delay this Often numbers. patient in surge a sees CTC the morning each so night, at centre the to come to robbed being of scared were too they reported patients Other ill.” was son my knew they because usual, than more much kwanza, 1500 me charged They taxi. a call to had I so us take wouldn’t buses normal the but here, Nelo bring to knew I so cholera about TV on notices the saw “I hygiene.” good favour don’t just here conditions but the water their treat and hands their wash should they know Luanda in to talking been we’ve people “The says Angola in cation edu such organise helped who Parker, Julia

ACTIVITY REPORT 2005/2 REPORT ACTIVITY - - Now that the project is well established, established, well is project the that Now ARVs. taking be will patients 900 2006, of end the By monthly. patients new 35 for (ARVs) antiretrovirals initiates and consultations medical 620 of average an conducts MSF associations. local with collaboration in mounted programme educational an and treatment testing, ling, counsel Include Activities country. the in highest the be to reported is cent, per 3.4 at prevalence, HIV where area rural a Couﬀo, Mono- of department the in project AIDS HIV/ comprehensive a developed has MSF concern. health a also is HIV/AIDS and death, of cause common a is Malaria day. per dollar a than less on subsist inhabitants its of cent per 33 over where and resources natural few with one, poor a though Africa, In countries stable more the of one is Benin Benin STAFF STAFF NATIONAL INTERNATIONAL MSF has worked in Benin since 1997. since Benin in worked has MSF area. this in antimalarial effective most the currently (ACT), therapy combination artemisinin-based with treatment requiring people 1028 the treated and fever with ple peo 3388 tested MSF malaria. for test tive qualita rapid a using diagnoses accurate more provide to intervened MSF malaria. by affected being as diagnosed were fever with patients of cent per 45 Agamé, of camp refugee the in 2005, September In malaria with patients treating and Diagnosing refugees. 6690 of population a for monthly consultations 2000 approximately performing activities, its re-establish to able was MSF and area the to returned many later, week One Agamé. from tres kilome 12 Lokassa, towards departure sive mas a made Refugees looted. were MSF of outposts medical the and camp the of destruction the in resulted residents local and refugees between confrontations lent vio 2006, February In Benin. of south the in Agamé, at camp a in refugees Togolese 10,000 to up for care medical ensure to project a run has MSF 2005, June Since refugees Togolese for Caring HIV/AIDS. to linked illnesses all for treatment free provide to authorities for advocate to ues contin it whilst partners, and authorities health local to transfer its preparing is MSF 00 6 6 MEDECINS MEDECINS 94 S ANS FRONTIERES ANS 11 -

- - - - - 29 - Africa INTERNATIONAL STAFF 27 INTERNATIONAL STAFF 58 NATIONAL STAFF 214 NATIONAL STAFF 787 Africa Burkina Faso Burundi

People living in the poor West African nation of Burkina Faso have an average life expectancy of approximately 48 years. About 90 per cent of people earn their livelihood through subsistence agriculture, mostly Markus Marcetic/MOMENT cotton, in a country vulnerable to drought and desertification. Lack of © An average family in Burundi has to work for two weeks to afford a medical consultation. MSF provides free health- access to safe and clean water is a problem for much of the population care for those who would otherwise do without, using mobile clinics to reach remote villages. and the risk of infectious diseases is high. A country with a long history of ethnic conflict, Burundi in 2005 continued along MSF regularly intervenes to provide medi- consultations are provided each month. a road of relative peace, seeing the demo- cal care during health emergencies. In Antiretroviral treatment (ART) has been cratic election of a new, power-sharing 2005 there was a cholera outbreak from supplied to patients since April 2003, and government headed by Pierre Nkurunziza. mid-August to November in the capital city approximately 85 new patients start treat- The country’s war-shattered economy and of Ouagadougou. MSF worked in a cholera ment monthly. Approximately 3500 infrastructure are high on the govern- treatment centre, where it was involved in patients will be on ART by the end of 2006. ment’s development agenda, but a cost- the treatment of 1050 people who had recovery system of healthcare means that contracted the water-borne disease. Health support for teenage street many Burundians still lack access to basic girls medical services, despite a May 2006 Meningitis is endemic in Burkina Faso and Ouagadougou has a thriving sex trade and announcement of free medical care for epidemics tend to break out during the MSF has been offering health education pregnant women and children under five major dry season, from January to March. and healthcare for teenage street girls years of age. In March 2006, the situation was particu- since 2005. Services include treatment for larly worrying, with the number of menin- sexually transmitted infections (STIs), Offering low cost primary health- gitis cases climbing to over 2000 persons in obstetrical care and psychological support care just seven weeks. MSF worked with the for survivors of sexual violence. There are MSF supports a number of hospitals Ministry of Health to carry out a vaccina- also efforts to improve the legal protection throughout the country, where health ser- tion campaign and provided supervisory available to these teenagers. MSF trains vices are provided for very low fees, with personnel, vaccine supplies and logistical local health workers so they are able to free access for the most vulnerable. support. In the districts of Banfora and treat girls with STIs. By July 2006, the proj- Malaria, a treatable but otherwise poten- Sindou, MSF teams managed the vaccina- ect had reached 300 teenagers. tially fatal disease, represents up to 50 per tion campaign and helped safeguard cent of MSF medical consultations at 400,000 people against this disease MSF also provided medical care and psy- health centres countrywide. through immunisation. chological assistance to 700 of the capital’s street children over the past seven years. A In Karuzi province, MSF works in the new- Supplying patients with HIV local organisation took on this project in ly rebuilt, 180-bed Buhiga Hospital, offer- treatment April 2006. ing surgery, maternity and paediatric care. In Ouagadougou, MSF has an established MSF also supports 12 primary healthcare HIV/AIDS project in the Pissy health dis- MSF has worked in Burkina Faso since 1995. centres in the province (450,000 consulta- trict, where an average of 1600 medical tions in 2005), and runs a therapeutic feeding centre that treated 10,669 children in 2005.

In Ruyigi district, MSF provides primary healthcare in seven health centres (180,000 consultations in 2005, with 93,000 cases of malaria treated) and provides support to a hospital in Kininya. Medical services include tuberculosis treatment, ante and post-natal care, surgery and physical and psychological care for women survivors of sexual violence. There is also testing and treatment for HIV. A similar project is running in Kazanza province, where MSF works out of a 100- bed hospital in Musema and four health Anthony Jacopucci ©

30 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 13 NATIONAL STAFF 95 Africa Central African Republic

“ There were 400 people attending a clinic in one village. Suddenly one of them thought they heard a vehicle approaching from a distance. All 400 An average family in Burundi has to work for two weeks to afford a medical consultation. MSF provides free healthcare for those who would otherwise do without, using mobile clinics to reach remote villages. rose and fled into the bush within seconds, leaving the MSF workers centres that conducted 96,500 consultations in 2005. standing alone and stunned.” Simon Collins, MSF doctor Responding to women’s healthcare ©Ton Koene needs MSF runs a specialised health centre for The civilian population in the north of the illness seen here, affecting more than one- women survivors of sexual violence in Central African Republic (CAR) is bearing third of patients. Others suffer from mala- Burundi’s capital city, Bujumbura. The “cen- the brunt of an ongoing conflict between dies including respiratory infections, tre des femmes” provides medical and psy- rebel and government forces. Violence bloody diarrhoea or snakebites. chological care as well as services for fam- between armed groups has led to the Patients needing more care are referred to ily planning and sexually transmitted torching of entire villages and attacks on Paoua Hospital, where another MSF team infections. The team also focuses on educa- civilians, causing many people to flee to works after having rehabilitated the facility. tion and raising awareness about sexual the bush, where they attempt to survive Approximately 500 people receive medical violence. On average 123 women were the most primitive living conditions. The consultations and 50 patients are hospital- treated monthly in 2005. fighting has caused a total collapse of the ised weekly. healthcare system. There is little capacity to deal with emer- Handing over sleeping sickness gency obstetric cases in Bujumbura. In MSF runs ten mobile clinics near activities 2006, MSF began construction of a 30-bed Markounda, along the border with Chad, From 2001 to mid-2006, MSF ran a Human gynaecologic-obstetric reference hospital assisting thousands of people, many of African Trypanosomiasis (sleeping sickness) with a surgical unit in Kabezi, 20 minutes whom suffer from malaria, worm infesta- programme in the Zemio, Mboki and Obo outside the city centre, to provide emer- tion or acute respiratory infections – condi- areas of the southeastern province Haut- gency care for women throughout the tions often caused by living in the open. By Mbomou. The project was handed over to province. May 2006, teams were conducting over the Ministry of Health and national sleep- 8000 medical consultations monthly. MSF ing sickness programme in April 2006, Helping Rwandan asylum seekers vaccinates adults and children against once disease levels had dropped signifi- In 2005/2006, some 20,000 Rwandans measles and other common infectious dis- cantly. During its project, MSF screened streamed across the border, citing harass- eases as a preventive measure. Plastic more than 76,000 people and treated 1509 ment by Rwandan authorities and fear of sheeting, blankets and soap are also dis- individuals. neighbourhood tribunals established to tributed. prosecute genocide suspects. MSF estab- MSF continues to screen and treat people lished a clinic in Musasa and offered basic To care for patients requiring more inten- with malaria in the area. The team trains healthcare to asylum seekers in the Musasa sive treatment, MSF set up a 16-bed hospi- laboratory staff and supervises five health and Songore camps. MSF also extended its tal in Markounda. Each week up to 15 peo- centres in the Haut-Mbomou. A mobile services to Burundians, some of whom ple are admitted to the facility and several health clinic operates close to Mboki town, walk up to six hours to receive free and hundred patients receive care through the performing approximately 1400 outpatient quality medical care. In the first seven hospital’s outpatient department. In May consultations monthly, many for people months of 2006, MSF performed 63,675 2006, MSF also began working in the 40- with malaria. Another 200 people are hos- medical consultations here, seeing mainly bed regional referral hospital in the city of pitalised each month for more intensive respiratory tract infections and malaria. Boguila Kota, southwest of Markounda. treatment.

MSF closes the Centre de Blessés In March 2006, MSF started providing med- In November 2005, MSF also responded to The scaling down of fighting in and around ical care in the northwestern town of a measles outbreak in Mboki and vaccinat- Bujumbura led MSF to close its ‘war Paoua. In April, the team began conducting ed a total of 4500 children. wounded’ health centre in March 2006. The mobile medical consultations along roads project ran for ten years and recorded 1101 near deserted villages. On average, 400 MSF has worked in the Central African new admissions in 2005. consultations are carried out each week, Republic since 1997. with approximately 60 per cent of patients MSF has worked in Burundi since 1992. under the age of five. Malaria is the main

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 31 INTERNATIONAL STAFF 89 INTERNATIONAL STAFF 9 NATIONAL STAFF 743 NATIONAL STAFF 72 Africa Chad Cameroon

Buruli Ulcer is a largely neglected health problem for the people of Cameroon. Untreated, this disease destroys the skin and underlying tissues, causing large ulcerations, possible infection of the bone, and deformities, usually of the ©Ton Koene arms and legs. Buruli affects A child receives an oral polio vaccine in one of the camps housing refugees from Central African Republic. mostly children under the age of 15, some of whom may lose their Chad experienced bouts of instability in Refugees from Darfur and Central 2005/2006. Several attempted coups on African Republic limbs or face permanent disability the government culminated in a large- MSF provides medical care – including pae- without early medical care. scale rebel attack on N’Djamena in April diatric and maternal care – and psychoso- 2006, resulting in hundreds of civilian and cial support to approximately 80,000 military casualties. Earlier, in December Sudanese refugees in four refugee camps. MSF runs a Buruli Ulcer project in the 2005, clashes between government forces MSF also treats the surrounding Chadian Akonolinga district of Cameroon, where it and Chadian rebel groups broke out in and population. Teams are involved in address- is estimated that more than 400 persons around Adré, located at the Sudanese bor- ing the consequences of sexual violence, are suffering from Buruli in a rural popula- der. Since then, rebels or armed fighters malnutrition, providing health education tion of close to 100,000. MSF works togeth- have undertaken regular violent attacks at and controlling communicable diseases. er with the local health authorities, health- villages on both sides of the border. care staff and school and community Since June 2005, increasing violence in the representatives to increase awareness Helping the wounded and displaced neighbouring Central African Republic about the disease and offer wound care, Surgical capacity is necessary to treat peo- prompted some 15,000 villagers to flee medical treatment, surgery and physio- ple affected by violence. In the Adré hospi- into southern Chad. MSF teams assist therapy. Treatment is organised in the dis- tal, MSF provides basic healthcare and Central Africans on both sides of the bor- trict hospital at the “Pavillion Buruli” and basic and emergency surgery to residents der. In Goré, Chad, MSF supports the 50- can last up to several months. MSF also and Sudanese persons who have fled bed hospital and two health posts in the supplies medical materials, training, sup- Darfur and are now living in refugee camps Amboko extension and Gondje. port and supervision and maintains and in Chad. Healthcare and surgery are pro- rehabilitates infrastructure and equipment. vided in the 50-bed hospital of Iriba, fur- Malaria, measles and meningitis ther north, and basic healthcare is avail- MSF runs a malaria project in Bongor dis- Case detection is steadily increasing able in a health centre at the border town trict, bordering Cameroon. During the because of growing awareness and cred- of Tiné. endemic season in 2005, almost 40,000 ibility of the treatment services in the people were tested and treated with arte- Akonolinga district hospital, where 145 MSF has improved surgical facilities in the misinin-based combination therapy (ACT). persons were successfully treated in 2005. hospital of the provincial capital of Abéché Between January and the end of July 2006, and has readied medical materials such as In Bongor’s district hospital, MSF provides 98 new cases were diagnosed and admit- kits and dressings to treat any war-wounds surgical training for local doctors and ted for treatment. resulting from flaring violence in the area. anaesthetist training for nurses. In April 2006 the mobile surgical team relocated to Helping develop a national HIV/AIDS The sustained instability in eastern Chad N’Djamena to provide care for 49 persons programme has led to further population displacement seriously injured by violence. MSF’s HIV/AIDS work continues to focus on along the border stretch. South of Adré, access to HIV counselling and testing and MSF operates fixed and mobile clinics to Throughout the year, MSF regularly care and antiretroviral (ARV) treatment provide healthcare, non-food items and responds to emergencies such as measles, with gradual involvement of local and drinkable water to thousands of villagers meningitis and cholera epidemics through- national actors. The MSF HIV/AIDS projects and displaced people in and around the out the country. In May 2006, MSF vacci- in Cameroon have been serving as “pilot” villages of Borota, Alacha, Adé, Koloy and nated over 50,000 people against meningi- projects both for MSF and the HIV/AIDS Dogdoré. In June 2006, more than 5000 tis. National Programme of Cameroon. children were vaccinated against measles in this area. MSF has worked in Chad since 1981.

32 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Africa © Michael Goldfarb

MSF nurse Pat Murphy manages the Buruli clinic, giving medicine and emotional support to patients receiving treatment. Patients are often stigmatised and face profound psychological and social hardships. Many with Buruli, especially children, find themselves alone and isolated from their families and communities. Buruli Ulcer: A Mystifying Disease By the end of July 2006, MSF was involved Tania, a young Cameroonese athlete, was a “The delayed recourse to surgery – the in the support, care and treatment for more 100-metre track champion when she found main treatment for the ulcer – is much than 4000 people with HIV/AIDS – 1300 on out she had Buruli. “It all started with a lit- more traumatic than if carried out early, ARV treatment – in the districts of Nylon tle spot on my left ankle. It was in the mid- when it is highly effective. At a later stage, and New Bell in the city of Douala. In dle of a competition and I did not want to wide excisions or removal of the affected Yaoundé, MSF supported the care and get distracted or stressed. But weeks passed skin area, including healthy tissues, are rec- treatment of more than 2200 people with and the spot became bigger and purulent. I ommended to stop the infection and pre- HIV/AIDS (1300 on ARVs), through its long- decided to go see a “mother”, a traditional vent recurrence or relapse at the same site. term support to the Military Hospital and a healer. She informed me it was onwondo or It requires skin grafting and means a long new project at the Presbyterian district Buruli Ulcer. stay in hospital,” explains a former coordi- hospital of Djoungolo. nator of the Akonolinga project. I was shocked. It was a terrible blow to my The system of financial participation by family, my coach and me. After two years of Patients suffering from Buruli Ulcer cur- patients for HIV testing, care and treatment being treated by traditional medicine and rently receive eight weeks of antibiotics as continues to be a major obstacle for the local nurse, and after another nodule well as wound dressing and surgery. increasing access to testing and treatment appeared on my left elbow, I found out Although initial results of the antibiotic in Cameroon, despite several governmental about MSF and decided to go visit them at treatment seem to reduce the need for sur- decisions in the last three years on cost the Buruli department of the Akonolinga gery, more evidence is needed before con- reduction and fee waivers for indigents and hospital. I had to have an operation and the cluding its effectiveness. children. MSF aims to work closely with nurses looked after me day after day, clean- local associations, activists and actors to ing and changing the dressing. Today, more Named after a county in Uganda, Buruli is lobby for the removal of barriers to HIV pre- than five years later, I am smiling again. I caused by mycobacterium ulcerans, a bacte- vention, care and treatment. know I will be able to have a normal life ria related to tuberculosis and leprosy. and I’m so thankful to those who helped Scientists do not yet know how the disease MSF has worked in Cameroon since 2000. me. But I want to tell those affected by the is transmitted, but it does not appear to be ulcer: please do not wait, go and visit the contagious. Currently diagnosed primarily Buruli ward at Akonolinga as early as pos- by clinical symptoms, Buruli needs more sible.” research for rapid and accurate diagnosis and effective treatment. Lack of awareness of Buruli by health workers and affected communities means that The World Health Organization estimates the disease is usually detected at a late that 100,000 people are suffering from this stage. Other factors for not seeking medical tropical disease, which has been reported in advice are financial constraints, beliefs that over 30 countries worldwide, particularly in the treatment does not work, fear of surgery West Africa, Central and South America, and anaesthesia or superstition and stigma. Southeast Asia and parts of Australia.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 33 INTERNATIONAL STAFF 27 INTERNATIONAL STAFF 207 NATIONAL STAFF 257 NATIONAL STAFF 1933

Africa Republic of Congo Democratic (Congo-Brazzaville) Republic of Congo

Renewed fighting between government forces and Ninja rebels in Millions of people continue to live in cri- Congo’s southern Pool region has caused increased hardship for sis throughout Democratic Republic of Congo (DRC) and the medical situation civilians living in this war-torn country. The recent violence follows remains grave. Five surveys conducted by years of bloody conflict that destroyed the region’s infrastructure MSF in different parts of the country in 2005 showed excess mortality – more including its healthcare system. The fighting also caused many than double the commonly accepted healthcare workers to flee. As a result, most people living in the Pool emergency threshold – and the absence of or exclusion from medical care for region today cannot obtain basic medical care. large parts of the population.

Fighting continued to affect regions in In Pool’s Kindamba district, MSF performs Sleeping sickness (Human African the eastern provinces of North Kivu, more than 2400 consultations monthly, at Trypanosomiasis), a parasitic disease South Kivu and Katanga as well as Ituri regional referral hospitals and through spread through bites of the tsetse fly, is district, causing the displacement of tens mobile clinics. The team offers in and out- also endemic here. After 20 years of screen- of thousands of people. Many live in the patient care, emergency surgery, and ing and treatment, MSF closed its last proj- bush without adequate shelter, water, maternal and childcare, including immuni- ect because of sharply reduced rates of the medical care or food and under the con- sations. In Mindouli district, another 2400 illness, but has urged the MOH to integrate tinuous threat of insecurity. Others have patients are seen monthly at mobile clinics such activities into its healthcare services. fled to villages and are hosted by local and in the district hospital. Mental health populations or live in camps. Against this services are also offered through local Handover of Kinkala project backdrop of violence, 2006 witnessed the counsellors and social workers, who help In May 2006, after performing 90,000 con- first and relatively peaceful presidential people overcome trauma related to the sultations and rehabilitating health struc- and parliamentary elections in the DRC in region’s violent past. tures, MSF handed over a basic healthcare 40 years. project in Kinkala, Pool’s provincial capital, HIV/AIDS care to the MOH. MSF had also begun providing Katanga province MSF assists HIV-positive patients at a new HIV/AIDS treatment in Kinkala; these Fighting between local militias and the programme in Mindouli. Counselling ser- patients will continue to receive care Congolese National Army (FARDC) flared vices and a patient support group have through the programme in Mindouli. up in late 2005, and in northern Katanga, started and the first patient with advanced thousands of people were once again AIDS began receiving antiretrovirals (ARVs) Prior to the project handover, MSF sent a forced from their homes. in February 2006. HIV-positive patients are surgeon and anaesthetist to Kinkala to per- often co-infected with tuberculosis (TB) form vesico-vaginal fistula surgery on 20 For most people in central and northern and MSF provides integrated care for co- women. Caused by prolonged labour and Katanga, upheavals and displacements infected patients in Kindamba and other obstetric complications, fistulas have become commonplace since the Mindouli. MSF is urging the Ministry of result in chronic incontinence, leading to war began in 1996. Malnutrition is one Health (MOH) to integrate TB and HIV/AIDS social isolation. The surgery helps women result of ongoing violence, which pre- care into its basic healthcare services. to function normally and, it is hoped, will vents people from farming their lands for facilitate a return to their homes and fami- fear of being attacked by armed groups. Endemic diseases lies. Malaria accounts for a large proportion of In November 2005, the small town of illness and death in this country. Advocacy MSF has worked in the Republic of Congo Dubie was overwhelmed when over work by MSF and others has led to a since 1997. 18,000 displaced persons arrived in a change in the malaria protocol from chlo- matter of weeks. Already running a make- roquine and fansidar to more effective shift hospital and a network of five health artemisinin-based combination therapy centres, MSF rapidly erected three emer- (ACT). Close to 1000 people were treated gency camps. In the first three weeks of for malaria in the first two months of 2006 January, MSF carried out 1224 medical alone. consultations and began a mass vaccination campaign against measles.

Responding to urgent needs for the displaced, in early 2006 MSF started a programme around Lake Upemba, in the centre of the province. With people living

34 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 “ Hundreds of thousands of people are suffering multiple displacements, direct violence by a variety of armed groups, malnutrition and outbreaks of preventable diseases. This reality has become so commonplace in many areas that it goes virtually unnoticed.”

Democratic Africa Excerpt from a speech delivered by MSF staff Helen O’Neill at the United Nations Security Council Arria Formula Republic of Congo meeting, January 24, 2006.

in squalid conditions on the lake banks, in bush, subject to violence and looting. MSF ly. Medical care is complemented by tar- straw huts or on floating islets, MSF opened two health posts in Kanyabayonga, geted health education concerning the opened a healthcare centre, launched a where most of the displaced persons were transmission and prevention of sexually measles vaccination campaign and distrib- hosted, and MSF teams continue to work in transmitted infections, HIV and issues sur- uted supplies such as plastic sheeting, Rutshuru and Kayna hospitals, providing rounding sexual violence. blankets and cooking utensils for displaced medical and surgical care. A therapeutic families. A cholera epidemic also struck the feeding centre is also running in Kayna. In addition to a long-running project in region around Upemba and Kikondja, lead- Kinshasa, which treats about 1900 patients ing MSF to open an emergency pro- Ituri with ART, a new HIV/AIDS programme gramme, treating 1742 cholera patients In Bunia, capital of Ituri district, MSF contin- opened in Dungu in Oriental Province in over 20 weeks. ues to run the ‘Bon Marché’, a comprehen- July 2005. Following rehabilitation of the sive hospital that includes a focus on pro- hospital, which was destroyed during fight- MSF also worked in Nyunzu, Pweto, viding care to survivors of sexual violence. ing, MSF began providing essential medi- Mitwaba, Shamwana, Ankoro and Mukubu, More than 4500 people aged between cine and training Congolese staff. One providing primary and secondary health ser- eight months and 80 years were treated aspect of the training focuses on treatment vices to displaced and resident populations here between April 2003 and December of the deadly Human African and responding to emergencies caused by 2005. In June 2006, MSF teams also began Trypanosomiasis (sleeping sickness), which epidemics and displacement. providing clinical treatment and monitor- MSF treats in a separate project in Isangi, ing when a pneumonic plague outbreak Oriental Province. North Kivu occurred several hundred kilometres north Bordering Rwanda and Uganda to the east of Bunia town in the area of Rety. Two isola- Multiple emergency interventions in of the DRC, North Kivu has been a theatre tion centres for the treatment of patients 2005/2006 of fighting between various local and for- were set up in Kwandroma and in Vedza The eruption of violence and disease is fre- eign militia as well as the Congolese army and 376 patients were treated. quent in DRC and MSF teams are required and UN blue helmets. Militias, as well as to be mobile and react at short notice, poor and unpaid soldiers, exert enormous Treating HIV/AIDS and Sexually often on a large scale. To help facilitate this, pressure on civilians, who are subject to Transmitted Infections (STIs) quick-reaction teams known by the French looting, extortion, rape and other violence HIV/AIDS is a major focus for MSF in the acronym PUC (Pool d’Urgence Congo) have on an almost daily basis. In Rutshuru hospi- DRC. In Bukavu, South Kivu, MSF provides been established in three major towns. tal in 2005, 26 per cent of monthly surgical comprehensive HIV/AIDS care with coun- Major interventions in 2005 and 2006 interventions were for war-related trauma. selling, testing and treatment of opportu- included a typhoid fever outbreak in Kikwit In 2005, 1292 survivors of rape were treated nistic infections, as well as antiretroviral and a major measles campaign in Mbuji by MSF in Beni, Kayna and Rutshuru. treatment (ART). The objective is to treat Mayi, during which 380,000 children under 1500 patients with ART by the end of 2006. 5 years of age were vaccinated. In early 2006, at least 40,000 people fled Two Karibu clinics opened in the north- their homes around Rutshuru, reaching the eastern town of Kisangani, in June 2005 MSF has worked in Democratic Republic of villages of Kanyabayonga, Kayna and and May 2006, and provide a combined Congo since 1981. Kirumba. Many others remained in the total of 3000 medical consultations month-

“ People arriving in Dubie were in a really bad state as they had walked hundreds of kilometres to get here, half-naked, with barely any food. Many mothers had given birth en route and some people did not survive. You just wouldn’t believe such a situation exists unless you actually see it.” Marcus Bleasdale © Megan Craven, MSF nurse An MSF nurse covers evening clinic in the hospital makeshift tent in Dubie, Katanga. Malnutrition, malaria, cholera and tuberculosis make up the largest percentage of diseases that kill in the DRC.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 35 INTERNATIONAL STAFF 62 NATIONAL STAFF 704 Africa Ethiopia

lenge in Ethiopia. There is still a very limited availability of the necessary drugs, even in areas where the disease is endemic. Transmitted by the sand-ﬂy, the disease attacks the immune system causing fever, wasting, an enlarged spleen, anaemia and death if left untreated. Today, kala azar is still widespread in many parts of the country.

In the district of Libokemkem in the northeastern Amhara Region, MSF treated 1150 patients for kala azar in the last eight months of 2005. In Humera, a town on the border with Sudan and Eritrea, MSF focuses on patients co-infected with HIV and kala azar and treated 1823 patients in 2005. A third project is based in nearby Abdurafi. © Åke Ericson/WorldPictureNews

A colour-coded measuring tape is used to examine the arm of young boy in an MSF feeding centre. If the tape Because much of the country lacks even the shows red, the child will receive treatment. El Kere, Ethiopia, June 2006. most rudimentary care, MSF runs primary Ethiopia remains one of Africa’s poorest countries, with a very low health facilities in a number of locations. Malaria remains a big concern despite a income per capita and a population that is almost two-thirds illiterate. recent change in Ministry of Health (MOH) Its economy is highly dependent on agriculture, which in turn is largely protocol to more effective drugs. In Amhara and Tigray, MSF treated approximately dependent on rainfall. 76,000 patients and then withdrew from most projects in 2006 with improved Many Ethiopians rely on food aid from August 2005, the project expanded to response capacity from the government. In abroad – in 2005, the UN reported between include tuberculosis (TB) treatment and by Foguera district, Amhara, MSF continues to five and seven million people dependent the end of May 2006, 191 patients had run a programme that has supported the on food aid out of a total population of 77 been enrolled. treatment of 49,448 patients with malaria. million. In years of poor harvest, as many as 14 million people risk lack of food, there- A second tuberculosis project is based in Emergency interventions for fore the drought of the past year was of Galaha in the arid and remote Afar Region, meningitis and cholera particular concern to MSF teams located in situated in the east of the country. Like the In January 2006, cases of meningitis were the southeast of the country. population of the Somali Region, the Afars reported in the Welayita region of southern are nomadic, moving every three or four Ethiopia. MSF worked with the MOH to In Cherratti and Barre in the Ogaden, also months in search of grazing areas and respond to this epidemic, providing medi- known as the ‘Somali Region’ of Ethiopia, water for their livestock. Given that a full TB cines and treatment training to medical MSF started a therapeutic feeding pro- course of treatment takes six to seven personnel at health centres. MSF also gramme for severely malnourished chil- months, with drugs administered daily, launched a vaccination campaign, reaching dren in March 2006. Because of the nomad- MSF has had to find an adapted approach 25,000 persons before handing over activi- ic nature of much of the population here, for treatment. The solution was to create a ties to the MOH. the project was adapted to become ambu- village of 400 huts centred around a health latory, with MSF teams moving around the centre. Patients are required to live in the In the western region of Gambella, where region rather than operating out of a fixed village under close medical supervision for up to 70,000 displaced persons in camps location. Nutritional assessment missions four months and are then provided with a are in urgent need of medical assistance, were also carried out in the Afder and further three months of medication they MSF has established a fixed health centre Gode Regions in January and February and can take on their own. Since the project just outside the main town of Itang. A monitoring continued throughout 2006. began in 2001, more than 2400 patients mobile team is ensuring the most vulner- have been treated and the project enrols able communities are receiving basic MSF is supporting primary healthcare approximately 40 new patients per month. healthcare and referral for treatment. In activities in Cheratti district, performing up May 2006, the team conducted an emer- to 100 consultations per day at the health Treating patients with kala azar gency intervention, treating about 2000 centre, and offering emergency, inpatient Whilst national treatment guidelines for cases of cholera. and birth delivery capacity as well as ante- kala azar (visceral leishmaniasis) are being natal care and therapeutic feeding. In reviewed, the disease remains a huge chal- MSF has worked in Ethiopia since 1984.

36 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 27 NATIONAL STAFF 367 Africa Guinea © Benjamin Béchet / DolceVita

The people of Guinea live in a country with significant poverty and three cholera treatment centres (CTC) in periodic instability, leading to a lack of healthcare. Even when patients Conakry and treating more than 3000 patients. In Boké, MSF provided medical can get to a health centre and afford to pay for medical services, short- supplies. A second cholera emergency ages of medicines and supplies means they may have to go without began in February 2006 in the Forest Guinea region, where MSF treated 1171 effective treatment. suspected cases.

This is frequently the case for those with camp near N’zérékoré, home to approxi- In early January 2006, MSF conducted a malaria, which accounts for about 30 per mately 19,000 Liberians. In addition to pri- three-week long vaccination campaign fol- cent of hospitalisations country-wide. mary healthcare, voluntary HIV/AIDS coun- lowing an outbreak of yellow fever in the Through its projects in Dabola, MSF has selling and testing was introduced in Boké area, and immunised 369,000 people. confirmed that artemisinin derivatives January 2006, and in mid-April the first In May, following a meningitis outbreak in (ACT) are the most effective drugs for the patient was put on antiretroviral medica- the prefecture of Mandiana, MSF immun- illness. MSF continues to offer rapid testing tions (ARVs). ised 175,000 people. and ACT for malaria at Dabola hospital and the nine health centres of Dabola prefec- MSF also runs a comprehensive HIV/AIDS Handover of tuberculosis project ture, where 4537 people were treated for programme of counselling, testing and Actively involved in Guinea’s National malaria in the first half of 2006. Although treatment in Conakry and Guéckédou. Programme for the Fight Against the government now intends to use ACT, it Drugs and medical material are provided to Tuberculosis since 1988, MSF has trained has been unable to provide the drugs enable treatment of severe opportunistic doctors and health workers to better man- because of a lack of funding. infections. MSF has also trained counsellors age TB, supplied drugs and laboratory and lab technicians and supplied health equipment, and increased awareness of Helping large numbers of refugees centres with HIV test kits. By the end of the disease. In 2005, MSF handed over its Over the past decade, Guinea has become June 2006, 850 patients were receiving life- last activities in the Conakry region to the host to tens of thousands of refugees from extending ARVs. Ministry of Health. MSF is now focusing neighbouring Liberia and Sierra Leone. only on TB patients co-infected with HIV/ Whilst the majority of refugees have been Responding to infectious disease AIDS. repatriated, some remain in camps, where outbreaks MSF provides healthcare to them and the MSF assisted the Ministry of Health (MOH) MSF has worked in Guinea since 1984. surrounding Guinean host population. in August 2005 to address a cholera out- In Forest Guinea, MSF works in the Lainé break in Boké and Conakry, by setting up

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 37 INTERNATIONAL STAFF 5 INTERNATIONAL STAFF 51 NATIONAL STAFF 16 NATIONAL STAFF 940 Africa Guinea-Bissau Ivory Coast

The West African country of Guinea-Bissau has a precarious infrastructure, lacking a general water and electricity supply even in its capital, Bissau. In addition to common diseases such as

malaria and TB, there have been Espen Rasmussen © recent epidemics of cholera, measles and meningitis – the Sporadic violence and instability continue in the Ivory Coast, most recent taking place in 2005. despite a peace agreement signed between the government and rebel forces in 2003.

The country has effectively been cut in two tres and has started voluntary counselling and the healthcare system was decimated and testing services. MSF also supports the through the conflict that began in 2002. government’s HIV/AIDS programme in Man. Ministry of Health (MOH) staff are slowly returning and medical services are resum- Providing essential healthcare ing, but there remains little or no health- At hospitals in Danané, Bouaké and Man, care for most of the population. MSF continues to provide essential medical care, including paediatric consultations, As well as providing basic healthcare in emergency medicine, obstetric and gynae- both the north and south, MSF is pioneer- cological care and surgery. In 2005, MSF ing new ways of delivering HIV care in the teams in Bouaké provided approximately west of the country, proving that this is 4500 consultations monthly and in Man possible in a place where fighting can more than 8000. Mobile clinics are used to

© MSF break out at any time. provide basic healthcare in more isolated areas and in the “zone of confidence”, the HIV prevalence is estimated up to 15 per buffer area between the north and south, cent in some areas. Previously, HIV/AIDS where MSF runs a hospital in Bangolo and care was administered by doctors in hospi- a health centre in Kouibly. The first cases of cholera emerged on tals, but for many people with HIV this is June 11, 2005 in Bissau, the capital. The not viable for a host of reasons, including In January 2006, whilst many organisations disease spread quickly to other regions distance and the difficulty in accessing were forced to evacuate amidst riots and and by the end of August, the entire hospital care because of conflict. As an demonstrations against international country was affected. MSF responded to a alternative, MSF is training nurses and clini- organisations – labelled occupying forces government appeal for help, sending cal officers to provide care in health clinics. by certain groups – MSF teams in Guiglo teams into Oio province, Bissau city, Sao Education and communications activities were able to continue their work, providing Domingos and Bijagos. By the end of the encourage people to come forward for vol- primary healthcare for up to 6000 dis- intervention, MSF had treated 5242 untary counselling and testing, with free placed persons and the local population patients of the more than 23,000 recorded antiretroviral therapy (ART) and treatment (3200 consultations per month) and treat- in the country. of opportunistic infections provided for ing severely malnourished children in a those in need. therapeutic feeding centre. MSF worked continuously in Guinea- Bissau from 1998 until 2000. MSF keeps in In Danané, MSF in 2005 built a new hospital Handover of prison project regular contact with the authorities to unit for pregnant women with HIV, dedi- After eight years working in MACA prison, help with any health emergencies that cated to providing treatment that will pre- formally the Maison d’Arrêt et de arise. vent these women from passing the virus Correction d’Abidjan, MSF successfully on to their babies. In its first four months, handed this project to the MOH at the end five per cent of the 922 women tested were of 2005. found to be HIV positive. In Bin Houye, MSF is supporting Ministry of Health HIV/AIDS MSF has worked in the Ivory Coast since treatment programmes in three health cen- 1990.

38 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 42 NATIONAL STAFF 399 “ When we opened the office in El Wak, people would

turn up at the door literally begging for water” Africa Kenya MSF emergency co-ordinator Ibrahim Younis

In the early months of 2006, the consequences of three consecutively failed rainy seasons tipped the mainly pastoral population of northern Kenya over the brink. With the onset of child malnutrition, MSF set up a therapeutic feeding programme in the northeastern town of El Wak, treated over 500 children for severe acute malnutrition and immunised 19,000 against measles. Responding to the urgent need for water, MSF trucked hundreds of thousands of gal- lons to five districts in the region.

Across the north of Kenya, the drought had a devastating impact on livestock. In El Wak, the bleached white earth became lit- tered with carcasses of goats, cows, donkeys and camels – a crippling blow to the people of this neglected region. In this part of Kenya, animals are the lifeblood, serving as wealth as well as the primary source of nutrition. © DieterTelemans

An MSF nutritional survey in March showed 30 per cent of children to be severely mal- Improving HIV/AIDS care Handover to local authorities nourished and many more teetering on the For the past decade, the primary focus of After building an HIV/AIDS clinic on the edge. When torrential rains eventually MSF’s work in Kenya has been HIV/AIDS. grounds of Mbagathi District Hospital, began in April, children already weakened MSF provides a comprehensive package of Dagoretti district, Nairobi, MSF has been by malnutrition developd diarrhoea and care, from testing through to treatment, in providing comprehensive HIV/AIDS care respiratory infections. Their nutritional sta- the slums of the capital, Nairobi, as well as alongside health authorities. MSF is now tus also worsened. During the month of Homa Bay and Busia in the west of the supporting the Ministry of Health to take May, the admission rate in El Wak increased country. By March 2006, over 8500 people over this project. by 50 per cent over previous monthly aver- were receiving antiretroviral treatment ages, and MSF began to see children suffer- (ART) from MSF sites and over 17,000 were The goal of increasing access to treatment ing from kwashiorkor, the form of severe enrolled in the projects. is showing the need to decentralise, and malnutrition that creates swelling and is make care available at a greater number of caused by insufficient protein and acute In Homa Bay and the Kibera and Mathare sites – not only through peripheral health infections, all a result of insufficient food slums of Nairobi, MSF has specialised in the structures but also directly through the intake. treatment of HIV/AIDS and tuberculosis community, which is increasingly commit- (TB) co-infection. Immune systems weak- ted to participating in the follow-up of In May, a second intervention was started ened by AIDS help to fuel tuberculosis and newly tested patients and supporting peo- 400 km west, in three of the most arid one of the objectives of the projects is to ple new to treatment. regions in Marsabit District. MSF adopted a develop an optimum treatment strategy. simplified strategy and ensured maximum MSF is piloting the field application of In Kenya as a whole, only about 75,000 of mobility of the team to effectively reach high-tech diagnostic methods to increase the more than 200,000 HIV/AIDS patients the scattered, pastoral population dis- TB case detection amongst patients who who urgently need antiretroviral therapy placed by ongoing inter-clan conflict and are co-infected with TB and HIV. In the now receive the drugs, according to the widespread loss of livestock. Two mobile sprawling Kibera slum, MSF runs three clin- health ministry. In June 2006, the govern- teams provided biweekly medico-nutri- ics, two including HIV/AIDS as one part of a ment made the positive step of providing tional assistance in 35 sites in villages or full primary healthcare package, with a free HIV/AIDS care in all public health facili- peripheral settlements. By the end of June, particular focus on mother-to-child health- ties: a vital move given more than 60 per 700 children at risk of death were enrolled care. Early diagnosis of children born to cent of Kenya’s 33 million people live on in the treatment programme and some HIV-positive mothers is now accessible at less than one dollar a day and about 1.2 severe cases were referred to health struc- all these sites and there has been a signifi- million Kenyans are HIV-positive. tures including the district hospital, where cant increase in treatment of infected MSF set up a therapeutic facility. infants below 18 months of age. MSF has worked in Kenya since 1987.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 39 INTERNATIONAL STAFF 5 INTERNATIONAL STAFF 96 NATIONAL/REGIONAL STAFF 12 NATIONAL STAFF 1288 Africa Lesotho Liberia

In July 2006, electricity was par- tially restored to Monrovia, the capital of Liberia, following a fourteen-year blackout. Stand- pipe water also became available in parts of the city for the first time in years. Rehabilitation efforts are starting to bear fruit in this country, now rebuilding after a 14-year civil war, but Liberia still lacks operational health facilities and personnel. In 2005, about 90 per cent of all ©Wayne Conradie healthcare services were provid- Patients waiting outside one of the 14 health centres in the Scott Health Service Area. ed by faith based-organisations Lesotho, a small mountain kingdom landlocked by South Africa, has or international NGOs such as the third highest HIV prevalence in the world. With 28.9 per cent of MSF. adults infected, it comes after only Botswana and Swaziland, and is the In 2005/2006 many Liberians who fled poorest of the three. the fighting during the war returned home from temporary camps and MSF MSF arrived in Lesotho in January 2006 PLWHAs; enrolled more than 1000 people began closing camp-based health and with the goal of launching a decentralised into HIV care; and initiated ART for nearly sanitation programmes and established approach to HIV/AIDS care and treatment. 300 people. Mobile medical teams visit new ones in the capital and around the Whilst HIV/AIDS care is typically only avail- each health centre on a weekly basis, many country. able at major centres in resource-poor in remote, mountainous areas, to provide countries, here the programme would offer direct clinical care for patients and offer Providing healthcare in the capital access beyond hospitals and urban areas, on-the-spot supervision and training for MSF has provided full support to hospi- providing HIV care and antiretroviral thera- nurses. Intensive support is also provided tals in Monrovia since 1999. MSF runs a py (ART) at 14 clinics in Scott Health in the outpatient department, wards, labo- 150-bed hospital in the Mamba Point Service Area (HSA), a rural health district ratory, and pharmacy at Scott Hospital. area and provides specialist paediatric with a population of 220,000. and obstetrics inpatient services at Island Essential to the project has been the devel- and Benson hospitals. After six years of The team has benefited from the many opment of strong partnerships with the supporting Redemption Hospital, MSF years of experience MSF has accumulated health staff and management and PLWHAs handed over its management to Liberian operating AIDS treatment programmes in Scott HSA (one of the many health dis- health authorities in November 2005. elsewhere, particularly in Khayelitsha and tricts managed by the Christian Health MSF also supports two primary care clin- Lusikisiki in nearby South Africa. Key fac- Association of Lesotho), as well as the ics in Monrovia, providing over 10,000 tors were built into the programme from Ministry of Health and Social Welfare, consultations monthly. the start, such as provision of free HIV/AIDS which provides all antiretrovirals for the care and treatment; delegation of tasks to programme through a grant from the Cholera thrives in the crowded condi- lower levels of health workers; simplifica- Global Fund. Through these partnerships, tions of Monrovia, with disease outbreaks tion of treatment guidelines; and protocols MSF aims to reduce AIDS-related deaths occurring regularly. In August 2005, at and empowerment for persons living with whilst strengthening the capacity of health the height of an outbreak, MSF teams HIV/AIDS (PLWHAs). workers and communities to cope over the intervened and treated 350 suspected long term with Lesotho’s truly overwhelm- cholera patients per week. Later in the In less than six months, the MSF team ing HIV/AIDS emergency. year, the MSF-supported cholera treat- trained more than 100 nurses, village ment unit was handed back to Liberian health workers, peer educators, and MSF began working in Lesotho in 2006. health authorities.

40 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 30 NATIONAL STAFF 314 Africa Malawi

With the security environment stabilising, MSF is developing health programmes focusing on tuberculosis, HIV/AIDS and reproductive health. A paediatric tuberculosis programme at Island Hospital encour- ages caregivers to help children to take their drugs correctly. A specialist mother and child healthcare centre was opened in early 2005 to improve reproductive health, conducting approximately 1500 ante-natal and 1300 family planning consultations monthly in 2005/2006.

Helping survivors of sexual violence

Since 2003, MSF has provided medical © Julie Rémy treatment and psychological support to survivors of sexual violence. MSF staff also A pregnant woman receives antimalarial drugs and iron from an MSF clinical officer at the Thyolo District Hospital. conduct outreach activities and information sessions in markets, schools, churches, HIV/AIDS has dramatically reduced average life expectancy in Malawi to mosques and clinics to raise awareness below the age of 40. It has left 700,000 orphans and vulnerable children. about sexual violence and to encourage survivors to seek care. In 2005, over 1400 Close to a million people in the country are now HIV-positive. The dis- persons were seen through MSF-supported ease has contributed to a huge shortage of qualified health staff, which structures. Half of them were under the age of 18. complicates efforts to address the disease, whilst approximately 170,000 people are in desperate need of antiretroviral (ARV) treatment. Medical care around the country In Saclepea, Nimba county, MSF runs a health clinic next to a camp housing about The government has been increasing the 2005, including 1300 patients who have 1000 Ivorian refugees. In 2005/2006, number of treatment sites to provide been on ARVs for two years and more than approximately 3000 outpatient medical greater access to life-extending care. MSF 200 patients who have successfully used consultations were conducted here month- is closely involved in this decentralisation this therapy for more than three years. ly. A new women’s health unit was also cre- in the southern district of Thyolo, where Another 250 new patients begin treatment ated, offering family planning services and the number of treatment sites has risen monthly. MSF also treats medically compli- treatment for sexually transmitted infec- from one to seven and close to 6000 cated cases including patients on second- tions. patients were using ARVs by July 2006. MSF line treatment (for whom firstline drugs also conducts a programme at the district have failed), patients with Kaposi’s MSF also runs several health clinics and hospital, started in 2002, to prevent moth- Sarcoma – an AIDS related cancer – and provides care to survivors of sexual vio- er-to-child transmission of the disease. By children. MSF also cooperates with the lence in Grand Bassa and River Cess coun- mid-2006, over 2000 women had made use regional hospital providing care in the ties, and runs a hospital providing free of this programme. adult medical and paediatric wards, where care. A community-based programme in approximately 700 patients are admitted Grand Bassa treated 271 malnourished MSF provides a comprehensive HIV/AIDS monthly. children from January to July 2006. programme in the country’s central Dowa district, with teams at district hospitals and Distributing food MSF has worked in Liberia since 1990. several health centres. Aside from the local Malawians in 2005 experienced food short- residents, care is provided for refugees ages resulting from the worst drought in coming from a number of African countries over a decade, and MSF provided nutrition- and now living in a camp in Dzaleka. By the al support to help HIV-positive patients end of April 2006, 424 patients, including and other vulnerable groups. In September 22 children, were receiving ARVs from MSF 2005, MSF started feeding malnourished in Dowa. A support group has also been patients, and had distributed approximate- created for HIV-positive children aged six ly 80 tonnes of food by the end of the year. and over, with high attendance. MSF has worked in Malawi since 1986. In the Chiradzulu district, MSF was providing ARVs to 6491 patients by the end of © Chris Hondros/Getty

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 41 INTERNATIONAL STAFF 15 INTERNATIONAL STAFF 6 NATIONAL STAFF 87 NATIONAL STAFF 11 Africa Mali Morocco

People living in Mali, a country located in the middle of Africa’s meningitis belt, suffer from recurrent epidemics of meningitis, cholera, measles and yellow fever. In 2005/2006, MSF responded to a number of health emergencies in this country where the majority of its

13.8 million inhabitants are without access to basic healthcare. An MSF team provides assistance to sub-Saharan immigrants in the “Kilometre Six”, next to Tangier. Their shacks are made with plastics and other materials supplied by MSF and living conditions are precarious.

Mali was then confronted with a number of In October 2005, approximately 3000 sub- meningitis cases in March 2006. Working in Saharan immigrants were rounded up conjunction with the MOH, MSF supervised from the coastal Spanish villes autonome vaccinations, furnished free treatment for of Ceuta and Melilla, and the cities of patients and organised transportation, Rabat and Casablanca. necessary refrigeration for vaccines and They were put in buses by Moroccan other logistics for the districts of Koutiala police forces and driven to the Sahara and Sélingué. In total, 179,539 people were region of the country, near borders with vaccinated. Mauritania and Algeria. Here more than 1000 people were dumped in the desert Increasing access to healthcare without any food, water, or access to Malaria is the leading cause of death in the healthcare. country. Although the government has updated its malaria drug protocol to use MSF immediately intervened, providing artemisinin derivatives (ACT), insufficient emergency medical care, distributing quantities and high prices preclude this food, water and blankets and denouncing protocol from being used throughout the this inhumane treatment. Over 100 peo- country. In July 2005, MSF began a project ple were treated for wounds and bruises, addressing malaria in Kangaba, offering some caused by failed attempts to jump ACT to those diagnosed with rapid malaria over fences into the Spanish territories tests at community healthcare centres. before being expelled to the desert. Many other contusions were caused by rubber MSF has also been developing a pro- bullets and beatings, claimed by victims gramme, in cooperation with five other to have resulted from violent force used

© MickaelTherer NGOs, to reduce maternal-infant mortality by Spanish and Moroccan authorities. in the northern regions of Gao, Timbuktu In the northwest part of the country, a and Kidal. Equipping health centres, In total, more than 4000 people, some cholera epidemic broke out in Kayes and increasing community education related to asylum seekers, were involved in a mas- Nara between June 2005 and January 2006. maternal health and performing obstetric sive expulsion. Eventually more than 3500 MSF teams backed up the Ministry of surgeries (such as fistula surgery) are the persons were repatriated to Mali and Health (MOH) by taking charge of patient principal components of this programme. Senegal, whilst others were relocated or care, controlling hygiene measures and dispersed on their own. educating the population about the dis- Withdrawal from training project ease. A total of 914 people were affected. After five years of MSF support, the nursing These were some of the thousands of ille- school “Sahel Formation” has provided gal immigrants that arrive in Morocco From September to November 2005, an regions in the north with more than 300 every year, en route to Spain and the intervention to identify and treat malnutri- qualified nurses and lab assistants in a European Union. Increasingly tight border tion was carried out in Goundam, an hour’s zone that previously suffered from a com- controls find many of these people stuck travel from Timbuktu. Out of 5000 children plete lack of health personnel. The school in an inhospitable situation with difficul- evaluated for malnutrition, 54 were hospi- remains open, and MSF has now withdrawn ties accessing food, water or healthcare. talised and 228 were treated as outpa- from the project. tients. National personnel at health centres Only weeks earlier, in September, MSF are now familiar with the techniques of MSF has worked in Mali since 1992. released a two-year report of medical data nutritional surveillance and will continue and testimonials from its healthcare proj- to monitor for child malnutrition. ects in Tangier, Nador and Oujda. Violence and Immigration, a Report on Irregular Sub- Saharan Immigrants in Morocco, showed an alarming 25 per cent of medical consulta-

42 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 59 NATIONAL STAFF 853 Africa Mozambique

An estimated 16 per cent of Mozambique’s population is affected by AIDS, creating an urgent need for effective, accessible HIV/AIDS care in a country where the majority of the population lives in rural areas and

An MSF team provides assistance to sub-Saharan immigrants in the “Kilometre Six”, next to Tangier. Their shacks are through comprehensive HIV/AIDS projects throughout the country. made with plastics and other materials supplied by MSF and living conditions are precarious.

tions between April 2003 and May 2005 In the capital city of Maputo, MSF was 1639 people by the spring of 2006, as part were for violence-related injuries, 62 per treating over 5600 patients with antiretro- of another comprehensive HIV/AIDS pro- cent of the most severe cases claimed to virals (ARVs) by the spring of 2006. MSF is gramme that includes education, voluntary have been inﬂicted by Moroccan and working with the Ministry of Health (MOH) counselling, testing and treatment. In all Spanish security forces. to make care available beyond main hospi- MSF sites, activities were developed to pre- tals and at the primary healthcare level – vent HIV transmission from mother to MSF has worked with the sub-Saharan decentralising care for asymptomatic cases child. These have been well integrated into immigrant population in Morocco since that do not require such intense medical the public health system. 2003, providing medical care to immi- supervision, and patients who have recov- grants with the support of the Moroccan ered immunity through their treatment. Preventing the spread of cholera health facilities. Vaccinations, ante-natal Training local staff is a significant part of In January 2006, torrential rain fell in Sofala care and family planning are necessary for this effort, as is field research aimed at sim- province, creating ideal conditions for this vulnerable population and MSF runs plifying the treatment for patients suffer- cholera, the potentially deadly, water- mobile clinics and monitors the commu- ing from HIV/AIDS and tuberculosis. borne disease that can spread rapidly with- nity for disease outbreaks. MSF provided out adequate sanitation. When the first 4245 medical consultations in the past In Niassa province, MSF has an ongoing cases of cholera appeared, MSF teams from year, caring for approximately 2500 people project in Lichinga district. Here, 650 Tete helped local authorities treat patients in Tangier, Nador and Oujda. MSF also pro- patients were treated in the spring of 2006, and stop the spread of the disease by provides shelter, blankets and relief materials with 400 of them undergoing treatment viding equipment and logistical expertise. to improve hygiene and help immigrants with ARVs. MSF is looking at decentralising MSF also organised training in logistics and attain minimum standards of living. comprehensive HIV/AIDS care, aiming for hygiene so local health workes are better its programme to be integrated into the able to deal with future outbreaks of chol- In early 2006, following continuous pres- public health system. era. sure from security forces and the deaths of 15 people, the majority of immigrants in Midway through the country, in Tete prov- MSF has worked in Mozambique since the north of the country moved to urban ince, MSF was providing ARVs to more than 1984. areas, whilst a few hundred remained in bad conditions in the forests. MSF continues to provide assistance to the forest dwellers through mobile clinics.

The Spanish government has now raised the height of border fences separating Spain from Morocco in Ceuta and Melilla, resulting in fewer concentrations of immigrants in these areas and fewer MSF interventions. However, MSF continues to advocate for more humane treatment of sub-Saharan immigrants based on these interventions, and monitors the health situation of potentially vulnerable populations in the Moroccan Sahara region as well as Algeria and north Mauritania – the departure point for immigrants heading to the Canary Islands, and an area to which few international organisations have access.

MSF has worked in Morocco since 1997. © Francis de Beir

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 43 INTERNATIONAL STAFF 66 INTERNATIONAL STAFF 42 NATIONAL STAFF 713 NATIONAL STAFF 348 Africa Niger Nigeria

Since 2005, MSF has been running an emergency operation to treat tens of thousands of children suffering from severe acute malnutrition in various parts of Niger. The therapeutic feeding strategy now utilises outpatient clinics and ready-to-use therapeutic foods, enabling MSF to treat far more children than in the past. Recovery rates climbed to more than 90 per cent in Niger in 2005.

In mid-2005, MSF opened seven new inpa- developing acute malnutrition, MSF is tient centres in Maradi province, two in working with the Ministry of Health to offer Tahoua province, and 27 ambulatory cen- free care to children under five in most of tres. When malnutrition levels began to fall, the health centres in the Maradi region. © David Levene most of these centres were closed or hand- MSF opened two paediatric units in Maradi ed over to other nongovernmental organi- in July 2005 to handle cases of severe sations (NGO). Staff then concentrated on malaria, acute respiratory infection and HIV/AIDS is a massive problem in Africa’s helping children in southern Maradi, where acute diarrhoea. More than 50,000 consul- most populous country. Many people in there continued to be a high rate of malnu- tations and 2000 hospitalisations were car- urgent need of treatment for AIDS and trition. In August, MSF started working in ried out in these two hospitals during related illnesses find that the medical the Tanout area of northern Zinder prov- 2005. From January through May 2006, attention they need is unaffordable or ince, setting up a therapeutic feeding cen- MSF carried out 30,000 consultations and unavailable. tre (TFC) and 11 outpatient feeding cen- 900 hospitalisations. tres. The TFC was closed in January 2006 In Lagos, MSF has established a compre- after treating more than 3500 children. Distributing food hensive HIV/AIDS programme, providing MSF also provided care in the Ouallam dis- In October 2005, the Niger government, care to more than 1500 people infected trict of the Tilaberi region during 2005, backed by the UN’s World Food with HIV. Over 1000 patients are receiving treating 501 severely malnourished and Programme, called for food distributions to the antiretroviral (ARV) medicines they 2355 moderately malnourished children in end. This was done two weeks after the need at General Hospital Lagos. the last four months of the year. The pro- harvest so as not to destabilise the market. MSF and civil society groups advocate for gramme was handed over to another NGO MSF called for these distributions to be access to free treatment and actively pro- in late December 2005. redirected towards the areas where fami- mote the use of lower cost, generic ARVs lies were suffering from acute malnutrition. to help expand this treatment. Whilst In 2006, MSF teams continued working in MSF teams began to distribute a propor- progress has been made to increase the the regions of Zinder, Maradi, and Tahoua tion of the UN aid to the most affected vil- availability of first-generation ARV medi- treating both severe and moderate cases of lages to the south of Zinder in late October. cines, access to newer, field-adapted AIDS malnutrition. By June 2006, more than In southern Maradi, MSF distributed drugs is an ongoing challenge. Research 25,000 children were receiving malnutri- 130,000 food rations for moderately mal- in the Lagos project has shown an acute tion-related medical care from MSF teams. nourished children. and growing need for affordable second- About 2000 children were being admitted line medications – the newer AIDS drug to its nutritional programmes each week. Meningitis outbreak formulations for patients who develop Because a sick child is at greater risk of In February 2006, a meningitis outbreak resistance to a first combination of medi- occurred in the southern districts of Maradi cines and must change their treatment. In province. MSF started a vaccination cam- 2005/2006, MSF, treatment advocates and paign, immunising more than 800,000 peo- civil society groups publicly urged phar- ple during February and March. Staff also maceutical companies to make these AIDS cared for some of the patients already drug formulations immediately available diagnosed with the life-threatening dis- to patients in Nigeria and other develop- ease. ing countries, achieving some success with initial shipments of the heat-stable, MSF has worked in Niger intermittently secondline drug lopinavir/ritonavir to since 1985. Nigeria in July 2006.

Multiple health emergencies In response to a nutritional crisis in several areas of northern Nigeria, MSF in mid- © Henk Braam

44 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 14 NATIONAL STAFF 133 Africa Rwanda

2005 conducted emergency interventions in Borno, Katsina and Sokoto states and treated more than 15,000 severely malnourished children at three stabilisation centres and dozens of outpatient therapeutic feeding sites. Mobile teams travelled to remote communities to provide nutritional education, healthcare and high caloric food supplements for children not requiring hospitalisation. MSF also con- © JenniferWarren ducted over 14,000 paediatric consultations, and treated many of these children for malaria. By the end of the year, fewer and fewer children were admitted for treat- Rwandans are confronting numerous consequences of the genocide ment, and MSF closed down or handed that began in 1994 and killed approximately 800,000 of the country’s over projects to local health authorities between January and March 2006. eight million people. Many people lost family members and the horrif- ic events that took place are having a lasting impact on many aspects When a cholera outbreak occurred in northern Borno state in October 2005, MSF of their lives. As a result of the genocide, there is now a gender imbal- set up a treatment site and cared for more ance within the country, a large number of widows heading house- than 1300 patients within two months. MSF also responded to a meningitis out- holds, and a lack of trained professionals such as judges, technicians, break in Jigawa state from April to June administrators and doctors. MSF is operating projects to provide 2006. MSF strengthened case management in three hospitals, directly treated 527 maternal healthcare services and help people cope with HIV/AIDS. patients, and conducted a vaccination campaign in four local governmental areas from May to mid-June, vaccinating nearly Some of Africa’s highest maternal mortality previous fee system. Free services are also 150,000 people. rates are found in Rwanda, with approxi- ensured for the poorest sections of society. mately 1071 women dying for every The southern oil-rich Niger Delta region is 100,000 live births. MSF is improving HIV/AIDS programmes the site of regular, violent clashes between reproductive health in Northern Province – In Kigali, MSF operates a comprehensive various groups struggling for oil and in formerly Ruhengeri Province – a region HIV/AIDS project aimed at preventing the October 2005, MSF opened a surgical pro- with inadequate access to both basic spread of HIV and providing treatment to gramme for trauma victims in Port healthcare and reproductive health those who are infected, offering care at Harcourt. From January to May 2006, MSF services. two health centres for some 7600 people staff performed 471 operations and admit- living with HIV/AIDS. Of those patients, ted 561 emergency patients. More than a MSF works in the maternity ward of the 2200 people are receiving antiretroviral quarter of the emergencies treated in May provincial hospital and six health centres medicines, including 260 children. MSF is were for violence-related injuries such as in the Burera district. Working closely with also helping implement the national AIDS gunshot wounds, stabbings, beatings, rape, community actors, this programme has protocol and promoting access to generic and domestic violence. three main areas of intervention: obstetri- antiretrovirals, the less expensive alterna- cal emergencies; implementation of family tive to patented brands. Malaria project closed planning; and maintenance of all general In November 2005, MSF ended its malaria reproductive health services including MSF has worked in Rwanda since 1991. project in Bayelsa state, also located in the ante-natal, delivery and post-natal care. Delta region. Local authorities were not Assistance for women survivors of sexual willing to improve health facilities and abuse, including psychological support, medical staffing, making it difficult for MSF was also integrated in 2006. to implement artemisinin-based combination therapy (ACT) in this malaria-prone Admissions have risen steeply since MSF region. While quinine is still of use, MSF has implemented very low flat fees aimed at proven that ACT is the most effective treat- improving access to care. Some 1464 ment for malaria. admissions were recorded the first quarter of 2006 in the maternity ward alone, dou- MSF has worked in Nigeria since 1996. bling the number of admissions over the

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 45 INTERNATIONAL STAFF 45 INTERNATIONAL STAFF 14 NATIONAL STAFF 567 NATIONAL STAFF 65 Africa Sierra Leone Tanzania

Sierra Leone is still recovering from years of civil war, which shattered Tanzania has not escaped the African its healthcare system and left most civilians unable to obtain basic AIDS epidemic. An estimated 120,000 people die each year from HIV/AIDS- medical care. With the government and many donor countries focusing related illnesses here – many never hav- on development projects, medical emergencies remain unaddressed in ing received a diagnosis or appropriate care. many districts. MSF is providing medical care to some of the country’s most vulnerable inhabitants: children, pregnant women and refugees. MSF runs a project to treat HIV/AIDS patients in the remote, southwestern Makete district. The team provides comprehensive care including antiretroviral Many women in Sierra Leone die from com- medical care in eight camps within Bo, (ARV) treatment. By mid-2006, 1216 plications during pregnancy or delivery, Moyamba, and Kenema districts. With patients were receiving care through the and close to one out of five babies dies increasing repatriation and camp popula- project, including 583 people taking during or just after birth. MSF is helping tions decreasing in some areas, MSF hand- ARVs. The team is also training commu- mothers and babies by reducing medical ed over activities in three camps in April nity members and healthcare workers risks and making needed medical care 2006 but continued to provide healthcare and providing needed medical supplies. more available. Women often live far from to refugees and the local population in hospitals, so in Kambia and Tonkolili dis- clinics located beside five other camps. Providing care in emergencies tricts, MSF has established “maternity Approximately 20,000 patients are seen Between September and December 2005, houses” where women in their final weeks every month in Southern province, includ- political violence surrounding presiden- of pregnancy can stay until they deliver. In ing 10,000 patients for malaria. An out- tial elections in Zanzibar, a semi-autono- these facilities, MSF treats HIV-positive break of measles occurred in the Tobanda mous island off the coast, led to many pregnant women to prevent mother-to- camp and nearby villages in November injuries among civilians. MSF provided child transmission of the virus. MSF staff is 2005, and MSF immunised 3363 children. care to some of the wounded, caring for also integrating HIV and tuberculosis (TB) approximately 275 people. care in MSF-supported public health units, MSF has worked closely with the Ministry and in the maternal and paediatric wards of Health (MOH) to change the national In February 2006, MSF travelled north to of secondary health facilities. Teams train malaria treatment protocol from chloro- the Kibondo area in northern Kigoma, and supervise staff and supply medicines quine to the more effective artemisinin- when approximately 7000 Burundian ref- and other medical materials. MSF clinics based combination therapy (ACT). Today ugees, “fleeing hunger”, entered the see approximately 2000 patients per ACT is available in the health facilities sup- country. Thousands of refugees gathered month in each district. ported by MSF, but not in other health in transit camps set up to accommodate structures. MSF continues to work with the only 100 people, so many slept out in the Helping refugees MOH to have ACT more widely available open. As only a few international NGOs By the end of 2005, an estimated 20,000 and to prepare health staff and communi- were providing assistance, MSF began Liberians were living in refugee camps in ties to use it correctly. working in the Nyakimonomono way sta- Sierra Leone, having fled their own country tion in March. The team ran an outpatient during its civil war. In 2005, MSF provided MSF has worked in Sierra Leone since 1986. clinic conducting about 180 medical consultations daily, distributed water, built shelters and monitored the group’s nutritional situation. By mid-2006, most of the refugees had left the area and MSF ended its intervention.

Malaria project closes in Zanzibar A malaria project based on the island of Zanzibar was closed in December 2005 after the project had achieved its goal of increasing access to ACT malaria treatment – the most effective treatment for malaria – in the districts of Unguja and Pemba.

MSF has worked in Tanzania since 1993. © DominickTyler

46 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 41 NATIONAL STAFF 487 Africa Somalia

“ We do over 40,000 consultations per year in two hospitals but this barely scratches the surface. People come from up to 700 km away to get medical care, because there is nothing else available to them. Across great swathes of the country there is literally no possibility of access to medical treatment.” MSF head of mission, Colin McIlreavy © Espen Rasmussen

In February 2006, the new government of Somalia met for the first reach activities, whilst the therapeutic time. Even agreeing on a regular location to convene proved arduous. feeding centre treated more than 600 children for severe malnutrition between With the old capital Mogadishu imploding into all-out war in April, the January and June, a figure almost ten times temporary solution for the transitional federal government was a con- higher than the previous year. Even in a ‘normal’ year, malnutrition is a chronic verted food warehouse in the southern town of Baidoa. problem in many parts of Somalia. MSF projects in Galkayo, Marare, Bakool, Galgaduud and Dinsor contain nutritional Following a fourteen-year period without a 109,000 outpatient and 7900 ante and components that treat children year round. functioning government, Somalia’s new post-natal care consultations were provid- political leaders are faced with the job of ed at this clinic. Direct beneficiaries are the Whilst news of the drought reached the rehabilitating a country ripped apart by 150,000 people of Yaqshid North district, public in 2006, most gaps in healthcare go rival warlords and with some of the worst although the catchment population is unnoticed. Diseases such as kala azar and health indicators in the world. close to a quarter of a million people. In tuberculosis are rampant in the country – Complicating their task is the rise of the addition to seeing high numbers of people in Bakool alone there were 543 admissions Islamic Courts, which took control of large with medical concerns such as respiratory for kala azar in the first half of 2006, most swathes of south and central Somalia by infections and intestinal parasites, MSF is of these children under age five. July 2006. the only organisation in the area treating epilepsy, asthma and other chronic health MSF opened new projects in the towns of The country has virtually no health infra- conditions. Dhusa Mareb and Guri El in the Galgaduud structure. People rely on the occasional pri- In Middle Shabelle, MSF attends to primary region in early 2006. In Dhusa Mareb, the vate pharmacy or clinic for care, but these healthcare in two districts – Jowhar and regional capital of Galgaduud, the town’s are out of financial reach for most. The only Mahady – through six outpatient dispensa- hospital had not functioned since the last free healthcare is provided by organisa- ries, seeing many patients with respiratory government collapsed in 1991. In the tions such as MSF. Yet with unpredictable infections and skin diseases. In 2006, MSF Istarlin Hospital in Guri El town, all but the and regular outbreaks of violence, interna- ran a measles vaccination campaign in most rudimentary medicines and equip- tional agencies are scarce in south and these districts, reaching 36,340 children ment were unavailable and the few remain- central Somalia, and MSF also temporarily aged 6 months to 15 years. In Yaqshid ing staff were unpaid and lacked training. evacuates its missions on a regular basis. North area, 54,897 children were vaccinat- With MSF support, the two hospitals were MSF operates projects in seven locations ed. already treating a combined total of nearly across south and central Somalia, including 3000 patients per month by mid-2006. the capital Mogadishu. A clinic in the The situation in Somalia worsened in Patients present at the clinic for injuries Yaqshid quarter stands as one the few pub- 2005/2006 with a severe drought that deci- resulting from car accidents and gunshots lic health facilities in the north of the city, mated livestock and left many southern and trauma as an indirect result of violent absorbing many patients from the neigh- parts of the country with dwindling conflict, including injuries sustained by bouring districts. The number of consulta- reserves of food and water. In early 2006, children playing with grenades. tions here are far beyond what a single the MSF-run hospital in the town of Dinsor facility can adequately absorb. In 2005, bolstered its team to provide mobile out- MSF has worked in Somalia since 1991.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 47 INTERNATIONAL STAFF 313 “ The health situation hasn’t improved and there are still only a NATIONAL STAFF 6242 few organisations that are offering medical assistance. For many Sudanese living in the areas where MSF works, life is

Africa just as difficult now as it was before the peace accord.” Sudan Christoph Hippchen, MSF coordinator, southern Sudan

Sudan is the site of MSF’s largest operations, with hundreds the Bentiu hospital, where a total of 17,125 of international and thousands of national staff working in consultations were provided in 2005. over 30 separate locations. Responding to staggering needs in Darfur In 2004, MSF launched the biggest human- At the end of 2005, whilst a much-heralded Within this climate of violence, lack of itarian operation in the organisation’s his- January peace agreement between the healthcare continues to be the biggest tory to provide assistance for the people in Khartoum government in the north and threat to the people of southern Sudan. Darfur. Two years later, MSF still had 170 the SPLA/M rebel group in the south had Health facilities are rare and despite areas international and over 2600 Sudanese staff held, sporadic fighting and a slow pace of opening up with the end of war, the working in 18 locations, where health change heightened fears that stability will absence of a transport system is a huge needs remained staggering. In North not last the six-year period before the barrier to access. This also represents a Darfur State in December 2005 alone, MSF south votes in a referendum on self-deter- challenge for humanitarian work, since carried out just under 20,000 medical con- mination. Armed conflicts continued to much of the country is only accessible by sultations. simmer in the south, east, and in the Darfur air – an option limited during a rainy sea- region to the west, where fighting and vio- son that reduces much of the Upper Nile Numerous attacks against humanitarian lence against the population has raged for region to swamp. workers have drastically reduced the abil- over three years, driving over two million ity to deploy aid and reach people in need. people from their homes. MSF offers primary healthcare in multiple Despite ceasefires and peace agreements, locations including Marial Lou and Akuem over a million remain in camps, totally reli- Violence continues in parts of in the Bahr El Ghazal province and Ler and ant on humanitarian aid for their survival, southern Sudan Wudier in the Upper Nile. In the Upper Nile whilst violence still rages around them. By July 2006, the expected increase in aid province alone, MSF treated 250,000 out- following the signing of peace accords was patients at six locations in 2005. Examples are manifold. On May 8, 2006, a slow in arriving. Hundreds of thousands of MSF also operates a 200-bed hospital in truck arrived at the MSF clinic in the town Sudanese returning from the north or from Kajo Keji in Equatoria, where 200 patients of Muhajariya, northeast of the South camps in surrounding countries found a were treated for sleeping sickness in the Darfur capital of Nyala. “The truck backed country ill-prepared for their homecoming, first half of 2006. This is the only hospital in up towards the clinic,” described MSF nurse with no transportation system, hardly any southern Sudan providing HIV treatment, Lisa Blaker. “When the doors of the truck health infrastructure, and occasional out- with 50 patients taking antiretrovirals as of opened and the tarp billowed up, I saw breaks of violence. July. injured people piled on top of each other.”

On 10 April, armed militia attacked the vil- A new project was opened in April 2006 in Of the 46 patients, 30 were civilians, many lage of Ulang, where MSF operates a clinic Bor in Jonglei Province. The town of Bor has requiring urgent surgery because of gun- that treated 11,000 outpatients in 2005. become host to thousands of people who shot wounds to their abdomens, shoulders, Most of the patients and villagers, along have returned to the south following the arms, legs and chests. Two patients died as with MSF staff, fled in search of safety. end of the war. With only a dilapidated hos- a result of their injuries. Some patients Thirty-one people were reported killed and pital and few medical facilities, the town is described how their husbands, children dozens injured; 15 were treated in the MSF ill-equipped to deal with any influx. MSF is and other family members were shot down hospital in the nearby town of Nasir. currently upgrading the hospital to be a and killed in front of them. referral structure with a fully functional sur- Subsequent outbreaks and threats of vio- gical unit and capacity for 100 inpatients. The team in Muhajariya admitted 127 lence forced MSF international staff to patients with violent trauma in April 2006 evacuate from Nasir and from clinics in In the town of Pibor, several hundred kilo- alone. The 35-bed hospital is regularly Wudier, Lankien and Pieri. In Pieri, most of metres to the east, MSF teams have carried overstretched with the volume of patients the patients in the MSF clinic, including out over 5000 consultations monthly, requiring care. 120 patients being treated for tuberculosis working out of tents during the construc- (TB), were forced to flee. Medical equip- tion of a new primary health centre. This A number of new projects were opened in ment, drugs and food for the patients were number includes outreach consultations in Jebel Marra, a mountainous area in the looted, leaving the clinic effectively the smaller health units of Lekuanguole centre of Darfur, in the spring of 2006. MSF destroyed. and Gumuruk, difficult to reach overland began working in two health posts in Lugo In November 2005, MSF was also forced to and obliging MSF to use boats if the river and Bouley, with a referral system to an evacuate its sleeping sickness project in swells enough during the rainy season. expanded health centre in Kaguoro. Clinics Tambura in the Western Equatoria region In Unity State, an area still disputed also opened in Killin and Gorni. By July, because of fighting. between north and south, MSF works in security constraints required evacuations

48 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Africa © SvenTorfinn and prevented adequate access in this plemented by community outreach and a and providing psychological, medical and region. MSF was unable to respond to a mental health programme to help people nutritional care to these children, the mor- cholera outbreak in Jebel Marra because of cope with the profound psychosocial stress tality average within the orphanage was a lack of security, and the level of malnutri- they are experiencing. reduced to 2.9 per cent. MSF will hand the tion in the area began increasing, as peo- project to local partners by the end of ple were trapped in the mountains and dif- MSF also provides primary and emergency 2006. ficult to get to. healthcare and nutritional support to more than 100,000 persons, more than half of MSF calls for more humanitarian MSF also runs a hospital in Niertiti, a town them displaced, in the more stable govern- support in Darfur of around 3000 residents and as many as ment areas of Kabakabiya and Serif Umra. The situation in the camps in Darfur con- ten times that number of displaced in the tinues to be precarious, with a reported 2.1 foothills of Jebel Marra. This hospital admit- Assisting marginalised populations million people completely dependent on ted 1128 patients in the first half of 2006. in the east external aid. In May 2006, MSF issued an Sporadic fighting also continued over the alert highlighting the dwindling donor Since 2004, MSF has worked in Mornay, a past year in Sudan’s eastern Red Sea and interest in the crisis. With the World Food camp for displaced persons housing about Kassala states. On the outskirts of Port Programme forced to reduce food rations 80,000 people. An MSF-constructed health Sudan, MSF runs the Tagadom Hospital, because of a lack of financing, a serious centre and hospital conduct an average of which treats a marginalised population nutritional crisis also threatened displaced 4900 medical consultations monthly. coming mainly from nearby shantytowns. persons, whilst other vital services such as Healthcare services are also provided by The hospital includes a home visitor net- drinking water supplies and hospital sup- MSF for displaced living in the Shangil and work, set up to care for displaced persons port were also affected by budget cuts. Shadat camps and Shangil Tobaya village, in the area, and a focus on maternal health- though this project was evacuated on July care. By mid 2006, 5000 consultations were As of July 2006, ongoing security incidents 23 after a security incident. performed here each month. caused MSF to continue to evacuate projects intermittently. Kalma is one of the largest displacement Handover of Mygoma orphanage camps in the world, where MSF runs a pri- Since 2003, MSF has been working in MSF has worked in Sudan since 1979. mary health clinic with almost 1000 consul- Mygoma orphanage, Khartoum, where the tations weekly and a women’s health cen- mortality rate of children was a staggering tre that includes treatment for sexual and 80 per cent. After collaborating with local gender based violence. The project is com- authorities, rehabilitating the institution

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 49 INTERNATIONAL STAFF 9 INTERNATIONAL STAFF 73 NATIONAL STAFF 90 NATIONAL STAFF 948 Africa South Africa Uganda

For nearly 20 years, people in ©Wayne Conradie northern Uganda have suffered South Africa has the largest number of people with HIV in the world, from brutal conflict between with about six million infected. Since 1999, MSF has provided care and government forces and rebel treatment for people with HIV in poor areas of the country. In 2001, the groups including the Lord’s first patients were enrolled into antiretroviral (ARV) therapy in Resistance Army (LRA). Khayelitsha, the largest township near Cape Town and eventually the first site in the country to provide ARVs at the primary care level. Large-scale displacements mandated by the government have added to the mis- By July 2006, the Khayelitsha HIV/AIDS clin- sexual violence against women and chil- ery. By mid-2006, almost two million peo- ics – run in partnership with the Western dren in South African townships. Simelela ple – nearly 90 per cent of the population Cape Department of Health – were provid- provides medical care and psychosocial of the north – had been uprooted to 200 ing care to 8000 patients and ARV therapy support and has integrated with other ser- camps. Unable to work or farm, these to 4000 people, enrolling more than 200 vice providers to offer forensic examination people are completely reliant on external new patients monthly. With plans to scale- and police assistance to rape survivors in a assistance. up ARV treatment to 15,000 people by single location. Whilst direct violence began to subside 2010 and a high demand for services, the in 2005/2006, many people continued to model is being further decentralised. After four years of presence in Lusikisiki, die from preventable diseases including Intense efforts of clinics’ organisation, tri- one of the poorest areas in the Eastern malaria, respiratory tract infections and age of patients, redefinition of staff roles Cape, the handover of MSF’s HIV/AIDS pro- diarrhoea. Most of the displaced living in and referrals are being implemented. gramme to the Eastern Cape Department the northern districts of Gulu, Lira, Pader of Health is expected to be finalised by the and Kitgum barely manage to survive Given the extremely high incidence of end of 2006. This highly decentralised, their deplorable living conditions. tuberculosis (TB) in the township and the nurse-based model is a good example of high level of TB-HIV co-infection (about 60 how to provide HIV/AIDS care to a scat- Providing basic healthcare in the per cent), an integrated response to the TB tered rural population with a high preva- camps and HIV epidemic has been developed at lence of infection. Currently 2100 patients In Lira district, MSF provides healthcare in the Ubuntu clinic in Khayelitsha, now the receive ARV treatment through a central six camps and runs a therapeutic feeding busiest primary care clinic in the province. hospital and 12 feeder clinics. centre in Lira town with a capacity for 360 children. The feeding centre also offers Central to the Khayelitsha programme in Coupled to all MSF’s clinical interventions tuberculosis (TB) treatment and in 2005/2006 has been the transfer of clinical is a strong community component imple- January 2006, MSF started counselling responsibilities from MSF staff to human mented in partnership with the Treatment and testing children suspected to have resources recruited by the provincial gov- Action Campaign (TAC). TAC volunteers HIV/AIDS. In February, 78 of 158 children ernment. Drugs, including ARVs, are fully provide intense community education tested were found to be HIV-positive. The procured by the government whilst MSF about HIV/AIDS, developing treatment lit- team treats the children’s opportunistic continues to provide managerial and tech- eracy and generating greater awareness infections and is exploring ways to set up nical support. about available support and the rights of antiretroviral (ARV) treatment. persons living with HIV. In Khayelitsha, MSF has also catalysed the In Kitgum district, MSF offers basic establishment of services dedicated to vul- MSF first worked in South Africa in the mid healthcare in five camps. The team also nerable groups. The Simelela rape survivors 1980s and returned in 1999 to respond to provides mental health support, care for centre is a response to the high degree of the needs of people affected by HIV/AIDS. survivors of sexual violence and makes

50 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Africa

“ It is no exaggeration to say that over the of meningitis at the end of 2005 caused past two decades, the fabric of society MSF to launch a mass vaccination campaign that reached 40,000 children. has been torn apart. The effect of living in the camps has crushed the life out of Improving water supply and sanitation many people. Alcoholism is rife and vio- The growing population in rural camps has lence, especially domestic violence, is stretched the water supply, such that people began collecting contaminated rainwa- common. What we treat is only the tip of ter from the street or from surrounding riv- the iceberg…people are not living in the ers and springs, leading to an increase in water-related illnesses. MSF has started camps, they are surviving. Nothing more.” improving the water supply and sanitation facilities in a number of locations. MSF staff Amaia Esparza Almost a quarter of the population has no access to latrines and those who do must share one with at least 60 other people. Waste management is virtually nonexistent © Jean-Marc Giboux and the burning of waste poses fire haz- ards to grass-roofed huts during the referrals to secondary facilities. In Kitgum Over the years, the LRA is reputed to have region’s dry season. MSF is drilling bore- town, MSF has established a clinic for chil- kidnapped more than 20,000 children to fill holes, repairing hand pumps, rehabilitating dren under the age of five, where up to its fighting ranks, although it is thought to springs, constructing waste pumps and 1500 patients were treated in one month of have only one-tenth that number of sol- building latrines to increase the availability 2006 alone, 356 with malaria. diers today. Every night as many as 4000 of safe drinking water and sanitation facili- children stream into shelters including the ties. MSF cooperated with the NGO Interplast Lacor shelter, near Gulu town. Walking as Holland in December 2005 and April 2006 far as 10 kilometres, these “night commut- Increased insecurity to provide reconstructive surgery in Kitgum ers” are a vivid symbol of the violence in Violent ambushes against civilian and town for civilians mutilated during the con- the region. MSF provides basic healthcare humanitarian vehicles in the final months flict. Six patients with war-related injuries and mental health counselling for many of of 2005 led to the suspension of MSF inter- were treated as well as 18 with cleft lip and these children. national staff travelling to the camps in palate conditions or burns. northern Uganda for almost three months. Focusing on HIV/AIDS Killings of aid workers and civilians com- In neighbouring Pader district, MSF works In the northwestern Arua district, MSF pro- pelled MSF in November to call on all in the Atanga and Pader Town Council vides comprehensive HIV/AIDS care to armed groups to respect the safety of civil- camps. In the village of Patongo, where a thousands of people, with 2500 receiving ians and their freedom of movement, as single camp houses close to 40,000 people, ARVs. Between 100 and 150 new patients well as the independence and safety of MSF provides up to 1000 weekly medical are admitted to the programme every humanitarian aid workers. Throughout the consultations at a health centre managed month, including patients from neighbour- north, MSF continued to provide emergen- in tandem with Uganda’s Ministry of Health. ing Sudan and the Democratic Republic of cy medical relief through the efforts of Malaria, respiratory infections and diar- Congo (DRC). TB is the most common killer national staff, and by February 2006, with rhoea are the most common ailments treat- of persons living with HIV/AIDS, and MSF Is improvements in the security situation, ed. MSF has built an 8-bed structure – working to integrate care for persons with most international staff had returned. including an isolation ward for patients both diseases, completing construction of suffering from bloody diarrhoea, meningitis a 40-bed isolation ward in Arua in Helping refugees from DRC and measles – to complement the existing 2005/2006. In February 2006, MSF in Kisoro district dis- 15-bed inpatient ward, which was insuffi- tributed blankets, soap and fresh water cient to meet the area’s needs. Malaria and meningitis amongst 10,000 refugees who had fled an In Nakapiripirit, along the border with attack on Rutshuru, DRC. Shortly thereafter, In camps in Gulu, MSF oﬀers basic health- Kenya, MSF sees increasing numbers of half the refugees were moved to the Naki care, giving special attention to young chil- patients suffering from kala azar and Valley camp under pressure from national dren and pregnant women and those suﬀer- malaria at Amudat Hospital and three authorities. The rest returned to DRC. ing from malaria. The team carries out water peripheral health centres. In July 2006, 300 and sanitation work and health and hygiene malaria patients and 60 patients with kala MSF has worked in Uganda since 1980. promotion among the local population. azar were receiving treatment. An outbreak

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 51 52 Africa 70,000 liters of water each week at the the at week each water of liters 70,000 distributing neighborhoods, hard-hit to water chlorinated trucked MSF weekly. people 475 than more treat to capacity the developed had MSF 2006, January late By beds. 500 of total a with city the in centres treatment cholera two up set MSF week. per 200 to rose cases of number the when December, in Lusaka in activities medical emergency of management over taking intervention, emergency an began immediately MSF sanitation. quate inade with areas impoverished in rapidly accelerate to potential the has disease water-borne this season, rainy April to November Zambia’s during problem perpetual A Lusaka. city, capital Zambia’s of north tres kilome 250 swamps, Lukanga the in reported were outbreak cholera massive a became what of cases first the 2005, of half second the In MEDECINS MEDECINS In patients. 3028 treated having month, the of end the at intervention its close to able was MSF and decline to started cases cholera of number the March, In television. and radio on and markets and schools in performances drama pamphlets, through spread disease’s the control to ways on tion informa distributed and measures hygiene strict promote to community the in out fanned staff MSF activities. burial hygienic and measures disinfection implemented also team The outbreak. the of height Zambia STAFF STAFF NATIONAL INTERNATIONAL S ANS FRONTIERES ANS 193

ACTIVITY REPORT 2005/2 REPORT ACTIVITY 22 - MSF has worked in Zambia since 1999. 1999. since Zambia in worked has MSF ment. treat ARV receiving were 2000 estimated an and locations, these at MSF from care ed relat HIV/AIDS receiving were people 6000 approximately mid-2006, By locations. these in HIV with infected people of cent per 40 and 30 between finding are ities activ Testing Hospital. District Kapiri inside clinic (ARV) antiretroviral specialised a built recently MSF where province, Central of district M’Poshi Kapiri the in and province Luapula in district Nchelenge northeastern rural and poor the in projects runs MSF vulnerable. most the of some to care AIDS HIV/ comprehensive provide to country the of districts two in works MSF crisis, this to response In disease. the from year each die people 100,000 than more and positive HIV- be to estimated are people million 11 country’s the of million 1.6 Approximately care AIDS Expanding died. people 151 and reported were cases cholera 5557 total, 00 6 - - - - - © Juan Carlos Tomasi uted blankets and plastic sheeting. plastic and blankets uted distrib also team The settlements. Farm Bellapaise and Farm Hopely Epworth, the in projects at 2006 April to January from consultations medical 20,000 over conducting Harare, near persons placed dis assisted MSF cities. of number a in es marketplac and settlements illegal ished demol government Zimbabwean the as homeless made were people 700,000 ed estimat an 2005, July and May Between transportation. and es servic laboratory care, inpatient tations, consul most for costs the bear who ple, peo most for reach of out care medical made have years recent in rates inflation Dramatic Zimbabweans. many of health the on havoc wreaking are HIV/AIDS and violence political poverty, Grinding Zimbabwe STAFF STAFF NATIONAL INTERNATIONAL MSF has worked in Zimbabwe since 2000. 2000. since Zimbabwe in worked has MSF areas. lated iso in living those for accessible more care HIV/AIDS making clinics, rural to treatment decentralise to efforts porting sup and facilities testing laboratory ing improv is MSF needed. as care given and HIV/AIDS for tested are projects at ted admit children Malnourished medicines. (ARV) antiretroviral with 3000 almost treats and thousands to care AIDS-related HIV/ provides MSF province, Manicaland of district Buhera and province North Matabeleland, of district Tsholotsho the province, Midlands in Gweru province, Matabeleland Bulawayo, of city southern the In week. each illnesses AIDS-related HIV/ from die people 3200 than more and HIV with infected is Zimbabwe of tion popula adult the of one-quarter Almost care HIV/AIDS treated. been had cholera of cases 900 over 2006, July By activities. motion pro health organised and centres health in systems water repaired and installed MSF workers. health trained and patients transported supplies, logistical and cal medi provided also Teams Harare. of tion sec Epworth the and East Mashonaland Manicaland, of provinces the in centres treatment cholera up setting by Health of Ministry the assisted MSF country. the of areas rural and urban to cholera spread rains heavy 2006, February early In 226 39 ------Asia and the Caucasus © Paolo Pellegrin/Magnum Photos

Congolese doctor examines a child at the health centre in Bir Pani, Pakistan.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 53 INTERNATIONAL STAFF 25 INTERNATIONAL STAFF 10 NATIONAL STAFF 120 NATIONAL STAFF 200

The Caucasus Armenia Georgia

Following the collapse of the Soviet Union, tuberculosis (TB) has risen steadily in Armenia within an inadequate healthcare system. The current system does not offer treatment for the drug-resistant form of TB because of its complexity: treatment is long and costly, causes severe side effects, and essential medicines are not readily available.

ed. Over 5000 consultations on STI/HIV

have taken place since the project’s incep- © Alexander Glyadyelov tion. Georgia, a former Soviet state, has high Alternative treatments for mental ill- levels of poverty and in recent years has ness seen only marginal improvements in the In Armenia, psychiatric institutionalisation standard of living. Economic stagnation has been the frequent solution for persons and ongoing territorial disputes over with mental illness and there is a strong South Ossetia and Abkhazia continue to stigma surrounding mental health issues in threaten destabilisation of the country.

© Alexander Glyadyelov much of the country. Since 2004, MSF has been supporting and developing outpa- Tuberculosis in Abkhazia tient mental health services in an attempt The bitter secessionist war fought by the In September 2005 MSF, in collaboration to provide alternative means of care. Abkhaz against Georgia in the early with the Ministry of Health (MOH) and the 1990s resulted in a political stalemate: City Hall Mayor, established a TB pro- MSF has developed a programme empha- Abkhazia has created its own govern- gramme in Yerevan and began treating sising a multidisciplinary approach to men- ment and institutions, but these are not patients in two pilot districts – Malatia- tal illness in the deprived province of internationally recognised and it is there- Sebastia and Shengavit. By May 2006, 65 Gegharkunik Marz. Between June 2005 and fore not entitled to external donor sup- persons were being treated for standard TB May 2006, 6488 psychiatric consultations, port. MSF remains one of the few interna- and 25 patients for the multi-drug resistant 434 psychological consultations and 1724 tional humanitarian organisations strain of the disease. MSF renovated two TB social worker interventions were recorded. operating in this isolated region. dispensaries in Yerevan, where patients are The programme includes a strong informa- hospitalised. Once the intensive phase of tion and education component, addressing MSF’s Health Access Programme, which treatment (up to a year) is over, patients and challenging the stigma of mental ill- targets the vulnerable and elderly, oper- are followed for several months through a ness. Day centres, offering a range of thera- ates through the City hospital in system of TB “cabinets” that include facili- peutic activities and skills workshops for Sukhumi, Abkhazia’s capital, and sup- ties for collection of sputum samples, the mentally ill, have now been handed to ports a network of eleven dispensaries in directly observed treatment rooms and a local partner Mission Armenia, and MSF the region. Doctors working in these basic laboratory. A dedicated drug-resis- plans to hand its mental health projects to facilities are given incentives by MSF to tant unit at the Republican TB hospital in the MOH by the end of 2006. ensure they provide free drugs and con- Abovian is also undergoing renovation. sultations to the most vulnerable. An MSF also provides assistance to the prima- average of 2200 consultations were per- Addressing sexually transmitted ry healthcare system in this region, reno- formed monthly in 2005. A mobile medi- infections vating ailing health structures in cal team in Sukhumi also visits people In the Shirak region of northwestern Kharchaghbyur, Tsjambarak, Vardenis, who are house-bound, and provides pal- Armenia, MSF runs a sexually transmitted Geghamasar and Daprabak; and providing liative care to cancer patients who have infections (STIs) management and preven- training and medical supplies to local staff. no other way of accessing pain relief. tion project. MSF is present in six local From June 2005 to May 2006, 14,292 pri- health polyclinics, where it focuses on con- mary care consultations were conducted In a region adjacent to Sukhumi, MSF fidential testing and treatment of STIs, by MSF-supervised doctors. International runs a tuberculosis (TB) and multi-drug– ensuring access to care is free for all. donor presence and funds for healthcare resistant tuberculosis (MDR-TB) pro- Awareness and education about STIs and infrastructure and support have increased gramme in Gulripsh hospital. Since 1999, HIV/AIDS are important components of this significantly over the past year and MSF over 1500 patients have been treated for project. MSF actively lobbies the MOH to will be phasing out its primary healthcare standard TB, and innovations in 2005 adjust the national protocols for STI care – support in this region by the end of 2006. included the introduction of ‘self-admin- a primary goal is to obtain inclusion of istered treatment’ where patients are antiretroviral drugs on the Republic’s MSF has worked in Armenia since 1988. allowed to leave the hospital after initial essential drugs list, so they can be import-

54 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 12 NATIONAL STAFF 229 Asia Bangladesh

In April 2006, an MSF survey revealed high mortality rates and increased malnourishment of small children in a makeshift camp near the town of Teknaf, in the southeastern tip of Bangladesh. The camp is home to more than 5000 Rohingya refugees – ethnic Muslims who fled neighbouring Myanmar, where they are subjected to widespread repression. The camp is a squalid and crowded stretch of land where people live packed into shelters constructed from wood and small pieces of plastic. treatment and can continue taking medica- MSF has set up a small clinic and provides Reducing the impact of malaria tion with minimal supervision. basic health and maternal care to the pop- As all of Bangladesh, the southeast region ulation in the camp and surrounding area. is characterised by general poverty and a The MSF team also attempts to help Malnourished children are enrolled in an lack of education in remote areas. The pop- patients with MDR-TB deal with a compli- ambulatory nutrition programme. An MSF ulation in this particular area also suffers cated drug regimen and unpleasant side technician improves the water quality and badly from malaria. Although this tropical effects from treatment. When patients test hygiene conditions in the camp; plastic disease can be treated, in the Chittagong negative for TB, they can go home, but sheeting and much-needed mosquito nets Hill Tracts many people die from malaria, must attend an ambulatory facility daily to are also distributed. especially children. MSF is running three receive medication and make monthly vis- clinics and a dozen mobile clinics and its to the doctor. In 2005, a psychologist On the border with India and Myanmar treatment sites in the districts of joined the programme to help support (Burma), MSF continues to work in the Khagrachari and Rangamati, where basic individuals who have had treatment set- Chittagong Hill Tracts. This mountainous healthcare is provided with a special focus backs and have been hospitalised for region is difficult to access and for decades on tackling malaria. Mobile teams take the extended periods. Working with a team of was ravaged by conflict and forced dis- fast-acting malaria combination therapy to health educators, the psychologist also placement. Until a peace accord was remote villages, seeing more than 80,000 holds group sessions to support those in signed between the government and the patients every year. Health educators also the ambulatory treatment phase. MSF has main rebel party in 1997, this area was teach villagers about malaria prevention, admitted 100 patients to the programme characterised by internal strife and vio- basic hygiene and pre-natal care. Midwives, since 2001. lence against the tribal population. Today, together with a team of birth attendants, ethnic fighting flares up sporadically, but look after pregnant women and newborns Surgical care the area is relatively stable overall and has and ensure that patients are referred to a In Georgia, MSF provides surgical assist- seen an increase in local efforts for devel- hospital when any complications arise. ance to the population of the Pankisi val- opment. ley, some of whom are Chechens displaced MSF has worked in Bangladesh since 1985. by the war. The surgical department of Akhmeta hospital and the Douisi surgical post receive drugs and materials and 30 operations per month are performed in Akhmeta. An average of 150 consultations and 50 minor surgeries are done per month in the Pankisi valley.

At the end of 2005 MSF handed over a primary healthcare programme in the Varketili-Vazisubani district of Tbilisi, the capital of Georgia. Six hundred patients with chronic illnesses were transferred to the care of Caritas. MSF continues to facilitate access to specialist care and surgery for patients from Abkhazia and Pankisi.

MSF has worked in Georgia since 1993. © Greg Constantine

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 55 INTERNATIONAL STAFF 18 INTERNATIONAL STAFF 18 NATIONAL STAFF 258 NATIONAL STAFF 79 Asia Cambodia China

In Cambodia, where approximately 180,000 people are estimated to be HIV-positive, MSF is currently focusing its work on treating people with HIV/AIDS. Government and NGO efforts, including those of MSF, have increased treatment access and by the end of 2005, Cambodia had 30 treatment centres. Over half of the 12,335 patients receiving antiretroviral treatment (ART) were being treated at seven MSF-supported centres.

An HIV/AIDS clinic at the provincial hospi- According to UNAIDS, up to 650,000 peo- tal in Kompong Cham is the only one avail- ple in China are infected with HIV. able to see patients, not only from its own Although the healthcare system generally province, but also from the neighbouring operates on a market-oriented, fee-for- provinces of Kompong Thom, Kratie and service approach, the Chinese govern- Stung Treng. By the end of 2006 it is ment has launched a comprehensive AIDS expected that 1600 patients will be receiv- response and has begun providing free ing treatment at this location. antiretroviral treatment to AIDS patients using a combination of Chinese and Treating tuberculosis imported antiretroviral medicines. MSF © Juan CarlosTomasi MSF runs a tuberculosis (TB) project in continues to operate a model for HIV/ Sotnikum and in 2005 introduced a com- AIDS programmes within the country. In the nation’s capital, Phnom Penh, MSF munity TB programme in 180 remote vil- works in Norodom Sihanouk hospital, lages, providing community-based TB Since December 2003, MSF has been where over 2300 people are now following treatment with the goal of increasing treat- treating AIDS patients in a small clinic a regimen of ARVs. In 2005, an average of ment access whilst ensuring adherence. located on the premises of the Guangxi 63 patients per month was added to the Village volunteers are assigned patients Centre for Disease Control in Nanning programme. Tuberculosis is the most com- and help ensure that medication is taken. City. Here, an average of 315 consulta- mon opportunistic infection for persons This programme is supported by bi-weekly tions are performed monthly and 276 who are HIV-positive and MSF offers inte- visits from a medical home care team. patients receive free antiretroviral (ARV) grated treatment for those co-infected treatment. MSF was initially the only pro- with TB and HIV at all its treatment centres. Malaria projects vider of free ARVs in the province of MSF has run a malaria project in the Guanxi; now, several government-run On the grounds of Siem Reap Hospital, MSF Sotnikum area over the past five years, sites have also opened. The MSF project runs a Chronic Diseases Clinic (CDC) where which will be handed over to the MOH by has been distinctive because of its strong over 2500 HIV/AIDS consultations were the end of 2006. emphasis on confidentiality and counsel- provided per month in 2005. Consultations ling. and care are also provided for people with MSF has also operated a malaria outreach other chronic illnesses such as diabetes project in the isolated Pailin area, utilising In central China, the spread of HIV/AIDS is and hypertension. MSF treated approxi- village malaria workers to screen people, atypical. Most people here contracted HIV mately 40 diabetics monthly in 2005. and providing effective artemisinin-based from unhygienic blood collection and combination therapy (ACT) for this increas- transfusion practices when selling their MSF runs CDCs to the west of Siem Reap in ingly drug-resistant illness. In 2005 over blood plasma, a common practice under- Sotnikum, and at Takeo Provincial Hospital 7000 people were treated, and the activi- taken by villagers to supplement their in the south of the country. Combined, ties will be handed over to the MOH at the incomes. In Xiangfan, Hubei province, these centres currently have over 1200 HIV/ end of 2006. MSF is currently assessing the MSF manages a treatment clinic in col- AIDS patients on a regimen of ARVs, 176 of effectiveness of a recently developed and laboration with the Xiangfan Centre for them children. effective antimalarial drug, Artekin, in this Disease Control. More than 360 patients setting. are registered in the clinic and 140 Together with the Ministry of Health (MOH) patients receive free ARVs. Care includes and other NGOs, MSF is supporting decen- MSF has worked in Cambodia since 1989. home visits and a strong educational tralisation of treatment from CDCs to pro- component. All MSF projects in China are vide more localised access to treatment. In highly community-oriented, with MSF the towns of Kampong Trach and Poipet, facilitating patient support groups and over 500 patients were receiving treatment providing information to patients’ fami- in decentralised sites by July 2006. lies, health workers and the wider community.

56 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 99 NATIONAL STAFF 1016 Asia Indonesia

The December 2004 tsunami continued to define MSF action in Indonesia throughout the second half of 2005, with medical activities centred mainly, but not exclusively, in Aceh.

MSF was one of the first international aid Asmat area, where MSF vaccinated over organisations to reach Aceh after the tsu- 13,500 children for measles. Here MSF is nami and at its peak was running projects offering measles follow-up care and

© Chien Min Chung in eight districts. These addressed a wide addressing other health needs. range of emergency medical needs with Blocked from Henan vaccinations, mobile clinics, mental health MSF was just closing its cholera pro- MSF has been trying since 2002 to work in programmes, surgery and the distribution gramme in Papua when the June 2006 Xiangfan’s neighbouring province of of non-food items. earthquake hit Java’s cultural capital, Henan, where an estimated 300,000 or Yogyakarta. Emergency team members more people are in need of HIV/AIDS treat- By the end of the year, the health situation flew straight from Papua to Yogyakarta, ment, many infected with HIV from selling in Aceh had returned to pre-tsunami levels with the first members arriving on the their blood. One-fifth of the patients in the and MSF programmes decreased accord- same day as the earthquake and trucks Xiangfan project come from Henan, and ingly. By this stage, MSF had rehabilitated filled with emergency supplies soon to fol- the demand from people in that province 27 health structures, a hospital and almost low. Although the majority of needs were to be enrolled in treatment increased sig- 300 wells; conducted over 40,000 medical swiftly covered by Indonesian emergency nificantly in 2006. Despite repeated consultations and provided over 2000 indi- services, hospitals were overwhelmed. An attempts to establish a Henan programme, vidual counselling sessions. Over the MSF surgical team worked alongside other provincial authorities continue to refuse course of the year, MSF had been reorient- Indonesian and international teams to help MSF access to the province. ing its programmes, placing more empha- clear the backlog of patients waiting for sis on reaching out to inland communities surgery, and a tented 100-bed, post-opera- Advocating for drug access whose access to healthcare had been tive ward was assembled to ease over- MSF is advocating at the national level for restricted by years of civil war and reinforc- crowding in the hospitals and provide China to facilitate access to AIDS medi- ing its mental health care for these, as well quality post-operative care to patients cines, particularly for fixed dose combina- as victims of the tsunami. Today, MSF main- from all over the city. Psychologists offer- tion pills (FDCs) that can simplify treat- tains a more streamlined but just as coming training to Indonesian medical staff ment. Intellectual property protection and mitted team in Aceh, focusing on mental and counselling those traumatised by the other factors currently block the use of health in three districts with a particular earthquake continue to work in the region. FDCs, resulting in restrictions in drug focus on working with people affected by choice, lack of availability of needed drugs, conflict. The team performs surgery in Sigli MSF has worked in Indonesia since 1995. and high prices for some medicines. hospital and provides primary healthcare Production capacity exists for many drugs to a population of approximately 475,000 that are either not available or too expen- through clinics, training, drug donation sive in China, but patent barriers often and health promotion. block generic manufacturing. A team of a pharmacist, campaigner and lawyer work Across the rest of Indonesia, MSF contin- full-time to document, raise awareness of ued to respond to outbreaks of disease, and overcome various barriers to accessing including malaria in Alor and measles in medicines. Sumba, and further developed its tuberculosis project in Ambon. In 2006 MSF’s emer- Handover of children’s shelter gency capacity in Indonesia was stretched Since 2000, MSF had been running a as teams used boat, plane and foot to project for street children in Baoji, Shaanxi reach people affected by simultaneous epi- province. This crisis centre and shelter was demics of cholera and measles in the established to provide medical, psycholog- remote island of Papua. This island has ical and social care for street children. In some of the worst health indicators for the 2005, 109 children were taken into the whole of Indonesia, with a high burden of shelter. After helping create a local NGO to infectious disease and communities living take over the management of this project, out of reach of even basic healthcare. MSF withdrew from Baoji in March 2006. Mobile teams were still operating in the

MSF has worked in China since 1988. © Jodi Bieber

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 57 INTERNATIONAL STAFF 39 NATIONAL STAFF 251 Asia India © Henk Braam

Civilians in India’s northeastern Assam and Manipur states continue to be affected by recurring outbreaks of political violence along religious and ethnic lines. Over the last five years, more than 150,000 people have fled their homes because of violence.

Indian authorities estimated that approximately 1500 people in MSF is also active in neighbouring Manipur Indian-controlled Kashmir lost their lives and 6000 were injured in the state, operating four primary healthcare clinics in the district of Churachanpur and powerful earthquake that struck northeast Afghanistan, the north of a clinic to treat people with sexually trans- Pakistan, and northwest India on October 8, 2005. mitted infections. Because of the state’s high rate of HIV infection, in March 2006, MSF began integrating HIV/AIDS care into MSF launched an emergency aid operation These activities were carried out in addi- the state’s existing health programme. By to assist those in need in both India and tion to the mental healthcare MSF offers mid-year, 200 patients were receiving care Pakistan, where the epicentre of the earth- people living in Jammu-Kashmir state, a from MSF, including antiretroviral (ARV) quake was located. In India, MSF aid com- conflict-prone region claimed by both treatment. Another HIV/AIDS project prised the distribution of thousands of India and Pakistan. Working from various opened in Mumbai to help patients exclud- blankets, tents, sets of clothes and bottles locations in and near Srinagar, in 2005 MSF ed from the national care programme and of water, two tonnes of food and a tonne of aided approximately 1500 people with those co-infected with TB. As of June 2006, medical supplies to help the injured and mental health problems related to the 124 patients were receiving comprehensive the 140,000 people rendered homeless. area’s tensions and conflict. care including 47 using ARVs.

MSF offered significant mental health sup- Providing care to the internally dis- Following the 2004 tsunami, MSF provided port to earthquake victims who were placed aid to survivors in the southern region of brought to the provincial capital, Srinagar, In the Karbi Anglong region of Assam state, Tamil Nadu. Working in 28 coastal villages, for medical treatment. Team members con- ethnic violence forced 40,000 persons to the team provided psychological counsel- ducted mental health counselling at four flee to camps or shelters in towns and MSF ling to a total of 770 people (5600 ses- area hospitals where people received med- began providing urgently needed assist- sions), handing these activities over to a ical care. MSF later extended its mental ance in October 2005. Malaria is an illness local partner organisation in December health programme, offering both individu- of concern in Assam and teams used 2005. Prior to this handover, MSF assisted al and group therapeutic activities for peo- artemisinin-based combination therapy people affected by flooding in the region ple in the districts of Tangdhar and (ACT) to treat approximately 10,000 malar- in November, distributing 3000 blankets Baramulla, areas strongly affected by the ia patients a month. Mobile clinics are used and providing 1300 consultations to the quake. A mobile medical clinic was to reach people in more than 50 camps, affected population. launched in the Kupwara district, treating where MSF sees many children with respi- approximately 40 patients daily. MSF also ratory infections, diarrhoea and malnour- In June 2005, MSF handed over a six-year- trained community counsellors to provide ishment. In early 2006, MSF carried out a long tuberculosis (TB) programme in mental health support for villagers during measles vaccination campaign in the Mumbai to local health authorities and the winter months, when snow cut off camps, trucked in clean water and installed redirected its attention to the care of TB remote areas from outside assistance. taps on water tanks. patients co-infected with HIV/AIDS.

MSF has worked in India since 1999.

58 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 6 INTERNATIONAL STAFF 0 NATIONAL STAFF 107 NATIONAL STAFF 2 Asia Iran Japan

Whilst all Japanese nationals are entitled to universal healthcare, the rules and requirements for access effectively exclude a large proportion of Japan’s homeless persons. The largest homeless community, approximately 7757 people, is found in Osaka prefecture and its capital Osaka City, where men aged 50 to 60 account for three quarters of the homeless population. Too young to collect a pension and too old to compete for a decreasing pool of jobs, many suffer from chronic conditions such as hypertension and diabetes that require ongoing access to medical care.

Nishinari Socio-Medical Centre in the heart of Kamagasaki, the city traditionally © Sibylle Gerstl considered the core for daily workers and the homeless of Osaka, remains the only Iran has become home to hundreds of thousands of Afghan refugees response to the medical needs of the over the past decades. Since 2002, the Iranian government has put homeless, but the structure is well beyond its capacity. Without healthcare or social intermittent pressure on its Afghan population to repatriate and nearly services, people have scattered into river- two million people have left Iran. sides, parks and train terminals. MSF has made several attempts to estab- Still, an estimated one million Afghans Mashhad to improve access to care. A total lish a fixed health centre in the area to remain, many intending to stay. No longer of 56,884 consultations were performed in restore healthcare for the homeless, but considered refugees by the authorities, and 2005, and 635 families were visited per discrimination against this population is since 2004 without rights to private health- month in their homes. fierce and widespread and has prevented care, they face barriers in access to medical the establishment of a fixed clinic. MSF services. Toward the end of 2005, MSF conducted a has met with continual opposition from MSF has been providing care to the Afghan community based epidemiological survey some of the local communities and population through both fixed and mobile to better understand the beneficiary popu- authorities. clinics in Mashhad and Zahedan. In 2005, lation, which has changed since 2002. The MSF conducted a total of 130,000 medical survey showed that over 80 per cent of the In 2005, MSF mobile clinics visited four consultations in these projects – seeing population has been present in Iran for parks on alternating weeks and conduct- primarily upper respiratory infections and more than 10 years, and many had access ed 1268 medical consultations, following diarrhoea – and made 2280 hospital refer- to jobs and primary healthcare, particularly 270 patients on file. The team treated rals, many for emergency care or surgery. in Mashhad. MSF will therefore be closing chronic conditions including hyperten- its Mashhad programme in 2006 and focus- sion, diabetes, joint pain and gastritis and In the economically deprived Zahedan, ing its efforts on improving primary and referred those requiring hospitalisation or MSF has seen an increasing number of con- secondary healthcare access for the more specialised care to health facilities in the sultations and hospital referrals over the vulnerable population of Zahedan. area. Patient histories were also collected past two years. Approximately 55 per cent in 2005, enabling the MSF team to better of the population in this area relies on MSF Providing post-earthquake assistance understand the mechanisms of socio- for access to medical consultation. In its In March of 2006, MSF distributed hygiene medical exclusion. two clinics providing primary care, 72, 349 kits and food to 1000 families in two vil- consultations were performed in 2005, and lages following an earthquake in Lorestan, MSF has worked in Japan since 2004. 1168 families were visited monthly in their approximately 400 km southwest of homes. Tehran. Medical assistance was also provided to people in isolated areas. Mashhad is Iran’s second largest city. In 2005, MSF ceased activity of three mobile MSF provided aid in Iran following the clinics travelling to surrounding villages, 1990 earthquake and has worked there and added a second fixed clinic in continuously since 1995.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 59 INTERNATIONAL STAFF 39 NATIONAL STAFF 925 Asia Myanmar © Claude Mahoudeau

Under military rule since 1962, Myanmar (Burma) is largely cut-off from the outside world. Much of the population is poor and many lack access to healthcare, including numerous minority groups, who remain under continuous pressure and regular violent attacks from the junta. MSF has worked in the country since 1992, providing primary care and attempting to reach the most vulnerable in order to reduce their suffering. Particular attention is given to those with malaria, tuberculosis (TB) and sexually transmitted infections (STIs). Gaining access to carry out independent humanitarian action has been challenging, and MSF continues to press the military authorities to gain access to people in need.

In 2005, more than 460,131 medical con- with malaria, malnutrition and HIV/AIDS, projects in southern Myanmar, MSF in 2005 sultations were conducted in MSF-support- including a large proportion of Rakhine treated over 100,000 patients including ed clinics in the capital of Yangon as well as Muslims (Rohingya) who are denied citi- over 22,000 for malaria. Approximately 370 Rakhine, Kachin and Shan states. In these zenship and access to healthcare. In 2005, persons with HIV are following antiretrovi- locations, MSF conducted over 6000 con- MSF tested 350,000 people for malaria and ral treatment. sultations for those with HIV and by July treated 150,000 with the disease. 2006, had approximately 1888 patients fol- Approximately 3000 severely and moder- Problems of access lowing antiretroviral treatment (ART). Over ately malnourished children were treated. Projects focusing mainly on malaria treat- 400,000 people were screened for malaria, ment for vulnerable ethnic minorities in with 175,000 treated. Required treatment Southern Myanmar Mon and Karen states were closed in March was started by 4310 of the close to 14,000 In Dawei and Myeik districts, MSF aims to 2006, as teams could not secure adequate people that were screened for TB. improve diagnosis and treatment for humanitarian space to operate its pro- malaria, tuberculosis, HIV/AIDS and STIs, grammes independently and without mak- Health education – mostly concerning sex- with specific attention to the vulnerable ing unacceptable compromises to the ually transmitted infections – is a large part populations: ethnic minorities, community authorities. of MSF’s work, and half a million people in sex workers and migrant populations – via these areas were reached in 2005. More fixed and mobile clinics. MSF has worked in Myanmar since 1992. than 40,000 medical consultations were conducted for people with sexually trans- In Kayah state, at the border with Thailand, mitted infections (STI) and over two million a place of continuing conflict between the condoms were distributed. junta’s army and ethnic groups, MSF is also assisting the population, mostly of the In western Rakhine state, MSF provides Karenni people, through two fixed clinics basic healthcare, seeing many patients and two mobile teams. Through all these

60 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 6 INTERNATIONAL STAFF 5 INTERNATIONAL STAFF 2 NATIONAL STAFF 25 NATIONAL STAFF 24 NATIONAL STAFF 7 Asia Kyrgyzstan Laos Malaysia

Within the prison system in National authorities and many internation- With its prosperous economy, Malaysia Kyrgyzstan, the incidence of al organisations do not perceive HIV/AIDS attracts high numbers of labourers from to be a major health problem in Laos. The poorer countries in Southeast Asia. Many tuberculosis (TB) is up to 25 times prevalence is low, with an estimated 600 to of them come from Indonesia and the higher than in the civilian sector, 3600 people living with HIV/AIDS. Because Philippines and a large number stay in of the low prevalence and limited invest- Malaysia without legal status. where the contagious disease is ment in prevention, there is little aware- A specific group within this population is present at already alarmingly ness of the disease and risk of a rapid those who have fled violence and perse- spread among vulnerable groups. With the cution in Aceh, Indonesia and Myanmar. high rates. Crowded prison condi- current HIV response in Laos, UNAIDS esti- They cannot be granted refugee status in tions provide an ideal environ- mates there could be more than 18,000 the country, as Malaysia is not a signatory people living with the virus by the year to the international refugee convention. ment for the tuberculosis bacilli 2015. This has major consequences for their to spread into the air quickly and acceptance in society and for obtaining Laotians have had only one place where essential services, including medical care. easily through coughing, sneez- they can access HIV/AIDS treatment: the Accessing healthcare is problematic for all ing, or even talking. MSF-supported care and treatment centre migrants, who find it difficult to pay the in the hospital of Savannakhet, a city in the higher fees required of foreigners, even in south of the country. By July 2006, MSF the public health system. Refugees have In 2005, MSF saw a role in helping was providing antiretrovirals (ARVs) for even more difficulty, as health staff in Kyrgyzstan confront its growing TB prob- more than 400 people in this location. The public and private facilities have a legal lem and opened a tuberculosis programme service provides a full range of care for the obligation to report undocumented in September. The project is focused on patients in Savannakhet, including coun- patients to the authorities. two detention centres, one in Bishkek and selling, testing, treatment of opportunistic a second in a nearby prison colony. High infections and access to ARVs. MSF started working in Malaysia in 2004, quality TB drugs were imported into the supporting a Malaysian non-governmen- country and MSF initiated medical training, Many patients treated in Savannakhet come tal organisation (NGO) in providing mobile the preparation of health education mate- from Vientiane, the country’s capital, or clinics for refugees in and around Kuala rial and started seeing patients. even further north. Some people must trav- Lumpur, setting up a system for referral to el up to 24 hours to get their treatment, hospitals, and introducing mental health By May 2006, 242 patients had been treat- which adds an extra burden and causes a activities for the often traumatised refu- ed for TB. Early in May, MSF also began to range of problems including diﬃculties get- gees. Depression, anxiety-related disor- rehabilitate the laboratory in one of 11 col- ting to the hospital or adhering properly to ders, thoughts of suicide and post-trau- onies for sentenced detainees and some their care and drug regimens. MSF has con- matic stress disorder are widespread. cells in SIZO 1, a pre-trial detention centre vinced the authorities to open a second in Bishkek, in order to provide better TB treatment centre in the country, in one of The work has expanded to support this care. The rehabilitation focuses on the sep- Vientiane’s leading hospitals, Settatirat, NGO in its medical work in detention cen- aration of infected patients and the provi- where MSF will provide technical support, tres, where arrested undocumented sion of a safe environment for sputum col- training and a temporary supply of ARVs. migrants are held, and at improvised set- lection. tlements in the forests near major con- MSF has demonstrated that HIV patients struction sites. The main disorders seen As more data are collected, it is becoming can be cared for within public health struc- are upper respiratory tract infections, skin apparent that many people in Kyrgyzstan tures, and is continuing to advocate for a infections and gastritis, related to poor liv- are multi-drug-resistant (MDR-TB), exhibit- national strategy so that testing and treating conditions and psychological stress. ing a strain of the disease that renders the ment will be part of the Lao health struc- MSF has supported the national NGO in two best anti-tuberculosis treatments, tures, carried out by Lao health authorities. medical and mental health services, rifampicin and isoniazid, largely ineffective. offered weekly in three locations, to Treatment is possible, but it is extremely MSF has worked in Laos since 1989. migrants living among the general popu- rigorous and difficult for the patients, tak- lation of Kuala Lumpur. The number of ing up to two years and normally requiring daily consultations averages between 80 lengthy hospitalisation. MSF will be assess- and 100 per location. ing the prevalence of MDR-TB in the prison MSF is also establishing a network of system throughout 2006. Malaysian doctors and psychologists who volunteer some of their time to provide MSF has worked in Kyrgyzstan since 2005 care to undocumented migrants. and previously operated an HIV/AIDS and STI prevention project from 1996 to 2001. MSF has worked in Malaysia since 2004. © Gabi Faber-Wiener

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 61 INTERNATIONAL STAFF 12 INTERNATIONAL STAFF 33 NATIONAL STAFF 97 NATIONAL STAFF 308 Asia Nepal Pakistan

On October 8, 2005 an earthquake measuring 7.6 on the Richter scale hit northeast Afghanistan, the north of Pakistan and northwest India. The epicentre was approximately 100 kilometres north of the Pakistani capital Islamabad, causing massive destruction in surrounding regions and killing an estimated 76,000 people.

The largest impact was in the north of Pakistan, where almost 80,000 people

© Florian Larguier were wounded and another three million people were affected, many of The team returns to the village of Radidjula. Equipment is frequently transported by donkeys on these remote mountain trails. whom instantly became homeless. The earthquake triggered a massive emer- Nepal’s civilians remain caught in a violent struggle between govern- gency relief operation by MSF, operating in both Pakistan and India. ment forces and Maoist rebels. The fighting has caused mostly civilian casualties – more than 13,000 people are estimated to have died in the In the immediate aftermath of the earthquake many victims were cut off from bloodshed since 1996. Hundreds of thousands of people have now help, as mountain roads had been been displaced in a country where nearly half the population already destroyed or blocked by landslides. Thousands of critically wounded had to lives below the poverty line. be evacuated by helicopter, and others were not able to reach hospitals until Fighting has limited access to healthcare MSF is also active in the western Kalikot several weeks later. The local population and worsened health conditions for most district. Starting in June 2005, MSF began began to rescue injured people, and local of the country’s inhabitants. Many health rehabilitating the 15-bed district hospital health structures were the first to provide workers have left their positions and move- so it could offer basic and secondary health medical care. National health authorities ment between Maoist and government- care, reproductive healthcare, TB treat- deployed medical personnel from across controlled areas is difficult, making refer- ment, and emergency services. MSF also the country whilst the Pakistani army rals and distribution of medical materials improved the power and water supply sys- mobilised helicopters, carried out evacu- extremely problematic. tems. MSF sees approximately 1600 ations, and loosened restrictions allowing patients per month in the outpatient a massive influx of international support. To provide assistance, MSF runs the 15-bed department and admits patients to the Salle Hospital in the capital of the Rukum hospital when required. The number of wounded put enormous district. MSF staff treat patients, supply strain on the heavily damaged health medicines and clean water and manage MSF expanded its activities with a new infrastructure. In the Azad Kashmir and waste disposal and hygiene. Each month, project in February 2006 in the Khotang the North Western Frontier Province of the team carries out approximately 2000 district. MSF offers 24-hour healthcare to Pakistan only 199 out of 564 health facili- medical consultations, including 100 hos- local residents including inpatient care and ties remained fully functional after the pitalisations. MSF also supports outlying emergency obstetric care. The team is also earthquake. Patients were often treated health posts in the same district, which rehabilitating Khotang’s Diktel District in makeshift hospitals and clinics, or conduct approximately 3000 medical con- Hospital and is recruiting badly needed along the road. sultations a month. health staff. MSF, already present on both sides of the MSF has worked in Nepal since 2002. Line of Control between Pakistan and India-administered Kashmir, immediately switched to emergency mode. Within six

62 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 structing permanent latrines. latrines. permanent structing con and water in trucking clinics, and pital hos a running by Bagh and Muzaffarabad around camps displaced the in those help to continued MSF assistance. sanitation and water shelter, medical, on dependent Mansehra and Bagh Muzaffarabad, of cities destroyed the from people 20,000 some of presence the despite winter, the during arose emergencies medical new no areas, some in harsh were conditions Although areas. project various the visiting in orities pri own its set and others on dependency logistical its lessen to helicopters two hired MSF and wounded, the evacuate and material relief basic distribute to deployed were contractors private and agencies UN armies, various from helicopters of fleet A families. 83,000 approximately benefiting area, affected the to items relief and medical of tonnes 2000 almost sent MSF winter. before items non-food other and blankets tents, deliver to and possible as people wounded many as treat to place took race logistical and medical A destroyed. been had homes whose those on impact potential its and winter ing approach the was worries main the of One home. return yet not could who those for problem major a remained sanitation and water Still, April. to October from kits hygiene 30,000 around distributing and latrines 1400 over just constructing – ties activi sanitation and water conducted MSF sites 119 On conditions. weather rating deterio and infrastructure the to damage the locations, many of remoteness the by hampered were efforts relief aid, viding pro in involved were actors many Though alone. months few first the in place taking consultations 11,000 over with vention, inter MSF the of start the from integrated was treatment health Mental Hattian. and Bagh Mansehra, in victims earthquake for care post-operative and surgery provide to up set also were hospitals Three measles. as such diseases against vaccinated were people 30,000 Over facilities. inpatient to referral for cases severe more identify to and pathologies general and wounds minor treat to consultations patient out 116,000 over undertook MSF months, ------aftermath of the earthquake, MSF’s regular regular MSF’s earthquake, the of aftermath the in required activity intense the Despite Pakistan throughout programmes Ongoing tion. malnutri for screens and day a sultations con child and mother 130 about conducts MSF Here country. their fled having after reside Afghanistan from Pashtuns of sands thou of tens where Quetta, of outskirts the at slum a Kuchlak, in project a started MSF time same the At consultations. 40,000 approximately performing after 2006 April in province Baluchistan western in camp refugee Afghan Kheil Mohammed the in Foundation Taraqee local the to projects healthcare primary its over handed MSF 2005/2006. throughout continued Pakistan in programmes

consultation near Muzaffarabad, Pakistan, October 2005. MSF October mobile a at Pakistan, treatment Muzaffarabad, medical near basic receives consultation wrist, and arm broken a from suffering 4, Bibi, Farza © Bruno Stevens/Cosmos

ACTIVITY REPORT 2005/2 REPORT ACTIVITY - - - MSF has worked in Pakistan since 2000. since Pakistan in worked has MSF women. pregnant for were dred hun several which of consultations, 15,000 almost conducted had MSF then, By end. an to came valley Leepa in activities and retracted was Control of Line the near work to permission MSF’s 2006, July By Kashmir. India-administered and Pakistan between Control of Line the to close Lamnian, and Valley Leepa in programme care health basic MSF’s of focus the also was health child and mother district, Kuram in As hospital. Alizai nearby the at care diatric pae outpatient and inpatient to redirected was 2006 April in and 2005 September in stopped hospital Shasho the to support refugees, Afghan most of tion/relocation repatria the following district, Kuram In 006

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63 Asia INTERNATIONAL STAFF 21 NATIONAL STAFF 640 Asia Thailand © Antoine de Changy

At Mae Sot, MSF offers tuberculosis treatment to undocumented migrants and refugees from Myanmar. Formerly treatment required close medical observation and possible residence in a “tuberculosis village”. In 2006 MSF introduced self-administered treatment, whereby patients visit a clinic once a month to see a doctor and receive a month’s supply of medicine.

Free access to healthcare in Thailand is available only to registered Thai nationals or to persons with a specific registration status. Vulnerable groups such as ethnic minorities and migrant workers are often excluded from the health system, causing them to do without treatment for serious medical conditions including HIV. MSF has responded by providing healthcare to marginalised groups throughout the country.

Establishing non-discriminatory care In Kuchinarai, Kalasin province, the district Providing basic medical care to for HIV/AIDS hospital in 2005 assumed responsibility for undocumented migrant workers MSF began its first-ever antiretroviral pro- 160 MSF patients receiving firstline antiret- There are thought to be over two million gramme in Bang Kruai district hospital in rovirals. MSF is now focusing on a pilot migrant workers in Thailand, with more 2000 using generic antiretroviral (ARV) programme to introduce secondline treat- recent arrivals contributing to the post-tsu- drugs. Since then, MSF has worked closely ment, an alternative drug regimen for peo- nami reconstruction of hotels and tourist with the Access to Essential Medicines ple who are not responding to the drugs resorts in areas such as Phuket. Many of campaign, local partners and the Thai gov- they were initially prescribed. This involves these workers remain undocumented and ernment to establish localised HIV/AIDS understanding why initial drug regimens lack access to healthcare. MSF is using programmes and MSF continues to advo- failed and ensuring that hospitals and hos- mobile clinics and a newly opened health cate for large-scale generic production of pital staff have the correct training, access centre in Phang Nha to provide basic medi- ARVs in the country. to facilities and drug supply necessary to cal care focusing on mother and child offer effective secondline treatment. health, treatment of sexually transmitted In Chiang Rai province, MSF is supporting infections and ensuring clean water and two public hospitals that offer HIV/AIDS Treating patients in Bangkok prisons sanitation. care to unregistered migrants from Laos MSF provides clinical support for HIV in and Myanmar. At the Mai Sai hospital, MSF two prisons in Bangkok: the medium secu- In 2005/2006, MSF also added 518 patients provides free ARVs to unregistered minori- rity Minburi Remand Prison, and to its tuberculosis programme treating ties who lack access to healthcare. An MSF Bangkwang, a maximum security male pris- undocumented migrants in Mae Sot, Itak doctor works alongside hospital staff and on where inmates are incarcerated for life. province. HIV testing and treatment is now MSF ensures drug supply, pays for lab tests MSF provides medicines, training, covers systematically offered to tuberculosis and hospital referrals. At Chiang Saen dis- lab costs and sends medical staff to work in patients because of high rates of HIV/TB trict hospital, MSF offers HIV treatment and the clinics several times a month. As of July co-infection, and treatment is now also care to unregistered minorities and to peo- 2006, 44 patients were taking ARVs. available for persons with multi-drug- ple who cross into Thailand seeking care resistant tuberculosis. specifically for HIV/AIDS.

64 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 MSF has worked in Thailand since 1983. since Thailand in worked has MSF 2006. in close will project the and Health of Ministry the to over handed been has ARVs on children 70 and adults 120 approximately for responsibility the Now Hospital. Provincial Phetburi the of department paediatric the and Hospital District Laem Ban at training and support technical staff, medical drugs, providing by programme treatment HIV an ported sup has MSF Thailand, central Phetburi, In 2006. December until treatment secondline on patients 33 the to drugs provide will MSF and programme HIV/AIDS national the into integrated were treatment firstline on patients All ARVs. receiving were patients 752 where province, Surin in project HIV/AIDS an closed MSF 2005 December In government Thai the to projects of Handover weekly. tions consulta medical 500 out carry to tinued con MSF 2006, July of As results. no with population, refugee this for responsibility take to Interior the of Ministry the and NGOs Refugees, for Commissioner High Nations United the lobbied MSF camp. the of charge complete in left NGO, remaining only the was MSF and October in departed (NGOs) organisations governmental non Other diarrhoea. and infections respiratory for mostly camp, the in ducted con been had consultations medical 6094 October, By today. even country their ing flee for reasons as persecution and sation marginali cite and War, Vietnam the during Americans the with aligned largely who ity minor ethnic an are Hmong The Thailand. northern in Phetchabun in refuge en tak had who people Hmong Laotian 6000 to supply water a and healthcare viding pro began MSF actors, other by addressed activities sanitation with 2005, July In refugees Laotian Assisting ------Turkmenistan STAFF STAFF NATIONAL INTERNATIONAL agement of prevalent female pathologies, pathologies, female prevalent of agement man the in staff hospital to assistance and care, post-natal and delivery, ante-natal, healthcare: maternal include to 2005/2006 in expanded was project Magdanly The Room. Baby Care Intensive MSF-initiated the of result a as saved now are babies premature Many month. every born are babies 75 of average an where ward, maternity the in efforts lifesaving to attention much devoted MSF 2005. in hospital the of areas care intensive and ward maternity the in out carried was systems, sanitation and water the of especially rehabilitation, Extensive healthcare reproductive Ensuring promoted. also are practices transfusion blood Safe facilities. friendly patient- and hygienic of creation the and management waste medical proper ing ensur laboratory, hospital the to support technical and training materials, vides pro also MSF infants. and babies of tion nutri poor to related conditions and tions complica neo-natal illnesses, respiratory diseases, infectious of management the in participate teams MSF staff. MSF of ment involve direct the and equipment training, through workers health local hospital’s the of efforts the supports and drugs and consultations free provides MSF patients. hospitalised 2000 and patients latory ambu 38,000 than more saw MSF 2005, In District. Magdanly in posts health primary four and Hospital Town Magdanly in (MOH) Health of Ministry the with collaboration in works MSF Tajikistan. neighbouring from refugees) (former immigrants some and origin, nic eth Uzbek of mostly people, 40,000 about to home is area The work. MSF’s of point focal the is Uzbekistan, and Afghanistan of border the to close Magdanly, country. the throughout people of number large a for needs health unmet in resulting are practices and policies healthcare national regime’s the clear is it obtain, to hard very is status health population’s the and disease of prevalence the on data accurate Although 1991. in independence gained it since Niyazov President by ruled been has republics, Soviet former the of one Turkmenistan,

ACTIVITY REPORT 2005/2 REPORT ACTIVITY ------ties have difficulty acknowledging – also also – acknowledging difficulty have ties authori health Turkmen which of existence the – HIV/AIDS (STIs). infections mitted trans sexually of variety a of management and recognition prevention, the about awareness raise to efforts increased MSF activities, health reproductive its Through complications. obstetric and conditions gynaecological 1999. since Turkmenistan in worked has MSF communities. rural area’s the to services health reproductive and maternal child, provide to able again once are Teams district. Magdanly of posts health primary in work its continue to sion permis for authorities health national with negotiated successfully MSF access, denied of months four after 2005, September In attention. specific MSF’s has 006

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65 Asia INTERNATIONAL STAFF 2 INTERNATIONAL STAFF 14 NATIONAL STAFF 5 NATIONAL STAFF 163 Asia South Korea Uzbekistan

The present conditions in North Korea make it impossible to provide independent and impartial humanitarian assistance directly inside the country and reach those that need it most. In 2005/2006, MSF provided care to North Korean refugees through projects operating out of South Korea.

In Seoul, MSF has been the only foreign organisation present in the transit govern-

mental centre of Hanawon, where North © Alessandro Cosmelli/Contrasto Korean refugees are placed for their first three months upon arrival in the country. MSF is one of the few humanitarian organisations present in Uzbekistan, MSF has developed mental healthcare activities in Hanawon to help refugees where a combination of increasing economic hardship and deterioration cope with symptoms of trauma – over 200 of tuberculosis services in the 1990s has led to an increased incidence of patients received MSF psychological support in 2005. tuberculosis (TB). This is most evident in the region of Karakalpakstan, which is also confronting economic problems caused by massive envi- Following strong lobbying by MSF, positive measures have been undertaken by South ronmental degradation in the Aral Sea area. Korean authorities to provide much-needed psychological support for North Koreans both within and after they leave In 2001/2002, MSF conducted a drug resist- months. Afterwards, patients have to be the transit centre. In April 2006, 150 men- ance survey in Karakalpakstan, showing treated in the ambulatory phase for about tal health professionals attended a confer- levels of multi-drug-resistant TB (MDR-TB) a year. The MSF team continues to try to ence mounted in collaboration with the that are among the highest in the world. improve the quality of life for patients by University of Psychiatry, Seoul, to discuss Thirteen per cent of people never before offering psychosocial assistance to them therapeutic approaches to care and review treated for TB were infected with MDR-TB, and their families, placing much emphasis the three years of the MSF mental health and 40 per cent of re-treatment cases were in 2005/2006 on the supervision of project. Responsibility for the provision of infected with this strain. MDR-TB is defined patients who are living in the community, psychological assistance to refugees was as resistance to the two most powerful but who must still take medication six days then handed over to local authorities. anti-TB drugs, isoniazid and rifampicin. It is per week. a man-made phenomenon caused by poor MSF worked in North Korea from 1995 to patient management, poor adherence to In collaboration with the Ministry of 1998 and has worked with North Korean prescribed regimens, poor programme Health, MSF recently opened an additional refugees since 1998. management, or a combination of these inpatient TB ward in the TB 1 hospital of factors. Nukus City. The ward has 30 inpatient beds designated for patients with PDR-TB (poly MSF began its MDR-TB programme in drug resistant tuberculosis), yet another Uzbekistan 2003, focusing its activities in form of tuberculosis that shows resistance Nukus City and Chimbay District in the to certain drug protocols. autonomous republic of Karakalpakstan. By May 2006, a total of 246 MDR-TB patients MSF has worked in Uzbekistan since 1997. had been enrolled in the programme.

MDR-TB is a very difficult disease. Treatment has very unpleasant side effects and involves hospitalisation for six to 12

66 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 The Americas © StephanVanfleteren

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 67 INTERNATIONAL STAFF 16 INTERNATIONAL STAFF 13 NATIONAL STAFF 50 NATIONAL STAFF 19 he Americas

T Bolivia Ecuador

The health system of Ecuador is fragmented throughout various institutions, making the implementation of national policies for diseases such as HIV/AIDS, malaria and tuberculosis very difficult. Up to 40 per cent of the population has no access to healthcare, in part, because of financial shortfalls in the public health sector.

MSF is working to improve healthcare for people with HIV/AIDS in the Flor de Bastión slum of Guayaquil, Ecuador’s largest city. Here MSF provides care to 540 persons with HIV, 281 of them receiving antiretroviral treatment. In 2005/2006, MSF has been decentralising care from the referral hospital to maternity clinics and health centres,

manda Sans promoting better patient access to diagno- © A sis, care and follow-up.

Bolivia is home to a large indigenous population, many of whom are The disease carries a strong stigma and in poor, geographically isolated and have little access to healthcare. Up 2005/2006, MSF worked on breaking down myths and stigmas attached to HIV – par- to 40 per cent of people are affected by Chagas disease in some rural ticularly amongst health staff – through areas, the highest prevalence in Latin America. Diseases preventable educational workshops and sensitivity training and contributed to forums on HIV with vaccines also continue to be an unresolved health problem. in different areas of the country.

MSF has focused on helping Bolivians with to local authorities at the end of 2006. Advocating for drugs to expand Chagas, the deadly parasitic disease that Awareness and advocacy efforts have also treatment can be transmitted through a “bug bite” been robust with MSF participating in Generic medicines, the cheaper alternative and eventually attacks the heart and diges- national and international Chagas forums to branded drugs, are key to expanding tive system. MSF currently operates proj- and media activities, lobbying at the treatment for HIV/AIDS. Registering drugs ects in semi-urban areas and in the city of department level and contributing to the in Ecuador is a complicated process, and Sucre, Chuquisaca department. As Chagas Chagas department network. the use of qualified generic medicines is cannot be effectively treated in adults, being introduced slowly given strong pres- emphasis is on diagnosis and treatment for Flooding in Bolivia sure from pharmaceutical companies to use Chagas in youth under 18, and by July Unrelenting rains caused flooding in branded drugs. MSF has been defending 2006, 193 patients had been treated with Bolivia’s highlands and the Amazon basin registration of generics with the goal of good results. MSF continues to support the in January 2006, drawing extensive human- including them in the national HIV/AIDS Ministry of Health’s Chagas prevention itarian aid. After assessing the health situa- protocol, and the National AIDS Plan is now activities, trains medical and community tion, MSF provided safe drinking water to giving greater consideration to generics health staff, and conducts community edu- approximately 600 families in Gualberto because of their lower cost. cation. Lobbying and advocacy to improve Villaroel province, La Paz department. MSF has also been lobbying for fixed-dose access to diagnosis and treatment for treatment (whereby different drugs are Chagas is also ongoing. Neglected diseases project closes combined into single pills) to become part In April 2006, MSF closed a neglected dis- of the national protocol. Fixed doses make In O’Connor province, Tarija department, eases project aimed at the diagnosis and it simpler and easier for patients to take MSF is testing and treating youth under 15 treatment of tuberculosis, malaria, leprosy their medicines and helps improve treat- for Chagas, attempting to reduce its and leishmaniasis in Pando, because epide- ment adherence. impact. By July 2006, MSF had screened a miological surveillance showed these dis- total of 7083 youths and treated over 1200 eases were not as prevalent as expected. MSF is working on a progressive handover in this rural area. Strategies to diagnose After training local health staff, MSF hand- of the Guayaquil HIV/AIDS project to the congenital Chagas in unborn babies have ed over diagnosis activities to the Ministry Ministry of Health, which should be com- also been implemented. MSF is now inte- of Health. pleted in 2008. grating these activities into public health structures, aiming to hand over the project MSF has worked in Bolivia since 1986. MSF has worked in Ecuador since 1996.

68 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 6 NATIONAL STAFF 33 he Americas

L.A., a person living with AIDS, Tela, Honduras.

Every year, about 20,000 to 30,000 Hondurans migrate from the countryside to the capital, many establishing themselves in squat slums within the centre of Tegucigalpa. With high rates of divorce, alcohol and drug abuse, family structure is fast-disappearing and many young children prefer to live on the streets. Easy prey for druglords and prostitution, these young people engage in high-risk behaviours and live amidst a climate of violence – yet they are routinely denied access to state healthcare.

Since April 2005 MSF, in cooperation with with the centre’s psychologist seeing Lending antiretroviral medicines to local organisations, has operated a thera- approximately 35 clients per month for the government peutic day centre for street children and symptoms of depression and anxiety alone. After transferring an HIV/AIDS project in youth in the heart of Tegucigalpa. The proj- Tela to national authorities in September ect offers medical, psychosocial and social- In 2005, the centre piloted psycho-educa- 2005, MSF intervened in November 2005 educational assistance to street children tional group work. One group was created and January 2006, lending antiretrovirals and youth up to age 24 in an effort to for young pregnant women and mothers to to prevent impending interruption of treat- reduce high-risk behaviour and provide exchange experiences and learn about sex- ment not only for its former patients, but healthcare. Almost 400 youths are now reg- ual, reproductive and natal care. The sec- for all 3000 patients enrolled in the nation- istered at the centre, which receives ond group, “Los Listos” (quick witted) was al antiretroviral programme. At both times, approximately 35 visits per day. aimed at male members and brings up drug stocks were about to run out because issues of violence and drug abuse. of untimely ordering of drugs by the Medical consultations number approxi- Facilitated by a psychologist and education Honduran government. MSF expressed mately 180 per month, most frequently for specialist, members discuss topics includ- public concern for these patients, and to respiratory infections, skin diseases and ing problems of substance abuse and dif- date no further difficulties obtaining these trauma caused by violence. Sexual and ficulties living on the street. Girls soon lob- drugs, financed by the Global Fund, have reproductive health care are emphasised in bied for a similar group of their own, and in been reported. response to the needs of girls and adoles- December 2005, a female “Las Listas” was cents exposed to the risk of pregnancy, created. In a separate endeavour, a number MSF has worked in Honduras since 1998. sexual exploitation, violence and sexually of well-attended informational HIV preven- transmitted infections. Psychological care tion sessions were also held in 2005/2006. is an important part of the services offered,

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 69 INTERNATIONAL STAFF 43 NATIONAL STAFF 178 he Americas

T Colombia

Now in its fifth decade, ongoing violent conflict in Colombia has conducted in the first four months, nearly caused the displacement of over two million people. Whilst many peo- 30 percent of them psychological consultations. ple in remote villages find themselves cut off from basic healthcare Offering medical assistance to survi- services, including immunisation programmes, those who have fled to vors of sexual violence urban shantytowns are subject to poverty, disease and rampant vio- In Chocó department, MSF is working in lence. Many people throughout the country are also suffering from the jungle city of Quibdó, population 120,000. There are two roads connecting mental disorders including acute trauma caused by witnessing or Quibdó to the rest of the country, but both being victims of violent events, but areas affected by violence are are extremely unsafe because of the ongoing conflict. often isolated and rarely benefit from visits by healthcare workers. Here MSF provides a package of sexual and reproductive healthcare services, targeting survivors of sexual violence in particular. treated per month, the most common ail- MSF works in the maternity wards of San ments being respiratory infections, diar- Francisco Regional and Ismael Roldan hos- rhoeal diseases and acute viral infections. pitals and also supports the city’s five Near Bogotá, MSF assists the newly dis- health centres, providing them with family placed in Soacha district, conducting medi- planning methods, emergency contracep- cal consultations and providing mental tion and drugs. Using mobile clinics, MSF health support for approximately 1000 dis- also provides medical and psychological placed persons monthly. The team also assistance in areas surrounding Quibdó. In informs displaced families about their right its first three months of activities, MSF per- to healthcare and provides information on formed a total of over 3000 medical, family © StephanVanfleteren how they can gain access to the compli- planning and psychological consultations cated government-run health system. through this project. Expanding care through fixed and Psychosocial care is provided for people mobile clinics living in Florencia, Caquetá. Here approxi- Providing help after violence and a In 2005/2006 MSF continued to provide mately 700 are seen monthly, largely for natural disaster essential medical services in numerous depression and post-traumatic stress. In November 2005, fighting between army urban and rural areas of the country, using In addition to providing healthcare via and guerilla forces escalated in the town of both fixed health posts and mobile clinics. mobile brigades, MSF supports health facil- San Juancito and hundreds fled this part of In addition to basic healthcare, many pro- ities in the Barbacoas region of Nariño Norte de Santander. Heavy rains caused grammes include vaccinations, reproduc- province, by training health staff, providing flooding and landslides in the same region tive healthcare, dentistry and psychosocial support to rehabilitate rural health struc- days later. In coordination with local support. tures and implementing water-sanitation authorities and the Colombian Red Cross, In the northeastern department of Norte and waste management systems. MSF provided two truckloads of emergen- de Santander, MSF conducted medical out- cy medical material, food, shelter and reach activities in isolated rural areas with- MSF is also providing medical and psycho- hygiene kits to approximately 300 dis- in the El Catatumbo region. Approximately logical assistance to victims of conflict in placed persons. 750 patients were seen each month at two Tolima and northern Huila departments, an fixed sites and through mobile activities. area of fighting, massacres and displace- MSF staff held ment. In 2005, MSF visited more than 20 On 3 February 2006, a local armed group in In the provinces of Córdoba, Chocó and different sites and conducted over 14,000 Norte de Santander detained five MSF staff Antioquía, MSF in 2005/2006 expanded its medical and over 4400 psychological con- members. Three team members, all activities, establishing a fixed clinic for sultations in this area. Colombian staff, were released the follow- people who had returned to Saiza, ing day. On 9 February, the final two inter- Córdoba, and starting a second one in Ríos When an evaluation carried out in Ibagué, national staff members were allowed to Sucio, Chocó. Mobile clinics were used to the capital of Tolima department, revealed leave the village where they were being provide healthcare to people living in out- that displaced persons had to wait on aver- held. After extensive analysis and evalua- lying villages, treating approximately 900 age three months before obtaining assist- tion of the security situation in its projects patients monthly. ance or medical coverage from govern- in Colombia, MSF decided to cautiously ment agencies, MSF opened a health continue its activities, with the exclusion of MSF also established a clinic for displaced centre in January 2006 to provide medical one area in Norte de Santander. persons living in the urban slums of and psychological assistance to new arriv- Sincelejo. An average of 1250 patients was als. More than 1000 consultations were MSF has worked in Colombia since 1985.

70 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 The Human Cost of Colombian Conflict

“ All families have suffered. Once I asked the

pupils in my class, 11-year-old children, how he Americas T many of them had lost a family member while the paramilitary were here. Out of 28 children, 20 told me they had at least one family member killed by the armed groups.” teacher from a rural community © StephanVanfleteren

Colombia is a thriving country with a lively culture and growing “ The man was found wandering around town. He said he was feeling level of progress. It has modern cities and flourishing scientific and bad, but he could not explain what was wrong. He kept talking and education centres. But behind this upbeat image, an extremely vio- crying…tears went down his cheeks and when we asked him why he lent, internal conflict has carried on unabated for decades. Fuelled by was crying, he said “Am I crying?” and he cleaned his face, started drug trafficking and foreign military assistance, the struggle by gue- crying again and kept repeating he did not feel well. He was disori- rillas, paramilitary groups and government forces to control territory ented, confused, with mental blackouts, he could not remember what and resources continues to take a high toll on the civilian population. had happened.” People who live in conflict zones in rural Colombia are often per- community leader, rural area ceived as resources for the armed actors who operate locally. “ My mother cannot sleep…if she hears a motorbike out in the streets “ We were taken somewhere and they started to threaten us and talk she wakes up and cannot fall asleep again…the thing is that last about chainsaws. After awhile, they let us go. I grabbed my kids and week we had to pick up our brother-in-law. He was almost unrecog- we left immediately for another town. We left only with the clothes nizable. They had beaten him up, and his head was chopped off. I we were wearing; we walked all night and part of the day, and the can’t get that image out of my head.” kids kept asking for food…” young man living in an urban slum mother from a rural community From Living in Fear, Colombia’s Cycle of Violence, a 64-page report Violence is the leading cause of death in Colombia. During the last compiled by MSF to raise awareness of the human cost of the con- decade, the homicide rate has been approximately 60 per 100,000 flict by giving a voice to those who must bear its harsh consequenc- inhabitants, one of the highest rates in the world. For every person es. who dies as a result of violence, many more struggle to survive it, often burdened by a range of physical and mental problems.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 71 INTERNATIONAL STAFF 29 NATIONAL STAFF 327 he Americas

T Haiti

Although increasing violence before Haiti’s national elections in MSF also works in the communes of Petite February 2006 briefly focused world attention on this poor island Rivière, supporting health structures and providing basic healthcare with a special nation, violence has ravaged the capital, Port-au-Prince, in waves since focus on maternal and child health. President Jean-Bertrand Aristide was forced to leave the country in Haiti has the highest level of maternal mor- early 2004. Civilians suffer from clashes amongst armed factions and tality in the Americas, with 523 deaths per between armed groups and UN soldiers. Fear, lack of infrastructure and 100,000 births. In March 2006, MSF opened the 60-bed Jude Anne Hospital in the capi- high healthcare costs prevent more than half of the country’s popula- tal’s Delmas area. The project specifically tion from accessing basic medical services. targets women living in the most violent parts of the city, who have difficulty accessing appropriate care, in part, MSF provides free emergency medical and Responding to specialised needs because of poverty and violence. Medical surgical care to people at the 56-bed trau- Specialised care for patients in need of care is provided for women with pregnan- ma centre at St. Joseph’s Hospital in the physical rehabilitation or mental health- cies presenting dangers to the mother and Turgeau neighborhood. During 2005, more care is provided by MSF in the capital’s child, as well as treatment to help prevent than 7000 people received emergency Pacot neighborhood. This includes post- mother-to-child transmission of HIV. medical assistance, almost 2500 of them surgical rehabilitation for patients with Emergency obstetric care services are avail- direct victims of violence. Half of those fractures from car accidents, paralysis from able around the clock. Between March and treated for such injuries were women, chil- gunshot wounds, amputated limbs or June 2006, the team performed more than dren or elderly. MSF also treated more than those with serious burns. More than 256 1200 deliveries and 450 surgical interven- 100 survivors of rape during 2005 and gave patients were admitted for treatment in tions, including 250 caesarean sections. referrals for further psychological care and 2005 and an additional 613 people legal assistance. received outpatient physical therapy. Project handover Eighty-seven patients received psychologi- In June 2006, MSF handed over the activi- The enormous civilian cost of Haiti’s vio- cal support. ties of its primary healthcare project in the lence caused MSF to speak out in January Decayette area to a local NGO. The project 2006, calling on all parties to respect the In one of the city’s most violent areas, Cité had focused on maternal and child health safety of civilians and allow immediate Soleil, MSF operates the 75-bed Choscal including pregnancy care, treatment of access to emergency medical care. MSF Hospital and primary healthcare centre in sexually transmitted infections and child also called on all armed actors to respect Chapi. More than 3000 consultations are immunisations. the safety of national and international aid carried out monthly, including maternal workers after a wave of kidnappings. and child healthcare and surgical consulta- MSF has worked in Haiti since 1991. tions.

“ We see about three gunshot victims a day. There are gunshot wounds that would kill someone eventually, but more slowly – maybe their bowel or liver is perforated and there is slow bleeding – where if you operate, you can actually do something to stop them from dying.” Dr. James Smith, MSF surgeon © GaëlTurine

72 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 INTERNATIONAL STAFF 26 NATIONAL STAFF 99 he Americas

Guatemala T

In October 2005, tens of thousands of people throughout Central America lost their homes, livelihoods and access to clean water when tropical storm Stan struck the region, causing landslides, flooding lowlands, contam- inating drinking wells and © KennethTong displacing an estimated 30,000 A blood sample is taken to test a child for Chagas disease, Olopa, Chiquimula. people. Around 1.5 million people were directly affected. Although months following the storm, there was no During 2005, MSF made significant prog- the Guatemalan government significant increase justifying a medical ress integrating all aspects of care (coun- intervention. selling, diagnosis, treatment for opportu- responded rapidly, help was nistic infections, ARV treatment and Helping those with HIV/AIDS follow-up) at all levels of healthcare deliv- needed to reach all of the areas Approximately 61,000 Guatemalans are liv- ery. This project will be handed over to the hit by the storm. ing with HIV/AIDS. Despite external sup- Ministry of Health (MOH) and the national port, national HIV/AIDS programmes have AIDS programme in 2006. MSF was one of the first international been slow in starting and national health organisations to arrive, bringing 11.5 institutions have done little to address the Collaborating with local organisations, MSF tonnes of relief materials to the Atitlán AIDS pandemic. There is a lack of specialist has been providing comprehensive HIV/ Lake area, including basic emergency med- centres and staff, and HIV/AIDS care has AIDS care in the town of Coatepeque and ical materials, blankets, mattresses and been highly centralised, available only in has begun the process of handing over the drinkable water. Within one week, MSF had Guatemala City. project (2000 patients, 500 on ARVs) to the provided 60,000 litres of drinking water MOH. and first aid for people living in shelters in MSF provides HIV/AIDS care in the city’s dozens of communities in Atitlán, Yaloc clinic, where 4000 medical consulta- In the remote town of Olopa, MSF has been Chiquimulilla, Coatepeque, San Marcos and tions were performed and 803 patients testing and treating people with Chagas Escuintla municipalities. were receiving life-extending antiretrovi- disease, which can be fatal without early rals (ARVs) by the end of 2005. MSF is also treatment. MSF in 2005/2006 screened Providing post-emergency advocating for planned treatment proto- almost 8000 children aged 15 and under, assistance cols for patients co-infected with HIV and and treated the 104 children found to have Once the initial emergency phase was over, TB. the disease. Local staff have been trained MSF focused on rehabilitating water sys- to take on these activities and MSF will tems, fixing infrastructure and resettling Halting the spread of a deadly close this project in December 2006. families. MSF also offered mental health influenza support to people traumatised by the In March 2006, MSF responded to an out- MSF’s project for street children in disaster in a number of locations and pro- break of influenza A in Roosevelt Hospital, Guatemala City’s Tzité clinic performed vided medical consultations in cooperation which affected immuno-compromised HIV 2702 medical and 719 psychological con- with local doctors. patients and killed more than 20 people. sultations in 2005. In mid-2006, MSF organ- MSF provided vaccines for hospital staff ised a regional symposium to share the A large part of the intervention involved and patients who were able to provide a team’s seven-year experience with academ- the distribution of items such as hygiene good immune response. Vaccinations were ics and practitioners, and plans to with- kits to help reduce the possibility of water- also sent for hospital staff in Coatepeque draw from this project at the end of the borne diseases. Overall, MSF distributed and Puerto Barrios. year. 5000 kits to nearly 25,000 people in one month and gave out more than 15,000 Handing over projects for HIV/AIDS, After reaching a total of 11,000 students in mosquito nets to prevent malaria. MSF also Chagas and street kids 14 schools in Coatepeque, a sexual educa- set up an epidemiological surveillance sys- MSF has been promoting decentralisation tion programme was handed over to the tem, based on a network of health centres, of HIV/AIDS services to provide better Ministry of Education in February 2006. to monitor for outbreaks of Hepatitis A, access to people in remote areas such as malaria, dengue fever and diarrhoea. In the Puerto Barrios, on the Caribbean coast. MSF has worked in Guatemala since 1984.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 73 INTERNATIONAL STAFF 5 NATIONAL STAFF 37 he Americas

T Peru

Lurigancho is one of the most populated prisons in Latin America. Health, MSF has developed a programme Located in Lima, the prison houses more than 8500 inmates in a space of simplified testing, streamlined drug regimens and decentralised care. The project designed for 1500 and up to 4000 visitors are received daily. In includes free and voluntary rapid testing Lurigancho, the risk of contracting HIV is five to seven times higher close to patients’ homes and the option of home-based care for those who cannot than outside the prison. come to the clinic. Social and psychological support are provided and MSF is creating a range of educational tools to help patients Starting in 2001, MSF, together with the from 8.2 per cent to 4.7 per cent in parallel and their families understand what is need- National Penitentiary Authority, developed with increased counselling. ed for successful HIV/AIDS care – not an a multidisciplinary project addressing sex- easy task given the high level of illiteracy in ually transmitted infections (STIs) and HIV/ In February 2006, after five years of devel- Villa El Salvador. AIDS within the prison. The goals were to oping the programme, MSF published improve the quality of medical care and Lessons Learned: a multidisciplinary work By mid-2006, MSF had built a new clinic treatment of STIs, provide care for people experience in STI and HIV/AIDS in Lurigancho and 250 patients were being followed, with HIV/AIDS and to train and involve prison in Lima, Peru and began handing including 181 patients receiving antiretro- health professionals from disciplines such over the project to local authorities. MSF viral treatment. Providing community- as psychology and education, who could will continue to support health workers based medical care and publicly address- then provide support to this vulnerable inside Lurigancho throughout 2006. ing the issue of HIV/AIDS has been a population. breakthrough in an area where HIV is little A new model of HIV/AIDS care understood and remains a stigma. From 2000 to 2005, over 1800 persons were In the Lima slum of Villa El Salvador, MSF treated for sexually transmitted infections. runs a comprehensive HIV/AIDS project at MSF has worked in Peru since 1985. Voluntary HIV tests were taken by 5673 the Centro Materno Infantil San José health inmates and HIV prevalence decreased clinic. Working closely with the Ministry of © Paco Arevalo

Chechen child swings in the back courtyard of the URiC Wolomin Refugee Centre, Poland.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 75 INTERNATIONAL STAFF 0 INTERNATIONAL STAFF 0 NATIONAL STAFF 24 NATIONAL STAFF 20 Europe Belgium France

In Belgium, one of the only rights granted by law to undocumented migrants is the right to access healthcare. Sadly, in practice this is incredibly difficult, mostly because of red tape and patients’ fear of saying who they are and where they live – required information in order to obtain treatment.

MSF has responded by providing health- trative maze and at facilitating contacts care to these people facing obstacles to with service providers and agencies in health services in the regular system. In charge of paying the bills. While this is a 2005, MSF conducted 140 medical and psy- major achievement, more structural chang- chosocial consultations in clinics in es are needed to facilitate easier access. Brussels and Antwerp. Seventy-four percent of these were undocumented Handing-over of HIV testing activities migrants, whilst most of the others were For the last 15 years, MSF’s Elisa Centre has asylum seekers waiting for a decision on provided free and anonymous HIV testing their applications. in Brussels. On Jan. 1, 2006, after a huge media and lobby push, this service was In addition to offering treatment, MSF finally taken over by the authorities and is © Julien Leveque strives to redirect patients toward the insti- now available in Brussels and Antwerp. tutions that should take care of them, get- Until then, Belgium was one of the only ting local and national authorities and wel- countries in Europe not offering free and Whilst healthcare and legal solu- fare agencies to face up to their anonymous HIV testing, despite recom- tions do exist, undocumented responsibilities and ensure care for the mendations from the World Health most vulnerable groups, care they are enti- Organization. migrants in France experience tled to by law. many difficulties in obtaining The data collected by MSF during the proj- In July 2005, lobbying efforts reached a ect proves that vulnerable groups are more the information and documents promising conclusion when MSF was able likely to come and get tested if it is both necessary to access state medi- to stop its medical consultations in Liège anonymous and free: in its last year of after reaching an agreement with the local activity, 2000 tests were undertaken at the cal aid. welfare agency. The agreement included Elisa Centre, with 1.6 percent of people the creation of a Relais Santé, aimed at testing positive for HIV. In 2005, MSF conducted 7100 medical guiding the patients through the adminis- consultations with migrants in ongoing MSF has worked in Belgium since 1987. programmes through medical/social clinics in Paris (4700) and Marseille (2400). Eighty-eight percent of those who received MSF care did not have medical coverage, although most were potentially entitled. MSF social workers conducted more than 2500 consultations to help patients obtain their rights to health coverage through social security and referred them to agencies for help with basic needs such as accommodation, meals, clothing, and legal information.

Although referral to specialists has been easy to manage, this was not the case for people suffering with mental disorders. New arrivals experience isolation and many have gone through a violent journey whilst trying to migrate, often from war-torn countries. In 2006 MSF intends to focus its medical activity toward those © Layla Aerts

76 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 journey. MSF also complemented food dis food complemented also MSF journey. their to related conditions orthopaedic or infections for help sought patients of ity major The referrals. necessary any dinated coor and day per patients 20 of average an saw physician MSF an clinic, mobile a Using aid. medical state due other any access not could they hospitalisation, emergency from Apart healthcare. to barriers strict and weather winter harsh faced – East Middle the and Africa of Horn the in zones conflict from mostly – migrants these France, leaving before days 20 of average an for outdoors Sleeping England. towards channel the cross to intending migrants to assistance provide to Calais in present was MSF 2006, March to 2005 November From Calais in assistance cold-weather Offering violence. to related indirectly or directly disorders mental suffer individuals these of many conflicts, armed with tries coun from come Having asylum. seeking MSF has worked in France since 1987. since France in worked has MSF care. primary continue to place in was Monde, Du Médecins actor, another that and system their improve would agencies state that ensuring after project the closed MSF March, of end the By kits. protection weather with tributions - - - - year. Upon arrival, many of these people are weakened and in need of of need in and weakened are people these of many arrival, Upon year. each Africa from boat by arriving migrants of thousands receives Italy and barriers to accessing abortion. accessing to barriers and childcare, and mother concerns area this in MSF by detected problems main the of One Agrigento. of town Sicilian the in opened was immigrants undocumented for ics clin with project new a 2005, of end the At society. Italian of rest the from excluded completely ghettos in live grants immi Here environments. social-economic Italian complex and violent difficult, most the of one in living immigrants mented undocu for healthcare providing Naples, in project new a started MSF mid-2005, In ties. authori health local to activities over hand gradually and rights healthcare and legal their of them inform people, vulnerable these treat to are goals clinics’ The identity. patient protect to codes anonymous use and service healthcare national the of part as operate clinics The Campania. and Sicily Rome, including country the of regions various in status legal lacking migrants for clinics health opened has MSF 2003, Since need. in people more reach to projects new opened and workers migrant and arrivals recent 20,000 over for care cal medi provided MSF 2005/2006, In attention. medical and water food, © Chris Maluszynski/Moment Italy STAFF STAFF NATIONAL INTERNATIONAL access to the overpopulated temporary migrant centre on the island. the on centre given been migrant not has temporary MSF Lampedusa. overpopulated of the to landing access harbour the at migrants arrived newly examine staff MSF 27 2

ACTIVITY REPORT 2005/2 REPORT ACTIVITY - - - - In southern Italy, where agriculture is the the is agriculture where Italy, southern In project workers’ farm Seasonal coast. southern Sicily’s on provided is assistance Similar referrals. medical urgent any on up follows and Sea, Mediterranean the through trips hazardous after land ple peo boat where harbour the at screening medical initial offers MSF year. per grants immi 12,000 than more for spot landing a is Sicily, of south island small a Lampedusa, South the in landings at Assistance MSF has worked in Italy since 1999. since Italy in worked has MSF pathologies. musculoskeletal or diseases respiratory and dermatological disorders, gastrointestinal as such tions, condi working and living harsh to related were detected pathologies Main Calabria. and Puglia Sicily, in workers farm seasonal to care medical provided MSF 2005/2006, In farms. on labourers day as work grants immi undocumented and seekers lum asy of thousands activity, economic main 006

MEDECINS MEDECINS S ANS FRONTIERES ANS ------

77 Europe INTERNATIONAL STAFF 0 INTERNATIONAL STAFF 7 NATIONAL STAFF 5 NATIONAL STAFF 60 Europe Luxembourg Russian Federation

Luxembourg is one of the most Eleven years after the start of the first ment area of 300,000 – indicating that developed and richest countries Chechen conflict and despite official rheto- rates of TB are very high. The programme ric claiming the situation has ‘normalised’, supports the existing TB dispensary system in the world, where the inhabit- the majority of Chechens still struggle with drugs and necessary equipment, and ants enjoy high health standards. through lives burdened by fear, uncertainty also provides specialist lab services. The and poverty. Thousands of Chechen refu- directly observed treatment system (DOTS) But hidden problems remain, one gees have been forced by Russian and has been adapted to the conflict setting of them being the rapidly growing Ingush authorities to repatriate from and MSF provides food to boost the nutri- neighbouring Ingushetia. Their homes tional status of patients. MSF health educa- use of illegal and psychotropic destroyed and lacking basic needs such as tors hold individual sessions, group work drugs. clean water and healthcare, many and public information campaigns on TB. Chechens face grim conditions in over- crowded, temporary accommodation cen- To improve the living conditions of the dis- With approximately 50 per cent of youths tres (TACs). Access to the republic remains placed, MSF organised distributions of under age 18 having already used illegal a pressing problem. non-food items such as mattresses, blan- substances, Luxembourg has the highest kets, stoves and building material. In 2006, prevalence of drug use by minors in In Grozny, the republic’s capital, a mobile MSF is constructing sanitary facilities Europe. team provides primary healthcare to six (water tanks, showers, latrines) for around MSF has created the Solidarité Jeunes proj- TACs, and general, gynaecological and pae- 200 families in some of the most precarious ect to help these youths, working with diatric consultations in four polyclinics. settlements of the Chechen capital. them, their families and relevant institu- These clinics see a total of 5600 patients tions – including most secondary schools, per month. MSF is also expanding and developing its several educational centres, and outreach surgical programmes in Grozny, providing programmes in the country. A special MSF continues to distribute medicine and training support and equipment to the emphasis is put on collaboration with the medical material to Grozny Maternity, neurosurgery and trauma wards of Hospital juvenile justice system, where the MSF pro- which is the central maternity and referral No. 9. A plastic and reconstructive surgery gramme constitutes an alternative to the hospital for all of Chechnya. In 2005, MSF programme for patients suffering disabili- classic repression response. The pro- provided drugs in support of 125,740 med- ties from violence or accident related trau- gramme provides psycho-medical, social ical consultations in health structures in ma, including gunshot wounds, mine inju- and psychotherapeutic care for young Shatoi, Sharoi and Itum Kale. In the rural ries and burns began in July 2006. users and their families. From mid-2005 to region around Grozny – Grozny Selsky – early 2006, efforts were geared toward MSF primary care mobile teams offer Providing ongoing care in Ingushetia expanding the services of Solidarité Jeunes healthcare in 10 different village settle- In neighbouring Ingushetia, which saw an by developing a concept of peer-interven- ments. A primary healthcare clinic was also increase in violent incidents in 2005, MSF tion (called CHOICE) for first-time arrested opened in May 2006 in Shelkovksy district continues to provide mobile general, drug users. From June 2005 to May 2006, in the northeast, offering gynaecological, maternal and paediatric clinics in Nazran, MSF worked with a total of 263 adolescents paediatric and general services. Sunzha and Malgobek districts. A medical and families. clinic also opened in July 2005 in the High rates of psychological distress Angusht IDP settlement. The clinics con- Exploring the needs of immigrants Mental health problems are widespread duct about 2700 consultations per month. MSF continues to participate in a working among the long-suffering population and Winterisation works were carried out in group with other NGOs and the governmental health services are a large compo- several of the spontaneous settlements, ment, monitoring the medical and psycho- nent of MSF’s programmes. A survey con- which still house about 9000 Chechens. logical situation of immigrants and asylum ducted by MSF in September 2005 in six seekers entering the country. After launch- Grozny TACs showed that 77 per cent of Mental health services are a critical compo- ing guidelines describing access to the respondents were suffering from discern- nent of the programme, with a team of health system in Luxembourg for these vul- ible symptoms of psychological distress. counsellors working in 25-30 spontaneous nerable populations, the MSF-led working Fifteen MSF counsellors work closely with settlements. In close collaboration with a group began to scrutinise government pro- the mobile medical teams, and also offer network of local volunteers, they identify cedures and practices concerning the 24-hour services for patients and staff in people who could benefit from individual expulsion of sick migrant people. The work- the republic’s main trauma hospital – No. 9. therapy and organise group sessions and ing group has submitted a proposition to community activities. the Ministries of Health and Immigration to Expanding treatment for tuberculosis clarify the criteria for such expulsions. MSF’s tuberculosis (TB) programme MSF worked in the North Caucasus from expanded in 2005 to include a 4th dispen- 1993 to 1997 and resumed activity in the MSF has worked in Luxembourg since 1996. sary, Karagalinkskaya. By June 2006 it had region in 1999. enrolled over 750 patients from a catch-

78 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Europe

“ We’ve been living in a constant state of alarm in Chechnya for so long that it ages and exhausts us and our physical health suffers” Chechen doctor © Jorge Dirkx

A child in MSF’s day centre for street children.

Taking healthcare to the streets of Moscow

“ We were sniffing not to be frozen over. When you The official system of police – hospital-priut (temporary orphanage) is more focused on coercion than rehabilitation, and does not sniff you feel warmer. You are doped and you don’t facilitate access to appropriate healthcare, or include street work. care about the cold.” At the core of MSF’s approach is outreach: every day and night, several teams of MSF medical and psychosocial staff walk the streets and visit the areas where street youth gather, treating kids on the The homeless youth that MSF works with in Moscow generally live spot if possible, and advising and accompanying kids to get more in and around trains, subway stations or markets, developing com- specialised services for treatment. MSF also runs a day centre promising survival strategies to cope with the hostile environment where kids can participate in a range of therapeutic and education- on the street. Some kids beg or work with street vendors, most are al activities and also shower, wash their clothes and take meals. The exploited and controlled by criminal groups, and others become MSF multidisciplinary team supports each individual to make a involved in prostitution. In winter, living conditions make them sustained decision to leave the street, encouraging youths to come prey to flu and pneumonia. Sniffing glue, drinking or injecting to terms with the difficulties of their past and take control of their drugs are ways to cope with hunger, weather and loneliness. future decisions.

Healthy growth is often interrupted through lack of adequate diet. The MSF street children and teenagers project focused much effort Sexually transmitted infections, dermatological and gastric prob- in 2005/2006 on developing networks with local organisations, lems, as well as the high risk of HIV/AIDS and other infections are establishing a partnership with a drug and alcohol rehabilitation but a few of the many health challenges faced by this vulnerable clinic called NAN. In June 2006 a photo exhibition documenting population. MSF provides primary care and first aid, referring the lives of the street kids, taken by the kids themselves, was also patients on to secondary care for more complex issues. mounted in Moscow.

Over the past ten years, official bodies responsible for the care of MSF believes there are, on any given day, 250 to 500 children living minors have attempted to respond to the multifaceted needs of on the streets of Russia’s capital. MSF works with an average of 80 homeless and neglected children, but teenagers living on Moscow’s kids each month, mostly boys of 15-16 years old. streets are invariably excluded from society. Their access to a full range of health services is fraught with obstacles. MSF has worked in the Russian Federation since 1988.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 79 80 © Swen Connrad/YumeVision Europe forty per cent of patients coming in for for in coming patients of cent per forty that show records Intake recovery. their for necessary conditions the find to unable are seekers asylum the trauma, repeated and violence of years 10 by down Worn safe. feel to home to close too still is feel and Poland in live to intended never Many country. host a not and west, go to point transit a only is Poland refugees, Chechen many for However, Poland. to back sent are they country, EU another to way their make Poland via EU the entered who seekers asylum If seeker. asylum an to status gee refu give to whether decide must Union European the into entry of country first the 2’rule, ‘Dublin the to According Poland. in reside to status temporary a obtain others many whilst status, this receive actually ers seek asylum Chechen the of cent per eight Only status. refugee receive to wait they where camps transit to sent and registered are they Poland, via Union European the of borders the cross seekers asylum When Poland. in camps separate 16 in held were people 3500 over 2005, November of start the At country. their fled have land own in their future a had longer no they thinking Chechens of thousands curity, inse and violence continuing and wars two Following Europe. Western in asylum seeking refugees Chechen of thousands hosting is Poland MEDECINS MEDECINS Poland STAFF STAFF NATIONAL INTERNATIONAL S ANS FRONTIERES ANS 3

ACTIVITY REPORT 2005/2 REPORT ACTIVITY 3 - - MSF began working in Poland in 2005. in Poland in working began MSF patients. 425 for sultations con individual 1336 of total a out carried MSF 2006, April and 2005 August Between decade. past the over up building been has that trauma with deal seekers asylum help to consultations individual provide Psychologists Lublin. and Bialystok Warsaw, in camps transit 16 all in works now and camps, transit seven in 2005 August in port sup psychological providing began MSF care. psychological provides MSF whilst support, social and care medical food, shelter, vide pro authorities Polish the centers transit the In problems. sleep and nightmares memories, recurring experience and stress post-traumatic from suffer consultation 00 6 - - - -

© Tangi Zahn patients who remain anonymous. Free Free anonymous. remain who patients for drugs basic very and consultations medical free provides and 4 Kreis trict dis city the in located is Meditrina, called point, meeting health The populations. marginalised to healthcare provide to Zurich of canton the in project a opened MSF study, six-month a conducting after 2006, January In needs. healthcare unmet these of some address to begun has MSF healthcare. necessary and basic most the even getting difficulties face people many level, care primary the at Even tion. popula the of sector a for exist services medical accessing in barriers however, doctor, a see to required insurance health and/or fees substantial With healthcare. excellent from benefit residents many and world, the in living of standards highest the of one boasts Switzerland Switzerland STAFF STAFF NATIONAL INTERNATIONAL MSF has worked in Switzerland since 2003. since Switzerland in worked has MSF Santé. Fri- organisation, local a to over handed was this 2004, In Switzerland. Fribourg, in project similar a operated previously MSF week. each rise to continues centre the visiting patients of number average the and out carried been had consultations 108 2006, June of end the by and organisations, service social and contacts community direct media, through clinic the publicised MSF referred. is patient the individual, an for responsible is institution public a out turns it If organisations. social and institutions cal medi specialists, physicians, of network its through patients refers Meditrina sary, neces When need. they treatment the for pay to means financial necessary the of possession in nor insured medically neither are who origin other or Swiss of people all for provided are consultations 3 0 - - - - INTERNATIONAL STAFF 0 NATIONAL STAFF 44

The village of Alta Chaab, southern Lebanon, August 2006.

In July 2006, civilians in Lebanon were trapped by an intensifying war extremely difficult and dangerous, and between Lebanese Hezbollah fighters and the Israeli Defense Forces MSF spoke out about the lack of access caused by the imposition on any move- (IDF). Ongoing fighting, including bombings, caused hundreds of ment. MSF publicly refused to accept the thousands of people to flee their homes and left many civilians with a paralysis of humanitarian assistance and reiterated its intention to use every pos- limited capacity to meet basic needs including healthcare. sible means to reach those in need.

Ceasefire The first MSF team arrived one week after ical supplies and medicines, surgical kits, When a ceasefire came into effect on 14 fighting began. MSF focused on providing and logistical materials such as sanitation August, the majority of the displaced peo- emergency aid including medical care, equipment and water bladders. Teams also ple returned home within a few days. fresh water and sanitation facilities to hun- worked with local medical teams to set up During this phase, MSF assessed needs in dreds of thousands of displaced persons mobile clinics. areas that had previously been cut off by seeking refuge in Beirut, Saïda, Sour, the fighting. It also brought medical and Jezzine, Nabatiye and the Aley region. Hard to reach non-medical care primarily to the south Assistance was also given to Lebanese refu- The IDF imposed an air and sea blockade and in the Bekaa Valley. gees who had crossed into Syria. MSF sup- and carried out airstrikes on several bridg- plied more than 60,000 displaced persons es and important roads. MSF obtained safe Throughout and following the conflict, in Lebanon and 3500 refugees in Syria with passage by sea and worked with Lebanese health staff and facilities relief items such as cooking and hygiene Greenpeace to transport 75 tonnes of addressed the majority of the medical kits, mattresses, blankets, baby formula, essential supplies from Cyprus to Beirut needs and MSF provided a supportive role. and tents. Mental health support was also aboard the Rainbow Warrior. Once the acute phase of the emergency provided to help people cope with the ended, organisations began to arrive to trauma experienced by the war. Ongoing airstrikes made it difficult to help reconstruction efforts and MSF ended obtain access to people in need, particu- its activities. MSF continues to monitor the Whilst Lebanese medical staff were able to larly in the south. When the last function- situation closely. cope with the crisis, medical supplies ing bridge across the Litani River in south- began to diminish, especially stocks for the ern Lebanon was destroyed, a human chain MSF has worked intermittently in Lebanon treatment of chronic diseases such as kid- was the only practical means for transport- since the 1980s. ney disease. MSF helped replenish needed ing four tonnes of supplies. Trucks, vans, supplies, sending over 300 tonnes of mate- ambulances and cars were targeted several rial to Lebanon including relief items, med- times, making land transportation

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 81 INTERNATIONAL STAFF 18 NATIONAL STAFF 62

Middle East Palestinian Territories

Many people living in the Palestinian Territories experience direct vio- When the January 2006 legislative elec- lence, isolation, restrictions on movement, and difficulties accessing tions brought Hamas to power, the US, Canada, European Union and Japan decid- healthcare. The living conditions have psychological consequences for ed to suspend their bilateral financial aid many individuals, manifesting as depression, anxiety, post-traumatic to the Palestinian Authority. However, they promised to continue to help the popula- stress disorder or psychosomatic illness. MSF teams provide psycho- tion meet its basic needs by reallocating logical and medical care and social work assistance to help. part of those funds to the UN and other international aid organisations working in the territories. On 13 April 2006, MSF pub- In mid-2005, MSF readied for possible con- Approximately 35 per cent of MSF’s licly denounced this plan. sequences of the Israeli government’s plan patients in Nablus live in one of the three to dismantle Israeli settlements in Gaza, refugee camps, the majority live in the old MSF emphasised that although it was a preparing an emergency programme city. Here the medical aspect of the pro- government’s choice to suspend aid, before the August withdrawal of nearly gramme supports work done by the team’s humanitarian actors could not be used in 8000 settlers. Ultimately, the army’s action psychologists. A social worker also plays a an attempt to veil retaliatory measures that was carried out without major clashes. key role, referring patients to agencies for would impact the entire population. It also socioeconomic assistance. pointed out that humanitarian aid groups In 2005, MSF undertook a large water and lacked the competence, means and sanitation project in a disadvantaged area In the West Bank district of Hebron, responsibility to act as a substitute for the of Gaza known as Al Fara Towers, located in approximately 70 per cent of MSF’s Palestinian Authority. Instead, MSF said, the Tuffah neighborhood of Khan Younis. patients experienced a traumatic episode meeting the basic needs of civilians living MSF carried out a scabies eradication pro- in the past year. MSF gives home-based in the occupied territories was the respon- gram in coordination with the local munici- treatment and support for individuals or sibility of the state of Israel, as set out in pality, while logisticians fixed leaking families using a team including a psycholo- the Geneva Conventions. MSF feared that indoor plumbing, constructed septic tanks, gist, a social worker and a doctor. MSF is this “instrumentalisation” of NGOs and con- and distributed food kits and household also trying to improve access to health ser- fusion of roles and responsibilities would items such as mattresses and blankets. vices by making regular visits to the jeopardise NGOs’ independence and could Bedouin communities living in the south of put them in danger in an already unstable Throughout the year, MSF worked in the the district, and to populations residing in context. city of Nablus in the West Bank, diversify- areas where movement restrictions make it ing its referral network. Through these nearly impossible for them to reach health MSF has worked in the Palestinian efforts, the team is now well known in this services. Territories since 1988. city of about 150,000 people. © Alan Meier

82 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Project Handovers Closed projects

MSF opens and closes a number of individual projects each year, responding to acute crises, handing over projects to other actors, and always monitoring and remaining flexible to the changing needs of patients within a given location. Several projects may be running simultaneously in a single country as needed. In 2005/2006, with the closure of the following single projects, MSF effectively ended its existing operations in Brazil, Sweden and the Ukraine.

general awareness around the issue and a recent change in the Brazil political climate. Previously a sensitive political issue rarely spoken about, now four out of six political parties stand behind changing Fully functioning health centre handed the legislation concerning healthcare for asylum seekers and other over to local groups groups. In March 2006, the Swedish Red Cross committed to continue the medical programme for one year, whilst the government The consequences of Brazilian inequality are dramatically clear in reviews legislation. the populous slums of Rio de Janeiro, which has over 500 such communities. MSF started working here in 1997, and began a MSF worked in Sweden from 2004 to 2005. project in 2003 in Marcilio Dias, a slum where residents experience some of the highest levels of social exclusion and violence, resulting in a diminished access to healthcare. Ukraine

MSF established the Marcilio Dias Health Centre, providing inte- Ministry of Health and NGOs continue grated primary healthcare, psychosocial services, and linkages for care for patients with HIV/AIDS community support around issues such as domestic violence, teenage pregnancy and drug abuse. MSF has now handed over a HIV/AIDS knowledge is poor and stigma is high in Ukraine. MSF functional and fully equipped health unit to local authorities and began to address HIV/AIDS here in 1999, launching a national edu- MOGEC, a nongovernmental community organisation created cation campaign in conjunction with the Ministry of Health and under the auspices of MSF in 1997. Over 43,000 consultations were national NGOS; and setting up a continuum of care model that provided during the 32-month duration of the project, and the focused on ongoing care from awareness raising and pre HIV-test centre provided access to healthcare for 14,776 people in 2005. counselling, to psychosocial support designed to help patients cope with their illness and adhere to treatment. MSF worked in Brazil from 1991 to 2005. Programmes were established in Odessa, Mykolayiv and Simferopol. Increased international financial commitment to HIV/ Sweden AIDS in Ukraine allowed MSF to withdraw from the project, as ongoing care for patients is now ensured for the near future. The Swedish Red Cross takes on programme programme handover was marked by a press conference and the for undocumented migrants opening of a photo exhibition in Kiev in late 2005. The exhibit showed the lives of people living with HIV, testimony to the fact Sweden is one of the few countries in the EU to charge full costs that people can cope with its effects, given affordable medical for emergency healthcare for undocumented migrants, the vast care and psychosocial support. majority of whom cannot afford these costs. In 2004, MSF started a programme in Stockholm to provide medical assistance to this MSF worked in Ukraine from 1999 to 2005. population.

A survey of 102 patients receiving care through MSF’s network between July and September 2005 showed that the majority of patients were excluded from non-emergency and routine healthcare, including severe chronic diseases such as diabetes and asthma, as well as pregnancy. MSF launched public communications to draw attention to the issue and advocated for a change in the legal framework to provide better access to this vulnerable population. The campaign clearly contributed both to an increased

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 83 Overview of MSF Operations

Largest Interventions Based on project expenditures (excluding coordination) In 2005, the largest countries of intervention remained Sudan, where MSF continued to provide assistance to hundreds of thousands dis- 1. SUDAN NORTH 6. SUDAN SOUTH placed; Niger, where MSF mounted a large nutritional intervention and 2. NIGER 7. LIBERIA treated 63,000 severely malnourished children; and Democratic Republic 3. DEMOCRATIC REPUBLIC OF CONGO 8. ANGOLA of Congo, where violence affecting civilians continued throughout the 4. PAKISTAN 9. IVORY COAST year. MSF responses to the Tsunami and Central Asia earthquake are 5. INDONESIA 10. CHAD also reflected, with large relief operations deployed in Indonesia and Pakistan. Activity Highlights (non-exhaustive) Definition Total (in thousands)

OUTPATIENT TOTAL NUMBER OF OUTPATIENT CONSULTATIONS 10,000 INPATIENT TOTAL NUMBER OF ADMITTED PATIENTS 382 MALARIA TOTAL NUMBER OF CONFIRMED CASES TREATED 2249 TF NUMBER OF CHILDREN TREATED WITH THERAPEUTIC FEEDING IN 2005 130 DELIVERIES TOTAL NUMBER OF WOMEN WHO DELIVERED BABIES 91 SEXUAL VIOLENCE TOTAL NUMBER OF CASES FOR ANY TYPE OF SEXUAL VIOLENCE TREATED 12 SURGERY TOTAL NUMBER OF MAJOR SURGICAL INTERVENTIONS 75 WAR TRAUMA TOTAL NUMBER OF CONFLICT TRAUMA SURGERIES 8 HIV TOTAL NUMBER OF HIV PATIENTS REGISTERED UNDER CARE AT END 2005 161 ARV TOTAL NUMBER OF PATIENTS ON ANTIRETROVIRAL TREATMENT AT END 2005 60 TB TOTAL NUMBER OF NEW ADMISSIONS TO TUBERCULOSIS TREATMENT IN 2005 22 MENTAL HEALTH TOTAL NUMBER OF INDIVIDUAL PARTICIPANTS IN INDIVIDUAL OR GROUP MENTAL HEALTH ACTIVITIES 149 MEASLES VACCINATIONS TOTAL NUMBER VACCINATED FOR MEASLES 806 YELLOW FEVER VACCINATIONS TOTAL NUMBER VACCINATED FOR YELLOW FEVER 361

In 2005, MSF aggressively developed its activities in the field of malnutri- MSF pursued its commitment to assisting victims of violence, with 76% of tion and more than doubled the number of children treated with therapeu- its surgeries, 88% of its assistance to victims of sexual violence and 95% of tic feeding. MSF also continued its investment in HIV/AIDS, more than war-trauma activities taking place in unstable contexts. doubling the number of patients under ARV between 2004 and 2005, and Large-scale immunisation campaigns were also conducted against measles, furthered its commitment to treating patients with tuberculosis. yellow fever, and meningitis. Project Locations Context of Interventions

Africa 63% Stable 53% Asia 23% Armed conflict 18% America 7% Internal instability 16% Europe 7% Post conflict 13%

In 2005, 63% of all MSF projects were located in Africa, followed by 23% of In 2005, 47% of MSF projects took place in unstable settings – armed con- projects in Asia, an increase over 2004 reflecting MSF deployment in natu- flicts, internal instability and post-conflict. A full 20% of MSF assistance ral disasters affecting Central and Southeast Asia in 2005. MSF closed and was targeted at displaced populations. opened more than 25% of its projects during the year, attesting to MSF’s dynamism and capacity to react to crises and develop operations according to context evolution.

84 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 Audited Facts and Figures

Médecins Sans Frontières (MSF) is an international, medical Owing to the fact that the Greek office rejoined the international humanitarian organisation that is also private and not-for-profit. movement in 2005, Greece is not included in the 2004 comparative MSF comprises 19 national branches in Australia, Austria, figures presented here. However, for information purposes, its total 1. SUDAN NORTH 6. SUDAN SOUTH Belgium, Canada, Denmark, France, Germany, Greece, Holland, expenditures in 2004 were 5.3 million euros. Its total income was 2. NIGER 7. LIBERIA Hong Kong, Italy, Japan, Luxembourg, Norway, Spain, Sweden, 4.5 million euros and its total balance sheet amounted to 5.3 mil- 3. DEMOCRATIC REPUBLIC OF CONGO 8. ANGOLA Switzerland, the United Kingdom, the United States, and with an lion euros. 4. PAKISTAN 9. IVORY COAST international office in Geneva. 5. INDONESIA 10. CHAD The figures presented here are for the 2005 calendar year. The The search for efficiency has led MSF to create specialised organi- Activity Report itself covers the period mid-2005 to mid-2006. sations – called satellites – in charge of specific activities such as All amounts are in millions of euros. humanitarian relief supplies, epidemiological and medical research NB: Figures in these tables are rounded off and this may result in studies, and research on humanitarian and social action. They slight addition differences. include: Epicentre, Etat d’Urgence Production, Fondation MSF, MSF Assistance, MSF Enterprises Limited, Médecins Sans Frontières – Etablissement d’Utilité Publique, MSF Foundation Kikin, MSF-Logistique, SCI MSF, SCI Sabin, MSF Supply and Urgence Développement Alimentaires. As these organisations are controlled by MSF, they are included in the scope of the financial statements presented here.

The figures presented here describe MSF’s finances on a combined international level. These 2005 combined international figures have been set up in accordance with MSF international accounting standards, which comply with most International Financial Reporting Standards (IFRS). The figures have been jointly audited by the accounting firms KPMG and Ernst & Young according to international auditing standards. A copy of the full 2005 financial report may be obtained from the International Office upon request. In addition, each branch office of MSF publishes annual, audited financial statements according to its national accounting policies, legislation and auditing rules. Copies of these reports may be requested from the national offices.

Where did the money go? Programme expenses* by nature Programme expenses* by continent

Stable 53% International staff 24.6% Africa 68%

Armed conflict 18% National staff 23.2% Asia 21.8%

Internal instability 16% Medical & nutrition 19% America 5.6%

Post conflict 13% Transport, freight, storage 17.3% Europe 3.7%

Operational running expenses 8.4% Non-allocated 0.9%

Logistics & sanitation 5.6%

Other expenses 1%

Training & local support 0.9%

* project and coordination team expenses in country

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 85 Programme expenses by country/region (including coordination)

Countries/Regions In M€ Countries/Regions In M€ Countries/Regions In M€ Countries/Regions In M€ Africa Asia/Middle East Americas

SUDAN 46.3 SIERRA LEONE 5.0 PAKISTAN 20.4 HAITI 5.5

DEMOCRATIC REPUBLIC ZIMBABWE 3.8 INDONESIA 19.7 COLOMBIA 4.8

OF CONGO 29.4 REPUBLIC OF THE CONGO 3.2 MYANMAR 5.6 GUATEMALA 4.1

NIGER 23.4 GUINEA 3.1 CAMBODIA 4.5 ECUADOR 1.5

ANGOLA 14.3 ZAMBIA 2.9 INDIA 4.1 BOLIVIA 1.2

LIBERIA 13.6 BURKINA FASO 2.6 SRI LANKA 3.3 OTHER COUNTRIES* 2.4

CHAD 9.2 RWANDA 2.5 THAILAND 3.1 TOTAL 19.5

IVORY COAST 8.3 SOUTH AFRICA 2.3 ARMENIA 2.5

NIGERIA 8.0 MALI 1.6 CHINA 2.2 Europe

BURUNDI 7.7 CENTRAL AFRICAN REPUBLIC 1.6 GEORGIA 1.7 CHECHNYA / INGUSHETIA /

UGANDA 7.7 CAMEROON 1.3 UZBEKISTAN 1.6 DAGESTAN 4.3

KENYA 7.4 TANZANIA 1.3 PALESTINIAN TERRITORIES 1.4 RUSSIA 2.2

SOMALIA 7.3 MAURITANIA 1.3 BANGLADESH 1.3 FRANCE 1.4

ETHIOPIA 7.2 GUINEA-BISSAU 1.1 IRAN 1.1 BELGIUM 1.1

MOZAMBIQUE 6.3 OTHER COUNTRIES* 1.5 OTHER COUNTRIES* 3.2 OTHER COUNTRIES* 3.6

MALAWI 5.3 TOTAL 236.5 TOTAL 75.7 TOTAL 12.6

* “ Other countries” combines all of the countries for which program expenses were below 1 million euros. Sources of income As part of MSF’s effort to guarantee its independence and strengthen the represents 9.1 months of activity. The purpose of maintaining retained organisation’s link with society, we strive to maintain a high level of private earnings is to meet the following needs: future major emergencies for income. In 2005, 86.1% of MSF’s income came from private sources. More which sufficient funding cannot be obtained, and/or a sudden drop of pri- than 3.4 million individual donors and private funders worldwide made vate and/or public institutional funding, and the sustainability of long- this possible. Additional public institutional agencies providing funding to term programmes (e.g. ARV treatment programmes), as well as the pre- MSF include among others, the governments of Belgium, Canada, Ireland, financing of operations to be funded by upcoming public funding Luxembourg, The Netherlands, Norway, Spain, Sweden, Switzerland, and campaigns and/or by public institutional funding. the United Kingdom. Unspent temporarily restricted funds are unspent donor-designated Expenditures funds, which will be strictly spent by MSF in accordance with the donors’ Expenditures are allocated according to the main activities performed by desires (e.g. specific countries or types of interventions) as needs arise. MSF. Operations gather programme-related expenses as well as the head- quarters’ support costs devoted to operations. All expenditure categories Additional disclosures: Tsunami disaster include salaries, direct costs and allocated overheads. Public donations received in response to the December 2004 tsunami disaster resulted in contributions totalling 111 million euros, of which 36.4 Permanently restricted funds may be capital funds, where the assets million euros were received in 2004, and the balance in 2005. The funds are required by the donors to be invested, or retained for actual use, rather received were used for tsunami-relief operations or “derestricted” with the than expended, or they may be the minimum compulsory level of retained consent of donors and spent where they are most needed within MSF’s earnings to be maintained by some of the sections. ongoing work. MSF spent a total of 24.5 million euros in 2004 and 2005 on operations in the regions affected by the tsunami – 1.7 million in 2004 and Unrestricted funds are unspent non-designated donor funds expend- the remainder in 2005. In total 19.7 million euros were spent in Indonesia, able at the discretion of MSF’s trustees in furtherance of our social mission. 4.0m in Sri Lanka and 0.8m in India and Thailand. An amount of 2.3 million euros of restricted tsunami funds remains unspent at the end of 2005 and Other retained earnings represent foundations’ capital as well as tech- are carried in the balance sheet within liabilities as “unspent restricted nical accounts related to the combination process, including the conver- funds”. The remainder of the donations received were “derestricted” or “re- sion difference. MSF’s retained earnings have been built up over the years directed” with the consent of the donors – approximately 30 million euros by surpluses of income over expenses. As of the end of 2005, their avail- of which were used to fund two other big emergencies that occurred in able part (the unrestricted funds decreased by the conversion difference) 2005 – the malnutrition crisis in Niger and the earthquake in Pakistan.

86 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006 2005 2004

Income In M€ In % In M€ In % Private Income 543.0 83.7% 342.8 74.8% Public Institutional ECHO*, EU & DFID** 44.8 6.9% 55.9 12.2% Public Institutional Other 45.5 7.0% 47.0 10.3% Other Income 15.7 2.4% 12.4 2.7% Total Income 649.0 100.0% 458.1 100.0%

How was the money spent? Operations 397.4 78.0% 321.5 76.3% Témoignage 15.9 3.1% 14.5 3.4% Other humanitarian activities 8.0 1.6% 7.9 1.9% Total Social Mission 421.3 82.7% 343.9 81.7% Fundraising 59.8 11.8% 49.2 11.7% Management, general & administration 28.2 5.5% 28.0 6.6% Total Expenditure 509.3 100.0% 421.1 100.0% Net exchange gains & losses (realised and unrealised) 4.1 -2.8 Surplus/(deficit) 143.7 34.2

* European Community Humanitarian Office ** UK Department for International Development

Balance sheet In M€ In M€ (year-end financial position): Non-current assets 35.5 31.7 Current assets 66.6 91.2 Cash & equivalents 352.1 201.8 Total assets 454.2 324.7 Permanently restricted funds 2.8 2.8 Unrestricted funds 384.6 236.6 Other retained earnings 1.5 -3.7 Total retained earnings and equities 388.9 235.8 Non-current liabilities 8.5 7.6 Current liabilities 49.9 43.3 Unspent temporarily restricted funds 6.8 38.0 Total liabilities and retained earnings 65.2 324.7

HR Statistics International departures (full year): 4,768 100% 3,803 100% Medical pool 1,276 27% 1,034 27% Nurses & other paramedical pool 1,558 33% 1,257 33% Non-medical pool 1,934 40% 1,512 40%

First time departures (full year): 1,466 (*) 31% 1,340 (*) 35% (*) in % of the international departures Field positions: 28,083 100% 24,666 100% International staff 2,227 8% 2,026 8% National staff 25,855 92% 22,640 92%

* unaudited figures

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 87 Contact MSF

Australia Médecins Sans Frontières Holland Médecins Sans Frontières / Switzerland Médecins Sans Frontières / Suite C, Level 1, 263 • Broadway Glebe NSW 2037 Artsen Zonder Grenzen Ärzte Ohne Grenzen Postal address: PO BOX 847 Plantage Middenlaan 14 • 1018 DD Amsterdam Rue de Lausanne 78 Broadway NSW 2007 • Australia Postal address: PO Box 10014 Postal address: Case Postale 116 T +61 (0)2 9552 4933 • F +61 (0)2 9552 6539 1001 EA Amsterdam • The Netherlands CH-1211 Genève 21 • Switzerland [email protected] • www.msf.org.au T +31 20 520 8700 • F +31 20 620 5170 T +41 22 849 84 84 • F +41 22 849 84 88 Pr: Dr. Rowan Gillies • GD: Philippe Couturier [email protected] [email protected] • www.msf.ch www.artsenzondergrenzen.nl Pr: Isabelle Segui-Bitz • GD: Christian Captier Austria Médecins Sans Frontières / Pr: Albertien van der Veen • GD: Geoffrey Ärzte Ohne Grenzen Prescott UK Médecins Sans Frontières (UK) Taborstrasse 10 • 1020 Vienna • Austria 67-74 Saffron Hill • London EC1N 8QX • UK T +43 664 444 1123 • F +43 1 409 7276/40 Hong Kong Médecins Sans Frontières T +44 207 404 6600 • F +44 207 404 4466 [email protected] Shop 5B • Laichikok Bay Garden [email protected] • www.uk.msf.org www.aerzte-ohne-grenzen.at 272 Lai King Hill Road • Kowloon • Hong Kong Pr: Valerie Wistreich • GD: Jean-Michel Piedagnel Pr: Dr. Reinhard Doerflinger • GD: Franz Neuteufl T +852 2338 8277 • F +852 2304 6081 [email protected] • www.msf.org.hk USA Médecins Sans Frontières / Belgium Médecins Sans Frontières / Pr: Dr. Tsz Wah Tse • GD: Dick van der Tak Doctors Without Borders Artsen Zonder Grenzen 333 7th Avenue • 2nd Floor • New York rue Dupré 94 / Dupréstraat 94 Italy Medici Senza Frontiere NY 10001 • USA 1090 Brussels • Belgium Via Volturno 58 • 00185 Rome • Italy T +1 212 679 6800 • F +1 212 679 7016 T +32 (0) 2 474 74 74 • F +32 (0) 2 474 75 75 T +39 0644 86 921 • F +39 0644 86 9220 [email protected] [email protected] or [email protected] [email protected] • www.msf.it www.doctorswithoutborders.org www.msf.be or www.azg.be Pr: Dr. Stefano Vajtho Pr: Dr. Darin Portnoy • GD: Nicolas de Torrente Pr: Dr. Jean-Marie Kindermans • GD: Gorik Ooms Acting GD: Gianfranco De Maio Other Offices Canada Médecins Sans Frontières / Japan Médecins Sans Frontières Médecins Sans Frontières Doctors Without Borders 3-3-13 Takadanobaba • Shinjuku • Tokyo International Office and 720 Spadina Avenue, Suite 402 • Toronto 169-0075 • Japan UN Liaison Office - Geneva Ontario • M5S 2T9 • Canada T +81 3 5337 1490 • F +81 3 5337 1491 Rue de Lausanne 78 T +1 416 964 0619 • F +1 416 963 8707 [email protected] • www.msf.or.jp Postal address: Case Postale 116 [email protected] • www.msf.ca Pr: Dr. Ritsuro Usui • GD: Eric Ouannes CH-1211 Genève 21 • Switzerland Pr: Dr. Joanne Liu • GD: Marilyn McHarg T +41 22 849 84 00 • F +41 22 849 84 04 Luxembourg Médecins Sans Frontières [email protected] • www.msf.org Denmark Médecins Sans Frontières / 68, rue de Gasperich • L-1617 Luxembourg Policy and Advocacy Coordinator: Laeger Uden Graenser T +352 33 2515 • F +352 33 51 33 Emmanuel Tronc • [email protected] Kristianiagade 8 • 2100 Copenhagen E Denmark [email protected] • www.msf.lu Pr: Dr. Rowan Gillies (As of 4 December 2006: T +45 39 77 56 00 • F +45 39 77 56 01 Pr: Dr. Romain Poos • GD: François Delfosse Dr. Christophe Fournier) [email protected] • www.msf.dk SG: Marine Buissonnière Pr: Dr. Soren Brix Christensen • GD: Philip Clarke Norway Médecins Sans Frontières / Leger Uten Grenser UN Liaison Office - New York France Médecins Sans Frontières Youngstorget 1 • 0181 Oslo • Norway 333 Seventh Avenue • 2nd Floor • New York 8 rue Saint Sabin • 75544 Paris Cedex 11 • France T +47 23 31 66 00 • F +47 23 31 66 01 NY 10001-5004 • USA T +33 (0) 1 40 21 29 29 • F +33 (0) 1 48 06 68 68 [email protected] T +212 655 3777 • F +212 679 7016 [email protected] • www.msf.fr www.legerutengrenser.no UN Liaison Officer in NY: Fabien Dubuet Pr: Dr. Jean-Hervé Bradol • GD: Pierre Salignon Pr: Dr. Kristian Tonby • GD: Patrice Vastel [email protected]

Germany Médecins Sans Frontières / Spain Médicos Sin Fronteras MSF Campaign for Access to Ärzte Ohne Grenzen e.V. Nou de la Rambla 26 • 08001 Barcelona • Spain Essential Medicines Am Köllnischen Park 1 • 10179 Berlin • Germany T +34 93 304 6100 • F +34 93 304 6102 Rue de Lausanne 78 T +49 30 22 33 77 00 • F +49 30 22 33 77 88 [email protected] • www.msf.es Postal address: Case Postale 116 [email protected] Pr: Dr. Paula Farias • GD: Aitor Zabalgogeazkoa CH-1211 Genève 21 • Switzerland www.aerzte-ohne-grenzen.de T +41 22 849 8405 • F +41 22 849 8404 Pr: Dr. Stefan Krieger • GD: Adrio Bacchetta Sweden Médecins Sans Frontières / Director: Dr. Tido von Schoen-Angerer Läkare Utan Gränser www.accessmed-msf.org Greece Médecins Sans Frontières Högbergsgatan 59 B • Box 4262 15, Xenias St. • GR-11527 Athens Greece SE - 102 66 Stockholm • Sweden MSF United Arab Emirates T +30 210 5 200 500 • F + 30 210 5 200 503 T +46 8 55 60 98 00 • F +46 8 55 60 98 01 Abu Dhabi Head Office • P.O. Box 47226 [email protected] • www.msf.gr [email protected] • www.lakareutangranser.se Abu Dhabi • UAE Acting Pr: Ioanna Papaki • GD: Muriel Cornelis Pr: Anneli Eriksson • GD: Dan Sermand T +971 2 6317 645 • F +971 2 6215 059 [email protected] • www.msfuae.ae Pr: President GD: General Director SG: Secretary General

88 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

The Médecins Sans Frontières Charter About this publication

GRAPHIC DESIGN Studio Roozen, Amsterdam, The Netherlands PRINTING Drukkerij Mercurius, Wormerveer, The Netherlands

COVER PHOTO Patients in the post-operation ward at the MSF Bon Marché Hospital, Bunia, Democratic Republic of Congo, May 2005. © Gary Knight (VII) T (+41-22) 8498 400, F (+41-22) 8498 404, E [email protected], www.msf.org [email protected], E 404, 8498 (+41-22) F 400, 8498 (+41-22) T Office International MSF witness to the plight of the people it helps. helps. it people the of plight the to witness bear publicly to and assistance medical needed urgently provide to organisations nongovernmental first the of one was MSF relief. emergency to access have should people all that believed who by 1971 in founded was (MSF) Frontières Sans Médecins MSF was awarded the 1999 Nobel Peace Prize. Peace Nobel 1999 the awarded was MSF countries. 70 over in aid medical provide to staff hired locally 25,850 approximately joined administrators and engineers sanitation and water experts, logistical professionals, medical other nurses, doctors, volunteer MSF 2225 over 2005, In countries. 19 in offices branch with movement humanitarian medical international an is MSF Today

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2005/06